1 p ! . fc-i - 1- 1 ' la i fZD ,3.1 P%3 €s CORNELL UNIVERSITY MEDICAL LIBRARY ITHACA DIVISION the: gift ow L,*1JL_ Z23: 9830 liimjw, il CORNELL UNIVERSITY LIBRARY 924 104 225 234 The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://archive.org/details/cu31924104225234 CONTRIBUTORS. BELFIELD, WILLIAM T., M. D. ; BEVAN, ARTHUR DEAN, M. D.; BLAKE, CLARENCE J., M. D. ; BRADFORD, EDWARD H., M. D. ; BULL, CHARLES STEDMAN, M. D. : BURRELL, HERBERT L., M. D. ; DELAVAN, D. BRYSON, M. D. ; DENNIS, FREDERIC S., M.D.; ETHERIDGE, JAMES H., M. D. ; EVE, DUNCAN, M. D. ; FORDYCE, JOHN A., M. D. ; GERRISH, FREDERIC H, M. D. ; GERSTER, ARPAD G., M. D. ; HARD AWAY, WILLIAM A., M. D. ; HARE, HOBART AMORY, M. D. ; HOLLO WAY, JAMES M., M. D. ; KELSEY, CHARLES B., M. D. ; LOVETT, ROBERT W., M. D. ; MATAS, RUDOLPH, M. D. ; MUDD, HENRY H, M. D. ; NANCREDE, CHARLES B., M. D. ; PARK, ROSWELL, M. D. ; PARKER, CHARLES B., M. D. ; PARMENTER, JOHN, M. D. ; RANSOHOFF, JOSEPH, M. D. ; RICHARDSON, MAURICE H, M. D. SMITH, CHAUNCEY P., M.D.; SOUCHON, EDMOND, M. D. A Treatise on Surgery BY AMERICAN AUTHORS. FOR STUDENTS AND PRACTITIONERS OF SURGERY AND MEDICINE. EDITED BY ^ROSWELL PARK, A.M., M.D, Pbofessoe of the Principles and Practice of Surgery and of Clinical Surgery in the Medical Department of the University of Buffalo, Buffalo, New-York; Member of the Congress of German Surgeons; Fellow of the American Surgical Association; Ex-President Medical Society of the State of New York ; Surgeon to the Buffalo General Hospital, etc. CONDENSED EDITION, WITH EEVISIONS. "WITH 625 ENGrBAVIHGS AND 37 FULL-PAGE PLATES IN COLOKS AND MOBTOCHBOME. LEA BROTHERS & CO., NEW YORK AND PHILADELPHIA. 1899. M<5-^ ^ c \<\ Entered according to Act of Congress in the year 1899, by LEA BROTHERS & CO., in the Office of the Librarian of Congress, at Washington. All rights reserved. WESTCOTT Sl THOMSON. ELECTROTYPERS, PHlLADA. PREFACE. The success achieved by this work has exceeded the most sanguine expectations, though it was reasonable to assume that a thoroughly modern treatise on surgery by the most experienced teachers and sur- geons of America would not fail of appreciation. The great demand for the work in its two-volume form brought with it sufficient indica- tions to warrant the belief that a somewhat condensed edition in a single volume and at a correspondingly lower price would add to its popu- larity. Advantage has been taken of this opportunity to revise the work to date, though, as it was really in advance of the time at its orig- inal issue, no organic changes have been found necessary. The essen- tially new treatment originally bestowed upon certain topics has been approved ; for instance, the distinction everywhere maintained between Hyperemia and Inflammation (i. e., Infection), the insistence upon the practical importance of Bacteriology, and the development of the sub- jects of Auto-intoxications and the Surgical Sequela? of Acute Non- surgical Diseases. The novel chapter on the Surgical Pathology of the Blood has justified the belief that the exact methods of clinical study so useful to the modern physician would be appreciated by his surgical confrb-e. In thus presenting the most modern results of research and experi- ence, care has at the same time been taken not to neglect the vast amount, of accumulated knowledge which is our heritage from the past, and unre- mitting effort has been devoted to afford under each topic a complete and condensed account of theory and practice representing the science and art of Surgery in its advanced position of to-day. Recent years have witnessed great progress in medical education toward the highest standards, and this tendency in the direction of a beneficent uniformity has rendered practicable the preparation of a text-book answering the requirements of the continually increasing proportion of students who seek the advantages of our best institutions. Their needs cannot be sharply differentiated from those of the student after graduation ; hence it is believed that this work will be found practically serviceable by the surgeon and the general physician desiring surgical information. That two editions of a work should be simultaneously extant is a 5 6 PREFACE. novelty worthy of comment. Eeaders desiring the fuller information in the two-volume edition will naturally prefer it. The condensed edition maintains the convenient division into General and Special Surgery, and thus preserves the conformity of the work with the sur- gical courses rapidly becoming universal. It will answer the needs of students as well as of those who desire a comprehensive and practical single-volume work on modern surgery. The reduction in price, pro- portionately much greater than the reduction in matter, is an advan- tage which all readers will appreciate, and one which has only been rendered practicable by the exceedingly wide sale already achieved. Especial care has been devoted to the very complete series of illus- trations, of which by far the greater part have been prepared expressly for this work. Colored plates have been introduced wherever they would best serve to elucidate the text. The Editor again desires to express his warmest thanks to the emi- nent contributors. He would also acknowledge his indebtedness to Charles E. Smith, Esq., of Philadelphia, and to Chauncey P. Smith, M. D., of Buffalo, for invaluable assistance ; also to Dr. Irving P. Lyon, for the supervision of the drawings and the beautiful original prepara- tions from which Plate I. was made. EOSWELL PARK. Buffalo, September, 1899. CONTRIBUTORS. WILLIAM T. BELFIELD, M.D., Assistant Professor of Surgery, Rush Medical College, Chicago; Professor of Genito-urinary and Venereal Diseases, Chicago Polyclinic. ARTHUR DEAN BEVAN, M.D., Professor of Anatomy, Rush Medical College, Chicago; Professor of Surgery, Women's Medical . School, Northwestern University, Chicago; Surgeon to the Presbyterian, St. Luke's, and St. Elizabeth's Hospitals, Chicago. CLARENCE J. BLAKE, M.D., Professor of Otology, Medical School of Harvard University, Boston ; Aural Sur- geon to the Massachusetts Charitable Eye and Ear Infirmary, Boston. EDWARD H. BRADFORD, M.D., Assistant Professor of Orthopaedic Surgery, Medical School of Harvard Univer- sity, Boston ; Surgeon to the Children's Hospital, Boston. CHARLES STEDMAN BULL, A. M., M. D., Professor of Ophthalmology, Medical Department, Cornell University, New York ; Surgeon to the New York Eye Infirmary ; Consulting Ophthalmic Surgeon to St. Luke's, Presbyterian, and St. Mary's Hospitals, New York. HERBERT L. BURRELL, M. D., Assistant Professor of Clinical Surgery, Medical School of Harvard University, Boston ; Surgeon to The Boston City Hospital and to The Children's Hospital, Boston. D. BRYSON DELAVAN, A.B., M.D., Chief of Clinic, Diseases of Throat, etc., College of Physicians and Surgeons, New York ; Professor of Laryngology and Rhinology, New York Polyclinic ; Con- sulting Laryngologist to the New York Cancer Hospital, the Hospital for Rupt- ured and Crippled, and the Macdonough Hospital, New York ; Ex- President of the American Larvngological Association, etc. FREDERIC S. DENNIS, M. D, M. R. C. S. Eng., Professor of Clinical Surgery, Cornell University, New York City ; Attending Surgeon to Bellevue and St. Vincent Hospitals ; Consulting Surgeon to the Mon- tefiore Home, New York City, and St. Joseph's Hospital, Yonkers, N.Y. ; Mem- ber of the German Congress of Surgeons, Berlin. 7 8 CONTRIBUTORS. JAMES H. ETHEEIDGE, A. M., M. D. (Deceased), Formerly Professor of Obstetrics and Gynecology, Eush Medical College, Chicago ; Professor of Gynecology, Chicago Polyclinic ; Gynecologist to the Presbyterian and Polyclinic Hospitals ; Consulting Gynecologist to the St. Joseph Hospital, Chicago. DUNCAN EVE, A. M., M. D., Professor of Surgery and Clinical Surgery, Medical Department of Vanderbilt University, Nashviile, Tennessee ; Chief Surgeon to the Nashville, Chattanooga and St. Louis Railway Co. ; Consulting Surgeon to the Nashville City Hospital. JOHN A. FOEDYCE, A. M., M. D., Professor of Dermatology and Syphilology, University and Bellevue Hospital Medical College, New York ; Visiting Dermatologist to the City (Charity) Hospital, New York FEEDEEIC H. GEEEISH, A.M., M. D., Professor of Anatomy, Bowdoin College ; Consulting Surgeon to the Maine General Hospital, Portland, Maine. AEPAD G. GEESTEE, M. D., Ch. D., O. M., Vienna, Visiting Surgeon to the Mt. Sinai Hospital, and Consulting Surgeon to the German Hospital, New York ; Ex-President of the New York Surgical Society. WILLIAM A. HAEDAWAY, A. M., M. D., Professor of Diseases of the Skin and Syphilis, Washington University, St. Louis; Ex-President of the American Dermatological Association. HOBAET AMOEY HAEE, M. D., B.Sc, Professor of Therapeutics and Materia Medica, Jefferson Medical College, Phila- delphia; Physician to the Jefferson Medical College Hospital, Philadelphia. JAMES M. HOLLOWAY, A.M., M.D., Professor of Surgery and Clinical and Operative Surgery, Medical Department, Kentucky University, Louisville. CHAELES B. KELSEY, M. D, Professor of Abdominal and Eectal Surgery, New York Post-Graduate Medical School and Hospital, New York. ROBERT W. LOVETT, M.D., Surgeon to the Infants' Hospital and Assistant Surgeon to the Children's Hospital, Boston. EUDOLPH MATAS, M. D., Professor of General and Clinical Surgery, Medical Department, Tulane Uni- versity of Louisiana, New Orleans ; Visiting Surgeon to the Charity Hospital of New Orleans, etc. CONTRIBUTORS. 9 HENEY H. MUDD, M. D., Professor of Clinical Surgery and Special Fractures and Dislocations, St. Louis Medical College ; Consulting Surgeon to the St. Louis City Hospital. CHAELES B. NANCBEDE, A. M., M. D., LL. D., Professor of Surgery and of Clinical Surgery, Department of Medicine and Sur- gery, University of Michigan; Emeritus Professor of General and Orthopedic Surgery, Philadelphia Polyclinic. EOSWELL PAEK, A.M., M. D, Professor of Principles and Practice of Surgery and Clinical Surgery, Medical Department of the University of Buffalo; Surgeon to the Buffalo General Hospital, etc., Buffalo, N. Y. CHAELES B. PAEKEE, M.D., M. E. C. S. Eng., Professor of Clinical Surgery, Cleveland College of Physicians and Surgeons, Cleveland, Ohio. JOHN PABMENTEB, M. D., Professor of Anatomy and of Clinical Surgery, Medical Department of the Uni- versity of Buffalo; Surgeon to the Erie County, Fitch Accident, and Children's Hospitals, Buffalo, X. Y. JOSEPH EANSOHOFF, M. D, F.E.C.S., Professor of Anatomy and Clinical Surgery, Medical College of Ohio, Cincinnati ; Surgeon to the Good Samaritan, Cincinnati, and Jewish Hospitals. MAUEICE H. EICHAEDSOX, A.B., M.D., Assistant Professor of Clinical Surgery, Medical School of Harvard University, Boston ; Visiting Surgeon to the Massachusetts General Hospital, Boston. CHAUNCEY P. SMITH, M.D., Assistant Attending Surgeon to the Fitch Accident Hospital ; Assistant Attending Surgeon to the Buffalo General Hospital ; Instructor in Surgery, Medical De- partment, University of Buffalo. EDMOND SOUCHON, M. D., Professor of Anatomy and Clinical Surgery, Medical Department, Tulane Uni- versitv of Louisiana, New Orleans ; Visiting Surgeon to the Charity Hospital, New Orleans. CONTENTS. PART I. SUEGICAL PATHOLOGY. By Roswell Park, M.D. CHAPTER I. PAGE HYPEREMIA : ITS CONSEQUENCES AND TREATMENT . 17 CHAPTER II. SURGICAL PATHOLOGY OF THE BLOOD 29 CHAPTER III. INFLAMMATION 44 CHAPTER IV. ULCER AND ULCERATION 72 CHAPTER V. GANGRENE 83 PART II. SUEGICAL DISEASES. CHAPTER VI. ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS ... 91 By Roswell, Park, M. D. 10 CONTENTS. 11 CHAPTER VII. PAGE THE SURGICAL FEVERS AND SEPTIC INFECTIONS 97 By Roswell Park, M. D. CHAPTER VIII. SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC ANIMALS 114 By Roswell Paek, M. D. CHAPTER IX. SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC ANIMALS (Continued) 130 By Roswell Paek, M. D. CHAPTER X. SYPHILIS 145 By John A. Fobdyce, M. D. CHAPTER XI. GONORRHOEA AND ITS SEQUELS 171 By William T. Belfield, M. D. CHAPTER XII. SHOCK AND COLLAPSE 185 By Roswell Park, M. D. CHAPTER XIII. SCURVY AND RICKETS 188 By Roswell Paek, M. D. CHAPTER XIV. SURGICAL ASPECTS AND SEQUELAE OF OTHER INFECTIONS AND DISEASES 192 By Roswell Paek, M. D. CHAPTER XV. POISONING BY ANIMALS AND PLANTS 198 By Roswell Paek, M. D. CHAPTER XVI. ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS .... 202 By Roswell Paek, M. D. 12 CONTENTS. PART III. SURGICAL PRINCIPLES AND METHODS AND MINOR PROCEDURES. CHAPTER XVII. PAGE CONTROL OF HEMORRHAGE; ABSTRACTION OF BLOOD; PARA- CENTESIS; COUNTER-IRRITATION 207 By John Pabmenteb, M. D. CHAPTER XVIII. MINOR SURGERY AND BANDAGING 215 By John Parmenteb, M. D. CHAPTER XIX. ANAESTHESIA AND ANAESTHETICS 230 By Hobaet Amory Habe, M. D. CHAPTER XX. SURGICAL DIAGNOSIS 245 By Chauncey P. Smith, M. D. PART IV. INJURY AND REPAIR. CHAPTER XXI. WOUNDS 257 By Chables B. Nancbede, M. D. CHAPTER XXII. GUNSHOT WOUNDS 264 By Charles B. Nancbede, M. D. CHAPTER XXIII. PROCESS OF REPAIR 284 By Chables B. Nancbede, M. D. CHAPTER XXIV. TREATMENT OF WOUNDS; ANTISEPSIS AND ASEPSIS 292 By Chables B. Nancrede, M. D. CONTENTS. 13 PART V. SURGICAL AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. CHAPTER XXV. PAGE CYSTS AND TUMOES 305 By Roswell Park, M. D. CHAPTER XXVI. SUKGICAL DISEASES OF THE SKIN 356 By William A. Hard a way, M. D. CHAPTER XXVII. BURNS, SCALDS, AND FEOST-BITES, AND THEIR TREATMENT . . 378 By John Parmenter, M. D. CHAPTER XXVIII. THE MUSCLES, TENDONS, 'AND TENDON-SHEATHS, BURSAS, AND FASCIA 385 By Herbert L. Burrell, M. D. CHAPTER XXIX. INJURIES AND DISEASES OF THE LYMPHATIC VESSELS AND NODES 407 By Frederic Henry Gerrish, M. D. CHAPTER XXX. SURGICAL INJURIES AND DISEASES OF THE VEINS 426 By James M. Holloway, M. D. CHAPTER XXXI. SURGICAL INJURIES AND DISEASES OF THE ARTERIES, IN- CLUDING ANEURISM 433 By Duncan Eve, M. D. CHAPTER XXXII. INJURIES AND DISEASES OF THE JOINTS AND JOINT-STRUC- TURES . . 463 By Joseph Ransohoff, M. D. CHAPTER XXXIII. OPERATIONS ON JOINTS 500 By Joseph Ransohoff, M. D. 14 CONTENTS. CHAPTER XXXIV. SURGICAL DISEASES OF THE OSSEOUS SYSTEMi/; V .* • By Bos well Park; -^.Tx FEACTUEES DISLOCATIONS CHAPTEB XXXV. By Henry H. Mudd, M- D. CHAPTEB XXXVI. By Henry H. Mudd, M.D. PAGE '512 545 597 PAET VI. SPECIAL OR REGIONAL SURGERY. CHAPTEB XXXVII. SURGICAL DISEASES AND INJUEIES OF THE HEAD 621 By Roswell Park, M.D. CHAPTEB XXXVIII. SUEGICAL DISEASES AND INJUEIES OF THE SPINE 672 By Edward H. Bradford, M.D. CHAPTEB XXXIX. SURGICAL DISEASES AND INJUEIES OF THE HEAET AND PERI- CARDIUM, WITH SUEGEEY OF THE LARGE BLOODVESSELS; LIGATIONS 707 By Duncan Eve, M.D. CHAPTEB XL. SURGICAL DISEASES AND INJURIES OF THE RESPIRATORY ORGANS 730 By D. Bryson Delavan, M.D. CHAPTEB XLI. SURGICAL DISEASES AND INJURIES OF THE FACE 764 By Edmond Souchon, M. D. CHAPTEB XLII. SURGICAL DISEASES AND INJURIES OF THE NECK 784 By Edmond Souchon, M. D. CONTENTS. 15 CHAPTER XLIII. PAGE SURGERY OF THE CHEST 805 By Frederic S. Dennis, M. D. CHAPTER XLIV. SUEGICAL DISEASES AND INJURIES OF THE MOUTH, TONGUE, TEETH, AND JAWS 849 By Arthur Dean Bevan, M. D. CHAPTER XLV. SURGERY OF THE ABDOMEN 872 By Maurice H. Richardson, M. D., assisted by Farrar Cobb, M.D. CHAPTER XLVI. HERNIA 930 By Maurice H. Richardson, M.D. CHAPTER XLVII. DISEASES OF THE RECTUM AND SIGMOID FLEXURE 952 By Charles B. Kelsey, M. D. CHAPTER XL VIII. GENITO-URINARY SURGERY 970 By William T. Belfield, M. D. CHAPTER XLIX. CHANCROID, OR VENEREAL ULCER 1023 By Roswell Park, M. D. CHAPTER L. SURGICAL DISEASES AND INJURIES OF THE FEMALE REPRO- DUCTIVE ORGANS 1026 By James H. Etheridge, M.D. CHAPTER LI. SURGICAL DISEASES AND INJURIES OF THE BREAST 1061 By Charles B. Parker, M.D. CHAPTER LII. AMPUTATIONS 1079 By Rudolph Matas, M.D. CHAPTER LIII. ORTHOPAEDIC SURGERY 1108 By Robert W. Lovett, M.D. 16 CONTENTS. CHAPTER LIV. PAGE PLASTIC SURGERY 1154 By Aepad G. Geestbb, M. D. CHAPTER LV. THE SURGICAL DISEASES AND INJURIES OF THE EYE AND ORBIT 1167 By Charles Stedman Bull, M. D. CHAPTER LVI. SURGICAL DISEASES AND INJURIES OF THE EAR 1200 By Clarence J. Blake, M. D. CHAPTER LVII. ON SKIAGRAPHY, OR THE APPLICATION OF THE RONTGEN RAYS TO SURGERY 1212 By Roswell Park;, M. D. GENERAL SURGERY. PART I. SURGICAL PATHOLOGY. CHAPTER I. HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. By Roswell Park, M. D. The reactionary results of injury to various tissues and the first local appearances due to the surgical infectious diseases are indicated by certain appearances which, for a few hours at least, are in large measure common to both. Their beginnings being pathologically similar, their results depend not alone on the violence or intensity of the process, but in predominating measure upon the primary influ- ences at work. The consequences of mere mechanical injury — such as strain, laceration, etc. — are in healthy individuals promptly repaired by processes which will be taken into consideration in the ensuing chapters. They are throughout conservative and reparative, and are directed toward restoring, so far as possible, the original condition. The consequences, on the other hand, of the surgical infections are more or less disastrous from the outset, although the extent of the disaster may be localized within a very small area, as after a trifling furuncle, or they may be so widespread as to disable a limb or an organ, or they may even be fatal. It is of the greatest importance, not alone for scientific reasons, but because treatment must in large measure depend upon the underlying conditions, to differentiate between these two general classes of disturbance, which we speak of as — A. Those produced by external or extrinsic disturbances — /. e. traumatisms, sprains, lacerations, etc. ; and B. Those produced by internal and intrinsic causes, which, for the most part, are the now well-known micro-organisms, such as produce the various surgical diseases. These latter disturbances may be imitated or simulated in the presence of certain irritants within the tissues, such as the poisons of various insects and plants ; the irritation produced by foreign bodies, 2 17 18 SURGICAL PATHOLOGY. minute or large ; and possibly the presence within the system of cer- tain poisons whose nature is not yet known, such as that of syphilis or certain others whose chemistry is fairly well understood, but whose presence cannot be easily explained, as uric acid, etc. Clinically, all these disturbances are manifested by certain phe- nomena common to each which may present themselves at one time more prominently, at another time less so. These significant appear- ances have been recognized from time immemorial as the color, rubor, dolor, tumor, et fuiietio Icesa of our ancestors, or as the heat, redness, pain, swelling, and loss of function of our common experience. When one or more of these are present, the surgeon cannot afford to disre- gard the fact, while he should, moreover, be able to account for each on general principles which should to him be well known. To their more exact study we must, however, make some preface in the way of general remarks concerning a phenomenon everywhere easily recognized, but as yet incompletely understood. This phenom- enon has reference to an undue supply of blood to a part, and is com- monly known under two terms which are practically synonymous — namely, congestion aud hyperemia. To begin with these, then, we must note, first of all, that congestion and hyperemia may be — A. Active; and B. Passive. They may also be spoken of as — 1. Acute; and 2. Chronic. Considering first the two latter distinctions, it will be found that the acute hyperemias are met with most often in consequence of sharp mechanical disturbances. The chronic hyperemias, on the contrary, are conditions which in many individuals are more or less permanent. Note accurately here the proper significance of certain terms. Hyper- semia means, in effect, an over-supply of blood to the given part : the term should have only a local significance. When the entire body seems to be too well supplied with blood, the condition is known as plethora, the counterpart of which term is usually anaemia. The direct counterpart of the term hyperamia should perhaps be ischamia, mean- ing a perverted blood-supply in reduced amount. With plethora and anemia as terms implying general conditions, with hyperemia and ischemia implying local conditions, there should be little room for confusion in phraseology. The active form of hyperemia used to be called " fluxion," a term now rarely used. Active hyperemia means an increased supply of arterial blood. In passive hyperemia the over-supply is rather of venom blood. In the former case the condition seems due to over- activity of the heart, with such local tissue-changes as permit it to occur. In passive hyperemia the blood-current is slower — there is a tendency toward, and sometimes there is actual, stagnation ; all of Avhich is usually due to obstruction to the return of blood' to the heart. The conditions permitting these two results may be widely variant. Active hyperemia may be produced by purely nervous influences even those of emotional origin. The flushing of the face which is HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 19 known as " blushing " is, perhaps, the most common illustration of this fact. It is well known also that this is, in some degree at least, the result of division of certain nerves which have to do with the regulation of the blood-supply. The cervical sympathetic is the best known and most often studied of these, and the consequences of division of this nerve in the neck are stated in all the text-books on physiology. So also by electrical stimulation of certain nerves the parts supplied by them can be made to show a very active hyperemia, which will subside shortly after discontinuance of stimulation, provid- ing this has not been kept up too long. In active hyperemia there is absolute increase of intra-arterial tension, and under these circum- stances pulsation may be noted in those small vessels where commonly it is not seen nor felt. This is the explanation of the throbbing pain complained of under many actively hypersemic conditions. This hyperffimia affords the explanation of the clinical signs to which attention has already been called. The increased heat of the part is the result of greater access of blood, which prevents cooling by radiation and evaporation : the peculiar redness is due to the greater filling of the capillaries with the blood, which gives the peculiar hue to the skin and visible textures ; while to the increased pressure upon sensory nerves is also due the pain. The minuter changes occurring within the congested part call for more accurate description. "Whether or not there be actual dilatation of capillaries under these circumstances is a matter still under dispute, but of the dilatation of the larger vessels there can be no possible question. As hypersemia is to such a great extent brought about by action of the nervous system, it is well to divide it more accurately into the hypersemia of paralysis, or neuroparalytic congestion, which is the result of a paralysis of the constrictor fibres of the vasomotor system, and into the hypersemia of irritation, or neurotonic congestion, which is due to the irritation of the dilators (Recklinghausen). Physiologists are fairly well agreed that as between the dilating and the constricting apparatus of the vasomotor system there is ordinarily preserved a cer- tain degree of equilibrium ; to which fact it is probably due that a normal condition of affairs is brought about after temporary disturb- ance, since, too, over-action in one direction succeeds reaction in the other. As Warren has illustrated this, our common treatment of frost- bite by cold applications is a concession to this fact, since by the cold application we endeavor to limit the reaction which would otherwise follow after thawing out the frozen part. The best examples of the hypereemia of paralysis are perhaps to be met with after certain injuries to nerves, as, for instance, flushing of the face and hypersecretion of nasal mucus, tears, etc. after injury to the cervical sympathetic. Such too, in its essentials, is that form of shock known as brain-concussion, which is often followed by nutri- tive disturbances among the brain-cells, with consequent perversion of brain-function. Waller's experiment of placing a freezing mixture over the ulnar nerve at the back of the elbow is also significant, the result being congestion and elevation of surface temperature of the fingers supplied by this nerve. Con- gestion and swelling have also been observed after fracture of the internal 20 SURGICAL PATHOLOGY. condyle of the humerus, bv which this nerve was pressed upon ; and similar phenomena may be noted 'in fingers or toes as the result of injuries of other nerves. Hvpersemia due to paralysis of the perivascular ganglia is observed sometimes in transplanted flaps, in the suffusion of a limb after re- moval of the Esmarch bandage, in the congestions of certain sac- walls after tapping, in the hvpersemia, perhaps even hemorrhage, from the bladder-wall after too 'quickly relieving its over-distention, in the swelling of the extremities when they begin to be first used after having been put at rest because of injury, etc. The hypercemias of dilatation are more acute in course and mani- festation. Along with them go sharp pain, hypersecretion of glands, cedema, and sometimes desquamation of superficial parts. The facial blush due to effusion ; the temporary flushing due to indulgence in alcohol ; the suffusion of the conjunctiva, perhaps the face, with hyperlachrvmation, accompanying facial neuralgia or heniicrania; and the hyperseruia consequent upon herpes zoster, urticaria, etc., are illustrative examples of this form. The erythema due to nerve irri- tation or injury, the swelling of the joints which appears after similar lesions, and that condition described by Mitchell as erythromelalgia, probably also belong here. In fact, almost all the reflex hyper- aemias are hypersemias of dilatation. The forms of hypersemia considered above belong mainly to the designation of active. Passive hyperaemia is most often a mechani- cal consequence of obstruction to return of blood which can be imitated at will, and which is not infrequently the result of sheer carelessness, as when an injured limb is bandaged too tightly. Experiment shows that when such mechanical obstruction has taken place there is tempo- rary increase of intravenous pressure, which soon returns to the nor- mal standard, such readjustment meaning that blood has found its way back by collateral circulation. Only when such rearrangement is pos- sible do we have anything like permanent passive hypersemia. In organs with a single vein, such as the kidneys, the question of obstruc- tion may assume a very important aspect. Under these circumstances the appearance of the involved part, when visible, is spoken of as cyanotic, while its surface instead of being abnormally warm is the reverse, due to impeded access of warm blood and more rapid surface- cooling. The blood under such conditions is often darker than natural, because, remaining longer in the part, it absorbs more carbonic dioxide or at least gives up more of its oxygen. So long as actual gangrene is in it threatened, the blood-column has a communicated pulsation, at least in the large veins. Escape of corpuscular elements may occur after the phenomena above noted have been present for some' time • but the corpuscles rarely, if ever, escape until there has been more or less copious transudation of the fluid portion of the blood — i. e. the serum. When anatomical changes can be grossly yet carefully observed as in the fundus of the eye, it is seen that under these circumstances the arteries become smaller, although whether this be a primary or secondary change is not to be made out. Discoloration of the integu- ment is the frequent result of leakage of blood-corpuscles and their pigmentary substance into the tissues, and is consequently a frequent HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 21 accompaniment of chronic passive oedema. It is seen very often in connection with varicose veins of the legs. Another form of passive congestion or hyperemia is that due to enfeeblement of the heart's action by serious injury or wasting disease. When under these circumstances the lung has become more or less infiltrated with fluid, with hemorrhagic extravasation, the condition is known as hypostatic pneumonia — a misnomer, nevertheless indicating a condition which is only too frequent in the aged and feeble. Results op Hyperemia and Congestion. These may be — 1. Speedy Subsidence of all Hypersemic Phenomena — Resolution. 2. Acute Swelling. 3. Chronic Enlargement. 4. Gangrene. 5. Nutritional Changes — Atrophy and Hypertrophy. 1. The speedy subsidence of hypersemic phenomena is often known as resolution — a term which has also been applied to the retro- grade phenomena after a genuine inflammation. For present purposes it implies, first, the subsidence into inactivity of the exciting cause or its complete removal. This may include the passing of an emotion, the removal of an irritant, the loosening of a bandage, the resort to certain applications or to constringing or astringing measures by which the effect is counteracted. A particle of dust in the conjunctiva may within a very few moments produce a very active congestion of the conjunctival vessels, which, ordinarily scarcely visible, become now prominent and easily noted. The removal of the offending substance permits a prompt return to their original size, and all this may be a matter of perhaps half an hour. This is an example of the speedy subsidence of the hypersemia of dilatation after removal of the cause. Should the hypersemia not subside at once, it is well known what aid may be gathered from cold applications, or in this instance from some gentle astringent collyrium, or from some agent whose physiological effect it is to produce vascular contraction — cocaine, adrenal extract. 2. Acute Swelling. — When the effusion above referred to takes place into loose connective tissues the condition is spoken of techni- cally as oedema, while Avhen it occurs into a previously existing cav- ity, such as that of a joint, it is known as an effusion. The amount of blood thus effused will be in large degree influenced by the anatom- ical and mechanical conditions obtaining about the part. It may be laid down as a general rule that when the extravascular pressure equals the intravascular pressure little or no more fluid may escape. As a matter of fact, it is seldom that the former even rises to the degree of the latter. Conversely, one method of treating such cedemas and effusions is by some device which shall make the ex- travascular pressure exceed the intravascular, when the fluid is, as it were, forced back into the vessels, and is made to resume its proper place within the same. This is often done by taking advan- tage of elastic compression, as when a rubber bandage is applied about the part. In certain parts of the body it may be done by 22 SURGICAL PATHOLOGY. pressure brought about by some other device. Pressure may be used practically for two purposes : A. To so increase extravascular pressure as to limit the possible amount of an effusion, as when it is put on early after an injury ; or, B. When it is used as a later resort for the purpose of reducing swelling which has already occurred. 3. Chronic Swelling. — This is something more than the swelling alluded to under Acute Swelling. Chronic swelling implies either a continuous passive hyperemia, or, what is much more common, a positive increase in tissue-elements as the result of an over-supply of nutrition brought by the blood, which itself was furnished to the part in a degree far in excess of its needs. The result is a more rapid reproduction of cell-elements, with result in the shape of tissue-thick- enings or tissue-enlargements, which are to the laity known as " over- growth," or to us as hypertrophy, or, more properly speaking, hyper- plasia, of a part. This chronic swelling or chronic enlargement is in some degree also connected with the phenomena of escape of white corpuscles from the blood-vessels and mitotic division of certain tis- sue-cells, which have up to this time been usually regarded as so dis- tinctive a feature of the true inflammatory process. 4. Gangrene. — This may be the result of sheer hypersemia — for the most part the passive forms — though most instances of gangrene due to intrinsic causes are inseparable from the presence of infectious micro-organisms. The gangrene which is spoken of here would include that due to the pressure of tumors, tight dressings, or any natural or intrinsic agency, and that due to pressure from without when not so pronounced as to produce immediate and total loss of circulation in a part. It includes the formation of many bed-sores and so-called pressure-sores, which may be due to an enfeebled heart, to an obstructed pulmonary circulation, or to external pressure in con- junction with cardiac debility. While insisting, then, that gangrene be recognized in this place as a possible result of hypersemia, it should be added that gangrene is in effect a tissue-death, and that dead tissue is always and everywhere practically the same thing, no matter by what causes brought about. Consequently, the subject of gangrene will be considered under a heading by itself. 5. Nutritional changes will be considered by themselves a little later. The consequence of persistent hypervemia is exudation — i. e. escape of blood-plasma from the vessels into body-cavities and tissue-interspaces. This leads to consideration under a distinct heading of Exudates. Exudation may occur alike in vascular and non-vascular, in firm and soft tissues, in, under, and upon membranes. With respect to location, exudates are described as/ree when found upon free surfaces or within natural cavities ; interstitial when found between the tissues or parts of tissues ; and parenchymatous when they are situated with- in the tissues themselves, particularly in epitheliafand glandular cells of any kind. As concerns quality, exudates are serous, mucous, fibrinous, or . . HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 23 mixed, the mixed forms including the so-called aero-purulent, the muco-purulent , the croupous, and the diphtheritic, as they used to be mentioned by the older writers. When any exudate contains red globules in sufficient quantity to stain it, it is called hemorrhagic. Serous exudates from free surfaces are sometimes spoken of as serous catarrhs ; when into cavities, as dropsies ; when into tissues, as oedema; when occurring beneath the epidermis they form serous vesi- cles or blebs or bullae. Fibrinous exudation refers to the fluid which coagulates soon after its exit from the vessels within those spaces into which it has oozed. When flocculi of coagula float in serous fluid it is known as a sero- fibrinous exudate. Pure fibrinous exudate occurs relatively rarely, save in and upon mucous membranes. The extent to which exposure to the air is responsible for the firm coagulation of the fibrin pre- viously held in solution is uncertain. The most potent factors in pro- ducing such coagulation are bacteria, but it is not yet disproven that coagulation may occur without their aid. When such coagulation occurs upon the surface of a mucous membrane it has been spoken of as croupous. When the epithelial covering as well as the basement membrane, and often the submucous tissues, are involved so that now the membrane cannot be stripped off without tearing across minute blood-vessels, the exudate has been known as diphtheritic. These terms may possibly be still retained in an adjective sense as implying the exact location of a surface exudate, but are scarcely to be used in any other significance. The following table illustrates significant differences whose full importance cannot be impressed before a study of inflammation has been carefully entered upon : Hyper^emic Exudates. Inflammatory Exudates. Poor in albumen. Rich in albumen. Rarely coagulate in the tissues. Usually coagulate in the tissues. Contain few cells. Contain numerous cells. Low specific gravity. High specific gravity. Contain no peptone. Contain peptone (product ji cell-disintegration). Treatment of Congestion and Hyperemia. These disturbances are to be combated, first of all, by insisting upon physiological rest. This, perhaps, is the most important meas- ure of all. The profession is greatly indebted to Hilton for the decided advance which he made in the treatment of congestive and inflammatory affections by insisting upon this principle in his cele- brated work on Rest and Pain, which every young practitioner should read. Aside from this first and underlying principle, the treatment must, in some measure at least, be based upon the time at which we are called upon to treat the case. If seen at once, before exu- dation has been excessive or the other disturbances marked, we may carry out a certain line of treatment for the purpose of limiting all these unpleasant features. On the other hand, if seen late, when 24 SURGICAL PATHOLOGY. exudation has been copious and when pain and other disturbances are due to its presence, a distinctly different course will be adopted. Toward the end first mentioned— namely, the limitation of hyperemia — we may adopt local and general measures. Local measures include graduated pres- sure, providing this be not intolerable to the patient, endeavoring to so equalize pressure that outside of the vessels it shall equal that inside. This may be done by careful bandaging, extreme care being taken that the pressure be applied from the very extremity of the limb ; otherwise, passive exudation might be augmented and gangrene be precipitated. Elevation of a limb will often accom- plish much the same purpose. Cold, which is in effect an astringent and which tends to contract blood-vessels, is another measure in the same direction, and if applied early will do much to limit the degree of the attack. This may be applied as dry or moist cold, and should be gradually mitigated as the congestion subsides. It acts through the vasomotor system, and is a measure to be resorted to with some caution. An efficient way of applying dry cold can be extempor- ized by a few yards of rubber tubing, held in place by wire or sewed in place to a piece of cloth, through which a stream or cold water is permitted to gently pass. Heat is another efficient means, acting, however, in a rather different way. Heat is a measure to be employed to hasten the disappearance of exudation — in other words, to quicken resorption, which it does by equalizing blood-pres- sure, dilating the capillaries, stimulating the lymphatic current, and in every way helping to clear the tissues of that which has left the blood-vessels. It is necessary also, at least in extreme oases, to employ some deter- gent or derivative measures, including blood-lettinr/, which is not suffi- ciently often resorted to. When done for this purpose, depletion should be carried out at the area involved if possible. This may be done either as venesection, by leeching either with the natural or the arti- ficial leech, or by a series of minute punctures or incisions, which give relief to tension, permit the rapid escape of fluid exudate, and often save tissues from the disastrous effects of strangulation. In some cases of deep-seated congestions these measures are inapplicable, and venesection at the point of election — say the cephalic vein in the arm — may be followed by great benefit. Another method of depletion is by administration of cathartics, such intestinal activity being stimu- lated as shall lead to copious watery evacuations. The salines rank high as measures directed toward this end, but in emergency much stronger and more drastic drugs may be administered, such as jalap, calomel, elaterium, etc. Diaphoretics and diuretics help to reduce temperature, and in some degree to deplete, but their action is usually slow. When exudation is considerable in amount and confined to some one of the body-cavities, it is often best combated, if at all obstinate, ' by the method of aspiration. This includes any suitable suction ap- paratus by which the fluid may be withdrawn through a small needle or cannula, the operation being trifling in difficulty, but one to be per- formed under strictest aseptic precautions, lest infection of an exudate already at hand be permitted. Certain individuals, especially the neurotic, will need more or less anodvne particularly when local applications fail to give relief. Sometimes a small dose of morphia administered hypodermically will act like magic in making efficient those measures which would otherwise be inefficient, in little children also some anodyne or hypnotic will be of great service. Under all circumstances it is well to beep the lower bowel empty, and certain elderly individuals with weak and enfeeb ed hearts will need the stimulation to be afforded by digitalis, quinine and alcohol, or preferably by strychnia administered subeutaneouslv HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 25 In cases of chronic hypersemia and its consequent hyperplasias (induration, thickening, etc.) there is no one measure so generally applicable and effective as the continued use of cold-water dress- ings. These are generally spoken of as " cold wet packs," and may be continued — constantly or intermittently — for many days. On Atrophy and Hypertrophy, and the Consequences op Altered, Diminished, and Perverted Nutrition. As a consequence of increase of nutrition we have produced a con- dition known commonly as hypertrophy, more accurately as hyperpla- sia. Hypertrophy literally means overgrowth, whereas hyperplasia more accurately describes that which constitutes hypertrophy — namely, numerical increase of constituent cells. Common usage has made the more inaccurate name " hypertrophy " cover nearly all these conditions. Hypertrophy or hyperplasia means enlargement of a part or of an organ beyond its usual limits, and as the result of increased function or increased nutrition. It is to be distin- guished from gigantism, which means inordinate enlargement as the result of a congenital tendency or condition. Hypertrophy is — A Phvsioloaical i L Compensatory ; 3 " \ Z. r rom deficient use. 3. Local ; B. Pathological -l .' □ ., ' [_ 6. Congenital. A. Physiological Hypertrophy. — 1. This includes many of the compensatory enlargements of an organ or a part when extra work is put upon it owing to deficiency of some other organ or part. This is spoken of as compensatory enlargement. Illustrative examples may be seen in the heart, which becomes larger and stronger when the blood-vessel walls are diseased and their lumen marrowed or when other obstructions to circulation are brought about ; again, in enlarge- ment of one kidney after extirpation of the other, or of the wall of the stomach when the pylorus is constricted or obstructed ; again, of the fibula after weakening or more or less destruction of the tibia, or of the shaft of any bone when it has been weakened at some point by not too acute disease ; or, again, of the walls of bursse after con- stant friction. 2. The best examples of physiological hypertrophy owing to defi- cient use are perhaps seen in some of the lower animals; as, for instance, in the teeth of such rodents as beavers when kept in cap- tivity and prevented from natural use. B. Pathological Hypertrophy. — 3, 4. Instances of this are every- where and every day to be met in the results of so-called chronic inflammation, a term which is a complete misnomer and should be expunged from text-book use. So-called chronic inflammation simply means increase of nutrition owing to a certain degree of hypersemia, which may have been produced in the first place as the result of trau- matism, which may come from chemical irritants circulating in the fluids of the part — as, for example, uric acid, etc. — or which are 26 SURGICAL PATHOLOGY. brought about as the result of perverted trophic-nerve influence. Instances of local pathological hypertrophy may be seen in the thickened periosteum after injury, in the enlargement of a phalanx known as the " baseball finger," and in numerous other places ; or they may be general, in which case they are brought about mainly by some irritating material in the general circulation. The unknown poison of syphilis notoriously provokes such nutritive disturbances. 5. Senile hypertrophy is connected with nutritional disturbances characteristic of old age, as to whose remote causes we are still in the dark. Instances of senile hypertrophy, however, are common, par- ticularly in the prostates of "elderly men, which are quite prone to undergo vexatious, and even vicious, enlargement. Fig. 1. Congenital hypertrophy: gigantism of both lower extremities (case of Dr. Graefe [Sandusky]). 6. Of congenital hypertrophy and that of unknown origin we see, for instance, examples in certain rare cases of hypertrophy of the breast, in leontiasis, perhaps even in acromegaly, etc.; and these are to be distinguished from gigantism, because in most instances of the former type the hypertrophic tendency is not manifested until youth or adult life, whereas gigantism is a condition in which the tendency was apparently manifested even before the birth of the individual. Atrophy. Atrophy implies impaired nutrition, and means diminution in the size of an organ or part, and is the converse of hypertrophy. It is neces- sary to make plain that in atrophy nutrition is only impaired and not HYPEREMIA .- ITS CONSEQUENCES AND TREATMENT. 27 arrested, since complete arrest of nutrition means necrosis — i. e. gan- grene. It may be — ( 1 . From Disuse without Disease ; A. Physiological < 2. Biological or Developmental ; (3. Senile. {4. Result of Acute Tissue-losses ; 5. Result of Phagocytic Activity; b. Result ot Continuous Pressure ; 7. Specific. A. Physiological Atrophy. — 1. This is always the result of disuse or impaired function from any cause. Its evidences are most quickly seen in the fatty structures and muscles — i. e. in the soft parts. It is true, however, even of the bones, or, of greater inter- est, even in the brain-cells. We see evidences of it also in minute organs ; as, for example, in the digestive glands in certain cases where diet is restricted. Again, we see it in the diminution of the size of the heart after hip -amputation, less being required of that organ. Again, in the entire structure of the rectum after colostomy. 2. Examples of the developmental type are best seen in the natural disappearance of the hypogastric arteries, the ductus arteriosus, the vitelline duct, the Wolffian bodies, and in the various generative ducts (Gartner's, etc.) shortly after birth of the human individual. We see it also in the prostate after double brchidectomy. Equally illustrative is the disappearance of the tail and gills of the tadpole, the eyes of animals living in caverns, and, in a general way, of organs which become useless owing to a different environment. 3. Senile atrophy is seen equally well in the hair-follicles, the teeth, the bones, and the sexual organs of elderly people — in fact, in all their tissues, even in the brain. B. Pathological Atrophy. — 4. Very acute atrophy of surrounding tissues is the necessary accompaniment of destruction by suppurative or other disturbances ; that is, parts disappear by absorption which have not been interfered with by pyogenic organisms. So complete may atrophy be under these circumstances as to cause disablement of an organ or part. This kind of senile disappearance is merely an expression of phagocytic activity, although not now a question of bacteria. 5. The same is true of that variety spoken of above as biological or developmental, since phagocytes are the active agents in producing the disappearance of the tadpole's tail. 6. A more slow form of pathological atrophy is seen in the gradual disappearance of tissues in the neighborhood of advancing tumors, enlarging cysts, etc. This is perhaps but another expression of atro- phy from continuous pressure. But a still better illustration is the atrophy which comes from immobilization of a part without pressure. This is notorious when splints or orthopaedic apparatus have to be long kept in place. 7. Specific forms of pathological atrophy are largely connected with disturbances in the central nervous system. They are often spoken of as trophoneurotic. Their exact mechanism is not yet understood, 28 SURGICAL PATHOLOGY. and cases may be confused under this head whose remote causes are widely different. Here should be included, for instance, the atrophy of a deep bone which occurs after extensive burn of the surface ; also that peculiar form of atrophy of tissues in the stump which produces the so-called conical stum}). These cases are indeed of a more com- plicated character, since if pressure be removed from the bone-end, especially in young people, the bone tends to grow faster than it should, while the soft parts disappear, partly as the result of mere disuse or loss of function. In this way conicity is produced, which sometimes calls for subsequent reamputation. Under this head might also be included the so-called " trophic inflammation " (misnomer) of some writers, such, for example, as ulceration of the cornea after division of the trigeminus. The general subject of atrophic elonga- tion also belongs here, referring to the fact that as a result of disuse, or sometimes of active disease, the bones, while showing atrophic changes in other respects, actually increase in length. Should such increase occur in one bone of those portions of the limbs which are supplied with two, the result would be posture-deformity and displace- ment of the terminal portion. CHAPTER II. SURGICAL PATHOLOGY OF THE BLOOD. By Roswell Park, M. D. The part played by the constituent elements of the blood in inflammation, suppuration, and other still more disastrous conditions is so great and so important that, before proceeding to discussion of these lesions, it seems necessary to set forth a resume of facts illus- trating the importance of accurate knowledge concerning this most important fluid. Thrombosis. \Z Thrombosis is a term applied to the formation of a thrombus — i. e. a clot within the cavity of the heart or one of the blood-vessels — the term being limited to coagulation of blood within these natural cavi- ties, and without specifying the exciting cause of the same. A clot so formed is called a thrombus. To be accurate, a distinction should be made between a thrombus, which is always caused before death — or, rather, during life — and the clot, which is essentially a post-mortem affair. Our application, then, of the terms " thrombosis " and " thrombus " refers solely to that which takes place during life. In order to appreciate the conditions which lead to thrombosis it is neces- sary to fully appreciate the reciprocal conditions which must normally be maintained between the circulating blood and the walls of the ves- sels in which it flows. Fluidity of blood depends always upon integ- rity of the vessel-wall. So long as its lining membrane be absolutely undisturbed and normal, blood will never coagulate within it, and the only thrombi that may be met within it are those which are propa- gated from a distance. Coagulation of blood is for the most part associated with the peculiar properties of fibrin. Fibrin, it is now well established, is produced by the union of two substances, known as fibrinogen and paraglobulin, which union takes place as the result of the activity of the so-called fibrin-ferment. The fibrinogen is ordinarily kept in solution in the blood-serum ; all of the fibrin-fer- ment, and at least the greater part of the paraglobulin, are contained within the colorless blood-corpuscles, by whose disintegration they are released. Consequently, so long as nothing happens to the leu- cocytes, coagulation cannot occur. It seems to be one of the peculiar activities of the endothelial lining of vessels to restrain this very dis- integration. Even when small quantities of fibrin-ferment are intro- duced from without, this membrane seems to have the power of ren- dering it inefficient, and large quantities introduced at once are necessary to artificially produce coagulation in this way. Physiolog- ical integrity of vascular walls, therefore, is inimical to thrombosis. Causes. — The underlying anise of all thrombi is, then, alteration 29 30 SURGICAL PATHOLOGY. of the endothelium. In consequence, when it is desirable to produce coagulation artificially advantage may be taken of this fact, and me- chanical injury to the vessel-walls may be quickly followed by the desired results. Advantage is also taken of this fact in surgery, espe- cially in certain methods of treating aneurism, by rude handling, by needling, by the introduction of horse-hairs, fine wires, etc. While such endothelial lesions are essential, there are, neverthe- less, numerous other accessory causes which must here be mentioned. These comprise — A. The presence of foreign bodies, as, for example, needles, hooklets of echinococci, parasites, particles of tumors, fragments from the heart- valves, and, most of all, that which is essentially a foreign body, a clot which has come from some other point. Around such foreign particles, by the way, will quickly group themselves a relatively large number of other leucocytes, affording thus another example of phago- cytosis, soon to be described. Mere slowing of blood-stream without some such mechanical irritation is not sufficient to produce coagulation. If, for instance, a section of vein be isolated between two ligatures, the ligation being aseptically done and the surroundings of the vein- wall disturbed as little as possible, the blood thus shut up within the vein remains fluid indefinitely. If, however, the vessel-wall be sepa- rated from its surroundings, so that its nourishment is compromised, the contained fluid quickly coagulates. B. Necrosis, gangrene, etc. lead to quick involvement of the endo- thelium of the vessels contained within the involved part, and conse- quently quickly to coagulation of the blood which they contain. C. Temperature has also an influence in the same direction, and extremes in either direction, or drying of vessels which may happen to be exposed to the air for some time, leads to the same results. D. Inflammatory and degenerative processes occurring in and about the vessel-walls tend always to produce coagulation. This is well seen in the influence exerted by the so-called atheromatous ulcers — i. e. the degeneration of certain areas in the walls of large vessels. E. Micro-organisms and their products are perhaps the most fre- quently effective of all the accessory causes of thrombosis. In other words, in all the surgical infectious diseases we may expect to find more or less, sometimes extensive, thrombosis in the vessels of the affected part. This may so far shut off circulation as to lead to gan- grene, which may be local or may terminate the life of the patient. Thrombi are classified as — 1. Primary; and 2. Propagated. The primary thrombus is one which has originated at the spot where it has been first produced, and is usually coextensive with its cause. ^ The propagated thrombus may be one which has been carried to a considerable distance, and is met with at a point widely different from that where it originated, or one which has extended along the vascular channel in which it was first formed, but far beyond the limits of its prime cause. "When a thrombus attaches itself to a part of the vessel- wall it is called parietal or valvular, because it does not completely occlude the vessel ; when it involves the entire circumference of the SURGICAL PATHOLOGY OF THE BLOOD. 31 vessel, but does not completely occlude it, it is spoken of as annular. The obstructive thrombus is that which completely fills a given vessel and shuts off all circulation through it. The propagated thrombus extends usually in both directions, and always much farther in veins than in arteries. Thus, thrombi may be met with extending from the ankles even into the inferior vena cava. The venous valves, which, on the one hand, may excite coagulation, on the other hand tend to fix the coagula more firmly in their place. In arte- ries thrombi usually extend finally to the first collateral channel on the cardiac side, but occasionally they extend farther. The cause of a primary thrombus is to be sought for at the site of its lodgement ; the cause of propagated thrombi is often to be met with at wide distance from the effect. Thrombosis is, again, to be spoken of as — a. Marasmic ; b. Mechanical or traumatic ; c. Infective. a. The marasmic forms are due to essential alterations in the constituents of the blood, which for the most part are due to starvation or wasting disease. Marasmic thrombi seldom give rise to serious disturbance during life until the condition is so complex and serious that the patient is at death's door. Post- mortem evidences of marasmic thrombi, however, are often found, and yet have but little surgical significance. They are seen perhaps as often in the cranial sinuses as anywhere. b. Thrombi of mechanical or traumatic origin are those, for instance, which are due to the presence of foreign bodies, to stagnation of blood as the result of ischsemia or local anaemia, to compression by tumors, etc. c. Infective thrombi are those distinctly due to the injurious effects of micro- organisms, and are those mainly concerned in the various manifestations of sepsis which are of such interest to surgeons. ( Vide Plate II. Fig. 2.) While the ordinary evidences of thrombosis are most often looked for in the veins of the extremities, in the lungs, and in the cranial sinuses, it must not be forgotten that thrombosis may occur equally easily in the portal system of vessels ; in which case we find the most marked expressions in this system and in the liver. In cases also of pysemia proceeding from lesions in the rectum or in the bowels we get our first evidences of infection, abscess, etc., in the liver, and not in the lungs, to which point infective thrombi from other sources are promptly carried. Thrombi also pass through certain metamorphoses which must be mentioned : A. Decolorization. — This is noted particularly in the red thrombi, and is due to disintegration of the red corpuscles, their coloring mat- ter being diffused and resorbed or transformed into hsematoidin. It would be a mistake, however, to suppose that all light-colored thrombi are those which, originally red, have been decolorized. The possi- bility of white thrombi must be always remembered. B. Organization. — This is the result of time, and means a meta- morphosis into solid vascular connective tissue. Newly-formed minute vascular loops project from the vasa vasorum into the throm- bus, and it becomes thus vascularized, while the completion of the organization is due, for the most part, to spindle-celled connective tissue, which is formed by wandering cells that penetrate into the 32 SURGICAL PATHOLOGY. thrombus from without. This gives the organized thrombus a certain resemblance to a sponge, and makes the original vein resemble a cranial sinus, since its interior is spanned by bands of connective tissue. Typical illustrations of this kind are seen, for instance, where the iliac veins join to form the inferior cava, by which a certain amount of obstruction to venous return is produced without its being total. The length of time required for these changes is indefinite. They begin, however, within a short time after ligature of a vein, and proceed with a rapidity varying according to circumstances. Fig. 2. Organization of thrombus (Letulle) : w, vasa vasorum still open ; m, media rich in muscle- cells; I, intima; /, fibro-vascular tissue; nc, new capillaries; nv, new arterioles. C. Calcification. — Calcium salts are occasionally deposited in thrombi, usually not until they have undergone considerable contrac- tion and alteration ; as the result of which we have formation of small masses, essentially minute calculi, to which the name of phlebo- liths has been given. These phleboliths are not infrequently found in more or less occluded and much distended varicose veins of the ex- tremities. Their formation is favorable in this regard, that they pro- hibit the occurrence of softening. D. Softening. — This is the most serious termination of the throm- botic accident, and is, for the most part, due to the agency of infecting organisms. A non-infectious form is, however, recognized, bv which there is a metamorphosis of original clot into an oily or pulpy fluid usually dark colored, but in the white thrombi often yellowish-white reminding one crudely of pus. The discovery of such material under these circumstances has led in time past to the supposition that pus, as such, was found floating in the blood — a condition that does not exist under any except most extraordinary circumstances. It is with infection of thrombi and consequent softening, however, that surgeons have most to deal, and the paramount importance to them of such disturbances is emphasized in those pages dealing with pyemia. SURGICAL PATHOLOGY OF THE BLOOD. 33 A closely-allied topic to that above considered is the subject of thrombophlebitis. This means, in effect, inflammation of one or more veins, which is directly due to the presence therein of thrombi. Such a condition is, in its strict sense, an inflammation, since it is always an infectious process. If in the veins of a non-infected region simple thrombi form, they may be occluded by organization of the included masses, but such a process never extends beyond the imme- diate area involved. On the other hand, if the process be essentially an infectious one, either from without or from within, then both ves- sel and its contained thrombi succumb completely to the infectious process, which is also essentially a spreading one ; and this is limited only by mechanical barriers, by conservative suppuration, or often only by the life of the individual. Excellent examples of thrombo- phlebitis are seen in the involved uterine sinuses in cases of puerperal septicaemia, and in the cranial sinuses after infected compound frac- tures, or particularly after disease originating in the middle ear has extended to them. Thrombo-phlebitis is essentially a surgical condition, terminating favorably occasionally by suppuration and spontaneous evacuation, but calling loudly for surgical intervention whenever it can be recog- nized and the parts are accessible. The principles of treatment of these conditions are positive and unmistakable. They comprise evacuation of the infective material and disinfection of the involved cavities and tissues. Thus, in sinus-phlebitis — i. e., thrombo-phlebitis of the lateral sinus — it has been made practicable not only to open the sinus in the mastoid region, but to expose the jugular vein in the neck, to ligate it, and to wash through from one opening to the other, effectually getting rid in this way of a long mass of infected throm- bus. By such bold and radical measures only may life be saved in many of these instances. \/ Embolism. Embolism means the transportation of any material by ichich a blood-vessel can be occluded or plugged, from some one point in the vascular system to some other point. The underlying idea is that of transportation or carriage. An embolus is anything so transported, without implying its exact character. The name is even applied to so insubstantial an affair as a minute bubble of air, which, however, in a tube containing a circulating fluid is a possible source of consid- erable disturbance. A single bubble thus carried would, by itself, be a trifling affair, but when numerous bubbles are thus transported the result is such local disturbance as may lead to loss of function. Thus, air-embolism, so called, may provoke profound, even fatal, disturbances, as, when with the returning blood-stream through the cranial sinuses or one of the large veins in the neck when opened by accident or operation, air is sucked in, it is carried to the right side of the heart, whose action is perhaps completely perverted because of the new and strange substance which thus enters it, so different from that for which its lining membrane is prepared and to which it reacts. The entrance of air into veins, which constitutes in effect air-embolism, has 3 34 SURGICAL PATHOLOGY. been in time past a bugbear to surgeons, but nevertheless is a source of probable danger when large venous trunks in proximity to the heart are thus exposed. Air-embolism is certainly a rarity. On the other hand, those substances which figure most often as emboli are vegeta- tions from the valves of the heart; drops of fat; fragments of tumors; pieces of softened and disintegrated thrombi ; foreign bodies, as hooklets of echinococcus cysts ; and, perhaps most often of all, the micro-or- ganisms clinging to some minute fragment of thrombus which has been dislodged. Embolism is also produced experimentally by the artificial introduction into the circulating blood of cinnabar or small particles of pith or other material. Emboli differ in number ac- smallest appreciable up to the largest, which may be met with in the larger venous trunks. They are dislodged from their primary site sometimes by accident, as by rude manipulation, injury, etc.; some- times by undue cardiac activity, as when detached from a valve-wall ; sometimes by the process of softening of thrombus and a subsequent introduction into the blood-stream as a result of some trifling motion ; or even by spon tan eous processes. Emboli also differ in numbers ac- cording to the nature of the primary lesion. In cases of so-called fat-embolism fluidified fat is taken into the returning blood-stream, carried to the heart, churned up with the contained blood, and distrib- uted to the lungs in such a way that myriads of minute fat-masses are distributed throughout the capillaries of the lungs, and free circu- lation of blood through them thereby impeded. It will thus be seen that the relations between thrombosis and embolism are most intimate, but that either one may occur without the occurrence of the other. Among the viscera, with the exception possibly of the brain, no- where are the disastrous consequences of such processes as those just described more apparent and indicative than in thrombosis and embol- ism of the mesenteric blood-vessels — a condition not so rare as journal articles would imply, yet nevertheless one seldom recognized either during life or after death. Its principal symptoms consist of intense abdominal pain, bloody diarrhoea, subnormal temperature, sometimes with vomiting, perhaps in the latter stages vomiting of blood. Shock is usually also extremely marked. The consequence of this condition is almost inevitably gangrene of the intestine supplied by that particu- lar portion of the mesenteric vessels. The pain comes on within a short time after the occurrence, and under the peculiar circumstances gangrene may be practically determined within fifteen hours. More than fifty cases of this kind are now on record in surgical literature, and the condition is one well worthy the prompt attention of the sur- geon, because only by surgical intervention — i. e. by resection of the necrotic mass of intestine — can life possibly be saved. Thus, Elliot 1 successfully resected 1\ metres of intestine for this purpose. Pat-embolism. Pat-embolism as a distinct, sometimes fatal, surgical condition has received of late so much study as to be now entitled to considera- tion by itself. By this term is meant a plugging of small arteries by 1 Annals of Surgery, Jan., 1895, p. 9. SURGICAL PATHOLOGY OF THE BLOOD. 35 minute drops of fat, which, having been set free somewhere about the periphery, are carried into the venous circulation and thence dis- tributed to various parts of the system. Inasmuch as the capillaries of the lungs are often the first lodging-place, fat-embolism here is most often met with, and consequently recognized and studied. But Pulmonary capillaries filled with fat in fat-embolism. it may obtain in the brain, the choroid, the kidneys, or other parts, provided only that there has been sufficient vis a tergo on the part of the heart to force the fat-globules through the pulmonary capillaries and into the systemic circulation. Fat-embolism occurs relatively quite often, and to a slight extent in nearly every case of fracture and laceration. So common is it, and so closely allied are some of its most prominent symptoms to those of shock, that as a matter of fact many cases heretofore considered shock are really to be regarded as instances of this condition. Indeed, even in a miscellaneous series of 260 dead bodies fat-embolism was found in 10 per cent. The injuries most likely to be followed by it are simple, and particularly compound fractures of bones ; laceration of soft parts, especially of adipose tissues ; certain surgical operations ; acute infections of bone and periosteum ; rupture of fatty liver ; and certain pathological conditions where the phenomena are not so easily explained — e. g. icterus gravis, diabetes, etc. Drops of fat may be seen floating on fluid or semi-fluid blood after many operations and compound injuries, and the possibility of escape of fat; — or, more accurately, its suction into the vessels from which this blood has escaped — is easily appreciable. But it has also been shown that absorption of fat is possible even from serous surfaces, and that fat-embolism may occur when fluid fat has been passed into the heart through the thoracic duct, although more slowly. Oil-drops are also found in the interior of the tissues, while in a piece of lung spread out in water in the visible vessels highly refracting fatty mate- rial may be noted. Fatty infarction, particularly in the lower lobes, is some- 36 SURGICAL PATHOLOGY. times plainly visible to the naked eye. Under a low objective, especially with osmic-acid staining, the presence of fat is easily and beautifully demon- strated. The essential danger in case of fat-embolism is of so clogging the pulmonary capillaries that oxygenation shall become^ so_ imper- fect as to lead to absolute asphyxiation from carbonic-dioxide poi- soning. When this fact is understood, the cyanosis, the rapid breathing, the over-action of the heart, etc. are easily and correctly interpreted. Fat-embolism by itself cannot cause inflammation nor infection nor sepsis in any sense. It may, however, lead to ecchymoses in con- junction with fatty infarcts in the organs most affected. The minute hemorrhages are easily explained by bursting of the capillaries in the attempt to force blood through them. Fatty emboli, however, take the same course as do septic — are carried first to the right side of the heart and distributed over the lungs ; are, if the patient live, forced through the lungs into the systemic circulation, and are then carried to the brain, kidneys, etc. The first symptoms are referable to the plugging of the pulmonary capillaries ; the secondary symptoms to the systemic disturbance. Symptoms. — Pallor of countenance with facial expression of anx- iety and distress, followed by cyanosis and contracted pupils, are seen. Patients are usually first excited, sometimes more or less disturbed, then become somnolent, and, finally, comatose in the fatal cases. The respiration-rate increases from normal up to 50 or 60, and breathing is sometimes stertorous. Dyspnoea, increasing in intensity until it becomes agonizing, sometimes marks these cases. Occasionally foam, possibly blood, proceeds from the mouth, as in oedema of the lungs. Occasionally, too, haemoptysis occurs. The pulse becomes weak, fre- quent and irregular, while toward the close it is fluttering. Tempera- ture is not notably disturbed, at least not typically. These symptoms set in usually within thirty-six to seventy -two hours after the lesion which has caused them. I have, however, known death to occur in one or more cases within eighteen hours after reception of injury. After fat has been forced through the lungs and carried to the kidneys it will be eliminated with the urine, and may be found float- ing upon it in the shape of oil-like drops. Discovery of this condi- tion is positive evidence of fat-embolism. It is to be distinguished from shock in that by the time the symptoms of embolic disturbance are at their height, all or nearly all symptoms of pure shock should have subsided. Furthermore, cyanosis and embarrassment of respi- ration are not indicative of shock ; and, finally, the discovery of fat in the urine will be corroborative. A mild degree of fat-embolism may be noted, if looked for, after almost all serious fractures. It will give rise to slight embarrassment of respiration and cyanosis and to the elimination of fat by the kidneys. Prognosis.— Prognosis is somewhat in proportion to the extent of the injury and the proximity of the lesion to the heart and lungs ■ also to the possibility of continuous entrance of fat^-t. e from its S'UROICAL PATHOLOGY OF THE BLOOD. 37 continual absorption. Prognosis really depends upon whether the heart can be given sufficient vigor and endurance to continue pump- ing blood with its burden of fat through the pulmonary circulation. A secondary danger may come from the circulation of this fat-ladened blood through the capillaries of the brain. Should the source of motive power thus become paralyzed along with general enfeeble- ment, death may ensue. When well-marked evidences of fat-embolism are present, but are followed by recovery, the worst of the trouble is usually over within forty-eight hours after it begins. Treatment. — Obviously, treatment is mainly directed toward the heart that it may stimulate it to carry its load of fat through from the venous into the arterial system. If it can do this, the fat is dis- posed of by oxidation or is saponified by the alkalies in the blood. Physiological rest of the injured part is the first indication, however, and if this occur in a patient, say with delirium tremens, powerful mechanical restraint may be necessary. The most powerful cardiac stimulants are called for — alcohol, digitalis, strychnia. In other respects treatment is largely symptomatic. Next to giving the heart vigor in this way, inhalations of oxygen give the most promise, because of the crying need of the system during this ordeal for this life-giving gas. 1 The Corpuscular Elements op the Blood. Within the past few years has eome into a considerable importance the so-called third corpuscle or blood-plaque, minutely described by Osier and others. It is composed of colorless protoplasm, averaging 1\ p. (mikrons) in diameter, and is present in proportion of about one to twenty of the red blood-corpuscles. While circulating in the blood these plaques do not ordinarily cohere, but immediately on their with- drawal they form aggregations ; to which fact is due the lack of their earlier recognition. They are most numerous in the infant and in the aged. Their presence is not yet fully accounted for, and their rela- tion to the formation of other corpuscles not yet distinctly determined. In acute infectious diseases and in certain chronic wasting forms they exceed their normal proportion. During crises of fevers and during convalescence from acute and extensive suppuration they are most often seen in large numbers. The blood-plaques are not the only corpuscles of the blood which undergo rapid increase or diminution in number, since this is true also of the leucocytes, which during acute inflammations rapidly aug- ment in number. Whether this is to furnish more which may escape from the blood- vessels and act as phagocytes, or whether destined to some other purpose, is not yet settled, though the former is probable. Under many of the circumstances connected with phlegmon and active corpuscular escape it is found that the spleen and lymph-nodes are materially enlarged. Temporary increase in the proportion of leucocytes is known as leucocytosis, which is a usual accompaniment of suppuration, even though the focus of activity be small. Diminu- 1 See paper by the writer, N. Y. Med. Jour., Aug. 16, 1884. 38 SURGICAL PATHOLOGY. tion in number of white cells is oligoleucocythsemia, and its sig- nificance will be alluded to below. The relation of the leucocytes, which contain most of the paraglobulin and peculiar ferment which are such important factors in the coagulation of blood, to thrombosis is most important ; and it must naturally follow that breaking-down of these cells — i. e. release of such materials — will have very much to do with coagulation, and that, therefore, thrombosis may be a frequent accompaniment of leucocytosis in inflammation. The colorless cor- puscles contained in the blood and lymph present several varieties more or less distinct from each other, and are classified as follows : Lymphocytes. — Small leucocytes with large, round nuclei and a relatively small amount of protoplasm, occurring conspicuously in the lymph-nodes. They stain readily, especially with aniline dyes, which color the nucleus deeply and the protoplasm faintly. These lympho- cytes grow until they become large-sized leucocytes, and it is charac- teristic that the larger they grow the more easily their protoplasm stains and the less so their nucleus. As they attain larger size their nuclei sometimes change in shape, and it is not always easy to distin- guish a large mononuclear leucocyte from certain fixed connective- tissue cells or endothelial cells. The eosinophile leucocytes contain in their protoplasm granules which do not stain with basic aniline dyes, like fuchsin, methyl vio- let, etc., but which readily take up the acid aniline colors, especially eosin ; whence their name. In this variety the nucleus is variable in shape and form, and is often lobed. Another form is represented by cells in which the nucleus is either lobed or composed of portions united by delicate filaments, giving the impression of a multinuclear cell — in fact, the nuclei often are really multiple. Hence this form is known as the polynuclear form. These leucocytes also contain a small central body of chromatin and polar filaments of achromatin. Their nuclei are deeply stained by aniline dyes, while their protoplasm remains for the most part unaf- fected. This latter is granular, and can only be stained by a mixture of acid and basic dyes, so that these polynuclear forms are often spoken of as neutrophil?. This form comprises about three- fourths of the total number of leucocytes in the blood. The term formerly used, myelocyte— i. c. a cell supposed to be found in the bone-marrow and distinct from the other leucocytes— has been nearly abandoned. Ehr- lich, who 1ms been the leader in this study of blood-cells, has shown that the eosinophile cells form in the blood at the expense of smaller ones which have been produced in various organs. Consequently an undue proportion of eosinophile cells indicates pathological activity of bone-marrow and betokens one form of leucocythsemia The entire modern study of leucocytes of the blood is based upon their reaction to certain staining agents, for the most part the aniline dyes. According to these reactions in connection with peculiarities of size shape, etc., we speak, then, to-day of the following varieties ot white corpuscles : 1. Lymphocytes, derived from lymphoid tissues of the body • in number from 20 to 30 per cent, in the leucocytes of the blood. Their Fn// 6 %•••*<'••.■ ;.,;*;■ &.-; /?y// *^«Sfc •s?.- <,<•; * '1 o i o e °r, o om o } 06 Fig.V. : Fcy.V/ff. f 9 | f • <' ^ DRAWN fli J*7 CM.;; PLATE I. BLOOD. (Prepared by Dr. I. P. Lyon.) Fig. I. TYPES OF LEUCOCYTES. a. Polymorphonuclear Neutrophile. b. Polymorphonuclear Eosinophile. c. Myelocyte (Neutrophilic), d. Eosinophilic Myelocyte, e. Large Lymphocyte (large Mononuclear.) /. Small Lymphocyte (small Mononuclear). Fig. II. NORMAL BLOOD. Field contains one neutrophile. Reds are normal. Fig. III. ANAEMIA, POST-OPERATIVE (secondary). The reds are fewer than normal, and are deficient in haemoglobin and somewhat irregular in form. One normoblast is seen in the field, and two neutrophiles and one small lymphocyte, showing a marked post-hasmorrhagie anasmia, with leucoeytosis. Fig. IV. LEUCOCYTOSIS, INFLAMMATORY. The reds are normal. A marked leucoeytosis is shown, with five neutro- philes and one small lymphocyte. This illustration may also serve the purpose of showing the leucoeytosis of malignant tumor, except that in this disease (ma- lignant) the reds show a well-marked secondary ansemia. Fig. V. TRICHINOSIS. A marked leucoeytosis is shown, consisting of an eosinophilia. Fig. VI. LYMPHATIC LEUKEMIA. Slight anaemia. A large relative and absolute increase of the lymphocytes (chiefly the small lymphocytes) is shown. Fig. VII. SPLENO-MYELOGENOUS LEUKEMIA. The reds show a secondary anaemia. Two normoblasts are shown. The leucoeytosis is massive. Twenty leucocytes are shown, consisting of nine neu- trophiles, seven myelocytes, two small lymphocytes, one eosinophile (polymor- phonuclear) and one eosinophilic myelocyte. Note the polymorphous condition of the leucocytes, i. e., their variations from the typical in size and form. Fig. VIII. VARIETIES OF RED CORPUSCLES. a. Normal Red Corpuscle (normocyte), b, c. Ansemie Red Corpuscles. d-g. Poikiloeytes. h. Microeyte. i. Megalocyte. j-n. Nucleated Red Corpuscles. j,k. Normoblasts. /. Mieroblast. m, n. Megaloblasts . SURGICAL PATHOLOGY OF THE BLOOD. 39 nucleus is large, and their non-granular protoplasm appears only as a narrow rim. 2. Large mononuclear forms, with large, oval, feebly-staining nuclei and a fair quantity of non-granular protoplasm ; 2 to 3 per cent. 3. So-called polynuclear leucocytes, those with polymorphous nuclei. These represent two-thirds of the whole number of leucocytes. They are smaller than No. 2, and have irregular nuclei. Their protoplasm contains numerous neutrophilic granules, and they are often called polynuclear neutrophiles. 4. Transitional forms, similar to No. 2, with irregular nuclei, in transitional stage from mono- to polynuclear form, constituting about 3 per cent, of the entire number. 5. Eosinophile cells, same size as No. 3 ; nuclei variable, protoplasm largely made up of refractive eosinophile granules. They constitute from 2 to 4 per cent, of the total of leucocytes, and originate in bone- marrow. Nos. 2, 3, and 4 are regarded as formed in both spleen and bone-marrow. These proportions are fairly constant in a state of health ; in the presence of certain diseases they vary widely. Hence the value of proper estimation and recognition of their relative proportion. It is also generally accepted that in certain diseases cells not met with in health may be found in the blood. These have not yet been suffi- ciently studied, but their recognition is a matter of growing import- ance. Their various appearances are indicated in Plate I. Leucocytosis as an Element in Diagnosis. — Leucocytosis dif- fers from leuccemia in that while both refer to the increase of the actual number of white corpuscles in a given volume of blood, and while in both instances these belong to the classes found normally present, in the former instance the condition is a temporary and evanescent one, while in the latter it is a permanent one and constitutes a marked fea- ture of the disease. It is perhaps incorrect to say that in leucaemia only the normal types of cells are present. All of the normals are present, but there are also present those which are not found under normal conditions. In leucocytosis the increase is mainly in the poly- nuclear cells. The normal standard implies that in a cubic millimetre of blood there should be present about 7,500 leucocytes to from 5,000,000 to 5,500,000 red blood-cells ; but the relative proportion of whites varies even from hour to hour within cer- tain limits, and a relative leucocytosis is normal during digestion of a hearty meal, during pregnancy, and in newly-born children. But, as an index of ab- normal conditions, one may say in a general way that leucocytosis as a diseased condition is nearly always associated with the inflammatory process, with cer- tain malignant tumors, and in other rare conditions which may be mentioned below. Any variation of more than 1,500 above or below the above standard of 7,500 should be considered abnormal. In malignant disease, especially in the soft and rapidly-growing tumors, and particularly in sarcoma of bone, there is marked leucocy- tosis, by which in doubtful cases a distinction may be made before operation between malignant conditions and tuberculosis, chronic arthritis, etc. It is furthermore stated that in malignant disease, even when no leucocytosis is present, a differential count of stained 40 SVEG1GAL PATHOLOGY. specimens will show marked increase in the percentage of polynuclear cells. In all forms of suppuration, deep or superficial, circumscribed or diffuse, and in all types of septic invasion and infection, leucocy- tosis is present. Cabot has shown how the test may be applied in eases of deep wounds, compound fractures, etc., where one is dis- turbed by rise of temperature, etc. and hesitates whether or not to re-dress the wound. If there be no leucocytosis present, there need be no fear of retained or accumulating pus. Furthermore, in such a case — for instance, as one of uncertain diagnosis between typhoid and purulent meningitis — an increase of leucocytes will point surely to the latter ; and diagnosis has been corroborated by the discovery of middle-ear disease, from which the meningeal complications pro- ceeded. It will be seen, then, that the relative and numerical estimate of the richness of the blood in its white corpuscular elements may be of the greatest service to the surgeon by furnishing indications of importance for the subsequent management of the case or for diagnosis. Red Corpuscles. — With care in examination certain differences can be detected in the behavior and size of the red corpuscles, which may also furnish important information. This brings up mainly in this connection the question of the anaemias, which are relative and jjotiitive. After an acute loss of blood, as after operation or accident, there is, of course, a deficiency in the amount of blood in the system, which, however, does not materially influence the proportion of reds to whites nor the number of reds present in a given volume. Oligocy- themia is a term applied to a deficiency of red corpuscles, or to a con- dition by which their relative proportion is recognizably lowered. If we accept from five to five and a half million of red cells in a cubic millimetre as the normal standard, it will be seen that we may have various degrees of oligocythsemia, which, however, is rarely reduced below a proportion of two million. Poikilocytosis is a term applied to that condition in which the red corpuscles are irregular in shape and in size, these irregularities varying from the slightest crena- tion of their borders up to a very marked alteration in all their proportions. It is possible, then, without long special training, to estimate both the Physical Properties of the Leucocytes. Phagocytosis. — All leucocytes have the power of shifting their location. The lymphocytes, so called, being the youngest of the white corpuscles, show it less than do even the older forms. Also the eosinophile cells are less able to manifest the peculiar activities of the other forms. It is particularly the mono- and polynuclear corpuscles which are endowed with most pronounced activity. These have the power, like the anifebie among the lowest forms of life, to not only spread themselves around inert bodies, like granules of car- mine or other particles used for experiment, or the particles of coal- dust found in certain conditions in the human body, but they have also the power to englobe many living organisms, for the most part vegetable (bacteria). Under the microscope it is possible to see liv- SURGICAL PATHOLOGY OF THE BLOOD. 41 ing bacilli performing active movements although enclosed in the nutritive vacuoles of the leucocytes in some of the lower animals. This amahoid power possessed by these cells of thus attacking and disposing of foreign bodies or ir- ritants has been demonstrated and proven, especially by Metchnikoif, and has been called by him phago- cytosis. His views were for a long time disputed, and are perhaps not yet absolutely and generally ac-ftj cepted. Nevertheless, they fulfil even- demand made upon them for explanation, and are susceptible of such demonstration under the mi- croscope that we now have practi- cally a new and apparently a cor- rect theory of the inflammatory process. (See next chapter.) Any cell which has this property is known as a phagocyte. It is shared by certain of the leuco- cytes with certain other cells to be spoken of later (wandering tis- sue-cells). Cells which possess this power do not attract all mi- crobes indiscriminately, and it is often the case that the leucocytes of an animal peculiarly susceptible to a certain kind of bacteria do not attract them at all, even though they be directly in contact. It is plausible that an expla- nation of the peculiar susceptibility of certain animals to certain diseases is furnished by this fact. (See Fig. 4.) On the other hand, leucocytes may and do englobe virulent mi- crobes. In man the mononuclear forms do not take up either the streptococcus of erysipelas or the gonococcus ; whereas these two organisms are readily attracted by the polynuclear neutrophile cells. The bacillus of leprosy, on the other hand, is never attacked by the polynuclear forms, but is speedily devoured by the mononuclear cells. This shows that the various leucocytes may exercise a marked selec- tive ability. This inclusion of minute bodies within amoeboid cells seems to be an evidence of a peculiar tactile sensibility upon the part of the latter. In fact, this is clearly established, and seems to be inseparable from the peculiar attraction between leucocyte and bac- terium to which the name chemotaxis has been given, and which is described in the ensuing chapter. If the included organism be, as is usually the case, killed, it is disposed of by a true process of intracel- lular digestion in a neutral or alkaline protoplasmic medium, and its inert portions are again extruded. On the other hand, if the leuco- cyte be poisoned or die in this phagocytic attempt, it presents usually as a so-called pus-ce\\ or corpuscle, and the solid part of pus is made Active phagocytosis. Endothelial cells en- closing the bacilli of swine septicaemia, from an hepatic vein of a pigeon : a, endo- thelial cells ; b, leucocytes (Metchnikoff). 42 SURGICAL PATHOLOGY. up in large measure of cells which have perished in this way. (See next chapter.) To regard phagocytosis as an affair mostly of certain tissue-cells arid invading bacteria would be altogether too narrow a view to take of it. It is really a process of the greatest importance and of constant per- formance in our systems. By virtue of it disintegrated muscle-fibres and other tissue-cells are disposed of, sloughs are separated, certain absorbable foreign bodies (catgut, etc.) taken away — i. e. absorbed — cellular tissue reduced in numerical strength (progressive atrophy) ; and a great variety of changes, either normal, as those pertaining to health and advancing years, or abnormal, like those incident to many diseases, are actually the product of this kind of phagocytic activity. The protective power, then, which the phagocytes exert as against bacteria is only one part of their normal functions, by virtue of which they become, in effect, perhaps the most important cells within our bodies. Their powers are limited, however, as will be seen when describing pus, for the so-called pus-corpuscle is nothing but a phago- cyte which has perished in its self-assumed task. It is known also that in certain instances phagocytes, which are incapable of defence as against the mature bacterial organism, are nevertheless capable of englobing its spores and preventing their development. This is true, for instance, in case of anthrax in animals ordinarily immune, as, for instance, the frog and fowl. If, however, in these very animals the vitality of the phagocytes be affected — as by cooling in fowls or heat- ing in frogs — phagocytosis is so far interfered with that the spores germinate within the enfeebled leucocytes and the entire organism is infected. (Vide also Plate II. Fig. 1," illustrating diapedesis.) HEMOGLOBIN. The principal interest of the red blood-corpuscles for the surgeon, aside from their relative number and shape, inheres in their relation to liEemoglobin, and haemoglobin is of particular interest here because much can be learned by estimating the proportion in which it be present. That the amount contained in the blood varies within wide limits under different conditions has long been known. The ideal normal standard is present in but a small proportion of cases, even in strong young men in the third decade of life. The average is con- siderably lower and can scarcely be placed above 90 per cent. Fe- males show a smaller amount ' than males — 3 or 4 per cent, lcs* After haemoglobin loss, as after surgical operations, much can be gained in the matter of prognosis by estimating the speed of it* re- generation. With regard to how much actual hemoglobin loss a patient can bear, it seems to be more important to determine how much still remains in the body. The minimum is apparentlv 90 per cent. In three cases dying of collapse after operation Mikulicz found only lo per cent, remaining. The rapidity of regeneration is a fairly accurate indication of improvement in every other respect. Regener- ation is interfered with by constitutional syphilis, and, on the other hand, is often apparently favored in cases of tuberculosis. In malig- nant tumors the average of haemoglobin is reduced to about 60 per SURGICAL PATHOLOGY OF THE BLOOD. 43 cent., and in these cases also complete regeneration is materially re- tarded. Incomplete removal or recurrence of cancer prevents typical regeneration or restoration, while after successful or radical removal complete restoration to the previous standard, often with positive gain, is obtained. Thus, a woman who had gained thirty pounds after resection of a cancerous pylorus showed after three months haemoglobin repair to the amount of 65 per cent. A prognostic sig- nificance often attaches to the accurate estimation of nsemoglobin at intervals after removal of malignant tumors. 1 1 See Park's Lectures on Surgical Pathology, p. 13. CHAPTEE III. INFLAMMATION. By Eoswbll Pakk, M. D. Inflammation is an expression of the effort made by a given organism to rid itself of or render inert noxious irritants arising from within or introduced from without (Sutton, modified). After having duly considered hyperemia as a phenomenon having an identity and termination of its own, we are prepared to study the more complex processes implied under the term inflammation, the first of which is the hyperemia already considered. The characteris- tic of the truly inflammatory process is that it does not stop with mere congestion nor with any of its above-mentioned terminations, but goes on to something more complex, now to be described. It must be understood, therefore, in this consideration that hypersemia here is the first act of the vessels, resulting from peculiar stimuli which must shortly be considered. Even the hypersemia seems to be now more distinct than under other circumstances, and along with the dilatation of vessels and the stagnation of blood-current the capil- lary vessels now seem crowded with blood-corpuscles to an abnormal degree, the rapidity of their motion is checked, and there is accumu- lation of blood-cells along the walls of the small veins, to which they seem to adhere as if by some new cohesive property. The result is that before long the vessel-wall appears to have received a new coat- ing of white corpuscles, this being more marked in the veins than in the arterioles, while in the latter the red are more numerously min- gled with the white than in the veins, in which the distinction be- tween the two classes of cells is better maintained. Next comes the phenomenon whose clear recognition and descrip- tion is inseparably connected with Cohnheim's name. This is known under dhTerent names as migration or diapedesis of the leucocytes. The programme is about as follows : A little protrusion of the vascular wall, a marked alteration in the shape of a leucocyte, which yet ad- heres to this point of its lumen, and then the curious fact so often seen under the microscope — the gradual passage of this cell throuo-h the vascular wall, from its inner to its outer side, by what is generally known as its amceboid movement. This migration of the leucocyte is not confined to its mere escape from the restriction of the vessel-lumen but goes on to an indeterminate extent after it has detached itself from the outer surface of the vessel. This seems to occur by virtue of the same amoeboid characteristic which it exhibited in passing through between the cells of the vessel itself. If this occur at one point, it occurs at innumerable points, in consequence of which a large number 44 PLATE II. N T3K 5 ^S^**r^«^*^ Small Vein showing Diapedesus of Leucocytes; ., Leucocyte escaping between Endothelial Cells; i,c, Leucocytes escaped; / Leucocytes migrating toward centre of attraction. (Engelmann.) FIG. 2. $ ' ■ & m ». V*"-' Septic Thrombosis of Pulmonary Capillaries, after Puerperal Septicaemia, Sh.o wing, rapidly increasing colonies of Streptococci. (Klebs.) INFLA MM A TION. 45 of leucocytes escape into the tissues of the part involved. This diape- desis occurs most markedly from the smaller veins, to a less extent from the capillaries. The cells which escape from the latter are usually accompanied by more or less red cells, the consequence being that the exudate which necessarily occurs at the same time is more or less tinged with the coloring matter of the blood, and is known as a hem- orrhagic exudate. (See Plate II., Fig. 1.) The above phenomenon, described in so few words, is in its minutiae a really complex one, depending on a variety of causes not easily ap- preciated ; but it is at least positive and well known, because it can be observed at will in the mesentery or web or tongue of certain animals which can be confined upon the stage of the microscope. The phe- nomena of inflammation, therefore, comprise, first, hyperemia, and then escape from the blood-vessels of the corpuscular and fluid elements of the blood. The former may be due, as already seen, to various irri- tations of a non-specific character ; while, as we shall learn, the latter practically never take place save when the irritation has been, as pathologists like to say, specific or infectious. The phenomena of true inflammation comprise practically the roles played by the three elements which conspire to produce those changes — namely, the tissues, the blood, and the specific irritants which are the primary causes of the entire lesion. Each of these must be considered separately. All observers agree that in actively inflamed tissues the number of cells is very greatly increased. A certain increase may be accounted for by that which has been already described — namely, the escape into the tissues of the wandering cells from the blood-vessels. But neither this alone nor the products of their rapid proliferation are sufficient to account for all the cells found in the truly inflammatory condition. It is now well established that in connective tissue there are two varieties of cells — the fixed and the wandering — the former concealed in the trabecular of the intercellular substance, while the latter are small, ordinarily round in shape, much resembling the white corpus- cles, possessed of amoeboid characteristics, and having the power of changing position. These are known as the wandering cells, which meander through the lymph-spaces of the tissues or back and forth into and out of the blood-vascular system, their migration being regu- lated by causes not yet known to us. Under natural conditions their number is relatively small. Once given a true inflammatory disturb- ance, and they are reproduced with amazing rapidity ; and their num- bers, added to those produced by diapedesis of leucocytes, with the combined proliferative activity of both forms, serve to account for the new cells whose presence characterizes phlegmonous and other similar disturbances. That these wandering connective-tissue cells have much to do with these changes is shown by the recently pointed-out but unmistakable evidences of excessive activity known as karyokinesis (/. e. nuclear activity). Karyokinesis is common not only in inflammatory disturbances, but in new growths of rapid formation, especially sarcomata, which are formed from mesoblastic cells, the same which have to do with con- nective tissue. Endothelial cells also undergo the same changes. 46 SURGICAL PATHOLOGY. The peculiar characteristics of the leucocytes have been already described at considerable length in the preceding chapter. It must suffice, then, here to say that during the inflammatory attack the leu- cocytes are increased in number — ■/. e. there is a temporary leucocyto- sis which is the usual accompaniment of suppuration. (According to Cabot, this is regularly present in purulent, but not in catarrhal forms of appendicitis.) The recognition of this fact may be of great value in diagnosis. For instance, leucocytosis is rarely present in tubercular disease unless suppuration complicate the case. It is met with in suppurative osteomyelitis and in all cases of pocketing of pus. More- over, when leucocytosis is present coagulability of the blood is increased. Of the various leucocytes, it is the mononuclear and poly- nuclear forms which are endowed with the most pronounced activity and which play the principal r6le among the blood-cells or phagocytes. That phagocytosis plays a most important part in the inflammatory process is a matter to be emphasized in more than one way and in more than one place. The account of the process already given must suffice for descriptive purposes ; the importance of the act, however, must be made most prominent in considering inflammation and suppuration. That the phagocytic properties of these cells are limited will be remembered when we recall that in certain instances phagocytes, which are incapable of defence as against the mature bacterial organ- ism, are yet capable of englobing the spores and preventing their development. Nevertheless, the activities of even the most lively phagocytes are capable of being influenced and repressed by extremes of heat and cold to which patients may be exposed, either locally or generally. Chemotaxis. Having considered briefly the cells which take prominent part in the inflammatory process, and the escape along with them of the fluid portions of the blood, whether these coagulate or not, it is necessary before speaking of specific factors to discuss for a moment that which induces the above cells to act in this way. That there is a peculiar, even a mysterious, attraction which brings specific irritant and phago- cyte together has been for some time recognized, but it remained for Pfeffer to study it carefully and to give it the name by which it now passes — i. e. chemotaxis— while others have widened our knowledge of it. Chemotaxis is a term implying a peculiar property of attraction and repulsion between, cells, both animal and vegetable. It mainly per- tains to vegetable cells alone, and has been offered as the explanation of the sporulation of ferns, for example ; but as it interests us most in this place, it is manifested between the animal cells of the human body and the bacteria, which are vegetable cells. As the result the former—?', e. the phagocytes— having power of migration, are drawn toward the latter. To be more accurate, this mutual or peculiar attraction is known as positive chemotaxis, it being also known that exactly the reverse obtains under certain circumstances, and that mobile cells will move away as rapidly as possible from certain organisms or substances for which they seem to have a repugnance, this being known as negative chemotaxis. INFLAMMATION. 47 Specific Irritants. These are essentially living organisms, grouped for the most part among the bacteria, fungi, and the protozoa, the first named being by far the most frequent. Before a lesion can assume the type of inflam- mation as here understood some one or more of these organisms must have secured an entrance into the tissues, the circumstances determin- ing such invasion being considered a little farther on. It is these living organisms which, having once invaded the tissues, determine that most active congregation and proliferation of certain cells which we have just described under the head of Phagocytosis. When once the irritants are present, there begins that very active conflict which Yirchow has so graphically alluded to as the battle of the cells. Now the mysterious chemotactic properties of the component substances manifest themselves, and now phagocyte is drawn toward bacterium, or the reverse, while the tiny war goes on with sometimes varying results, it being a question which can prove victor in the conquest. This is no fiction of the imagination, but is again a contest which may be seen under the microscope in certain of the lower animals, while its results may be seen in the examination of pus from any human source. In another place I have likened also this conflict to that in which certain of the enemy resort to poisoned weapons, because modern biological chemistry has now shown very evidently that it is a part of the life-history of many of these micro-organisms to produce, probably as excretory products, albuminoid or other substances having sometimes extremely toxic properties. And so it comes about that in many of the surgical infections, while the local destruction is produced by the actual death of tissues which have been invaded by micro- organisms, the general or systemic symptoms, ordinarily spoken of as the toxic symptoms, are literally due to poisons generated in the infected area, dispersed throughout the system, and often proving fatal. The local effect of these specific irritants when they are not promptly attacked, devoured, and removed by phagocytes is pus, which means cellular death, or gangrene, which is death of masses of cells which have not had time to separate from each other. Pus, then, is the ordinary consequence of the contest above alluded to, and each pus-cell represents the dead body of a phagocyte which has perished in the at- tempt to protect the parent organism from harm. That it has died valiantly can almost invariably be determined, because within its dead body may be seen the body of one or more of the minute invaders which it has attacked. This, then, is the light in which inflammation and infection should be viewed. In other words, we may have escape of fluid portions of the blood, which may or may not coagulate ; we may even have some escape of corpuscular elements with some activity in the extravascular cells, which shall lead to temporary or even permanent enlargement of a part; all of which may be provoked by injury or by the presence of certain chemical irritants within the blood or tissues ; for example, alcohol, uric acid, etc. But the factors which provoke the greatest activity on the part of intra- and extravascular cells, and which deter- 48 SURGICAL PATHOLOGY. mine the richness in albumen of fluid exudates, or their prompt coagu- lation so soon as blood-serum has escaped from the vessels, and which particularly determine the furious rush of phagocytes and that kind of intercellular conflict which leads many of the contestants on both sides to death, are living organisms which are introduced from without, whose presence at the point of inflammation is abnormal and injurious, which are offending substances in every respect, while the whole phenomenon of inflammation is an expression of an effort to rid the system thereof. Taking this view of the subject, there is a most important distinction between hypersemia andits consequences, which is absolutely a non-infectious condition, and inflammation and its consequences, which is always an infection and is always followed by more or less death of cells, the same being often extruded m a semifluid mass known as pus. Next must be studied the — Circumstances which Favor Infection. 1. The Virulence of the Infecting Organisms and the Amount Introduced. — There is the widest difference between various forms of micro-organisms in the matter of virulence ; and it is true that there are very great differences between the same species under dif- ferent circumstances, these differences depending on conditions as yet absolutely unknown. With certain organisms it is enough to infect an animal with one alone in order to bring about a fatal result, this meaning that the organism itself is extremely virulent and the animal extremely susceptible. In a guinea-pig, for instance, a single virulent anthrax bacillus will produce death, whereas in a more resistant animal many are required, and in yet others there is absolute immunity against the disease. Man is much more susceptible to the pyogenic organisms than most of the lower animals, which is one reason why wrong deductions have been drawn from many experiments, and why veterinary surgeons, who are so careless of all antiseptic precautions, yet, as a rule, have good results in work which, done after the same fashion on the human being, would be inevitably fatal. It is one reason also why one may draw false inferences from experimental work done, for instance, upon dogs, which survive many an operation which can scarcely be successfully repeated upon a human being. The influences which affect the vitality and virulence of micro-organisms are most numerous and widespread. Temperature, sunlight, moisture or dryness, association with other bacteria, source, are but a few of the conditions known to be more or less operative. Inoculation of a small number of certain bacteria may be harmless : up to a certain number it may produce only a local disturbance, like abscess, while a still larger dosage may produce fatal results. This is not the case with all, however, but only with some organ- isms. Bacteria which have been repeatedly passed through the animal body become more virulent than those cultivated for many generations in test-tubes in the laboratory. This variable virulence is especially characteristic of the colon bacillus, the anthrax bacillus, and the micrococcus of erysipelas. Nor does it always follow that the most virulent organism is necessarily cultivated from the most toxic or serious manifestation of its activity. 2. Association. — Bacteria are seldom found in pure cultures under natural conditions. By mutual association remarkable changes are produced, sometimes in the direction of enhanced virulence some- times in the direction of attenuation of effect. Certain organisms extremely dangerous alone, lose their power when combined with INFLAMMATION. 49 others, while still others have their virulence increased to a rapidly fatal degree. In fact, these effects are so strange and so contradictory that no law governing them has yet been formulated, it being neces- sary to establish each case by experimental investigation. The viru- lence of the anthrax bacillus under ordinary circumstances is well known, as is also that of the streptococcus of erysipelas in man. Yet when these two organisms are introduced simultaneously the mixture is apparently wellnigh harmless. On the other hand, the simulta- neous inoculation of certain other species greatly increases the danger from either alone. The diplococcus pneumoniae when combined with the anthrax bacillus seems to have a greatly augmented power. 3. Hereditary Influences. — The fact that immunity against cer- tain infections and susceptibility to other conditions are transmitted from parent to offspring is one which admits of no dispute. The explanation, however, is almost as remote from us to-day as it ever was. But the recognition of the fact is of the greatest importance to all practising surgeons. That bacteria frequently enter through wounds and bruises is self-evident, but we all know that such wounds are more likely to suppurate in some than in others, and the causes of infection in some are, to a certain extent, connected with hereditary habit of tissues. The same causes influence not merely liability to infection, but its severity and character. There are undoubtedly also local as well as general variations, and it is very certain that among these the results of bruising or contusion are by far the most prominent. There is also undoubted experimental evidence that under certain circum- stances bacteria produce only local lesions, whereas under others they produce general and even fatal infection. 4. Local predisposition is a factor of almost equal importance. Once given a distinct infection, and hyperaemia is sometimes a con- tributing cause of inflammation. Per contra, anaemia of tissues seems to be again a favoring condition. In parts involved in chronic con- gestion the blood flows more slowly, while the vessels are dilated and apparently susceptibility is increased. Infection here produces a type of disease ordinarily spoken of as hypostatic inflammation. General anaemia, again, is a predisposing cause, while toxaemias, including diabetes, etc., are still more so. The liability of diabetic patients to suppurative and even gangrenous infections is proverbial. The presence of foreign bodies has much to do also, and, infection once having occurred along with its introduction, the presence of a for- eign body will nearly always excite suppuration ; otherwise, it will ordinarily remain inert. The withdrawal of trophic nerve-influences also apparently permits infection, as is instanced by the ease with which bed-sores form in paralytic patients. Obstruction to the cir- culation or to escape of secretions more easily permits infection : for example, in the appendix, in the kidney, in the gall-bladder, the sali- vary glands, etc. Furthermore, one may formulate a quite comprehen- sive statement and say that all such lesions as solutions of continuity, hemorrhages, degenerations, vascular stasis produced by strangula- tion, etc., and all perforations, increase more or less the liability to infection. 5. Pre-existing Disease. — Here are reckoned — first, previous and 50 ' • SURGICAL PATHOLOGY. long-existent toxaemias— e. g. syphilis, diabetes, scurvy, etc. Other conditions, like lithsemia, cholsemia, acetonemia, and the various con- ditions represented by oxaluria or in which acetone, peptone, and ex- cess of uric acid are found in the urine, come also under this head. One need never be surprised to find suppuration occurring in those cases in spite of due observance of all ordinary precautions, since by their existence immunity is destroyed and vulnerability increased. (Vide also chapter on Auto-infections.) Recent toxcemias also have important bearing in this same respect. For instance, after typhoid fever and other acute wasting disease, in- cluding the exanthemata, surgical operations are sometimes followed by failure, and should always be postponed until complete recovery, except in cases of emergency. The condition to be hereafter described as enterosepsis, and which in time past has been spoken of under many different names, as fecal anaemia, stercorsemia, etc., is one which posi- tively makes dangerous the performance of all operations, and which certainly predisposes to septic disturbances of all kinds. The post- puerperal state is also one in which operations are to be avoided if possible. Certain -anatomical changes peculiar to the various ages also belong in this category. Old age with its accompanying arterial sclerosis, its cardiac debility, and other well-known tissue-alterations, favors sluggishness of wound-repair and leads not infrequently to sloughing or to bed-sores. Amyloid changes betoken impaired vitality. Chil- dren are much more liable to acute osteomyelitis than adults. Nurs- ing infants are apparently exempt from many of the infectious diseases, but possess relatively small power of vital resistance to surgical operations. General ansemia and impaired nutrition of the body predispose to most infections, acute starvation notori- ously so. 6. Personal Habits and Environment. — Diet has much to do with tissue-resistance. Rats fed on bread are more susceptible to anthrax than those fed on meat. Hunger makes pigeons highly sus- ceptible to the same disease, and artificial immunity induced in various animals is quickly destroyed by starvation. Prolonged thirst seems to have the same result. Prolonged fatigue notoriously reduces im- munity, as already mentioned. The various drugs which destroy red corpuscles impair immunity, and even by injection of water into the circulation the bactericidal power of the blood is reduced. White mice .fed with phloridzin, which produces artificial diabetes, become highly susceptible to glanders, from which they are ordinarily exempt. In this connection may also be mentioned the various toxaemias alluded to under the previous heading, which may proceed from the intestine, from the genito-urinary tract, and probably also from other sources. Climate has more or less to do, as also extremes of weather, with power to resist infection or to survive serious operations. Dark habi- tations, poorly ventilated, constitute surroundings which notoriously predispose to infection of all kinds. Rabbits inoculated with tuber- culosis and confined within a dark cell, badly ventilated, become rap- idly diseased, while others similarly inoculated, but allowed to roam at large, present but slight evidences of the affection. Certain occu- INFL A 31 MA TION. 5 1 pations predispose to certain diseases. This is pre-eminently the case, for example, with workers in mother-of-pearl, who are exceed- ingly liable to a particular form of osteomyelitis ; and with those who make phosphorus matches, who are prone to suffer from a peculiar necrosis of the lower jaw : that prolonged suppuration may produce such changes in the blood and tissues that vital processes of repair, cell- resistance, and chemotaxis may be so far interfered with as to facili- tate subsequent infection, is a matter upon which I have elsewhere in- sisted. Finally, the influence of local injury to tissues, particularly of con- tusions which cause tissues to lose their vitality, is strenuously insisted upon by all, and is spoken of repeatedly in other places in this work. Many tissues will succumb to inoculation after bruising, liga- ture en masse, etc. which before such injury are not in the le.ast dis- turbed. 7. Fcetal Infection. — It is only in a very limited class of cases that infection can be transmitted from mother to fcetus, but there are instances of this kind in which the surgeon is deeply concerned. As Welch has stated, syphilis is the only infection capable of direct transmission through the ovum or spermatozoon ; but intra-uterine infection may occur in many ways, and many diseases may be thus transmitted. The placenta is usually regarded as a perfect filter ; nevertheless, it is occasionally passable by micro-organisms. These may be caused by pre-existing lesions in the placenta or by the viru- lence and activity of bacteria. It is known that in animals the bacilli of chicken cholera (inoculated into the mammalia), of symptomatic anthrax, and the pyogenic cocci frequently traverse this barrier. In mankind infection in utero has been observed in small-pox, measles, scarlatina, relapsing fever, syphilis, tuberculosis, croupous pneumonia, typhoid fever, anthrax, and surgical sepsis. Sources of Infection. That the effects of bacterial invasion may be anticipated and guarded against most effectually it is necessary that the practitioner be thoroughly familiar with the sources from which they come, and the localities in and about the body which they most commonly inhabit or where they are met with in largest numbers. Skin and Mucous Membranes. — Of all possible sources of infection, the skin itself is probably the most fertile. It is exposed to contam- ination by air and by everything which may come in contact with the body, and there is perhaps no organism ever met with in disease which may not be found upon its surface or within its recesses. In fact, these recesses, such as the crevices beneath the nails, the spaces between the toes, and the various pockets like the tonsils, the axillae, etc., are those most commonly inhabited by micro-organisms. Bacteria may penetrate the skin by means of three different routes — namely, the sweat-glands, the hair-follicles, and the sebaceous glands by means of their regular openings. The hairy appendages of the skin are even greater sources of danger than the skin itself, since a direct path of infection into the depths of the skin is afforded by their follicles. Experimentally it has been 52 SURGICAL PATHOLOGY. shown that when bacteria are rubbed into the skin where there are no follicles, there is absolute freedom from infection, whereas the reverse is equally true, and it is clinically generally recognized that furuncles and carbuncles form almost exclusively in those parts provided with hair and sebaceous glands. The mucous membranes are in constant contact with micro-organisms, and furnish conditions in many respects favorable for their rapid development. Nevertheless, the latter is interfered with, and often inhibited, by certain me- chanical and chemical influences which afford us protection. The conjunctiva is an extremely exposed membrane, which harbors, however, but a relatively small number of bacteria under ordinary circumstances. The tears before escaping from the conjunctival sac are sterile, and are probably saline enough to act as an antiseptic bath for the cornea. Moreover, by free escape of secre- tion through the nasal duct the conjunctival sac is kept constantly irrigated, to which is mainly due, in all probability, its ordinary healthy condition, since we know how commonly lesions follow obstruction to the lachrymal duct. The hor- rible results of Egyptian ophthalmia — j. e. the pyogenic form of conjunctivitis — are familiar to all travellers in Egypt. This disturbance has by Howe and others been clearly shown to be in the main due to the flies which are attracted toward the eyes of the infants, and which are most pronounced carriers of infec- tion, while the superstitious notions of the parents restrain these children from instinctive protection of the eyes when thus irritated. There is probably no greater common carrier of pyogenic infection than the common house-fly, and nowhere is this agency more abundantly demonstrated than in the hot climates of the Orient. Upper Respiratory Tract. — The oral cavity and pharynx are never free from bacteria. Miller has studied over one hundred species that he has found under various circumstances in the human mouth. Some of these are pathogenic ; others are apparently absolutely innocent. Many of the forms which grow in saliva will not grow in ordinary media. ( Vide Plate III., illustrating infection of the teeth.) Miller has also shown that all forms of dental caries are but expressions of bacterial invasion even of those apparently most solid structures, the teeth ; and of late we have been taught more fully that such invasion may extend far beyond the confines of the teeth alone, and may spread to various, even to distant parts, and produce possibly fatal mischief. Abscesses in the brain and extensive septic infections have been clearly traced to invasion along the line of the dental tubules. One of the most virulent of all the common inhabitants of the mouth is the pneumocoecus of Frankel, known also as the micro- coccus lanceolatus of Sternberg. In virulence it is a most variable organism, but it is present in a virulent state in only 12 or 15 per cent, of cases of infection due to it. This is the organism which is the cause of lobar pneumonia, and frequently of broncho-pneumonia, as well as of numerous phlegmons and other inflammations of the throat, and which, getting into the general circulation through the tonsils or other possible ports of entry about the mouth, causes serious septic and inflammatory disturbances in widely distant regions. Aside from dental caries, a widely-opened port of entry is often afforded bv those ulcerations around the margins of the gums which are produced by accumulations of tartar. Disease in the antrum of Highmore for instance, and many other local destructions, are frequently caused in this way. The next most common port of entry is the ton.v/, which contains a variety of crypts which are often filled with secretions or retentions loaded with bacteria. And one of the most common sources of an PLATE III. *> '.'^E«*«^"':-..."a ■fepai s. Artificial Dental Caries — Id cross section ; tubules filled with bacteria. (Miller.) Putrid Tooth Pulp. Infection of Dental Tissue (i-iooo.) (Miller.) FIG. 4. c Dental Caries ; disappearance of dental tissues as result of presence of bacteria (Miller.) FIG. S. Dental Caries ; tubules filled with cocci. (Miller.) FIG. 6. Dental Caries. (1-500.) (Miller.) Dental Caries ; tubules plugged with cocci. (1-500.) (Miller.) IN FLA MM A TION. 53 infection which leads to involvement of the cervical lymph-nodes in tubercular disease is an infection [springing first from the tonsil or the teeth. In spite of the fact that myriads of bacteria are swept into the nasal cavities with the air we breathe, relatively few are met in the nose. A peculiar capsule bacillus, closely allied to that described by Fried- lander, has been found in a number of cases of ozasna, while the pneu- mococcus of Friinkel is also often found there, and is known to produce abscesses of the brain. One specific organism — namely, that of rhino- xcleroma — concerns the nose almost solely, its first ravages at least being met with in this location. Alimentary Omal. — Probably more micro-organisms enter the ali- mentary canal than gain access in any other way, these coming both from food and drink as well as air. Once within its confines, rela- . tively very few of them are capable of prolonged existence. Welch states that the meconium of new-born infants is sterile, but that within twenty-four hours it usually contains abundant bacteria. That bac- terial infection through this passage-way is a very fertile source of non- surgical lesions is well known. The possibility of surgical infections being produced in the same way is both more remote and less demon- strable. Naturally, anaerobic organisms find here more favorable conditions, and even extremely acid or extremely alkaline conditions do not serve to destroy all such life. Pyogenic cocci are often present, and are frequently found, in peritoneal exudates. In the intestines of herbivorous animals the tetanus bacilli and those of malignant oedema are regularly found. The fungus of actinomycosis also easily finds its way into the bowel along with ingested food. Under ordinary con- ditions the bile in its natural reservoirs is free from bacteria, but the colon bacilli and pyogenic cocci often invade these precincts. Genito-urhutrif Tract. — Even the healthy urethra always contains bacteria. While these may wander upv/ard to an indefinite extent, there is every reason to think that the urine contained within the bladder in a condition of perfect health is free from bacteria, and that if such gain entrance they do not long remain. The same is true of the female bladder and urethra. The vagina contains organisms of many species, some of which do not grow on ordinary culture-media, but are to be recognized by the microscope. While it is quite generally acknow- ledged that the vaginal secretion is, as a rule, possessed of bacteri- cidal properties, there is as yet no satisfactory nor comprehensive explanation of this fact, its normal acidity not being sufficent in this direction. The Milk in the Lacteal Ducts. — In a condition of perfect health milk secreted from the ideal mammary gland is sterile, but may easily become contaminated upon its exit from the nipple. Conversely, under many favoring conditions these organisms may travel into the lacteal ducts from the skin without, and thus contaminate the milk. In all probability, the breast corresponds in behavior to other glands whose ducts open upon the surface, and, while such openings invite entrance of bacteria, their migrations do not extend far from the sur- face unless some of the other conditions already mentioned predispose to further infection or extension. 54 SURGICAL PATHOLOGY. In summarizing the general topic of possible sources and paths of infection we may say that bacteria may enter and exert deleterious action — A. From within the system ; and B. From without. A. From within they may get into the tissues either through the inspired air, through food and drink— i. e. ingesta— or by means of more direct inoculation, as, c. g., by foreign bodies or by venereal con- tact. The danger through infection by inspired air is relatively very small, and concerns most probably a limited number of organisms, of which the tubercle bacillus is the'most important. Foul air and air which emanates from sewers, cess-pools, etc., while most unpleasant to breathe and deleterious in many other ways, does not necessarily contain any micro-organisms which can be injurious. This fact, in opposition to generally-received notions, is, nevertheless, proven by recent investigations. The ingesta furnish the most fertile source of contagion from within, but the diseases thereby produced fall for the most part into the domain of medicine rather than that of surgery. B. Infection from without the body may come by actual contact with previous skin or mucous lesions, and particularly from noxious insects and certain parasites. Among surgeons the principal sources of contact-infection to be enumerated and guarded against are — 1. Skin and hair; 2. Instruments ; 3. Sponges or their substitutes ; 4. Suture materials ; 5. The hands of the surgeon and his assistants ; 6. Drainage materials; 7. Dressing materials ; and 8. From miscellaneous sources — e. g. drops of perspiration, unclean irrigator nozzle, a contaminated nail-brush, the clothing of the op- erator, etc. While insisting here upon the recognition of these sources of dan- ger, the precautions to be taken against them are to be considered under another heading, to which the reader must at present be re- ferred. One of the greatest sources of possible infection has of late been shown to be the presence of flies and other noxious insects, which act as carriers of infec- tion. The Egyptian ophthalmia, which ruins the sight of 30 per cent, of the inhabitants of Egypt, has been shown by Howe and others to be due to infection by this mechanism ; and a very simple bacteriological experiment will suffice to show that the foot-tracks of a single fly across a wound furnish abundant opportunities for infection with organisms which are presumably virulent. In fact, the danger of carriage of infection by this means is greater than from almost all other sources, except the use of improper materials during surgical operations. Classification of Infections. We speak of infections in another way as primary, secondary, and mixed ; and it is necessary, for purposes of accuracy at least, to make a reasonably clear distinction between them. By primary infection is meant infection with a single form of organism whose effects are INFLAMMATION. 55 prompt and speedy. Of this erysipelas or syphilis may serve as a good illustration, although in the latter instance the character of the < 'tin- tag i am vivum is not yet definitely known. Most of the acute infec- tions, in fact, belong to the primary type. Secondary infection means that after certain disturbances due to a primary infection — i. e. one of a given type — there occurs at some later period and from a distinct source another infection whose results may be more or less disastrous, and cause the case, at least for the time being, to assume a different aspect. W r e may have an illustration of this in the case, for example, of primary tuberculosis with distinct infection of a number of lymph-nodes, which, acting as filters, have caught in their tissue-net a large number of tubercle bacilli that, lodging there, have produced the usual well-known results and have practically converted the infected nodes into granulomata. In these infected masses well-known changes, such as those which follow tuber- cular infection — atrophy, caseation, calcification, etc. — may be occur- ring, when suddenly there comes infection of a pyogenic type and from another source, and suppuration of the granuloma is the result. It is possible even to have a tertiary infection, of which the follow- ing may be a hypothetical instance : Primary infection with scarlatina or measles, by which vital susceptibility is in some instances notori- ously lowered ; as the result of this, secondary tubercular infection in an individual previously resistant ; and, third, a suppurative infection, as above described. In contradistinction to these distinct events, separated by an ap- preciable, sometimes a considerable, length of time, we recognize a mixed infection, where two or more organisms are implanted at or about the same time. A very common illustration of this is met with in most cases of gonorrhoea, in which there is a synchronous attack made by the gonococcus, which is a specific micro-organism, accom- panied by staphylococci or streptococci, whose effect will complicate the case and make it assume a less particulate type of infection. Mixed infections may often occur in other ways, as syphilis and chancroid, chancroid and gonorrhoea, etc. Most cases of mixed infection belong rather to surgery than to general medicine, and constitute an apparent violation of the rule to which physicians often point — that two distinct infectious diseases are seldom communicated or acquired at the same time. Nevertheless, the facts remain as above. Bacteria of Pus-formation. Bacteria which act as agents in the formation of pus are collec- tively known as pyogenic organisms. These are divided into two groups : A. The Obligate; and B. The Facultative. Obligate pyogenic organisms are those whose activity is always manifested in the direction of pus-formation, which seem to produce it if they produce any unpleasant action whatever. On the other hand, the facultative organisms are those which are known occasionally to be active in this direction, and yet which are not always nor neces- 56 SURGICAL PATHOLOGY. sarily so. The members of the group A are fairly well known and catalogued, and are not very numerous. On the other hand, there is reason to think that many organisms may have the occasional effect of producing pus, as it were by accident or at least in a way not abso- lutely natural nor peculiar to themselves, but are yet frequently found when there is no pus present. A suitable list of the facultative organ- isms, therefore, can hardly be made, and will not be here attempted, the effort being only to mention the more common organisms which play this facultative role. It must be mentioned also that even the adjectives " obligate " and " facultative " are to be accepted with some mental reservation, since staphylococci, for instance, may be met with even in the absence of pus, although nearly all that we know about these organisms implies that pus would be the result of their presence if one wait. Furthermore, there are certain other organisms, not, strictly speaking, bacteria, which also have the power of producing either pus or pyoid material. These will also be mentioned in their place. Some of them belong not only to the vegetable, but to the animal kingdom. Obligate Pyogenic Organisms. — A. The staphylococcus pyogenes aureus, albu*, citrem, etc. — One of the marked characteristics of the staphylococci as a group is the powerful peptonizing action which they exert. Moreover, the chemical products of their life-changes seem to be more potent both in a local and a general way, leading to greater destruction of tissue in their immediate vicinity, with greater inhibi- tion of the chemotactic powers of the leucocytes ; that is, with more interference with phagocytosis, by which their progress would be inter- Fig. 6. *&*"3H6 «• '^ 0<. Staphylococci in pus ; X 1000 (Friinkel and Streptococci in pus ; X 1000 (Frankel and Pfeiffcr). Pfeiffer). fered with. Their presence is often to be recognized by a peculiar odor, as of sour paste, which when detected should always lead to a prompt change of dressings and disinfection of the wound (by irriga- tion, spraying with hydrogen dioxide, etc.). B. Streptococcus pyogenes and Streptococcus eryxipefatis. — These two organisms do not differ in morphology or characteristics, and, while INFLAMMATION. 57 for some time considered as distinct from each other, are now by most observers regarded as identical. The streptococci grow in chains of variable length, and individual cocci vary in size. They grow with and without oxygen, in all media, at ordinary temperatures, do not liquefy gelatin, stain readily, sometimes but not invariably coagulate milk, and vary very much in longevity. They differ extra- ordinarily in virulence as obtained from different sources. There are many streptococci not included under the above head which are indistinguishable morphologically and in other respects, and yet which are in a measure or entirely free from all pathogenic activity in man. A careful bio- logical study reveals remarkable and unexplainable transformation in effect as between the different members of this species, a part of which may be referable to conditions pertaining to the organism infected, but part of which appar- ently pertains to the bacteria themselves. It is held by some that scarlatina is an invasion by certain organisms of this class ; this, however, is not yet defi- nitely established. When found in the stools of children with summer diar- rhoeas they are regarded as indicating actual ulceration of the intestinal mucosa. In contradistinction to the staphylococci, the streptococci manifest a strong predilection for lymph- vessels and lymph-spaces, along which they extend themselves with great rapidity. They have much less peptonizing power than the staphylococci (except in the absence of oxygen) ; hence streptococcus infection assumes usually the type of widespread infiltration rather than of circumscribed and distinct oedema. One sees remarkable in- stances of this in cases of phleg- monous erysipelas. It is suggested also that the peculiar manner of growth of the streptococci, in long chains which may coil up and en- tangle blood-corpuscles, has much to do with the formation of fat- emboli and with general pysemic disturbances. Both these bacterial forms have the power of producing lactic fermentation in milk ; and it is quite sure that lactic- a.cid formation sometimes takes place along with suppuration in the human tissues, causing acidity of discharge, sour odor, and watery pus. It would appear also that these two pyogenic „. , , . „,. ^^^^^^^™ „rr , , £ 4. ■■ Staphylococcus infiltration of perirenal tissue, forms have less power of ptomaine or f rom a case of pyaemia ; x 1000 (Frankel and toxine formation than many others, and, Pfeiffer). consequently, that the pyrexia attend- ing suppuration or purulent infiltration is not always to be ascribed to this cause alone, for fever may in some measure be due to tissue-metabolism attend- ing their growth, the metabolic products being pyretic. This is in a measure substantiated by the fever attending trichinosis, where the question of ptomaine- poisoning has not yet been raised. C. Micrococcus (anceo/atus, known also as the diplococcus pneu- monia, or the pneumococcus of Frankel and Weichselbaum, and as the micrococcus of sputum septicwmia of Pasteur and of Sternberg. It is of interest to surgeons because it causes many localized inflam- mations and is a frequent factor in causing septicaemia ; it is very often present in the mouths of healthy individuals. It may produce 58 SURGICAL PATHOLOGY. all the various forms of exudates as the result of congestion set up by its presence. It may produce otitis media, meningitis, osteo- myelitis, and serious suppurative disturbance in the periosteum, the salivary glands, the thyroid, the kidney, the endocardium, etc. D. The micrococcus Mragomw. — Suppurations produced by these organisms alone are prolonged, mild in character, not painful, but accompanied by much brawny induration of tissues. E. The micrococcus gonorrhoea, or gonococcus, is found constantly in the pus of true gonorrhosa, in many cases the pus being a pure culture of this organism. These cocci are always met with in pairs (biscuit-shaped), while their inclusion within the leucocytes or their attachment in or to epithelial cells is characteristic. Unlike all other pyogenic cocci, these do not stain by Gram's method, being decolorized by iodine, by which fact they may be distinguished. They are cultivated with difficulty, and are known rather by their clinical effects than by their laboratory characteristics ; are human parasites, other animals, so far as known, being practically immune. The gonococcus may also produce abscesses, and may be carried to distant parts of the body, where its effects are most commonly noted as pyarthrosis, although endocarditis, pericarditis, pleu- risy, etc. are known to be due to it, and fatal pyaemia has been produced in con- sequence. In some way, not always clear, it is probably the explanation of the post-gonorrhoeal arthritis so often wrongly spoken of as gonorrheal rheumatism. F. The Bacillus coli communis or Colon bacillus. — This is an ordi- nary inhabitant of the intestinal canal ; varies extremely in virulence and somewhat in morphological appearances ; coagulates milk ; is often associated with other organisms ; migrates easily both along the ali- mentary canal and from it into the surrounding tissues or channels. It is a frequent disturbing element in the production of kidney and hepatic disease, as also in the production of appendicitis and perito- nitis. Ordinarily its pyogenic properties are not virulent ; occasion- ally, however, it becomes extremely virulent. G. The bacillus pyocyaneus, a widely-distributed organism, often met with in the skin and outside of the body ; a motile, liquefying bacillus, growing at ordinary temperatures, seldom met with alone, but occasionally producing pus without association with other organ- isms ; it stains the discharges and dressings a characteristic bluish- green and imparts sometimes an offensive odor. Suppuration caused by this bacillus is usually prolonged, but characterized by little constitutional disturbance. Facultative Pyogenic Organisms — i. e. those which have the power of provoking suppuration, but which have other and more dis- tinct pathogenic activities as well. A. Bacillus typhi abdominalis.— -This is found in many pus-foci, developing during or after typhoid fever. It is occasionally met with alone, though most of these abscesses are really mixed infections. It is most commonly met with in the bone or beneath the periosteum. Such abscesses are frequently met with in the ribs, and may not be noticed until months after the convalescence from the fever. The pus contained within them is not always typical in appearance but may be unduly thin or unduly thick. B. 'Bacillus protem.— Under this name are included three distinct forms which were originally described by Hauser as distinct species, but which are now regarded as pleomorphic forms of the same organism. It is a motile bacil- lus, met with in decomposing animal and vegetable material, and occasionally INFLAMMATION. 59 found in the alimentary canal. It has been found to produce pus, especially in the peritoneal cavity and about the appendix. It may even cause general infec- tion and peritonitis. C. Bacillus diphtheria;. — A non-motile bacillus, varying considerably in size and shape, changing the reaction in sweet bouillon from acid to alkaline; pro- duces a most dangerous infective inflammation of exposed surfaces, with tena- cious exudate amounting to a distinct membrane. As a part of its life-history it also produces a powerful toxalbumen, which is one of the most profound cell- poisons known, the disintegration of the cell-constituents due to its action being rapid and pronounced. This will account for the sudden heart-failures which are so often reported in connection with the disease. D. Bacillus tetani. — More will be said about this organism when consider- ing Tetanus, and to that subject the reader is referred. The tetanus bacillus is occasionally found in pus which comes from the area through which the orig- inal infection was produced. But these bacilli do not travel to any distance in the human body, and are practically never found away from the area primarily involved. Under most of these circumstances the pus is the product of a mixed infection. E. Bacillus 02dem.at.is maligni. — This, too, will be more fully considered under a different heading. (See Malignant (Edema.) It is a long, anaerobic bacillus, widely distributed in the soil and the faeces of animals. There is rea- son to think that this, like the tetanus bacillus, may occasionally lead to forma- tion of pus. F. Bacillus tuberculosis. — This organism likewise will receive fuller descrip- tion in an ensuing chapter. (See Tuberculosis.) The pus of old cold abscesses, in which the more obligate pyogenic organisms have long since died out, usually still contains this organism in mildly virulent form. On the other hand, fresh suppurations occurring in connection with tubercular disease are mixed infec- tions. There is reason to hold, however, that this organism is capable of pro- ducing pus even when none of these are present. For example, in that form of acute miliary tuberculosis which is occasionally met with as bone-abscess it may be found, for whose origin we naturally look to this organism. G. Bacillus anthracis. (See Anthrax.) — This is one of the most malignant and resistant organisms known, being in the highest degree poisonous for the smaller animals, man being less susceptible. One of its characteristic lesions in the human body is a form of pustule commonly known as malignant pustule, the pus in which is usually a pure culture of this organism. H. Bacillus' mallei. — This is the organism which produces glanders in the lower animals and in man. That form of the disease which is commonly known as farcy, in which the infected nodules rapidly break down, is most likely to contain pus which shall be more or less a pure culture of this organism. I. Bacillus lepra. — This is the micro- organism which produces leprosy and which closely resembles the tubercle bacillus. It is constantly and exclu- sively present in the lesions in leprosy, which are often of the suppurative type, the bacilli being enclosed within pus- cells, as well as found in the fluid sur- rounding them. Although suppuration in these cases may be in a large measure due to secondary infection, it is positive that the leprous bacilli deserve to be grouped in this place. J. The bacillus pneumonia of Fried- lander was at one time regarded as the cause of croupous pneumonia, which is now known to be due to the micro- coccus lanceolatus. The Friedliinder bacillus, however, is capable of pro- ducing broncho-pneumonia, and is occasionally met with in empyema, suppu- Fig. 8. Friedlauder's pneiimococci, from sputum ; X 1000 (Frankel and Pfeiffer). 60 SURGICAL PATHOLOGY. rative meningitis, and inflammations about the naso-pharyngeal cavity, of which it is known to be an occasional inhabitant. K. The Bacillus of Rhinoscleroma. — A distinctive organism has been described for this disease, and given this name. It has such wide morphological differ- ences, however, that it is possible that it is only the bacillus of Friedl'ander above mentioned. At all events, an organism of this general character is con- stantly found in the thickened tissues from the nose in this disease. ( Vide Fig. 10.) Fig. 9. A ■ • 9 A " ; M Rhinoscleroma : infiltration of tissues about the nose (case reported by I)r. Weude, Buffalo). Bacilli of rhinoscleroma; X 1000 (Frankel and Pfeiffer). L. The Bacillus of Bubonic Plague. — This was recently discovered by Kita- sato, and, in view of the recent ravages of the disease in the Orient, has. as- sumed considerable importance. It grows upon most media, and is found in the blood, in the buboes, and in all- the internal organs of patients suffering from this disease. The smaller animals are susceptible upon inoculation. Animals fed with inoculated foods die also, showing the possibility of infection through the intestine. When exposed to direct sunlight for a few hours the bacillus dies. The general expressions of the disease are those of hemorrhagic septicaemia and its consequences. M. The Bacillus of Rauschbrand. — This is seldom, if ever, seen in this country. It is known in England as " the black-leg" or " quarter-evil." It is an anaerobic organism, frequently met with in cattle, which causes a peculiar emphysema of subcutaneous tissue, which spreads more deeply, and is followed by a copious exudate of dark serum with gas-formation. The smaller animals are not ordi- narily inoculable ; but, if to the culture-material used be added 20 per cent, of lactic acid, their insusceptibility is overcome and they succumb quickly to the disease. So also, as in the case of the tetanus bacillus, by addition of the bacil- lus prodigiosus or of proteus vulgaris the disease may be induced in otherwise insusceptible animals. Fungi. Besides the micro-organisms everywhere grouped as bacteria, there are other minute organisms which have also the power of engendering pus. One of these is the ray-fungus, known as the act inomycis, which causes the disease known as lumpy jaw or actinomycosis. Suppuration is always a concomitant of the ad- vanced lesions of this disease, and, while it may be in many instances a mixed infection, it is not necessarily so. Moreover, the pns produced under these cir- cumstances contains minute calcareous particles which are pathognomonic, and by which a diagnosis can sometimes be made off-hand. Besides these fungi, others, belonging rather to the class of vegetable moulds, which are yet pathogenic for human beings, may be occasionally met with under these circumstances— for example, the fungus of Madura-foot, the leptothrix, and other moulds from the mouth, while the different varieties of aspergillus may be found in pus about the ear, or even in that from the brain. INFLAMMATION. 61 Protozoa. The protozoa also have the power occasionally of producing, if not absolute ideal pus, something so strongly resembling it that we may include them among the facultative pyogenic organisms. The best known of these protozoa are the amcebce which are so often met with in the intestinal canal in certain countries, and which are occasionally met with in the United States, especially as the exciting causes of a peculiar type of dysentery often accompanied by abscess of the liver. In these abscesses the amoebse are usually found, and no other organ- isms. Another group of the protozoa, known to biologists as the coccidia, are also capable of causing pus-formation, more particularly in some of the lower animals. Numerous other parasites, belonging higher in the animal kingdom, are undoubted exciters of pus-formation, though it is not necessary to lengthen the list beyond those already mentioned. Clinical Characteristics of Pus from Different Agencies. Staphylococcus. — Dirty white, moderately thick, with sour-paste odor. Streptococcus. — Thin, white, often with shreds of tissue. Colon Bacillus. — Thick, brownish, with fetid odor, or thin, dirty white, with thicker masses. Micrococcus Lanceolatus. — Thin, watery, greenish, often copious. Bacillus Pyocyaneus. — Distinctly green or blue in tint. Bacillus Tuberculosis. — Thick, curdy, white paste, or thin, green- ish, with small cheesy lumps or even with bone-spiculse. Actinomycis. — Thick, brownish white, with small firm nodules of yellow color. Amozba Co/i. — Thick brownish-red. Bacterial, Determination as an Indication in Treatment. There is a practical side of great importance pertaining to the recognition of the nature of the infectious organism in many cases of suppuration and abscess. For instance, pus which is due to strepto- coccus invasion indicates a collection which should be freely evacu- ated and carefully drained. This is also true in essential respects of staphylococcus pus, particularly that due to the S. aureus. Putrid pus from any source calls for disinfection and free drainage, the former preferably perhaps by hydrogen dioxide. Pus which is due to the colon bacillus is not often extremely virulent, which accounts for so manv cases of appendicitis recovering with or without opera- tion. A collection of this pus calls for little more than mere drain- age and opportunity for escape. Pus from a recognizable tubercular source may still contain living tubercle bacilli. This means either that the cavity whence it came should be completely destroyed and eradicated, or else that the margins of the incision or opening through which it has escaped should be so cauterized that infection of a fresh surface is impossible. The same is true of abscesses due to glanders bacilli and to certain cases of suppurating bubo following chancroid, where the whole course of events shows the virulent character of the organisms at fault. Suppuration. Although it may be possible to produce in certain laboratory ex- periments metamorphosed material which very closely simulates pus, 62 SURGICAL PATHOLOGY. or, in fact, by injection of chemical irritants, to sometimes quite faith- fully imitate the suppurative processes, nevertheless, the student must be promptly brought face to face with the statement, to which for surgical purposes there is no practical exception, that suppura- tion — i. e. formation of pus — is due to the presence in the tissues of the specific irritants already catalogued and described, and of the peculiar peptonizing or other biochemical changes which bacteria exert upon living animal cells. Coagulation-necrosis is the term applied to the characteristic changes occurring in the tissue-cells when thus attacked, which may be summarized as a fading away of cell-outlines, diminution in reaction to reagents, and a sort of merg- ing together of cells and intercellular substance. Coagulation- necrosis is not the sole result of bacterial activity, but may be brought about from other causes. Nevertheless, pyogenic bacteria do not exert their deleterious action upon the tissues without bringing about changes included under this term. In an area thus infected, as already described, leucocytes — i. e. phagocytes — are present in largely increased numbers for purposes already distinctly described. As we get nearer to the centre of activity phagocytes are more numerous than are cells, and intercellular barriers completely break down. Where bacteria are found in greatest numbers, there also occurs the greatest phagocytic activity, and there too will be found the charac- teristic evidence of suppuration — i. e. pus. As already indicated, the poly nuclear leucocytes are most active of all in the process of defence. Where coagulation-necrosis is most marked there has been the greatest activity of conflict with the greatest death of cells. Around these areas bacteria and cells are found in indiscriminate arrange- ment. Tissue-vitality is impaired by intoxication of the cells by the excretory products of the bacteria — i. e. the so-called ptomaines, toxines, etc. — and their power of resistance is thus weakened. From the mechanical results of pressure tension around the centre of activity is increased ; by which tension vitality is still more impaired and more rapid tissue-death occurs. Thus there occurs migration or burrowing of pus ; or, to put it more clearly, the tissues break down in front of the advancing destruction, and always in the direction of least resistance. This is known as the pointing of pus, and this it is which brings it many times to the surface, and often in other and less desirable directions. Abscess. An abscess is a circumscribed collection of pus. The term is used in contradistinction to purulent infiltration, in which the collec- tion is by no means circumscribed, but is exceedingly diffuse and extends itself in various directions, the amount at any particular spot being almost inappreciable. Purulent infiltration is commonly regarded as much the more serious of the two conditions, since it is much harder for pus to safely escape under these circumstances than when it can all be evacuated through a single opening. The term phlegmon _ is ^one which is now generally used, both at home and abroad, to indicate a suppurative process usually of the general cha- PLATE IV. 3r-. bseess in Kidney of Rabbit after Intravenous Injection into an Ear-vein of Culture of Pyogenic Cocci. Dense mass of cocci surrounded by area of coagulation necrosis due to their toxic activity. Outside this a zone of phagocytes. INFLA MM A TION. 6 3 racter of purulent infiltration rather than of abrupt abscess, but some- what generally employed to cover both conditions. The adjective phlegmonous is coupled with the name of any of the other surgical infectious diseases to indicate that it is complicated by suppuration — c. g. phlegmonous erysipelas. Pus is a product of bacterial activity which is usually formed rapidly rather than slowly, and abscess- formation or phlegmonous activity of any kind is ordinarily a matter of but a few days. In connection with this I would like to summarize the story of inflammation and suppuration, to paraphrase Sutton, and read it zoologically, as though it were the story of a battle. The leucocytes (phagocytes) are the defending army, the vessels its lines of communi- cation, the leucocytes being, in effect, the standing army maintained by every composite organism. When this body is invaded by bacteria or other irritants, information of the invasion is telegraphed by means of the vasomotor nerves, and leucocytes are pushed to the front, rein- forcements being rapidly furnished, so that the standing army of white corpuscles may be increased to thirty or forty times the normal standard. In this conflict cells die, and often are eaten by their companions. Frequently the slaughter is so great that the tissues become burdened by the dead bodies of the soldiers in the form of pus, the activity of the cells being proven by the fact that their proto- plasm often contains bacilli in various stages of destruction. These dead cells, like the corpses of soldiers who fall in battle, later become hurtful to the organism which, during their lives, it was their duty to protect, for they are fertile sources of septicaemia and pyamia. This illustration may seem a little romantic, but is warranted by the facts. Around the margin of the site of an acute abscess is formed a barrier, by condensation and cell-infiltration of the surrounding tissues. This is not a distinct wall nor membrane, yet, nevertheless, serves as a sanitary cordon to confine the mimic conflict within reasonable bounds. This is the zone of real inflammation ; within it there are tissue- destruction and coagulation-necrosis. (Vide Plate IV.) By virtue of the peptonizing power of the pyogenic organisms the parts involved in this necrosis gradually liquefy, the intercellular substance dissolv- ing first. It is this which in the main forms the fluid portion of the pus. Various tissues show widely differing resistance to this soften- ing process. In true glands the interlobular septa seem to break down first, and in this way suppuration extends around the acini or gland-lobules, and thus pus may contain masses of easily recognizable size. These masses are ordinarily known as sloughs. It is by virtue of the so-called lymphoid cells, which are those principally involved in producing the barrier or boundary of the acute abscess as above described, that granulation-tissue is formed, which promptly takes up the effort of repair so soon as pus is evacuated. This boundary has no sharp limit, but shades off into healthy sur- rounding tissues. Under the term "abscess" is ordinarily meant that which is more minutely described as acute abscess. Under certain circumstances, especially where they are produced by the facultative pyogenic organisms rather than the obligate, abscesses form much more slowly, and may be spoken of as subacute. These are 64 SURGICAL PATHOLOGY. terms used in contradistinction to the so-called cold abscess, which, although clin- ically bearing a certain resemblance to the acute, is in almost every pathological respect widely different from it. Cold abscesses will be considered at length under the head of Tuberculosis. It is possible to have an acute pyogenic infec- tion of a cold abscess ; in such case we have acute manifestations. Gravitation- abscesses are those where pus forming in one part tends to migrate, usually in the direction in which gravity would take it, extending into portions deeper or lower down. Perhaps the best illustration of this is the pointing of a psoas abscess below Poupart's ligament. Metastatic abscesses are those which are formed as the result of embolic processes, each one being in miniature a repetition of a lesion which has already occurred at some other part of the body. The under- lying fact concerning metastatic abscesses is that the primary process has occurred in some other portion of the body, whence it has been distributed as above. These will be more fully considered in the chapter dealing with Pyaemia. The characteristic product of all acute suppurative lesions is pus. This is an opaque fluid of creamy consistence and whitish or grayish appearance, varying somewhat in density, met with in amounts from a minute drop to collections of half a gallon or even more. Under ordinary circumstances it is odorless, and its reaction, either acid or alkaline, very faint. It is, like the blood, composed of a fluid and a solid portion. The solid portion consists of so-called pus-corpuscles and other debris of tissue, which will vary with the site of the disease and the parts involved. The source of the pus-corpuscles has already been cited at length, and the statement already several times made that they are in effect the bodies of phagocytes which have perished in the biochemical fight for existence of the parent organism. In them may frequently — almost always, in fact — be seen cocci or bacilli, which are also found in large quantities in the surrounding fluid. Pus should be ordinarily without odor, but under certain circumstances it possesses an odor which will vary in character according to the source of the pus or the nature of its principal bacterial excitant. Pus from the upper end of the alimentary canal frequently has the sour smell so characteristic of gastric con- tents ; that from the neighborhood of the lower end, the characteristic fetid odor which is for the most part due to the action of the colon bacillus. Inasmuch as this colon bacillus is found in widely distant parts of the body, it may also give unpleasant odor to pus even from a brain-abscess. When the pus has become contaminated by any reason with the ordinary saprophytic organisms, it may smell like any other decomposing material. The older writers used to speak of this as ichorous pus, while sanious pnswa.fi supposed to be that more or less mixed with blood, undergoing ammoniacal decomposition or else strongly acid. Pus sometimes has a well-marked blue or bluish-green tint. This is clue to the pres- ence of the bacillus pyocyaneus, already described. An orange tint is sometimes given by the presence of hasmatoidin crystals, due to the original hemorrhagic character of the infected exudate. The former appearance indicates usually a discouragmgly slow course to the suppurative lesion, while the latter has been regarded by some as affording an unfavorable prognosis. Distinctly red pus whose tint is due to the presence of a bacillus giving bright-red cultures on blood-serum, has been noted in other instances. This can readily be distin- guished from blood, because upon dressings it does not change color. Pus may form quite superficially, when we speak of it as a sub- cutaneous suppuration, in which case there is a minimum of pain, because tension is not great and because the distance to the surface is short. Collections which form beneath the fasci*, especially the deeper fascia; of the limbs and trunk, give rise to much more extensive dis- turbance, both locally and generally, and frequently do not point for many days, or, instead of pointing, burrow deeply and find their out- IS FLA MM A TION. 6 5 let at some undesirable point. These are known as subfascial collec- tions. Subperiosteal abscesses give rise to still more pain, because of the unyielding character of their limiting structures, and the symp- toms caused by them are often very acute and very distressing. An illustration of the pain and disaster which may follow deep suppuration may also be seen in the ordinary panaritium or bone-felon, where the path of infection is from without, but the destructive lesion is confined within absolutely unyielding tissues, at least at first. Along certain tissues infection spreads with amazing rapidity. This is particularly true of the delicate areolar tissue met with between tendons and tendon-sheaths, and the infectious process may follow this tissue wherever it shall lead, even along complex courses. The question is often raised, Can pus be resorbedf There is no question but what under many circumstances small amounts of pus are disposed of by phagocytic activity, and the disappearance of puru- lent infiltration under the influence of favoring remedies, or even when left alone, is not infrequently noted. True pus-resorption is entirely a question of phagocytic possibilities, and can only occur in very limited degree as a result upon which it is not safe to count, and which is capable of encouragement only up to a certain point. One inevitable law seems to govern collections of pus, and that is, that when they advance or migrate in any direction it is always in that of least resistance. This causes it to take peculiar and sometimes dis- astrous courses, but it is a law which is virtually never violated. It leads, for instance, to the bursting of abscesses into the brain, into the pleural cavity, into the peritoneal cavity, the bowel, and elsewhere ; it leads to a condition where pus may travel slowly along a path even a foot or more in length, rather than come directly to the surface, a dis- tance of perhaps an inch, and affords one of the best reasons for early operative interference in order that the disastrous effects of burrowing may be obviated. When the collection of pus is limited to a drop or a fraction thereof, the little abscess is usually spoken of as a furuncle, especially when in the skin. The average " boil " of the layman is a subcutaneous or subfascial abscess near the surface. When the infil- tration is pronounced, and when there has been more or less extensive destruction of tissue, with perhaps formation of numerous outlets for the desired escape of pus and detritus, we have what is known as a carbuncle; all of which will be of treated in Chapter XXVI. In certain peculiar conditions small superficial furuncles or boils form, sometimes in great numbers and almost synchronously, or, as it were, in crops. This condition is spoken of as general furunculosis. Signs and Symptoms of Abscesses. — The appearances by which the presence of pus may be suspected or detected are those of conges- tion and hyperemia, more or less abruptly circumscribed and markedly accentuated. Along with these there is more or less oedema or oedem- atous infiltration of the skin and overlying tissue, which permits of that peculiar appearance known as " pitting on pressure." Often, too, there is a distinctly (Edematous swelling of the parts, especially around the margin, with brawny infiltration of the centre of the infected area. Numerous vesicles occasionally are noted upon the skin, which may be filled with reddish serum. As softening and actual pus-formation occur, we get a condition which to the palpating fingers gives the cha- racteristic sensation known as fluctuation. Fluctuation ordinarily 66 SURGICAL PATHOLOGY. simply points out the presence of fluid beneath ; but when in an area marked as thus described fluctuation is noted, it practically always means the presence of pus beneath. It is best detected by manipulat- ing in a direction parallel to and concentric with the axis of the limb or part. The pain is also significant in most instances : patients speak of it, ordinarily, as having an intense and throbbing character. Along with these local signs occur often more or less reliable symptoms indi- cating some degree of septic intoxication — i. e. pyrexia, chills, malaise, sweats, etc. — which are always corroborative indications, their inten- sity being a reasonably correct index of the severity and gravity of the local infection. It is but seldom that a superficial collection of pus can ever be mistaken for anything else. In small and superficial abscesses (boils, furuncles) as pus ap- proaches the superficial layer (epidermis) of the skin it may often be discovered through its thin covering. In deeper lesions there is often room for honest doubt, even on the part of the most experienced. The measure now usually resorted to for purposes of diagnosis and exact recognition is the exploring or aspirating needle. The old exploring needle was one of good size, having a groove along which, after introduction, pus might pass. Since the common and every-day use of the hypodermic syringe, a small aspirating needle attached to the ordinary syringe is now the measure commonly adopted. Such a needle may be introduced into the brain, into the liver, or into almost any and every soft tissue without danger, and if properly manipulated is almost sure to facilitate detection of pus. Exploration done with either of these means and for this pur- pose should always be conducted as an aseptic, even if a minor operation, in order that no extra infection may be added from without. The skin should be care- fully washed, the needle sterilized, etc. It is often good surgery to resort to the knife either for the above purpose or in order that by a longer incision or by the opening of the cavity deep exploration may be made. Such explorations are usually of benefit even though one fail to find a circumscribed collection of pus, since by relief of tension and local abstraction of blood they act in a revulsive way and do much good. Acting upon the same prin- ciple, one may use the trephine or the bone-chisel for the purpose of opening the cranium and exploring for deep collections of pus, or of opening into the medullary canal of the long bones and hunting there for that which we have reason, from external appearances, to suspect. Treatment. — So soon as suppuration threatens, one should adopt speedy measures, either for the purpose of bringing about resorption, if possible, or of favoring and hastening suppuration. In theory anti- septic applications are demanded ; in practice they are sometimes of benefit. These may consist of mere soothing applications, like the lead-and-opium wash of our forefathers, or some other wet or dry astringent applied upon the surface, or they may consist of cold appli- cations, which by their astringent action shall limit the amount of exudate and possibly prevent its further infection. Or, as is the cus- tomary practice everywhere, one may take advantage of the well-known properties of moist heat, and by the application of hot poultices or fomentations may encourage exudation, but particularly hasten super- ficial breaking down, and thus hurry that desirable time when the abscess shall point, or at least shall come near enough to the surface to plainly show that its contents are pus, and to permit of easy evacu- ation. Such local applications, therefore, give relief from pain and INF LA MM A TION. 6 7 hasten favorably the suppurative process. In cases of phlegmonous infiltration I favor, above all other measures, the application of an ointment composed of resorcin 5, ichthyol 10, mercurial ointment 35, and lanolin 50 parts. Under the influence of this antiseptic and sor- befacient preparation, and of moist heat, one may see many phleg- monous infiltrations assume a kindlier type, and may even perhaps secure the actual resorption of pus. Finally, in almost every case the time comes when pus must be evacuated. Here, again, the universal rule may be laid down to which there are practically no exceptions. This needs to be deeply stamped on the mind of every student and young practitioner. It is — that pus left to itself will do more harm than will the knife of the sur- geon if judiciously used for its evacuation. All action take in accord- ance with this rule may be considered wise and timely. The operation of evacuation may at one time be a mere puncture, or possibly the aspirator needle alone will be enough ; at other times it requires ex- tensive and careful dissection and entails no little responsibility. This is particularly true in such deep-seated suppurations as those around the appendix and in the brain, while in deep-seated bone- lesions of this character the extensive use of the bone-chisel or the cutting forceps will be called for. But the rule holds good, no mat- ter where the pus may be, and so long as good judgment be shown in the operative procedure nothing but good can come from recognition of this law. After the evacuation of pus the cavity should be cleansed so far as circumstances permit, and disinfected with hydrogen dioxide, perhaps even with caustic pyrozone, or, if these be not at hand, with other suitable antiseptic solutions. Ordinary judgment should be manifested in evacuating every abscess, in order that opening be made at that point which in the common position of the body shall be most favorable to drainage by mere gravity alone. If circumstances compel opening where advan- tage cannot be taken of gravity, then one or more counter-openings must needs also be made, these at points to be selected where drainage may be best effected, and at the same time where anatomical conditions do not make it injudicious to incise. Drainage must, furthermore, be favored by the introduction of drainage tubing or of other aids, such as gauze, strands of catgut, bundles of horse-hair, etc. Finally, a dressing must be applied which shall be both protective and absorb- ent, and in quantity sufficient to make compression of the walls of the abscess-cavity — not sufficient to obstruct drainage, but enough to favor prompt adhesion of surfaces, which by speedy granulation shall ensure prompt healing. Certain abscesses are so located in proximity to large vessels or dangerous anatomical regions that the greatest care must needs be exercised in opening them. Here much better than the bold incision is the careful dissection made under an anaesthetic. This may be true of abscesses in the neck ; it certainly is true of those around the appendix ; for example, where the general peritoneal cavity is only shut off by more or less delicate adhesions, and where one must literally feel his way with great precaution lest adhesions be torn and the pre- viously protected cavity be infected. At other times, especially in abdominal abscesses, it is necessary to pack sponges or absorbent gauze in and about the parts in such a way that any fluid which may inadvertently or necessarily escape shall be caught by these dressings and thus kept out of harm's way. 68 SURGICAL PATHOLOGY. Accompanying Disturbances.-The disturbance of function which accompanies all congestion and exudation, whether provoked by specific irritants or not, has already been alluded to ; but in cases of surgical infections, especially those which produce local suppura- tion, disturbance of function is much greater, while there are other more, widespread disturbances which sometimes constitute the worst feature of these cases. The presence, of pus is often indicated, espe- cially when deeply seated, by one or more chills, and the occurrence of a chill is alwavs marked by pyrexia to varying degree, it is correct to say that the chill is an expression of a general septic dis- turbance; but it is necessary also not to forget that general septic disturbance is a frequent accompaniment of pus which is not promptly evacuated so soon as formed. Moreover, in certain cases suppuration and septic infection seem to occur synchronously, one being local, the other general. The other general disturbance, or perhaps the most widespread general disturbance with which suppuration is so often complicated, is septic infection. In fact, it mav be questioned whether pyrexia is not really an expression of this condition. With the general state- ment that any collection of pus, no matter how small, may cause recognizable signs of septic infection, and that, on the other hand, large collections may be formed without serious septic symptoms — in other words, with'the statement that suppuration and expressions of septic infection may be blended in almost every conceivable way — the further consideration of sepsis as a distinct condition will be relegated to another chapter. It is important to summarize what may become of pus when once it has formed and is not promptly evacuated. Without going freely into the subject, pus may when long present be — A. Absorbed. B. Encapsulated. 0. Undergo various degenerations or chemical alterations. A. The possibility of the absorption of pus, or, what is equivalent to it, its spontaneous disappearance, has already been mentioned. While it does not usually take this course, it may thus disappear, as, for instance, in the anterior chamber of the eye in cases of hypopyon, or in various other localities, particu- larly when present only in small amounts. The absorption of pus is purely a matter, so far as we know, of phagocytic activity plus the power of the tissues to take up various fluids. B. Encapsulation. — This only occurs when pus has been present for some time and when the virulence of the pyogenic organisms is not intense. We may get encapsulation of pus in any part of the body, the most typical illustra- tion naturally being within the bones. Around the purulent focus, as around any other irritating foreign body, the capsule is formed by condensation of sur- rounding tissue. This is, in fact, the way in which most cold abscesses with their limiting membranes are produced, those produced by tubercle bacilli having ordinarily relatively slight irritating properties. Inasmuch, then, as the biological activity in such a focus is small, there is time for such encapsula- tion ; while by the membrane thus formed, or the sanitary cordon as I have already spoken of it, protection is afforded to the surrounding tissues. In such a collection fresh infection may incite acute disturbances again, and many abscesses which thus lie latent for considerable lengths of time are fanned, as it were, into a conflagration, when a new and acute inflammation is produced. 0. Of the various metamorphoses and chemical changes that occur in that which was originally pus, the caseous and the calcific are the most common. These also are connected largely with the tubercular process, although calcare- IN FLA MMA TION. 6 9 ous particles are met with in the pus of actinomycosis. Under their respective heads these degenerations will be more particularly described. Certain particular names have been given to collections of pus in particular localities or under peculiar circumstances. A collection of pus in the anterior chamber of the eye is known as hypopyon; when in any pre-existing cavity, it is known as empyema of that cavity, the distinction between empyema and abscess being that " abscess " means a circumscribed collection where previously there was no cavity, while " empyema " implies a normal cavity, without respect to size or loca- tion, filled with this abnormal fluid. By common consent, without other authority than common usage, the term empyema, when not used in connection with some particular cavity, is understood to refer to a collection of pus in the pleural cavity. Other names are also used which are particulate and distinctive ; in these the prefix pyo- is used, while the suffix indicates the part involved : thus we have pyothorax, pyopericardium, pyarilwosis, etc. Sinus and Fistula. These are terms applied to more or less tubular channels abnorm- ally connecting various parts of the body, or connecting some cavity with the surface of the body in a way anatomically quite abnormal. Or they may be regarded as tubular ulcers, or ulcerated tunnels, connecting as above. A more exact distinction between the two terms would imply that a sinus connects the surface with some deeper portion where a cavity is not normally present — i. e. with a focus of disease ; whereas a fistula properly refers to a tubular passage connecting natural or pre-existing cavities in an abnormal manner. Thus, we speak of buccal, rectal, vesico-vaginal fistulse, etc., whereas a passage leading down to an old abscess or to a focus of disease in bone, for instance, is properly spoken of as a sinus. It is possible for the margins of a fistula to become more or less cicatrized and to cease to be ulcerous ; whereas the entire track of a sinus is practically a continuous ulcer, only tubular in arrangement. Causes. — A. Congenital. — There are numerous points about the body where, as the result of arrest of development or failure to grow, fistulous passages which are comprised within the normal foetal arrangements, but which should close later, either before or at birth, fail to do so. In this way we get, for example, congenital fistulse of the neck, persistent urachus, persistent omphalo-mesenteric duct, etc. These are in no sense primarily connected with diseased condi- tions, but may become so secondarily. B. Pre-existing abscess with unhealed channel of escape — e. g. rectal, fecal, and other fistulas and sinuses which connect with tuber- cular foci in any part of the body. C. Previous traumatic or other destruction of normal tissues, as, e.g., vesico-vaginal fistulse due to tissue-death from pressure, buccal fistulse from gangrene of the cheek, as in noma. D. Foreign bodies — bullets, ligatures, etc. — which prove irritating or infectious enough to prevent absolute healing. More or less tortuous 70 SURGICAL PATHOLOGY. sinuses will almost always be found leading down to the irritating material. E. The presence of necrosed or necrotic material, as, for example, a sequestrum in bone, which is usually evidenced by the presence of one or more sinuses. Treatment. — If the determining cause be still acting, the treat- ment is practically summed up in the advice to remove the cause. Consequently, when the sinus leads down to diseased bone or other dead or dying tissue, the complete evacuation of the cavity is neces- sary before the sinus may heal. If the cause be a foreign body, its removal should be at once insisted upon. Fistuhe of congenital origin and those which connect two normal cavities of the human body are usually due to a cause which has ceased to act. Consequentlv, one here endeavors solely to atone for the re- sult. One may acquaint himself with the direction and, in a general way, with the course of a sinus by the use of a probe curved to suit the case and manipulated by a gentle hand, force never being required. Or sometimes, when the silver instrument fails to pass, a flexible bougie or catheter may be introduced. Information is thus gained as to the direction and extent. This information, however, is of less value than is ordinarily esteemed, since the character of the passage can be for the most part judged by the appearance of the discharges. With sinuses of recent origin leading down to recent suppurative foci it may be enough to enlarge the opening and to wash out thoroughly the cavity as whose exit it serves. If, as sometimes happens, a par- ticle of gauze, tube, or sponge have been left therein, its removal is probably all that is necessary to secure prompt healing. In cases of longer standing it is good practice often to inject antiseptic and stimu- lating substances, or even to cauterize the interior by means of strong solutions or by means of zinc chloride or silver nitrate melted upon the end of a probe. The chronic sinus, as well as the chronic rectal fistula, is almost invariably an expression of local tubercular disease. Accordingly, these passages will be found lined with the same dense fungating membrane which lines a cold abseess-cavitv — the membrane protective in its purpose, to which I have given the name pyophylactic. Whenever such tissue and such membrane are met with, thev should both be extirpated as thoroughly as possible, since in this wav onlv can absolute eradication of the tubercular infection be relied" upon. After such complete excision — which means usually laying open the entire sinus — the parts may perhaps be brought together with sutures (this, at least, is usually possible about the rectum) in such a wav as to secure primary union; otherwise, the whole sinus, as well as the cavity to which it has led, must heal by the granulating process, both being kept packed with gauze or some other desirable foreign body which shall act as an irritant, thereby provoking more rapid forma- tion of granulation-tissue. When it is necessary thus to pack a cavity, or when it is desired to keep its upper exit open lest it heal before the lower part, ordinary white beeswax, as suggested bv Gunn makes a very serviceable material. This can be moulded in hot water to fit the cavity, can be tunnelled or bored for drainage, can be dimin- ished in size as the cavity heals, and is absolutelv non-absorbent. INFLAMMATION. 71 Finally, there are numerous plastic methods which have been re- sorted to in various parts of the body, most of which are made to comprise, first, the absolute eradication of the diseased tract, and, later, the closure of the wound, thus made, by transplantation or slid- ing of flaps or any other plastic expedient which may be considered best. These, as well as the special treatment made necessary for par- ticular forms of sinus and fistula, will be dealt with more at length under their proper headings. CHAPTER IV. ULCER AND ULCERATION. By Roswbll Park, M. D. The term ulcer pertains to surfaces/and should be defined as a sur- face which is or ought to be granulating — i. e. healing. While an ulcer may be the result of what is known as ulceration, it is by no means necessarily so, the term ulceration being one of very loose significance and applied to many different processes. For our present purposes the idea underlying ulceration is infection, and, when limited to its proper significance, the term should never be used for a process in which infection and consequent breaking-down of tissue do not virtually comprise the whole process. In this regard, therefore, it is to be abruptly distinguished from certain disappearances of tissue already alluded to under the head of Atrophy or Interstitial Absorption. It is therefore not correct to say that the sternum ulcerates away, making room for a growing aortic aneurism, the question of infection not here being raised. These distinctions should be accurately maintained and constantly borne in mind. Ulcers. The causes of ulcers may be — A. Traumatic ; B. Local; or, C. Constitutional. A. Traumatic. — This would include all those surfaces which are granulating and healing more or less rapidly, or are displaying, in other words, a kindly disposition toward healing, and which may have been originally produced by wounds, burns, frost-bites, etc. These include also those ulcers which are due to pressure, as from splints, bandages, various orthopaedic apparatus, or from external friction. Ulcers which form around foreign bodies may also be included under this head, their essential cause being traumatic. This should include also destruction of the surface by various chem- ical agencies, such as strong caustics ; also the consequences of intense heat or cold, including particularly burns and frost-bites. B. Local.— 1. Among local causes may be mentioned local infec- tions with tissue-death in consequence, such as occur in tuberculous leprous, syphilitic, and other specific manifestations where surfaces are involved. 72 ULCER AND ULCERATION. 73 2. Tumors, either benign or malignant, whose blood-supply is cut off and whose surface is thereby predisposed to infection. 3. Perverted surface-nutrition, such as is most commonly met with, for example, in connection with varicose veins of the extremities, where, Fig. 11 Chronic ulcer of leg. aside from any perverted trophoneurotic influence, there is stagnation of blood, saturation of tissues with serum, and final leakage of the same, even to the surface. In other words, a passive hypersemia leads here to oedema, perversion of nutrition, failure to repair trifling surface-injury, and a commencing ulcer is the consequence. 4. So-called pressure-sores or bed-sores, which in some cases may be regarded as having a traumatic origin, but which, nevertheless, would not occur from purely traumatic influences without predisposing tissue- changes. The bed-sore is probably the best illustration of this. Simple ulcer is known as bed-sore, while a sloughing ulcer of this kind is fre- quently alluded to as decubitus. Such ulcers are usually found over those regions of the body made most prominent by bony projections, upon which undue pressure is made when debilitated patients have lain for a long time in bed. 5. Ulcer is the frequent result of numerous skin diseases, into whose etiology as yet bacteria have not been introduced — e. g. pemphigus, eczema, etc. 6. Ulcer is the occasional result of embolic or other disturbance of the principal artery of the part, by which nutrition is cut off and tissue- death results. 7. Bites of insects or other parasites or of noxious animals frequently lead to ulceration. 8. Certain more specific forms of ulcer are described by some writers, apparently with more or less reason, among them being chancroid, per- forating ulcer of the foot, etc. Chancroid will be found described in Chapter XLIX. Perforating ulcer of the foot is a circumscribed cir- cular ulcer with thickened edges, often nearly concealed by overhanging skin. It may be found in any part of the sole of the foot, but is most common near the first joint of the great toe. The borders of the ulcer are usually anaesthetic. By some it is closely associated with trophic nerve-disturbance ; by others it is regarded as having a specific etiology 74 SURGICAL PATHOLOGY. of its own. The probability, However, is that it is simply a subvariety of pressure-sore. C. Constitutional.— 1. Ulcers are frequently met with in certain con- stitutional conditions which are characterized by tendency to local man- ifestation at points of least resistance. Among these should be mentioned scurvy. 2. There are ulcers of apparently distinctive trophoneurotic origin, of which that mentioned above as B, 8 — perforating ulcer of the foot- may possibly be one. These notoriously accompany certain nervous dis- orders of central origin, prominent among which are locomotor ataxia and tabetic disease of all forms. 3. Ulcers are produced sometimes as the result of specific or selective action of certain drugs, among them mercury and phosphorus being the most prominent. These manifestations are met with in the mouth most commonly, and may perhaps be regarded as infections at points of least resistance. Nevertheless, they are commonly associated with the tend- ency of these drugs. 4. There are many constitutional conditions in which vitality is so lowered that a special liability to ulcer — i. e. infection and production of ulcer at many points — is noted. It is well, however, to mention that the common diseases in which this tendency is most often noted are typhoid, diphtheria, diabetes, and syphilis. With this summary of the common causes of ulcer it should be again insisted upon that ulcers may be due to direct consequence of traumatic loss of substance or to the process of ulceration — i. e. as a consequence of previous infection, or as permitted by trophoneurotic disturbance and ischsemia. In this connection also ulceration should be spoken of as a process of molecular death, in which cells die successively and more slowly, as distinguished from gangrene, in which there is simultaneous death of large aggregations of cells, by which a slough or its equiv- alent is produced. Ulcers are spoken of as healthy when the process of granulation is proceeding with average rapidity ; indolent, when the reverse obtains ; sloughing, when there is actual visible tissue-death in connection with the ulcerative process ; phagedenic, when the gangrenous tendency is well marked and the process exceedingly rapid ; irritable or erethistic, when the surface is exquisitely sensitive ; hemorrhagic, when bleeding easily ; fungous or fungoid, when the granulations have risen above the . surface and are being manufactured at altogether too rapid a rate. The best examples of the indolent ulcer are seen in connection with varicose veins of the extremities ; of the phagedenic ulcer, in certain cases of chancroid ; of the irritable ulcer, in ulceration of the cornea, where the pain and photophobia are intense; or in fissured ulcer of the anus, where the pain and sphincter spasm are sometimes agonizing. Ulcers are described according to their shape as regular or irregular ; us fissured, when they extend more or less deeply and abruptly into the surface involved ; as fistulous, when they have a tubular arrangement ; as rodent, when they spare nothing in their course. The borders of ulcers are described as healthy, indurated, tumid, edem- atous, undermined, livid, inflamed, etc., these adjectives explaining them- selves. The surfaces of ulcers are described as healthy when thev have normal ULCER AND ULCERATION. 75 color and appearance, inflamed, excavated, covered with sloughs, callous, etc. The callous ulcer is one which exhibits little change from month to month ; its surface is dirty, and its secretion thin and muco-purulent. It is usually sunk considerably below the surrounding level, while its border is firm and nodular. The best examples of this form are those accompanying varicose veins. In size or area ulcers may vary from the slightest local destruction of tissue to an area covering an entire limb or a large part of the trunk of the body. In depth also they vary within lesser limits, while an external ulcer may connect with some deep lesion by means of a tubular passage or sinus. It thus appears that the term ulcer may be applied to the result of a natural effort to repair loss of substance without intro- ducing the element of disease, or that it may be the consequence of local infection with local tissue-disaster. The character of the material discharged from an ulcer will vary much according to the category in which it belongs. The healthy, healing or granulating surface, often spoken of as ulcer, discharges a material in gross appearances much resembling pus from an acute abscess. In consistency it is the same, and in color and other appear- ances. Nevertheless, its origin is essentially distinct. This material represents simply the waste of reparative material sent up to the surface for the purpose of hurrying the process. Its fluid, like that of pus, comes from the serum of the blood ; its corpuscular elements, like those of pus, are leucocytes or wandering tissue-cells, which have been fur- nished in great numbers — in fact, in excess. As it comes to the surface — or as, rather, it is rejected from the surface, being superfluous in amount— it is quite likely to become contaminated with bacteria by contact infection, and consequently may be seen under the microscope to contain various micro-organisms. This contamination has been final, however accidental and irrelevant. This material is not pus ; has no infectious properties, except those which may accidentally be conveyed to it; represents no warfare of cells, only excess of supply or over- demand ; and should be spoken of as pyoid or puruloid material, and never confused with pus. In amount it will vary according to the activity of the reparative endeavor, and somewhat according to the amount of irritation of the surface by dressings which may be applied. If a granulating surface be absolutely protected from possibility of con- tact-infection, it will never contain micro-organisms ; while this pyoid, if allowed to remain too long, especially when infection is permitted, may decompose and become irritating, and is a material to be gently dislodged by a spray or an irrigating stream with each dressing, which dressing should be made once in twenty-four to sixty hours. Processes op Repair. An ulcer having been defined as a surface which is or ought to be granulating, it becomes necessary to define the granulation process and to show how healing is thereby achieved. Granulation-tissue is a name applied to a new and temporary tissue of embryonic type, which acts as a scaffolding or temporary structure, permitting the construction of more permanent tissue. It is produced entirely by the activity of 76 SURGICAL PATHOLOGY. cells, which are the single and polynucleated leucocytes and the wander- ing cells already so often mentioned. They are frequently known as embryonal cells when performing this function ; sometimes as formative cells. They have a distinct nucleus, which stains readily, and, having this resemblance to epithelial cells, they are often spoken of as epithe- lioid cells— sometimes as fibroblasts, because they may later assume the dignity of connective-tissue cells. They assume a multitude of shapes. In a way not yet sufficiently described,* between these cells as they are drawn toward the point at which they are most needed, perhaps by chemotactic activity, there appears an intercellular substance, which later becomes fibrillated. As these fibres develop the remaining cells become entangled between them, and we have in this way a new connective tissue formed of cells of originally mesoblastic origin. Of such tissue the solid part of granulation-tissue is built. It is necessary to empha- size that this tissue is essentially different from the epithelium which it is expected will subsequently cover it. If a normal granulating sur- face be scanned with a magnifying glass of small magnifying power, it will be seen to consist of numerous minute projections, each of which is known as a granulation, and which consists of the tissue above described formed as a minute eminence around a budding capillary blood-vessel, from which a little projection has occurred upon the exposed surface. This capillary bud is the result of karyokinetic activity on the part of the endothelium — namely, the hypoblastic cells of which it is essentially composed. In each of these cells, under certain circumstances, the karyokinetic threads already spoken of develop and become loosely coiled, while the chromatin in the nucleus increases in amount and the nucleolus disappears. The chromatin threads become thicker, arrange themselves equatorially around the poles of the nucleus, and gradually turn so as to point toward it, while a new membrane forms around each separate coil, and two nuclei are thus made out of one. While this is going on within the nucleus the cell-protoplasm undergoes active rotary motion, is finally segmentated, and by the time the nucleus is divided is nearly ready for complete division of the cell. While nuclear division is usually bipolar, it may be multipolar : if a rearrangement of the pro- toplasm is delayed, the result becomes a multinuclear cell, known as a giant cell. The consequence of this endothelial activity is new cell-formation and the construction of a projection from the capillary which soon attains the dignity of its parent vessel, and, as connective-tissue cells form around it, soon becomes a granulation by itself, each granulation, being marked by a capillary loop of its own. Healing by granulation or the granulation process, no matter how set up or caused, is essentially the formation of hundreds or thousands of these tiny structures, a new one being formed on top of those which precede it, while those first formed and deeper down undergo condensation and metamorphosis of tissues, by which they are converted into something higher in the tissue scale. Under ideal conditions true granulation-building proceeds pari passu with epithelial reproduction around the margin of the granulating surface, so that by the time granulation-tissue has completely filled the defect, no matter how caused, epi- thelial covering has been completely constructed and the healing process thus completed. These two processes, however, do not necessarily keep pace with each other; and, should surface-repair take place relatively early, we may have a depressed scar ; while, on the other hand, should it not proceed rapidly enough or, to put it m another way, should the granulating process be too rapid we have such excess of granulations as shall rise considerably above the surrounding level ULCER AND ULCERATION. 77 and may, under certain circumstances, become so exuberant that nutritive ma- terial cannot be formed rapidly enough, and those granulations farthest away from the centre of supply may die. Such exuberant granulation is often spoken of as fungoid, and constitutes that great bugbear in the eyes of the laity which is termed by them proud flesh. It has no further significance than that the supply has exceeded the demand and that the granulating process has been overdone. Such exuberant granulations may be cut away with scissors or knife, may be burned away with caustic agents or the actual cautery, or may be disposed of in any other manner without harm and only with benefit; in fact, it is often neces- sary to suppress this exuberant tendency by caustics and pressure, in order that the desired epithelial covering may be properly formed. Epithelium, being an epiblastic structure and capable of no other origin save from its like, can only be supplied from those regions where it has pre-existed. Consequently, ulcers involving the external surface of the body demand a lively epithelial reproduction in order that they may have a normal covering. Epithelial activity sometimes becomes retarded, and is much slower toward the termination of the healing process than at the beginning. The epithelial covering of a healing ulcer is always marked by a delicate whitish or pinkish film, which pro- ceeds from the periphery as well as from any little island of original epithelial structure left. It is notorious that after a certain amount of this repair the process sometimes comes to a complete halt, and the vari- ous expedients for stimulating and promoting it, as sponge-grafting and the different methods of skin-grafting, have been devised solely to atone for such sluggishness or inability. Ulcers of small size which are more or less exposed to the air in healthy indi- viduals, while also exposed to possibility of infection, nevertheless seem to escape it, owing to the defensive power of the blood-serum and the active cells. Such discharge as naturally comes from them, when not excessive, undergoes evapo- ration until a point is reached where a dry crust or scab is formed. Under this scab granulation proceeds up to a point where the pressure of the scab itself, presum- ably on the level of the surrounding parts, checks its activity, while at the same time epithelial reproduction goes on until it has been completed. Then the scab, being no longer of use, drops off or is detached by slight friction. Such is granulation-tissue : at first a mere trellis-work of temporary and delicate cell-structure, traced in a certain amount of intercellular homogeneous substance, into which the budding vessels project, the whole mounting nearer and nearer to the surface, day by day with variable rapidity, diminishing in this regard as the days go by, so that frequently the granulation process comes to an apparent halt before enough new tissue has been formed. While the superficial granulations preserve the characteristics above noted, those deeper down undergo firmer and more complete organization, and the delicate embryonic structures show the same tendency which they do in the growing embryo, by virtue of what Virchow has called metaplasia, to become converted into something higher and more dignified in the tissue scale. It is not given to these cells to specialize themselves to the extent permitting complete repair of organs of special sense. Thus, while a wound in the cornea or retina may be completely healed, it heals by cicatricial tissue, and not by repair of the special structures involved. On the other hand, tissues of more common connective type — fibrous, bone, cartilage, etc. — are capable of regeneration ; and it seems to be a part of the privilege of these new granulations to merge themselves into that kind of tissue necessary for filling the gap. Nevertheless, the most common result of granulation is 78 SURGICAL PATHOLOGY. Cicatricial deformity following burn (original). its metablastio conversion into fibrous tissue which has the special charac- teristic of contractility without elasticity. As the result soars contract; in consequence of which most FlG - 12 - disfiguring results are some- times the almost inevitable consequence of healing of extensive losses of substance. In certain instances it is pos- sible by constant effort to overcome the unpleasant ef- fect of this cicatricial con- traction. For example, after I extensive burn of the anterior part of the arm, the forearm will be gradually and perma- nently flexed upon the arm by virtue of contraction of the scar in front of the elbow, unless some forcible means be prac- tised for maintaining exten- sion of the arm for at least a part of the time. So with many other injuries and the various mechanical or other expedients required to prevent the untoward re- sult. Nowhere are the con- sequences more disfiguring or I serious than about the face,! where eyelids are drawn out I of shape, the contour of thel mouth altered, or where some- 1 times one may see extensive I manifestations of this samel most undesirable consequence I (See Figs. V2 and 13.) As the result of healing of the granulating surface, v have what is known as al cicatrix or scar. This is| composed of fibrous tissue, probably more or less dis-l torted by virtue of its con- tractility, and of epithelial covering furnished from thel margin of the original ulcer, I constituting a thin, glistening I membrane, applied closely to I the scar-tissue beneath, with- 1 out intervening fat or tissue I which permits of the play of Cicatricial deformity followingtarn : side view , ; ,„, the one upon the other. When case (°nsuuii)- this epithelial surface is abraded, it is repaired with difficulty, and a raw ULCER AND ULCERATION. 79 similar irritation of the Fig. 14. or ulcerating scar is usually a difficult thing to heal. Manifestation of perverted epithelial outgrowth is frequently provoked at these points by the action of continuous irritation. In consequence we have what is generally recognized as the U-ausformatkm. of a chronic ulcer, or the site of one, into an epithelioma, or possibly, connective-tissue elements, into a sar- coma. This is the so-called cancerous degeneration of previous ulcers, and is noted occasionally. The lesion is one which often requires disfiguring, or even mutilating operations in order to get rid of the malignant disease. The surface of a superficial scar while thus covered with epithelium shows a complete lack of all the other skin-elements. No hair grows upon such a surface, because the original hair- follicles are destroyed ; neither is it moistened by perspiration nor anointed by sebaceous ma- terial, because the secretory glands have also disappeared. It is a surface which often needs more or less protection, especially when in ex- posed situations. Treatment. — Here, as in all other instances, the first effort of the surgeon should be to remove the cause, be it what it may. This may be done by local, or may require constitutional, measures. If a definite local cause can be made out, its removal may be a slight, or may entail a more or less serious, surgical operation. Aside from this disposal of the exciting agent, treatment must be divided into the general and the local. General treatment Epitneiiomatous dege is scarcely called for when dealing with ulcer, necessitating ai healthy ulcers; but in all those instances where the constitutional condi- tion of the patient is below par or where there is a general poisoning or infection underlying the ulcer itself, prompt and energetic constitutional treatment should be at once instituted. In scurvy, for instance, the diet and hygienic surroundings of the patient should be rectified immediately. In syphilis no lasting nor deep impression can be made on local manifes- tations without general constitutional treatment. In tuberculosis and the other surgical infections much will be accomplished by internal medica- tion, by proper hygiene, as well as by local applications or operation. The importance of these general measures is likely to be under-esti- mated, and many fail to realize the advantage of combining suitable internal and external therapeutic measures. Local Treatment. — First of all should be mentioned the complete insistence upon repose which brings about that which we best know as physiological rest. . The ulcer which may never heal so long as the parts are constantly moved may show a prompt and kindly tendency so to do as soon as the part is put absolutely at rest. This may mean wearing a splint or restraining apparatus, or it may mean confinement in bed, :neration of chronic amputation (original). 80 SURGICAL PATHOLOGY. Fig. 15. Cicatricial deformity following specific ulcer (original). depending upon the locution of the ulcer. Physiological rest will be enforced sometimes by such measures as stretching a sphincter in order to temporarily paralyze it in cases of irritable rectal ulcer, where the principal pain is produced by the reflex spasm of its fibres. Again, the eye with irritable ulcer of the cornea is some- times kept so tightly closed by the same kind of spasm there that it is necessary at times to divide the lids, or the orbicularis muscle at the angle of the lids, in order to make access to the part. This is in a measure carrying out the principle of physiological rest, because it permits proper exposure and treatment. The absolutely healthy and kindly-healing ulcer needs no treatment except protection. Epithelial covering will probably keep pace with filling of the depression by granulations, and all that it is necessary to do is to prevent external irritation. Should there be excess of discharge, the simplest possible absorbent dress- ing, with enough of some antiseptic material to prevent putrefaction by contamination with the ordinary bacteria of the surrounding air, should be employed. The ulcer which is be- coming tardy in its repair may be stimulated by silver nitrate, zinc chloride, or other more or less caustic applications, which act as a spur to the sluggish granula- tions, destroying those with which it comes in contact, but stimulating those below to do their duty more promptly. The conventional applications to ulcers fall usually under two cate- gories — the watery solutions and the unguents. Of late the investigations of the laboratory have led to the employ- ment of numerous peptonized preparations, among which may be men- tioned peptonized cod-liver oil and some of the partially or predigested foods, such as bovinine, etc. These appear to have the power of digest- ing sloughs and of causing a speedy separation or disposal of everything which one wants to get rid of in the endeavor to secure a healthy con- dition of the ulcerating surface, and give in many instances most sat- isfactory results. When sloughs are present it is frequently an advan- tage to dust over them some of the preparations, like papoid, caroid, etc., which have the power of catalytic disposition of decomposing material without reference to action of bacteria. Under their use there seems to be a sort of solution and disposition of these dead products. With a foul ulcer — one from which the discharge is more or less offen- sive, due usually to decomposition of sloughing masses not yet sep- arated — the method of continuous immersion in hot water, when it can be carried out, is always valuable. But I have never found anything for this purpose equal to ordinary brewers' yeast; it may be applied on absorbent cotton (which should be soaked in it) and covered with oiled silk. Its wonderful property may perhaps be ascribed to the nuclein which it contains in a nascent state. At all events, it will, when fresh, clean off a sloughing surface better than anything I have ever used. ULCER AND ULCERATION. 81 Many ulcers are surrounded with such firm, indurated borders that it seems impossible that any active regenerative process can arise from such source. Hence incisions have been practised for centuries. These have been made radially from the centre or have been made parallel to the margin of the ulcer, or sometimes the firm, dense tissues have been minced or chopped by a series of cross-cut stabs or incisions ; as the result of which renewed activity has been set up, and an impetus, oftentimes sufficient, has been given to the healing process. These methods, however, have now yielded to that just above alluded to. The comparatively recent ulcer in which granulation has come to a stand-still is often treated with the sharp spoon or curette. The result of this has been to provoke again a speedy renewal of granulation efforts, and treatment by curetting is standard and often useful. Actual cauterization of the ulcer with a view to such complete destruction of its covering and border as shall lead to their separation by the sloughing process is occasionally practised. This is perhaps best performed with the actual cautery. It lacks, however, the valuable features of the operative method to be described below. Modern methods have made it plain that it is often an absolute waste of valuable time to resort to the older expedients of stimulation, incising the edges, etc., and that one can accomplish by an operation in perhaps three weeks what ten times that length of time would' fail to do by older methods. The most effective method, therefore, in dealing with, old and chronic ulcers is to anaesthetize the patient, to excise the entire affected area — i. e. the surface which ought to be granu- lating and the firm border and tissue in its neighborhood — and then to cover this surface either with skin-grafts, pared off with a razor according to the Thiersch method, or with a strip of skin whose full thickness is raised, which is taken from surrounding parts by some auto- or hetero- plastic method. This line of treatment is so far preferable to all others that, except in case of refusal of the patient to submit to it, it is the one which must hereafter universally commend itself. It may afford opportunity for extensive plastic operations or for the exercise of the best discretion and knowledge of experienced men ; yet cases are rare in which it cannot be successfully carried out. These methods of skin- grafting have so far supplanted the older method of sponge-grafting that the latter is now scarcely ever practised. It may possibly have a sphere of usefulness in certain ulcerated cavities, but under all other circumstances it must take a position far below the plastic methods in practical value. Finally, ulcers of specific type — syphilitic, tubercular, leprous, glanderous, etc. — all need methods in which the first effort shall be not so much to arrange for healing as to dispose of infectious material. The knife, the scissors, the sharp spoon, come first into play here, the surgeon bearing in mind that almost all this material is more or less infectious, and that inoculation of his own hands is possible as the result of carelessness. After taking away with instruments all the granula- tion-tissue with its surroundings which seems to expose to danger, it would be well to thoroughly cauterize the part with the actual cautery, nitric acid, bromine, zinc chloride, or something of the kind as a mat- ter of insurance of the desired purpose. The markedly hemorrhagic ulcer, whose surface bleeds on the slight- 82 SURGICAL PATHOLOGY. est contact or disturbance, is often a cancerous ulcer, though not neces- sarily so. This ready bleeding is usually the cause of the extreme fragility of the tender walls of the rapidly new-formed blood-vessels. In many instances it is enough thoroughly to scrape until one comes down upon harder or more resisting tissue. Hemorrhage may be pro- fuse for the moment, but it is almost invariably easily controlled. Caustics may then be applied or not, according to the judgment of the surgeon. Another method is to treat such a surface with the actual cautery. Another is to operate, even in the presence of really incurable disease, simply in order to check tendency to fatal hemorrhage before the natural tendency of the disease has expended itself. In a general way, with regard to all small ulcerating can- cerous surfaces, one may say that if they bleed excessively or are unduly irritable, it is perfectly legitimate to attack them by operative measures in spite of the im- possibility of effecting a cure. Numerous other methods of treating ulcers may be found in the older text- books, but they have, in whole or in part, been abandoned for the comparatively few already mentioned. CHAPTER V. GANGRENE. By Roswell Park, M. D. This is known also as necrosis, although by general consent this term is usually limited to gangrene of bone. It is known also to the laity as mortification, and to the older writers, especially when soft parts die and separate in sloughs, as sphacelus. Gangrene means death of tissue in visible and more or less circumscribed masses. It is to be dis- tinguished from ulceration because now we have to deal not with a pro- cess of molecular disintegration, particle by particle, but with death in toto and synchronously of a large perhaps innumerable number of cells. Gangrene is described as due to causes which may be — ■ A. Traumatic, including the so-called thermal causes as essentially mechanical injuries. Under this head would come all cases where injury is the primary cause, whether this injury be the crushing of a limb, the separation or occlusion of its main blood-vessels, the division of its main nerves, the crushing or pulpefying of its entire structure by machinery or accident, and also those so-called thermal cases which are due to intense heat or intense cold. To these might be added the chemical causes, comprising injuries by powerful caustics, alkalies, or acids, which are known to cause speedy death of every living tissue with which they come in contact. B. Local Causes. — These are largely connected with ischcemia, pro- duced in one way or another. Gangrene from oedema — itself the result of passive hyperemia and exudation — is not infrequent, the most com- mon expression of this condition being seen, perhaps, in the external genitals of the male. Embolism due to valvular heart disease, thrombosis due usually to a preceding phlebitis, but possibly to marasmic origin, especially met with after confinement, with disturbance in the uterine sinuses, shutting off the circulation by endarteritis, which thus assumes the form obliterans, are some of the local causes which concern the blood- vessels alone. In fact, the majority of cases of spontaneous gangrene are probably due to changes in the vessels, endarteritis being the cause of a condition known as atheroma of vessels, in which fungoid out- growths or, rather, ingrowths into the vessel-lumen, are common. Any one of these, if detached, may serve as an embolus. The degenerative excavations in the thickened walls of the blood-vessels which discharge more or less cholesterin and other debris, and which have in time past been known as atheromatous abscesses (misnomer), are frequently the 83 84 SURGICAL PATHOLOGY. precursors of the disease under consideration. As the result of these changes alone, without reference to formation of emboli, vessels may become completely occluded, especially when slightly injured. Extravasation of blood is another cause connected with the blood- vessels, this coming usually from traumatic rupture, possibly from idiopathic causes. At any rate, the tension in the part may threaten its life because of the pressure which overcomes the circulation of blood. Ligation of the main trunk of an artery is sometimes followed by gan- grene, no matter how carefully done, collateral circulation being insuf- ficient to sustain the nourishment of the part. In certain fractures, simple as well as compound, the blood-supply of a part is rudely broken off by injury to a blood-vessel in such a way as to cause local or general death, either of a bone or of the entire limb. Flaps made for plastic purposes, arranged without sufficient regard to their proper blood-sup- ply, or so dressed after operation as to sustain undue pressure, are often so shut off from the heart as to die for want of blood. Finally, gan- grene may be the result of pressure either from splints, bandages, etc., or from tumors increasing in size, or possibly, as in certain pressure- sores, etc., from the mere weight of the body. Here, too, chemical agents must be mentioned, referring now to the peculiar action of certain foods or drugs, particularly ergot. Thus, antiseptic solutions, partic- ularly carbolic acid, may be made strong enough to destroy the vitality of certain tissues. Carbolic gangrene (Warren) is a possibility not to be forgotten. C. Constitutional Causes. — Among these are to be mentioned partic- ularly that symptom-complex ordinarily known as diabetes or glycosuria. It is notorious that this means a depraved condition of the system in which gangrene is threatened or permitted under circum- stances which otherwise would have little or no disastrous effect. Thus diabetic gangrene has come to be one of the recognized mani- festations of the general subject. That the trophic nerves have a more or less pro- nounced effect in determining gangrene in certain cases seems to be now quite well es- tablished. It is well known how quickly bed-sores form after injuries to the spine, while in certain nervous affections a mini- mum of friction of the skin may determine its death, particularly about the labia or scrotum. It is said that the insane, when ^Sf^^SSm^^ir^.^ slee P l>v chloral, may develop ™ . , „ , decubitus from pressure in a single night, lnere is also a well-known form of symmetrical qangrene, known some- times as Raynaud's disease, which is characterized by symmetry of lesions and absence of definite pathological changes. The so-called dujih mortal, or dead fingers, are expressions of trouble of this same character; so is a so that condition described by neurologists as erythro- melalgia A condition almost leading up to gangrene, but perhaps not absolutely terminating in such a way, has been known as local asphyxia Fig. 16. GANGRENE. 85 which seems to be a condition of arterial spasm with venous congestion and slight oedema. As constitutional causes also must be included the deleterious effects of certain drugs, particularly ergot, mercury, and phosphorus. D. Infectious Causes of Gangrene. — In the instances already men- tioned I have avoided reference to the infections micro-organisms. There remain to be considered special types of gangrene due to the activity of certain micro-organisms — among these that variety of gangrene known to our fathers as hospital gangrene, as well as phlegmonous erysipelas, malignant oedema, gangrenous emphysema, noma, ainhum, etc. Gangrene as the result of infectious processes is met with, for instance, in severe cases of phlegmonous erysipelas, where death of tissue seems to be due to the combined influence of the invading organisms and of mechanical agencies — i. e. tension produced by stasis and exudation, with such stretching of tissues or overcrowding them with inflammatory products as to virtually strangle them, in consequence of all of which they die. Gangrene of an entire hand may thus result, or, more commonly, the gangrene is limited in extent to the more super- ficial parts, so that sloughs separate. A peculiar and specific form of gangrenous inflammation is that also known as malignant cedema, which is due to a peculiar anaerobic bacillus, and which will be treated of separately under a distinct head- ing. Quite like it in several respects is the gangrenous emphysema of certain writers, known also as the fulminating form, or, as the French call it, the "gangrene foudroyante." More or less emphysematous condition may accompany malignant cedema ; yet that we do get gaseous forms of gangrene without the specific bacillus of malignant cedema is established. Hospital gangrene, so called, has been in years past the terror of mili- tary surgeons and camp hospitals. As a type it has almost completely disappeared from observation, and, in its old manifestations at least, is now practically never seen. Noma, known also as gangrenous stomatitis, cancrum oris, and gan- grwna oris, is a term applied to a form of tissue-necrosis affecting the cheeks or parts about the face of young children, occurring frequently Noma (Original). as a complication of the exanthemata. A similar condition occasionally involves the external genitals. From the fact that it seldom passes 86 SURGICAL PATHOLOGY. Fig. 18. across the middle line, it has been regarded by some as of neurotic origin. Naturally, bacteria are always found in the decomposing tissues ; but whether there as cause or as result is not yet absolutely established. The probability is, however, that we have to deal with a specific form of infection. The loss of substance is usually so great as to determine complete perforation of the cheek, so that the jaw-bones may be laid bare. The gums and alveolar processes also frequently share in the process, and the teeth accordingly drop out. Death of tissue is rapid, and septic infection may accompany it to such extent as to cause death of the little patient within two or three days. While theoretically most vigorous measures are necessary for combating it, these patients are often so reduced as to preclude the possibility of doing much, and death is the common termination of noma. Should patients recover, there is extensive deformity as the result of cicatricial contraction. Along the coast of Africa and in the West Indies there occurs among the negroes a peculiar gangrenous affection of the toes known as ainhum. This may assume either the moist or the dry type of gan- grene, but the result is gradual separation of the part, usually by the dry process, as if it had been strangulated by • a ligature. The disease is very slow and may ex- tend over ten years. The minute cause is as yet unknown. Finally, gangrene is the termi- nation of the infectious process in several other zymotic diseases, among the best illustrations being that afforded by diphtheria. The formation of diphtheritic ulcers in the mouth and the vulva, about the eyes and elsewhere, as the result of separation of sloughs, is too frequent to pass" unnoticed, yet at the same time does not essentially differ from the sepa- ration of sloughs due to any other specific cause. All these acute zymotic diseases, therefore, need to be regarded as among the possible causes of gangrene by infection of tissues. The symmetrical gangrene, often paroxysmal, affecting the fingers and toes, described by Raynaud and often called by his name, is due to vaso- motor spasm, and is accompanied by neuralgia and sensory disturbances, with coldness of the part and discoloration suggestive of impending gangrene. (Vide above.) Billroth and others have also described a spontaneous or angio-neurotie gangrene of the extremities, occurring during youth, in abrupt distinc- tion to senile gangrene, whose course is tedious and painful, and which will usually necessitate amputation. The cause of this condition has been found to be a well-marked arteriosclerosis and thrombosis, both in the arteries and veins. This form of gangrene occurs most often in the frigid zone — v. g., in Northern Russia. Section of noma cheek ; showing necrosis of tissue from bacterial infection (Miller;. GANG BENE. 87 Gross Appearances. — In a general way, tissue-death, known as gangrene, assumes two quite opposite types — the moist and the dry. In moist gangrene, aside from those general appearances which plainly indicate commencing putrefaction of tissues, and the loss of heat due to- shutting off of the blood-supply, one of the most characteristic Pig. 19. features is the formation of a so- called line of demarcation — i. <=., border whichs separates the dead from the living tissues. While this is usually plainly indicated by a red line which usually more or less abruptly separates the dis- colored, usually dark, dead por- tion from the bright-red, con- gested appearance of the living tissues, we note that this area of redness shades out into a more and more natural appearance as we pass upward, while below the line we note a surface, usually covered with blisters, from which exudes a foul-smelling altered serum, while the gangrenous por- tion usually assumesa dark, finally an almost black, appearance, re- taining only the crude outlines of its original shape. Along with this the objective evidences of putrefaction are unmistakable, appearances and odor being charac- teristic. With all there are more or less constitutional disturbance, and a recognizable, often a profound, condition of septic infection, due to the fact that along the line of demarcation absorbents are still active, and that the poisonous products of putrefaction are being absorbed into the general system. Consequently, collapse, profuse perspiration, septic diarrhoea, etc., are commonly noted. In gangrene from frost-bite the process is usually somewhat more slow than in the more distinctly traumatic forms. In gangrene from extravasa- tion of urine the separation of sloughs is often extensive, and com- plete sloughing of the scrotum with exposure of the testicles is a not infrequent result. In decubitus or bed-sore the process is still more slow, but always of the moist type. After a variable length of time there is separation of slough and a resulting large, often foul, ulcer. Dry — or, as it is usually known, senile — gangrene presents a very distinct contrast to the moist type. It is met with almost invariably in patients over fifty, and occurs often as the result of causes which are slow of action. As the result of the shrinking and corrugation of the tissues, along with the dryness of the same by evaporation, we have a peculiar appearance known as mummification, the foot, for instance — for the feet are usually first involved — very much resembling the foot of a person who has been embalmed, except that it is discolored. It is pos- Moist gangrene of foot (original). 88 SURGICAL PATHOLOGY. sible sometimes to have a combination of moist and senile gangrene, especially when there has been infection by which putrefaction is per- mitted. "When from the outset putrefactive processes are absolutely prevented, the gangrene of this type is almost invariably dry. In prac- tically all of the cases of this character there will be found evidences of vascular disease, usually in the femoral artery and its branches. Gangrene of the foot alone is most commonly due to endarteritis, while gangrene of the foot and leg together are usually due to embolism or thrombosis. Signs and Symptoms. — Aside from those already mentioned, which are recognizable at a glance, there is but little more to say. The ap- pearance and the odor of a part will quickly indicate impending or actual traumatic gangrene. The pallor, the coldness, and the dryness of senile gangrene are also characteristic. In the latter form, at least up to a certain point, constitutional symptoms are not indicative nor essentially of septic type. Just so soon, however, as a process of spontaneous sepa- ration begins putrefaction is inevitable and sepsis unavoidable. In moist gangrene there is seldom acute pain. This is one of the predominating subjective features of the senile forms, at least in many instances. Hem- orrhages occur, sometimes terminating fatally, in the moist forms when large vessels are eroded. This is particularly true of the phagedenic or hospital form. A recognition of their possibility may enable us to avoid sudden death from this source. Treatment. — We shall speak first of treatment of threatening gan- grene, which, so far as it may be possible, should impel us to attack and remove the cause. Threatening bed-sores may be avoided bv equalizing surface pressure, and this best with the water-bed ; by protecting the skin or by stimulating and toughening it with alcoholic and astringent lotions ; by frequent changes of position ; by attention to the heart, which should be stimulated to a point that may make it capable of for- cing or distributing blood equably over the entire body. So, too, with limbs which are enveloped in dressings or splints : it is always well to leave exposed the tips of the toes or fingers, at least when practicable, in order that discoloration of the same may be quickly' recognized and the threatening disasters averted. Local gangrene as the result of pressure by tumors, aneurisms, etc. cannot alwavs be averted, though one realize its imminence. These are cases where one needs must sit hopelessly and helplessly by and see that occur which he can- not obviate. For gangrene which has actually occurred there is but one relief, and that is the removal of the dead and dying tissue. The method and loca- tion of the operation must be determined somewhat, however, by the general character of the cause. For a case of acute traumatic gangrene amputation at the nearest point of election above the injury will often suffice. In case of gangrene from frost-bite the tissues in the neighbor- hood of the line of demarcation are often so affected or their vitality so compromised that to simply separate the tissues along the lines at which nature is endeavoring to remove them is not enough, and to go an inch or so above this line is simply to operate in tissues which bleed readily and heal badly. Consequently, here it is often good judgment to select a suitable point at some distance above. But it is especially in the forms GANGRENE. 89 of diabetic ancT senile gangrene that surgeons have now laid down the rule that if amputation be done at all, it must be high. If one have senile gangrene of the toe, for instance, as the result of disease of the vessels, he may be sure that it will be wise to amputate at least above the ankle ; whereas if any greater portion of the foot be threatened, it will be emi- nently judicious to amputate above the knee, if at all. I have repeatedly under these circumstances found the tibial arteries so brittle as to snap under a ligature, and even the femorals so disorganized as to require handling and ligating with the greatest caution. These high amputations are therefore necessitated by the condition of the vessel-walls ; all of which must needs be explained to many patients before they can appre- ciate the reasons for such high operations or consent to them. While amputation for traumatic and acute cases is, in the majority of instances, if not too long delayed, successful in saving life, in the senile, and par- ticularly in the diabetic forms, it is in the majority of cases a disappoint- ment ; and my advice to all, especially to young men who are chary about assuming responsibility, is to have these matters definitely under- stood and the situation thoroughly canvassed before consenting even to make such an operation, urgently as it may seem indicated. PART II. SURGICAL DISEASES. CHAPTEE VI. ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. By Roswell Park, M. D. One of the greatest advances made in recent pathology has been the establishment of the fact that a great many of the morbid conditions from which the human race suffer are those due to causes arising entirely from within their own systems and in consequence of deficien- cies of elimination or of perverted physiological processes which, in large degree, are themselves the result of errors and indiscretions in diet, in manner of life, in habits, etc. That these general facts have been recognized for centuries is perhaps a credit to the powers of observation, of practitioners of past generations. Exact knowledge, however, has come only with exact laboratory methods of research and most pains- taking study of the secretions and excretions, both under normal and morbid conditions. The subject of auto-intoxication has been too com- monly relegated to the domain of internal medicine, and has been sup- posed to be one in which the surgeon, as such, need take only passing interest. The alkaloids are by no means the only poisonous products which the human body may produce and retain. That most important excre- mentitious material of all — i. e. carbonic dioxide — could not be retained in the organism for more than a few moments without death as the in- evitable consequence. The various soluble ferments elaborated by certain glands may exert deleterious influence, both local and general ; and in the saliva are also found products which are not ferments. The biliary acids also, if they do not find free escape, may produce fatal poisoning. So also leucin, tyrosin, and all of the excrementitious products which arise from insufficient liver-activity, are capable of producing forms of intoxication — such, for example, as eclampsia, etc. By no means all of the alkaloids produced within the body are poisonous. Some of them are met with in the normal tissues, and they are, perhaps, only one of the many results of the disassimilation of animal cells. Nor are all these poisions of bacterial origin, although many are only formed in the presence of microbes. From these constantly-menacing sources of intoxication man escapes by virtue of his intestinal, cutaneous, pulmonary, and renal emunctories. For instance, the usefulness of the perspiration is shown by the odor 91 92 SURGICAL DISEASES. which it assumes under the influence of certain disorders. Amongst hypochondriacs and the inactive, fatty acids are eliminated abundantly by the skin. Hence the odors of hospital wards, asylums, prisons, etc. So, too, in the case of many who suffer from deep-seated, indolent ulcers, the odor of the skin is suggestive of the presence of pus. During twenty-four hours there are eliminated from the lungs 1100 grams of carbonic dioxide, water, etc., which sometimes contain ammonia and various volatile fatty acids ; all of which will explain fcetor of breath when it is the result of incomplete nutrition and destruction of food. Of all the organs of elimination, the most important is the kidney, which can never be charged with reabsorbing a part of its own products, as does the intestine. The kidneys eliminate fluids and solids, not gases. The most important of the toxic principles contained in the urine are — 1. Urea, which ordinarily plays a most important and useful role in the economy, since it possesses the property of forcing the renal barrier and removing along with itself both the water in which it is dissolved and other toxic matters. Urea is toxic, but only in the sense that any other substance, even water, may be so — i. e. it is toxic only in relatively enormous doses, much less so than sugar, and no more so than the most inoffensive salts. This is contrary to generally received views, but is experimentally clearly established by the researches of Bouchard. 2. A narcotic substance, and 3. A sialogogue substance, whose composition is unknown. 4. 5. Two substances having the property of causing convulsions, one having the power of contracting the pupils. Composition of both un- known. 6. A substance which produces heat by diminishing heat-production — possibly a coloring matter. ' 7. Potassium salts, which are really convulsing agencies, and are the most toxic perhaps of any of the poisons contained in the urine. The chloride of potassium, for instance, is toxic at 18 grams for every kilo of animal. Salivation and myosis, as well as diarrhoea, are often noticed in so-called urwmia. In that form known as hepatic uraemia, when the liver no longer forms urea, the kidneys scarcely act. In other words, if urea be no longer present in the body, the kidneys are deprived of their principal stimulation to physiological activity. Consequently, urea, for so long a time the bugbear of physicians, is shown to be most dangerous when absent. When urea is deficient it is most wise to resort to withdrawal of large quantities of blood-serum or of water in which the other toxic substances are dissolved. This is best done by venesection, whose value in so-called uraemia past experience amply corroborates! When kidney activity ceases intoxication is most likely to be produced by potassium salts. Correct performance of hepatic function is also most necessary in order that surgical cases may progress without disturbance. Bile escapes direct absorption by the blood, but not all contact with it, since in the intestine it is in contact with mesenteric capillaries, but must pass again through the liver, which shall take it up anew and pour it once more into the intestine. Bile in the blood is always dangerous, although its toxicity is relatively much smaller than has been generally supposed. Of all the bile thrown out into the duodenum, we are only able to account for about one-half. Its coloring matter and biliary salts are metamorphosed. Yet in certain morbid conditions bile as such, may be reabsorbed in the liver along the margin of the hepatic cells 'in ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 93 these cases, if the kidneys remain permeable, auto-intoxication is simply threat- ened; if they have ceased to be permeable, actual auto-intoxication is the result. Putrefaction of intestinal contents affords another source of auto- intoxication. This comes both from imperfect metamorphosis of food and from bacterial infection. Here the conditions are most favorable. Nitrogenous substances become peptonized, and peptones form the best culture-media for microbes. Water is present in sufficient quantities, and a constant temperature of 37° C. is maintained. The digestive tube is always open, and invaded at frequent intervals. By such mechanism are formed those products whose effects are revealed in the so-called putrid fever of Gaspard. Brieger has shown that alkaloids are developed during the act of peptonization. Fecal matter contains also excretin, whose toxicity has been amply proven, and several other alkaloidal sub- stances, soluble in various media, varying in toxicity. The potassium and ammonium salts contribute largely to the toxicity of faeces ; bile also, but in lesser degree. It has been shown that the aqueous extract of putrid matter is very toxic, but that of fecal matter is much more so. The most serious features of the various conditions grouped in time past under the heading Bright's disease are their so-called urmmic fea- tures. These happen at the period when retention of toxic products is peculiarly harmful. So long as the urine be ample in amount and of high enough density — i. e. containing enough toxic materials in solution — there is no danger of intoxication. But when it no longer eliminates in twenty-four hours what it ought to, then we see the chronic and par- oxysmal nervous accidents, the oedemas, fluctuations of temperature, etc., which are properly considered so serious. Oliguria with urine of increas- ing density and general oedema of the tissues may be noticed, although the other secretions continue natural and the tongue be moist. So long as the normal amount of solids is eliminated, this form of " uraemia " may be due to mere accumulation of water, and may not be serious. Ordi- narily, urannic patients are those whose urine has lost its toxicity. Usually on the day in which so-called ursemic accidents happen the urine quite ceases to be toxic and is scarcely more so than distilled water. Urea alone is not to be held guilty for this condition. In order to kill a man with urea it would require the quantity which he makes in sixteen days. Nevertheless, it may become harmful after undergoing transformation into ammonium carbonate or other substances. Among the most poisonous substances in the urine are the extractive and coloring materials. Normal urine loses one-half of its toxicity by decoloration ; bile acts in the same way. Urea alone represents about one-eighth of the total toxicity of urine. Ammonia is toxic, but present in small amounts. The coloring matters of the urine cause two-thirds of its toxicity, the remainder of which is to be ascribed to its mineral salts, which it contains in the following proportion : A litre of urine ordinarily contains 44 grams of solid matter, of which 32 are organic, 12 mineral. Of the latter, potassium salts constitute 3 grams, sodium salts 7.50, and other earthy salts constitute the remainder. In these conditions physicians have, in time past, relied largely upon purga- tives, hoping thereby to remove urea from the blood. But intestinal elimination has no elective affinity for it, and removes it only in its normal proportion with the balance of the blood. Purgatives, however, help, first, by dehydrating the tissues 94 SURGICAL DISEASES. — i. e. removing water with toxic material in solution. But they should be followed by restoring to the tissues pure water. By bleeding more extractives are removed than by any other channel, except by the kidneys. A bleeding of 32 grams removes from the body as much toxic matter as would 280 grams of a liquid diarrhoea or 100 litres of perspiration. This much may be removed by two leeches. It is espe- cially in the subacute nephritis of scarlatina, etc. that bleeding finds its greatest indi- cation. If the kidneys be chronically diseased, the utility of bleeding is doubtful, for we cannot continue it incessantly. Between the arterial capillaries of the bowels, however, and the liver is found a mass of blood accumulated in the portal vessels. This may now be regarded as a reserve which can be thrown into the general cir- culation when needed, in order that thereby we may augment arterial tension and so increase kidney function. Cold injections into the bowels will often accomplish this, and serious anuria often disappears after their use. It is reasonable now, also, to make deliberate use of urea by subcutaneous administration as the most power- ful diuretic known, surface friction, caffeine, digitalis, etc. being far behind it in efficiency. In that particular form of intoxication noted in the eclampsia of puer- peral patients inhalations of chloroform are most valuable. Potassium salts should, under these circumstances, never be employed. We may also take advantage of the fact that an exposure of urine in compressed air will diminish its toxicity, on account of contact with the oxygen, as well as of the fact that the most toxic bac- teria are those which grow without oxgyen. Consequently, by causing these patients to inhale this gas we may in large measure overcome this kind of auto- intoxication. The value of a thoroughly active liver is also not appreciated to the full extent by most surgeons. The blood of the portal vein is so much more toxic than that of the hepatic vein that it is most evident that the function of the liver is, in large measure, to purify and remove from the blood that comes from the intestines no small amount of highly toxic material. This has been called by Flint and others the depura- tive action of the liver. That facts above stated or others related thereto have not been entirely lost sight of by surgeons in time past is shown by such expres- sions as septic enteritis, enter asepsis, etc. which are used by various writers. In previous writings I have made a separate and distinct topic of so- called intestinal toxwinia, which here I have preferred to introduce as simply one of the many possible auto-intoxications. To be sure, it is a condition not always permitting of exact definition, nor, still less, can the exact toxic agency be certainly indicated in a given case. Neverthe- less, it has been made plainer and plainer within the past few years that there is perhaps no condition which so predisposes to saprcemia, septicemia, or even pycemia, as this vague condition of intestinal toxsemia, which, nevertheless, is so often present, I have long maintained that many surgical patients present forms of blood-poisoning in which the poison has not proceeded from the wound, and for which the surgeon is not responsible, except in so far as he may have neglected to avail himself of certain precautions based on facts which this chapter purports to teach. The practice of preparing patients for operation by a course of purgatives emetics, etc., which has prevailed at many times in the past, is based upon the crude recognition of certain principles which it is desired here to make much clearer. Some one, if not each, of the general symptoms included under the name enterosepsis, stercoraemia, copraimia, or whatever one may choose to call it is cer- tainly due to the activity of the colon bacillus, which seems to be made more"" viru- lent by certain conditions of diet or retained fecal excretions, and to sucn an extent that it now wanders widely from its normal habitat and may be found in distant parts of the body. Enterosepsis may be mistaken for surgical fever, and is to be dis- ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 95 tinguished from it, perhaps, only by the careful study of the excretions of a given case and establishing the fact that they are free, and that consequently pyrexia, etc. cannot be due to diminished elimination. Aside from the migrations of the colon bacillus, it is also possible for such ;i degree of auto-intoxication to occur that infection by other organisms is permitted, as it would not otherwise be; and thus that which is to-day stercorsemia may become in a day or two a genuine sep- ticaemia, vital resistance being lowered to the extent of permitting local infection that could otherwise not have occurred. The various conditions are clinically so often merged together that it is difficult or impossible to separate and identify them. Nevertheless, the fact should be taught as plainly as our language may permit that enterosepsis differs from saprsemia, to be considered shortly, in that in the one instance the putrefying material is contained within a normal cavity, whereas in saprsemia it is contained within an abnormal cavity, in either case corresponding to a septic suppository, varying, however, in the place of insertion, varying also in the nature of the surrounding tissues, which in the latter case are much more capable of absorption and of becoming infected than in the former. A determination of indol and indican is often of the greatest value, both in determining the extent of infection and the presence of pus. Indol is set free under the following circumstances: a. Suppuration in a closed cavity, b. Con- tinued suppuration in a cavity with an outlet, c. Ulceration or necrosis of tissue. The degree of indicanuria will depend on the length of time during which pus has been present, the possibility of absorption from the tissues surrounding it, and their extent. When pus is fully formed in a serous sac the indican-reaction be- comes intense in proportion to the length of time during which pus has been present. This is particularly true in the empyemas of childhood. In continued suppuration with a free outlet the production of indol will be great ; but the amount finally eliminated will depend upon the character of the surrounding tissue. When solid tissue, like bone, becomes affected the elimination of indol is most intense. Rapid biogenic degeneration of tissue causes an increased amount of indol to be deposited in the liver, and it is possible at post-mortem, by simple extraction with absolute alcohol, to take from the liver this excess deposit in the shape of its oxidation-product, indigo blue. Lardaceous degeneration is characterized by marked and persistent elimination of indol, which seems to be a product of tyrosin. It occurs most often in the liver, in which indol is notably deposited. Its primary factor is deposited by the blood, in which later indol circulates and is oxidized. Lardaceous material gives a red or blue color with oxidizing agents, which latter yield with indol an indigo red or blue. The practical outcome of such a chapter as this is, then, to insist as strongly as possible on the preparation of patients, whenever this is feasible, for an ordeal which comprises the combined effect of anaesthesia and consequent disturbance of secretion and elimination, with loss of blood and of strength, and subsequent confinement in bed, with, more- over, all that this entails in further impairment of activities of important organs. It is not always possible, practically rarely so in emergency cases, to adopt these precautions ; in which cases they must be atoned for, so ffir as possible, by extra attention in the same directions after the emergency is passed or has been met. In the former case, however, the functions of the skin, the kidneys, and the abdominal viscera must be regulated — the first by hot-air baths ; the second by this same measure in conjunction with copious draughts of pure water, the correction of hyperacidity of the urine, and the administration of whatever drugs may be of benefit as diuretics, etc. ; and the third by a course, perhaps covering several days, of gentle or active purgation, by which the ali- mentary canal shall be entirely emptied of all that may serve to act as a source of poisoning. In addition to this, in certain cases careful mas- sage will dislodge from the muscles and other tissues material which they ought not to retain, and which shall be washed away, as it were, by 96 SURGICAL DISEASES. the extra amount of fluid which this preparation necessitates. In addi- tion, also, the activity of the heart should be stimulated, perhaps by- digitalis, but preferably by that best of all tonics, strychnia, which is to be administered hypodermically in average doses of a thirtieth or twenty- fifth of a grain, morning and night. When these precautions are taken patients will successfully pass through most trying ordeals without any- thing which may give rise to alarm. When they are not possible, the risk of operating, even in a small way, is materially enhanced. So, too, after operations when these precautions have not been taken it is neces- sary to give most careful pains to atoning for their lack by such active purgation as a now reduced patient may bear — by hot-air baths, if feas- ible, and by the administration of such intestinal antiseptics as charcoal, naphthaline, corrosive sublimate, bismuth salicylate, salol, etc., for the purpose of reducing to the lowest possible minimum the opportunity for formation of poisons which shall disturb the proper repair of injury. CHAPTER VII. THE SURGICAL FEVERS AND SEPTIC INFECTIONS. By Roswell Park, M. D. Surgical Fever, known also as Traumatic Fever, or Aseptic Wound-fever. In times past, when operations were never done aseptically and when ideal wound-healing was unknown, the surgical fevers were all grouped together, and a certain amount of febrile disturbance was looked for after any injury. But with the introduction of antiseptic methods and with healing of wounds by primary union, with absence of all septic phenomena, and at present when the careful use of the clinical ther- mometer is common, it is noted that there is, nevertheless, a certain rise of temperature more or less quickly after an operation or recep- tion of a wound, with fever of mild grade persisting for several hours or two or three days, and with certain other accompaniments which are usually noted along with it. This phenomenon has been carefully studied, and so completely separated from the septic fevers as to have deserved a distinct recognition under the names above given, of which the most common in this country is surgical fever. So long as this fever be free from indications of septic character it is without significance and needs only symptomatic treatment. It begins usually within the first twenty-four or thirty-six hours, after which tem- perature may rise progressively or with a morning remission to a height of 102°, or possibly 103° F. In children we are more likely to get extremes in this regard than in healthy adults. It will be followed by some disturbance of alimentary function, glazing or drying of the tongue, deficiency in urinary secretion, and will nearly always subside spontaneously — invariably so if cathartics, diuretics, cool sponge-baths, etc. be properly resorted to. It is usually due to the retention of blood- clot, ligatures, etc., or tissues which have been ligated and whose stumps remain ; in all of which instances there is some foreign material to be removed. This means unusual phagocytic activity, perhaps temporary leucocytosis, with active metamorphosis of clot and other material ; of all of which the elevated temperature is an accompaniment and expres- sion. It is not unlikely that the antiseptic materials sometimes used have also to do with this pyrexia. Iodoform and carbolic acid are among materials in common use which are known to be irritating and capable of producing toxic symptoms. Often after the use of the latter the urine will be discolored and will furnish the clue to the fever. In young children particularly, and not infrequently in adults, mental disturbance, even to the point of active delirium, may characterize the case. This is not always to be explained by cerebral ansemia due to loss of blood during the operation or accident, but is undoubtedly in certain instances due to drug-toxsemia, or in other cases to intoxication from materials furnished by the altered tissues. 7 97 98 SURGICAL DISEASES. Surgical fever of strict type may merge into a more or less continuous fever as the result of intestinal toxaemia permitted by failure to thoroughly evacuate the bowels, and this intestinal toxamiia may be a predisposing cause of genuine septic infection. Consequently, a surgical fever which does not disappear within two days is to be viewed with suspicion, espe- cially if it do not subside after the administration of cathartics. Some of these surgical fevers are accompanied by eruptions, a number of which may be due to drugs, but some of which at least are due to intrinsic poisons. Thus, carbolic acid and iodoform give rise occasionally to erythematous eruptions, and the concomitant administration of drugs like potassium iodide, quinine, anti- pyrine, and copaiba may produce urticarial or other manifestations. Again, it is known that certain toxines — produced, e. g., by the bacillus pyocyaneus — are capa- ble of causing dilatation of the superficial vessels and various flushes or eruptions. To one of these, which dilates the capillaries, Bouchard has given the name of eetasine. Consequently, it by no means follows that every eruption or rash follow- ing operations or injuries is of a specific character. On the other hand, it seems to be established by numerous observers — among whom Paget is perhaps the most prominent — that surgical patients, particularly the young, are notoriously liable to infection by scarlatina ; and in the experience of Thomas Smith, of 43 children whom he cut for stone 10 had scarlet fever. Consequently, in spite of the fact that a certain number of cases of eruption may have been mistaken for scarlet fever, it is undoubtedly true that in surgical and puerperal cases patients are more than usually liable to this invasion. The whole subject of surgical fever may, then, be epitomized as con- sisting of elevation of temperature and certain accompanving disturb- ances, which appear to be essentially due to the results of tissue-metab- olism, including also metabolism of blood-clot, ligatures, etc. It is not a necessary nor conspicuous accompaniment of all surgical cases, and in some individuals, even after grave operations, will scarcely be noted. It is more likely to be extreme in children than in adults, other things being equal. As the result of excessive loss of blood it may be post- poned. It may be complicated, and more particularly prolonged, by any one of the auto-infections, particularly that already spoken of in the preceding chapter as intestinal toxaemia, as the result of which septic infec- tion may ensue, and that which was at first a legitimate surgical fever may thus become merged into one of the septic conditions next to be con- sidered. In the absence of auto-infection, and with kindly and sympto- matic treatment, surgical fever should quickly subside until it becomes indistinguishable, and this usually by the end of the second or third day. Proceeding, then, in the order of pathological complexities, the next of the surgical infectious fevers to be considered is Sapraemia. Sapr^mia. It is my purpose to use the term saprsemia here as indicating a con- dition which I often liken to an intoxication produced by a supposititious septic suppository, although the case is by no means imaginary in which this condition occurs. The term was first used bv Duncan, and was laigely confined, at least at first, to puerperal cases. This is its own justification, because some of the most ideal cases of saprsemia are those of puerperal origin. In each of the three conditions comprised under the general term of septic infection it is not now a question of particular organisms but of intoxication by products which are more or less common to at least THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 99 several of them. In a general way, they are, for the most part, due to the activity of the orr/mumm already grouped an pyogenic. Those which produce pus arc easily capable of causing septic infection. In addition to these, it is probable that certain of the saprophytes or ordinary putre- factive organisms may produce the same effect. For purposes of minute study it is of interest to isolate and, so far as possible, determine the exact action of, each organism. For present purposes, however, it is neither necessary nor, perhaps, wise. In sapraemia the symptoms begin promptly, depend for their inten- sity upon the dosage of poison, and recede quickly as soon as the source of poisoning is removed or its activity antidoted. Two illustrations of the possible causes of saprsemia will, perhaps, best illustrate its pathology. Take, first, that physiological operation of nature's own performance — namely, the act of delivery of the full-term foetus. At the completion of this operation there is left a fresh, bleeding wound of large area which is more or less exposed to putrefactive agencies. This is reduced with the contraction of the uterine walls to a comparatively small cavity containing more or less freshly-coagulated blood. So long as this clot does not putrefy it is disintegrated inoffensively, to be dis- charged, at least for the most part, with the lochia?. Let, however, germs of putrefaction enter, either during the act of labor or afterward, and linger, and putrefactive processes are set up in the clot with the prompt production of certain toxines and ptomaines. We have here a septic suppository with conditions most favorable for absorption by the containing tissues. How quickly the poisoning may show itself, and how quickly subside after removal of the putrefying clot, daily experi- ence may tell. Saprcemia, then, is intoxication produced by absorption of the remits of putrefaction of a contained material within a more or less shut contain- ing cavity whose walls are capable of absorption of noxious products as they form. So long as putrefaction be essentially limited to the contained mass, and do not spread to and involve the containing or surrounding tissues, the case is one of sapraemia. So soon as the process spreads from the containing tissues the case merges from one of saprcemia into one of septicemia. That this may occur in any case without prompt inter- vention will be readily understood. Patients may sometimes die of saprsemia, though rarely, and in such case ordinarily as the result of gross neglect. Once the septicsemic process be begun, however, its spread cannot be with certainty checked, and that case which to-day is saprsemic and redeemable may, to-morrow, become septicsemic and prac- tically lost. The symptoms of saprsemia are not essentially different from those common to septic infection, save that ordinarily they are, at least at first, milder. There are flushing of the face, dry tongue, mental disturbance often, a considerable degree of pyrexia, while usually the whole train of symptoms is ushered in by a chill which may have been preceded only by slight malaise. These are usually followed by nausea and vomiting, with headache, and often, later, by diarrhoea or active purging. Should a case go on so far, delirium may occur, possibly even fatal coma. On post-mortem examination of a fatal case there would be few changes 100 SURGICAL DISEASES, revealed : alterations in the blood, a failure to coagulate, some softening of the spleen and liver would probably be the only notable changes. Treatment. — For a condition so easily recognized treatment should be prompt, and will then be almost always effective. It is all summed up in the urgent advice to remove the cause, although this may not always be easy of performance. In the first case supposed — i. e. one of puerperal saprcemia — the treatment would be to empty the uterus, to give vigorous antiseptic douches, to irrigate as often as necessary, to prevent offensive odor to the discharge, and to combat the general signs of poi- soning by plainly indicated measures. Heart-depression should be overcome by the use of diffusible stimulants and by hypodermic injec- tions of strychnia in doses of -^ grain or more. The bowels should be promptly unloaded by a mercurial, followed by a saline cathartic. Sup- pression of urine may be treated by venesection and by hot-air baths or sweats ; diuretics should also be prescribed, and fluids should be admin- istered copiously. If the patient be very restless, an opiate should be promptly given ; if delirious, necessary restraint should be resorted to. Essentially the same measures should be carried out in a surgical wound, or in case of compound fracture, or any injury where retained material may be undergoing changes already alluded to. General meas- ures should be the same. Our forefathers were certainly wise in advis- ing the use of purgatives in these cases, for nature often sets us the example in the shape of watery and most fetid evacuations, showing that there is much retained whose evacuation should be hastened. Septicemia. According to the views thus enunciated, the difference between sa- prsemia and septicaemia is not one of character so much as of location. In septicemia the putrefactive action is no longer confined to material enclosed by, yet not of, the tissues themselves, but has spread from this to the surrounding living cells, which are now being attacked by bacterial enemies ; in other words, we deal now with infection of living tissues rather than with mere intoxication. This is now a progressive invasion of tissues by continuity, with a constantly proceeding systemic intoxi- cation by poisons produced ever in larger doses. So rapid mav this action be — as may be seen in malignant diphtheria, for instance — that the individual speedily succumbs before abundant evidences of abscess or local gangrene appear. On the other hand, providing that the toxic action be less pronounced or the patient's vitality more enduring — i. e. his tissues more resistant — abscess, phlegmon, or local gangrene may result, the destruction of tissue being limited to the environs of the parts first involved. While septicemia, then, may be a direct continuance of an original saprsemia, it is not intended to intimate that it may not originate de novo ; that is, many cases may begin as a pronounced septicaemia from a local infection. This is the case, for instance, with the majority of dis- secting wounds, etc. Symptoms. — In septicaemia we have a period of incubation, usually two or three days at least, often longer. If this follow an operation, the mild fever which would indicate the slumbering fire is usually regarded THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 101 as merely surgical fever. But when, instead of subsiding, this rises and is followed by prostration with alimentary disturbance, loss of appetite, headache, etc., quickly followed by those general symptoms which we speak of as typhoidal, the alarm is sounded and should be quickly heeded. Usually, but not always, there is a preliminary or premonitory chill, after which prostration will be much more marked than before. The severity of the general symptoms can in no degree be foretold from the size, loca- tion, or character of a wound. The character of the fever is essentially continued, usually with morning remissions. Gussenbauer has called attention to a class of cases in which subnormal temperature is caused by the absorption of ammonia compounds. To these he has given the name ammonkemia. This condition may be seen oftenest in connection with gangrenous hernia, and has even been mistaken for shock (Warren). In septicaemia proceeding from infection of a visible portion of the body there are usually seen evidences of lymphangitis and perilymphan- gitis — of course of septic character. These will be evidenced by tender and purplish lines, extending subcutaneously along the course of the known lymphatics or in connection with the more prominent subcutane- ous veins. The lymph-nodes, into which these visible vessels as well as the deeper ones empty, become quickly enlarged and tender ; the whole lymphatic system participates ; the spleen in aggravated cases becomes notably enlarged, and even the bone-marrow more or less involved. Diarrhoea is commonly an early but controllable symptom. A heema- togenous icterus of mild degree is another frequent accompaniment. The conjunctiva becomes plainly discolored, and the skin slightly so. Should the blood be examined, marked leucocytosis will be noted, and should cultures be made from it, in many instances at least the organisms at fault can be detected and recovered from it. The vigor of the heart- muscle is seriously impaired ; the pulse becomes rapid and weak. In scarcely any form of septic infection is this more prominent than in diphtheria ; and microscopic examination shows the rapid disintegration of the cells of the heart-muscle, as well as those of other parts of the body, even to the almost complete molecular disintegration of the nuclei. Erythematoid, pustular, even hemorrhagic eruptions are met with upon the skin, some of which are probably to be explained by thrombosis of the dermal capillaries. Certain complications are not infrequent, among which inflammations of the pericardium and endocardium — e. g. ulcera- tive endocarditis — are frequent. As the case becomes aggravated tem- perature rises irregularly ; the hot, dry skin becomes cold and clammy ; prostration and indifference more marked ; diarrhoea more colliquative ; icterus more pronounced ; urine more reduced in quantity or suppressed ; and these symptoms are succeeded by indifference, mental apathy, stupor or delirium, and finally death, patients being comatose and collapsed. While these are the general indications of septicaemia, the wound or site of injury has undergone changes which are also characteristic. They comprise, first, the cedema and redness of wound-margins, which may be seen even in saprsemia, followed by increasing tumefaction, escape of foul-smelling discharge, and finally by sloughing and gangrene of the parts involved. On microscopic examination the capillaries are filled with infective thrombi and vessel-walls infiltrated with micro-organisms, which abound also in the lymph-spaces. Bacterial infection can be 102 SURGICAL DISEASES. traced in microscopic sections from the infected area, from the point in the neighborhood of the wound where microbes infest the tissues, to points remote from it, where they are sparsely found, if at all. The same evidences of infection may be traced along the lymphatic vessels, and often the veins. The post-mortem evidences of septicaemia are plainly indicative on first sight : the blood is of a consistency like tar, does not coagulate ; evidences of putrefaction are plain to sight and smell; the serous membranes, particularly the pia mater, are often extravasated ; the mus- cles are discolored and of a darker hue than natural ; oedema of the lung is frequent ; the intestines reveal a gastro-intestinal catarrh, the duode- num and rectum particularly showing punctate hemorrhages ; the spleen is darkened, enlarged, and very much softened ; the liver shows similar signs, less marked, and at times an emphysematous condition due to putrefactive gases. Cultures can be made from all the fluids and tissues of organs thus affected. It is also of the greatest importance to empha- size that such material is powerful!)/, often fatally, infectious; and some of the worst forms of dissecting wounds and most rapid instances of fatal infection have come from carelessness in making these post- mortem examinations. So far as concerns the character of the wound, which is most likely to be followed by septicaemia, there is but little to be said. In a general way, wounds made by infected tools, the butcher's knife, the anatomist's scalpel, etc., are the most dangerous, and too often those which are so small as to either escape observation or be considered too trifling to call for treatment. All forms of phlegmonous erysipelas, many cases of gangrene following frost-bite, nearly all instances of traumatic gangrene, most cases of carbuncle, and, in fact, all similar lesions, are extremely likely to be followed by septicaemia. The so-called spontaneous cases have an equally infectious origin, though one which is concealed. In unrecognized instances of appendicitis, for instance, and in many other conditions, although the path of infection may not be easily traced, it is, nevertheless, always present, and can be found if diligent enough search be made. Too often the nasal cavity, the tonsils, the teeth, the middle ear, the deep urethra, and the rectum are overlooked as offering possi- bilities for septic infection which may follow this general type. Treatment. — This must be both local and general. Local treat- ment should consist in complete and absolute removal, so far as mav be possible, of the active cause. This will comprise the reopening of wounds, evacuation of clot, cutting or scraping away of sloughs and gangrenous tissue, with cauterization of the exposed living tissue, in order that absorption may not be rather promoted than prevented, and will often include such heroic measures as the amputation or extirpation of a part. For tissues which are not too completely riddled by disease and lost beyond possibility of redemption continuous immersion in hot irater offers often the best possible prospect, By it putrefaction seems checked, the separation of dead from living tissues is accelerated, relief of pain or discomfort is afforded, and prompt disinfection of material which is foul and infectious is guaranteed. An excellent local application is the mixture, resorcin (5 parts), ichthyol (10 parts), ung. hvdrarg. (40 parts), and lanolin (45 parts), already mentioned in Chapter III., or else the THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 103 application of brewers' yeast, already spoken of in the chapter on ulcers. Of greatest value also will now be found the silver ointment of Crede (Unguentum CredS). This permits of absorption of silver through the unbroken skin (as in the case of ung. hydrarg.), and the dissemination throughout the system of the remarkable antiseptic virtues of the silver itself. Many cases of septic infection promptly yield under the influence of the argentine preparations which Crede has lately introduced. In suitable cases, also, the subcutaneous injection, repeated as may be indicated, of antistreptococcic serum will be followed by prompt and most beneficial effects. As in diphtheria, the earlier the injection be given the better the prospect of benefit. The general treatment of septicaemia is, in the main, stimulant and tonic. Fever is not now to be treated with arterial sedatives nor often with antipyretics. It is an expression of poisoning, and its too prompt suppression prevents both the recognition of the intoxication and the measure of its degree. Pyrexia, then, is best combated with cool sponge baths and stimulant measures of a general character. The principal reliance must be upon nutrition and stimulants. Assimilation must be impaired when gastro-intestinal catarrh is so prominent a fea- ture as it is in many of these cases. Consequently, the simplest and most assimilable food, often that which is predigested, should be admin- istered. Milk, eggs, beef-peptonoids, and fruits are among the most appropriate. Of all the stimulants and tonics which the materia meclica affords, the two best are alcohol and strychnia. Strychnia is preferably administered hypodermically in doses of -^ grain, subcutaneously, from two to four times a day, or even oftener. Heart-depression is best combated by this measure, or by quinine in large doses, while digitalis and atropine may be added if necessary. For internal use alcohol is, par excellence, the remedy. This is administered now in doses only to be measured by their effect. In fact, the administration of alcohol in these cases is a matter of effect, and not of dosage. Aside from these measures, the intestinal antiseptics should be administered, among these being corrosive sublimate, T -J- ff grain every three or four hours, salol in large doses, bismuth salicylate, or naphthaline — any or all of these in connection, preferably, with powdered charcoal. Intestinal pain and frequency of stool can be more or less controlled by opium, while real disinfection of the alimentary canal is only to be accomplished by the above remedies, in connection perhaps with flushing of the colon with saturated boric-acid solution or something of that kind. Pain is to be controlled by morphia administered subcutaneously. Pyemia. The derivation of the term "pyaemia," which came into general use in 1828, is misleading. Although septic fever always accompanies suppuration, it is not the case that pus, as such, circulates in the blood, as the term pysemia implies, the error having arisen originally from mistaking the contents of breaking-down thrombi for pus from ordinary sources. While a recognition of the etiology of the disease is new, the disease itself has been recognized for many centuries. Pyaemia is only met with in connection with suppuration ; so far as known, never without it. In those cases which appear to be free from suppuration pus will be found on careful search. Pyaemia may be de- 104 SURGICAL DISEASES. scribed as septicemia plus thrombotic and embolic accidents which lead to distribution of infectious material to all parts of the body. This distri- bution is, for the most part, made by the blood-vessels, although to some extent the lymphatics undoubtedly participate. AVhen pyogenic organisms reach blood-vessel walls they often set up a mycotic phlebitis, which, by virtue of the coagulating blood, becomes quickly what is known as thrombo-phlebitis. Infection proceeding through the vessel- walls, the endothelial lining is loosened, while to these rotting spots leucocytes adhere and coalesce into a more or less homogeneous mass. This so-called white thrombus becomes also infected with bacteria : por- tions of it, loosened and dislodged, are carried by the returning blood- stream to the right side of the heart, whence they are distributed through the lungs. Dislodgement may be by mere force of the blood-stream, or may be assisted by movements of the part or handling of the same. These particles of thrombi are loaded with the infectious organisms which have begun the disease, and wherever each one settles a repro- duction of the original thrombo-phlebitis is quickly produced. In this way numerous infected thrombi are formed within the vessels of the lungs, which, again, loosen, and are now swept into the left side of the heart, whence they are distributed with arterial blood in all directions. While it is true that they are probably equably distributed, it is also positive that certain tissues seem more capable of lodging and being attacked by the contained organisms than are others. When it is once appreciated that each particle of infected clot is capable of setting up, either in the lungs or in the other tissues, upon the second distribution, other abscess-formations analogous in etiology to that from which came the first disturbance, then, and then only, is the fundamental idea of metastatic abscess fully impressed. The term metastasis may be regarded as synonymous with transportation, and metastatic abscesses are those produced by transportation of infected particles from one part of the body to another. Wherever they lodge similar trouble will result, providing only that the patient live long enough. Contiguous minute metastatic abscesses quickly coalesce, and in this way large collections of pus are formed. The blood also contains organisms not attached to thrombi, and from the blood of the pysemic patient cultures can be made at almost any time. Until this be done it will be virtually im- possible to incriminate any particular organism as the one at 'fault. Thrombo-arteritis is the equivalent in the arteries of thrombo-phlebitis in the veins, and is accompanied by the same detachment of endothe- lium, adhesion of leucocytes, etc. 'Whenever such a lesion occurs in artery or vein, coagulation-necrosis takes place and suppuration occurs around it. The metastatic abscess is thus the result of breaking down of this affected tissue, and is often spoken of as miliar if abscess. Parti- cles of infective thrombi cling also to the valves of' the heart, and a septic- endocarditis may result. The possibility of so-called, spontaneous or idiopathic pyaemia is occasionally discussed. This means nothing more than a pyemia whose cause is concealed. The explanation will be found sometimes in an acute infectious osteomyelitis, sometimes in ulcerative endocarditis or inflamed appendix or other portion of the peritoneal cavity Again it may proceed from middle-ear disease, in which there is so little THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 105 discharge as scarcely to attract attention. Thus, causes which predis- pose to suppuration, which have already been discussed in Chapter III., come into play here, and the influence of exposure, fatigue, starvation, etc. is not to be ignored in furnishing an explanation for the so-called idiopathic cases. In the majority of instances, however, pyaemia follows surgical operations and injuries, among which are compound fractures, deep injuries with small superficial evidence thereof, compound injuries of the skull, and injuries by which veins are exposed. Inasmuch as the typical pyemic manifestations require a certain length of time for their development, the onset of this disease is more delayed than in the case of septicaemia. While the case may be manifestly one of septic infec- tion of unrecognizable type, the characteristic indications of pyaemia seldom appear in less than ten days, and frequently not for several days longer. Symptoms. — The symptoms of pyaemia do not essentially differ from those indicating the other septic infections already mentioned. The principal difference is in the frequency of chill and range of tempera- ture. Chills are much more common at the inception of the condition, and much more frequent throughout its continuance, than in other septic conditions. The chill may be slight or assume the proportions of a rigor, and each chill is followed by colliquative sweat and exhaus- tion. In other words, chills, which are infrequent in septicaemia, are common in pyaemia. There is reason to think that with each fresh dis- tribution of emboli we have one or more chills as the objective evidence thereof. Distinctive also in large measure of pyaemia is the temperature curve, which much resembles that of intermittent fever, without the regularity of change characteristic of malarial fevers. It is without regular remissions, and has been spoken of as irregularly intermittent. The first rise is abrupt and usually excessive, while with each fresh chill or series of chills similar abrupt alterations will be noted. These occur so frequently and fluctuate so irregularly that in order to note them accurately the temperature should be taken at least every two hours. With all this irregularity, the temperature never drops to normal, except possibly toward the last. As the lungs fill up with the first crop of infected emboli, and the first series of metastatic abscesses form there, there is more or less dyspnoea and sense of oppression : there may be also pulmonary compli- cations — pleurisy, bronchitis, etc., even pulmonary oedema. Quite fre- quent it is to have expectoration of frothy and discolored sputum; occasionaliy there is blood in the sputum. A peculiar sweetish odor of the breath has been noted by many observers in this disease, and is sup- posed to be idiopathic and characteristic. With the dispersal of the second crop of emboli from the lungs we are now quite likely to get icterus, with, later, evidence of metastatic abscess in the liver, where we find large collections of pus as the result of coalescence of small abscesses. The sensorium is not so affected in pyaemia as in septicaemia, and in the former disease patients are more likely to be alert and active in mind. General hypercesthesia and restlessness are common. Colliquative sweats are also a feature distinctive rather of pyaemia. There is the same liability to eruptions, etc., which may mislead or complicate the 106 SURGICAL DISEASES. diagnosis. There is undoubtedly a dermatitis met with sometimes in pyaemia, the lesions assuming a papular or pustular form, due to local infections of the skin. Purpuric spots are also seen, and vesication is not infrequent, Within the mouth sordes collect quickly upon the teeth or gums ; the tongue becomes dry and brown and heavily coated. Diarrhoea is less common in pyaemia. The urine is usually scanty and high-colored, containing solids in excess ; albumen is sometimes found therein, as well as peptone. The presence of peptone in the urine is probably an indication of the breaking down of pus-corpuscles in various parts of the tissues. One most significant objective evidence of pyaemia is met with in the metastatic collections of pus within the joints, which occur relatively early, and which, if multiple, may surely lead to a correct diagnosis. One of the earliest joints to be involved is the sterno-clavicular, although none of the joints are free from possibility of invasion. The articular serous membranes seem to have the property of carrying and holding the infective thrombi better than almost any other tissue in the body. The pyarthrosis of pyemia is for the most part painless, yet implies loss of function of the affected joints. The distention of these is usually evident to the eye, the fluctuation pronounced, tenderness not extreme, but the swollen part merges out into tissues which are cedematous and reddened. When pain in the limb is extreme, it is usually because of metastatic abscess within the bone-marrow cavity. In other words, we now have a metastatic osteomyelitis. In all cases of pysemia prostration is marked, yet the pulse is seldom so weak as would be anticipated, at least until toward the last. As cases progress from bad to worse subsultus tend in tint is often noted. The appearance of the wound or site of operation, if such there be, does not differ essentially from that already described under Septicaemia. There is usually, however, less discharge, granulations are smoother and dryer, and, if tissues be gangrenous, they are not so offensively wet and nasty as in the other case. Evidences of thrombo-phlebitis and lymphan- gitis will proceed from the wound toward the body, as in other instances of septic infection. Prognosis. — Prognosis is almost always bad. While recovery may occasionally follow where metastatic infiltration has not been too general, the ordinary case of pysemia will die within twelve to fourteen days after its recognition. In other instances the entire process is much slower, and isolated cases occur which entitle us perhaps to make a separate designation for so-called chronic pyarmia, which differs but little from the acute form, save in the extreme slowness with which the entire programme is gone through. The student should never be unwilling to recognize pysemia, as such, simply because he finds no evidence of infec- tion from without — e. g. no wound. I have known a fatal case of pysemia from a suppurating soft corn which was not discovered dur- ing life. Cases are also known from peridental abscesses, etc, which had been overlooked. Death is the result of tissue-destruction and septic intoxication. It is brought about, however, largely by sheer exhaustion. Post-mortem Appearances. —In the vessels these consist essen- tially of thrombosis, excellent examples of which may be seen for THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 107 instance, in the cranial sinuses and in the large veins. Aside from these, with the enlargement and softening of the spleen, the fiver, and lymphatic structures, already described under Septicaemia, the principal objective evidences consist in the discovery of metastatic abscesses in many or all parts of the body. As stated above, there is no tissue nor organ in which they may not be found. The mechanism of their pro- duction has been already described. Infarcts may also be met with, in the kidneys especially, the liver and spleen as well, and indicate areas already cut off from blood-supply by thrombo-arteritis, in which abscess-formation would have occurred had time been given. In the liver large abscesses may be found ; joint-cavities may be filled with pus ; the lungs are usually the site of innumerable small abscesses. The other post-mortem changes commonly noted are not difficult of explanation, but are not so characteristic nor pathognomonic as to call for further mention. In a joint which has become filled with pus there has usually been loosening of the cartilage and more or less disorganiza- tion of all the joint-structures, which appear to have undergone most rapid ulcerative destruction and putrefaction. Treatment. — Treatment of pyaemia is in large degree unsatisfactory. That which used to be the terror of surgeons in the preantiseptic era is now, thanks to Lister and others, almost abolished. Pyaemia is a rare disease in modern surgical practice. Its possibility should be borne constantly in mind, however, and the necessity for careful antiseptic or for a rigid aseptic technique is in large degree based upon fear of pyaemic consequences. When once established, the disease is to be treated on nearly sim- ilar lines to those laid down for septicaemia. Amputation or extirpation of the part from which infection has first proceeded may be of avail, though usually it will prove too late. Among the most successful, yet radical, of measures for surgical treatment of this disease is to expose the infected area, freely open the involved veins, and either excise them or scrape them out and thoroughly disinfect them. This treatment has been particularly successful in certain cases of cranial infection follow- ing middle-ear disease, etc. (For more with regard to this work in a special location consult the chapter on cranial surgery.) That there should be complete disinfection of the infected area, and that continuous immersion in hot water, if practicable, should be prac- tised, are just as important here as in other septic cases. Metastatic abscesses should be opened and freely drained, and every accessible col- lection of pus should be evacuated, either by the knife or perhaps with the aspirator needle — <■. g. in the liver. So far as medicinal treatment is concerned, it is practically the same as in septicaemia, while the surgeon's mainstays will be alcohol and strychnia. These, with cathartics and intestinal antiseptics, will prac- cally sum up the drug-treatment, the surgeon meantime not neglecting the matter of nutrition, crowding it in every assimilable form. 108 SURGICAL DISEASES. Erysipelas. Erysipelas is an acute infectious disease characterized by its tendency to involve the shin and cellular structures, to extend along the lymphatic vessels, to involve wounds and injuries under certain conditions, accompanied by more or less fever of septic type, leading frequently to septic disturbances of profoundest character, yet tending in the majority of instances to spon- taneous recovery. It has been observed probably from prehistoric times, but has not found a proper description nor appreciation until perhaps within the past century. It occurs in so-called traumatic and idiopathic form — which latter simply means that the site of infection is not dis- covered — and also in a virulent and contagious type, which leads to the appearance of a large number of cases over a widespread area of terri- tory ; in other words, it often appears in the epidemic form. On account of the characteristic reddening of the skin it goes by the suggestive name of the rose among the German laity. It may assume the type of an infectious dermatitis, subsiding without suppuration, or a similar lesion of exposed mucous membrane may be noted, or, occasionally, its viru- lence seeming greater, its lesions are met with in more deeply-seated parts, accompanied by suppuration or even gangrene, and it is then spoken of as of the phlegmonous type. In a small proportion of cases the infectious organism appears to be transported from one part of the body to another, and thus we have metastatic expressions of this disease. The most common expressions of this are seen in erysipelatous meningitis after erysipelas of the face or scalp, and erysipelatous peritonitis after the disease has manifested itself on the truncal surface. It is of a type which makes itself almost interchangeable with puerperal fever ; and in time past, when epidemics of erysipelas have involved certain states or areas, it has been noted also that nearly every obstetric case developed puerperal septicaemia. Etiology. — There is more than passing interest connected with this last statement. It is now definitely established that the infectious organ- ism is a streptococcus which is most strongly allied to, if not identical with, the streptococcus pyogenes, the ordinary pyogenic organism of this form. The specific organism has been separated, studied, and its role assigned unmistakably by Fehleisen, and the organism is frequently spoken of as Fehleisen's coccus. Preserving always its morphological characteristics, it acts, as do many other pathogenic organisms, within wide limits in viru- lence. Cultivated from some cases, it scarcely seems infectious, while from others it is violently and quickly fatal. Pathology. — The disease manifests a remarkable tendency to travel via lymphatic routes. So long as it is confined to the skin and super- ficial tissues we have the general appearance of an acute dermatitis. When it migrates deeper it nearly always leads to suppuration, which is another reason for thinking that the streptococci of erysipelas and of pus-production are the same. In the affected and infected area the minute lymphatics will be found crowded with the cocci, which are seen much less often in the small blood-vessels ; also in the tissues beyond the apparently infected area they may be found dispersed less freely. The bacterial activity seems most active along the advancing border of THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 109 the superficial lesion. Here the phenomena of hyperemia and phago- cytosis are most active. Even in the vesicles that are characteristic of the disease the organisms may be found. All the discharges from this region are infectious, often in the highest possible degree, and extreme caution should on this account be observed in any operation, even in dressing such cases. A finger pricked by a pin from a dressing may subject the individual to loss of life. The dressings containing the discharges should be promptly burned imme- diately upon their removal. The most frequent path of infection is through some wound, and so thoroughly recognized is this fact that it is now a duty upon first recog- nition of a case of erysipelas to separate it from all surgical cases, or, if the erysipelatous patient cannot be isolated, to remove from his prox- imity all other wounded individuals. The erysipelas which evidently follows injury, however slight, is always spoken of as traumatic. The term "idiopathic" or "spontaneous" should be restricted to those cases in which the path of infection is not discovered, and should be accepted then as simply an expression of ignorance in this regard. Symptoms. — With the exception of the local appearances, they are essentially the same in both of the above-mentioned forms. The most characteristic feature of the disease is the dermatitis with its peculiar roseate hue, which it is impossible to describe in words. In tint it dif- fers but very little from that noted in certain cases of erythema. It is, however, accompanied by an infiltration of the structures of the skin, so that the area which is reddened is at the same time elevated above the surrounding surface. Its edges are often irregular. As exu- date takes the place of blood in the tissues, the red tint merges into a yellow. At this same time there is more induration of the skin and more tendency to pit on pressure. Vesication of this involved area is now frequent, the vesicles often coalescing and forming large blebs and bullae, which fill with serum that may, later, become discolored or puru- lent. When exposed to the air, unless the tissues become gangrenous, this serum usually evaporates and forms scabs. This disturbance of the skin is always followed after a number of days by desquamation. This infectious dermatitis shows a constant tendency to spread in all directions. Its most characteristic appearances are limited to the margin of the enlarging zone, while at the same time in its centre there may be evidences of recession of the disease. If it commence in the neigh- borhood of a wound, it will probably spread in all directions from it. Beginning in the face, it spreads upward usually ; in the trunk, in all directions ; while if on the extremities it tends to migrate toward the trunk. Wandering erysipelas is a term often applied to these phe- nomena. The metastatic expressions of the disease have been already alluded to. When this infection attacks a recent wound the local appearances are not essentially distinct from those already spoken of under Septicaemia. The wound-margins separate to a greater or less extent, the surfaces slough, and a very characteristic sero-purulent discharge occurs. Gran- ulating surfaces usually become glazed — often covered with a membrane resembling that of diphtheria ; deep sloughs may occur, undermining of HO SURGICAL DISEASES. wound-edges, even hemorrhages, from destruction of vessel-walls. In rather rare instances, however, under the influence of the microbic stim- ulation granulations proceed even faster than normal. Whether, now, the disease proceed from an evident injury or not the constitutional symptoms vary but little. There is usually a period of malaise with nausea, followed by evident alimentary disturbance, coating of the tongue, elevation of temperature, sometimes with, sometimes with- out, occurrence of chill. Within a short time complaint of pain or unpleasant sensation will lead to examination of the area involved, when the above symptoms will be noted along with evidences of lymphangitis and enlargement of lymph-nodes. When chill occurs it is very promptly followed by pyrexia. Temperature fluctuates according to no known principles, with a tendency to assume the remittent type. When the disease subsides spontaneously, it is by a gradual process of betterment, with gradual subsidence of temperature. In other instances the consti- tutional symptoms assume more or less of the septiccemic or typhoid type, and it is easily appreciated that the patient's condition is practically one of mild septicemia, which often becomes serious, sometimes even fatal. When, now, the disease assumes the phlegmonous type, the constitu- tional symptoms become more and more typhoidal and septicaemia becomes most pronounced. Locally, exudation goes on to the point of threatening, even of actual gangrene, unless tension be relieved by incisions. Pain is usually intense, partly because of confined exu- dates beneath unresisting structures. More or less rapidly the local and constitutional signs of pus-formation are noted, and unless these be observed and acted upon early we will have not only suppuration, but more or less actual gangrene, so that not only pus, but sloughs of tissue, will be discharged through the incision, or will, when this be delayed, make their escape by death of overlying textures. In all phlegmonous cases there is practically coincidence of septi- caemia, already described, and of the local appearances above noted. In proportion to the extent of the lesion in these phlegmonous cases, and failure to afford relief, will be the opportunity for septic intoxica- tion. Even the mucous membrane does not always escape, and in the nose, the pharynx particularly, but even in the vagina and rectum, a distinctive erysipe- latous lesion may be met with. The disease may travel from the pharynx through the nose to involve the face, or through the Eustachian tube to the ear and thence to the scalp, or vice vend. Erysipelatous laryngitis is most to be feared on account of oedema of the glottis, which would be quickly fatal unless promptly overcome by intubation or tracheotomy. An infectious exudation into the lungs is also known following erysipelas, and has been considered an erysipelatous pneumonia. The cellular tissue of the orbits may also be involved, in which case we will have abscesses which should be opened early ; while, again, the parotid and other salivary glands may become involved, usually in suppuration. Many cases are accompanied by much gastric irritation, which it is difficult always to explain. Ulcers are sometimes found in the intes- tines, as after burns. These usually give rise to bloody diarrhoea. The cerebral symptoms may be simply those of delirium from irritation or of meningitis from infection. Strange phenomena have followed the disease in certain instances — cessation of neuralgic and of vague unex- plainable pain, improvement in deranged mental condition, spontaneous THE SURGICAL FEVERS AND SEPTIC INFECTIONS. Ill disappearance of tumors, etc. Advantage has been taken of this lasb in the treatment of these cases. (See Cancer.) It is quite likely that some of the worst forms of phlegmonous ery- sipelas are due to mixed infection. It is known, for instance, that to inject the bacillus prodigiosus together with the streptococcus of ery- sipelas will greatly enhance the virulence of the latter, so that reac- tion may proceed even to gangrene. Post-moetem Appearances. — These are not distinctive, but are a combination of local evidences of suppuration and gangrene, with the deterioration of the blood, the softening of the spleen, etc., which are characteristic of septic poisoning. Only in the skin, and then under microscopic examination, can any distinctive pathognomonic appearance be made out. This will consist of the crowding of the lymphatic vessels and connective-tissue spaces with cocci, in the evidences of rapid cell- proliferation, in the quantity of exudate, in vesication, sloughs, etc. Diagnosis.— Diagnosis of erysipelas has mainly to be made from various forms of erythema, from certain drug-eruptions, and perhaps from other forms of septic infection which do not assume the clinical type of erysipelas. The gastric symptoms of this disease are some- times produced by certain poisonous foods or the distress which is pro- duced by medicines, such as quinine, antipyrine, etc. Prognosis. — The majority of instances of idiopathic erysipelas run a certain limited course, although the eruption may spread to almost any distance from the body. When the disease attacks surgical cases, and especially when it involves wound-areas, the prognosis is not so good. When, too, the disease assumes an epidemic type, and involves indis- criminately cases of all kinds, it will be found to have a virulence that may make it a most serious affair. In proportion to the extent to which it assumes the phlegmonous type it will be found locally, if not gen- erally, destructive. The ordinary case of facial erysipelas will get well with almost any treatment or perhaps with little or none. Nevertheless, unexpectedly, meningitis may develop, and even a mild case is to be treated with care and caution, as though one feared disaster. Treatment. — Danger comes from two sources — namely, from septic intoxication and local phlegmons or gangrenous destruction. Each is, therefore, to be combated so far as possible. Treatment, first of all, should consist of isolation — this rather for the benefit of others than for that of the patient himself. Rather in opposition to views held a number of years ago, it must be stated that there is no specific internal treatment for this disease. The tincture of iron, for example, which was long vaunted as such, has proved utterly unsatisfactory, and is of benefit only as a supporting measure in a limited class of cases. In general it finds but little field of usefulness in this or in any acute surgical disease. Constitutional measures should be employed— first, for the purpose of maintaining : free excretion by bowels and kidneys ; second, for the purpose of sup- porting and maintaining strength ; thirdly, for tonic and, more import- ant still, lively stimulant measures to certain thoroughly prostrated and debilitated patients ; and, fourth, for the purpose, so far as may be, of combating intestinal sepsis or intoxication from any other source. The robust patients with this disease need no particular tonic, but these are 112 SURGICAL DISEASES. the patients whom it less often attacks. The aged, the enfeebled, the dissipated, the prostrated individuals, and the confirmed alcoholics are those who need vigorous stimulation, partly by alcohol and quinine, partly by strychnia, preferably given hypodermically, and by the other diffusible stimulants by which perhaps alone they may be kept alive. Pilocarpine, given subcutaneously and pushed to the physiological limit, has been highly praised by some. If, along with prostration, there occur restlessness and delirium, then anodynes and hypnotics are most ser- viceable, and should be administered to meet the indication — morphia hypodermically and any of the agents which produce sleep are now most serviceable. Finally, if there be any drug which can be administered in doses sufficient to saturate the system with an antiseptic which shall at the same time not prove fatal because of toxicity, this is the ideal medicament for constitutional use. Such a drug is not yet known, but it will be well in many of these cases to give some near approach to it internally, as by administering corrosive sublimate, salol, naphthaline, or something else of this general character in doses as large as can be comfortably tolerated. When patients become violent — and they sometimes do in the delirium of this disease — it is not only legitimate, but absolutely necessary, to resort to mechanical restraint — a strait-jacket, a restraining sheet, a camisole, etc. Nourishment must also be kept up by the administration of the easily assimilable and, if necessary, of predigested foods in sufficient quantities. Locally, the number of remedies that have been resorted to in time past is legion. In a very mild case of spontaneous erysipelas — i. e. where no infection can be traced — it will sometimes be enough to put on a simple soothing application, like the lead-and-opium wash of our forefathers. It often gives relief to a patient to have the part protected from air-contact, which may be done by some soothing ointment or by dusting the part with some powder, such as oleates of bismuth sub- nitrate, zinc oxide, etc., these being rubbed up with powdered starch if necessary. Again, it gives relief to protect by a film of rubber tissue or of oiled silk. Even before the distinctively bacterial origin of the disease was gen- erally accepted it had been suggested to use antiseptic applications, either in watery solution or combined with oil or some unguent ; and to-day, now that the infectious character of the disease is so completely estab- lished, this remains the ideal method of local treatment, the difficulty being only to find that which shall be efficacious as an antiseptic, yet not injurious in other ways. Compresses wrung out of solutions of various antiseptics are often serviceable. Of all the numerous applications which I have ever tried, I have found but one thing which has given the universal satisfaction aiforded by the following prescription or something equivalent to it : Resorcin (or naphthaline), 5 ; ichthyol, 5 ; mercurial ointment, 40 ; lanolin, 50. The proportions of these ingredients may be varied, and I often increase the amount of ichthyol, especially when the skin to which it is to be applied is not too tender. The aft'ected parts are anointed with this, and then covered with oiled silk or some imper- meable material, simply to prevent its absorption by the dressings ; the parts are then enveloped in a light dressing and bandaged. Whenever THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 113 I have to deal with local evidences of .septic infection I use an ointment essentially the same as this, and have learned to count on it with more reliance than anything that I have ever resorted to. This one better thing hinted at above is Crede's silver ointment, which is to be used as described above, and has been already alluded to in the treatment of septicaemia. As the disease becomes mitigated the ointment may, if desirable, be reduced with simple lard, and may be discontinued when local signs have disappeared. Absorption of any of these preparations may be hastened by a series of scratches over the affected area with the sharp point of a knife, not deep enough to draw blood, but deep enough to expose better the absorbent vessels of the skin. Treatment of threatening phlegmon, or that which is from the out- set phlegmonous erysipelas, must be much more radical, and consists primarily of free incision down to the depth of the deepest tissues involved. For instance, in treating dissecting and other septic wounds of the fingers this means incision down to the tendon-sheaths, often down to the bone itself. Unpleasant as this may be, possibly even crippling, it is only by such radical measures, early put into effect, that still worse disaster may be avoided. Finally, some aggravated local cases are well treated by a series of deep incisions, even with the use of the curette, the surface after careful clearing being kept buried under some antiseptic solution (silver-lactate 1 to 500) or ointment. CHAPTER VIII. SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC ANIMALS. By Roswell Park, M. D. Tetanus. — Synonyms: Trismus, Lockjaw. Tetanus is an acute infectious disease, at present of infrequent occur- rence, invariably of microbic origin, characterized by more or less tonic muscle-spasm, with clonic exacerbations, which, for the most part, occurs first in the muscles of the jaw and neck, involving progressively, in fatal cases, nearly the entire musculature of the body. Certain races of people seem predisposed, and in certain climates and geographical areas the disease is exceedingly prevalent. Negroes, Hindoos, and many of the South Sea Islanders show a peculiar racial predisposition, and, in a general way, inhabitants of warm countries are less resistant. This is shown partly by the fact that in various European wars the Italians and French have suffered more than the soldiers of more northern climes. Tetanus is by no means confined to adult life, since infants are far from exempt, and in the tropics the trismus of the new-born is the cause of a high mortality-rate. In Jamaica one-fourth of the new-born negroes succumb within eight days after birth, and in various other hot countries the proportion is at times equally great. One plantation-owner states that fully three-fourths of the colored children born upon his plantation succumbed to the disease. The peculiar reason for this infection will appear a little later when speaking of tetanus neonatorum. Men seem more commonly aifected than women, probably because of their occupa- tions, by which they are more exposed. Military surgeons have had to contend with the disease in its most frightful form, and it has been noted that soldiers when worn out by fatigue or suffering from the disaster of defeat seemed more liable to the disease. In 1813 the English soldiers in Spain suffered from tetanus in the proportion of 1 case to 80 wounded men. In the East Indies, in 1782, this proportion was doubled. Quick variations of heat and cold, such as warm days and cold nights, coupled with the other exposures incidental to military life, seem to exert a great effect. Curiously enough, the wounded in many campaigns who have been cared for in churches have suffered more from the disease than those cared for in any other way. Tetanus, however, is by no means neces- sarily confined to any one clime or race, but may be met with anywhere, at any time, providing only that infection have occurred. A celebrated Belgian surgeon was unfortunate enough to lose by tetanus 10 cases of 1L4 DISEASES COMMON TO MAN AND ANIMALS. 115 major operations before he determined that the source of the infection pertained to his hsemostatic forceps. So soon as these were thoroughly sterilized by heat he had no further undesirable complications. If the disease can be so conveyed by the instruments of a careful surgeon, how much more so by the dirty scissors of a careless midwife, etc. ! It is true, also, that the popular notions of the laity concerning the liability to tetanus after certain forms of injury are not ill-founded. Small ragged wounds of the hands and feet are those which ordinarily receive little or no attention, and are among those most likely to be followed by this disease. The toy pistol, which, a few years ago, was such a prevalent and widely-sold children's toy, was guilty of many a small laceration of the hand, due to careless handling and the peculiar injury produced by the explosion of a small charge of fulminating powder in a paper or other cap. It was not the character of the laceration or injury thereby produced, but the fact that such injuries occurred in the dirty hands of dirty chil- dren, which were most likely to become infected, that has caused the so-called toy- pistol tetanus to be erected almost into the dignity of a special form of this disease. During the month of July of 1881, in Chicago alone, there were over 60 deaths from tetanus among children who had been injured in this way by these notorious little toys. This led to their sale being suppressed by law. Etiology. — In time past two theories have had strong advocates, one being that which would account for the disease by irritation of nerves — a nervous theory ; while the second, the humoral, would explain the disease by alterations in the blood. Each has had its most ardent defenders, but both have now completely yielded to the investigations of a few observers, among whom Kitasato and Nicolaier are the most prominent. These ardent workers have been able to clearly establish the parasitic, nature of this disease and to isolate and investigate the organisms by which it is produced. This was in 1885. The bacillus of tetanus is a somewhat slender rod-shaped organism, with a pecu- liar tendency to spore-formation at one end, which gives it a drumstick appear- ance. It is essentially an anaerobic or- ganism, and can never be cultivated in contact with the air. In laboratory experi- ments it is grown in the depths of a solid culture-medium or else in fluids and on surfaces in an atmosphere of hydrogen gas. It is one of the apparent contra- dictions of bacteriology that this organism, which can only be grown as an anaerobe, Tetamls bacim showing apore . format j on nevertheless abounds in earth, particu- (Kitasato). larly the rich black loam which best sup- ports luxuriant vegetable life, and that it practically inhabits the upper layers of the soil, which accounts for the fact that so many contaminations and infections have occurred from stepping upon planks or boards with nails projecting, or from introduction of splinters, or from lacerations of the hands and feet which are so often followed by contact with such materials. There is nothing about a rusty-nail wound which, by itself, predisposes to tetanus, but the rusty nail upon which the barefooted boy steps is either itself infected or leaves a rent or wound which the boy may infect within the next few moments, and which is not likely to receive the careful attention which it ought to have. Verneuil has of late laid stress upon the fact that in localities where horses are kept tetanus is more prevalent, and that the infectious organism abounds in and upon stable-floors, about barn-yards, and wherever the excretions of a horse may be found. Bacteriologists are all aware Fi&. 20. \ *,v -?• -4 ' *>\ V V til ■ % ' •>. "r>^- 116 SURGICAL DISEASES. that in the intestine of herbivorous animals the bacilli (anaerobic) of tetanus and malignant oedema are often found. Verneuil has further shown that almost the only instances of tetanus which occur on shipboard are upon those ships which are used for transportation of horses and cattle. His statements are at least interesting, if not absolutely well founded. At all events, tetanus is certainly of telluric origin. A French veterinary surgeon of twenty-five years' experience had not seen a single case of tetanus until 1884, when he "removed a tumefied testicle from a horse with the ecraseur, and it died of tetanus ; in the following six months he castrated five, and they all died ; another castrated fifteen in one day, and they all died but one ; another in ten days castrated six bulls and operated on three fillies for umbilical hernia; five of the bulls died and one of the fillies." This will illustrate how the infectious agent may be conveyed by instruments, etc. The tetanus bacillus manifests other peculiar properties, for some of which it is most difficult to account. Upon susceptible animals it is violently infectious, but is very rarely found at any distance from the tissues in which it has first lodged, and it has never been satisfactorily demonstrated far away from them. In labora- tory investigations the period of incubation is seldom longer than forty-eight hours. Another peculiarity of the organism is that it generates certain poisoDS of most active properties which may be separated from pure cultures, by whose injection the peculiar spasms of the disease itself may be reproduced. These have been isolated, especially by Brieger, who has given to them the names of tetanin, tetano- toxin, spasmotoxin, etc. Tetanus neo-natorum, or tetanus of the new-born, a condition already alluded to, is a remarkably fatal affection, very prevalent among the negro race, especially in hot climates. It in no wise differs from trau- matic tetanus, but is such in effect, since the infection in these instances always follows the division of the umbilical cord, which is usually effected by dirty scissors in the hands of a dirty midwife, while the thread with which the cord is tied is itself a possible source of infection, as well as the rags which are used to cover the umbilicus in the first dressing. It is virtually always fatal, because of the weakness and lack of resistance of these little patients. It occurs usually within a week after birth, if at all. Tetanus cephalicus, called also tetanus hydrophobicus and head- tetanus, is only a peculiar manifestation of this same affection, confined for the most part to the head and usually following injuries to this region. The muscle-spasms are, for the most part, confined to the facial, pharyngeal, and cervical muscles, sometimes extending to the abdominal. These manifestations may be in some measure reproduced in animals by inoculating them on the head rather than upon the extrem- ities. It is the least fatal form of the disease. Symptoms. — There is always a, period of incubation , usually three or four days, occasionally a week in length, and rarely considerably longer. It is generally held that the longer the period of incubation the more hopeful the prognosis. While for the most part the disease assumes a most acute type, a chronic tetanus is described and occasionally met with. The first warning of the disease usually comes as more or less stiffness of the cervical and maxillary muscles, which is likely to be spoken of by the patient as a " sore throat," because of the consequent difficulty in deglutition. A complaint to this effect should be always regarded as a warning, especially if, on inspection, no visible reason for it can be detected in the pharynx. This complaint is usually made in the morn- ing after an ordinary night's rest. This muscle-stiffness will be followed by increasing tonic spasm in the muscles of the jaw, making it difficult to open the mouth, while the head and neck gradually become stiffened DISEASES COMMON TO MAN AND ANIMALS. 117 and fixed by spasm of the cervical muscles. These muscles may now be felt more or less rigidly contracted, as if by voluntary effort, and the condition, which is at first not painful, becomes after some hours a source of discomfort, perhaps of actual pain, to the patient. If, now, the disease pursue the usual course, the other muscles of the body become grad- ually affected, usually in the order of their proximity, but not necessarily so. The abdominal muscles are firm and board-like, and the dorsal mus- cles more or less contracted, sometimes to an extent which causes arching of the spine. Should the original wound or port of entry for infectious germs have been in the hand or foot, the muscles of this limb become contracted, more or less rigidly, holding it in a position which is not easily changed, even by efforts of the attendant. Sensation is also often more or less perverted. In this condition of tonic rigidity the muscles remain, to relax usually only with death. Characteristic tetanic spasm in a rabbit twenty-six hours after inoculation with pure culture of tetanus bacilli (lizzoni and Cattani). The most characteristic features of the disease, however, are the pecu- liar clonic exacerbations, which convert spastic 'rigidity into violent and convulsive muscle-activity, so that the limbs, and even the frame, of the patient are more or less contorted, the muscle-exertion being sometimes most painful to witness. Peculiar effects are thus produced : the mouth is peculiarly puckered, and its corners drawn upward and backward by the risorius muscles, giving to the face that peculiar expression known as the " sardonic grin." When the abdominal and flexor muscles of the thighs are especially involved, the body is more or less curved forward, and this is known as emprosihotonos. When the muscles of the back especially are involved, with the extensor muscles of the thighs, we have opisthotonos, while, when the body is bent to one side or to the other, it is spoken of as pleurosthotonos. It is said that opisthotonic convulsions occur to such extent in rare instances that the heels may even touch the head. At all events, the patient's body is frequently raised from the bed, so that he rests upon the head and feet. Another most characteristic feature of the disease is the peculiar reflex irritability or hyperesthesia by which these convulsive attacks apparently are produced. Into this one falls more or less rapidly within the first day after the inception of the disease ; and to such a height may it be augmented that the slightest movement in the room, jarring of the bed, or displacement of clothing, even noise or a flash of light, may immediately bring on a convulsion. Eupture of muscles has been reported during some of these violent convulsions. 118 SURGICAL DISEASES. During the coarse of this disease the jaws are so fixed that patients speak with extreme difficulty and the tongue cannot be protruded. The mind is clear until the end. The pain is rather the acute soreness due to intense muscle-strain. There is spasm of sphincters by which urine and feces are often retained. There is nothing characteristic about the temperature, which is seldom much augmented. Attempts to swallow give pain, and are resisted specially because of the renewed muscle- spasm which is likely to follow the irritation inseparable from the act itself. As the result of spasm of the glottis peculiar respiratory sounds may be noted. Until the last only the voluntary muscles are involved. Finally, however, come spasms of the accessory respiratory muscles, and, lastly, of the diaphragm ; and death is usually produced by involvement of these muscles analogous to that of the others. Death results, then, usually from apnce.a or suffocation.^ During the last hour or two perspiration may be copious and temperature may rise. Chronic tetanus is characterized throughout by a milder and much more prolonged series of symptoms. The period of incubation is much longer, and, while the general programme of the acute form is adhered to, it is of less severe degree and is spread over a longer time ; in fact, cases covering two months or more are reported. In chronic tetanus the prognosis is much more hopeful than in the acute form. So far, nothing has been said about the appearance of the wound. This is but slightly, if at all, affected. In some cases it will be found to have completely healed before the onset of the disease. If suppu- rating or open, its evidences of repair will be found unsatisfactory and some indications of septic infection may be noted. Pricking or needle sensations may be subjective phenomena. Prognosis. — Prognosis is almost invariably bad. No case of acute tetanus under my own observation has ever yet recovered. Still, occa- sionally recovery does ensue. Whether this be due to a peculiarity of the patient or to the medication is, perhaps, still doubtful. If patients live more than five or six days, the prognosis is thereby certainly bettered. Post-mortem Appearances. — These are rarely distinctive. In most instances there are evidences at least of hypersemia, if not of more active changes, in the upper portions of the cord. Much less often slight changes have been noted in the brain, consisting, in some measure, of disintegration and softening. Evidences of ascending neuritis in the nerve-trunks leading to the injured area have been claimed in some instances. As a matter of fact, however, few, if any, distinctive post- mortem changes can be described as due to this disease. Diagnosis. — This must be made as between strychnia-poisoning, hysteria, hydrophobia, tetany, and, in the very beginning, from pharyn- gitis, tonsillitis, etc. When the disease is fully developed it is not likelv to be mistaken for anything else. Tetanus may be simulated by hysteria in patients of a certain class, but in this event the phenomena will be so uncertain, so contradictory, and the evidences of real organic disease so essentially lacking, that it is not likely that mistake can occur. Treatment. — If any case can be imagined in which efficient treat- ment is most urgently demanded, it is one of tetanus. In scarcely any disease, however, is treatment so unsatisfactory. In the rare instances in which patients recover one questions whether it is not due to indi- vidual resistance rather than to medication. Treatment may be sub- DISEASES COMMON TO 31 AN AND ANIMALS. 119 divided into heal, constitutional, and specific. If there be still an open suppurating or discharging wound, it is well to anaesthetize the patient and to thoroughly cleanse this out, basing this advice in some measure upon general principles — largely upon the fact, already stated, that only the immediate surroundings of such a wound are found infected by the bacilli themselves. Consequently, thorough scraping, excising, and cauterization , either with powerful caustics or the actual cautery, are indicated. If it be in a finger or toe, amputation may be the simplest method of eradicating the local lesion. Constitutional treatment may be divided into nutrition and medication. The tendency too often in these cases is to be careless or indefinite with regard to the excretions and the nutrition of the patient. If, for instance, each attempt at catheterization throw him into convulsions, the bladder may become over-distended, and even may possibly burst. So, too, there is apprehension usually with regard to fecal evacuations. At the same time, these patients are allowed to almost starve because of the difficulty of feeding them. My advice first, then, is to resort to chloroform at least often enough to permit the introduction of a stomach-tube — through the nostrils, if necessary — by which nutrition may be introduced into the stomach without causing the violent convulsions that would certainly occur without an anaesthetic. At the same time, the catheter may be used if necessary. In the way of active medication there is no agent so efficacious for controlling the tetanic spasms as chloroform, which may be administered occasionally, or more or less continuously, according to the wishes of the attendant. By its use the severest spasms at least can be kept in abey- ance, and the horrible character of the disease somewhat mitigated. Of the other medicaments used, most of them are of the nature of nerve-sedatives, such as chloral, the bromides, Calabar bean, cannabis ind.ica, opium, etc. By continuous but mild dosage with Calabar bean (eserine, hypodermically) the severest manifestations can often be, in a measure, controlled, providing only it be given in small doses. Curare, on account of its peculiar effect in paralyzing voluntary mus- cles, has been suggested and frequently resorted to. On account of the difficulty of getting a reliable specimen, it is not always at hand, and even then one must experiment with it in order to learn the exact dose of a given specimen which the patient can safely tolerate. Hot-air baths or diaphoretics, by which copious perspiration may be induced, have yielded good results in certain cases. In fact, they were in general use several centuries ago. Cold applications down the spine, or spraying the spinal region with ether or other volatile substances by which heat is abstracted have also had their advocates, the intention being to pro- duce spinal anaemia, so far as possible, as the reflex result of external cold. But to do this means to disturb the patient, and the practice has not been generally followed. Specific treatment means in these instances taking advantage of the now well-known properties which the blood-serum of an animal artifici- ally immunized against the disease possesses. This is in accordance with recent experimental labors with a number of different diseases, of which tetanus is one. It is, in effect, similar to the serum-therapy of diphtheria so recently introduced. 120 SURGICAL DISEASES. The most hopeful modern remedies are formalin, injected about the injured area, in very weak solution (say 1 to 1000), and especially the antitoxin now prepared in several laboratories in this country, and to-day quite easily procured. More lives can be saved by this preparation, if Used early enough and freely enough, than by any other known remedy. It is of vital importance, however, to use it at the very outset, and to repeat its use as soon or as often as may be indicated by any exacerba- tion of symptoms. In a few cases great benefit has seemed to accrue from introducing it within the dural space, or even within the cerebral substance, after making one or more small trephine-openings. The writer was the first in this country to adopt this suggestion from France, and believes in the value of the method in selected cases. Hydrophobia. Hydrophobia is an acute specific or infectious disease, so far as known never originating in man, but transmitted to him, usually through the bite or by inoculation from the saliva of a rabid animal — in this country iisually the dog, although the wolf, the cat, the skunk, and even certain of the domestic poultry, are capable of conveying the disease. It can also be inoculated in other animals, like rabbits. The virus is ordinarily conveyed in the saliva of the rabid animal. This may be wiped off as the teeth of the animal pass through the clothing of the injured indi- vidual ; consequently, infection does not certainly follow such bites. But those upon exposed portions of the body, where animals generally bite, are almost invariably followed by infection. Hydrophobia is fre- quently spoken of as rabies, sometimes as lyssa. While rare in this country, it is by no means rare in Central Europe, especially perhaps in Russia, where bites from infuriated wolves are relatively common. In the United States infection comes almost invariably from the rabid dog, in whom this disease presents two types. The so-called furious form is that which is marked by frenzy and canine mad- ness, the objective symptoms being more pronounced and alarming, though not less dangerous, than the other variety. After the period of incubation, which varies considerably, these animals show depression and uneasiness, and even thus early their saliva is infectious. Their sense of hunger becomes perverted ; they exhibit unusual tastes, secrete saliva abundantly, which becomes very tenacious and even frothy, exhibit a dry and cedematous condition of the faucial mucous membranes; the character of the bark is altered, while they are usually infuriated at the sight of other dogs. In this stage there is usually insensibility to pain. Finally, come more or less paralysis of deglutition, quickened respiration, dilated pupils, and frenzy and madness of manner, by which they attack indiscriminately men and other animals. To this stage of furious excitation succeeds one of paralysis, and, finally, death follows from exhaustion. These manifestations usually last about a week. Dumb hydrophobia is the more common form. Here paralysis appears much earlier and involves especially the lower jaw ; the tongue falls out ot the mouth ; and the posterior extremities are quickly paralyzed. This form is much more quickly fatal than the other. Hydrophobia in man is rare in this country, yet is occasionally met with. Its etiology is as yet completely obscure. That a contagium vivum is present is positive, but its nature is absolutely unknown. Symptoms. — The period of incubation in man is very variable, ten weeks being perhaps the average. It is shorter in children, as also when DISEASES COMMON TO MAN AND ANIMALS. 121 the bites are numerous. It is even stated that it may be so long as a year or more, during which time the poison seems to lie latent. When the active symptoms supervene there are, locally, discomfort about the wound, itching, heat, and peculiar unpleasant sensations. It is said also that, in some cases at least, vesicles make their appearance in the neigh- borhood of the original lesion. As in animals, so in man, the disease may assume either the furious or the paralytic type. These cases are nearly all marked by mental depression and apathy, with complete loss of courage. The earlier symptoms are connected perhaps with the respiration, which is infrequent, while inspiration is halting and speech is interfered with. The facial appearance is often changed to one of anxiety, even despair. The muscles of deglutition are next involved in a combination of spasm and paralysis, and the act of swallowing is interfered with, sometimes made almost impossible. Although patients can swallow their own saliva, thev find it most difficult to swallow any foreign substances, such as water, etc. This is not due to the fear of water, as the term " hydrophobia " would imply — -this being an absolute misnomer — but is due to reflex spasm excited by the attempt. It is accompanied by more or less sense of suffocation and palpitation of the heart. Indeed, a paroxysm of this kind may be precipitated by the attempt to swallow, so that the patient instinctively refuses water or any other fluid. Reflex excitability is also very great, and a breath of air or a trifling disturbance may precipitate a paroxysm, almost as in extreme cases of tetanus. As the case progresses the saliva becomes more tena- cious and viscid, faucial irritation more marked, and the attempts to expel the secretion, along with the disturbed respiratory efforts, have given rise to the foolish lay notion that these patients bark like dogs. The paroxysms, as the case progresses, become more marked, the patient more restless, until, later, furious mania or muttering delirium is present, to be followed by prostration and paralytic phenomena, muscle-tremor, etc., and death. The paralytic form in man, as in dogs, is marked by the much earlier paretic phenomena, anaesthesia, and, finally, respiratory paralysis, which terminates the case. Curtis and others have insisted that the hydrophobic paroxysms are not convulsions in the ordinary sense of the term, but are due to temporary inhibitions of the most important respiratory and cardiac centres as the result of peripheral impressions. He would liken them to the shock of a shower-bath. Post-mortem Changes. — Post-mortem changes are indistinct and only suggestive. For the most part they are found within the nervous centres — most prominently in the medulla, then in the hemispheres, and then in the spinal cord. There is hypersemia, with minute ecchymoses, with infiltration of the adventitia of the vessels and perivascular extrav- asation. The changes met with in the other viscera bear no constant relation to symptoms. Nevertheless, Gowers holds that because of the location of the lesions and their intensity in the neighborhood of certain nerve-nuclei we have here a distinguishing anatomical character. of the disease. Diagnosis. — As between hydrophobia and tetanus, diagnosis is not difficult, as already described. In certain hysterical individuals nervous paroxysms, largely due to fright, may be precipitated by dog-bites and other incidents or accidents. In these cases there is rarely, if ever, such a period of incubation, and in a true hysterical case there will be no 122 SURGICAL DISEASES. such mimicry, of this awful disease. A condition known as lyssophobia (fear of hydrophobia) has been described. It is seen for the most part in hysterical subjects. It is said to have even been fatal, but this must have been from other complications. Treatment. — There is no authenticated case on record of recovery after medication by drugs. It is probable that recovery has never fol- lowed anything save the modern inoculation-treatment. The essential and only successful treatment for this disease has been elaborated as the result of the labors of that indefatigable French savant, Pasteur, and is among the most glorious triumphs of laboratory research, against which it is so often charged that it is not practical in its results. It is in some respects a curious commentary on the study of infectious disease that we can secure and work with the peculiar virus of hydrophobia, and at the same time be utterly unacquainted with its true character. To this fact is due the modern cure. It is based upon the fact also that the virus obtains not only in the saliva, but in the nervous system of animals suffering from this disease ; also to the fact that its effects are intensified and hastened by inoculation directly into the cerebral substance. Virus obtained from the brain or cord and inoculated into the dura of another animal quickly precipitates the disease. It is, moreover, modified in virulence as it passes through successive animals of certain species — for example, monkeys. Curiously enough, it is increased by passage through rabbits, and the period of incubation thereby shortened. The weakest virus can by proper handling and manipulation in this way be so intensified as to produce disease within seven days after inoculation. Desiccation reduces the virulence, and preparations from the cord of an infected animal may be attenuated to almost any desired extent by drying. By inoculating a dog or a rabbit, for instance, with virus prepared from this weakened source, and daily making injections from stronger and stronger preparations, he is in the course of a couple of weeks rendered practically immune to the disease. Animals thus made immune are trephined, and the virus injected beneath the dura, by which much more certain results are obtained. Glanders and Farcy. Glanders as it is ordinarily known in man is a specific infectious dis- ease, transmitted, for the most part, from the horse, characterized by rapid formation of specific granulomata, particularly in the skin and mucous membranes, which quickly break down into ulcers, and by the general toxaemia of any acute infection. In German it is known as rotz ; in French, as mar re; while its old Latin name was "malleus" (hence we speak of the bacillus mallei). It was also known in former davs as equinia, In horses the disease has also been known as farcy, because of the peculiar subcutaneous nodules which farriers and hostlers almost from time immemorial have called " farcy buds." The disease, while capable of transmission from man to man, is virtually always produced by contagion from some of the domestic animals, most commonly the horse, although sheep and goats are known to occasionally have it, and dogs are quite susceptible, though seldom showing manifestations of it. Like some of the other infectious diseases, glanders appears to be variable in its manifestations. While infection occurs probably through some superficial abrasion, it is almost certain that it may also occur through the unbroken mucous membrane of the respiratory organs. It is said to be also capable of transmission from mother to foetus in utero. So far as known in man, infection occurs practically invariably through some slight abrasion, either of the skin or the mucous mem- DISEASES COMMON TO MAN AND ANIMALS. 123 brane of the nose, the eye, or the mouth. The discharges from the nostrils of affected animals are extremely virulent, and infection comes usually from this source. It is said to have been communicated from one patient to another by eat- ing from the same dish or by drinking from a pail used by a diseased horse. Glanders is due to the specific bacillus known as the bacillus mallei. It is shorter and plumper than the tubercle bacillus, in length about one-third the diameter of a red corpuscle. It is a non-motile organism, occasionally spore-bearing, not very resistant, belonging to the facultative anaerobic forms, growing best at blood-temperature, taking stains easily, and losing them in the same way. Symptoms. — Glanders is met with almost invariably in workers and hangers-on in stables. The acute — the common — form has a period of incubation of from three to seven or eight days, after which both local and general symptoms supervene. About the infected region a form of cellulitis appears, assuming often a more or less phlegmonous type, with implication of the adjacent lymphatic nodes and evidences of periphlebitis and perilymphangitis. Over the affected area vesicles appear, which become hemorrhagic, and later suppurate. A wound which has healed may reopen. Almost always there are accompanying constitutional disturbances of septic type, occasionally chills, pyrexia, etc. It is rather characteristic of glanders to have severe pain in the muscles and extremities, with epistaxis and formation of metastatic tumors and oedematous swellings in various parts of the body. Fre- quently, later in the disease, comes a somewhat distinctive eruption, papular in character, merging into pustular. Hemorrhagic bullae are also often seen. Pustulation and oedema of the face change its appear- ance notoriously. There take place also oedema of the eyelids and muco- purulent discharge from the conjunctiva and the nose. This latter dis- charge is often even ozaenous in character. Upon inspection of the naso- and oro-pharynx a similar condition will be noted. In connection with these local signs more or less general furunculosis will also be observed. Obviously, as these local conditions intensify and multiply septic disturbance will be increased, and the patient dying of acute glanders dies in large measure of septicaemia or intoxication and exhaus- tion combined. A chronic form is known, distinguished mainly by slowness or tardiness of lesions, though the local changes are not particularly different in character. There is perhaps more tendency to suppuration and less to lymphatic complications. The nodule which breaks down will leave a foul ulcer, the discharge from all these lesions being extremely infectious. Diagnosis. — This is not always easy, but may be based in suspicious cases to some extent upon the occupation of the patient. The presence of multiple lymphatic lesions and subcutaneous nodes, especially when breaking down as above described, and accompanied by ozaenous dis- charge from the nose, should at least be most suggestive, and will serve to distinguish between this disease and, for instance, typhoid fever. The chronic type of glanders might be mistaken for syphilis, and here is where the real difficulty of diagnosis will probably obtain. In doubt- ful cases the crucial tests would be microscopic examination of discharges after staining for bacilli, and the cultivation test. Prognosis. — A generalized attack of glanders is a matter of gravest import, especially when acute. Scarcely more than 10 or 15 per cent. 124 SURGICAL DISEASES. of such cases recover. In the more chronic manifestations the prognosis is very much better, half of the patients making a final recovery. Treatment. — All infected animals should be quickly isolated and destroyed, their carcasses being burned. If possible, the infected wound or abrasion should be coaxed to bleed freely, and then cauterized with some active caustic. By prompt interference with the first manifesta- tions it may be possible to cut short the disease. This would necessarily be done by excision, cauterization, packing, etc. Bayard Holmes has reported a case in which, during two and a half years of chronic mani- festations of this disease, he anaesthetized the patient twenty times for the purpose of opening new foci or scraping out old ones, finally obtaining a permanent cure. There is no specific treatment, but the septic symp- toms should be combated as already indicated in the chapter on Sep- ticaemia. By making a glycerin extract from the filtered and evaporated culture of the glanders bacillus it is possible to prepare a toxalbumen analogous to tuberculin, which reacts in a similar way. By it animals may be fortified against inoculation, and by its use a peculiar reaction is produced in those affected by the disease. It is known as mallehi, and by it are tested all horses used for the preparation of the diphtheria antitoxine, in order that all possibility of glanders may be eliminated. It is probable that it might be made of therapeutic value in treating the disease when actively present in man. Anthrax. Anthrax is more commonly known as splenic fever, malignant pus- tule, or wool-sorters' disease; in Germany, as Milzbrand, and in France, as charbon. It is an infectious disease of cattle, which has devastated many parts of Central Europe, and which has been frequently met with abroad among men, though but rarely in the United States. All the domestic and nearly all the experimental animals are subject to it. Gronin has stated that in the district of Novgorod, in Eussia, during four years more than 56,000 cattle and 528 men perished from anthrax. Poul- try and dogs are not exactly immune, but possess a low susceptibility to the disease. It seems to prevail in low districts and in marshy grounds. The disease is the result of the invasion of the bacillus anthracis, which is a relatively large-sized bacillus, varying in breadth from 1 to 11 and in length from 5 to 20 mikrons. It is most easily cultivated outside the body, and multiplies with great rapidity in the body of sus- ceptible animals, is the type of spore-bearing bacilli, and is "so easily recognized and worked with that it is commonly used in laboratory investigations. The demonstration of its specificity we owe to Davaine in 1873, although he had described it in 1850. Anthrax bacilli may enter the body through the respiratory organs, through any abraded surface, and possibly even through the alimentary canal. They may also pass through the placenta and affect the foetus in utero. They are too large to pass through the walls of the capillaries of ordinary size ; consequently, they plug them and produce a mechan- ical stasis which is rapidly followed by gangrene. From the kidney structures and capillaries, however, they must escape, since bacilli are found in the urine in certain cases of anthrax. In man the disease occurs usually as the so-called malignant pustule or ivool-sorters' disease, the latter name being given because of the DISEASES COMMON TO MAN AND ANIMALS. 125 Fig. 22. Bacilli of anthrax : section from liver ; X 500 (Friinkel and Pfeiffer). liability of those individuals who come in contact with the carcasses and hides of diseased animals or their immediate products. The period of incubation is brief — on the average two or three days. The first lesion appears usually on the face, hands, or arms, and is characterized by local discomfort with formation of a small papule, which rapidly becomes a ves- icle with an areola of cellulitis about it. This is rapidly followed by indu- ration and infiltration, and these by local gangrene, the result being the separation of a core-like mass, much as in certain cases of carbuncle. The affected area is usually discolored, often quite black. The process is not usually accompanied by suppuration, nor is there the pain of true carbuncle. The lesions tend to spread peripher- ally, but there is more or less vesi- cation of the surrounding skin. On account of the local ischaemia there will always be cedema of the affected region, and sometimes the swelling and local disturbance become ex- treme. These peculiar lesions have given rise to the common name, malignant pustule, which is well deserved. At last a line of demarca- tion becomes manifest, and if the disease progress favorably the included area is sloughed out, leaving a surface which it is hoped will soon become covered with reasonably healthy granulations. Absence of pain, and usually of pus, are significant features of anthrax. Should, however, mixed infection occur, wo are quite likely to get pus- formation. When the disease partakes less of the characteristics of malignant pustule and more of a general infection, the local symptoms may not predominate, but, on the contrary, septic indications may be- come serious and even fatal. The evidence of more or less toxa?mia is usually at hand, however, and the toxine of anthrax is almost as destructive of muscle-cell integrity as is that of diphtheria. The local lesions may be single or multiple, but will be met with almost always upon exposed areas of the body. Post- mortem Appearances. — These will depend upon the clinical course of the disease. In the sloughing tissues the bacilli are very numerous, while around the margin more than one bacterial form will probably be met with — i. e. mixed infection. Should saprophytic organ- isms complicate the case, they may have replaced the anthrax bacilli by the time the examination is made. The latter abound, however, in the blood, and may usually be found occluding the capillaries of the liver, spleen, kidney, etc. In intestinal infection, particularly in ani- mals, the mesenteric nodes are involved. Inasmuch as septic features accompany all fatal cases, putrefaction will be found to begin early, and the changes in the blood and the gross changes in the other organs will, for the most part, remind one of sepsis rather than of anthrax. 126 SURGICAL DISEASES. Prognosis. — Prognosis for man is not usually unfavorable, the majority of cases recovering with more or less local destruction of tis- sue. Should, however, infection become generalized, the case will prob- ably terminate fatally. Treatment. — This must be both local and constitutional. The former should consist of the most radical possible attack, and should include complete excision of the infected area, with the use of active caustics or the actual cautery. In fact, the latter instrument offers a most valuable means for combating the destructive tendency of the dis- ease. Sloughing and separation of the cauterized mass may be hastened by warm antiseptic poultices. Subcutaneous injections of 5 per cent, carbolic solution have been practised with apparent benefit in a number of cases, but should only be relied upon in the treatment of the milder manifestations. Benefit will accrue from the use of the ichythol-mercury ointment whose for- mula I have given when considering the treatment of Erysipelas. It has been suggested to treat these cases by the employment of the bacillus pyocyaneus, since it is known that this organism when injected with the anthrax bacillus materially attenuates its effect. Malignant CEdema. This disease has been recognized for some time, mainly by French and Continental clinicians, and under such names as gangrene foudroy- ante, gangrene gazeuse, gangrenous septicaemia, and gangrenous em- physema. The name malignant oedema was given by Koch, who identified the infectious organism. It is one of the most dangerous forms of gangrenous inflammation, and occurs sometimes after serious injuries, and, again, after most trifling lesions, such as those inflicted by the dirty pointed instruments of the gardener, etc., or even the stings of insects. Two cases are on record where the disease followed a puncture of the hypodermic needle for the administration of morphine. In one of these the organism was found in the solution ; in the other it prob- ably had been deposited upon the skin. Malignant oedema is essentially a specific form of gangrene (see Chapter A T .), and is mentioned here rather because of its specific cha- racter. It is characterized by rapidity of spread and the specific nature of the exudate, as well as by the speedy destruction of the tissue in- volved, and by more or less gas-formation. It is not the same as the gaseous phlegmons described by some German surgeons, yet partakes of their general character. (Gas phlegmons have been rarely noted, their peculiarity being formation not only of pus, but of more or less offensive gases, which escape when the plegmon is incised. The gases are due to the presence of saprophytic organisms, and gas phlegmons, as such, are to be regarded as instances of mixed infection.) Malignant oedema is known by the brownish discoloration of the overlying skin, which is streaked with blue where the overfilled veins show through it, while the underlying tissues are sodden with fluid and more or less blown up by the gaseous products of decomposition, so that the finger detects a firm crepitus, as is common in subcutaneous emphysema. From the wound, if one there be, flows a thin, foul- smelling secretion, which may also be expressed from the deeper layers. That the neighboring lymph-spaces and nodes are actively involved is evident from the enormous swelling of the latter, as well as from the general condition of the patient. The rapid elevation of temperature with but trifling remissions remains DISEASES COMMON TO MAN AND ANIMALS. 127 constant until shortly before death. The tongue early becomes dry and cleaves to the palate, its surface being covered with a thick, foul fur. Patients early become apathetic, complaining only of pain and burning thirst. Delirium and coma usually precede death, which may occur in even so short a time as fifteen to thirty hours. After death the cadaver bloats quickly and putrefaction goes on with amazing rapidity. Post-mortem Appearances. — At the seat of the lesion even mus- cles and tendons will be found macerated, bone denuded and surrounded by a putrid fluid, the entire region presenting a notable swelling and infiltration of soft parts with reddish fluids and stinking gases. The overlying skin will be stretched, and superficial blisters may deepen the intensity of the process. The veins are clogged with decomposed blood and broken-down thrombi, and in the heart and large vessels will be found putrid liquid as well as gas, to whose presence early and sudden death is probably due. Prognosis. — This, for the most part, is bad, especially when the bacil- lus of malignant oedema is alone at fault. Patients may escape with their lives, but always at the expense of more or less tissue-destruction. Treatment. — This must consist of extensive incision to permit escape of fluids and gases and relieve tension ; of such antiseptic appli- cations as can be made available ; of immersion of the affected part in a hot antiseptic bath, if this be possible ; and of such vigorous stimu- lation by the most powerful measures — strychnia, alcohol, etc. — as may be possible, in order to support the patient through the period of pro- found depression characteristic of the disease. Actinomycosis. This also is a subacute, but always destructive infection by a specific micro-organism, though not a bacterium. Known always as actinomy- cosis in man, the disease, which is most common in cattle, has been known commonly as lumpy jaw or swelled head, and years ago was usually regarded as cancer or as a malignant affection. Many old museum specimens labelled as cancer of the tongue, jaw, etc. have of late been shown to be instances of actinomycosis of these parts. It is occasion- ally met with in man, so that now there are probably at least three hundred cases on record in this country and in Europe. The organism was recognized some fifty years ago by Langenbeck and Lebert, but was not scientifically described until thirty years later. The names of Bollinger, Israel, and Ponfick will always be connected with these researches. The organism itself belongs among the ray fungi, is known as the actinomyeis, and occupies a somewhat uncertain place in classification. It is large enough, when entire, to be noted by the naked eye, has ordi- narily a yellowish tint, a tallowy consistence, and may be seen under the microscope to consist of a cluster of branching prolongations, club- shaped at the end, radiating from a common centre. They give it rudely a sunflower appearance. It is stained with difficulty, best with a com- bination of picrocarmine and some aniline dye. In tissue-sections ihe Gram stain is the best. It is cultivated with difficulty, but can be grown upon solid media and may be inoculated. As met with in tissue or in pus these fungi constitute small granula- tions, giving usually a gritty sensation to the finger, which is due to the presence of calcium salts. The recognition of this calcareous material 128 SURGICAL DISEASES. is of great importance, since it may enable a diagnosis to be made off- hand which otherwise might puzzle one. In the only case so far met with by the author the diagnosis was established within a minute by the detection of these little particles. The disease is very common among cattle in certain regions, and causes the candemnation of many animals in every large stockyard establishment where inspection is careful and scientific. It occurs oftener in young than in old animals, and most often in those which come from valley regions and marshes. In animals infection occurs almost invariably through the mouth, which Fig. 23. Fig. 24. Actinomycosis bovis, from sections of a " lumpy jaw," showing ray fungus (Crookshank). Actinomycis, from lirer of a male natient : a, rays of fungus ( T ' 5 oil immersion). is easily explained by the fact that in grazing the lips, tongue, and gums are likely to be irritated and infected at any time from soil containing these fungi along with growing grain. The path of infection, then, is usually by the mouth, while acci- dent seems to determine whether the infection shall manifest itself mainly in the intestinal canal or the respiratory tract. In animals there is less tendency to sup- puration than in man, the infection in man being usually a mixed one. The name lumpy jaw, so generally given to the affection, is indicative of the most conspicu- ous lesion in cattle, for the organism, having once invaded the gum, for instance, passes quickly to the bone, or, having involved the tongue, is not slow to infect the lymphatics of that region. In consequence we have tumors, often of inordinate size, which may involve the bones or the soft parts and cause great disfigurement, along with necrosis, leading eventually to the death of the animal. These tumors are essentially granulation-tumors due to the presence of a specific irritant — namely, the actinomycis — which acts here as do the tubercle bacillus, the lepra bacillus, etc. in other infectious granulomata. In man the disease is almost always accompanied by abscess-forma- tion, the pus containing the distinctive yellow gritty particles which are found in no other disease. The strong resemblance between the lymphoid cells of this form of granuloma and the embryonal cells of sarcoma has permitted the perpetuation, until recently, of confusion between these two neoplasms. Large abscesses form as the result of the coalescence of small ones, and by the time the disease is recognized extensive destruction and loss of substance may have taken place. In man it is not alone about the mouth that the disease is noted, although primary lesion here is bv no means infrequent. It leads to affections similar to that already spoken DISEASES COMMON TO MAN AND ANIMALS. 129 Fig. 25. of in cattle, with a progressive infiltration and breaking down, including actual necrosis of bone, etc. The pus will escape at various points, and may give to the surface an appearance as of many craters with a central cause. When the disease has involved the lung, either directly or indirectly, the fungi and the calcareous particles may be found in the sputum. Should there be suspicion of this involvement, the sputum should always be examined. Even in the heart-substance tumors of this same character have been found. The first case noted in man had undergone extensive vertebral caries. Intestinal infection is possible, in which case multiple lesions will form in the intestinal walls, which may contract adhesions to the abdominal parietes and dis- charge externally through them. The appendix has been found involved in such lesions. Infection of the skin has also been described, though this occurs more rarely. Diagnosis. — Actinomycotic lesions have been in time past mistaken for cancer, sarcoma, tuberculosis, syphilis, etc. Without going more minutely into differences, it is enough to say that in man it will always be characterized by more or less sup- puration, and that in the purulent discharge from the infected focus the I characteristic yellow calcareous par- 1 tides should enable recognition of this disease at once. Prognosis. — So long as the focus j is accessible it is a purely local I matter, and prognosis is as favorable as in local tuberculosis ; but, inas- much as in too many cases infection I has proceeded to a point where the surgeon cannot safely follow it, prog- nosis must be guarded. Actinomy- cosis is free from acute manifestations, for the most part free from pain, pur- sues a chronic course, and is charac- terized, as are the other slow infec- tions, by progressive emaciation, prostration, etc. Inasmuch as it is essentially a chronic condition, time is afforded for careful study in doubt- ful cases, for microscopic examination, etc. Treatment. — This must consist of radical extirpation of all infected tissues and areas. If this can be done thoroughly, and safely in other respects, one may hold out a prospect of positive cure. Free incision, wide dissection, the use of the actual cautery, etc. are always called for in these cases. If it involve the tongue alone, for instance, there is an excellent prospect; if but a portion of the jaw be involved, a complete excision of one-half or more may be followed by excellent results. If, however, the lung, liver, vertebrae, or other vital and inac- cessible parts be involved, surgical measures may afford amelioration,, but can hardly be expected to cure. Actinomycosis in man (Musser). CHAPTER IX. SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC ANIMALS (Continued). By Roswell Park, M. D. Tuberculosis. The most important and frequent of the infectious diseases common to animals and man is tuberculosis. This is, for the most part, a sub- acute or chronic affection, although in a small proportion of cases it assumes an acuteness of type which may make it fatal within so short a time as fourteen or fifteen days from the first recognizable symptom or even less. Tuberculosis as a form of disease is more prevalent than any other, and is the cause of death of a proportion variously estimated at from 20 to 30 per cent, of mankind. It is a disease which intimately concerns the surgeon, perhaps even more than the physician, inasmuch as it is also the most common of all the so-called surgical diseases. The frequency with which it is met varies in different parts of the country, and~ in some measure with the character of the population. In the average surgical clinic of the United States probably 25 per cent, of cases of surgical disease are manifestations of this affection. Synovial membrane with tubercles ; X 70 : giant-cell in the middle of a sharply outlined tubercle- about it round-cell infiltration (Krause). ' Surgical tuberculosis now covers the entire range of disease-manifestations formerly inaccurately and inaptly described as scrofula. The term scrofula is now 130 DISEASES COMMON TO MAN AND ANIMALS. 131 Fig. 27. expurgated from medical terminology, and there is no longer any excuse for its continuance, save possibly in making certain explanations to the laity, who are not yet educated to the new term. All of the active manifestations formerly regarded as scrofulous are now known to be due to tuberculosis. To the presence of tubercle bacilli in the tissues is due that distinctive aggregation of cells which constitutes the so-called miliary tubercle. Its presence and arrangement are apparently the direct outcome of the irritation produced by these minute foreign bodies, and its method of grouping is so characteristic that it may be everywhere and usually easily recognized. Its centre is composed of one, possibly several, giant celh, whose nuclei are usually arranged around the margin, with perhaps de- generative changes going on in the interior of the cell itself. In this giant cell, as well as outside of it, may be seen one or several tubercle bacilli. Around this centre are clus- tered a number of large cells, known as epithelioid, which may also contain bacilli. These cells are probably de- rived from epithelium when at hand, or from the endothelium of the vessel- walls, or from the fixed tissue-cells. Outside of this are yet other, usually spindle-shaped, cells, contained in a connective-tissue network and re- garded usually as lymphoid cells. When tubercle is experimentally pro- duced the bacilli seem more numerous than they do in instances of spon- taneous disease. This little aggrega- tion of cells constitutes a mass which may be recognized by the naked eye — a minute, usually white point or nodule, which is known as a miliary tubercle. It is subject to any one of several changes to be presently con- sidered, and it is usually found in large numbers when present at all. The punctate appearance of miliary tuberculosis is perhaps best seen upon the cerebral membranes or the peri- toneum in cases of acute miliary tuberculosis. By coalescence of a number of these nodules larger tuber- cles are formed, and by combination of coalescence and caseous degen- eration are produced the large cheesy masses which our forefathers called yellow tubercle. The epithelioid cells are by some regarded as modified leucocytes ; by yet others, as the product of division of the fixed cells. The giant cell is probably the result of irritation in one of these cells, the stimulus being sufficient to provoke division Tuberculosis of serous membranes [tunica vaginalis testis] ; round-cell infiltration (Goldmann). 132 SURGICAL DISEASES. of the nucleus, but not of the entire cell. Since the principal cellular activity- occurs in the interior of this nodule, the result is a condensation about the periph- ery which furnishes eventually a sort of capsule, as it were, the tissues being hard- ened and condensed as if for this special purpose. The effect of this is to interfere with vascular supply, and finally to shut it off completely. So long, now, as no pyogenic infection occur, the original tubercle may gradually shrivel down and disappear, or, most likely, caseous degeneration will occur, and it may persist as a cheesy nodule for an indefinite length of time. As such a tubercle grows old the cells lose their identity, refuse to take stains, and a slow or quiet coagulation- necrosis results. In this nest sometimes calcium salts are precipitated, the result being a calcareous nodule. On the other hand, during the active stage of this tubercle-formation cell-resistance may be lowered, either from general or constitu- tional causes ; the original focus disintegrates ; tubercle bacilli are liberated, and are now carried hither or thither, metastatic tubercles being the result of their dissemination. Spontaneous healing of tubercle is possible, and may be due to three different causes : (a) Necrosis and exfoliation of diseased tissue (e. g. in lupus) ; (b) Cicatricial formation ; (c) Retrograde metamorphosis. Looked at from another point of view, the possible fates awaiting the miliary tubercle are the following : (a) Absorption; (6) Encapsulation; (e) Cheesy Degeneration ; (d) Calcareous Degeneration ; (e) Suppuration. Absorption of tubercle undoubtedly is possible under favorable circumstances, but just what constitute these favoring circumstances no one knows, since they occur in cases which do not terminate fatally. To be able to describe them would be to detail minutely the changes which permit of recovery after non-traumatic tubercular infection ; which clinical fact is amply demonstrated by the experience of the pro- fession. Absorption is probably largely a matter of phagocytosis. Encapsulation has already been spoken of, the capsule being formed by the condensation of the original cells of the tubercular agglomera- tion, the infectious organisms being thereby imprisoned so long that they are practically starved, and finally die. The tubercle bacilli, however, may long lie latent in such a cellular prison, and should anything occur to break the prison-wall, they may escape and still prove actively infec- tious. In this way are to be accounted for the fresh eruptions from old miliary or other deposits. Caseation is a condition more fully to be described in works on pathological anatomy. It comprises a series of changes in the chemical constitution of the cells by which an albuminoid mass much resembling casein in composition and appearance is produced. The English equiv- alent eheemj well describes many of these masses, which both cut and appear very much like domestic cheese. They have a yellowish color, and are met with in masses in size from a pin's head up to a robin's egg. These are the yellow tubercles of the older writers, and such a cheesy tumor has been called tyroma. Calcification refers to a peculiar deposition of calcium salts within the interior of these nodules, the first precipitation occurring usually in the centre of the giant cell, which is itself the topographical centre of DISEASES COMMON TO M AN AND ANIMALS. 133 the miliary tubercle. As time goes on it may spread from this, until a mass easily recognizable by the naked eye and detectable by the finger is produced. Such calcareous particles are frequently found in sputa, and are always an index of the tuberculous character of the case. They differ markedly from the yellow calcareous nodules found in the pus of actinomycosis, and the only circumstances under which the) - are likely to be confused are met in pulmonary disease, which may prove to be either one or the other. Cold Abscess. Suppuration, as indicated, is the result, for the most part, of a mixed or secondary infection with pyogenic organisms. I have in the previous chapter grouped tubercle bacilli as among the facultative pyogenic bac- teria, yet I must say that, for the most part, pus is not formed in this disease except in consequence of coincident activity of other bacterial organisms. The matter of suppuration of tubercular foci is one of the greatest importance to the surgeon, because thereby is produced a dis- tinct class of so-called abscesses — namely, the cold or congestion abscesses. These, as usually coming under the surgeon's notice, are of the chronic type, and are free from almost all the ordinary signs of abscess-forma- tion. They are invariably the result of local infection, sometimes per- haps by the tubercle bacilli alone, but most often by combined action of these with pyogenic forms. For their formation a previous tubercular lesion is essential, and such is always met with. Wherever old tuber- cular lesions are met with, there may cold abscesses also form. No tissue or organ is exempt : they are found in the brain, in the bones, viscera, joints, skin, in fact everywhere. Cold abscesses have not only a significance of their own, but for the most part an identity. Their most distinguishing feature is a limiting membrane, which forms whenever sufficient time has elapsed. Much has been written about this in time past, and much error has been perpetu- ated with regard to it. This is the membrane formerly considered and called pyogenic, under the misapprehension that by it the pus or contents of the abscess were produced. I wish to emphasize in every possible way that this is a sad error. This membrane does not act to produce pus, but is rather the result of condensation of cells around the margin of the tubercular lesion, forming, as it were, a sanitary cordon for the abso- lute and definite purpose of protection against further ravages. I there- fore insist that the term pyogenic membrane be abolished, there being no such membrane under any circumstances, and that this be known as that which in effect it is — namely, a pyopfiylactic membrane. It is a protection against pus, and, were it not for its presence, there would be no limit to the spread of tubercular invasion. As it is, a lesion thus surrounded is shut off from most possibilities of harm, rarely encroaches, except by the most gradual processes, and, on the contrary, often con- tracts and reduces its dimensions, the watery portion of its contents being gradually absorbed and the more solid and cellular portions becoming condensed, finally, into matter which undergoes caseous degeneration, so that eventually recovery may ensue as the consequence of a metamor- 134 SURGICAL DISEASES. pilosis of an original cold abscess into a caseous nodule surrounded by the old pyophylactic membrane, which is now serving as a capsule. The contents of the cold abscess are, in some instances at least, of rather acute origin, and consequently may have been originally pus or its near ally. Upon the other hand, in cases which have occurred very slowly this material never is, and never was, real pus, but is a semifluid debris having certain properties which remind one of pus. It has been my effort hitherto to devise for this material a name which should distinguish it from pus and indicate what it really is. Inas- much as most of it has been of a puruloid character, at least at one time, I have suggested that it be called archepyon (i. e. originally pus or puruloid). As this flows from such a cold abscess, it is more or less watery and contains caseous, some- times calcareous, nodules in masses of considerable size, and not infrequently sloughs of tissue and old shreds of white fibrous tissue which resist decomposition for a long time. This material has been thus imprisoned, sometimes for months or even years, and consequently has lost most of its resemblance to what it originally was. The organisms which first produced it have long since died out, and it is practically sterile. If any organisms survive, they are the tubercle bacilli, which are very much more resistant and tenacious of life than the ordinary pyogenic organisms. This is why most culture-experiments fail, and why even inoculation with the contents of an old cold abscess is often without effect even on most sus- ceptible animals. Nevertheless, the bacilli which the semifluid contents do not contain, may yet linger in the meshes of the pyophylactic membrane ; and here lurks the greatest danger in dealing with these lesions. In old cases the pyophylactic membrane is very tough and very adherent by its outer surface. It can sometimes be peeled off in strips of considerable extent, at other times cannot even be separated, or some- times is so placed as to render it impossible to follow it to its termina- tion. Complete extirpation of this membrane, or at least complete destruc- tion, is the duty of any one who attacks such a tubercular lesion ; and when its complete removal is impracticable, failure to remove it should be atoned for by some powerful caustic, such as zinc chloride, nitric acid, caustic pyrozone, or the actual cautery, which shall be made to follow it to its ultimate ramification. The membrane and the tissues underlying when thus cauterized will separate as sloughs, and these will be replaced by presumably healthy granulations, which should be encouraged until the original cavity be filled or the surface healed over. In a general way, then, it may be said that acute abscesses, as indi- cated in the previous chapter, have no real limiting membrane, although there is more or less condensation of tissues about the focus of infec- tion. A typical membrane is distinctive of tubercular abscesses, and is to be regarded always as their natural protection and a barrier against their further encroachment — nevertheless, a membrane whose inner sur- face may harbor still active organisms, which yet cannot escape throuo-h its outer texture. Consequently, to simply incise it or inefficiently scrape it is to do a worse than useless thing ; and one should never attack it unless he is prepared to thoroughly extirpate it or destroy its integrity, and in this way finally dispose of it. Cold abscesses, when near the surface, cause a bluish or dusky dis- coloration of the overlying skin, while the superficial and subcutaneous veins of this region are usually enlarged. Fluctuation is also a promi- nent phenomenon in connection with them when they can be palpated. Deep collections of this kind may be mistaken for cvsts or tumors, in which ca^e the aspirator needle may be used to facilitate diagnosis. They vary in size from the smallest possible collection of fluid to abscesses which may contain a gallon or more of puruloid material or archepvon. DISEASES COMMON TO MAN AND ANIMALS. 135 They are known often as gravitation-abscesses, because by the mere weight of the contained fluid they tend to elongate or spread themselves in the direction in which gravity would naturally carry a collection of fluid. Thus, cold abscesses originating from tubercular disease of the lower spine frequently work their way along the psoas muscle and present below Poupart's ligament as psoas abscesses, or elsewhere about the thigh, while those which come from similar disease of the uppermost cervical vertebrae may present behind the pharynx, as the so-called retropharyngeal abscesses; and those from the dorsal spine present not infrequently as lumbar abscesses. These are but two or three familiar examples of what may occur in any part of the body. Treatment. — Aside from the treatment of cold abscesses, already indicated, by radical measures, other means have been suggested, and particularly for the treatment of those in which such extreme measures are impracticable or simply impossible. It is sometimes efficacious to simply tap or remove by aspiration the contents of such a cavity. It may never refill, or but slowly, and after repeated tapping alone a very small percentage of such cases will subside into inactivity and the lesion be subdued, if not absolutely cured. Of late treatment by injection of solutions or emulsions of iodoform has been quite generally accepted. This is based upon the alleged specific properties of iodoform as being pecu- liarly fatal to tubercle bacilli, presumably by liberation of free iodine. A cavity to be thus treated should be first emptied as completely as possible, after which may be thrown into it a glycerin emulsion or an ethereal solution, or a suspension in sterilized oil of iodoform, usually in strength of 5 to 10 per cent. From 25 to 200 c. c. of some such preparation is introduced, while the walls of the abscess are more or less manipulated in the endeavor to completely disseminate the mixture. The cannula through which it has been introduced is then withdrawn ; and this can usually be done without any, or at most with but little, unpleasant iodoform effects. This is due to the prophylactic membrane, which limits the activity of the iodoform, as it has done that of the previous contents of the abscess. Such cavities have also been treated by washing out through a trocar with an injection of various antiseptic or stimulating solutions, among which we may mention hydrogen per- oxide, weak iodine solutions, etc. My own advice is to treat all tuberculous lesions radically when such measures are not contraindicated by their multiplicity or by too great depression of the patient, and so long as lesions are accessible to ordinary operative procedures. This same advice pertains also to those which have already spontaneously evacuated themselves or where the overlying skin is threatening to break and permit escape of contents. Almost any case where this is imminent is one in which the surgeon, as such, ought to interfere. On the other hand, in deep collections and in debilitated individuals the treatment by injection may at least be tried. With added years of experience my conviction has grown, however, that the best way in which to treat accessible tubercular lesions is by the most radical and merciless extirpation, and that, while this subjects patients to operative ordeals, it nevertheless shortens the period of time during which they are under treatment, hastens convalescence, and leads to very much more permanent results. The Gummata op Tuberculosis. The other and essential characteristic of tubercular disease, by which it manifests itself in surgical lesions at least, is the infectious granu- loma to which it gives rise. This is a term first applied by Virchow to new formations of granulation-tissue, which are the result of the presence of an invading and specific irritant. This tissue varies little in type, if 136 SURGICAL DISEASES. at all, from that already described when dealing with the healing of ulcers, and is common to the neoplasms which are met with in tubercu- losis, syphilis, leprosy, glanders, and some of the other local infections. So little does the tissue-type vary in these different instances that it is difficult, if not impossible, to distinguish by microscopic sections of the unstained tissues, or at least those unstained for bacteria, to which class of lesions they belong. The production of granulation-tissue is, how- ever, of such general prevalence and such important significance that it must be spoken of at some length in this place. This tissue may be met with in any of the tissues of the body, but is seen per- haps least often upon the serous membranes of the cranial and peritoneal cavities, whereas in the joint-cavities it is common. It is provoked, as just stated, by the presence of tubercle, and has the power of penetration into and substitution for almost all the other tissues of the body. Thus in a primary tubercular focus within the bone a granuloma will form and extend its limits, while the surrounding bony tissue melts away before it; and it is by the growth of this tissue in a particular direction that tubercular products from within the bone-cavity are finally carried to the surface. When this material has escaped from bone or from tissues without the bone toward the surface, its presence is marked by induration, by livid dis- coloration of a limited area of skin, with elevation of the surface, which finally breaks down and shows discolored, bleeding, and pouting granulations, which in the absence of restraint now proliferate more rapidly, and often to the point where they get away from their own blood-supply, and consequently necrose upon the surface. This is the fungous granulation-tissue, especially of the German writers, and may be met with upon the surface, or is frequently seen in opening into joint- cavities and other tissues infected by tubercle. The appearances of this fungous tissue are modified somewhat by environment and pressure: in joints flat and radiating, masses of it will be found, extending along the synovial surfaces and into the articular crevices. This fungous tissue may grow in any direction, but apparently always does advance in the direction of least resistance. It leads to complete perforations of the flat bones, like those of the skull, while tuberculous masses from the dura may cause multiple perforations, the granulation-tissue finally escaping through the overlying skin. In tuberculosis of synovial sheaths and bursae it extends along, and may completely fill and even. distend, them. It will separate tissues which are united together, and it may lead to disintegration and disorganization of the firmest textures in the body. So long as it be not exposed to the air nor to pyogenic infection it will preserve its characteristics for a con- siderable length of time. Immediately upon exposure it is likely to break down, and infection will travel speedily along it into the deeper cavity whence it has sprung. A mass of this tissue contained within the normal tissues, condensed more or less by pressure, uninfected, and not freely supplied with blood, is entitled to the name of tuberculous gumma, whose tendency, however, is for the most part to break down and suppurate. Such gummata may be found in any part of the body, and differ only in unessential respects from the diffused and more or less infiltrated masses of granulation-tissue which occupy serous cavities or which extend in various directions. The lesions of surgical tuberculosis, except those already spoken of as constituting cold abscess, are so essentially connected with the presence of granulation-tissue, just described, or of this form of the infectious granulomata, that no student can appreciate the subject until he is quite familiar with this tissue in its various phases and "in various locations. Of such great importance is it that this be realized that some of the local manifestations of this new tissue must here be considered, although they may be rehearsed in other form in succeeding chapters. In the skin and subcutaneous tissues and in and under mucous membranes this granulation-tissue may be studied at places where it is free from most of the mechanical restraints to growth, and where in other respects its appearances are typical. The most characteristic DISEASES COM M ON TO MAN AND ANIMALS. 137 manifestations in the skin occur as lupus, a disease for a long time con- sidered cancerous or of uncertain etiology. We are in position now to teach, however, that lupus is always a cutaneous manifestation of this protean disease. In its incipient stages lupus consists of multiple minute nodules of granulation- tissue just beneath the surface, containing all the elements of true miliary tubercle, Fig. 28. Fig. 29. Lupus of hand, tubercular disease of bones, with absorption (Krause). Epithelioma developing upon lupus—" lupus- carcinoma " (Steinhauser). with infiltration of the surrounding skin, even into the subcutaneous fat. The most common location of these lesions is on exposed surfaces. Bacilli are not numerous, yet may be demonstrated in all these lesions. The tendency is more or less rapidly to break down, the result being a tubercular ulcer, which, as it extends, manifests usually a disposition to cicatrize in the centre while enlarging around its periphery. The dermatologists describe several different forms of lupus under the names hypertrophicus, vulgaris, maculosus, etc., all of which are essentially the same in character, the differences being largely constituted by the rapidity or slow- ness with which the granuloma of the skin breaks down. From the surface these growths mny extend and involve parts at considerable depth, even the periosteum. This name should also include the lesions described as scrofuloderma or scrofulous ulcers of the skin, they being all of the same real character. A variety known as anatomical tubercle has been described by numerous writers, found especially upon the hands of those who haunt dissecting-rooms or handle dead bodies, and is supposed to be the result of local inoculation. It appears usually as a warty growth, which ulcerates and becomes covered with a scab — is usually most indolent in character, but is followed by lymphatic involvement, and in rare instances by death from tubercular disease. In the lymphatic structures and lymph-nodes tuberculosis is a most frequent affection. In these localities it may occasionally be primary, but is almost always a secondary lesion. It is in separating from the lymph-stream the tubercle bacilli, which would otherwise be passed into 138 SURGICAL DISEASES. the general circulation, that the lymph-nodes, acting as filters, render us the greatest possible service. These filters, however, almost always become themselves infected, and, enlarging, they assume the appearances Fig. 30. Fig. 31. Tuberculosis of mesenteric lymph-node ; X 200 (FrSnkel and Pfeiffer). Tuberculosis of cervical lymph-nodes (Holloway). known to the laity as scrofula, which in time past have been so generally spoken of as scrofulous glands. These lesions abound rather about the axilla and the cervical and bronchial nodes than about the lower extrem- ities. Nevertheless, the retroperitoneal, mesenteric, and inguinal nodes are occasionally infected. In these nodes will be found giant cells sur- rounded with epithelioid cells, containing bacilli and undergoing cheesy degeneration or suppuration. Infection often proceeds from centre to periphery, and then to the surrounding tissues, the filter, as such, having become so choked that nothing seems to pass it. By virtue of this sur- rounding infiltration (which used to be known as periadenitis, when lymph-nodes were spoken of as lymph-glands) generalized infection is in some measure prevented, while the natural barriers are altered and nat- ural distinctions between tissues are lost. This makes complete extirpa- tion of these tubercular foci often very difficult, while the adhesions which they contract, for instance, in the neck are often to the large vessels and nerve-sheaths, by all of which their operative treatment is naturally complicated. When infection from the superficial nodes extends toward the surface it is easily recognized by the dusky hue of the overlying skin, the hardness, infiltration, and, later, the fixation, of these masses, accompanied usually by evidences of suppuration. In the bones we find as often as anywhere expressions of tubercular disease. Strange to say, it is not much more than fifty years since Nelaton called attention to the frequency of these intraosseous lesions, and demonstrated the essentially tuberculous character of much that had hitherto been overlooked or considered under that vague term scrofula. . All those forms of bone disease comprehended under the names Pott's disease, spina ventosa, tumor albus, etc. are now known to be distinctly DISEASES COMMON TO MAN AND ANIMALS. 139 tubercular lesions. In many instances these follow the slight circulatory disturbances brought about by contusions, sprains, etc. This is espe- cially the case in those who are predisposed to this disease. Tuberculosis of bone always assumes the phase of miliary lesions, followed by the formation of a granuloma, which may gradually encroach upon surrounding tissues or may assume a more fulminating type and spread rapidly. Apparently because of the circulatory conditions, these lesions are most common near the epiphyseal lines of the long bones, seeking seemingly the ends of the bones, as pulmonary lesions seek the terminations of the lungs. These lesions may be solitary or multiple. Beginning always minutely, they spread so as to produce foci perhaps even two inches in diameter. As the result of the formation of Fig. 32. Tubercular spondylitis (caries) : a, osteogenesis and osteosclerosis ; c, cavity formed by degenera- tion of tubercular focus (Krause). granulation-tissue, the surrounding bone melts away and disappears, the result being a great weakening of its structure and expansion of its dimensions in order to make room for the growing mass within. The tendency of this granulation- tissue thus imprisoned is always to escape in the direction of least resistance. This carries it sometimes into the joint, sometimes out through epiphyseal junc- tions, and sometimes through channels in the bone made by its own pressure, with external escape and appearance of the dusky distinctive tissue, felt beneath and then upon the skin. Where bone is so weakened in one direction it is usually strengthened by compensatory deposition of calcium salts at other points, and the result frequently is a striking combination of odeoporosis in the immediate presence of the disease, with osteosclerosis, sometimes to a remarkable degree, even to eburna- tion, of an adjoining portion. When this mass undergoes caseous degeneration, the progress of the disease is much slower and the pain less. When it undergoes sup- puration, there are more evidences of inflammation, with more pain and systemic disturbance, as well as local swelling, tenderness, etc. The surrounding muscula- ture is rarely involved, although the periosteum is nearly always so. In fact, it is stated that in an inflamed and suppurating bone-lesion, if the muscles are exten- 140 SURGICAL DISEASES. sively invaded, it maybe regarded as of syphilitic rather than of tubercular origin. The pijophylactic membrane already alluded to is seen in almost every instance of tubercular disease. The spina ventosa of old writers refers to the expansion of the shaft and medullary cavity of a long bone whose interior is occupied by a mass of tubercular gumma, which is perforated at one point, and through which opening it escapes as does lava from a crater to involve the structures on the outer side. The appearance of this granulation-tissue in joints as fungous tissue has already been alluded to. In a general way it preserves its fungoid characteristics until attacked by pyogenic or saprogenic organisms, when it quickly breaks down, form- ing an ulcer if upon the surface, or a cold abscess if not externally open. Tuber- cular disease of the bone is most common in the young, and in them the majority of tubercular joints are those whose bony structures have been first involved. In other words, the majority of cases of tubercular pyarthrosis are due to primary bone disease. As the result of the tubercular infection the bones become distorted, best illustrated in Pott's disease of the spine ; while, as the result of the constant irritation, joint-ends become displaced by chronic muscle-spasm, and joint-contours entirely altered by expansion of the affected bone and thickening and infiltration of the overlying soft parts. I have often, for the sake of illustration to medical students, drawn a certain analogy (following Savory) of the gross resemblances between lungs and bones in their behavior when involved in tubercular disease. In either case the structure is in a measure spongy and contains cavities and networks of tissue ; in each case the structures are invested by a resisting membrane — in the one instance, pleura, in the other, periosteum. Again, each is closely related to a serous cavity — the lungs to the pleural cavity, the bones to the serous cavities of the joints. Tuber- cular disease manifests a predilection for the extremities of both organs. Perfora- tion into the adjoining serous cavity is frequent, and previous to perforation col- lections of serous fluid are frequently noted — in the one instance pleurisy, in the other hydrarthrosis. Moreover, these fluids quickly or often become contaminated, and then become purulent, constituting empyema or pyarthrosis as the condition may be. One sees, too, in each place the same striking combinations of weaken- ing of tissue and strengthening in order to atone for the undermining of the disease. These are not all of the similarities that might be adduced, but are perhaps suffi- cient for the purpose of showing that tubercular disease is essentially one and the same thing, no matter what tissue be invaded. In the tendon-sheaths and bursse we frequently find manifestations of tuberculosis. When seen early these are always in the direction either of miliary affection or, most commonly, of tuberculous gumma, while when seen late the disease has usually advanced to the point of suppura- tion, and we now have cold abscess of the affected parts. In many joints and tendon-sheaths, particularly the latter, we find certain detached, usually colorless, firmly resistant masses, of smooth and polished sur- face, lying in a collection of fluid, in size from a minute particle up to that of a melon-seed. These have been known at various times as rice-grains, melon-seed bodies, corpora oryzoidea, etc., and for a long time their explanation was a mystery. It is now well established that in the majority of instances at least these are the result of fungous granulations which have become detached in small pieces, which then, in the absence of infection, have shrunken and become rounded and polished by attrition. The bursal enlargement and distention with fluid in which they are usually found is commonly spoken of as hygroma of that particular bursa. Tuberculosis of these bursse, however, does not always result so harmlessly as the formation of these bodies, but, on the contrary, tubercular infiltration may extend beyond the serous limits to the surrounding soft parts, with a tendency finally to external escape, just as in the case of bone-lesions. These constitute affections of the soft parts which are more or less destructive, and are always difficult, often im- possible, to deal with, because of the mutilation which a thorough extirpation of the disease would necessitate. In the testicles and ovaries, particularly in the former, tubercular disease is frequently met with. In the testicles it begins usually in the epididymis, forming a somewhat dense nodule and a distinct tumor DISEASES COMMON TO MAN AND ANIMALS. 141 easily appreciated from the outside, although its minute character may be still concealed. The tendency here almost invariably is to progres- sive infiltration and breaking down, either into a caseous mass or, more commonly, into puruloid material, while sometimes acute infection supervenes. It is not always easy to distinguish between syphilis and tuberculosis of the testicle, though the latter is usually characterized by the same tendency to effusion into the adjoining serous cavity (i. e. that of the tunica vaginalis) as is manifested in disease of the lungs or bones. When the disease is extensive the overlying skin is involved, and frequently by the time the surgeon has to deal with these cases perforation and escape of fungoid tissue on the outside have occurred. In the kidneys, in the ureters, as also in the bladder, tubercular lesions are noted, the miliary form being particularly frequent in the former. Tubercular disease of the kidney leads sooner or later to casea- Gross appearance in tuberculosis of the mamma (Dubar). tion and a condition of pyonephrosis or its equivalent, which calls practically always for extirpation of the affected organ. Tubercle bacilli are sometimes recognized in the urine, but only when the lesion has an opportunity of discharging into one of the urinary passages. In the peritoneum tubercle appears usually in the miliary form, leading sometimes quite rapidly to such extensive involvement of, and interference with, visceral functions as to produce anasarca or more general disturbance prior to death. Acute miliary disease here is as rapid and as essentially fatal as the same affection of the dura or pia, while the more chronic forms are followed by degenerations that may involve the intestines either in agglutinated masses or in ulcerations and possible perforations. The indication in all tubercular lesions of serous membranes is for exposure by operation, disinfection of the sur- face, and evacuation of retained fluids. Recovery from tubercnlar per- itonitis, even of acute type, after abdominal section is now definitely established as a possibility. The same would probably be true of tuber- cular meningitis were we permitted to expose the membranes and attack them or drain them in the same way. Although a few distinct organs or tissues have here been specifically considered in their relations to tubercular disease, there is no organ nor tissue in the body which is exempt from its ravages and in which evidences of tubercular disease may not be found. Even the mammary gland occasionally presents tumors composed of tubercular granuloma which more or less simulate malignant disease, while, nevertheless, calling for the same radical treatment. (Vide Fig. 33.) 142 SURGICAL DISEASES. Paths of Infection. — The tubercular virus may enter the body through various channels. Probably in the majority of instances it gains entrance through the respiratory tract, less often by the aliment- ary canal, and occasionally by air-contact of open wounds or direct infec- tion by local agencies. It is now well established that tubercular disease is not inherited, although a predisposition to its ravages certainly is transmitted from parents to children. In what this predisposition consists is not always easy to say. As the tubercle bacillus grows in the tissues, it is by preference an anaerobe, and it seems to be lowered in activity or banished by access of oxygen. It has been shown that in those individuals in whose pallid skin, long bones, flabby muscles, and pale con- junctivas we recognize a predisposition to this disease, the heart is disproportion- ately small as compared with the weight and size of the lungs. This means a relatively feeble pumping-power, and is perhaps the best explanation yet offered for what is everywhere accepted as a fact. The mucous membranes of the nose and throat are trie first lodging-places usually for germs carried by the air, these find- ing here the warmth and moisture necessary for their detention, development, and growth. So long as these membranes be unbroken and healthy, infection is rarely possible, but let tubercle bacilli become caught in the crypts of the tonsils or the adenoid tissue in the nasopharynx, and the other disturbance, set up by irritant organisms of various species, will usually bring about conditions favoring their growth and incorporation into the living tissues. This Iymphadenoid tissue, then, is as often as any the port of entry for these organisms. The explanation for local and surgical tuberculosis in bones and other accessible tissues probably is connected with causes determining at these points an area of least resistance in which the germs find tissues more susceptible than elsewhere, and in which they may live and thrive. Not the least interesting and important of the considerations regard- ing tubercular disease is the possibility of an acute outbreak of tubercu- losis after long latent or chronic manifestations of the disease. This means, in effect, the onset of general miliary tuberculosis which shall quickly terminate fatally, and death is not the infrequent result of such extremely rapid outbreaks from tubercular disease of joints, bones, ovaries, etc. For the disease when it has assumed this extremely rapid type there is, so far as we yet know, no help. Diagnosis. — So far as the general recognition of tubercular disease is concerned, it is not often difficult. It is accompanied usually by more or less marked cachexia (at least this is the case when infection is serious and widespread), one of whose principal characteristics is the so-called hectic (habitual) fever of old writers. This was a fever of a remittent type, accompanied also by more or less colliquative night-sweats, with dryness of the skin during the daytime, flushing of the face, etc. Hectic fever, as a matter of fact, often accompanies tubercular disease, but is seldom met with until pyogenic infection has occurred and suppuration is taking or has taken place. There is now much reason to consider hectic fever as an auto-intoxication from absorption of morbid products. In advanced cases we may find evidence of amyloid changes, although these are seldom recognized prior to autopsy. Altogether, it is seldom difficult to recog- nize tubercular disease except when at a considerable depth. Here, so long as there be no suppuration, there is little tendency to leucocytosis, by which diagnosis as between sarcoma and tubercular infection may per- haps be made. Sometimes when in doubt the exploring trocar or an exploratory incision may be resorted to, it being always best to be pre- DISEASES COMMON TO MAN AND ANIMALS. 143 pared at the same time to proceed with whatever further operative pro- cedure the findings may indicate. Treatment. — It is well to emphasize, first of all, that tubercular disease when circumscribed and accessible is a distinctly curable affection. If this be once accepted, it puts a much more hopeful aspect upon the condition than it formerly bore. It moreover justifies operations of a much more radical nature than were formerly practised. Treatment should be divided into the hygienic and constitutional and the local and operative. Of all the natural remedies, oxygen undoubtedly ranks first. This means the best of ventilation, an outdoor life if possible, and preferably in localities and at altitudes free from dust and well supplied, with ozone. When this is impossible inhalations of dilute oxygen are capable of doing much good. The diet should be rich and nutritious, at the same time capable of complete digestion. The emunctories should be stimulated and elimination favored in every possible way. Undoubtedly the old standard remedies — cod-liver oil, compound syrup of hypo- phosphites, et al. — are beneficial, and much good may be accomplished by their proper use. Certain remedies have been at various times supposed to be endowed with specific properties, and for many years clinicians have endeavored to find that substance with which the system could be safely saturated which should yet prove inimical to the parasite causing this disease. Such agent has not yet been discovered ; nevertheless, much has been done in this direction. Of the remedies which to-day are lauded for this purpose, I will speak of two — namely, creosote and guaiacol. These are somewhat difficult of administration, but if the latter be given in the form of the carbonate, generally known as benzosol, it comes the nearest in my estimation to the ideal for which we are striving that has yet been discovered. Benzosol should be given to the adult in doses of at least a gram a day, perhaps more. It is much better tolerated and much less offensive than the guaiacol from which it is made. I have never seen anything but benefit result from its use, and yet would not laud it as by any means a positive cure. Nevertheless, in conjunction with other local and constitutional measures its administration may be followed by com- plete recovery. Of the various local measures, I would place first of all physiological rest, which can be achieved in some places better than in others. The various forms of apparatus resorted to by orthopaedists are simply mechanical measures in furtherance of this purpose. A number of surgeons have much faith in iodoform, used locally in solution or sus- pension in some menstruum like glycerin, oil, etc. The benefit which has been claimed in some cases is certainly not duplicated in the experience of all surgeons ; nevertheless, it has undoubtedly been of service. A recent and most promising method of treating tubercular disease of the extremities has been suggested by Bier, and consists in the establishment of a permanent hyperemia by the application of a rubber tourniquet on the proximal side of the lesion. It would appear that the access of more blood which is thus permitted is inim- ical, presumably by the presence of the oxygen which it brings, to the develop- ment of the disease-germ. The method depends for its rationale upon the fact that the congested lung does not become tubercular. Lannelongue has suggested what he calls the sclerogenic treatment of tubercular lesions, by injection of a very dilute 144 SURGICAL DISEASES. solution of zinc chloride, which serves as an irritant and produces a tissue-sclerosis that serves the purpose of a prophylactic membrane, while at the same time the solution is fatal to those germs with which it comes in contact. This treatment is painful and has not found wide acceptance. The astute surgeon, who gains the confidence of his patients and retains it, will not hesitate to remove by a suitable operation that tuber- cular focus which he feels confident that he can reach and extirpate. The resulting tissue-defects may be in many instances atoned for by plastic operations. At other times this procedure means excision of some joint, which leaves usually a much better functionating member than would the disease if permitted to go on to spontaneous recovery — i. e. ankylosis — and at the same time removes a focus of disease which is a menace, if left, to the future welfare of the patient. It may mean at other times amputation, but the artificial limb-maker now supplies a member vastly more useful than a natural one crippled by this infec- tious disease. In a general way, then, time may be saved and recovery ensured by early and judicious operation, while later in the course of this protean malady it may be absolutely necessitated in the endeavor to save life. How much better, then, to operate early when less is required and when the future outlook is so good ! After operations where clean extirpation and reunion of the parts with primary healing is impossible, I recommend a local dressing of balsam of Peru containing 10 per cent, of guaiacol and 5 per cent, of iodo- form. Gauze saturated with this and packed into the cavity best accom- plishes the purposes of a surgical dressing for such cases. Deep pain of tubercular lesions, especially in bone, is often relieved by ignipuncture, meaning thereby a perforation into the depth even of the bone-marrow by the actual cautery (Paquelin's), which may be thrust directly through the skin or which may be used after exposing the bone by incision. The use of the actual cautery, by the way, is indicated in eradicating and destroying tubercular tissue when a neat dissection or extirpation is impossible. Tuberculin. — Finally, the treatment of tuberculosis cannot be dismissed with- out a reference to the glycerin extract made from a filtered culture of the tubercle bacillus, containing the peculiar toxalbumen first prepared by Koch, for ever asso- ciated with his name, and first given to the world in 1890, when its announcement created a perfect furore and aroused hopes that have never yet been, perhaps never may be, completely realized. Yet, in spite of disappointments which have often followed its use, I wish to state here my own convictions that it is a remedy of great value when judiciously used in selected cases. I have never faltered in moderate confidence in its efficiency, and have not ceased to use it since it was first introduced. To-day I believe that in almost any case of surgical tuberculosis, when properly used, it is capable of doing great 'good, but I would by no means rely upon it alone, but would use it as an adjuvant in the after-treatm'ent of ope- rative cases or as a remedy of prime importance in certain cases not adapted to operation. One should begin its use by doses of 1 milligramme, injected beneath the skin near the lesion two or three times a week, depending upon the reaction produced, increasing the dose gradually until even a decigramme may be given at once without undue reaction. The diagnostic value of the material must also not be forgotten, since by its use one may possibly decide in mooted cases as between tubercular or some other disease. Of the modifications of this remedy introduced by Klebs, Hunter, and others there is not time here to speak in detail. Undoubt- edly they all have virtues of a common character, and, so far as my own observa- tion is concerned, one has but little to choose as between them. CHAPTER X. SYPHILIS. By J. A. Fordyce, M. D. Synonyms. — Lues venerea ; Morbus gallicus ; Pox ; Verole, etc. Syphilis is a chronic, general infectious disease, acquired by direct con- tact with a lesion of the malady in another individual, through the medium of some infected object, or by inheritance. It is generally a venereal disease, though many exceptions to this rule exist. The infection pursues a somewhat regular though indefinite course, periods of activity alternating with periods of repose or latency. It begins with an initial sore, the point of entrance of the virus, after a period of incubation following exposure. In inherited syphilis no primary sore is present. The initial lesion is followed by a second period of incubation, during which time a slow, general infection of the body is taking place, characterized by lymphatic node-enlargement, pains in the joints and bones, usually worse at night, anaemia, fever, loss of strength, and by other symptoms indicating a progressive intoxication of the organism. Syphilis presents many points of similarity in its symptomatology and morbid anatomy to the chronic infective granulomata with which it is usually classed. In many of them the virus retains its activity for long periods of time, and in certain stages produces lesions which are local rather than general. Attention has also been called to the resemblance which exists between syphilis and the acute exan- themata, in that a definite period of incubation in all these diseases is followed by symptoms of general infection, with an outbreak on the skin and mucous mem- branes and transitory congestions of various organs and tissues. The acute erup- tive fevers and syphilis are alike in conferring a partial or complete immunity against subsequent attacks, and it is a noteworthy fact that the essential nature of the contagion of these affections has eluded our investigations. Stages op Syphilis. — Although not separated by well-defined limits, it is generally customary to divide syphilis into three stages or periods, which may be briefly defined as follows : Primary syphilis embraces that period of the disease which elapses from the moment of infection to the appearance of general symptoms, including the first incubation, the time from exposure to the appearance' of the initial sore, as well as the second period of incubation, the time following the primary lesion to the appearance on the skin of the charac- teristic exanthem. The first stage of syphilis, while varying in dura- tion from eight weeks to four or five months, is pretty regular in its evolution. The secondary stage, or secondary syphilis, includes for conve- nience of study and classification the early eruption on the skin and mucous membranes, as well as the accompanying disturbance of the general health and other phenomena which are peculiar to the time in 10 145 146 SURGICAL DISEASES. question. One type of eruption may be rapidly succeeded by another, or intervals of latency may occur between the successive outbreaks of the disease for a period of from one to three years, or longer, before the development of lesions which belong to the so-called tertiary stage. This period of syphilis, which is of exceptional occurrence and multi- form in its manifestations, is spoken of as the stage of gummatous for- mation, and includes the deeper-seated and destructive lesions of the skin and underlying tissues, visceral and bone affections, as well as other pathological changes which are directly or indirectly due to the specific virus. The early eruptions are usually superficial, of symmetrical distribu- tion, rapid in their development and course, while the later ones occur without order, are slower in their evolution, and show a greater tendency to undergo degenerative processes with destruction of the implicated tissues. In primary and secondary syphilis the disease can be conveyed by inoculation and heredity, while in the later stages it is exceptional for such transmission to take place. In whatever way syphilis manifests itself, the process is of an inflammatory nature, both in the initial lesion, the transitory eruptions on the skin, to the forma- tion of gummy tumors and interstitial connective-tissue growth in the late stages of the disease. The implication of the blood-vessels in the inflammatory process, leading to thickening- of their coats and partial or complete obliteration of their calibre, plays an important rSle in the pathology of the" syphilitic disease and its results. This blood-vessel inflammation is found in the initial lesion, the secondary eruptions, in gummatous tumors, and in connection with the chronic connective- tissue hyperplasia resulting directly from the irritant action of the specific virus or which occurs in organs which are or have been the seat of syphilitic new growths. Etiology. — Most of the chronic infective granulomata have been shown to depend on the presence of specific micro-organisms. As syphilis presents so many features in common with these affections, it is rational to suppose that it depends on a similar cause. The infectious character of the disease, its period of incubation, its gradual implication of the lymphatic system, the blood, and all the tissues of the body, clearly point to some infectious agent which multiplies in the system, and either directly or by virtue of its chemical products evokes the tissue-reaction and a general condition which constitute the morbid process. The facts that the lower animals are immune to syphilis and that cultivations from the infectious lesions yield no uniform or satisfactory results, render the study of its etiology one of great difficulty. The claims made regarding the pres- ence of micro-organisms in syphilitic lesions before modern bacteriological methods came into use are without value. In 1884, Lustgarten 1 claimed, by a special method of staining, to have found bacilli in the initial lesion, secondary papules, and in gummata, which closely resembled tubercle bacilli, but were thought to differ from the latter in their staining reaction. It has since been found that the tubercle bacilli cannot well be differentiated from the so-called syphilis bacilli by the method in question. Secondary Infection in Syphilis. — Pyogenic cocci have been found in syphilitic skin-eruptions, the bones, liver, and lungs of children who had died with hereditary syphilis (Kassowitz and Hochsinger). Kolisko, 1 Wiener med. Wochenschrift, No. 47, 1884. SYPHILIS. 1 47 Chotzen, and Doutrelepont made similar observations, and believed they gained entrance to the general circulation through the skin-lesions. While attributing to them no etiological importance in producing the disease, they yet thought the fatal issue in some cases of hereditary syphilis depended on septic processes brought about by such secondary infection. Their presence in the bones was believed to explain the sup- puration which is here sometimes met with in children with the disease. As the specific lesions in. acquired syphilis seldom suppurate, many modern writers believe that the exceptional occurrence of suppuration is determined not so much by the direct action of the virus of syphilis as by a secondary or mixed infection with pyogenic germs which gain access through solutions of continuity or are incited into activity by the^ diminished resisting power of the diseased tissues. The presence of pyogenic cocci in the deeper layers of the normal epidermis, as shown by Welch and others, renders the theory of the secondary infection of the specific lesions extremely probable. Gummata of the skin suppurate much more frequently than similar lesions of the internal organs, and pustular lesions in general are more frequent among the poorer classes of society who pay less attention to personal cleanliness. The character of the syphilides is altered by other forms of mixed infection, notably by a combination about the face and scalp with the seborrhoeal eczema of Unna. Finger, 1 in a very interesting and sug- gestive article, was the first syphilographer who endeavored to classify the symptoms which might be produced by the virus directly and those which presumably depended on its toxic product. The initial sore, as well as the lymph-node enlargement, he considers due to both the specific germ and its ptomaine. The latter, absorbed into the general circulation from an early date, confers the immunity which syphilitics present from an early period and long before the outbreak of the general eruption. The anosmia and other evidences of impairment of the general health are to be referred to a progressive intoxication from the chemical products which are being gradually absorbed into the general circulation. The secondary eruption, containing as it does the con- tagious element in a concentrated form, must be due to the bacillus alone or combined with its toxine. Tim hypothesis explains in a satis- factory manner the partial or complete immunity acquired by mothers who bear syphilitic children from the father with the latent disease, and other facts, which no other theory had attempted to do. Predisposing Causes — Aside from the virulency or attenuation of the virus which must be considered in explaining the severer and milder forms of infection, the resisting power of the individual upon whom the poison is inoculated plays an important role in the future development of the disease. The extremes of life — youth and old age — all conditions which impair the resisting power of the patient, as tuber- culosis, anaemia, malaria, alcoholism, etc., render it probable that the future course of the affection will be grave. Tuberculosis, while it renders the course of syphilis more severe, limits the free use of mer- cury, and thus deprives us of our most useful therapeutic agent. Syphilis sometimes renders a latent tuberculosis active ; tubercular abscesses of the lymph-nodes not infrequently occur during secondary 1 Arehiv. f. Dermal, u. Syph., p. 331, 1890. 148 SURGICAL DISEASES. syphilis in individuals who were apparently in robust health before their infection. Tuberculosis of the lungs has been precipitated by the presence of syphilis. Chronic alcoholism is an important factor in increasing the vulner- ability of the tissues to the specific poison. As both alcohol and syphilis have a predilection for the blood-vessels, their combined effects result in a more serious pathological condition. The Lesions and Secretions which Convey the Infection. — It is necessary for the syphilitic virus to come in direct contact with an abrasion of the skin or mucous membrane to convey the disease. This may occur directly or through the medium of some infected object. The initial lesion and all the early eruptions have been proven to be virulent by many observations, as well as by experimental inoculations. The secretion from condylomata lata, which are so frequently found on the female genitals, are believed by many to be the most frequent source of infection. Successful inoculations with the blood of patients during the early eruptive period have been made. It is not definitely established how long the blood retains its infective properties, but in the opinion of Finger and others it does not contain the virus during the latent stages of the disease — in the intervals between the periods of the eruptions. It is generally believed that the physiological secretions, milk, saliva, perspiration, tears, and urine from syphilitic subjects do not contain the virus or in such a diluted form that infection from them is not possible. As the micro-organisms of certain infectious diseases may pass through the glandular epithelium and appear in the saliva, milk, urine, etc., the possibility of transmitting the disease by such secretions is not abso- lutely excluded. The semen from syphilitic individuals cannot give rise to the disease by inoculation. The hereditary transmission of the dis- ease from the father to the child without a previous infection of the mother is well established. The infection of the ovum by the diseased spermatozoon is accomplished by a different, process from experimental inoculation. The mother may convey the disease to her child through an infected ovum, the father being healthy. It is generally conceded that pathological secretions not properly belonging to syphilis are not infectious unless mixed with the patient's blood or disintegrated portions of specific lesions. Gonorrhoea or chancroid may be contracted from a patient with syph- ilis, and yet no constitutional infection follow. When vaccinal lymph is taken from a syphilitic subject, syphiiis will not be conveyed unless there is an admixture of blood. Experimental inoculation made with the secretions of tertiary lesions have given negative results only. These results coincide with our every-day experience, which teaches us that the late lesions are, as a rule, neither inoculable nor transmitted by inheritance, and that such persons may be reinfected. As at one time the innocence of the secondary lesions of syphilis was affirmed, a wider experience may modify our view regarding the infectious character of the later ones. Modes of Infection.— The delicate mucous membrane of the gen. ital organs is easily abraded during sexual intercourse, and the absorp-, tion of the virus is thus facilitated. It is not difficult, therefore, to under- stand that over 90 per cent, of all primary sores occur on the genitals. SYPHILIS. 149 In man the chancre is most frequently found on the inner side of the prepuce, its free edge, the glans, or sulcus coronarius. It is also met with on the skin of the penis, the scrotum, in the urethra, on the peri- neum, about the anus, etc. In women the labia, the tissues about the clitoris and urethra, and the fourchette are frequently its seat. It is found less often on the vaginal walls and the os uteri. Chancres on extragenital parts, as the lips, the tongue, the tonsils, the eyelids, and nipples, are not infrequently met with as the result of unnatural prac- tices. Chancres of the lips are found in 3 per cent, of all cases, many being acquired in an innocent manner. Wet-nurses are infected on the nipples by syphilitic children, multiple chancres sometimes resulting j children, too, are infected by wet-nurses with lesions on the nipples. Chancres on the face and fingers sometimes follow bites. Surgeons may acquire the disease on cuts or lesions of the hands when operating on patients with active syphilis. Accoucheurs and gynecologists are some- times infected on the fingers in vaginal examinations. Infants may be inoculated during parturition. These modes of infection are by direct contact. Mediate Contact. — The syphilitic poison may be conveyed by drink- ing vessels, eating utensils, or any articles used in common by members of a family or by individuals. In certain occupations, as where an im- plement like the blowpipe in glass-factories is passed from one person to another, infection has been produced. The disease has also been con- veyed by surgeons' instruments, dentists' instruments, etc. Vaccinal syphilis is now seldom encountered, as " humanized lymph " is not often employed. Syphilis may, however, be conveyed during vac- cination by the use of an infected instrument. The disease when acquired in an innocent — i. e. non-venereal way — is often spoken of as syphilid insontium. The Chancre. Synonyms. — Initial lesion ; Primary sore ; Syphilitic chancre ; Initial or Primary sclerosis ; the Hard or Infecting: chancre ; Hun- terian chancre, etc. The interval that elapses from exposure to the syphilitic virus to the appearance of the primary sore, or chancre, is called the first i ncubation- period. Experimental inoculation made on healthy persons showed that the minimum duration of this period was ten days ; the maximum, forty- two days ; its most frequent duration, from three to four weeks. After accidental inoculation clinical observation has shown the mean dura- tion to be about three weeks. It may exceptionally last seventy days or longer. Every case of syphilis, with the exception of the hereditary form, or syphilis conveyed from the infected foetus to the mother, begins with a primary lesion. It may be so slight and heal so rapidly as to escape observation, or in such a locality as not to be readily found. It must, however, have been present. It is seldom that an absolutely typical sore in its early stages comes under the observation of the surgeon. It is frequently complicated with other infections or its appearance has been changed by caustic applications. The classical sign, induration, 150 SURGICAL DISEASES. may be wanting from a primary lesion which is followed by the consti- tutional disease, or it may exist in a purely local sore. Errors in diag- nosis are of frequent occurrence from placing too much diagnostic im- portance on a single feature. A typical chancroid may be converted into an indurated initial lesion, and instances of well-defined indurated sores have been observed without any constitutional disturbance. The initial lesion is usually single, unless several abraded spots are inoculated at the same time, or other eruptions, like herpes or the lesions of itch, are present where infection takes place. It is not at all unusual to see two or three chancres at the same time, and as many as a dozen have been observed to develop simul- taneously. Immunity to subsequent infection seems to take place very soon after a successful inoculation, although it is possible for a second infection to occur within a short time after the original one. Induration. — This one sign is almost pathognomonic of the chancre. It is present to some extent in the vast majority of cases. When well developed it extends beyond and beneath the limits of the superficial erosion or ulceration, and feels, when grasped between the thumb and fingers, like a piece of cartilage imbedded in the skin. Its firm and elastic consistency serves to distinguish it from other inflammatory infiltrations, while its boundaries are much better defined than in the chancroid.. The superficial variety gives to the finger the sensation of feeling a thin piece of cardboard or parchment beneath or in the skin. The development of the uncomplicated initial lesion is, as a rule, unattended by any subjective sensations, and frequently its possessor is ignorant of its existence. The ulceration or abrasion rapidly heals, but the specific induration passes away slowly and is of uncertain duration. It sometimes disappears within a few weeks after the secondary eruption, or in exceptional cases may last for six months or a year. It generally leaves no trace of its existence, but may terminate in a superficial pig- mented or pigmentless scar or spot or a keloid-like induration which gradually disappears. Varieties of Chancre. — After experimental inoculation on parts of the cutaneous surface removed from sources of irritation or infection it assumes the appearance of a dry scaling papule. A small patch of round or oval redness marks its beginning : this soon becomes more prominent and infiltrated, developing into a pea or bean-sized nodule, over which the epidermis may be slightly thickened. An abrasion may develop over the centre of the papule, giving exit to a serous discharge which dries as a thin crust. The papule may slowly disappear without ulceration, or become more infiltrated at the base and present a super- ficial ulcerated surface surrounded by a slightly elevated margin. The ulceration in this, as well as in other varieties of the initial lesion, takes place at the expense of the cell-infiltration rather than of the normal elements of the skin, being apparent rather than real, and healing with- out loss of the connective tissue of the derma. The Superficial Erosion. — This is the primitive lesion in the vast majority of chancres which are not preceded by the soft sore. When seen sufficiently early, it appears as a rounded, sharply-defined spot, of a dark-red color, from which the superficial epithelium has been detached, exposing a moist, smooth, or slightly granular surface. There mav be an insignificant central depression, but the edges of the erosion" are usually on a level with the surrounding skin. One or more such lesions SYPHILIS. 151 may exist, which gradually develop an indurated base and heal more slowly than an ordinary excoriation or abrasion. The induration may be superficial and thin, assuming the parchment-like form, or extend deeper, giving rise to a distinct nodule. As the cell-infiltration in the initial lesion is in the main located about the blood-vessels, their anatomical distribution explains in part the varied outlines of the scleroses. The presence or absence of much loose connective tissue beneath the sore also moulds the outlines of the infiltration. The Hunterian chancre, or ulcerating initial lesion, is the most pronounced and well-developed form of the syphilitic sore. It orig- inates in an erosion or papule which increases slowly in size, is sharply circumscribed, of round or oval outline with a somewhat flattened top. With the increase in size its consistency becomes harder until it approx- imates that of cartilage. In color the new growth is brownish- or bluish-red. After a duration of ten or twelve days its epithelial cover- ing becomes macerated, giving rise to a serous discharge, or it becomes covered with a gray film. The centre of the infiltration undergoes a process of molecular disintegration ; its edges become elevated, so that an appearance of ulceration is presented which gives the impres- sion to the observer of a greater loss of tissue than is in reality the case. After three or four weeks' duration the Hunterian chancre begins to undergo a slow process of involution, which is hastened by the local and internal use of mercury. It heals without loss of tissue or with an insignificant scar. The Mixed Sore. — The subject of chancroid is considered in another part of this work (Chapter XLTVTII.). It is sufficient to state here that it is a local infectious ulcer, with a short period of incubation, almost exclusively met with on the genital organs. Infection with the virus of chancroid and syphilis may take place at the same time, the former passing through its stages of papule, pustule, and ulceration, with free suppuration. At the end of two or three weeks, the incubation-period of the syphilitic sore, the base and edges of the chancroid assume a characteristic induration and a brown-red color ; granulations spring up and the secretion of pus becomes less. Within a few days the local infectious ulcer is converted into a typical sclerosis which pursues the ordinary course of the latter. The syphilitic infection may, of course, follow that of the chancroid, but usually is simultaneous. Complications or the Chancre. — Local pyogenic infection is responsible for an extensive ulceration or suppuration of the primary sore. At times the inflammatory process may be so intense that the parts become much swollen and painful. When the preputial opening is narrow the occurrence of a chancre on its inner surface or in the sulcus coronarius often leads to complete phimosis or paraphimosis. The retention of the secretion from the sore in the preputial sac mace- rates the epithelium of the glans, producing an intense balanoposthitis, the discharge from which may simulate a gonorrhoea. Under such con- ditions the entire penis may become red, painful, and swollen. A neglect at this time to relieve the tension by a dorsal incision of the prepuce may result in superficial or deep gangrene, with partial or com- 152 SVROICAL DISEASES. plete destruction of the glans, and possibly urethral fistulse or other complications. Extragenital Chancres. — Certain peculiarities are. presented at times by chancres of the general integument or mucous membranes at a distance from the genital organs. A chancre at the margin or bed of the nail seldom shows marked induration ; exuberant granulations are sometimes seen, and frequently suppuration is profuse. On the cheek or chin, where the tissues are lax, it attains a large size. It may ulcer- ate and be covered by crusts, and has been mistaken for malignant dis- ease. A tonsil which is the seat of a chancre enlarges, generally ulcer- ates, and at times is covered by a pseudo-membrane simulating the diphtheritic membrane. Enlargements of the submaxillary and cervi- cal lymph-nodes are simultaneously present. Difficult deglutition is often experienced. Chancres on the lip are commonly indurated, and sometimes present well-marked ulceration with a dark-red granulating surface (Plate V. Fig. 3). Enlargement of the Communicating Lymph-vessels and Nodes. — After the appearance of the initial sore, the next manifestation of the specific infection is in the lymph-nodes in anatomical communication with the lesion. Exceptionally, one or more lymph-vessels or thick- ened veins may be felt. as firm, hard, painless cords extending along the dorsum of the penis to its root. At times nodules form in the course of these thickened vessels, which undergo spontaneous involution or ulcerate. Diagnosis of the Initial Lesion. — Chancroids are practically always found on the genitals. They are generally multiple, have a short period of incubation, and begin as a pustule or small ulcer sur- rounded by a red areola ; a pseuds-induration may result from cctmtic or other applications. The floor of a chancroidal ulcer is irregular, covered by a grayish membrane ; its edges are frequently undermined, and it secretes pus freely. Chancroidal pus is auto-inoculable, both on the genitals and general integument. A single or double bubo, with a marked tendency to suppurate, is found in about 25 per cent, of cases of chancroid. It must be borne in mind that a chancroid frequently assumes an induration as the result of a double infection, and that the initial lesion of syphilis, from local infection or irritating applications, ulcerates and secretes pus. Herpes of the genitals occurs as a grouped vesicular eruption which seldom lasts longer than a few days. A history of former attacks is of aid in diagnosis. Cauterization of such lesions with carholic or nitric acid may obscure their normal features and cause them to simulate chancres or chancroids. A chancre of the lips or genitals has been mistaken for an epithelioma. The latter occurs later in life, is slower in its evolution, and does not implicate the lymph-nodes as soon as the initial lesion. A late lesion ef syphilis is sometimes found at the site of the original chancre or elsewhere, which has been mistaken for a primary sore. The serpiginous exten- sion or central ulceration, as well as the absence of the primary lymphatic involve- ment, would serve to distinguish it from primary syphilis. Pathological Anatomy of the Chancre.— The blood-vessels, including both the arteries and veins, show marked changes in the earliest stages of the development of the initial lesion. They are surrounded by large numbers of single, nucleated polyhedral cells, which are believed •y j " so 3 -o o s ^ £ c | 5- § S . js«s % 3 E. DO?-© E co o H - e+ £fi r > m r •5' SYPHILIS. 153 by Unna to represent proliferating connective-tissue cells (" plasma- cells"). Few multinucleated leucocytes are seen. The endothelial cells of the vessels multiply, as shown by numerous mitoses and thick- ening of their intima ; the middle and outer coats are also thickened and infiltrated by leucocytes. As a consequence of the involvement of the vessels' walls and from outside pressure their calibre is encroached upon and frequently found to be obliterated. A section through a chancre, at the height of its development, reveals a dense cell-mass in the papillary and subpapillary region of the derma, which is pretty sharply defined on all sides, the blood-vessels lying for some distance outside of the infiltration are surrounded by the cells previously mentioned and present thickened walls. The epidermis at the edge of the induration in many cases is hypertrophied, the interpapillary process extending for some distance into the cutis. Leucocytes are also to be found between the cells of the epidermis, which is in part or wholly destroyed over the centre of the sclerosis. When the sclerosis is uncomplicated by a secondary infection, remains of the epidermis can frequently be seen over the central erosions, so that its complete restoration after the involution of the chancre generally takes place. Prognosis of the Chancre. — It has been maintained by some writers that the future course of syphilis depends to some extent on the size or number of the initial lesions, and that an extragenital location of the chancre is apt to be followed by a severer type of the disease. The character of the tissues on which the virus is implanted has more to do with, the future evolution of the constitutional disease than the size, number, or location of the primary sores. The most insignificant chancre may be followed by a malignant form of syphilis, while large and multiple initial sores may cause only a slight constitutional reaction. The chancre in patients with nephritis, diabetes, tuberculosis, or other severe systemic diseases may become gangrenous and produce extensive local destructio7i of the parts. Constitutional syphilis is also apt to be a more serious disease in such patients. Treatment of the Chancre. — In the opinion of the great majority of syphilographers at the present time it is not possible to abort syphilis by chemical agents or the actual cautery, nor by excision of the initial lesion, even in conjunction with removal of the inguinal ganglia. When a chancre is situated at the preputial margin in a patient with phimosis, it may be removed by a circumcision. No hope should be entertained, however, of preventing or modifying the future course of the disease by such procedure. It is only mentioned as a hygienic measure which may, under certain circum- stances, be indicated. The fact that immunity to further infection is present during the first period of incubation, before the characteristic sore has appeared, shows that some infectious matter has entered the general circulation, and that syphilis, before and at the time the chancre appears, is something more than a local disease. Local Treatment. — The sore should be kept clean by the free use of soap and water. Where an erosion or superficial ulcer is present, calo- mel is perhaps the best application to use until the raw surface has healed. The ordinary black wash, a solution of bichloride of mercury (1 : 2000 or 1 : 3000), or a solution of permanganate of potassium (1 : 3000) may also be employed several times a day as local antiseptic agents. When gangrene or phagedenic ulceration occurs as a complication, more active local medication is indicated. Compresses wet in a weak 154 SURGICAL DISEASES. solution of chlorinated soda and kept constantly applied are an effica- cious method of limiting the spread of gangrene or phagedena. The free use of iodoform is also valuable in stimulating healthy granulations after the separation of the gangrenous mass or limiting a spreading ulcer- ation. After ulceration has healed the application of equal parts of mer- curial ointment and vaseline, mercurial plaster, or ointments containing other mercurials, hastens the absorption of the induration. Its absorp- tion is also more rapidly carried on during the internal use of mercury. Chancres on the female genitals should be treated in the same way, more care being here required, however, to preserve cleanliness. Chancres of the vulva should be freely covered with calomel and the parts kept sepa- rated by pledgets of absorbent cotton. An initial sore at the meatus or within the urethra is difficult to treat satisfactorily. When at the meatus it may lead to stenosis of this orifice if the canal is not kept open by means of a small roll of lint saturated with a dilute mercurial ointment or a tampon of iodoform gauze. Deeper-seated chancres may be treated by astringent injections, combined with the liberal use of mercurial oint- ment externally. If the initial lesion be in every way typical and the inguinal or other nodes present the characteristic enlargement, the internal use of mercury is indicated even before the eruption appears on the skin. Chancres always gives rise to much mental distress, and when on extragenital parts, as the face, are disfiguring. They may be painful when located on the glans or prepuce in patients with phimosis. In such cases, when the diagnosis is clear, one should not hesitate to resort to mercurials internally, as the involution of the sore is thereby hastened. When, however, the character of the sore is at all doubtful, one should await the appearance of the secondary eruption before beginning the general treatment. Constitutional Syphilis. The time between the appearance of the chancre and the outbreak of an eruption on the skin and mucous membranes is called the second incubation-period. Its average duration is forty-jive days: the shortest time reported is twelve days, the longest two hundred days. After experimental inoculation the shortest duration was eight to fourteen days ; the longest, one hundred and fifty-nine days. During and before this time a sloiv infection of the entire economy is taking place, which may produce a serious disturbance of the general health or be of such slight intensity that the patient is unaware of any change in his condition. A generalized hypertrophy of the lym- phatic nodes, in addition to those in direct communication with the pri- mary sore, can be made out by the end of this second incubation-period.' In some cases enlarged nodes can be detected two or three weeks before the skin-eruption appears ; again, not until or after the cutaneous out- break. The nodes along the posterior border of the sterno-eleido-mastoid muscle, other nodes about the neck, the supraclavicular, the axillary nodes, and the epitrochlear, are the ones which can usually be felt. In addition to those mentioned, any of the superficially located nodes may undergo hypertrophy, and the visceral nodes have been found enlarged in certain cases where autopsies have been made. The enlarged nodes vary in size from that of a bean to a pigeon's egg : they are rounded or oval in outline, painless, somewhat hard, and never suppurate unless SYPHILIS. 155 some local condition produces a secondary infection. In tuberculous subjects previously enlarged nodes may become inflamed and even sup- purate, the syphilitic virus seeming to render active the bacillus of tuber- culosis, which is probably present at the same time. The duration of the enlargement is indefinite. It may pass away in a few months, a year, or some evidence of its presence may be detected after two or three years. When other causes are excluded the presence of a generalized lymphatic involvement may be of service in diagnosticating a past syphilitic infection after the cutaneous manifestations have disappeared. In late syphilis a gummatous or interstitial change, involving one or more nodes, has been occasionally observed. Among the evidences of a progressive intoxication of the system dur- ing this period, anaemia is frequently met with in a greater or less degree. Stoukovenkofif 's ' investigations showed that the first blood-change con- sisted in a rapid increase of the number of white blood-corpuscles, a diminution in the amount of oxyhsemoglobin and in the number of red blood-corpuscles. These blood-changes were found to be more pro- nounced in cases where fever was present. Bieginsky 2 has, in the main, confirmed these observations. The blood-changes are more pronounced in women than in men, sometimes producing a feeble action of the heart, extreme prostration, and other accompaniments of the anaemic state. The pathological state of the blood continues in a more or less marked degree during the erup- tive stage. Fever is present in a certain percentage of cases shortly before and during the early eruptive period. The majority of patients are affected, according to the observations of some writers, while less than half show febrile reaction, according to others. As a rule, the rise of temperature occurs only in the evening, and seldom exceeds 100° or 102° F. In exceptional cases it has reached 105° F. A form of intermittent fever has been observed during the existence of late visceral or nervous syphilis. Early syphilitic fever is a transitory manifestation, lasting, as a rule, but three or four days. It not infrequently precedes the outbreak of a pustular syphilitic eruption, and when accompanied by severe pain in the head and back the condition may closely simulate a variola. Pains of a neuralgic or rheumatoid character are often experienced in the joints, bones, and muscles. Sometimes an effusion into one or more joints can be made out, and not infrequently a painful thickening of the periosteum, especially over the long bones or cranium, is distinctly evi- dent. Localized or diffuse headaches of a severe character, with inability to sleep, or dull, ill-defined pains in the head, are often exceedingly troublesome. Ail the pains mentioned are intensified at night. Vertigo, epileptiform attacks, hysteria, temporary paralysis of certain muscles, analgesia of the extremities, increased tendon and skin reflexes are among the rarer manifestations of this period. Attacks of subacute pleurisy, enlargement of the spleen, and jaundice have been noted during the secondary stage of syphilis. The relationship of syphilis to other diseases, and the influence which it exerts on the healing of wounds, are interesting questions to consider. 1 Ann. de Dermat. et Syphil., 1892, p. 928. 2 Arch./. Dermat. u. Sypk, 1892, p. 43. 156 SURGICAL DISEASES. Reference has been made to the increased gravity of the disease in tuberculous and alcoholic subjects. Bright's disease and rheumatism are aggravated when an added specific infection is present. A latent syphilis sometimes becomes active after 1 an attack of malaria. Some observations seem to show that fractures occur more readily in syphilitic subjects, probably as the result of local bone disease, and that their union is at times delayed. Cooper relates a case where the callus which formed around a fracture of the arm was rapidly dissolved by the admin- istration of iodide of potassium for a rupial eruption. A specific lesion of the skin, of subcutaneous tissues, or of bone may be local- ized by an injury or chronic irritation of the parts, but wounds or surgical opera- tions which are made during the active stage of syphilis heal as readily as on a non-syphilitic individual. A specific eruption, gumma, exostosis, or ulceration may rapidly disappear after an attack of erysipelas at the site of the lesions. A recurrence is apt to follow the disappearance of the erysipelas. Epithelioma may occur at the site of an ulcerating gumma of the skin or mucous membrane. An intimate relationship exists between the development of cancer of the tongue and the peculiar change in the epithelium known as leukoplakia, which sometimes follows specific lesions subjected to chronic irritation. Syphilis op the Skin; the Syphilides; Syphiloma. The administration of mercury during the second incubation-period, a greater resisting power on the part of the tissues, or other causes may retard the appearance of the specific eruption on the skin or mucous membranes. It must be borne in mind, however, that the disease is a constitutional one, with or before the appearance of the chancre, although at times slight evidence of its presence can be detected. In some instances the primary sore is of so doubtful a character that a diagnosis cannot with certainty be made before the appearance on the skin of the characteristic rash. As well-marked indurated chancres with inguinal lymphatic involvement have been observed that were not followed by any secondary eruptions, it is possible for syphilis to end its existence during the primary stage. In malignant, precocious, or galloping syphilis destructive lesions occur early in the course of the disease, anticipating by months or years their usual date of evolution. Gummata appear on the skin, mucous membranes, or in the viscera, producing deformity or the permanent impairment of the functions of important organs. A profound cachexia results from the intensity of the infection and the accompanying lesions. The historical account of the European epidemic of syphilis in the fif- teenth century shows that such forms were not so infrequent as they now are. The cutaneous eruptions of syphilis are the most constant and cha- racteristic manifestations of the disease : they are known as syphiloder- mata or syphilides, a qualifying adjective being employed to designate a special form of primary lesion or combination of lesions which is present. Syphiloma is a term which is sometimes used to include the late nodular or gummatous formations in the skin, mucous membranes and viscera. ' SYPHrLIS. 157 All the primary and secondary lesions which are met with in non- specific dermatoses are also found in syphilitic ones. The latter can readily be recognized in the majority of cases by certain peculiarities of development, distribution, involution, color, grouping, polymorphous cha- racter, absence of itching, etc. Syphilis may imitate a psoriasis or lupus in its cutaneous expression, so that it is difficult to determine which affec- tion is present. It is incorrect, however, to refer to such an eruption as a syphilitic psoriasis or syphilitic lupus, as these terms would imply a combination of the two diseases ; which does not occur. The early syphilides occur in a symmetrical manner, have a general distribution, are superficially seated, disappear spontaneously, and pursue a more rapid course than the later ones. They show a tendency to lose their symmetrical distribution after a number of months have elapsed from the time of infection. The individual lesions composing the erup- tion now group themselves or assume circular or gyrate outlines, indi- cating to the trained observer a relapsing syphilide and also the proba- ble duration of the disease. The first eruption, which usually appears in the form of macules, is often followed, before its complete involution, by a papular, and this by a pustular or ulcerative, syphilide, so that a mixed or polymorphous erup- tion is present. The color of syphilitic lesions is due in great measure to the marked implica- tion of the blood-vessels in the pathological process, which favors blood-stasis and exudation of the red blood-corpuscles into the tissues. The pigment which results from their disintegration in greater or less amount gives to the lesion a lighter or darker shade. At first the lesions may have a pinkish-red color which soon assumes a brownish or yellowish-red tint that has been compared to the color of raw ham or copper. A yellowish or brownish-black pigmentation may remain at the site of the lesions after their disappearance. Exceptionally, the absence of the normal skin-pigment, leukoderma, may mark the location of the lesions. It should be remembered that other skin affections may present equally marked pig- mentary changes, and that the color of the eruption is only of diagnostic value when taken in conjunction with other features. The absence of itching, burning, or other subjective sensations in connection with the eruption is of diagnostic importance. The later or tertiary cutaneous manifestations of syphilis differ from the earlier ones in their irregular and exceptional occurrence, their local- ized distribution, deeper seat in the tissues, slower course, and in their tendency to cause loss of tissue and leave permanent cicatrices. The cen- tral involution and peripheral extension of the infiltration is also more marked in the late syphilides 1 . The secondary lesions contain the virus of syphilis in an active state, while the tertiary lesions are slightly if at all virulent. Experimental inoculation of the secretions of late syphilides has invariably given negative results. The specific influence of mercury on the early eruptions, and of the iodides in causing the disappearance of the later ones is a remarkable instance of the selective action of drugs in different stages of the same affection. In many cases the two stages are not separated by well- defined limits, but are united by intermediate eruptions which present many of the characteristic features of both. Roseola syphilitica, the macular or erythematous syphilide, is usu- ally the first cutaneous manifestation of syphilis. It appears at the end of the second incubation-period as a generalized eruption of circum- 158 SURGICAL DISEASES. scribed spots of hyperemia from the size of a split pea to that of the finger-nail. The spots are bright-red or bluish-red in color, and are not elevated above the skin-level. The eruption begins, as a rule, on the abdomen, then on the chest, and finally on the extremities. The face is exceptionally attacked. A week or two elapses before the eruption appears on the extremities. It may last for several days or several weeks, and usually disappears without desquamation, leaving at times light-brown pigment-spots to mark its former situation. The papular syphilide may be the first eruption or follow the macular syphilide. It occurs in the form of large or small papules, constituting the lenticulo-papidar and the miliary-papular eruptions. The papular eruptions are generalized in the early months of the dis- ease (Plate VI.) ; later, their distribution is circumscribed, and finally they may form transition types from the early to the later tubercular or gummatous new formations. The papule is the initial form of all the subsequent secondary lesions. It varies in size from a pin's head (the miliary papule) to that of a split pea and larger (the lenticular papule). It consists of a sharply circumscribed, solid infiltration in the derma, of a light-red or brownish-red color, projecting above the level of the skin. When not the seat of secondary changes, as suppuration, it heals with- out scarring. In its declining stage it frequently scales, forming the papulosquamous syphilide, a common form and one often mistaken for psoriasis. On the palms and soles a number of scaling lesions may coalesce, giving rise to the eruption which has been erroneously called syphilitic palmar and plantar psoriasis. Annular and gyrate forms result from the central involution and peripheral exten- sion of the lesions. The papule maybe surmounted by a vesicle, bulla, or pustule, giving rise to a great variety of lesions to which distinct terms have been applied, as the varicella-form, the variola-form, the impetigo-form, the eothyma-form, and the acne-form of the syphilides. It should be remembered that all these forms of eruption represent changes which take place in the papule and follow its localiza- Grouped papulo-pustular syphilide and numerous pigmented spots from former lesions. tion, size, and outlines, papular, pustular, and transition forms of eruption being frequently seen on the same patient (Plate VII. and Fig. 34). They do not repre- sent essentially different lesions, but occur, as a rule, after the papule is developed from some condition of the patient or an increased virulency of the syphilitic poison. The ecthyma-form syphilide, or the large pustular variety, occurs PLATE VI. Grouped Miliary Papular Syphili de. PLATE VII. Mixed Papular and Papulo-Pustular Sypbilide. SYPHILIS. 159 by preference on the lower extremities or scalp as a superficial or deep affection, giving rise to large, irregularly-shaped ulcers, having a livid, grayish, or gangrenous floor which secretes a bloody pus that dries in the form of dark-brown or black crusts. Ulceration extends beneath the crusts. This type of eruption is rarely seen during the first six Fig. 35. Ulcers resulting from the deep ecthyraatous syphilide. months. It is more usual as a late secondary or intermediate eruption. In Fig. 35 two symmetrically situated ulcers on the legs are shown which are the result of this form of the syphilide. Rupia, or the rupial syphilide, is a form of the large pustular erup- tion resulting in ulcers which are covered by concentric layers of crusts. It may occur within the first six months as a precocious eruption, as a late secondary, or as a tertiary outbreak. The papule, if it exist at all, has a very transient duration, the first lesion being a bulla or pustule. The secretion is abundant, thick, and dries rapidly in superimposed layers of greenish-brown or blackish-brown crusts, beneath which the 160 SURGICAL DISEASES. ulceration extends on all sides : as a consequence, each newly-formed layer is larger than the one which precedes it, which gives to the lami- nated layers a conical shape (Plate VIII.). If the crusts are removed, an indolent ulcer with an irregular base and undermined edges is revealed, which is frequently slow in healing. Irregularly rounded, depressed white scars, surrounded by a pigmented areola, are left after the ulcer heals, and are quite characteristic of a past syphilis. A rupia is pathog- nomonic of syphilis, as no other dermatosis assumes such a form. The prognosis of this eruption is not favorable in its severe and generalized forms. It is slow in healing, and death has resulted from sepsis due to absorption of purulent matter beneath the crusts. By careful local and general treatment the majority of cases terminate in recovery. Ulceration ivith permanent scar-formation may result from any of the pustular eruptions during the secondary stage. The existence of ulcers in syphilis does not imply, therefore, that the disease has reached the so-called tertiary stage. A pap- ular eruption on the trunk is apt to be accompanied by pustules on the scalp and hairy portions of the leg, as if the papules in these localities had been infected by pus-organisms. Tertiary Syphilis. The statistics of Haslund l show that tertiary syphilis in general occurs in about 12 per cent, of all cases infected. The skin is involved more frequently than any other tissue or organ, and nearly as often as all the other organs combined. If we assume that tertiary lesions develop at the site of the earlier ones from latent virus that is rendered active by irritation or other causes, the increased frequency of skin lesions in late syphilis can be explained by the more frequent implica- tion of the skin during the secondary stage, and its greater liability to traumatisms and irritation. The syphilides of the late period of the disease are the tubercular or nodular and the gummatous. The former are found in the superficial or deeper layers of the skin as grouped or discrete, circumscribed, brown- red nodules, from the size of a pea and larger, which may coalesce into large, flat areas of infiltration. The nodule or tubercle resembles the early papule in its histological structure, and is considered by some writers to be a more highly developed form of this lesion. In its early tendency to degeneration and ulceration, producing atrophy and scarring of the skin, it is closely related to the gumma. Both the nodule and the gumma are considered by many syphilographers as varieties of the same lesion. The tubercular syphilide can exceptionally undergo absorp- tion without leaving a scar. As a rule, it spreads in a serpiginous man- ner, healing with loss of tissue, and advancing by a broken, elevated margin which represents the most recent deposit. In this way it pro- duces lesions with the outlines of circles, segments of circles, and horse- shoe- and kidney-shaped infiltrations. When absorption takes place with- out ulceration, a clinical picture is formed sometimes closely resembling lupus vulgaris (Fig. 36). The serpiginous infiltration, instead of undergoing interstitial absorption, as in the last form, may ulcerate, become infected, and secrete pus or pus mixed with 1 "On the Causation of Tertiary Syphilis," Brit. Journ. of Dermal., 1892, p. 210. PLATE VIII. • % Early Rupial Syphilide. PLATE IX. Tubercular Ulcerating Syphilide, showing lesions in different stages. SYPHILIS. 161 blood, which dries in the form of yellowish-gray or greenish-black crusts, giving rise to the tubercular ulcerating or the pustulo-ulcerating syphilide. A part or the whole of the marginal infiltration may break down, and numerous foci are some- times met with in various stages of development (Plate IX.). The entire duration of the tubercular syphilide may, in severe cases, be fifteen to twenty yean. The ulcerating serpiginous syphilide develops at times from the papulo-pustules of the late secondary or intermediate period of syphilis. The cicatrices resulting from these forms of syphilide are generally white, superficial, smooth, with scalloped or irregularly outlined borders, surrounded by a pigmented zone, and are quite suggestive of the condition which preceded them. The scar- tissue is less than would be anticipated from the appearance of the active stage of the disease. The Gummatous Syphilide. — The true tjiuniiia begin*, as a rule, in the subcutaneous tissue, affecting the skin secondarily. It is observed as a round or oval tumor, from the size of a cherry or smaller to one as large as the fist. The gummy tumors in the beginning are hard, elastic, Fig. 36. Tubercular serpiginous syphilide resembling lupus vulgaris. sharply circumscribed, and freely movable beneath the skin, which may not be elevated. This may be painful or only slightly sensitive to pressure. In their development they may become attached to the tis- 11 162 SURGICAL DISEASES. sues beneath, as well as to the overlying skin, forming projecting tumors which closely resemble other non-specific growths. The skin covering a gumma which has undergone central softening becomes somewhat red- dened and swollen, or it may be the seat of a nodular infiltration. An examination at this stage reveals distinct fluctuation : an incision made into the growth gives exit to a thick, viscid, mucilaginous-looking fluid of a yellowish-gray color containing few pus-corpuscles. The appear- ance of the contents of the broken-down gumma has given the growth its name. The tumor may be absorbed during the stage of fluctuation, leaving the skin covering its former seat thin, depressed, and somewhat pigmented. The subcutaneous and cutaneous tissues have been in part destroyed by the new growth, so that a permanent atrophy of the affected area remains. The detritus of the gummy tumor at times undergoes a cheesy or calcareous degeneration which becomes encapsulated or is eliminated by ulceration. One or several openings form over a softened gumma, giv- ing exit to disintegrated and sloughing tissue : these open- ings may unite, forming a single gummatous ulcer, or remain distinct (Fig. 37). The ulcer is at first smaller than the cavity and surround- ing infiltration : its edges are thickened, bluish-red, and undermined, its base being made up of the degenerated tissue of the gumma. The ulcer remains open until all the affected tissue has been softened and expelled. The reparative process is slow, and may be complicated and delayed by infection of the surrounding skin, gangrene, phagedena, etc. The ulceration may furthermore extend deeply, involving the underlying muscles and bones. Necrosis of the tibia, skull, and other bones follows at times a chronic gummatous ulceration. Deformity and contraction may result from deep destruction of tissue about the joints, the lip, or the eyelids. A thickening of the lower extremities, face, and elsewhere, allied to elephantiasis, has followed the destructive process. The subcutaneous gumma is generally a single growth : a group of half a dozen or more may be seen, however, which forms a characteristic picture when the stage of ulceration begins. The cicatrices are depressed, circular, white, with a pigmented margin, and may be adherent to "the bone or subcutaneous tissue. A group of such scars would suggest the nature of the affection which produced them, while a single cicatrix might not be at all characteristic. An ulcerating gumma of the leg. SYPHILIS. 163 G-ummata are the most important syphilitic neoplasms from a surgical standpoint, as they frequently occur without other symptoms of syphilis and closely simulate other conditions. They have been mistaken for abscesses, sarcomata, lipomata of the subcutaneous tissue, for malignant disease of the tongue, the muscles, the breast, etc., and for tuberculosis of the bones, testicle, and other organs. Deep-seated nodules of the subcutaneous tissue are sometimes seen in scrofulous subjects, which adhere to the skin, ulcerate, and present almost identical features with the syphilitic affection. They are usually symmetrical and heal with scarring, or, if atrophy takes place without ulceration, the loss of tissue may not be pronounced. The chronic ulcer of the leg in subjects with varicose veins differs from the gummatous ulcer in its more frequent localization on the lower part of the leg, its chronic course, and in the absence of any feature suggesting syphilis. Syphilitic ulcers occurring in such patients at times lose all their surrounding infiltration and are converted into simple ulcers. Ulcers following localized gangrene due to obliterative endarteritis, gangrene of the extremities necessitating amputation, and the symmet- rical form of gangrene of the extremities — Raynaud's disease — have been observed to develop during the course of syphilis. Pathological Anatomy of the Syphilitic Inflammation. — An implication of the blood-vessels is met with in all stages of the disease. The connective-tissue elements of the vessel, as well as the intima, are the seat of a proliferative inflammation which often leads to its occlusion. A section from a secondary papule properly prepared shows a fibrosis and leu- cocytic infiltration of the vessel's coats. The inflammatory cells, which are at first confined to the immediate vicinity of the blood-vessel, soon become generalized. These cells usually undergo necrosis and are absorbed. The degeneration begins in the oldest part or centre of the lesion, while an active cell-growth takes place at the periphery. This method of involution and evolution of the infiltration explains the ringed and serpiginous outlines which many eruptions assume. The necrosis of the cells is more pronounced in certain types of eruption than in others. In the pustular lesions it takes place so rapidly that frequently a typical papule does not form. In both the initial lesion and in the non-suppurative syph- ilide the cell-degeneration can be distinctly seen in the microscopic sections. In these lesions, as well as in syphilis in general, there is little tendency on the part of the newly-formed cells to organize into permanent connective tissue. An exception to this rule is found in certain visceral affections due to syphilis where connective-tissue growth occurs, either as a result of the vascular changes in the parts or directly from the action on the cells of the specific virus. It follows, too, on gummatous deposits in the liver, the lungs, the testicle (Fig. 70), and other organs, causing pressure on and destruction of the implicated tissue. The fibrous tissue which surrounds gummata of the skin and subcutaneous tissue does not show the same tendency to spread as a similar condition in the viscera or nervous system. In congenital syphilis both the liver and spleen are very often enlarged from an infiltrating growth of connective tissue. The first changes consist of a small-celled ■deposit about the branches of the hepatic artery or portal canals, which becomes later more generalized and organizes into connective tissue or degenerates into miliary gummata. As the greater part of the arterial blood in the foetal circula- tion passes directly through the liver, it can be easily understood that when this blood is charged with the toxines or bacteria of syphilis the first and most pro- nounced effect may be manifested on this organ. Histology of the Gumma. — These neoplasms begin as small 164 SURGICAL DISEASES. round-celled infiltrations in the connective tissue with a tendency to peripheral extension. Giant cells may be found in the advancing mar- gin. The centre of the gumma undergoes a necrosis which involves not only the recent infiltration, but the connective tissue of the part as well, leading to a permanent destruction of the implicated tissue. The blood-vessels of the gumma are not so numerous, nor do they play so important a role, as in the early processes. The characteristic pathological feature of the gumma consists in a degeneration of the con- nective tissue, of a hyaline and fatty character, which may be expelled or dry into a cheesy mass. In the viscera the contraction of a cavity resulting from a disinte- grated gumma results in considerable deformity of the implicated organ ; and in the central nervous system, where loss of tissue is of vastly more importance than in the skin, it may produce consequences which are irreparable. Syphilis of the Mucous Membranes — Most of the eruptions which are seen on the skin may be found on the mucous surfaces, their appearances being altered by the local heat, moisture, and irritation to which they are subjected. A sharply-defined erythema of the fauces and soft palate usually accompanies the macidar eruption. A syphilitic vaginitis and urethritis have been noted. It is quite probable that other mucous membranes, which cannot be inspected, are also the seat of similar catarrhal inflammations. Mucous patches or plaques, which represent the cutaneous papule, frequently occur on the genitals of women before the outbreak of the eruption on the skin, their development being favored by local heat and moisture. In this locality and where similar conditions are present, as about the anus, beneath the breast, at the angle of the mouth, etc., the papule becomes abraded, hypertrophied, or is covered by a grayish- white membrane, and at times ulcerates. These vegetating hypertrophic and other abraded papules in such places are called condylomata lata, to distinguish them from the pointed warts, or condylomata acuminata, which are not syphilitic. They secrete a thin, watery fluid and are a potent source of contagion. At the angle of the mouth they may be fissured and painful from the movement of the parts. Mucous plaques in the mouth arise from the modified papule, and exist in the papulo-erosive, the papulo-hypertrophic, and the papulo- ulcerative forms. The epithelial covering of the lesions is macerated and assumes a grayish-white or opaline appearance. The patches may vary in size, from a line or two to half an inch or more in diameter, and are slightly elevated above the surface. The edge of the tongue and inner side of the lip are favorite sites for them. They show a marked tendency to recur after healing, especially in smokers, and are often seen after other evidences of the disease have passed away. These late and recurring lesions lose their moist character, become quite smooth, shiny, of a bluish-white color, and may mark the begin- ning of the condition known as leukokeratosis. This affection of the mucous membrane of the tongue and buccal cavity not infrequently follows local syphilitic lesions which have been subjected to chronic irritation. It also occurs in individuals who have never had syphilis and are not smokers. It is not influenced by anti syphilitic remedies, SYPHILIS. ] 65 and must be regarded as the result of the disease rather than as syphil- itic per se. Leucokeratosis appears as circumscribed or diffuse smooth patches of a bluish-gray color over the tongue and on the mucous membrane of the cheek, extending backward in radiating lines or bands from the angle of the mouth. The epithelium covering the patches becomes thickened, fissured, and may be the seat of an epithelioma. Its surgical interest depends on the frequency with which it is followed by this malignant growth. Ulcerative lesions of the tongue or any part of the buccal cavity may follow disintegration of the papule, the nodular, or gummatous deposits. Such ulcerations sometimes spread at their margins, and may assume the outlines of the corresponding cutaneous eruptions. Gummata of the tongue begin as single or multiple, deep-seated, pea-sized, or larger tumors, over which the mucous membrane may be quite normal. These gummata develop slowly, without pain, and may reach the size of a pigeon's egg before undergoing resolution or break- ing down. When they ulcerate a small opening appears over their central portion, which rapidly enlarges to an abscess-cavity. The differential diagnosis between epithelioma and ulcerating gumma is not always easy. In general terms, it may be stated that cancer is usually single, while the syphilitic neoplasm is often multiple. The ulceration in cancer is superficial, painful, bleeds easily, discharges freely, and is often the seat of papillary outgrowths ; its edges are more elevated and the induration about the ulcer more pronounced. The communicating lymph-nodes are soon implicated in the cancer- ous disease, while they are absent after the late specific neoplasm. An epithelioma may develop on a gummatous ulceration. In such a case a differential diagnosis is at times only possible after a microscopic exam- ination. Interstitial Glossitis. — In late syphilis, as a result of an interstitial sclerosis involving the muscular structure, a part or the whole of the tongue becomes greatly hypertrophied. Later, from contraction of the fibrous tissue, the tongue grows smaller, its mucous membrane becomes smooth, deep furrows form over the tongue which cannot be effaced by stretching, and the organ is harder and less movable than normal. A permanent deformity of the tongue results which is little influenced by treatment. Hereditary Syphilis. Syphilis may be transmitted by the mother through the infected ovum ; by the father, through the infected spermatozoon ; or bj/ both parents. A mother who acquires syphilis after impregnation has taken place may transmit the disease to the foetus through the utero-pl a cental circulation. The later such infection takes place after conception the less probability is there that the child will be affected. When transmission takes place under the last condition — utero-placental infection — the placenta is found to be diseased, and no longer acts as a filter to retain the hypothetical microbe. A child born from a mother who is infected with syphilis in the late months of her pregnancy may be healthy, but is immune to sub- sequent infection, as are other healthy children of syphilitic parents 166 SURGICAL DISEASES. (Profeta's law). Such a child may be delicate, ansemic, and have little resisting power to other infectious diseases, or may develop a late hered- itary syphilis. A healthy mother who gives birth to a syphilitic child from the father may be infected with the disease through the utero-pla- cental circulation : she may acquire a modified form of the disease, which manifests itself in cachexia, impairment of the general health, or by late syphilitic lesions ; she may remain healthy with an acquired immunity to subsequent infection (Colles-Baumes' law). When pregnancy occurs with recent syphilis in one or both parents, it results in the death and pre- mature delivery of the foetus ; the birth at term of a dead child ; a living child with the disease in an active stage ; or of one in which the disease does not manifest itself for several weeks to two or three months after birth. Either parent may, in exceptional instances, transmit the disease after healthy children have been born. The longer the time between infection and impregnation, however, the less chance there is of transmit- ting the disease by inheritance, and the milder the disease when so con- veyed. The infectiousness of the virus is generally weakened by treat- ment and time, but no one can say when it ceases. The prognosis in congenital syphilis is much more grave than in acquired. The greater number of children born with the active disease die soon after birth. When its symptoms are delayed until the first or second month, if the nutrition is not bad, recovery generally takes place under proper treatment. From one-third to one-half of all cases die before reaching adult life. Symptoms. — The early symptoms of congenital syphilis appear in the majority of cases within the first three months, never later than the fifth month. Nearly half the cases present some sign of the disease within the first month. If no evidence of the disease is present during the first six months, the child, as a rule, remains well, or at most develops a form of late hereditary syphilis. Syphilitic children are poorly nourished, and remain deficient in both their physical and mental development. They have little resisting power to other disease, and not infrequently acquire tuberculosis, rachitis, or other disorders of nutrition. Nasal catarrh — snuffles — from a specific affection of the mucous membrane of the nose, is one of the most common of the first symptoms of the disease : this is fol- lowed or accompanied by a modified erythematous rash, of a patchy character, over the abdomen, about the anus or thighs —by mucous patches and fissures at the angles of the mouth or about other apertures. A generalized erythematous, pap- ular, or a mixed eruption is at times present. On the palmar and plantar surfaces, occasionally on other parts of the integument, the eruption assumes a bullous or pustular character. This so-called pemphigus syphiliticus develops because of the delicate character of the epidermis over the specific infiltration. The papules about the anus and mouth readily break down and form superficial ulcers. Papulosquamous eruptions may be found localized on the face, the extremities, the trunk, or generalized. Later in life the nodular or gummatous syphilide may be met with, which presents the same appearance as in the acquired disease. A frequent and characteristic affection of the long bones, known as osteochondritis syphilitica, in some cases closely resembling rachitis, occurs early in hereditary syphilis. A swelling takes place at the junction of the epiphysis and diaphysis which may resolve under treatment, or in severe cases ulcerate with extrusion of the diseased epiphysis. Bony SYPHILIS. 167 union may take place between the epiphysis and diaphysis, or abnormal ossification follow, which can result in shortening or deformity. Par- rot's opinion that rickets was always due to hereditary syphilis is not now accepted. Circumscribed or diffuse thickenings of the bones of the skull, espe- cially the frontal and parietal bones, combined with atrophy of the bone- substance in places, is common in congenital syphilis. An osteitis and periostitis of the phalanges — dactylitis syphilitica — occurs in both hereditary and acquired syphilis. Hutchinson first called attention to a deformity of the upper central incisor teeth of the second set which he looked upon as diagnostic of hered- itary syphilis. When cut, these teeth are short, narrow, and thin. After a time a notch is formed by the breaking away of a crescentic portion from their edges, which is permanent for some years. The appearance described is often absent in syphilitic patients, or may result from other causes. Sudden deafness without pain or purulent discharge in a young per- son points to hereditary syphilis (Hutchinson). When deafness, inter- stitial keratitis, and the notched teeth are present in the same patient, the diagnosis of congenital syphilis is looked upon as positive. Treatment. — Syphilis in healthy individuals of early adult life is, in the majority of cases, a benign affection, often disappearing without treatment, and producing little if any impairment of the general health. Unfortunately, we have no certain means of determining when the dis- ease is cured, or of foretelling the cases that will prove mild and of short duration, and those that may involve important organs and endanger the future health, or even the life, of the patient. It is, therefore, of the greatest importance to explain to one suffering with the disease the necessity of systematic and prolonged treatment, not only during an active outbreak of symptoms, but during the latent periods as well. When any doubt exists regarding the character of the primary sore, treatment should not be begun until the appearance of the first cutaneous eruption. The future course of the affection is probably not at all influenced by such delay, and both the surgeon and patient are assured of the certain existence of syphilis, and both are more active in carry- ing out a prolonged treatment than if a doubt exists regarding the diagnosis. The presence of a sclerosis on extragenital parts or the early occur- rence of severe general symptoms during the second incubation-period may be indications for the use of mercury before the characteristic rash has developed. Many surgeons who have had a wide experience with the disease do not hesitate to begin the use of mercury when a character- istic chancre and its accompanying adenopathy are present. Before the use of mercury is begun the patient should consult a dentist and have the teeth put in good condition. If all cavities are filled and the tartar removed from the teeth, larger doses of mercury can he taken with less liability to salivation. Alcohol in all forms should be prohibited unless some special indica- tion may arise for its use. Smoking should not be allowed, as it is apt 168 SURGICAL DISEASES. to irritate mucous patches in the mouth or throat and to determine suc- cessive outbreaks of such lesions. Syphilitic mucous patches irritated by tobacco-smoke terminate at times in leucokeratosis and epithelioma. Attention to the ordinary laws of hygiene should be insisted on, and every means employed to preserve the patient's health. Iron, tonics, cod-liver-oil, etc. may at times be indicated in conditions which arise from syphilis, as well as from other causes. They possess no specific action on the syphilitic virus, however, and are sometimes employed for an ansemia which mercury or the iodides can only control. The contagious character of the syphilitic secretions and discharges and the necessity of great care in the family and other intercourse should be explained in detail to the patient. If marriage takes place during the contagious stage of the affection, or if the disease develops after marriage, the patient must be informed of the danger to the wife and offspring which will follow the advent of pregnancy. The two specific remedies which we possess are mercury and iodine, the latter usually given as potassium iodide. Certain vegetable reme- dies, like sarsaparilla and guaiacum, are occasionally used as auxiliaries. Mercury exerts a pronounced specific influence over the local and consti- tutional manifestations of the primary and secondary stages, and it is not without curative effect in the later stages. The potassium iodide causes the rapid disappearance of local lesions and general symptoms in the tertiary stage. It is useful in combination with mercury when early pustular and ulcerative lesions occur, and in the late secondary and intermediate stages of the disease. Mercury alone is the remedy with which to begin the treatment of syphilis. It may be given by the stomach, by inunction, by hypodermic injection, or by fumigation. The most convenient and generally employed method is by the stomach, and in the majority of cases it is not neces- sary to resort to other means of introducing it into the system. It should be given in sufficient doses to exert a prompt effect on the dis- ease, and yet care must be observed to avoid salivation and diarrhoea. The condition of the mouth must be carefully watched, and as soon as the gums become tender and swollen or show a disposition to bleed the administration of mercury must be stopped for a few days, or, better, the number of doses or the quantity given reduced. A wash of alum and potassium chlorate, ad. $j, to a pint of water, should be frequently used to prevent and relieve this condition of the mouth. Saline laxa- tives, administered during the existence of a mercurial sore month, hasten its cure by eliminating the drug more rapidly through the bowels. In pronounced ptyalism, with swollen and spongy gums and superficial abra- sions of the mouth, mercury should be promptly discontinued. The flow of saliva in such cases is limited by atropine, in doses of ^ of a grain every four hours. The mercurial stomatitis may be quickly relieved by carefully painting the gums with a 2 to 5 per cent, watery solution of chromic acid once a'day, in addition to the other measures mentioned, care being taken that the mouth is thoroughly rinsed with water thereafter. The protoiodide of mercury, in pill or tablet form, given in doses of gr. | to gr. 1, t. i. d., has had a wide popularity and islargely used as a routine treatment of secondary syphilis. It is not as efficient as the other preparations mentioned, and is apt to give rise to gastro-intestinal irritation when used in larger doses. SYPHILIS. 169 The tannate of mercury, in doses of from \ to 1 grain, t. i. d., is an active drug, and is said to produce less stomach and bowel disturbance than the protoiodide. For the relapsing eruptions of the late secondary stage it is some- times of advantage to give the biniodide of mercury in doses of •£% to -^ of a grain dissolved in an excess of iodide of potassium. When early pustular and ulcerative lesions are slow in healing the quantity of the iodide in the last prescription may be increased. During the first six months the use of one or another of the prepara- tions mentioned should be kept up pretty constantly. At the end of this time, if no symptoms of the disease are present, medication may be discontinued for a month or six weeks, and then resumed for three or four months. A longer period of rest may then be permitted, followed by a third course of mercury or mercury combined with the iodide. If the patient's health keep good and no indications arise against its use, a fourth or fifth mercurial course may be advised. Inunction Treatment, — This method has the great advantage of not so readily disturbing the digestion, and when, for any reason, the internal use of mercury is not well borne inunctions should be advised. It is the most efficient and rapid method in causing the symptoms to disappear. It is disagreeable, uncleanly, cannot readily be concealed, and requires considerable time to be properly carried out. At health-resorts, like Hot Springs in Arkansas or Aachen in -Ger- many, where experienced rubbers can be employed, it is the method which is almost exclusively used in early syphilis. The patient should be directed to rub one drachm of the unguentum hydrargyri each day, for a period of twenty to thirty minutes, over a limited portion of the integument until the body has been completely covered. The legs may be chosen for the first day, the thighs the second, the back the third, the arms the fourth, and the chest and abdomen for the fifth day. At the end of this time the same course should be repeated. From thirty to fifty inunctions may be given, followed by a period of rest for a month or six weeks. At the end of this time another inunction-treatment should be employed or mercury given by the stomach. In syphilis of the viscera or nervous system the inunctions can be advantageously combined with the administration of the iodides. Hypodermic Treatment. — Of the many soluble and unsoluble salts of mercury which have been advocated for hypodermic and intramus- cular injections, corrosive sublimate is probably the most efficient and least dangerous. The following formula and method are given by Cooper l for its employment : 1^. Hydrarg. bichlor., gr. xxxij ; Ammonii chlor., gr. xvj ; Aqua? dest., §ij. — M. SiG. Ten minims to be used for one injection. The injection should be given through a platino-iridium needle pre- viously sterilized. The gluteal region is the most convenient site to be 1 Syphilis, Alfred Cooper, 2d ed., 1895. 170 SURGICAL DISEASES. chosen. The point of the needle is inserted into the gluteus maximus muscle and the solution slowly injected. One injection a week is given for six or seven weeks, and then at longer intervals. By means of these intramuscular injections a sure and rapid mercurialization of the patient is effected, and in certain emergencies they are to be recommended. As a routine method of treatment, however, they cannot be advised, and few patients will submit to them. Local treatment is often necessary for certain lesions of the secondary and tertiary stages. For the condylomata lata about the genitals, anus, and other regions the free use of calomel is the most efficient agent. Mucous patches on the lips and mouth should be cauterized with the nitrate-of-silver pencil or a chromic-acid solution (gr. xx— xxx to aq. 3j). Ulcerations in the throat may be sprayed with a solution of bichloride of mercury (gr. ss-j to aq. §j). Localized eruptions disappear more rapidly after the application of an ointment containing mercury. When on the face, a dilute ammoniated mercury or calomel ointment should be employed to avoid the stain left by the blue ointment. Specific infiltrations of the tertiary stage are favorably affected by the local use of mercu- rial ointments or plasters. Mercury is contraindicated in syphilis when tuberculosis exists, in nephritis not due to syphilis, and in pronounced ansemia from other causes. Pregnancy is an indication for its vigorous employment. Congenital syphilis should be treated by hydrarg. cum creta, gr. j, t. i. d., or, better, by the use of inunctions of blue ointment, gr. xx, once a day, thoroughly rubbed into the body. The ointment should be diluted with vaselin, to prevent its irritant effect on the delicate skin of the infant. Indications for the Use of the Iodides. — The iodides are frequently given between courses of mercury or after the completion of the mer- curial treatment, for the purpose of rendering soluble and eliminating the mercury which may remain in the tissues. Their most striking effects are produced in the late stages of the disease in causing the rapid disap- pearance of gummata, and other specific infiltrations, and in the healing of syphilitic ulceration of the skin and mucous membranes. No other therapeutic agent can produce so marked and rapid effects as the iodides in late syphilitic neoplasms. Certain persons are very sensitive to the iodides, small doses pro- ducing catarrhal symptoms in the nose, throat, and bronchial tubes. Tolerance, of the drug in such patients may generally be acquired by beginning with minute doses and slowly increasing the amount taken. Papular, pustulous, bulbous, erythematous, nodular, and purpuric erup- tions are at times produced by the ingestion of the iodides. Certain of these eruptions may be confounded with syphilitic lesions. CHAPTER XI. GONORRHOEA AND ITS SEQUELS. By W. T. Belfield, M. D. Etiology. — Gonorrhoea is an infection of human tissues by a specific bacterium, the micrococcus or gonococcus of Neisser, reinforced by one or more varieties of the common pus-bacteria ; practically, it is therefore a mixed infection. The gonococcus is not only an obligate parasite — never found except in animal tissues — but it is also a parasite of human tissues only, other far as known, being an is acquired only by con- unfavorable its growth. animals, so Hence it tact, direct or indirect, with a suf- ferer from the disease. The com- monest seat of the infection is the genito-urinary tract of male and fe- male, and it is hence usually trans- mitted by sexual contact. Yet cer- tain other mucous membranes are susceptible to the infection, and it is occasionally carried indirectly — by soiled fingers, towels, and syringes, or by unnatural intercourse — to the mucous membrane of the eye and rectum, even of the mouth and nose. While all accessible mucous mem- branes may be infested by tbe gonococ- 1 cus, yet those lined with cylindrical epi- thelium seem to atf'ord more favorable conditions for the parasite than do the flat-celled membranes ; and the disease persists more obstinately in the former than in the latter — in the uterine cervix, for example, longer than in the vagina. While the infection always begins on a mucous surface, it does not always remain limited to these : it may spread by continuity to the sub- mucous tissues, by the lymph-stream to the nearest lymph-nodes ; it may enter the blood-current and produce metastatic infections in distant structures — serous membranes and fibrous tissues of joints, bursse, ten- don- and muscle-sheaths, pleura, peritoneum, meninges, peri- and en- docardium — constituting a veritable pycemia analogous to that Avhich follows wound-infections. The many follicles and pockets which line the genital canal of either sex are naturally included in the bacterial invasion : in the male, the numerous lacunse of the urethra, Cowper's glands, the prostatic utricle and glands ; in the female, the lacunse of the urethra and urethro-vag- inal septum and the vulvo-vaginal glands. 171 Gonococci in fresh gonorrhceal pu (Frankel and Pfeiffer). X 1000 172 SURGICAL DISEASES. This is a fact of great clinical importance, for long after the general .surface has recovered its normal condition and the patient is apparently well, the gonorrhoeal infection may persist in some of the hidden pock- ets in quantity sufficient to infect a partner in the sexual act, and even, when favored by alcoholic or sexual excess, to reinfect the genital canal of the individual himself. The serous and fibrous structures which may become the seat of metastatic infection through the blood-current exhibit all grades of reaction, from serous hypereemia to purulent inflammation, the effect depending, in part at least, upon the varieties of bacteria concerned in the process. Diagnosis. — Until the discovery of the gonococcus in 1879 there was no distinctive feature by which a gonorrhoeal infection could be dis- tinguished from other purulent inflammation of the genital tract ; hence there occurred many errors in diagnosis, and by consequence many false conclusions as to therapeutics. When, however, a profuse purulent discharge presents large num- bers of gonococci enclosed in both pus and epithelial cells, we are war- ranted in a diagnosis of gonorrhoeal infection. In practice, it is only the slight, chronic gonorrhoeal discharges, containing but few gonococci, which can be confounded with the non-gonorrhoeal discharge containing the pseudo-gonococci ; and since cases of chronic gonorrhoea or gleet are exceedingly numerous, and cases of non-gonorrhoeal urethritis exhibiting the pseudo-gonococci are quite rare, the detection of the characteristic dip- lococcus furnishes a very strong presumption of gonorrhoeal infection, even when the discharge is slight and the cocci few. The clinical distinction between gonorrhoea and other purulent inflammations of the genital tract is even less trustworthy : it is true that an acute urethritis, beginning from three to seven days after suspicious connection in one who has for a long time had no urethral disease may safely be pronounced gonorrhoea ; but there are numerous cases of urethritis which do not conform to these conditions, and in which the clinical diagnosis can be only a probability. In practice, the differentiation of the gonorrhoeal from other purulent inflammations of the genital tract must often rest upon both clinical and microscopical evidence. AVe may divide all such inflammations in the male into four classes : 1. Gonorrhoeal infection from without, marked clinically by an incubation of three to seven days (usually), and a severe inflammatory reaction in a patient previously free from urethritis : the microscope shows an abundance of gonococci contained in both pus and epithelial cells. 2. Gonorrhoeal infection from -within {auto-infection, the "bastard clap " of the older authors), marked clinically by an incubation of six to twenty-four hours, and slight or no pain, in a patient with a history of uncured urethritis, as shown by slight gleety discharge, gumming of the meatus, or merely pus-threads in the urine ; the microscope shows gono- cocci, but less numerous than in the first class of cases. These two classes include over 90 per cent, of all cases of purulent urethritis in the male. 3. Non-g-onorrhceal infection from without, beginning within twenty-four hours after connection, with slight inflammatory reaction, GONORRHOEA AND ITS SEQUELM 173 in a patient previously free from urethritis : the microscope shows no gonococci, or at most a few, with an abundance of pus-bacteria. Such cases occur especially after excesses in alcohol and venery with a woman suffering from leucorrhcea, notably when at or near her menstrual period. 4. Non-gonorrhceal infection from within. — This may be an extension to the anterior urethra of an inflammation in the bladder or prostate due to vesical calculus, enlarged prostate, gout, or other cause. It is not rare in elderly men suffering from these complaints, and is of mild degree ; no gonococci are visible. In this category one must classify cases of urethritis from injury, as by urethral instruments ; from caustic injections for the prevention of gonorrhoea, etc., in which the history plainly indicates the cause. The possibility that a mild urethritis following connection may be due to an urethral chancre should never be forgotten ; the diagnosis is made by inspecting the fossa navicularis. Conditions favoring 1 Infection. — It is certain that not every sexual act with an infected woman conveys the infection, for it is repeatedly observed that of several men who cohabit with the same woman in the same night, one will acquire, another escape, the disease. To this result doubtless several factors contribute : the natural susceptibility of different urethras must vary, some having greater natural immunity, some having acquired such immunity by repeated infections with the gonococcus. Moreover, influences which depress the vitality of the urethral tissues, such as excessive drinking, favor infection ; and prolonged sexual excite- ment, by which the naturally acid fluids of the urethra are rendered alka- line, must have the same effect, because the gonococcus grows well in alkaline, poorly in acid, media. A profuse and acrid leucorrhcea of the female, especially when heightened by the congestion incident to men- struation, must similarly favor the transfer of infectious material. The prevention of gonorrhceal infection after exposure is impos- sible. Thorough washing of the parts and immediate urination doubt- less contribute to that end, but are often ineffectual. The use of caustic injections after the act is to be condemned: they may be relied upon not to remove nor destroy the infectious material, but to irritate 'the epithelial lining of the urethra, and thus pave the way. for bacterial growth. The popular belief that a true gonorrhoea can be acquired from a non-gonor- rhceal leucorrhcea or menstrual discharge, or from a "strain," is erroneous; while it is doubtless true that a simple and brief urethritis can be so acquired. Gonor- rhoea in a patient proves the pre-existence of the disease in another person and the transfer of infected matter. The disease is occasionally transferred without sexual contact, by means of infected towels, syringes, urethral instruments, etc. The patient should be warned to protect his oivn eyes, as well as the persons of others, . from such accident ; and the physician should be most careful to sterilize all urethral and vaginal instruments after each use of them, particularly upon a case of even suspected gonorrhoea. Clinical History. — During a period of incubation varying from two to fourteen (usually three to five) days after exposure no evidence of disease attracts the patient's attention : then an itching sensation a swelling, reddening, and gumming of the meatus, and a smarting pain 174 SURGICAL DISEASES. during urination, are observed, soon followed by the appearance of thick pus ; these features become rapidly intensified, until in a few days the severe inflammation extending along the penile urethra is manifested by great swelling of the meatus, oedema of the prepuce, redness, often excoriation of the glans, heat and soreness of the entire penis, and a constant discharge of thick yellow or greenish pus. During this period the passage of urine causes acute pain ; the stream issuing from the meatus is small, twisted, or scattering. As the inflamed tissues sur- rounding the urethra are less distensible than normal, erections — which are apt to be frequent — are exceedingly painful and often distorted, the penis presenting a more or less sharp curve whose concavity is usually downward, sometimes also laterally : this is the condition called chordee. There is usually a slight rise of the body-temperature. Seminal emis- sions during sleep are increased in frequency. This condition persists, if untreated, for ten to fifteen days, when the symptoms gradually subside : the purulent discharge may persist for several weeks after pain and soreness have ceased. These extensions are designated by the name of the tissue or organ invaded : the infection may attack the entire genital canal, the urinary tract, the peritoneum where contiguous to these, and the blood-current itself. These will be considered in natural sequence. Balanitis, an extension of the infection to the glans penis, often occurs in slight degree. In exceptional cases, especially where cleanli- ness is neglected or impossible because of phimosis, a severe infection of the glans and corona occurs, causing extensive erosions, even ulcera- tions. Folliculitis, extension of the infection to the lacunas and follicles branching off from the urethral canal, always occurs ; but so long as the pus produced in these follicles is freely discharged into the iirethra no distinct clinical phenomena are induced. If, however, the orifice becomes occluded, the follicle becomes distended with pus : when located near the fossa navicularis these distended follicles protrude on the exter- nal surface, on one or both sides of the frenum, as hard, tender nodules as large as buckshot. In a few days these usually soften, discharge externally, and heal spontaneously : sometimes they discharge internally into the urethra, and exceptionally in both directions, making a urinary fistula that it may be difficult to close. Periurethral Inflammation. — When, however, these inflamed and distended follicles are located behind the fossa, the course of events is not always so simple : while the follicle may discharge externally with- out complications, yet the inflammation may involve the periurethral tissues, making a hard, distinct tumor as large as a hazelnut. This may remain unchanged for months, or it may become the seat of a rapidly- spreading suppuration : the pus sometimes empties into the urethral canal, sometimes rapidly infiltrates the spongy or cavernous bodies. In either case the urine may escape into the periurethral tissues, causing the so-called urinary infiltration : abscess and fistula, septic phlebitis, em- bolism, and pysemia, are all possible unless incision and drainage of the infiltrated tissues be promptly made. These processes destroy more or less of the normal periurethral tissues : the cicatrix by which they are ultimately replaced may later GONORRHCEA AND ITS SEQUEL JE. 175 constitute a stubborn stricture, and even occasion a notable deflection of the penis from its normal straightness during erection. The clinical signs of diffuse periurethral inflammation are those of septic infec- tion in general : pain at the site of the inflamed follicle, at first dull, then acute and aggravated during urination and erection : diffuse suppuration and urinary extravasation (the latter usually follows soon upon the former) cause throbbing pain, a dark-red oedema, chills, and high fever. Cowperitis is the designation given to the same process occurring in the two large follicles (glands of Cowper or Mery) which are situated between the layers of the triangular ligament in the perineum and open into the membranous urethra. It occurs after the tenth day of the dis- ease, and occasions a tense, painful swelling in the perineum, noticed especially by the patient when sitting. In all respects, except the anatomical surroundings, it is identical with folliculitis of the anterior urethra. Prostatitis. — The prostatic urethra is provided with thirty or more glands or follicles, besides the relatively large follicle termed the utricle, or masculine uterus. When the gonorrheal infection invades this portion of the urethra (causing the so-called deep urethritis), these numerous fol- licles are invaded by the gonococcus ; and there may result a peri- urethral inflammation and suppuration, just as in the anterior urethra. This process is in this locality called prostatitis. Periurethral suppura- tion and infiltration of urine may occur, the pus and urine burrowing into the pelvic connective tissue or the perineum, and the abscess point- ing into the rectum, suprapubic space, or perineum. Septic infection from the prostatic urethra is especially prone to cause phle- bitis, peritonitis, and pyaemia. Fortunately, folliculitis of the deep urethra or prostatitis usually terminates by spontaneous evacuation of the pus into the urethral canal. Deep Urethritis. — In a majority of cases of gonorrhoea the infection extends in the second or third week through the membranous and pros- tatic urethra to the bladder. This extension is usually indicated by distinct symptoms which proceed from the irritation of the prostatic urethra. Normally, this portion of the urethra exhibits a triple func- tion : in it originates the impulse to urinate ; it is intimately concerned in erection and seminal ejaculation ; and it is a sphincter of the bladder. Hence the disturbance of its tissues by the gonorrhceal infection causes three notable symptoms : (1) increased frequency in the desire to urinate; (2) prolonged erections and frequent emissions ; and (3) marked difficulty in expelling the urine, sometimes amounting to complete retention, com- pelling the use of the catheter. A dull pain, a sense of heat and weight in the perineum, rectum, and suprapubic region, and a sharp pain at the end of urination and referred to the glans penis, accompany all but the mildest cases. The last urine evacuated is apt to be mixed with blood, varying in quantity from a few drops to a light hemorrhage. Ampullitis and Vesiculitis. — The extension of the inflammation to the dilated extremity of the vas deferens (ampulla) and the seminal vesicle occurs in a percentage of cases as yet imperfectly determined, but probably almost as often as deep urethritis ; for the clinical distinc- tion between the latter and vesiculitis has not always been made. The chief symptoms marking the extension from the prostatic urethra to the 176 SURGICAL DISEASES. seminal tubes are the pronounced heat and pain in the rectum and the large admixture of blood and pus with the seminal discharge. The examiner's finger, introduced into the rectum, easily recognizes the swollen, tense, and tender vesicles above the prostate. Epididymitis and Orchitis. — The further extension of the gonor- rhoeal infection along the vas deferens finally involves the epididymis, and sometimes the tubules of the adjacent testicle itself. Epididymitis occurs in from 5 to 20 per cent, of cases of gonorrhoea, rarely appearing before the third week. The first symptoms noticed may be increased frequency of urination, then pain and tenderness either in the testicle or at the external inguinal ring. Sometimes a chill and fever usher in the local swelling ; in a day or two the epididymis has become swollen, tender, and exceedingly painful, the skin covering it dark-red and oedematous : the testis usually participates in the swelling and pain. All these symptoms begin to recede in four or five days, and subside in two weeks, except that hard, sensitive nodules may remain in the epididymis for many weeks, even months. In exceptional cases suppuration and local necrosis occur in the epididymis and testicle. Cystitis of gonorrhceal origin is usually limited to the vicinity of the vesico-urethral orifice : many cases so called because of the frequency and pain in urination, are really instances of prostatitis and deep urethritis. Ureteritis, pyelitis, and suppurative nephritis are infrequent extensions of the gonorrhceal infection : they are marked by chills, fever, and pain, referred to the region of the kidney, the course of the ureter, the testicle, and the thigh. An enlargement of the kidney is often perceptible. The pus passed with the urine is greatly augmented, and there is more albumen than the pus accounts for. Lymphangitis and Adenitis. — The lymphatics surrounding the urethra are always invaded by the gonorrhceal bacteria, and some of the inguinal nodes are usually slightly swollen and sensitive ; in the severer cases a lymphatic vessel along the dorsum of the penis is perceptible as a hard, sensitive cord leading to the inguinal nodes, which are distinctly swollen, and in exceptional instances suppurate (suppurating gonor- rhceal bubo). CEdema of the prepuce is frequent in the first week of the urethri- tis, subsiding as the more acute symptoms lapse : sometimes the oedema is so great as to constitute a veritable phimosis, or, if the patient retracts the swollen foreskin, he may be unable to return it, presenting the con- dition called paraphimosis. The latter is an unpleasant complication, because the narrow orifice of the retracted prepuce so constricts the penis as to cause great oedema of the glans, and in occasional instances —fortunately, rare — extensive necrosis and sloughing in front of the con- stricting ring. Usually, however, this ring itself sloughs awav, the strang- ulation of the glans is relieved, and the swelling gradually 'subsides. Post-gonorrhceal arthritis, often miscalled gonorrhceal rheuma- tism, occurs in only 2 or 3 per cent, of cases of gonorrhoea, and is caused by the infection of various tissues by means of the blood-current. It begins at any time, from three days to three months after urethral infection many cases starting in the first month. It affects especially fibrous struct- ures and serous membranes, and exhibits an acute variety— beginning with chill, fever, and local swelling— and a chronic form, which may be GONORRHCEA AND ITS SEQUELM. 177 primary or a continuation of the acute. It attacks most frequently the knee-, ankle-, hip-, shoulder-, and elbow-joints and those of the fingers and toes ; sometimes only one joint is atfected, sometimes several are simultaneously or successively involved. The local inflammation lasts in acute cases two to three months, in chronic cases several years. Besides the joints, bursa and tendon-sheaths are often attacked, especially those of the legs, feet, and hands ; the muscles of the neck, the conjunctiva, and iris also become the seat of the infection. The meninges, peri- and endocardium some- times participate in the disease, which is then apt to terminate fatally. The morbid anatomy presents nothing distinctive from lesions of the same structures due to other causes, except that the gonococcus is sometimes found in the inflammatory exudate, especially on serous surfaces. Pysemia. — As the gonorrhceal infection includes the pus-microbes as well as the gonococcus, we can understand that a real pyaemia, differing in no respect from that proceeding from a septic wound, may follow a gonorrheal urethritis. Such is really the case, though, fortunately, in rare instances. Treatment.— The rational treatment of gonorrhoea — the destruc- tion of the invading bacteria — is as yet undiscovered : it should be dis- tinctly understood that our treatment of the disease is only palliative, and that the infection may steadily advance and long persist in spite of any treatment. An enumeration of the numerous remedies and methods which have been from time to time recommended, and of the many specifics and sure-cures even now current, would fill this volume : only the measures sanctioned by large experience will be here mentioned. Anterior Urethritis. — The patient presenting himself with a recent gonorrhoea should be first carefully instructed as follows : He should scrupulously avoid constipation, bodily activity, alcohol, and sexual excitement ; he should destroy or sterilize by boiling all clothes and handkerchiefs soiled by the discharge, and should wash his hands im- mediately after every contact with the infected parts or dressings ; he should not protect his linen by inserting a wad of cotton under the fore- skin (as most Gentiles do), because the cotton dams up the pus in the urethra and spreads it over the glans penis ; he should indulge sparingly in meats, coffee, and tobacco, and should keep the horizontal position as much as possible. He should procure a gonorrhoea-bag — a cloth or rubber sack which encloses the penis and is secured by tapes around the waist — or make a substitute by sewing tapes to the toe of a stocking, and place some absorbent cotton in the bottom ; in this way the linen is protected, while the pus drains freely from the urethra. Medicinal treatment is internal and local ; the former consists of — (1) Laxatives, especially calomel and salines ; these are beneficial in all cases, and imperative when there is a tendency to constipation, which must be carefully avoided ; 2. Balsams excreted by the kidneys, such as santal oil, freshly powdered cubebs, and copaiba. Of these pure santal oil is decidedly the most valuable. Freshly powdered cubebs, a teaspoonful every two to four hours, markedly lessens the amount of discharge, though frequently disturbing the stomach ; the oleoresin of copaiba, a ten-minim capsule six times a 12 178 SURGICAL DISEASES. day, has a slighter influence upon the discharge, but a greater effect upon the stomach, and occasionally produces an annoying scarlet rash. Internal antiseptics, so called, such as salol, which when given by the mouth are excreted by the kidneys as carbolic and salicylic acids, etc., have failed to pro- duce the beneficial effect hoped from them, and have been abandoned, though there is still a lingering belief that boric acid, in doses of three to five grains four times daily, does exert a good influence. 3. Diuretics. — Water, milk, potassium acetate and bitartrate are use- ful to dilute the urine and thereby diminish the irritation of the inflamed urethra by contact of this fluid. Internal medication may therefore be outlined as follows : calomel in quarter-grain doses, three to six a day for one or two days ; for the next six days a half teaspoonful of potassium bitartrate and five grains of sodium phosphate in a glass of hot water, night and morning ; after which the calomel may be repeated. Naturally, the size and frequency of these doses must be determined by the effect produced. Twenty minims of good savtal oil or a teaspoonful of fresh cubebs may be given from four to eight times daily as the stomach permits. The local treatment of gonorrhceal urethritis is exceedingly important : the ancient prejudice against it, based upon the ill effects of severe and caustic injections, does not hold against the later methods. Of all local remedies, hot water holds the first place, and cannot be used too freely nor too often : it should be applied to both the exterior and interior of the penis. This organ should be immersed, as often and as long as circumstances permit, in a glassful of water whose tempera- ture may be at first 100° F., and is gradually raised by the addition of hotter water to 105°, 110°, or 115° F. At intervals injections of the same water should be thrown into the urethra. The addition of boric acid to the water, a teaspoonful to the pint, enhances the moral, and possibly the physical effect of the water. Injections into the urethra should be made with a hard-rubber syri?ige holding half an ounce and terminating in a blunt tip without nozzle ; and it is wise for the physician to instruct the patient how to inject, both verbally and by administering an injection, and causing the patient to repeat the process in the doctor's presence. Before an injection the patient should empty the bladder: the syringe, filled with hot water (100° F. or more), is held in the right hand, the tip placed carefully between the lips of the meatus, which are then gently compressed laterally by the thumb and fingers of the left hand ; by the right hand the piston is pressed slowly and gently home until the urethra feels distended. The syringe is then removed, the escape of the water being prevented by compression of the meatus. After a half minute the water is allowed to escape, and a second injection of hotter water (105° to 110°) is made. After this one of the following solutions is injected : hydrastin muriate, saturated solution, or zinc permanganate, 1 : 4000 (1 grain to 8 ounces of water). It is understood that the hot-water injections are continued. The hydrastin is not irritating, and presents only one disadvantage — the yel- low color, which, however, is easily removed by water. These injections should be made from six to ten times per day. Under such treatment the acute symptoms commonly subside in a week, and in two weeks the discharge becomes slight in quantity and resembles thin milk. When this occurs the hot-water immersions are discontinued and zinc-chloride solution, one-half grain to six ounces, sub- stituted for the permanganate. GONOERHCEA AND ITS SEQUELAE. 179 Various plans have been practised for the purpose of aborting a gonorrhoea : these may all be dismissed as certainly useless and often dangerous. Under such treatment as has been outlined perhaps one-third of the cases of acute gonorrhoea are apparently cured in from three to six weeks ; but it should be impressed upon the patient that the cessation of free discharge from the meatus does not prove that he has recovered ; for long after this stoppage of the flow there may persist various evidences of disease, such as a gumming together of the lips of the meatus, espe- cially during the night ; the appearance of a milky drop at the meatus in the morning ; and the constant presence in the urine of thick white threads (clap-threads) of pus, which soon sink to the bottom of the vessel (these are commonly called by the German name, tripper-fdden). The persistence of any of these phenomena indicates the presence of one or more infected areas in some portion of the genital canal, and the case must be considered one of chronic gonorrhoea. Chord.ee is not frequent under the hot-water treatment : if it occur, an attempt to prevent it may be made by the administration at bedtime of thirty grains of sodium bromide or two grains of camphor monobromide with a grain of eodeia. When awakened by the painful erection, the patient should empty the bladder and apply cold water or a cold metallic object to the penis and perineum. Constipation favors chordee. Balanitis may be controlled by hot applications of boric-acid solution, followed by vaseline inunctions. Phimosis is reduced by immersions in hot water and injections of the same under the foreskin. Paraphimosis needs no treatment but hot water, unless the swelling of the glans seems to threaten necrosis of tissue : in this case the end of a probe-pointed bistoury should be inserted under the constricting band, which is then divided, the incision being dressed with iodoform or aristol. Folliculitis in the penis needs no special attention unless symptoms of periurethral suppuration become apparent — local redness, tenderness, and boggy swelling : in such case incision and perfect drainage should be promptly made, followed by hot-water immersions of the septic tissues. Periurethral suppuration, occurring in any portion of the tract from meatus to bladder, must be recognized early and treated promptly, for it is apt to be followed by urinary infiltration and the severest forms of septic infection. When discovered, whether in penis, perineum, or pros- tate, the pus should be promptly evacuated from the nearest cutaneous surface. Deep urethritis occurs in the majority of cases of gonorrhoea, and often requires no especial treatment ; indeed, it is often unnoticed by both patient and physician. In more severe cases, when frequent and difficult urination, pain in perineum and rectum, and some fever attract attention, the patient should remain in bed, take frequent hot-water fomentations, hip-baths, and enemata ; the perineum should be irritated by mustard plasters or even blistered by cantharidal collodion ; and the pain and straining to urinate, often agonizing, quieted by morphine ; complete retention of urine, requiring the use of the catheter, is not 180 SURGICAL DISEASES. unusual. Not infrequently these severe symptoms are suddenly relieved by a discharge of pus from the prostatic follicles into the urethra ; but occasionally the pus burrows into the perineum, vesico-rectal or supra- pubic tissue, requiring prompt evacuation. Vesiculitis and ampullitis often follow closely upon deep urethritis, from which they can be distinguished by the finger in the rectum, reveal- ing an oblong, tender swelling on one or both sides above the prostate. Rest in bed, hot hip-baths, and enemata, and morphine should be used until the more acute symptoms subside ; then with a finger in the rectum gentle pressure toward the prostate should be made. Sometimes this manipulation is rewarded by a gush of foul pus through the urethra and meatus, and rapid subsidence of both swelling and symptoms. If, how- ever, the effect fails and the symptoms increase in severity, an incision should be made into the sac from the rectum, the cavity washed out and lightly packed with gauze. Epididymitis can usually be aborted by painting the skin along the cord and epididymis with guaiacol, using fifteen to thirty minims for each application, and making three applications in the first twenty-four hours, and two each day thereafter for a few days. The skin is usually peeled by the guaiacol, and the excoriations should be dressed with vaselin. Both testicles should be held up against the symphysis in the following manner: The entire scrotum is enveloped in a thick layer of cotton, which is covered with oiled silk or sheet rubber, surrounded by a gauze bandage, and the whole raised and supported against the symphysis by a jockey-strap or a silk handkerchief pinned to the underwear. The cotton should be changed every day. By the early use of guiacol and this bandage confinement to bed can usually be avoided : under other treatment a week's rest in bed is commonly inevitable. Orchitis. — A certain amount of orchitis usually accompanies epidid- ymitis, and is relieved by the treatment for the latter : the local appli- cation of guaiacol may be extended over the testicle if this organ is swollen. Post-gonorrhceal arthritis, or gonorrhceal rheumatism, has until recently been unaffected by any of the numerous remedies tried upon it : treatment has consisted of wrapping the inflamed joints in cotton and oiled silk, placing the patient upon a water-bed and administering ano- dynes. Inunction of the inflamed joints and tissues with guaiacol (not more than two drachms being applied per day) promises better than any medication hitherto advised. Chronic Gonorrhoea; Gleet. By common consent, a gonorrhoeal infection of the genital tract in the male which persists more than eight weeks is termed a chronic gon- orrhoea, and the discharge from the meatus, when present, is called a gleet. It has been customary to consider chronic gonorrhoea and gleet syn- onymous terms, but this is one of the many errors which have descended to us from the earlier surgeons ; for by a gleet we understand a discharge from the meatus, but the gonorrhoeal infection often persists in the pros- tatic urethra and seminal tubes long after the anterior urethra is prac- tically well and without any discharge from the meatus ; for the pus produced in the deeper parts may be prevented from reaching the ante- GONORRHOEA AND ITS' SEQUEL JE. 181 rior urethra by the cut-off muscle. Hence a chronic gonorrhoea may- long exist without a gleet — an important clinical distinction. Gleet is the continuation of a gonorrheal discharge from the meatus, and may vary from a 'profuse milky to a slight watery flow. Sometimes there will during the day be no distinct discharge, but only a gumming of the meatus ; but in the morning, with or without milking the penis, a drop or two of milky fluid appears, the so-called morning drop, or, as the French call it, the military drop. The first step toward the intelligent treatment of gleet is therefore the discovery of the infected area, which may be found anywhere from the meatus to the vas deferens. For practical diagnosis and treatment the genital surfaces may be divided into three portions : (1) the anterior urethra (to the bulbo-membranous junction) ; (2) the deep urethra (from bulb to bladder) ; and (3) the prostate, ampullae, and seminal vesicles. It is chiefly important to know whether the pus-production is limited to the anterior urethra or extends also to the deep urethra : in the latter case some involvement of the prostate and seminal tubes may be expected. Persistence of suppuration is due to the existence of diseased areas, which are of three classes: (1) plastic exudate in the submucous tissue, causing a catarrh of the surface and developing into stricture ; (2) pre- existing stricture ; (3) imperfect drainage, as in the prostatic follicles and seminal vesicles. The anterior urethra is explored by — (1) bulbous sounds and (2) the urethroscope (endoscope). The bulbous sound (Fig. 39) is so shaped as to detect a lack of normal disten- sibility of the canal ; that is, a stricture. This natural distensibility (calibre) varies in different portions of the urethra, being greatest in the bulb and the prostate and Fig. 39. Bulbous sound. least at the meatus, the scrotal and membranous portions. The calibre also varies in different individuals, maintaining a fairly constant ratio (about four-tenths) to the circumference of the flaccid penis : in general it ranges from 30 to 36 of the French scale. By means of the bulbous sounds any strictures worthy of note can be detected, provided the meatus will admit a bulb of full size. If, as often hap- pens, the natural contraction of the meatus prevents a satisfactory exploration by these instruments, the surgeon must either divide the meatus to 35 Fr. or employ an Otis (or similar) urethrometer. Division of the meatus should never be per- formed if that orifice admits a 22 Fr. bulb ; for, while the operation is trivial, the result is a gaping deformity of the natural nozzle-shaped orifice, whereby the expulsion of urine and semen is unfavorably influenced, and the patient's liability to gonorrhoea and urethral chancre undoubtedly increased. Fjg. 40. opt*. Urethrometer. Instead of cutting a normal meatus, the surgeon should use the urethroinet'^r of Otis (Fig. 40), an ingenious instrument constructed on the umbrella principle. 182 SUROICAL DISEASES. introduced when closed, it is dilated by a screw at the handle to the desired size (33 Fr. or more), and then drawn forward, the variations in calibre necessary tor its passage being indicated on the dial. Neither bulbous sounds nor urethrometer should be passed into the muscular portion of the urethra beyond the bulb : the distensibility of this portion of the canal is tested by cylindrical sounds. The prostatic urethra is practically never the site of contractions (stric- tures) as the result of gonorrhoea. Inspection of the entire urethral surface can be made through one of the many urethroscopes in use : by it the surgeon may detect diseased areas by the unnatural redness and granular appearance of the surface. While urethroscopic inspection is always desirable in cases of gleet, it is not always essential. Digital examination per rectum should never be neglected in deter- mining the source of a gleety discharge, even though the anterior urethra is found to be strictured or otherwise diseased ; for the prostate and seminal vesicles are often the seat of persistent infection and contribute to the discharge. To determine the condition of these parts the surgeon's fore finger- best enclosed in a rubber condom which is anointed with glycerin — is introduced into the rectum of the patient, who may either lie upon his back or stand with the feet apart and body bent forward. The finger first determines whether the prostate is swollen, asymmetrical,, or unduly sensitive ; then the finger-tip is made to " milk " the prostatic follicles by gentle pressure on the organ from above downward (toward the anus) : the prostatic utricle, which lies between the lateral lobes of the organ, and is often distended with pus, should be included in the milking pro- cess. The appearance of a purulent discharge at the meatus during this manipulation shows that the prostatic follicles are diseased. The finger should then be inserted farther into the rectum, so as to compress or " milk " the seminal tube and vesicle on each side : the escape of pus and catarrhal products in notable quantity indicates that these tubes are implicated in the chronic infection. Treatment of Chronic Gonorrhoea and Gleet. — The treat- ment of gleet should always be preceded by a determination of the seat of the disease, as already outlined : a routine prescription of injections or use of sounds, while curing a certain number, will fail to relieve many that are amenable to intelligent treatment. Certain general measures are applicable to all cases of gleet : they should carefully avoid constipation, alcohol, and sexual excitement. It may be here remarked that instances are not rare in which an obstinate gleet has stopped suddenly and permanently after indulgence in beer or wine by a patient who has long abstained, or after sexual intercourse by a man who has long been continent. Patients afflicted with gleet should drink plenty of good water and avoid the excessive use of tobacco and coffee. The special measures required are — (1) sounds ; (2) injections — ante- rior and deep urethra ; (3) milking of prostate and seminal tubes ; (4) medicines internally and locally ; (5) local applications to diseased patches through the endoscope. (1) Sounds. — A stricture should be treated by gradual dilatation car- ried to the full calibre of the urethra, 32 to 3G Fr. If a narrow meatus GONORRHCEA AND ITS SEQUELjE. 183 prevents the use of large sounds, the surgeon should choose between enlargement of the meatus (advisable in exceptional cases only) and dilatation by means of special instruments, the dilators of Otis, Tuttle, Fig. 41. Otis' dilating urethotome. Oberlander, etc. Even when no decided stricture is detected, the passage of large sounds through the deep as well as the anterior urethra is an advisable accessory to other treatment. The surgeon who possesses one of the special dilators should gradually overstretch (by 2 or 3 mm.) any contracted ring. (2) Injections. — Of the multitude of injections recommended for gleet of the anterior urethra the following are useful : hot water (100° to 115° F.) alone and containing in solution hydrastin muriate (saturated) or picric acid, zinc permanganate, nitrate of silver, one grain to eight ounces : alcohol is an old and valuable remedy, beginning with one part in twenty of water, and gradually increasing to one part in five. Deep Injections. — Liquids injected from the meatus do not ordi- narily reach the deep urethra, because arrested by the " cut-off" muscle. Injections into the deep urethra are therefore usually made through a tube introduced beyond the bulbo-membranous junction. Special syringes for this purpose have been designed by Guyon, Ultzmann, Keyes, and others (Fig. 42), whereby an exact number of minims of a given strong Fig. 42. Deep urethral syringe. solution can be deposited in the deep urethra — a process often called instillation. A better practice is irrigation of the deep urethra with a larger quantity of a weaker solution. For this purpose a small soft catheter (sterilized) is introduced until the urine flows, then withdrawn about an inch and a half, and a five-ounce rubber syringe or small fountain syringe (hung low) attached. The solution passes into the deep urethra, and thence into the bladder, the cut-off muscle preventing its escape through the penis ; the catheter is then withdrawn and the patient empties the bladder, thus passing the solution a second time over the deep urethra. The solution used should be hot (100° F.), and may consist of nitrate of silver, one part to ten thousand of water, bichloride of mercury, one to twenty thousand, or permanganate of potassium, one to five thousand, employed every two or three davs. Many patients can with practice inject the bladder without a catheter : this is, when practicable, preferable to the injection by catheter, and is accomplished by placing the patient in a reclining position, with thighs flexed upon the body. A fluid gently injected by means of a five-ounce 184 SURGICAL DISEASES. syringe may, after slight delay at the cut-off muscle, flow into the blad- der. Elderly men are especially favorable subjects for such injection. (3) Milking- the prostate and seminal vesicles is always required when these parts are obviously diseased, and, like the passage of sounds, is sometimes useful even when no infection of these parts is detected. This manipulation should be performed at first very gently and for only two or three minutes at a time : the pressure used and the time expended may be gradually increased, and the intervals between sittings reduced from six days to three. If the pain caused persists for several hours, the next application should be more moderate, as violent pressure may cause an extension of the infection along the vas deferens to the epididymis. (4) Medicines administered by the mouth cannot be relied upon to influence a gleet : the best effects are obtained from turpentine oil in three- to five-drop doses, santal oil in ten-minim doses, and tincture can- tharides in three-drop doses, four to six times daily. Iron and other tonics are beneficial to a patient showing any signs of anaemia, and sometimes are quite essential to a cure. In the suppository form drugs are applied directly to the prostate and vesicles with benefit when these parts are involved : ichthyol, two grains, ext. belladonnse or hyoscyami one-quarter grain, may be thus administered three times daily. Syphilitics should take mercury or iodine, and scrofulous subjects guaiacol : in malarial districts quinine may have a decided effect in checking a gleet. (5) Local applications to diseased areas through the urethroscope are sometimes necessary : the diseased surface is brought into the field, cleansed with cotton, and touched with a stick of copper sulphate or a strong (10 to 20 per cent.) solution of silver nitrate, the application being repeated every few days as the course of events indicates. The treatment of chronic gonorrhoea and gleet may be thus summarized : In addition to the hygienic measures necessary for all, and the tonic treatment required by some, direct measures should be adapted to the part of the genital tract involved : for the anterior urethra, sounds, injections, applications through the endoscope ; for the deep urethra, irrigations, large sounds ; for the prostate and seminal tubes, the treatment for the deep urethra combined with the milking process and suppositories. When does a chronic gonorrhoea cease to be contagious ? is a frequent and most important question, to which we can give no definite answer. Theoretically, the contagion ceases when the gonococci dis- appear absolutely from the body, but, practically, we cannot determine when this happy event occurs in a given case. So long as we find these bacteria in a free discharge or even scattered through the pus-threads (tripper-fdden), which are passed with the urine long after free discharge has ceased, we believe the individual capable of conveying the infection ; but we know that the gonococci may lurk in crypts and follicles of the genital canal even when a careful search fails to detect them in the pus- threads. Under the excitement of intercourse a rapid multiplication of these organisms may occur, resulting in the infection of the woman and the reinfection of the patient's own urethra. This is especially apt to occur in the frequent and prolonged sexual indulgence of recent marriage. Gonococci have been found in the pus-threads three and four years after the last infection. CHAPTEE XII. SHOCK AND COLLAPSE. By Roswell Paek, M. D. Under these two terms, which are nearly interchangeable, is de- scribed a condition of reflex depression which occurs often after severe injuries or accidents, and often as the result of mental emotions from apparently trivial causes. If one is to distinguish between shock and collapse, one should reserve the former term for cases which follow injury or accident, and the latter for those cases occurring spontaneously or from mental or intrinsic causes not connected with physical violence. Shock may be of all degrees, from the most temporary faintness from which one recovers within a few moments, up to a condition of vital depression which terminates fatally, there being no reaction in spite of all efforts to produce it. Symptoms. — These at least can be referred almost solely to vaso- motor paralysis, obviously of reflex origin from the peripheral (i. e. the sensory) nerves. They consist of an expressionless face, of pallor of the skin and visible mucous membrane, with corresponding coldness of the same (7. e. reduction of surface-circulation and heat) ; of dilated pupils, reacting slowly to light ; irregularity of the heart's action, with a weak, irregular, thready, or imperceptible pulse ; irregular respiration, breathing being irregular both in rate and depth ; mental inactivity and apathy ; loss of voluntary muscle-movement ; impairment of superficial sensibility ; actual reduction of body-temperature ; occasionally nausea or actual vomiting. These at least constitute the symptoms in the majority of cases, and form what may called the apathetic or torpid type of shock. Again, we may have shock of the so-called erethistic type (Travers), in which patients are restless and excited, uncontrollable, and yet with irregular pulse and breathing, often with dilated pupils. Finally, we have a third type, described by Travers as the delayed, in which the symptoms are as above detailed, but come on only some hours after that which has produced them, but which may be only an expression of con- cealed (internal) hemorrhage. The delayed type is often seen in those who escape serious accident with a minimum of physical harm. As shock becomes more pronounced, mental depression deepens into coma, or mental excitement subsides into it ; the surface becomes colder and bathed with perspiration ; and death follows. These symptoms are those generally noted, whether following injury to the head and denot- ing so-called concussion of the brain, or loss of blood, or wound of the abdomen with injury to the viscera, blows upon the testicles, gunshot 185 186 SURGICAL DISEASES. wounds, or other accidents which are notorious causes of shock. They follow also after perforation of the bowel, as in typhoid fever or appen- dicitis, or fatal cases of empyema, or the depression following the receipt of bad news, or fright, etc. ; in other words, the physical condition is practically the same no matter what the exciting cause. Diagnosis. — Shock has practically only to be diagnosed from fat- embolism, or possibly from a general and more or less permanent condi- tion of physical depression. From the latter it is usually easily disso- ciated ; differentiation from the former is not always easy, and it is unquestionable that many patients have died of fat-embolism in whom the actual cause of death has not been appreciated, yet has been ascribed to shock. (See Fat-embolism, Chapter II.) ,' .- ''■ \ Shock is sometimes scarcely to be distinguished from other conse- quences of exhaustive hemorrhage, such as acute reduction of the normal amount of haemoglobin, save by careful estimation of the latter. ( Vide Chapter II.) Treatment. — The treatment of shock consists in those measures by which reaction may be safely brought about. At the very outset one must bear in mind two or three cautions that may not safely be neg- lected. One is, that it is injudicious to establish reaction too quickly, lest it be succeeded by over-action with attendant disasters in the shape of secondary hemorrhages, etc. Another is, that, volition being so largely destroyed, these patients cannot swallow nor act as they would under other circumstances. It is a mistake, then, to expect a patient suffering from shock to drink strong liquors, for instance, as would one when not so suffering, since a little of the irritating fluid may escape into the larynx and set up a violent coughing-fit which, of itself, might prove fatal. The same is true of inhalations of strong volatile stimu- lants, like ammonia, etc. These measures, therefore, should all be resorted to with care and discretion. Cerebral ancemia is evidently a part of the condition of shock, and should therefore be combated by a dependent position of the head. Hence the patient should be laid flat, or even with the head lower than the rest of the body — /. e. the feet and extremities raised. It is a good plan occasionally to bandage the extrem- ities from their tips toward the body, in order that the blood which they would naturally contain may be pressed into needed service in the vital organs. Should, however, cyanosis be noticed, it may be held that the depression of the head is being overdone. Warm stimulating drinks, if they can be swallowed, are always of avail ; and whiskey, brandv, etc. should be given dilute and warm rather than strong and cold. External heat is evidently indicated, and in many cases can be well applied by immersing the patient in a bath-tub of warm water, taking pains only to keep the face out of water. When this be not at hand, bottles and other receptacles for warm water may be applied about the patient, care being exercised not to burn him. Enthusiastic application of too much heat under these circumstances has often been the cause of serious burns with great resulting discomfort. Artificial respiration may be resorted to, or the diaphragm may be stimulated to activity by the Faradic current, applied with one pole over the phrenic nerve, the other over the dia- phragm. When the stomach does not retain, or when the patient cannot swallow stimulating drinks, almost as much benefit can be gained by SHOCK AND COLLAPSE. 187 resorting to enemata of hot black coffee with brandy, with ammonium carbonate, etc. Nitrite of amyl will frequently bring a flush to the face, and will relieve vasomotor spasm of the cerebral capillaries and of the body surface, thus helping to equalize the circulation. It will be found sometimes of great value. The principal remedies by which to stimulate the activity of the heart are strychnia and tincture of digitalis, both of which should be administered subcutaneously and in comparatively large doses. A flagging respiration may also be stimulated and sustained by atropia, given in the same way. Under these circumstances, when these drugs are called for, it would be well to give in one hypodermic injec- tion 1 c.c. of tincture of digitalis with -^ of a grain of strychnia and Y^-jj- of a grain of atropia. This may be repeated in half an hour or an hour if necessary, while the digitalis alone may perhaps be given at more frequent intervals. The erethistic or extremely restless type of shock may always be profitably treated by small, at all events sufficient, doses of opium, pref- erably by morphia, -|- to ^ grain subcutaneously, and repeated p. r. n. Such a case as this requires most careful and constant watching and judicious stimulation, in order that one may stop abruptly when reaction becomes too marked or comes on too suddenly. When shock is due, in large measure at least, to loss of blood, either by acci- dent or operation, the infusion of a saline solution, consisting of sterilized water 1000, ammonium carbonate 1, common salt 6, may be practised, this fluid being slowly introduced through a hollow needle into one of the superficial veins where- ever it may be most easily reached. It should not be introduced rapidly, but maybe employed very gradually to the extent of 500, 1000, or possibly even 2000, c. c. of this fluid. It serves to equalize the circulation and to give to the endocar- dium the stimulus which it must get from a certain volume of fluid of normal specific gravity in order to excite cardiac motions. A fluid thus prepared and used is probably just as efficacious as blood or milk, is much more easily obtained, and serves in every respect as well. Finally, the question of immediate operation has often to be most carefully considered. There can be no question but that shock is often alleviated by prompt removal of mutilated limbs or parts whose frag- ments, when still connected with the trunk, seem rather to perpetuate the condition. So, too, prompt surgical attention to severe compound fractures, as of the skull or of the limbs when bone-ends are much dis- placed or are projecting, seems to be a most important measure and an essential part of the treatment of shock. CHAPTER XIII. SCURVY AND RICKETS. By Roswell Pakk, M. D. Scurvy. Scurvy is an affection by general consent placed among the so- called surgical diseases, manifesting, at all events, many distinctly sur- gical features and possibly of parasitic character, although this feature of its existence has not as yet been incontrovertibly established. It is in large degree a starvation disease, its principal characteristic being that of mal-assimilation, accompanied by more or less profound amentia. It has certain points of resemblance to that condition of multiple neuritis met with in warm climates and known usually as beri-beri. The former is apparently due to the absence of a vegetable regimen, while beriberi is largely due to the absence of an animal regimen, nature hav- ing intended that man's diet should be mixed, and having ordained that suffering and disease practically always follow confinement to one or the other. Pathology. — The pathology of scurvy is very obscure. The con- dition is certainly dependent upon chemical alterations in the blood, without, however, morphological changes which are distinct or pathog- nomonic. The ease with which hemorrhagic effusions occur, the degeneration of muscles and other tissues, the frequent detachment of cartilages, can, in a general way, be accounted for by conditions thus summarized ; for which, however, we have no minute explanation. Moreover, scurvy may so complicate various other diseases, and usually does when occurring in large bodies of men — as in armies, prisons, among convicts, etc. — that it is hard to dissociate morbid phenomena and assign to each its proper place. Symptoms. — The disease begins by a condition of more or less generalized prostration, with an icteric tint of the skin, malaise, mental torpor, loss of appetite, insomnia, etc. The first recognizable or dis- tinctive local appearances occur about the margins of the gums. Here, in the intervals between the teeth, the gums become livid, friable, and bleed easily, while the breath assumes a characteristic fetid odor. These appearances are followed by local pains, diversified and sometimes ex- cessive, and extravasations of blood in the skin and under the visible mucous membranes, causing small ecchymoses, which by themselves would be considered as simple purpura hsemorrhagica. These pass through the usual phases of extravasations, while it is made evident by pain, nodular masses, etc. and by post-mortem examination that similar hemorrhages occur in the deeper tissues, especially in the muscles, even in the bones and epiphyses. So easily, in advanced stages, do hemor- 188 SCURVY AND RICKETS. 189 rhages occur that there is often external bleeding, particularly from the gums and mucous membranes, while from points thus involved pyogenic infection may proceed internally ; and at last one sees a picture of, as it were, an animated corpse, with surface discolored and mottled, often appearing terribly bruised, with ulcerations where extravasations have failed to resolve, and where infection has occurred, possibly with epiph- yses loosened, and, if time permit, necrosis of bones of the extremities. In such cases death results from marasmus and sepsis. Tbeatment. — So long as the patient be not in the desperate condi- tion last described the prognosis and promise of treatment is very good, since all the milder manifestations of scurvy can be completely dis- sipated by suitable feeding and medication. Loss of teeth and cica- trices of ulcers, of course, leave permanent traces, but function can be completely restored. So far as the purpura is concerned, it is simply one expression of the scorbutic condition. Nearly all cases of scurvy will present purpuric manifestations, but by no means all cases of pur- pura are necessarily scorbutic. The canons of treatment may be summed up in proper diet and in the administration of certain drugs. Proper diet should be issued at once, but administered, especially in severe cases, with extreme caution. The food selected should be given in small quantities, but frequently. It will consist in large measure of fresh fruits and vegetables, while cranberries and lime-juice figure largely among the former. Buttermilk is excellent, and cider may be allowed ; lemonade is also highly commended if it contain not too much sugar. For the local condition in the mouth an antiseptic mouth-wash con- taining a fair proportion of hydrogen dioxide is most advisable. Alco- holic stimulants are called for, at least up to a certain point. Strychnia and cinchona preparations will give force to the heart's action and the horizontal position, for a time at least, will prevent sudden heart- failure. The compound syrup of hypophosphites, with the newer meat preparations, will supply lacking material, while the hemorrhagic mani- festations are best controlled by the fluid extract of ergot and aromatic sulphuric acid, separately or combined. Of the importance of fresh air, cleanliness, etc. one need scarcely speak in this place. Rickets. Rickets, or rachitis, is another of the diathetic conditions, in this instance not yet considered of parasitic origin, met with most commonly in infancy and early childhood, although its resulting lesions may per- sist throughout life. It is characterized by nutritional disturbances and organic irregularities. Pathology. — Rickets is spoken of as " foetal " or " congenital " according to whether the infant presents characteristic markings at birth or whether they develop later. So far as one can see, the most marked constitutional defect is in the supply of calcium salt, which leads appa- rently to formation of bone which has not enough of compact tissue to make it strong. Especially along the line of junction between bone and cartilage do we see the most marked expressions of rachitic lesions. Here the cartilage is evidently actively growing, while the bone-forma- 190 SURGICAL DISEASES. tion proceeds with difficulty, and the proportion of vascular tissue is excessive. The result is prolongations of soft vascular into the carti- laginous tissue, by which the latter becomes more or less absorbed and ossification is essentially interfered with. In fact, in severe cases it may be entirely lacking. In consequence, at epiphyseal lines one may have a layer of osteoid tissue which is not cartilage and will not become bone Because of its yielding nature, then, it warps under the mechanical strain to which the bones of the extremities in young children are con- stantly subjected. The osseous lesions of rickets differ from those seen in osteomalacia in that in the latter the softened tissue is practically decalcified bone, while in the former case most of the affected tissue has never got so far as genuine bone-formation, but is arrested in its perverted state. The result of rickety changes in the skeleton is a thickening of the shafts of long bones, of the outer table of flat ones, of the epiphyseal extremities of shafts and frequently a stunting of their development, so that they do not attain their normal length. The periosteum, having much to do with the development of bone, is also affected in rickets, with the result that when the changes occur, mostly subperiosteal^, we get warpings and curvings of the bone-shafts, while so long as the dis- turbance is epiphyseal more or less abrupt curvatures and angular deformities will be produced as the result of muscle-action. So marked are the changes in some instances that it has been stated that bones may even lose three-fourths of the calcium salts which they ought to con- tain. When, as is the case, rachitic bones are so soft as to be easily cut with a knife, it is not strange that marked deformities occur as the result of muscular activity. (Vide Plate X.) Thus, in the extremities we get bow-legs, knock-knees, clubbing of the ends of the long bones, bending of the neck of the femur, flat-foot, club-foot, etc. ; while the clubbing of the bone-ends may be also well marked in the bones of the upper extremity, where, however, marked deformity is less common, because the upper extremity does not bear the weight of the growing body. In the skull the bones remain soft and yielding to pressure, with a tendency to return to their original membranous condition, and this is the condition comprised under the term cranio- tabes rachitica. The fontanelles always remain open for an undue time ; the sutures are broad and membranous. The bones of the face grow less rapidly, giving to the face a disproportionately small size; dentition is delayed and the teeth decay very easily. The upper incisors often project far over the lower. In the thorax we get enlargements of the sternal ends of the ribs, causing a row of nodules spoken of as the rachitic rosary. The ribs tend to sink in, the sternum to be protruded forward, and the deformity known as pigeon-breast becomes often pronounced. Curvatures of the spinal column, especially kyphosis, are common, and distinct degrees of lateral curvature are frequently begun as a rachitic deformity, to be magnified by perverted muscle-action as the child grows older, [n the pelvis the innominate bones approach each other, causing the pelvic cavity to become contracted, or the sacral promontory projects too far, or in various other ways the normal pelvic diameters are so far compromised that rachitic deformities of the pelvis constitute the most common and most serious obstacles to normal labor in adult women, and are the most frequent cause of major obstetric operations. While the rachitic changes in the osseous system are the most distinctive and easily recognized, numerous other organs and tissues of the body are more or less seriously compromised. Ventricular dilatation, leading to chronic hydrocephalus, is one of the common results of rachitis of the skull, which may be followed by con- vulsions and may terminate fatally. So, again, we get porencephalon and cerebral sclerosis. Disturbances of digestion are common in rickety children : the liver is sometimes decreased, sometimes much enlarged; the spleen, particularly, often PLATE X. i Congenital Pseuclo-Raehitis, showing Aplasia of Cartilage ; a, Osteo-Periosteum ; b, Quiescent Cartilage; c, Periosteum penetrating between Bone and Cartilage. (Klebs.) SCURVY AND RICKETS. 191 enlarges, and sometimes to enormous dimensions. In various other parts of the body we get the same expressions of malnutrition as are met with in tubercular disease. Rickety children perspire easily, particularly at night, when the head will often be found bathed in perspiration. They are fretful and irritable as a rule, and difficult to control. A child with protuberant belly, due to enlargement of liver and spleen, as well as to crowding up of pelvic organs, with relaxation of abdom- inal walls, with a contracted and distorted thorax, with the skull flattened on the top, with clubbed bone-ends, with a history of resting badly at night and sweating profusely, constitutes a clinical picture of rachitis so marked that it can be recognized at a glance. Between this picture in its worst forms and the slightest deviation from the ideal type one may meet with all degrees in manifesta- tions of rickets in the children of the rich or the poor, while in adults one may often see evidences of that which had obtained during early childhood. In order that all these features may be made out the children should be stripped and examined from head to foot. While rickets may be a very acute disease, it is, as a rule, chronic, and children dying essentially from this disease die rather from cerebral or other manifestations which may be regarded as in some degree acci- dental. Scurvy and other nutritive disturbances may be associated with rickets. Treatment. — The treatment for the condition consists mainly in proper nutrition. Mother's milk is certainly preferable to any other, and should be insisted upon if possible. If feeding must be artificial, it should be in accordance with the very best precepts of modern thera- peutics. Cod-liver-oil emulsions are of advantage ; compound syrup of the hypophosphites is a remedy of great virtue. Very minute doses of phosphorus seem to be of value — 1 milligramme pro die. It is a mis- take to let rickety children begin to walk, or even to creep, too early. They should be kept, so far as possible, in cribs or upon the back. The modern opotherapy of rickets includes as a most valuable adjunct the exhibition of thyroid and pituitary extracts, from which remarkable results are often seen. The dose must be graduated to the age of the patient, based on a dose of five grains for an adult, and given thrice daily. This will by no means preclude the necessity for most careful regulation of diet, etc., but will constitute a most valuable adjunct in treatment. ( Vide N. Y. Med. Jour., Dec. 12, 1896, p. 785.) The deformities due to rickets are so numerous as to constitute a large part of those to which special or orthopaedic surgery is addressed. The mechanical and operative treatment of these cases will be referred to in other and appropriate parts of this work. CHAPTER XIV. SURGICAL ASPECTS AND SEQUELAE OF OTHER INFECTIONS AND DISEASES. By Roswell Park, M. D. As the result perhaps of the conditions which, two centuries ago and more, so distinctly separated the barber-surgeons from the practitioners of medicine, there has been evolved, partly from tradition and partly from custom, an artificial and unfortunate separation of surgery from so-called internal medicine. The consequence has been a more or less deep-rooted feeling, in the minds of young practitioners especially, that medical cases were to be treated exclusively by non-operative measures, and that surgical cases could scarcely be expected to present any per- plexities that were not to be solved by an operating surgeon. It has been no small part of the benefit resulting from modern teachings that these imaginary boundaries and limitations have been swept away ; and one of the lessons which this text-book is intended to inculcate is that broad principles underlie disease conditions, and that one must appreci- ate their bearings thoroughly in order to practise either medicine or surgery successfully. In order better to inculcate this teaching I have deemed it wise to insert a chapter with the above general heading, in order to impress, so far as one may, the statement which some learn too late, that any of the co-called internal diseases may present at almost any time indications, sometimes urgent, for distinctly surgical interference. Some of the surgical sequelae of the exanthematous and continued fevers are well known and commonly recognized : for exam- ple, orchitis following mumps, suppurative inflammation of the middle ear after scarlatina, and bed-sores after typhus and typhoid. These are, of course, easily recognized, but concerning many others the text-books are singularly silent. Moreover, scarlatiniform eruptions occasionally follow various opera- tions and give rise to great perplexity. (Vide Med. News, Feb. 20, 1897, p. 234.) Dysentery. Joint-complications in this disease have been recognized from the earliest times. One hundred and fifty years ago Strack expressed him- self thus : " If the dysenteric poison affect only the chest, it causes asthma ; if the limbs, it produces arthritis ; if both, abscess." Joint- pains and swellings, with other suppurations, have been noted in several of the epidemics of this disease which have ravaged various parts of the world at different times. Post-dysenteric arthritis may assume notice- able and even pyaemic aspects, and is occasionally fatal." The bones and 192 SUROIGAL SEQUELJE. 193 joints may become involved in painful and even suppurative swellings, not alone during the active stage of the disease, but during the period of convalescence ; while mildness of the primary attack does not neces- sarily provide immunity from later complications. Here, too, as in many other instances, thrombosis of large veins or thrombo-phlebitis is also observed. When the joints are involved, it is usually in irregular order and not simultaneously. Joint-lesion does not necessarily proceed to suppuration, perhaps only to the point of oedema and fluid exudation or hydrops. Cholera. Cholera is usually too rapid and too violent in its course to be fol- lowed by secondary infections. Nevertheless, Poulet reports from Val- de-Grace several instances of articular and osseous lesions, some of these characterized by mere effusion of fluid which was sometimes very thick and resembled balsam, while at other times pus was present. Pneumonia. Pneumonia having now taken its place as a distinct germ-disease, and the micrococcus of Frankel and the capsule coccus of Friedliinder being now well established as the active agents in the two principal forms of this disease, we need not be surprised at finding collections of pus in various other parts of the body. For the most part, the surgical sequels of pneumonia occur as a post-pneumonic pyarthrosis, which in time past was also considered as a rheumatic affection. These lesions are probably of embolic or, strictly speaking, of metastatic origin. Influenza, or Grippe. Within the past few years this disease has assumed great prominence in medical literature, and not a few instances have been reported of surgical sequela? — abscesses, purulent ear disease, pyarthrosis, bone- lesions, etc. Even necrosis has been repeatedly observed. Measles and Scarlatina. The frequency with which these exanthems are followed by surgical complications has been noted by many authors. Inasmuch as the infec- tious agent is not yet recognized, we must probably consider their sur- gical sequelse as due to secondary pyogenic infections, which are relatively very common. Remembering what has already been said upon the principal ports of entry for disease-germs, in connection with the notable lesions of the mucous membranes and the lymphadenoid tissue of the nasopharynx which are characteristic of these two diseases, it will be readily appreciated how pyogenic organisms may secure an entrance permitting their distribution to various parts of the body, while the lowered resistance of these patients permits the pernicious activity of these germs to make itself felt when otherwise it would not be. It is notorious that surgical tuberculosis appears often as a sequel of the exanthemata, and it is in no degree straining after effect when one explains the entrance of these germs in the way above described. Consequently, in the lymphatics, in the periosteum, bones, and joint- cavities especiallv, and iii and about the eye and ear, we very frequently find mani- festations of suppurative disease. It is generally believed that these sequelse are 13 194 SURGICAL DISEASES. more likely to appear when the eruption has been incomplete. The fact that hyperplastic thickening of periosteum and neuralgic pains of the affected parts are often met with without suppuration has given, in time past, some reason for the rheumatic character which Bonnet and others have ascribed to these manifestations. While the absence of pus takes these out of the category of pyogenic infections, it nevertheless leaves them still as surgical complications which have often to be dealt with by mechanical measures, such as orthopaedic apparatus, etc. ; while too frequently more or less formidable operations, as for relief of ankylosis, etc., have to be performed. Post- scarlatinal arthralgia may be explained as a local ischsemia ; so may acute swelling or chronic thickening. But pus is always an expression of infection, and cannot be otherwise regarded. Retropharyngeal abscesses and a peculiar necrosis of the alveolar process of the jaws, particularly described by Salter, are among the various serious surgical complications of scarlatina. Epiphyseal separations and purulent destruction of ribs have also been noted. Typhoid. Although in elaborate treatises, as by Liebermeister and Murchison, bone- and joint-complications find no mention as sequels of typhoid, they have nevertheless long been recognized by surgeons. Post-typhoid hip-dislocations have been reported by several German surgeons. Boyer observed spontaneous dislocation of both thighs after what he called " essential fever," and the general topic of spontaneous luxations sub- sequent to typhoid has been seriously discussed by the German Congress of Surgeons. Those affections of joints which used to be considered rheumatic occur much less often after typhoid than after dysentery. Nevertheless, post-typhoidal arthral- gia and myodynia have been recognized by several French writers. Probably not a few times patients with affected joints, supposed to be rheumatic, have later been discovered to be suffering from genuine typhoid fever, and it has been after- ward recognized that the joint-lesion was merely a bizarre expression of the typhoid poisoning. The works on general practice call attention to the frequent complications of the pleural and pericardial serous membranes in this disease. They say little, however, about the implications of the articular serous membranes though one is as easy to explain as the other. Post-typhoidal polyarticular serous arthritis has been described by more than one writer. Multiple joint- abscesses have been more rarely seen. Pus has also been known to collect, not only in the joints, but in the tendon-sheaths and bursa?. The lymph-nodes are also frequently affected, and cervical, axillary, and inguinal abscesses are not rare. Post-typhoidal pyarthrosis, as leading to spontaneous luxation, has had even a medico-legal interest, since luxation has been known to occur while raising or lifting a patient the question of violence being subsequently brought into court. When the joint disease assumes the monoarticular form it is likely to terminate in suppuration • when polyarticular, pyarthrosis is much less common. In the pus from many of these abscesses typhoid bacilli may be recognized, but by no means in all. I have found them in a case of abscess in the abdominal wall occurring during con- valescence from typhoid in a young woman. A non-suppurative but extremely painful form of periostitis is occasionally met with ; and I never have seen more exquisite tenderness nor expressions of greater suffering than I met with in a case of this kind in a young lad in whom the bones of both lower extremities of the pelvis, and the lower spine were all involved. The slightest jar upon the floor called out a cry of pam, and to minister to his ordinary wants was a most distress- ing task. He eventually recovered without any pus-formation. Deep suppura- tions in bone are less often met with, but occasionally occur ; even necrosis with separation of sequestra has been noted. SURGICAL SEQUELS. 195 Thrombosis and thrombo-phlebitis are also well-known sequels of typhoid, which may lead to most unpleasant complications. Typhoid fever appears to bear a peculiar relation to the growth of bones, since it has been noticed that during its course, or during convalescence, they show an extraordinarily rapid growth in length, even to the extent of 1 mm. a day. This is probably caused by the irritation of the typhoid toxine upon the osteogenic tissue, since hypersemic areas have, by numer- ous observers, been found in the bone-marrow of those dying of the disease, and bone-pains are a frequent accompaniment of the disease. Typhoid bacilli have the power of remaining latent in the tissues for considerable lengths of time after cessation of all active symptoms, and they have been found alive and capable of active growth so long as seven months after cessation of the fever. Remembering the multiple ulcers of the lymphoid tissue which characterize the intestinal lesions of typhoid, one will not find it hard to explain pyogenic or other septic infection by absorption through these open ports of entry ; and the typhoid bacilli themselves, entering the circulation through these paths, may be carried to all parts of the body, and have been found in the pia — in fact, everywhere. Diphtheria. This also belongs to the diseases frequently complicated by lesions, aside from those of laryngeal obstruction, calling for surgical relief. Abscess occurs so frequently as to scarcely call for comment. Here, as in the cases of scarlatina, the location of the throat-lesions and the absorbing powers of the lymphadenoid tissue so completely involved will readily account for all septic or pyogenic manifestations at a dis- tance. Multiple abscesses have been found, for instance, in the liver, the spleen, and lungs, in and around the bones — everywhere, in fact, where abscesses can form — betokening thereby a pysemic manifestation. Infectious nephritis is also common. Mann, of Denver, has communicated to me personally, since the first edition of this work, cases of embolus of the femoral artery with result- ing gangrene, as sequels of diphtheria, as well as instances of true diph- theria of the penis, established by bacteriological diagnosis. Mumps. The infectious character of this disease is not questioned to-day, although not definitely established. Orchitis, ovaritis, stomatitis, enlargement of the tonsils and spleen, and albuminuria are frequent accompaniments of the disease, while articular and periarticular compli- cations have been noted by several writers. Bursal abscesses and pyar- throses have also been reported. In time past these surgical complica- tions have been spoken of as rheumatoid or rheumatic, their essential significance not being recognized until comparatively recently. Variola. The writers of the earlier part of this century allude frequently to the rheumatoid complications of smallpox, among which pyarthrosis 196 SURGICAL DISEASES. seemed perhaps the most common, as certainly the most serious. The various arthropathies are the most interesting of the surgical complica- tions of this disease. That joints become swollen, red, and painful is not infrequently noted, and that one joint after another is involved is also the usual programme. Infectious Endocarditis. The individuality of this condition has been recognized only within the last thirty years, and accurately only within ten. That it deserves the characterization of " malignant " often given to it is well known. It is, in fact, an infectious disease with a special localization in the heart, the term cardiac typhus, given to it by some, being very expressive. Although so apparently spontaneous, it is itself, in fact, usually a sec- ondary lesion, perhaps sometimes a primary infection. When we con- sider the peculiar location of the disease, we shall have no difficulty in appreciating the readiness with which metastatic complications may arise. The arthritic manifestations, too, often assume a pysemic cha- racter, and even at the beginning of the affection, as Trousseau pointed out, there are frequently severe joint-pains. Dental Caries. Nearly one hundred species of micro-organisms from the mouth have been studied and identified by W. D. Miller, who has clearlv established that dental caries is due to the specific action of some of these parasites, which, gaining entrance into the dental tubules, deter- mine fermentation and acid-production, with erosion of the dental struc- ture of the teeth and an increase in softening and destruction. In this way the teeth, as already indicated in Chapter III., become wide-open paths of infection for germs which may travel but a short distance, causing only local disturbance, or which may be carried to other points about the head, producing disturbance in the antrum, in the neighboring bones, in the middle ear, and not infrequently in the brain. Abscess in the brain has been distinctly traced to caries of the teeth. Tubercular in- fection is also common through this channel, and its most common ex- pression is probably the invasion of the cervical lymphatics, superficial and deep, constituting those lymphatic tumors of the neck formerly known as scrofulous, with their disastrous train of adhesions, suppura- tion, erosion, etc. Syphilis and G-onorrhcea. These are surgical affections whose secondary complications in the way of abscesses, infarcts, tumors, etc. will be dealt with in other parts of this work. It will simply be well to group all of these infections— those just mentioned— along with anthrax, glanders, etc. into a class of infections which may be followed by tardy or verv late surgical sequela? which may call for more or less radical operation". In the case of gon- orrhoea this is seen best, perhaps, in the so-called pm-tubea of the female pelvis, which often call for operations years after the date of the pri- mary invasion. SURGICAL SEQUELS. 197 The Puerperal State. This is seldom followed by surgical sequelae, save in the instance of mechanical lacerations demanding plastic repair, or of septic infections, which, when life is saved, sometimes lead to disastrous, though remote, consequences. Puerperal septicaemia is in no respect different, path- ologically speaking, from septicaemia due to any other presumably strep- tococcus invasion ; and the predilection which streptococci manifest for serous membranes, and especially joints, is well known. Consequently, after puerperal fever one may meet with articular or periarticular ab- scesses, affections of tendon-sheaths, lymphatics, etc., or the complica- tion may assume a different type, the veins and their contents being mainly involved, with thrombosis, infarct, etc. for its immediate results. The possible outcome of these various lesions will be appreciated if one simply reflect upon the known course of the blood and bear in mind the facts stated in Chapter II. As stated at the outset, it was intended to make this chapter sug- gestive rather than complete. In summarizing it would be well, there- fore, to say that there is probably no disease of known or suspected germ-origin which may not be followed by disastrous or unexpected surgical complications, while even those degenerative changes for which as yet no theory of parasitism has been invoked are followed by con- ditions, often painful in the extreme and crippling, which may call for most serious surgical measures. In other words, the surgical complica- tions of any so-called non-surgical disease may loom up at any moment in any case, and may even tax to the utmost the resources of a surgeon, who should be promptly summoned in the unwillingness of the general practi- tioner to act as such. Surgical sequelae are always unfortunate, but are always most so when unfortunate delay in their recognition or in sum- moning special help has been permitted to occur. CHAPTER XV. POISONING BY ANIMALS AND PLANTS. By Roswell Park, M. D. Certain poisons or deleterious substances are introduced in various ways into the human system from without, some of which produce only symptoms of moderate intensity, while others are quickly fatal. Thus, it is authentically stated that in India many thousands of individuals lose their lives every year as the result of the bites of poisonous snakes. Nothing approaching such injuries in frequency or intensity can be found in any other part of the world. Animal poisons may be introduced by animals of many species. The poison of hydrophobia has been already sufficiently described. The bites of the mammalia may be serious and may be followed by septic symptoms, but they are not regarded as due to any special toxine secreted by the animal. A number of reptiles, how- ever, possess special poison-glands which, for the most part, are con- nected with a tooth on either side of the upper jaw which is canal- iculated and serves as a duct through which the poison is injected when the animal inflicts its bite. The principal poisonous serpents in North America are the rattlesnakes — of which there are several species, usually placed at eighteen — the copperheads, the moccasins and the vipers. Some of these have movable poison-fangs, some fixed. In other parts of the world others equally or even more poisonous are known. The poison-gland is analogous to the parotid in location and structure. The duct which runs through it is so dilated as to contain a small amount of the pecu- liar poison. The amount of poison contained in these reservoirs varies from eight to twelve minims, and is secreted somewhat slowly. It seems to be, in some cases at least, a glucoside ; in others, a toxalbumen. It is capable of being preserved either dry or in alcohol or glycerin. The active poisonous principle seems to per- tain to a globulin, or to a peptone. Almost all of these venoms are innocuous if swallowed, and like septic infections seem inoculable only through the tissues and the circulating fluids. According to Mitchell, the venom of the rattlesnake renders the blood incoagulable, paralyzes the walls of the capillaries, and facili- tates escape of leucocytes into the tissues, thus making actual hemorrhagic swelling occur easily ; while the red corpuscles rapidly lose shape and fuse together into irregular masses and their hemoglobin is dissolved or disappears. This poison seems to paralyze both the respiratory centre and the heart. Cobra-poison, not containing globulin, at least to such extent, does not produce the rapid changes of rattlesnake poison. Symptoms. — A snake-bite is like a hypodermic injection of a deadly poison, and symptoms set in usually very promptly. These are both local and general. There is more or less local pain, with swelling and discoloration, these being due to effusion of blood. They increase in intensity, and are followed by vesication and necrosis of tissues — i. e. gangrene — if the patient survive long enough. Constitutional symp- 198 POISONING BY ANIMALS AND PLANTS. 199 toms are not long delayed, and are characterized by severe prostration, including cold, clammy sweat, feeble and rapid pulse, irregular respira- tion, etc. When patients die, they die usually in collapse. The patho- logical changes are not sufficiently well marked or characteristic to detain us here. Treatment. — Treatment of snake-bite must be most prompt if it is to be successful. It should consist of the promptest possible incision and drainage of blood from the part, with application of a tight ligature or tourniquet above the bite, in order to prevent diffusion into the rest of the body by means of the returning blood and lymph. Bleeding should be facilitated by cups or by sucking of the wound. If there be any known antidote to snake-poison, it consists of potassium perman- ganate or calcium hypochlorite (chloride of lime), which may be applied locally in solutions, the former strong enough to have a very marked color and capable of producing local irritation (1 per cent.). Along with these local measures, constitutional stimulation should be most active by means of both volatile and other stimulants. There is a popular fallacy in favor of inducing alcoholic intoxication. To do this is undoubtedly a mistake. Nevertheless, alcohol may be given freely, dosage being limited not by amount, but by effect. Strychnia, digitalis, atropia, etc. will often prove serviceable. The tourniquet should be after two or three hours very gradually released, while one should be ready to antidote the poison which may thus enter the system with the necessary doses of stimulants above mentioned. Even so much strychnia as half a grain may be administered in divided doses with happy effect, it being apparently, in large measure, a true antidote to the snake-venom. There is much reason from recent experimentation to expect benefit from a serum-therapy — i. e. by injection of serum from immunized animals who have been fortified by increasing doses of the snake-poison. In this country such treatment, however, will be called for so seldom that there is not the hopeful outlook for the serum-therapy of snake-bite that there is in India. A large lizard found in the southwestern part of this country and in Northern Mexico, known as the Gila monster (Heloderma suspectum), is generally credited with being a poisonous animal. The probability is that the bite is fatal to some of the lower animals and may produce more or less serious disturbance in man. Nevertheless, there is little real evidence that this is to be considered in the same category with the venomous serpents above mentioned. Certain species of spiders are venomous, the tarantula being the best known. Certain scorpions also inflict poisonous stings, and centi- pedes and other animals occasion at least serious local disturbance by bites or stings. These insects and animals seldom attack unless irritated or disturbed. Tarantula-bites are occasionally inflicted in the Northern States by spiders which have concealed themselves in shipments of fruit, bunches of bananas being especially likely to be their hiding-places. The injuries inflicted by these animal organisms cause local pain, con- siderable swelling, with remote effects on the nervous system, prostra- tion, restlessness, etc. They are seldom fatal, but may cause exceeding great annoyance and even serious disturbance. These cases are to be treated in the same way as bites of poisonous serpents, adapting the 200 SURGICAL DISEASES. measures and the energy of the treatment to the severity of the symp- toms. Wasps, hornets, and bees are capable of inflicting severe stings, while smaller and more domestic insects, like mosquitoes, bedbugs, etc., inflict minute injuries, which, nevertheless, sometimes occasion excessive annoyance. Their sting is followed by pain, burning sensation,_ some- times intense itching, and more or less swelling. Enough poison is deposited to produce local vasomotor paralysis, as the result of which wheals resembling those of urticaria, or more extensive swellings, quickly result. If the sting of an insect has been broken off in ridding one's self of it, it may remain and intensify the disturbance. Two or three injuries of this kind create at most local disturbance, but there are numerous instances on record where men and animals have been stung to death when attacked by swarms of these little enemies of our race, death apparently being due to intensification of effect owing to increased dosage of poison. If a sting occur upon loose tissues, like the eyelid, or upon the tongue or lips, swelling and suffering may be extreme. If symptoms of depression present, they must be combated by stimulants, diffusible or other, and by hypodermic medication pro re nata. Local discomfort may be alleviated by ice, by menthol, by chloral-camphor, etc. 1 The arrow-poison of various Indian and savage tribes is a compo- sition of very variable and usually unknown nature. It is compounded, for the most part, from vegetable substances, and, if one may judge from the specimens of curare sold by importing houses, their strength must be most unreliable. While some of these preparations are made by the natives from species of Strychnos growing in the northern part of South America, this tree certainly is not in universal use for this purpose : in the East Indies they are made from a species of Upas (the deadly Upas of song and story). Some of the poisoned arrows of certain tribes are dipped in putrefying blood. A wound made by these is not necessarily promptly fatal, but would tend to kill by setting up septic disturbance. The vegetable poisons have, for the most part, the property of paralyzing the motor nerves and the circulation, to such an extent even that death may occur within a few moments after injury. All of these poisons are innocuous when swallowed, and game killed by their agency may be eaten with impunity. Arrow- poison of the vegetable variety which is not fatal within a few hours may be recovered from if only stimulation be vigorous enough. Artificial respiration is a factor of very great importance in keeping such patients alive. Many of the lower forms of marine animal* are capable of inflicting stings by their rays, or minute injuries in other ways, which give rise to great temporary annoyance. The stinging nettle, etc. are instances of this kind. The lesions produced in this way partake of the nature of a more or less acute dermatitis. In the vegetable kingdom there is one species of plant which is capable in certain instances of [producing the most intense dermatitis. I refer here to the so-called poison-ivy (Rhus toxicodendron, etc.). Not all individuals are susceptible to this poison — least so those of thick skin and dark hair. It is rather those of blond type and thin skin who seem most liable to its irritation. 1 Oil of lavender is a pleasant means of local protection against mosquitoes, etc. Oil of tar is also in common use. A mixture of equal parts of camphor and chloral, with menthol dissolved in the mixture (camphor and chloral when mixed without other ingredients quickly form a dense fluid like glycerin), gives great local relief from the itching and pain of insect -bites. POISONING BY ANIMALS AND PLANTS. 201 The active agent is toxicodendric acid, and it is capable of setting up the most intense irritation of the eczematous type, with a large amount of hyperemia and oedema, especially of soft tissues. Thus, when the face is involved the eyelids become so puffed as to make it almost impossible to separate them for purposes of vision. Ivy-poisoning comes practically always from contact with the plant, which grows in various parts of the country, and with which one may come in contact in most unexpected places. Symptoms supervene usually within twenty-four hours, probably much less, and in well-marked cases do not subside for three or four days. The itching is almost intolerable, and is best combated by strong alkaline solutions or brine. A very dilute bromine solution is also of very great benefit, but is not always ready at hand in instances of ivy-poisoning in the woods. Salt and soda, however, are nearly always at hand, and can be used with great relief in pretty strong solutions. Vigorous catharsis will also help, and hypodermic injections may be necessary for the enjoyment of sleep. Certain other species of sumach will also produce similar symptoms, usually- less severe, in a comparatively small proportion of susceptible individuals. This is true in milder degree of certain species of the genus Cypripedium. CHAPTER XVI. ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. By Roswell Park, M. D. Delirium tremens as an expression of acute or subacute alcoholic poisoning is in no essential degree a surgical condition. Nevertheless, it so notably and often so disastrously complicates surgical cases that it is necessary to take it into account in this place. This form of toxic delirium may occur while the individual is still drinking hard, or not until several days have elapsed after active drinking has ceased. It is precipitated in many cases, where otherwise it would simply remain imminent, by surgical injuries and operations. In an individual in whom it is feared, we should become apprehensive in proportion as the muscu- lar system becomes unsteady and tremulous, the mind disturbed, and the individual sleepless. Patients in a well-marked condition of delirium tremens become often so uncontrollable and so lost to sensation of pain that it raav be practically impossible to enforce the physiological rest which their sur- gical condition demands. The restraining sheet will answer for general purposes, but the strait-jacket, and even the most carefully applied plaster splint or mechanical restraint, will not always be sufficient to carry out the indication. Ingenuity may be taxed beyond its limit to enforce the needed rest, for patients will tear off bandages and injure themselves in various ways. Treatment. — The local indications,, as just expressed, are in the direction of physiological rest if it can possibly be enforced. Constitu- tionally, the indications are in two directions : First, to keep up nutrition and excretion; secondly, to properly medicate. Nutrition is difficult unless excretion be maintained. Hot-air baths, laxative enemata, pref- erably of cold water, when necessary, and administration of a fluid and easily assimilable diet are measures of the utmost importance. Should the case present features of an acute alcoholic gastritis, stomach-feeding may be altogether abandoned and the rectum utilized for this purpose. Medication must consist mostly of stimulants, with such sedatives, laxa- tives, diuretics, etc. as may be necessary. Whatever may be the general wisdom of the course, it is probable that in surgical cases it is not wise to abruptly deprive these patients of the alcohol which they have so abused. Consequently, it is well in many instances to continue a mild degree of alcoholic stimulation, at least for a time, letting them down, as it were, by the easiest possible stages. Two stimulants rank higher than all others put together as substitutes for alcohol, and in some degree antidotes to its effect. These are strychnia and digitalis. The former should be given preferably subcutaneously ; the latter by the 202 ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. 203 stomach if tolerated ; otherwise, by the rectum or beneath the skin. My own preference for the use of digitalis is in the direction of large and few doses. I have not hesitated in many instances to give 1 5 c.c. of ordinary tincture, repeated once or twice at intervals of a few hours, and then to discontinue it. The effect is both to brace up the heart and to equalize the circulation, while at the same time it acts as a most efficient diuretic ; and I never have had occasion to regret such doses ; on the other hand, I have often seen them do great good. Of the sedatives, bromides, chloral, and remedies of that class are those most often resorted to, and must be given in doses sufficient to meet the indication. One should remember, however, that they are all more or less depressant, and that stimulation by strychnia, etc. is necessary even while they are being administered, in spite of the apparent physiological antagonism between them. Occasionally nothing will take the place of opium, best given in the shape of morphia intro- duced beneath the skin. Whatever may be one's tastes or preferences for drugs under ordinary circumstances, he can but feel that in serious surgical cases com- plicated by delirium tremens the first indication is toward the surgical lesion, and preferences, past methods, etc. must all be secondary to enforcing such quietude as shall permit repair of injury. The first indication, then, in most of these instances is in the direction of ensuring rest and sleep, even at the expense of inconvenience or misfortune in other directions. I write this with a full realizing sense of its significance, yet with positive conviction as to its truth. Traumatic or Post-operative Mania. This it would be difficult to distinguish from a form of mania uni- versally recognized and known as puerperal mania, the two conditions being, I take it, essentially similar. Regarding these cases from a surgeon's standpoint, and carefully avoiding any attempt at minute explanation of the phenomena, I would only say that such cases are met with in the practice of operating surgeons, as in the experience of obstetricians, presenting themselves either as mild forms of harmless mental aberration, or assuming almost any of the types of insanity as made out and classified by experts in that subject. From the mildest mental alienation, then, up to furious and even homicidal or suicidal mania, one may meet with all degrees of departure from the normal standard. Toxic Antiseptics. As stated above, it is generally recognized that in people perhaps of peculiar idiosyncrasies the administration of certain drugs ordinarily considered harmless is followed by more or less toxic symptoms. Obviously, if this were universally the case, or even in the majority of instances, the use of these drugs would speedily be abandoned. As it is, it is well to at least have in mind the consequences which are occasionally known to ensue, and perhaps to weigh in every case the chances as to whether it be worth while to use a given substance of known occasional toxic power as against another which is not known to possess it. Of the less active antiseptic agents, there is, for example, boric acid, ordinarily considered absolutely innocuous, yet which is known rarely to cause intestinal disturbance, while in at least one instance serious toxic effects followed its use. Naphthalin also, ordinarily considered 204 SURGICAL DISEASES. as harmless, will sometimes produce vertigo or vasomotor symptoms, especially when administered internally. So many of the antiseptic materials used are more or less irritating to the skin that such local ex- pressions as eczema, etc. provoke very little comment except on the part of the patients, whose comfort is sometimes temporarily very much dis- turbed by their action. Yet, inasmuch as it is the patients' welfare which we ordinarily seek, we must remember that the drug-eczema produced by corrosive sublimate, much more rarely by other antiseptics, which may so disturb a patient as to prevent sleep and make him irritable and particularly restless, is undoing very much of the good which we have sought to do him, because it is interfering with one of the first essentials of ideal wound-healing — ■/. e, physiological rest. Iodine, by itself or in certain combinations, is a drug whose activity should never be forgotten. Applied upon the surface, it ordinarily tans the skin, and, aside from being objectionable, does no good. Injected in solutions of varying strength, as it has been in times past more than at present, into serous cavities (for example, hydroceles, etc.), it occasionally gives rise to symptoms which may even be alarming. Fatal poisoning following its injection into an ovarian cyst has been reported, and I have seen alarming symptoms produced by injection of the ordinary solution into a hydrocele sac. Much of the virtue or- dinarily ascribed to iodoform is supposititiously credited to the libera- tion of free iodine by its decomposition. Whether or not this be true, it is certain that iodoform is one of the most frequently toxic of the antiseptic agents in ordinary use. In mild cases it produces headache, restlessness, wakefulness, and often a distinct taste of iodoform in the mouth. In more pronounced degrees of poisoning there is fever, with often mental derangement which may amount to delirium or even to acute mania, and may cause well-founded suspicion of meningitis. Death has repeatedly occurred, from syncope or in coma, after its use. Carbolic acid produces unpleasant effects, both upon patient and operator, or with whomsoever it may come in contact. Aside from its local effect upon the skin, which is most unpleasant, but which usually passes away within a few hours, it seems to affect especially the kidneys, causing often temporary albuminuria with discolored urine, deranged secretion, and sometimes much more acute forms of disturb- ance, similar to those met with after its internal use. Carbolic poison- ing was met with most frequently during the era when Lister's original directions were scrupulously followed, and at a time before Aye learned that it is much better to remove dirt than to try to antagonize its action. Certain eminent operating surgeons -were even compelled to discontinue its use because of its unpleasant effect upon themselves as well as upon their patients., Finally, among the powerful antiseptic agents in common use, the very active are the soluble preparations of mercury, ordinarily corro- sive sublimate, in solutions of varying strength, which are used for irrigation, douching, etc. and for preparation of dressings. Aside from an intense and even serious eczema which may follow its local use, one- may meet with any or all of the expressions of mercurial poisoning after using it, particularly on certain individuals of peculiar suscepti- bility to this drug. Salivation, intestinal irritation, and all other well- ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. 205 known phenomena of mercurial poisoning have been occasionally pro- duced, with the result that the solutions and preparations of corrosive sublimate now used are much weaker than those which were used at first, and that in many instances where it is desired to avail one's self of its properties we at the same time protect the area involved against toxic activities by dusting with some standard sterilized powder or by anointing it with some sterilized ointment which shall protect the skin, while at the same time permitting the dressings to be applied where they may best absorb wound-discharges. PART III. SURGICAL PRINCIPLES AND METHODS AND MINOR PROCEDURES. CHAPTER XVII. CONTROL OF HEMORRHAGE; ABSTRACTION OF BLOOD; PARACENTESIS ; COUNTER-IRRITATION. By John Parjienter, M. D. Control of Hemorrhage. The methods of controlling' hemorrhage are many, and vary according to the nature of the hemorrhage, the situation of the vessels concerned, etc. The subject will be considered in a general sense only in this place. We may divide our measures for the control of hem- orrhage into Temporary and Permanent, I. Temporary Measures. — Among the recognized temporary expe- dients are (a) Digital compression, which implies the use of the finger or thumb applied over the bleeding point or over the vessel at some acces- sible place in its continuity. The amount of force required for all vessels, provided they are situated superficially, is surprisingly little. (More force is required for arteries than veins, of course, and also where a large muscle-covering exists without underlying bone against which to press the vessel.) When the vessels lie deeply, however, this method is too tiring and inexact to be depended upon. Furthermore, long-continued pressure may endanger the vitality of the adjacent tis- sues. This danger and that of the conversion of an open into a con- cealed hemorrhage constitute two sequelae resulting from injudicious pressure which should always be avoided. (6) Haemostatic Forceps. — These serve a double use — to crush the vessel (in case of arteries) and to differentiate it from the adjacent tis- sues prior to torsion or the application of a ligature. It has bluntly serrated ends which easily catch and crush the vessel. Forceps are of various forms and sizes. For small arteries forceps usually effect per- manent closure after a few minutes' application. Even the largest vessels may be closed if the pressure continues sufficiently long. In using haemostatic forceps great care should be employed not to include any tissue excepting the vessel itself. Local necrosis is often caused by their too prolonged application to too much tissue, and doubtless fre- quently leads indirectly, if not directly, to suppuration in otherwise aseptic wounds. In removing the forceps it should not be made to 207 208 SURGICAL PROCEDURES. tpart and tightly twisted with any kind of stick (cane, umbrella, etc.). As a ~~ means of controlling hemorrhage tour- niquets possess certain elements of dan- If applied too long, at injudicious Illustrating forced flexion for control of hemorrhage. drag upon the vessel, and should be slowly removed in order not to dis- turb the clot already formed. (c) Tourniquets. — Of these the commonest, cheapest, and most gen- erally useful is the Esmarch tourniquet, which is a piece of f-inch rubber tubing about 1J to 2 feet long, with a hook at each end. A sim- ple rubber bandage does equally well. r Where neither is obtainable a hand- I places, such results as paralysis of im- ■ ! portant nerves, sloughing, great oozing , of serum from the wound, and much after-pain may result. They are there- fore to be used with caution, and dis- pensed with as soon as the vessel can be isolated and closed. (d) Forced Flexion. — In suitable cases pressure can be made by putting a joint, such as the knee or elbow, in a position of forced flexion with immobilization, as shown in Fig. 43. II. Permanent Measures. — (a) Ligation. — This is done by tying the vessel with some form of ligature (catgut, silk, kangaroo-tendon, etc.). The ligature may be applied at the open end of a vessel or in its con- tinuity. Applied with moderate force, the middle and inner coats are cut through and curl up, although this is not necessary for the oblitera- tion of the vessel. The only object in using force sufficient to destroy the inner coats is to ensure so firm a hold upon the vessel as to prevent its slipping off. An internal clot forms, which reaches usually to the next highest branch, organization begins, and the ligated parts become a mass of cicatricial tissue. All in all, ligation is the simplest, safest, and best method of controlling hemorrhage. Some substitutes for ligation may be mentioned here : they are torsion and deep suturing. Torsion is effected in two ways : In small vessels it suffices to catch the end with a hsemostatic forceps and twist it around several times, stopping short of severing the twisted from the main portion. When dealing with larger vessels it is better to seize them near the end (one-third of an inch), with one haemostatic forceps applied at right angles to the axis, and, having secured this firmly, to then twist the distal portion as above described (four or five complete turns usually suffice). This method is applicable to vessels as large as the femoral, and has the advantage of enabling us to dispense with ligatures. The method is peculiarily valuable in plastic surgery and where scar is to be avoided. Beep suturing (ligature en masse) consists in passing a ligature through the tissues around a vessel by means of a needle whose points of entrance and emerg- ence are near to each other. The method is indicated in cases where the end of the vessel cannot be caught up, as occurs in certain wounds or in dense, unyielding tissues. (6) Pressure. — This may be effected by long-continued digital pres- sure or by leaving a hsemostatic forceps clamped upon the vessel for a CONTROL OF HEMORRHAGE, ETC. 209 period of from twelve to forty-eight hours according to its size and tone, and by the use of gauze or other form of dressing. It is most applicable in regions where other means for arresting hemorrhage cannot readily be employed ; that is, in the rectum, vagina, nose, medullary canal, socket of a tooth, wounds of the deep palmar or plantar arch, etc. The coap- tation of the edges of a wound by sutures is another method of apply- ing pressure, and is especially useful where the skin is vascular, as in the scalp and scrotum. Fig. 44. Obliteration of artery following ligation. (c) Styptics. — These are chemical agents which arrest hemorrhage by inducing coagulation of the blood. Chief among these are persulphate and perchloride of iron, powdered alum, tannin, gallic acid, nitrate of silver, vinegar, cocaine, chloroform and water (one drachm to the pint), turpentine, antipyrine (5 to 20 per cent, solution), Park's mixture of antipyrine and tannin, solutions of each, of 15 per cent, strength, mixed. If too strong, styptics easily cause necrosis and sloughing of the tissues, and thus prevent primary union. (d) Heat. — This may be applied in the form of water at the tem- perature of 120° to 150° F. or by means of the actual cautery. Hot- water irrigation is of great value upon extensive raw surfaces or in cavities which ooze. The actual cautery, of which the Paquelin is the best and most commonly employed, should be used at a dull-red heat and applied for a few moments to the bleeding point. It is a powerful haemostatic. It checks hemorrhage, either by forming an aseptic eschar at the end of the vessel or causing the end to curl up and invert, thus finally closing the vessel. A bright-red or white heat is not haemostatic in action. An iron heated to dull red or the galvano-cautery may be used in place of the Paquelin. (e) Cold. — In the form of exposure to air, ice-water, or ice cold has long been used for checking hemorrhage. It causes contraction of the muscular coat, and therefore acts more promptly and effectually in arterial than in venous bleeding. The exposure of an amputation-stump 14 210 SURGICAL PROCEDURES. to air set in motion by a fan quickly causes the surface to become dry and glazed over. (J) Elevation.— -If the upper or lower limb be held in a vertical posi- tion for sixty to ninety seconds and a tourniquet applied, we find that we have rendered the 'part almost bloodless; so also when hemorrhage is occurring elevation quickly lessens or stops the oozing from veins and capillaries. This is so well recognized that elevation of an amputated stump for the first few hours after operation is almost a routine practice. (g) Acupressure, acufilopresxure, and acutorsion are now rarely employed. Occasionally the one or the other method may be useful. Acupressure consists in passing a long needle through the soft parts in such a manner as to compress the vessel beneath it. When, in addition, we bind a ligature about the projecting ends of the needle, the procedure is called acufilopressure. Acutorsion consists in drawing out and trans- fixing with a needle the end of the vessel. The needle is then given a half or complete turn, when clot-formation occurs and hemorrhage is checked. Abstraction of Blood. (1) Venesection, or Phlebotomy. — This consists in opening a vein, preferably the median basilic, although the median cephalic may be selected, and, where cerebral inflammation or apoplexy exists, the external jugular is often chosen. It should be borne in mind that the median basilic vein crosses the brachial artery, being separated from it at this point by the thin aponeurosis of the biceps. In fat persons, where an excessive amount of fat covers the veins, venesection may be difficult. A bright light or reflector may be advantageously employed in such cases, the veins revealing their situation by their shadow. The opening into the vein should be made either above or below this point, the artery having been first identified by its pulsations. Venesection is usually done as follows : The elbow having been previously rendered aseptic, a bandage is applied about the middle of the humerus sufficiently tight to retard the venous return, but to leave the radial pulse quite perceptible. The arm is allowed to hang down and the fingers given some object like a roller bandage to grasp, to better fill the vein. In a few seconds the vein becomes quite prominent, when an oblique incision maybe made through the skin and wall of the vein, or, what is better, a bistoury may be thrust under the vein and a cut made outward. The opening in the skin should be generous to avoid subsequent infil- tration. The blood should be allowed to flow until the pulse becomes soft and slow. The amount necessary to produce this effect varies with the individual, but in general it averages between eight and twenty ounces. Should the flow become too slow before the desired effect has been produced, it may be hastened by having the patient alternately close and open his hand and tightly squeezing whatever object he may be holding. The muscular contraction induced increases the flow. When sufficient blood has been abstracted, the encircling bandage should be removed and antiseptic dressings applied with moderate pressure. The antiseptic management of venesection is highly important, as bent-arm, due to suppurative cellulitis and suppurative thrombosis, followed by fatal pvsemia, has occurred not infrequently. (2) Arteriotomy. — This procedure may be used where rapidity is necessary. The temporal artery is usually chosen because of its super- ficial situation, convenient size 1 , and the ease with which the bleeding from it can be controlled by pressure. Its exact position mar be deter- mined by its pulsation, which can be readily felt, and in "some indi- CONTROL OF HEMORRHAGE, ETC. 211 viduals seen. The artery should not be entirely cut through to secure the best flow, although complete division is sufficiently effective. If only partial section of the artery has been made, when the bleeding has been completed the vessel should be cut entirely through and firm anti- septic dressings applied. (3) Scarification. — This is performed by making several small cuts or punctures in the affected part, through which the blood will exude more or less vigorously according to circumstances. Where applicable, heat to the part and the dependent position will promote exudation of blood. (4) Cupping. — This may be either dry or wet. In dry cupping the blood is simply drawn to the surface, and thus, in the strict sense of the word, is not abstracted. It is, however, taken from the congested part, its effect upon which is virtually the same as though the blood was removed from the body. Dry cupping is effected by using a cupping-glass or tumbler, the interior of which has been previously heated with an alcohol lamp or a piece of burning paper, or, better still, by rinsing one or two teaspoonfuls of alcohol around the sides of a glass, which is then inverted to allow the excess of alcohol to escape: the edges of the glass are wiped free of alcohol and the remaining film within the glass ignited. The glass is then applied to the affected area. The skin becomes congested and rises in the glass. By far the best, most rapid, and accurate cupping apparatus is the Allen surgical pump. Wet cupping implies the abstraction of blood from the body. Formerly it was done with a complicated instrument containing ten or twelve sharp knives working in a half-circle through slits in a metal plate fixed to a frame. The instrument is rarely or never used to-day. The complicated mechanism made it difficult to render it aseptic and to keep in order. A better way is to scarify the part with a tenotome or bistoury and apply the cupping-glass as before described. The amount of blood withdrawn will depend upon the degree of suction and the depth of the cuts. The cupping ended, an antiseptic dressing should be applied. (5) Leeches. — These are not often used at the present time. There are two varieties, the American, which can abstract about a teaspoonful of blood, and the tiwedish, which draws about three or four teaspoonfuls. The latter is most commonly used. Leeches may be applied as follows : The skin of the region selected is washed and, if necessary, shaved ; it is then smeared with milk or blood. The leeches are taken from their receptacle and allowed to swim in a basin of fresh water for two or three minutes, after which they are urged to crawl over a clean towel for a similar period. Each leech is then taken up in a test-tube or small glass, and this is inverted over the spot chosen, when the leech usually fastens upon the skin. Sometimes considerable time elapses before it will attach itself. When it has drawn sufficient blood a little salt or snuff will make it relax or drop off. The wound may then be dressed with some antiseptic gauze. Care must be exercised in the application of leeches. They should never be applied over loose cellular tissue, such as the scrotum, penis, or eyelid, nor over superficial veins, arteries, or nerves. When applied to the neighborhood or interior of cavities they should be prevented from going too far, either by stuffing the continuation of the cavity with cotton or gauze or by securing the leech. 212 SURGICAL PROCEDURES. The mechanical leech is a device consisting of a scarificator-cup and exhausting syringe. After scarifying the part the cup is applied, a vacuum produced, and the blood slowly withdrawn. It is in no way comparable to the Allen pump, which possesses other advantages as well. Paracentesis. Paracentesis may be performed in one of three ways — viz. aspira- tion, tapping, or incision. Aspiration is the withdrawal of fluid from a closed cavity without the admission of air by means of an instrument with which a vacuum is produced and an outward flow of the fluid induced. There are many kinds of aspirator, from the piston trocar to the more elaborate bottle- aspirator of Potain, which is the one most commonly used. It consists of a suction-pump connected with a bottle by rubber tubing and pro- vided with stopcocks ; the bottle is, in turn, connected in a similar way with the needle. The bottle is first exhausted of air, when the needle is inserted into the cavity containing the fluid, the stopcock is turned, and the fluid flows into the bottle. Should this become full, the stopcock is turned off, the bottle emptied, and the process repeated until the desired amount of fluid has been withdrawn. The area about the point to be aspirated should be thoroughly aseptic, as should the instru- ment in all its parts, especially the needle or trocar. The place of puncture may be made anaesthetic with ice, rhigolene spray, or, what is usually more convenient, by touching it with a drop of carbolic acid, which is both antiseptic and anaesthetic. Aspiration is more commonly employed to remove effusions within the pleural, peri- cardial, ventricular, and subarachnoidian cavities, encysted collections within the abdomen, and fluid in the joints, especially the knee. Tapping is effected by means of the trocar and cannula. The same preparation of the instrument and parts should be made as in aspira- tion. The instrument should be plunged quickly and firmly into the cavity and the trocar withdrawn. If the trocar be a large one, it is better first to incise the skin with a scalpel to prevent the opening in the skin from remaining patulous. Where a large collection is to be removed it is well to attach a piece of rubber tubing to the cannula to carry the fluid into some receptacle, and thus avoid wetting the patient's clothing and immediate surroundings. Tapping is usually practised in dropsy, and when neither an aspirator nor trocar can be obtained the valvular incision may be employed. The skin having been drawn well aside from the line selected, an incision is made down through the skin and underlying tissues until the cavity is reached, and when drained sufficiently the skin is allowed to slip back to its original position. This puts the incision through the skin well to the side of that through the tissues beneath, and gives to the whole the action of a valve. The method has been successfully used in pleural and joint effusions, in spina bifida, and in cold abscesses. Counter-irritation. Like abstraction of blood, counter-irritation, except in the milder and less effective forms, has dropped out of fashion. So pronounced is the writer's conviction upon the value of this procedure as accomplished by CONTROL OF HEMORRHAGE, ETC. 213 the actual cautery that he regards the Paquelin thermo-cautery as an almost indispensable part of a surgeon's armamentarium. Counter- irritation is of especial value in the treatment of chronic inflammation (so called) the result of chronic congestion and tissue new formation, in which condition it both relieves pain and promotes the absorption of existing exudates. The»various means of producing counter-irritation include rubefa- cients, vesicants, the seton, and the actual cautery. To these may be added issues and acupuncture, which, however, are rarely ever used at the present time. (1) Rubefacients. — In this list are found hot water, turpentine, mus- tard, ammonia, capsicum, chloroform, and others, most of which, if applied sufficiently long, produce a vesicant action. Speaking broadly, the effect of rubefacients is not of signal value in most surgical conditions requiring counter-irritation, and, inasmuch as their method of applica- tion is so generally understood, we may pass them by without further consideration. (2) Vesicants cause an effusion of serum and lymph under the skin. Chief among these are mustard, cantharides, chloroform, and ammonia. Mustard is usually employed as a plaster made by mixing equal parts of the flour with wheat or flaxseed meal, to which enough lukewarm water has been added to make a paste. (It should be remembered that boiling water, by altering the active principle, renders mustard valueless as a vesicant.) It may also be con- veniently used in the form of the mustard leaf, which is first dipped in warm water and applied. In either form the plaster should be left in situ for half an hour or more, and applied directly to the skin without intervening gauze or oint- ment, as is done where the rubefacient effect alone is desired. Although always at hand, and therefore convenient, mustard is not to be commended as a vesicant, because it is more painful than others to be mentioned and the resulting ulcers are often very slow in healing. Cantharis is used in two forms — the cerate and cantharidal collodion. The cerate may be spread upon adhesive plaster, leaving a margin suf- ficient for adhesion to the skin in order that the cerate may be held in place. It should be removed in from six to ten hours and followed by a poultice. Cantharidal collodion is an admirable form in which to use this drug, its advantages being that it is not easily displaced and can be applied to irregular surfaces. It is painted on the selected surface with a brush, several layers being applied. Chloroform and ammonia are both used in a similar way. A few drops are applied upon the skin and covered with a watch-cover, or absorbent cotton saturated with them may be applied and covered with oiled silk, greased brown paper, or some impervious material. Within half an hour vesication has been usually produced. The use of these agents is open to the same objec- tions as in the case of mustard — viz. pain and slow-healing ulcers. Silver nitrate, in strong solution, or the solid stick applied to the skin, produces vesication. (3) The Seton. — This consists of a subcutaneous sinus with two open- ings, through which some foreign body, usually silk, is passed. This is easily made by thrusting a needle having a generous eye and armed with large silk through the desired place, the ends of the silk being tied together. After two or three days the wound is dressed and the silk drawn back and forth through the wound a few times, this being subsequently repeated daily. The irri- 214 SURGICAL PROCEDURES. tant effect may be increased bv smearing savin or mercurial ointment upon the silk. The writer has employed the seton in post-cervical pain with marked benefit. (4) The Actual Cautery.— In point of view of wide range of appli- cability, efficiency, and speedy action the actual cautery ranks first among counter-irritants. The old 'cautery-irons, the red- or white-hot poker, and other crude forms have been superseded by the Paquelin thermo- cautery. Its principle depends upon the power of benzine to render heated spongy plat- inum incandescent. Having heated the tip in an alcohol flame, the rubber bulb connected with the benzine receiver is compressed and the benzine vapor is forced into the spongy platinum, which becomes heated to any degree up to white heat, according to the pressure upon the bulb. When ready for use the following precautions should be observed : The part to be cauterized should be thoroughly cleansed and shaved. The cautery, having been brought to a white heat, should be touched upon the part in spots half an inch distant from each other, or in the form of streaks parallel or crossing each other. The amount of pressure and the duration of contact upon the skin will determine the depth of the burn, which it is better to limit to partial rather than to entire destruction of the cuticle. The counter-irritant effect in the former condition is greater because of the exposure of the terminations of the sensory nerves. After cau- terization has been produced the part may be dressed with ice-water, poultices, with or without some anodyne or an ointment containing 10 per cent, of iodoform. Where it is desired to keep up the effect the ulcer may be dressed with savin or mercurial ointment, as previously men- tioned when speaking of blisters. It is proper to mention here that the therm o-cautery may be used to produce a rubefacient effect. This is done by heating the largest tip to a white heat and holding it within a quarter or half an inch of the surface until the pain causes the patient to exclaim or the skin is seen to redden, when it should slowly be shifted an inch or so. The writer has found this of great sedative value in tympany following laparotomy, after synovitis, and other analogous conditions. Ignipimcture — /. e. puncture with a fine cautery-point, made by plung- ing it into the skin and underlying tissues in a number of places — produces admirable counter-irritation in deep-seated congestions or inflammations. CHAPTER XVIII. MINOR SURGERY AND BANDAGING. By John Parmenter, M. D. Knots. The knots in common use by the surgeon include the reef or square knot, the surgeon's knot, the granny, the Staffordshire knot, and the clove hitch. (a) The reef knot is formed by passing one end of the ligature over and around the other, drawing the single knot thus formed sufficiently tight, when the process is repeated, using the same end that was first employed. (b) The surgeon's knot differs from the reef knot only in the first stage of its formation, where the one end is carried over and around the other twice. This makes the knot more secure by preventing the slipping of the single knot while the second is being made — an accident which easily occurs where great tension is Fig. 4 Fig. 46. Reef knot. Fig. 47. Fig. 48. Granny knot. Fig. 49. Clove hitch. Staffordshire knot. necessary or slippery ligature materials are used. The surgeon's knot requires more force to produce the same amount of tension. 215 216 SURGICAL PROCEDURES. (c) The granny differs from the reef knot in that in the second stage of its formation the end first employed is passed under and around its fellow. It is a good knot, easily made and thoroughly secure, some authorities notwithstanding. (rf) The Staffordshire knot is especially useful for securing pedicles. It is made by transfixing the pedicle with a double-threaded transfixing needle, slipping the loop over the stump, and pushing it down to the point of entrance of the ligatures (the needle having been withdrawn), when one ligature is placed over and the other remains under the loop : each is pulled tightly and secured by a square knot. The Staffordshire knot thus secures each half of the pedicle, and is a safe and reliable knot when properly made. When carelessly made it is highly dangerous. (e) The clove hitch may be properly considered in this place, although not em- ployed in the class of cases in which the knots just described are used. It is easy to make and does not slip. In fact, the more it is pulled upon the more secure becomes its grasp. Its formation is best conveyed by observing Figs. 47, 48. Sutures. Sutures are employed in various forms according to the necessity of the individual case or the preference of the operator. Those in most frequent use are : Fig. 50. Fig. 51. Fig. 52. 1 Continuous suture. Interrupted suture. Modified plate suture, using gauze instead. Fig. 53. Fig. 54. Fig. 55. Modified quill suture, using gauze. Billroth's chain-stitch. Transfixion suture. la) The continuous suture (Fig. 50) is made by passing the needle in at one side of the wound and out through the other at an opposite point, when the suture is MINOR SURGERY AND BANDAGING. 217 tied : the needle is again inserted into the side first penetrated and brought out upon the opposite side. This process is repeated until the wound is closed, when the double thread is tied with single thread into a square knot. This suture can be quickly placed, and if done with due care leaves a good scar. It is easy to strangulate the lips of the wound if more than moderate force be employed. Furthermore, unless the wound be quite dry the continuous suture requires that drainage be coincidently employed, as wounds thus closed are too tight to permit much escape of fluid from underneath. In long wounds it is well to tie the suture at varying intervals to avoid giving way of the entire suture should a' part fail. (b) The interrupted suture is the form most commonly employed. It is made by passing the needle through the tissues from one side to the other at an opposite point; the suture is then tied with an appropriate knot and cut off. The process is repeated as often as necessary, the sutures being from one-quarter to one-half an inch apart according to the tension. (c) The plate, transfixion, and quill sutures are shown in Figs. 52, 53, 55, and require no special description. They are all useful where tension is to be overcome or close approximation is required. Gauze makes an admirable substitute for the plate or quill. (d ) The Lembert suture is used in intestinal surgery. It includes all the coats of the intestine except the mucous. When the sutures are tied the serous surfaces are approximated. The sutures should be placed about one-eighth of an inch apart. (e) The Czerny suture brings the edges of the wound directly into apposition, but is employed only in intestinal suture. Secondary sutures are used in cases where from hemorrhage or expected suppuration the surgeon has been compelled to pack the cavity with gauze. The sutures (of non-absorbable material) are placed, but not drawn so as to coapt the edges of the wound. After a few days the packing is removed and the sutures tied, so as to bring the lips of the wound into apposition. Removal of Sutures. — Sutures are usually left in place from four to nine days : the time varies with the vascularity of the region and the tension. The knot should be seized with dressing-forceps and pulled upward and to one side, when the suture will show the part previously just underneath the skin and easily recognizable by its bleached appear- ance and moist condition. This is divided with appropriate scissors in the moist part, and the suture removed with the forceps previously applied to the knot. This detail of cutting through the moist part of the suture should be observed, as by dragging a dried part of the suture through the wound the latter may be easily infected. Transfusion and Infusion. The object of these procedures is to give bulk to the blood in the vessels from which it has been in part withdrawn through hemorrhage, to add nutriment, and to furnish red blood-corpuscles to the blood. That the two latter effects are ever produced is very doubtful. The giving of additional bulk is of unquestioned efficacy. The transfusion of blood, either directly or indirectly, from an animal or a human being into an exsanguinated person is to be men- tioned only to be condemned . It has been proven beyond doubt that the injection of defibrinated blood into the circulation is a dangerous pro- cedure. After a few days the red corpuscles injected die, haemoglobin is set free, and quickly causes destruction of the white blood-corpuscles, with formation and accumulation of fibrin-ferment, and not infrequently death of the individual. 218 SURGICAL PROCEDURES. Direct transfusion is much less dangerous, but impracticable, as it is commonly difficult to find one ready to donate the blood. Furthermore, the blood may coagulate in the conducting tube, and under any circum- stances it is doubtful whether the red corpuscles thus injected retain their vitality. It seems, therefore, needless to describe the technique of transfusion, which is attended with so many dangers, and for which the infusion of a normal 0.6 of 1 per cent, saline solution may be more safely and advantageously substituted. A good formula is aq. destil. 1000, sodii chloridi 6.0, sodii carb. 1.0. This should be sterilized, warmed to 42° C, and rendered alkaline by the addition of one drop of sodium hydrate (sat. sol.) to every half-litre of the solution. Ludwig suggests the addition of from 3 to 5 per cent, of sugar to the alkaline solution, claiming that the addition of the sugar adds nutritive value, increases endosmotic action, whereby the blood absorbs the parenchymatous fluids more readily, and furthermore preserves the red blood-corpuscles from destruction better than the plain solution. The apparatus required con- sists of a glass funnel with rubber tube attached, which, in turn, is con- nected with a glass cannula. In order that the pressure exerted by the infused solution should not exceed that in the large veins the flask should be held a few inches above the level of the opening in the vein. Eighty or ninety cubic centimetres should be injected each minute until from 500 to 1500 c.c. have been used, according to the individual ease. The quality of the pulse will indicate when sufficient has been injected. Kneading of the abdomen favors diffusion of the solution. An admirable and efficient substitute for the above-described method is the subcutaneous infusion of the same solution, which is prepared, sterilized, and warmed as previously mentioned. This is then injected under the skin with an appropriate needle in amounts varying in all from 500 to 1000 c.c. This is often spoken of as hypodermoclysis. The anterior abdominal wall and the thighs are good regions in which to inject the solution. Massage helps the absorption of the fluid. Catheterization. Catheters are used chiefly to withdraw urine from and to wash out the bladder. Three kinds are in common use — viz. the metal, gum, and flexible — each of which has its distinctive advantages. In addition there are special forms, such as the prostatic, the elbowed (catheter Coude), and the olivary. The technique of catheterization varies with the form employed and the condition of the urethra. In the following brief description a normal urethra and a stiff catheter are presupposed : Having placed the patient preferably in the recumbent position, and having selected a good- sized catheter (No. 24 French) which has been previouslv made aseptic, well warmed, and thoroughly oiled, the operator holds the same between the thumb and forefinger of his right hand. Resting the little finger of the same hand uponthe patient's abdomen at or just beneath the umbil- icus, the catheter is inserted into the meatus, when the penis is slipped over the catheter as far as it can be made to go. (This procedure has the advantage of rendering the urethra smooth by obliterating the folds MINOR SURGERY AND BANDAGING. 219 of the mucous membrane.) The catheter is then carried from its hori- zontal to a vertical position, when by pressing slightly downward and at the same time depressing the shaft between the thighs of the patient the instrument will usually glide into the bladder. Cleansing of Catheters. — Catheters should be kept in a strictly aseptic condition, otherwise inflammatory troubles, such as urethritis and cystitis, are prone to occur. After using, the catheter should be thoroughly rinsed in clean water, care being taken to remove all clots or debris from the bore of the instrument. (That portion of the cathe- ter between the eye and the tip is most liable to be insufficiently cleansed.) If running water lie not at hand, water may be forced through the catheter with a syringe, and considerable pressure should be used to ensure dislodging of the material contained within. This done, it should be followed with some antiseptic solution, such as carbolic-acid solution, 1 : 20, Condy's fluid, etc. Metal and glass catheters have the advantage that they may be sterilized by boiling. Other catheters after lying for twenty minutes in the antiseptic solution may be carefully dried and laid away for future use, wrapped in some impervious material like rubber tissue, oil silk, and the like, (ilass catheters may be kept in the antiseptic solution permanently. Normal Obstacles to Catheterization. — The novice may encounter several points along the normal urethra which tend to prevent the further passage of the instrument : 1st. The catheter may catch in the fossa naviculars, an accident which may be easily avoided by keeping the tip close to the floor of the urethra during the first part of its passage. 2d. It may be stopped at the triangular ligament. When this occurs the catheter should be withdrawn a little and the tip made to hug the roof of the urethra. 3d. Fahc passages, previously made by using misdirected and excess- ive force. These are often difficult to avoid, but can usually be circum- vented by keeping the tip of the catheter close to the side of the urethra opposite the opening of the false passage. 4th. The neck of the bladder may form an obstacle, under which cir- cumstances withdrawing the stylet a little, and thus tipping up the end of the catheter, will usually cause it to ride over the urethral floor into the bladder. Untoward Effects sometimes following- Catheterization. — These are both local and constitutional. Chief among the local effects we have — 1st. Pain. — This is usually severe in nervous persons upon whom the catheter is passed for the first time. It may be mitigated by exer- cising gentleness and thoroughly oiling the instrument. A 4 per cent. solution of cocaine may be previously injected if deemed necessary or advisable. 2d. Hemorrhage. — When this occurs it is rarely serious, and ceases soon after withdrawal of the instrument. If ordinary care has been used and hemorrhage follows, it usually denotes a pathological condition of the urethral mucous membrane. 3d. False Passages. — As before said, these are usually due to mis- directed and excessive force, but may occur from very slight pressure 220 SURGICAL PROCEDURES. when the mucous membrane has been congested for a long time from previous disease. Their occurrence may be recognized by the sudden giving way of previous resistance, sudden pain, followed by a sensation of grating appreciable alike to patient and operator. Further confirma- tion may be gained by noting any deviation of the handle of the catheter from the median line, by feeling the tip out of the middle line upon rectal palpation, and by the fact that no urine escapes. False passages may be avoided only by exercising the greatest gentleness and intelli- gence in manipulation. 4th. Extravasation of Urine— This occurs in connection with false passages alluded to, and the prevention of the latter implies avoidance of the former. 5th. Inflammatory conditions, such as abscess, urethritis, prostatitis, and cystitis, not infrequently result from the use of unclean catheters, mere mention of the cause, uncleanliness, indicating how best to avoid the condition. Constitutional Conditions. — The more common constitutional conditions may be traced to the effects of catheterization upon the ner- vous centres or to sepsis. Of the former we have, chiefly — 1st. Syncope, Retention, and Suppression of Urine. — The use of cocaine and the recumbent position, combined with the greatest gentle- ness during the passage of the catheter, will do most to prevent or mitigate these unpleasant and sometimes dangerous effects. 2d. Urethral Fever. — This is believed by some to be of nervous origin, by others to be due to the absorption of toxic alkaloids. The use of measures similar to those employed in the case of syncope are usually of pronounced value. 3d. Pycemia. — This may occur even with the formation of meta- static abscesses, and is usually due to infection from without. The writer has seen one case of purulent synovitis of the knee-joint result from the use of an unclean catheter ; a.t least this seemed to be the only solution of the origin of the trouble, inasmuch as commoner causes of this affection could be pretty safely excluded. Artificial Respiration. There are various methods of producing artificial respiration, some of which accomplish the result through pressure upon the thorax, others bv means of direct inflation of the lungs. Of the former methods, those in most common use are Sylvester's, Marshall Hall's, and Howard's. Of these, Sylvester's is the simplest and easiest of execution. This method makes use of the arms as levers to expand the chest through the medium of the muscles which pass from the arms to the chest-wall, the origin and insertion of these muscles interchanging at each step. The patient is laid upon his back with the shoulders somewhat elevated by a pillow or cushion placed under them, the neck extended, and the head thrown back. The tongue may be drawn forward by an assistant if necessary. Foreign bodies, including water, must be removed from the pharynx. The surgeon should then seize the forearms just below the elbows and carry them over the patient's head as far as they can go. This action expands the thorax. A little extra jerk when the arms are at their highest point increases the efficiency of the movement. The arms having been thus held about two seconds, they should be brought down to the sides of the thorax and pressed firmly against the same for two seconds, when they are again elevated, and the MINOR SURGERY AND BANDAGING. 221 entire procedure repeated until no longer necessary. Pressure against the liver upward assists in emptying the lungs of their contents. The number of complete movements in a minute should equal that of normal respiration (sixteen to eigh- teen). If the patient be small, it is important that the feet be firmly held to prevent the body being pulled forward when the arms are carried upward. Should this occur, the efficiency of the procedure in expanding the thorax will be much diminished. Marshall Hall's method is practised as follows: The patient is rolled from the position on his back to that on his side ; the uppermost arm is pulled forward and pressure made directly upou the side of the thorax to expel the air from the lungs. The body is then rolled over on to the back, which movement causes respiration. The process is repeated as often as sixteen or eighteen times per minute. The method is not as efficient as that of Sylvester. Howard's method is best described in the words of its author : 1. Instantly turn patient downward, with a large firm roll of clothing under stomach and chest. Place one of his arms under his forehead, so as to keep his mouth off the ground. Press with all your weight two or three times, for four or five seconds each time, upon patient's back, so that the water is pressed out of lungs and stomach and drains freely out of mouth. Then, 2, quickly turn patient, face upward, with roll of clothing under back just below shoulder-blades, and make the head hang back as low as possible. Place patient's hands above his head. Kneel with patient's hips between your knees and fix your elbows firmly against your hips. Now, grasping the lower part of patient's naked chest, squeeze his two sides together, pressing gradually forward with all your weight for about three seconds, until your mouth is nearly over mouth of patient ; then with a push suddenly jerk your- self back. Rest about three seconds ; then begin again, repeating these bellows- blowing movements with perfect regularity, so that foul air may be pressed out and pure air be drawn into lungs, about eight or ten times a minute for at least one hour or until patient breathes naturally. The above directions must be followed on the spot the instant patient is taken from the water. A moment's delay and success may be hopeless. Prevent crowd- ing around patient ; plenty of fresh air is important. Be careful not to interrupt the first short natural breaths. If they be long apart, carefully continue between them the bellows-blowing movements as before. After the breathing is regular let patient be rubbed dry, wrapped in warm blankets, take hot spirits and water in small, occasional doses, and then be left to rest and sleep. The procedures based on direct inflation of the lungs include mouth- to-mouth inflation and forced respiration. Mouth-to-mouth inflation is practised in the following way : The tongue hav- ing been drawn forward, the operator applies his mouth directly to the mouth of Fell's apparatus for forced or artificial respiration. the patient, at the same time closing the nostrils. The operator then blows into the mouth of the patient, following this action with forcible pressure upon the 222 SURGICAL PROCEDURES. walls of the thorax. This process should be repeated fourteen times in a minute. A good modification is to blow through a catheter which has been previously- passed through the larynx, or to pass an intubation-tube to which has been attached a rubber tube through which air can be easily forced. Forced respiration is effected by means of a bellows, the best form being that elaborated by Dr. George E. Fell of Buffalo. With it air can be forced into the lungs, either directly through the mouth and larynx or through a tracheotomy-tube. The writer has had occasion to test the efficacy of this apparatus a number of times, and cannot exag- gerate its usefulness. Whatever form of artificial respiration be made use of, such adjuvants as warmth, stimulation, and rubbing of the body in the direction of the venous circulation are not to be forgotten. Corns. Corns belong to the papillomata, and may be defined as an undue development of the cuticle attended with increased vascularity of the underlying cutis and more or less enlargement of its papillas. They are caused by intermittent or occasional pressure. There are two varieties — the hard and the soft — the former situated upon exposed parts like the little toe or the back of the toes, the latter being found between the toes and deriving their character from the moisture usually existing in this jjlace. For the same reason a soft corn grows more rapidly than a hard one. Corns are usually flattened and circular in shape externally, and extend beneath the skin in a conicular wedge-shaped manner. It is to this latter circum- stance, whereby the apex of the cone or wedge presses upon the sensitive papillae underneath, that corns owe their painful character. Old corns frequently have a bursa develop underneath them. This may become inflamed and even suppurate, a process usually very painful and occasionally terminating in ulceration, which may perforate deeply into the tissues, even to the bone. Treatment. — The treatment should combine prevention of recur- rence with destruction of the corn. When new and small, corns will commonly disappear on removing the pressure of tight or ill-fitting shoes and placing around the corn a felt ring (U-shape), whose edges shall take the pressure of the shoe from the corn. When it has existed for a long time a hard corn should be thoroughly softened with warm water, after which a solution containing salicylic acid 1 drachm, ext. henbane 4 grains, flexible collodion 1 ounce, may be painted upon the part once or twice a day. Iodine, potassium chromate, silver nitrate, and other similar agents have been recommended. Inflamed corns should be treated by elevation and rest of the part, together with antiseptic fomentations. If pus forms, it should be evacuated, great and almost immediate relief usually following. Bunions. A bunion is an enlarged normal bursa or one produced adventitiously by the pressure of an ill-fitting shoe. Bunions are usually found on the inner side of the great toe at the metatarso-phalangeal joint. When the shoe has its inner border slanting outward, as in very pointed shoes, or MINOR SURGERY AND BANDAGING. 223 it is too short and narrow, the best conditions are present for producing a bunion. Another cause is prolonged continuous standing upon a weak tarsus, which produces flat-foot and the oblique outward direction of the .great toe which accompanies the condition. It may become much enlarged and inflamed, and not infrequently terminate in suppuration. Very commonly, too, the joint becomes prominent on its inner side from enlargement of the head of the metatarsal bone. In extreme cases the great toe mav lie at almost a risj-ht angle to the long axis of the foot and over or under the adjacent toe. In such cases the deformity is pro- nounced and the interference with walking quite marked. Treatment. — This is preventive or curative. Remembering the eti( ilogy of bunions, it is apparent that proper shoes are necessary. The inner side of the shoe should be almost straight, there should be suf- ficient width to permit the foot to spread normally, and the shoe should be sufficiently long. When inflamed the foot should be elevated and put at rest. Incision is indicated when pus is present. In the old and inveterate forms, -without much or any inflammation, a blister may be applied, and its counter-irritant effect maintained by rubbing in an oint- ment of biniodide of mercury, 10 grains to the ounce of lard. Where the head of the metatarsal bone is unduly enlarged and the deformity great, excision of a wedge-shaped piece of bone, followed by fixation of the toe in a normal position, is indicated. Except in very old and feeble subjects amputation is rarely called for. Ingrown Toe-nail. Two causes operate to produce ingrown toe-nails : one is the pressure of a shoe or tight stocking which is too narrow ; the other is the over- growing of the cuticle adjacent to the edge of the nail. This latter is a very common cause, which is frequently aided by the bad practice of rounding off corners when cutting the nail. In the milder grades of the trouble there is little to be seen on inspection except the overhang- ing cuticle. When, however, ulceration has occurred, the side of the nail may be covered with foul granulations which exude pus. The pain and inability to walk may be very great when the inflammation is pro- nounced. In some severe cases widespread cellulitis may be present. The therapeutic indications are to remove pressure either of the shoe or cuticle and to substitute healthy for unhealthy granulations. Patients with ingrown toe-nails should wear well-fitting shoes and stockings. When the cuticle overhangs it may be pushed back into normal place by inserting a small roll of cotton under the edge of the nail and along the border of the same. Adhesive plaster applied so as to draw the cuticle from the edge of the nail has proved of signal value in the writer's hands. In the more severe eases the granulations should be touched with silver nitrate or copper sulphate, or, better still, they should be curetted away and the remaining surface thoroughly disinfected and cauterized. Others, again, may only yield when to the above treat- ment is added continuous pressure and some astringent powder. This may be done by dipping a small hard roll of absorbent cotton into pow- dered lead nitrate and binding it over the granulating surface with adhesive plaster. Sometimes removal of the contiguous portion of the 224 SURGICAL PROCEDURES. nail is indicated, but this procedure is rarely necessary if both patient and surgeon will exercise a little patience and employ treatment along the lines above indicated. Skin-grafting. The Thiersch Method. — In this method about half the thick- ness of the skin is used. It is removed by putting the skin on the stretch either with broad sharp retractors or by grasping the part so as to accomplish the same effect, when, with a keen razor previously wet with a sterile normal (.6-1.0 per cent.) solution of common salt, strips anywhere from one to twelve inches long are removed. These are transferred to the wound upon the razor-blade or a spatula, and spread evenly and closely upon the surface with probes. The preparation of the granu- lating surface for the reception of the grafts is of vital importance to success. It should have been made aseptic and healthy. When granu- lations are deep red or "raw beef" in color, with little or no pus, and cicatrization has already begun, we have the best surface for grafting. It is not necessary, however, to wait until this condition is present. Provided the surface be aseptic, the superficial granulations may be cur- retted off, a very light touch being sufficient to do this. It has been recommended to remove any line of cicatrization which may be already formed, as experience has shown that subsequently ulceration frequently occurs in just this place. All hemorrhage is to be thoroughly checked before the grafts are put in position. The after-dressing consists in first placing a layer of sterilized green protective or rubber tissue sufficiently large to cover the entire surface and overlap the edges a little. This is to be laid on evenly, and over this are applied gauze compresses satu- rated in the normal saline solution and absorbent cotton, all firmly held in place with a bandage. Gold- or tin-foil may be used in place of the protective or rubber tissue, and sterilized oil may be substitued for the saline solution. The oil dressing is certainly more convenient than the solution, with which the dressings must be kept constantly saturated to ensure success. Any dressing which sticks is apt to dislodge the grafts, their adhesion to the underlying surface in the first few days being very slight. No antiseptic solutions should come in con- tact with the grafts. The dressing should not be changed under four or five days, and should then be removed with the greatest care lest the grafts be disturbed. A similar dressing should replace the first, and not be discontinued under two weeks, after which some ointment may be used. The advantages of the Thiersch method are the rapidity of healing of extensive defects and the relative non-contractility of the new skin thus formed. Extraction of Teeth. There is, perhaps, no minor surgical procedure which requires for its proper completion a more thorough application of anatomical knowledge and more manual dexterity than the extraction of teeth. When one con- siders the frequency with which the average practitioner is called upon to perform the operation, it is apparent that he should possess sufficient knowledge to appreciate the dangers arising from the application of immoderate and misdirected force. MINOR SURGERY AND BANDAGING. 22fj Instruments Required. — The instruments required are forceps and the elevator. There should be at least five pairs of forceps, and, better, seven. (The more experienced, however, the operator the fewer the forceps needed.) The forceps have various shapes to meet the require- ments. The elevator is of use where the forceps cannot be applied, as, for instance, in troublesome stumps lying beneath the alveolar border. Method of Extraction. — To extract teeth properly the operator should bear in mind certain anatomical points. The teeth are arranged in the form of an arch in which each tooth is a keystone, it being nar- rower at the inner alveolar border than at the outer. It can therefore be dislodged most easily by force acting in a direction outward — ('. c. toward the check. Furthermore, the alveolar border is much thinner upon the outer than upon its inner side. (An exception must be made at the site of the third molar (wisdom) tooth.) The tooth should be seized with appropriate force upon the fang well beyond the crown. Pressure outward is then made, this frequently splitting the socket on the outer side and coincidently rupturing the periosteum on the inner side of the tooth. The pressure is then reversed and the tooth brought back into its original place, this motion causing the periosteum on the outer side to break. By quickly repeating these rocking movements the periosteum is entirely torn through and the socket sufficiently bent or split to leave the tooth free, when by adding a direct pull the tooth is extracted. Naturally, the technique varies somewhat with the tooth extracted and its situation, whether in the upper or lower jaw. In the upper jaw direct pressure upward permits the forceps to be easily applied to the fang. In the lower jaw the operator adjusts the forceps to the neck of the tooth and presses it down with the thumb of his left hand placed over it in the mouth, the fingers of this hand grasping the lower jaw firmly from below. Accidents from Extraction. — (a) Hemorrhage. — This may be severe enough to threaten life in those having a hemorrhagic diathesis. Ordinarily it is not of moment. The socket having been thoroughly cleared of clot, ice or ice-water may be put into it, followed, if necessary, by a cotton plug soaked in some astringent, such as persulphate or perchloride of iron, tannin, alum, and the like. This plug should be pressed firmly into the socket and reach its uppermost part, otherwise the pres- sure of the blood will quickly dislodge it: should plugging prove inadequate, the fine point of a Paquelin cautery may be used with advantage. Where the tooth that has just been extracted is at hand, it may be placed in the socket and pressed firmly in. This often succeeds admirably. (b) Dislocation or Fracture oftlte Lower Jaw. — These injuries should receive immediate treatment, the details of which will be found else- where. (c) Fracture of Opposing Teeth. — This results from slipping of the forceps or their sudden and unanticipated release from breaking of the crown, etc., whereby the forceps hit the teeth above or below, as the case may be. (d) Fracture of the Tooth Extracted. — When this occurs all pieces should be removed with appropriate forceps. Should the removal of the remainder of the fang require much bruising or breaking of the alveolus, it is better to postpone its removal until it has risen nearer the alveolar border. 15 226 SURGICAL PROCEDURES. {() Extraction of Healtliy Teeth. — This may happen through mis- take, or a healthy tooth may be pulled coincident v with one diseased. The socket should be cleansed and the tooth washed in warm water and replaced. After pressing it firmly into place, it may be retained by closing the teeth and maintaining this apposition with an appropriate bandage. (/) Forcing a Tooth into the Antrum of Highmore. — This accident is due to pressing too firmlv in the effort to grasp the fang. The tooth should be removed and the parts thoroughly cleansed to avoid inflammation and suppuration within the antrum. (g) Tearing of the Alveolar Border. — Careless application of the for- ceps is the usual cause. When slight the gum may be pressed into place. If more extensive, one or more stitches may be required. (h) Injury to the Inferior Dental Nerve. — This may occur as the result of dislocation of the lower jaw or from fracture. Perfect reposition of the parts is the treatment indicated. (<) Dropping of a Tooth or of Pieces of Instruments into the Larynx. — The result may be immediate suffocation, or, if the foreign body escape through the vocal cords, a septic pneumonia is apt to occur. To avoid this complication the operator should invariably make sure that the for- ceps have released the tooth previously drawn before again introducing them into the mouth. When the accident has occurred removal of the foreign bod}- is imperative, and may be accomplished by appropriate measures. Bandaging. The tendency in bandaging to-day is toward simplicity, and this is due in part to modern ideas of antiseptic and aseptic surgery and in part to the materials employed. The need for elaborate descriptions of the various methods of band- Fig. 5' Figure-of-8 bandage of leg aging different parts of the body does not seem to exist and therefore diagrams instead of verbal descriptions will be employed the latter being too complicated and indefinite to justify the space they occupy in the average text-book of surgery. ^ Among the materials used in bandaging may be included cotton cheese-cloth, crinoline, gauze, flannel, rubber, and' materials which havi MIX OR SURGERY AND BANDAGIXG. 227 been impregnated with plaster of Paris, starch, silicate of sodium, etc. In selecting a bandage one must have in mind the part to be bandaged, the amount of restraint and. support required, the length of time the latter is to be maintained, the effect upon the shin, the circulation of the part, Fig. 58. Fro. 59. Velpeau's bandage. Ascending spica bandage of the groin. and such other considerations as maybe indicated in individual cases. For instance, crinoline is easily impregnated with plaster of Paris, starch, or other stiffening material, and when so used has peculiar advantages in giving firmness to the dressing. Where moderate firm- Fig. 60. Fig. 61. Head-and-neck bandage. nesswith some elasticity is desirable cotton is a good agent. We employ bandages to give rest and support to affected parts, to retain splints and dressings, to prevent or reduce swelling, and to check hemorrhage. Bandages may be divided into three general classes — the roller, tri- angular or scarf, and special bandages. The roller bandage varies 228 SURGICAL PROCEDURES. in width and length according to the requirements in individual cases. It is employed as the mujlc or double roller, the former being the one in common use. It is usually employed upon the head and extremities, although applicable to other situations. Roller bandages are made in various sizes, the average being 2|- to 3 inches by 7 to 8 yards. They may be made into rolls for use, either by hand or with appropriate apparatus found in instrument-stores. The method of applying a roller bandage varies with the region to be bandaged. Its application to an extremity, however, is sufficiently illustrative of its use in general, and maybe briefly described as follows : Bearing in mind the amount of firmness and support required, and that the pressure must be evenly distributed over the part, the roller is MINOR SURGERY AND BANDAGING. Fig. 66. Fig. 67 229 /:■ ■ T-bandage Kelly's bandage with pe seized with the right hand, the free end being detached with the thumb and fore finger of the left hand, the bandage unrolled for some three or four inches ; the free end is then placed upon the inner side of the limb, and the roller carried around it again and again, each time overlapping the one preceded by about half its width. Where the extremity is cone-shaped the reverse must be employed, this being done by turning the bandage on itself. This process is repeated until the part again becomes cylindrical or until the region is sufficiently covered. When the bandage has been applied the remaining free end is pinned to the underlying layers. The triangular or scarf bandage is sim- ple, efficient, and of wide applicability : it has proven of great value in emergencies upon the battle-field and elsewhere. Special bandages include the many-tailed H and T bandages, all of which are found use- Barton's head bandage as em- ful in certain regions of the body, a few tvr>- ployed for suspension in apply- ., , ,.° , „. •''_„ „_ ;Jjf mg piaster-of-Paris bandage. icaJ examples being shown in Ilgs. 66, 67, 68. CHAPTEE XIX. ANAESTHESIA AND ANESTHETICS. By H. A. Hare, M. D. The word ancesthetic was first suggested, as a suitable term for a drug which removed the sense of pain, by Oliver Wendell Holmes in November, 1846, the discovery of this property of ether or ethyl oxide having been put to practical application by Dr. Morton, a dentist of Boston, on September 30, 1846. The first public use of ether for surgical purposes was made by Warren on the 16th day of October, 1846, in, the Massachusetts General Hospital. Although Long of Georgia caused anaesthesia by ether as early as 1842, and Jackson. of Boston asserted that it was he who made the discovery, and not Morton, it has been decided by com- petent judges that the latter (Morton) really deserves the credit for the general introduction of ether as an anaesthetic for surgical purposes. In November, 1847, just one year after Morton's discovery, Simpson of Edinburgh first noted the anaesthetic power of chloroform on himself and some friends. Since this time no other substance designed to produce general surgical anaesthesia has been intro- duced which approaches the usefulness of these two drugs, and they remain the almost universal anaesthetics of the day, if we except nitrous-oxide gas, the appli- cations of which are very limited. Before discussing the action and uses of ether and chloroform it is proper to consider several general facts concerning both of them and the use of anaesthetics in general. The first fact to be borne in mind by the surgeon is that these drugs are not to be used except when really needed, and when employed are to be chosen with distinct ideas as to their indi- vidual peculiarities and indications in each case. A patient under the effect of so powerful a drug that consciousness is destroyed is nearer death than the ordinary human being, since the primary depressing influ- ence upon the high nervous centres may speedily pass to the lower vital centres in the medulla oblongata. Again, the day is fast approaching, if not already here, when the sur- geon must choose the anaesthetic to be used in each individual, just as he directs one or another cardiac stimulant in circulatory failure accord- ing to the end to be obtained. No one should use ether exclusively or chloroform exclusively, for there are, as we shall point out later on, indi- cations and contraindications governing the use of both. Another point to be remembered is that the skill of the anaesthetizer does not consist so much in getting his patient under in a short time as it does in producing surgical anaesthesia gently, cmily, and tenderly, so that the heart and mind will not be disturbed by suffocation, fright, strug- gling, or overdosing with the drug. Many anEesthetizers think that their responsibility ceases as soon as the patient returns to consciousness, but nothing is more erroneous, for much of the post-anaesthetic distress, the vomiting, the bronchitis, the pulmonary congestion, and the condition of anuria may be avoided by properly giving the drugs we are discussing. 230 ANESTHESIA AND ANESTHETICS. 231 It is quite as much a duty to avoid excessive drugging under these circum- stances as it is to avoid overdosing when digitalis or any other powerful drug is used, for the skill of the physician consists not only in knowing what to give, but in knowing when enough has been used to produce the results sought for. The dose of the anaesthetic is to be governed by the response of the individual, and the physician who drowns his patient with chloroform or ether is producing poisoning and not therapeutic anaesthesia. Every person to whom an anaesthetic is to be given should be examined to determine the condition of the heart and blood-vessel x, and, if time permits, the urine should be examined repeatedly for several days prior to the operation to determine the condition of the kidneys, since the danger of artificial anaesthesia is greatly increased by the pres- ence of disease of the heart, blood-vessels, or kidneys. Immediately before the drug is given careful inquiry should be made to discover whether the patient has some foreign body in the mouth, such as false teeth, tobacco, pins, or, as is frequently the case to-day, chewing-gum, which if not removed may cause grave difficulties by falling to the back of the mouth and so obstructing the air-passages. The patient also should be asked whether he or she has ever taken an anaesthetic before, and if so whether it had any untoward effect. In this manner idiosyncrasies may be discovered which will enable the physician to be on the lookout for accidents. An anaesthetic should never be given without the consent of the patient or his friends if it be possible to obtain it, but in an emergency case, should no friends be at hand and the patient incompetent to decide for himself, then the surgeon may fearlessly take the responsibility of giving the drug he deems safest. Care should always be taken when a woman is to be anaesthetized that a reliable assistant, pref- erably a female nurse, is present, both for the comfort of the patient and for pro- tection of the physician, since cases are on record where the patient has accused her medical attendant of assault while he had her under the effects of the drug, either for the purpose of blackmail or because in the anaesthetic sleep she has experienced an orgasm of which the anaesthetizer has appeared to be the cause. Leaving for later on the discussion of the relative safety of the minor anaesthetics, we come to a study of the safety of ether and chloroform. There has been much difference of opinion as to the relative safety of these drugs, but at present the profession is practically a unit in recog- nizing that ether is the less dangerous by far, although a large number of eminent men still employ chloroform to the exclusion of ether, on the ground that when given with care accidents are almost unheard of. When we remember that in many eases the giving of the anaesthetic is entrusted to the least experienced professional man present or to a nurse, the relative danger of ether and chloroform is a factor of importance. Published statistics as to the relative safety of ether and chloroform during anaesthesia are open to many objections and vary with startling discrepancies, so that even the largest collections of figures are to some extent at fault. The chief fault is that in none of the statistics are the deaths really resulting from the direct action of the drugs separated from those in which it has only needed the action of a powerful sub- stance to upset the balance of function in some diseased organ and so produce a fatal ending. The following table shows the approximate death-rate from ether and chloro- form, and the variations in statistics according to different collectors: 232 SURGICAL PROCEDURES. ETHEK. 1 death in 23,204 cases. 1 death in 16,542 cases. (314,738 cases), 1 death 14,987 cases. 1 death iii 23,204 cases. (14,581 cases), 1 death 4860 oases. 1 death in 23,204 cases. 1 deatli in 16,677 cases. 1 death in 23,204 cases. (42,141 cases), 1 death 6020 cases. CHLOROFORM. 1 death in 5860. (524,507 cases), 1 death in 3258. 1 death in 2873. (12,368 cases), 1 death in 1236. 1 death in 3749. 1 death in 2873. (201,224 cases), 2286. 1 death in 3000. 1 death in no death in 2900 cases. Andrews, Julliard, Ormsby, Roger Williams, Lee, Medical News collection, Coles, Gurlt, Richardson, Ziegler, Vogel, Korte, and Esmarch, In studying this table the fact must be constantly borne in mind that one or two cases of heart disease or advanced renal disease, causing " death from the anesthetic," so called, may seriously alter the percent- age, but the preponderance in favor of ether is so great as to settle the question of relative safety for ever. It is only fair to state, in addition to these figures, that Oilier has collected 40,000 etherizations without a death, Poncet 15,000, Tillier 6500, and Chabot 730. Similarly, McGuire of Virginia claims 28,000 ehloroformizations without a death, Von Nussbaum 40,000, and Lawrie of India about 30,000. When ether is first inhaled, even when well diluted with air, it is apt to cause a sensation of oppression or even of suffocation, which can be overcome by gradually increasing the strength of the vapor and by the aid of the patient, who, if intelligent, will often voluntarily overcome his shallow breathing and take deep inspirations of air laden with the vapor. This primary sensation of suffocation, with that which often comes on just as the patient is about to pass into unconsciousness, can nearly always be avoided, at least in part, by not giving the drug too freely, or rather by allowing enough air to enter with the vapor of the ether to prevent cyanosis. Only in the most hurried cases is it proper to pour the ether on the inhaler and then hold it tightly over the patient's face at the very begin- ning of the administration. Not only is such a method harsh and calculated to frighten the timid, but it is capable of straining the heart through congestion arising from the struggles of the patient, and, if am* weakness of the blood-vessels is present, may cause their rupture by the rise of arterial pressure produced by the drug, the struggling, and the partial asphyxia. Very commonly there follows after this period of reflex irritation a few long-drawn breaths, and then fixation and immobility of the chest ensues, so that for thirty seconds or a minute it would seem as if the patient was forgetting to breathe, and then a deep respiration like a long- drawn sigh ensues, followed by a rapid, deep breathing, which, by reason of the large amount of ether inhaled, either renders the patient partially anaesthetic and ready for a minor and brief operation or more commonly it initiates what is known as the stage of excitement, during which the patient shouts, sings, cries, swears, or fights, according to his tempera- ment and previous condition. This stage rarely lasts for more than a few minutes, and then the patient actually passes into the complete ANESTHESIA AND ANESTHETICS. 233 anaesthetic condition and is ready for the surgeon's method. The puke. from the first under ether is accelerated, although in some cases, where because of fright or other reason the pulse has been very rapid, it may be slowed by the steadying or stimulant effect of the drug. The respi- rations when" once the patient is anaesthetized are more rapid and deeper than in health, and the skin is dry and warm, though often flushed, particularly about the face and neck. With the development of well-marked muscular relaxation snoring or stertorous breathing comes on, and the increased secretion of mucus and saliva due to the irritant effects of the ether increases the noisiness of the respiratory cycle. If the ether be pushed beyond all therapeutic bounds, the pallor of the surface changes to a deathly lividity. while the skin becomes cold and perhaps relaxed and moist, the pulse fails ; the respiration is gradually extinguished from intoxication of the res- piratory centre, so that death ensues from this cause. The muscular system is totally relaxed and flabby, but the heart continues to beat feebly for some moments after the breathing ceases. In producing its effects ether depresses first the perceptive and intellectual cerebral centres, next the sensory side of the spinal cord, next the motor side of the cord, then the sensory and motor portions of the medulla oblongata; and with this depression death ensues. Turning from the general effects produced by ether to its therapeutic application, we find that it has certain advantages and disadvantages. The chief advantage connected with its use is that it is by far the safest anaesthetic substance so far discovered for the production of anaesthesia during prolonged surgical operations. The patient passes under its effect, as a rule, quite rapidly, and once anaesthetized needs but a small additional quantity to keep him under its influence. Besides the lethal effects of ether we have still before us a considera- tion of the non-fatal accidents which may occur under its influence and the sequela which follow its use. The accidents which occur during the use of ether are rarely very alarming, and consist chiefly in arrest of respiration through depression of the respiratory centre by the excessive action of the drug, or stoppage of breathing caused by an accumulation of mucus or some foreign body in the air-passages. The appearance of the face must be the guide under such circumstances as to the methods of relief to be employed. If the face is, as usual, very much flushed or dusky or cyanotic, artificial respiration is to be resorted to by the general methods described later in this article under the treatment of anaesthetic accidents. If it is very pede, thereby indicating cardiac as well as respiratory failure, then the artificial respiration should be aided by inversion of the patient and the injection of stimulants. The sequeke following etherization are chiefly pulmonary and renal, and it is probable that a certain number of deaths result from these secondary manifestations of the action of this drug. As will be pointed out when discussing the choice of an anaesthetic, bronchitis, pulmonary congestion, and catarrhal pneumonia often seem to be produced by it. Very rarely, even croupous pneumonia has ensued. Renal disorders from the use of ether rarely arise in persons with primarily healthy kidneys, and consist in varying degrees of irritability and inflammation up to that which results in the condition of anuria 234 SURGICAL PROCEDURES. which is the most serious and fatal complication which can arise, because death is nearly always assured by this symptom, and because it is prac- tically irremediable. The use of ether in the case of diabetics is dangerous, and Becker has found in 188 cases of etherization acetonuria in no less than two- thirds. Baxter has reported a death from ether given to a diabetic, who passed into coma from the anaesthetic state. An important fact in this connection with the development of catar- rhal complications after ether is that surgeons, as a rule, are careless of the maintenance of the body-temperature during an operation. In a series of studies made by the writer some years since it was found that even under brief operations the temperature might fall from 1° to 4° F., this fall being due in part to the evaporation of the ether and to the depression of the vital processes. Naturally, irritation of the respiratory mucous membrane plus exposure to cold will predispose to pulmonary complications, and the chilling of the surface produces pulmonary and renal congestion. Vomiting following the use of ether is unfortunately very commonly seen, and is practically a constant sequel in those who have inhaled the drug upon a full stomach. It is supposed to be due to irritation of the vomiting centre and to the swallowing of saliva and mucus. It is to be avoided to some extent by giving the drug on an empty stomach. Once developed, the vomiting is to be treated by counter-irritation in the form of a mustard plaster over the epigastrium, by the use of one- grain doses of acetanilide every hour, 1 or by rectal injections of bromide of sodium and laudanum in starch-water. Sometimes washing out the stomach with a stomach-tube gives relief. For persistent singultus drachm-doses of Hoffman's anodyne are very effective. Chloroform. This drug was discovered practically simultaneously by Guthrie in America and Soubeiran in France. It is a colorless, transparent, volatile fluid of a hot sweetish taste and rather pleasant odor, having a specific gravity of 1.491 at 60° F. It is liable to decomposition in the presence of sunlight, and generally contains about 1 per cent, by weight of alcohol to retard this change. A pure chloroform has been made by a freezing process by Pictet, which is said to be less liable to decomposition than that made by the ordinary method. Great importance is to be attached to the use of pure chloroform, as many of the fatal accidents are believed to be due to the use of a poor article. It should be absolutely neutral, and when evaporated in a watch-glass should leave no residue of any kind or any strong odor. When chloroform is inhaled by the healthy man there may be for a moment a slowing of the pulse and a rise of arterial pressure, due in part to the cerebral excitement of the patient and to the irritation of the respiratory mucous membrane produced by the anaesthetic vapor, which may also reflexly cause cardiac inhibition. This condition is, however, very fleeting, and is replaced by a pulse more rapid than nor- mal and one which is less powerful. The arterial tension is generally 1 A very useful formula in this connection is one composed of 1 grain of acetanilide, 1 grain of monobromated camphor, and 1 grain of citrated caffeine, given every hour for six or eight doses. ANAESTHESIA AND AN /ESTHETICS. 235 decreased. The respiration may for a very brief period be partially arrested, but this symptom is often entirely absent, and never so marked as when ether is given. The pupils are primarily a little dilated, but permanently contracted during full anesthesia. If they suddenly dilate during the ancesthetie pe- riod, death is imminent. In other words, relaxation of the iris under chloroform is a part of the relaxation of death. Should the patient struggle violently, the drug must not be pushed, and it is to be borne in mind that the use of the drug is more apt to cause sudden death if the patient be an athlete or a drunkard. The action of the chloroform in producing anaesthesia is identical with that of ether, acting first on the perceptive centres, then on the intellectual centres, and then on the motor centres. Care should also be taken while it is being used that the bodily heat does not fall. The effect of chloroform on man and lower animals has been studied with extraordinary care all over the world, and much conflicting testimony exists con- cerning it. The writer has embodied his views as to its safety in his report to the Governor of Hyderabad, India, and believes that the medium ground there taken is the correct one; and it is an interesting fact that Randall and Cerna of Galves- ton undertook a series of studies designed to contradict these conclusions, but in the end endorsed them. The writer very positively asserts that chloroform practically always kills by failure of respiration when administered by inhalation up to the point of producing poisoning, provided — and this provision is most important — that the heart of the anaesthetized is healthy and has not been rendered functionally incompetent by fright or violent struggles, or, again, by marked asphyxia. There can be no doubt that chloroform always impairs the circulation by causing a fall of blood-pressure by its depressant effect on the vasomotor system and upon the heart, and for this reason any idiosyncrasy or disease might readily result in a cardiac death from it. The accidents which may result during the use of chloroform will be discussed under the head of the Treatment of Accidents under Anaes- thetics. We shall now speak of the sequelae which may follow the use of chloroform. The most important of these is renal disorder, for pul- monary complications are very rare indeed. The truth of the matter seems to be that both ether and chloroform possess the power of distinctly irritating the kidneys, but it also seems to be undoubtedly true that, as chloroform acts as an anaesthetic in very small quantities, it is always to be the anaesthetic of election where ope- rative procedures are demanded in the face of renal complications. Vomiting following the use of chloroform is comparatively rarely seen, although nausea may be present in susceptible persons. Ethyl Bromide. The position of bromide of ethyl as an anaesthetic is still undecided. Originally introduced with much promise, it soon fell into disrepute because of several deaths which took place under its use, but within the the last few years it has been more largely employed, notably by Mont- gomery of Philadelphia. The advantages possessed by ethyl bromide are its speedy action, the patient becoming anaesthetic in a very few moments, and the equallv 236 SURGICAL PROCEDURES. rapid passing away of its effects, the patient returning to consciousness almost at once when the drug is removed. Other advantages are that it produces no disagreeable after-effects. Generally the patient is able to walk perfectly in a very few minutes without much vertigo or nausea. Sometimes during its inhalation tonic spasm of the muscles with rigidity develops. The proper manner of using bromide of ethyl is to pour two or three drachms on a well-made ether cone, and then to give as pure vapor of the drug as possible, with little air. If much air enters, the anaesthesia is imperfect and the operation of the drug unsatisfactory. Sometimes, even if the drug be well given, a temporary tonic contraction of the muscles comes on and is more or less persistent. A. 0. E. Mixture. Various mixtures of chloroform and ether have been made and used for the production of anaesthesia. The most commonly used of these is the so-called " A. C. E. mixture," composed of alcohol, chloroform, and ether. It was thought that, as alcohol and ether stimulated the heart and chloroform depressed it, a combination of the three drugs would antagonize each other on these vital points while acting to produce anaes- thesia. Unfortunately for this theory, the drugs differ so in volatility that they are not absorbed simultaneously in equal amount, and the alcohol tends to produce bronchial irritation and prolonged intoxication. The mixture is not to be commended. Nitrous-oxide Gas. This gas is the safest and most rapid general anaesthetic that we pos- sess. As its anaesthetic influence does not last more than a minute, and in many persons not more than fifteen to thirty seconds, it can only be used for very brief minor operations, and as a matter of fact is seldom used except by dentists for the production of anaesthesia during the extraction of teeth. When the gas is given to man there may be a momentary increase in sensitive- ness, followed by analgesia, during which time little feeling exists, although the patient generally knows what is being done. Immediately after this he becomes absolutely unconscious and jerking or twitching of the muscles may occur. The superficial reflexes are abolished, but the knee-jerk is present and ankle-clonus is often present. Often the bladder and rectum are emptied, but vomiting rarely occurs. The subsequent symptoms are tinnitus aurium, headache, and dimness of sight. Sometimes nitrous oxide is used to anaesthetize a patient when the surgeon is in a hurry, unconsciousness being then preserved by the addi- tional use of chloroform and ether. Nitrous oxide ought not to be given to persons with fatty heart or athe- romatous vessels. The Choice op an Anesthetic. As already stated, ether and chloroform are still the anaesthetics of election for all general purposes. Nitrous oxide is only suited to minor and brief operations, and is difficult of use because of the bulk of its ANAESTHESIA AND ANAESTHETICS. 237 containers : the other anaesthetic substances are either dangerous or, like ethyl bromide, only suited for the production of rapid passing effects. (1) On general principles ether is to be preferred to chloroform, whenever no contraindication to its use exists, because of its greater safety. This is particularly the case where an inexperienced person is to give the anaesthetic. It is, however, inferior to chloroform in very young children and in persons who have bronchitis, because of its irritant effect on the respiratory mucous membrane. Renal disease also renders ether a dangerous anaesthetic, because the kidneys are irritated by it, and, again, marked atheroma or aneurism contraindicates its use, since it greatly increases arterial- pressure and so tends to produce arterial rupture. Similarly, it will- be found best not to attempt the use of ether in hot climates, because of its volatility, nor on the battlefield, where rapidity of action is essential and where its bulk is so great as to make its use difficult. Ether should never be given in the presence of a naked flame, unless the flame be high above the cone, as the vapor is inflammable. The vapor of ether being heavier than air, gravity causes it to sink to the floor. (2) Chloroform is not as safe as ether for the average case, but is to be preferred, where ether cannot be used, to any similar drug. It is to be preferred in hot climates (where ether is inapplicable), and here a free circulation of air increases the safety of the patient. It may also be selected whenever a large number of persons are to be rapidly anes- thetized, so that the surgeon may pass on to others and save a majority of lives, even if the drug endangers a few, as on the battlefield, where only a small bulk of anaesthetic can be carried. (3) Its employment is indicated in cases of Bright' s disease requiring the surgeon's attention, owing to the fact that anaesthesia may be obtained with so little chloroform that the kidneys are not irritated, whereas ether, because of the large quantity necessarily used, would irritate these organs. Quantity for quantity, ether is of course the less irritant of the two. (4) In cases of aneurism or pronounced atheroma of the blood-vessels, where the shock of an operation without anaesthesia would be a greater danger than the use of an anaesthetic, chloroform is to be employed, since the greater struggles caused by ether and the stimulating effect which it has on the circulation and blood-pressure might cause vascular rupture. (5) In children or adults who already have bronchitis, or who are known to bear ether badly — or, in other words, have an idiosyncrasy to that drug — chloroform may be employed. (6) Persons who struggle violently and who are robust and strong are in greater danger from the use of chloroform than the sickly and weak, probably because the struggles strain the heart and tend to dilate its walls. In operations upon the nose or throat chloroform is the best drug to employ, as by its use vomiting is avoided, only small quantities are needed to keep the patient under its influence, and the operator can readily examine the area of his operative procedures. Similarly, in 238 SURGICAL PROCEDURES. some cases where vomiting following upon thoracic or abdominal opera- tions is greatly to be feared chloroform is to be preferred to ether. Because of its rapidity of action chloroform is largely used to the exclusion of ether during labor. From the time at which chloroform was first introduced into medicine as an anaesthetic until to-day it has been universally recognized that parturient women seem to possess an immunity to its poisonous properties ; and it is one of the curi- osities of medical literature that while the journals fairly teem with reports of chloroform deaths when the anaesthetic has been given for ordinary operations, death from this drug in parturient women is almost unknown. Various explana- tions have been put forward by obstetricians and . others as to the reason of this apparent immunity. Administration. We have already referred to the necessity of giving anaesthetics gently and in not too concentrated form. Ether is best given by means of one of two inhalers. The first is that of Allis, which is designed to give the patient plenty of air heavily laden with ether vapor. It consists of a wide collar- shaped piece of leather with a fenestrated metal lining, through the openings of which is passed from side to side a wide roller bandage. The ether is poured on these diaphragms, and the air passes over them, becoming heavily charged with the evaporating ether. A simple and readily-made inhaler for ether is made by shaping a towel, containing between its folds a stiff" piece of paper, into a cone or cornucopia, in the apex of which is placed some absorbent cotton or a small sponge. Upon this cotton is poured the ether, and the large open end of the cone is placed over the patient's face. If well made, this is a very satisfactory inhaler which can be hastily prepared for each case. Other ether-inhalers exist by the score, but nothing is gained by using them. Ether should be so freely given that the air is only present in about 5 per cent, while the patient is struggling, thereby differing from chloro- form, which ought always to be given with about 95 per cent, of air. For the inhalation of chloroform the safest method of administration is by Lawrie's or Esmarch's inhaler, because these provide free circula- tion of air and do not distract the attention of the anaesthetizer from the respiratory movement by complicated apparatus. Apparatus much like these in allowing a free amount of air are the Hyderabad chloroform- inhaler or open-ended cone, with Krohne and Seseman's respiration- indicator attachment. The Junker inhaler, even with its modifications, is too complicated and cumbersome, and, while less chloroform is wasted in administering the drug, it must all be thrown out of the bottle afterward. If used at all, it should be used with the increased air-supply and respiration-indi- cator of Krohne and Seseman. A very useful addition to our methods of producing anaesthesia by- ether and chloroform is the administration of oxygen gas by inhalation with the anaesthetic vapor. By this means cyanosis is less likely to come on, accidents are more rare, and it is claimed that vomiting is often entirely avoided. It has been suggested that the mixture of oxy- gen with the vapor of these drugs may produce some chemical changes, ANAESTHESIA AND ANAESTHETICS. 239 but this view is incorrect. The mixture of ether vapor and oxygen simply forms a high explosive mixture. If ozonized ether is conducted into anhydrous ether, it forms a thick liquid which explodes if heated. Fig. 69. Fig. 70. Esniarch's sists of inhaler and chloroform bottle. The inhaler con- a wire frame covered by a thin piece of flannel. Krohne and Seseman's modi- fication of Lawrie's inhaler, with respiration-indicator at- tached. The inner lining is white felt, the outer case is leather. It can be used directly or by the air-pump attached to the top. It is probably ethyl peroxide. Chloroform when mixed with oxygen undergoes no change. If one of these inhalers is not employed, the chloroform is to be given by letting it fall drop by drop on a folded napkin held far enough away from the face to permit the inhalation of 95 per cent, of air with 5 per cent, of chloroform vapor. This free supply of air is important, whether we believe death to be imminent from cardiac or respiratory failure ; but this supply of air matters little to the patient if he does not breathe freely, nor does the dose of chloroform amount to aught if it is not drawn into the chest. The dose of chloroform is not the amount on the inhaler, but the amount taken into the chest, and, finally, the amount absorbed by the blood-vessels. We agree so heartily with Lawrie's personal conclusions as to the manner in which chloroform is to be used that we print them below : 1. Chloroform should be given on absorbent cotton stitched in an open cone or cap. 2. To ensure regular breathing, the patient lying down, with everything loose about the neck, heart, and abdomen, should be made to blow into the cone held at a little distance from the face. The right distance throughout the inhalation is the nearest which does not cause struggling or choking or holding of the breath. Provided no choking or holding of the breath occurs, the cap should gradually be brought nearer to, and eventually may be held closer over the mouth and nose as insensibility deepens. 3. The administrator's sole object while producing anaesthesia is to keep the breathing regular. As long as the breathing is regular and the patient is not com- pelled to gasp in chloroform at an abnormal rate, there is absolutely no danger whatever in pushing the anaesthetic till full anaesthesia is produced. 4. Irregularity of the breathing is generally caused by insufficient air, which makes the patient struggle or choke, or hold his breath. There is little or no tend- ency to either of these untoward events if sufficient air is given with the chloro- 240 SURGICAL PROCEDURES. form. If they do occur, the cap must be removed and the patient must be allowed to take a breath of fresh air before the administration is proceeded with. 5. Full anaesthesia is estimated by insensitiveness of the cornea : it is also indicated by stertorous breathing or by complete relaxation of the muscles. Directly the cornea becomes insensitive or the breathing becomes stertorous the inhalations should be stopped. The breathing may become stertorous while the cornea is still sensitive. The rule to stop the inhalation should, notwithstand- ing, be rigidly enforced, and it will be found that the cornea always becomes insensitive within a few seconds afterward. It is only necessary to add that the patient should be so dressed for an operation that his respiratory movements can be easily seen by the chloroformist. The use of chloroform requires that it shall be used only in the purest form, as medical literature shows that impure chloroform is very dangerous to life. Care should be taken that chloroform is not given in a room where there is a burning gas-jet unless there be good ventilation, as it is decomposed by the flame, setting free irritant fumes of chlorine, and thereby causing respiratory inflammation. Accidents from Anaesthetics. There still remain to be considered the methods which we are to resort to in accidents under anaesthetics. First, let us discuss the treat- ment of arrested respiration. This should be treated by the use of the Cut showing how proper traction on the tongue pulls on the epiglottis. ANESTHESIA AND ANESTHETICS. 241 Sylvester method, as by this means a greater amount of air enters the chest than by any other. For the free entrance of air we must so place the head that the epiglottis and tongue will not obstruct breathing. As long ago as 1889, Howard of London published a very interesting paper on this topic, which has since been widely quoted. While recognizing the value of his studies, a series of studies made by Martin and the writer have led us to reach somewhat different conclusions in regard to the posture of the head and its influence on the patulousness of the windpipe. Howard's statements in regard to the r61e of the epiglottis in cases of arrested respiration in anaesthesia are as follows : 1. The epiglottis falls backward in apncea and closes the glottis ; therefore the first thing in order and importance is the elevation of the epiglottis. 2. Traction upon the tongue, however, whatever the force employed, does not and cannot raise the epiglottis, as supposed. 3. The epiglottis can only be raised by the extension of the head and neck. Cut showing how dragging the tongue over the teeth fails to pull on the epiglottis. Often in cases of circulatory failure during anaesthesia complete inversion of the patient may be practised with good effect, as seen in the accompanying cuts, taken from photographs of Dr. Kelly's method (Figs. 73 and 74). For the cardiac failure which comes on in cases of anaesthesia the best drug we can employ hypodermically is strychnine in full doses, at least ^ grain, repeated in ten minutes if need be, and associated with Y^ T grain of atropine sulphate, since it has been proved that strychnine is the best physiological stimulant to respiration and the heart that we 16 242 SURGICAL PROCEDURES. have, while the atropine aids its influence on these functions and stimu- lates the vasomotor system. When an accident occurs under chloroform, this medication is par- ticularly necessary, for, as already pointed out, the influence of chloro- form on the blood-vessels is its primary and dominant effect. Fig. Showing the inversion of the patient as adopted by Kelly, and the method of performing artificial respiration simultaneously. This influence the author believes to be very much more worthy of attention than is generally recognized. Every physiologist knows that the action of the heart and respiration is greatly influenced by vasomotor relaxation. The gasping respiration of sudden faintness is probably due more to sudden vascular dilatation than to direct failure of the heart, and the exceedingly rapid pulse of shock is seen in conjunction with the relaxed blood-vessels so characteristic of this state. The integrity of the vasomotor system is as necessary to life as the integrity of the heart, since it is under the government of this system that the cardiac mechanism is active and the vital interchanges take place throughout the body. Acting upon this belief, the writer has found, both in the laboratory and at the bedside, that atropine enables more chloroform to be given without circulatory depression than can be used if no atropine is administered, and there is good reason to believe that the use of atropine by surgeons for the purpose of stimulating the respiratory functions or preventing cardiac inhibition by irritation of the vagus in reality prevents dangerous symptoms, chiefly by its vasomotor influence. Of the methods of artificial respiration, Sylvester's is by far the best, as it drives more air into the chest, or, in cases where this cannot be done, ANAESTHESIA AND ANESTHETICS. 243 we should not forget the very remarkable results to be obtained by prac- tising Laborde's method of rhythmical traction on the tongue. The tip Fig. 74. Same as Fig. 73. of the tongue being grasped, it is drawn out of the month regularly sixteen times a minute, and, probably by reflexly stimulating the respi- ratory centre, renews respiratory movements in apparently hopeless cases. Local Anesthesia. The production of local anaesthesia is sought for either through the influence of cold, which benumbs the nerve-endings or trunks, or by the use of cocaine or carbolic acid, which paralyzes peripheral sensory nerves when it is brought in contact with them. The advantages of local anassthema in minor operations are manifest. When cold is used, we can employ a small piece of ice dipped in salt, or a spray of chloride of ethyl or chloride of methyl or rhigolene. The chlorides of ethyl and methyl as commonly employed are contained in glass bulbs the ends of which taper to a point. This point having been broken off, the heat of the hand forces a fine spray of the liquid out of the glass, which as it strikes the skin becomes volatilized and simul- taneously freezes the surface. The skin becomes blanched, then shriv- elled and hard to the touch. After the anaesthesia, which lasts for a 244 SURGICAL PROCEDURES. few moments, is over, the part becomes pink and remains congested in appearance for some hours. Rhigolene or ether may be used in an ordi- nary fine atomizer. Aside from cold, we most commonly use cocaine for local anaesthetic effects. As this drug cannot penetrate the skin, it can be applied only to mucous membranes, unless Ave introduce it under the skin by means of a hypodermic needle. The strength of solution of cocaine for mucous membranes varies with the membrane to which it is to be applied. Thus in the eye a 2 per cent, solution is often strong enough. In the nose from 2 to 4 per cent, solutions may be used, whereas for the proper ansesthetization of such dense membranes as are found in the vagina and rectum 10 per cent, solutions may be needed. The applica- tion of cocaine to the ocular, vaginal, and rectal mucous membranes is almost never followed by untoward symptoms, but when applied to the nasal or urethral mucous membrane it may be rapidly absorbed and produce profound collapse. The application of cocaine to the urethral mucous membrane is peculiarly dangerous, sudden death having followed its use in this area. Very weak solutions should be employed in small amounts in the urethra for this reason. When anaesthesia of parts protected by the skin is to be obtained, the drug in 4 per cent, solution may be injected under the skin very gently. Schleich has lately introduced a method of using a solution of 2 parts cocaine muriate, \ part morphia muriate, 2 parts sodium chloride, in 1000 parts of sterilized water, which is deposited iii many beads or separate drops, the tissues being infiltrated or disteiided with the fluid. By using a sufficient quantity of the solution (even a weaker one being useful) extensive operations can be done without pain and without danger. A still later and more satisfactory formula, in which beta- eucaine is substituted for cocaine, is the following: Beta-eucaine 0.1, sodium chloride 0.8, distilled water 100. The use of beta-eucaine is free from many of the unpleasant constitutional sequela? often noted with cocaine. Local anaesthesia of the skin for minor operations may be obtained by drawing a camel-hair pencil wet vnth carbolic acid over the line in which the incision is to be made. CHAPTER XX. SURGICAL DIAGNOSIS. By Chauxcey P. Smith, M. D. It is well for the student to make a systematic, thorough, and method- ical examination of ever}' patient. He will have a knowledge of that case which will give him a better insight into its treatment, while he will gradually learn what is normal, and hence speak with some weight on what is abnormal or diseased. He will thus become familiar with joints, chests, malformations, diatheses, and many diseased conditions foreign to that one for which the patient comes. It will train him for close observation, and, furthermore, many times enable him to bring into play preventive medicine — /. e. the treatment of the future. Much may be learned of the patient — his habits, his strength, mal- formations, diseases, etc. — from inspection. To be thorough, one notes the expression, whether of pain, apathy, or paralysis, and one may often judge of the patient's occupation and general condition. External Examination. — When the patient is seen, observe his general appearance, whether robust or feeble. Note the color of the face — e. g. the florid face of plethora, the green of chlorosis, the pale- ness from anaemia, whether constitutional or due to hemorrhage, the sallow or yellow hue seen in septicaemia and hepatic disorders, the waxy skin of Bright's, the cyanosis due to obstructive respiratory or circula- tory disease, the crimson flush of pneumonia and erysipelas. The color of the conjunctiva is as important — c. g. the paleness seen in anaemia, the yellow of jaundice, the watery eye of the alcoholic, the glassy eye of cachexia. It should be observed particularly for hemorrhage when there is a history of injury, which, if subconjunctival, denotes serious intra- cranial mischief. In females note the presence or absence of chloasma, which occurs in pregnancy and during the menstrual periods. The Bye. — General protuberance, or exophthalmos, is seen in tumor* involving the antrum and brain. If this symptom be coupled with enlargement of the thyroid and irregular heart, the diagnosis of Base- dow's disease is simple. Conjugate deviation is seen in apoplexy. The pupil is contracted to a pin-point in opium-poisoning ; inequality is observed in brain-tumors, fracture of the skull, or some interference with the sympathetic nerve, such as carotid aneurism. A bright eye is seen in fever, coma-vigil in the typhoid state ; the presence of the arcus senilis denotes arterio-capillary fibrosis. Puffiness is seen about the eye- lids in inflammations near by, in nephritis, and in chronic alcoholics. The Head and Face. — Baldness, usually partial, of the eyebrows, moustache, or hair is common in lues. It is also seen at the back 245 246 SURGICAL PROCEDURES. of the head and in rickets, due to restlessness. Sears about the face denote some previous injury or disease. Their presence is important in epilepsy : if about the angle of jaw, tuberculosis is usually the cause; if on the lip, syphilis, although the primary lesion of lues may be found at the ala? of the nose and inside the mouth, particularly on the tonsd and soft palate ; if suspected, examine the contiguous lymphatic nodes. Sweating is a symptom in pyaemia, in rickety children — particularly at night — and in uraemia. In the latter the sweat has a urinous odor. The real age may be judged by the face, as well as the apparent age. By this is meant the real age from the life led, whether of overwork, anx- iety, or dissipation. Observe the general contour of the head and face, the symmetry or asymmetry. Myxoedema gives a moon-face ; acromeg- aly, prognathism of the lower jaw with overgrowth of the superciliary ridges. Rickets causes a box-shaped head. A general bulging of the face is seen in neoplasms of the antrum and unilateral swelling in infec- tive processes of the jaw. The Neck. — Enlargement of the lymphatic nodes of the neck is of great assistance in diagnosis. Bilateral enlargements are found in lues, the nodes being small, hard, shot-like, and movable ; in tuberculosis, either of the nodes themselves or secondary to a similar process in the lung ; they are usually large, adherent, often fluctuating or soft, and increase progressively in size as one approaches the primary lesion ; as, for instance, if due to infection through the tonsil, the largest node lies near the angle of the jaw, while from that point each node decreases in size until the supraclavicular lymphatics may be noted only with dif- ficulty. Bilateral enlargement is seen in Hodgkin's disease, the nodes standing out in great bunches and the enlargement continuing into the axilla. Unilateral enlargement is secondary to infective processes of the jaw, to faulty dentition, to malignant growth of tonsils, tongue, salivary glands, lips, or to tuberculosis. Occasionally it is seen in carcinoma of the breast and pylorus. The mouth should be examined as to the state of the tongue, the presence or absence of malignant disease or chancres ; the gingival border, for the blue line of lead- or green line of copper- poisoning. The state of the teeth is of importance, particularly in lym- phatic enlargement of the neck, in alveolar abscess, and as a possible source of infection in meningitis and antral abscess. Sordes are seen upon the teeth in low fevers. The breath has a sweet odor in pvsemia, a penetrating putrid odor in gangrene of lung, and a characteristic foul smell in epithelioma of the tongue or tonsil. Erysipelas usually starts from the angles of the mouth or eyes or alse of the nose and spreads therefrom. It rarely crosses the middle line. Tumors of the thyroid body rise and fall with deglutition. Thev may be unilateral or bilateral, fusiform or globular, and are common in women : the growth is often coincident with pregnancy, and can readily be distinguished from aneurism of the carotid by the foregoing symp- tom and by pressure-effects in the latter, and by the fact that aneurisms follow the line of the great vessels. The ear should be examined for the presence or absence of a dis- charge, whether of pus, denoting middle-ear and possibly mastoid dis- ease, or of blood, which with history of injury points to fracture of the SURGICAL DIAGNOSIS. 247 skull, in which case the blood is soon replaced by a serous discharge of* cerebro-spinal fluid. Expansile pulsation is seen often in the suprasternal notch in aneur- ism of aorta. Upper Extremity. — The general contour of the shoulder should be observed, particularly where there is a history of injury. Too much stress cannot be laid upon the importance of observing not only the injured but also the sound shoulder. Great stress is laid upon this point, which it is necessary to follow not only about the shoulder, but also at the elbow, the wrist, the hip, or the ankle. In other words, compare the injured with the sound part : by doing this not only may the pathological condition be discovered, but also often much time and expense may be saved in court. One general proposition should be laid down which not only covers the upper extremity, but also the lower, and takes in every joint of the body ; and that is, any swelling in or about a joint which follows the general contour of the joint is due to some lesion within it. Whether this lesion be diagnosed as due to blood, pus, or serum depends entirely upon the skill of the observer. And, on the other hand, any fusiform swelling about a joint when the demarcation of the capsule which marks the limit of the normal joint cannot be made out is due either to effusion, which may be purulent, or to malignant growth. Dropping of the shoulder is seen in fracture of the clavicle, ; marked prominence of the acromion in subglenoid dislocation. The fusiform swelling which follows the foregoing rule is limited by the capsular lig- ament in joint diseases, which must be differentiated from the more fusi- form and less well-defined swelling due to sarcoma. Flatness of the shoulder is seen in atrophy of the deltoid muscle, which may be caused by injury or disease of the circumflex nerve, and in fracture of the humerus. If, following injury, a large swelling, fill- ing the axillary fossa, which may or may not have expansile pulsation, appear, with absence of the radial pulse, it would indicate traumatic aneurism of the subclavian or axillary artery. In elderly people pulsation is often observed at the inner side of the elbow, and is due to arterio-venous aneurism of the brachial artery and cephalic veins. It usually results from careless bleeding. The arm is swollen and (edematous in infective processes ; e. g. if the hand be involved in a cellulitis or a malignant oedema. This swelling is accompanied by a brawny feeling and by constitutional symptoms, which are absent when it is secondary to incomplete extirpation of the mammary gland and lymphatic nodes. In this latter condition the marble-like oedema is due to obstruction to the venous return caused by the scar. The axillary lymphatics are enlarged in carcinoma and infective pro- cesses in the mammary gland, in inflammation of the hand or arm in tuberculosis of the lymphatic nodes of neck, in lues, and occasionally in irritation of the female breast. The epitrochlear node is enlarged in infections of the hand and in syphilis. Great importance is put upon its enlargement in the diagnosis of the latter condition. The Elbow-joint. — When the elbow is extended the inner condyle, olecranon, and external condyle will be on the same transverse line. This is very important, as when there is any dislocation these three bony points will be out of line, while, on the other hand, in a fracture 248 SURGICAL PROCEDURES. which does not involve the joint they will still remain in their normal position. Inspect the forearm for atrophy of muscle-groups which may be due to injury or disease of their respective nerves. Local enlarge- ments of the bones of the forearm are common : those with a tender, brawny surface are seen in inflammations, either subcutaneous, subperi- osteal,' or of the osseous tissue itself. Toward the distal extremity, par- ticularly if there be a history of injury, look for the silver-fork deform- ity of Colles' fracture and for the shorter and more abrupt deformity seen in a backward dislocation of the carpus. .Severe infections of the hand are accompanied by brownish-red streaks running up the arm to the lymphatic nodes — /. e. lymphangitis — or else by the purple lines of phlebitis. Much may be learned as regards the general condition of the patient from the hands, as the claw-hands of pseudo-muscular atrophy, the general flexion of fin- gers and hand seen in severe palmar or digital inflammations, the general over- growth of fingers of acromegaly, the spade-like hand of myxoedema, the clubbed fingers of phthisis, the cyanosis seen under the nails, indicating poor circulation, and hence often observed in conjunction with the clubbed fingers of phthisis, or the small round ulcers or scars occurring on the tips of the fingers observed in Keynaud's disease. A small fusiform, semi-fluctuating swelling in the line of a metacarpal bone or phalanx is suggestive of spina ventosa. The fingers of gout and of rheumatoid arthritis are excellent indices of the patient's condition. Wast- ing of the interosseous muscles is seen in progressive muscular atrophy and in leprosy. Athetosis due to intracranial lesions, or glassy skin, with absence of hair, seen after nerve-section, should not escape observation. The Chest. — Observe the shape: in emphysema it is barrel-shaped; in rickets the sternum is pushed forward (the so-called pigeon breast) and is associated with that enlargement of the costal cartilages known as the " rickety rosary." A long, flat, narrow chest indicates a tendency to tuberculosis of the lung. Unilateral enlaee/cment is found in pleural effusion, whether of pus, blood, or serum. The fifth interspace to the left may bulge, and is the favorite pointing-place for a purulent pleurisy. Protrusion of the sternum is a common symptom of aortic aneurism and mediastinal tumors, while in these conditions there is a prominence of the cutaneous veins of the chest due to deep obstruction. The scapula is prominent in lateral cur- vature of the spine, whether the scoliosis be primary in the vertebral column or secondary to unequal lengths of the legs. In fracture of the clavicle the winged scapula is common, as the fracture itself allows the shoulder to drop forward. The accessory muscle* of respiration are brought into play when there is obstruction to respiration, whether the obstruction be in the larynx as a foreign body or a membrane, or whether in the lung itself, as in fat-embolism. " Cheyne-Stobs respira- tion is met with in fatty degeneration of the heart, tubercular menin- gitis, uraemia, and apoplexy. Unilateral immobilization is significant of pneumonia, pleurisy, and fractured rib. The Breast.— Observe the general contour, the condition of the nipple and its areola. It is enlarged in lactation, sarcoma, chondroma, and abscess; its size is decreased after the menopause and in atropine scirrhus. The presence of chloasma denotes pregnancv or uterine dis- orders. The nipple is only retracted in carcinoma. ' Oftentimes the areola may have a baeony, waxy, or lardaceous appearance — Paget's SURGICAL DIAGNOSIS. 249 disease — which precedes mammary cancer from one to three years. The breast has a general protuberance in sarcoma and retromammary abscess. Primary syphilitic lesions are not infrequent about the nipple, due to an infected nursing child. Oftentimes from the nipple, in women who have passed the menopause, a thick, purulent-looking fluid can bo squeezed : it may be mistaken for pus, but its true nature, which is modified secre- tion, may be diagnosed by the microscope. Carcinoma, the most frequent malignant mammary neoplasm, is usually situated to one side of the nipple. The tumor is the size of a walnut, is hard, adherent to surrounding structures, hence not sharply defined, and the overlying skin is coarse and has been likened to pig- skin. The nipple may or 'may not be retracted. The axillary lymph- nodes are enlarged. Sarcoma invades the whole breast, which is much increased in size, presents no distinct border, and is of unequal consist- ence ; overlying veins are prominent ; there is no axillary involvement unless ulceration has commenced. In retromammary abscess the whole breast is protruded ; there are axillary involvement and associated symptoms of inflammation. Occasionally a small hard tumor is found with associated axillary involvement in a middle-aged woman, which may be mistaken for carcinoma. It is a retention-cyst, and may be distinguished by its depth in the gland, its lack of infiltration and of skin-changes. For the recognition of any tumor of the breast the palm of the hand should be used. Any one, if he feels with his fingers, can find a tumor in a normal breast, which is simply mammary-gland tissue. If the palm of the hand be taken, the mammary gland spreads itself out against the ribs, but any tumor by means of this procedure will readily be distinguished. In examining for adhesions the arm should be abducted to make the great pectoral muscle tense; if the muscle is relaxed, false diagnosis is easy. If an ulcerating breast present for diagnosis, attention should be given to the character of the secretion: blood is common in sarcoma; a thin, sanious watery secretion and occasionally scabs are seen in carcinoma. Small blue circumscribed spots upon the anterior surface of the chest — taches bleuatres — are caused by pediculi either of the pubes or axilla. Abdomen. — From the general appearance of the abdomen much may be learned. Rigidity and oftentimes rigid retraction are seen in dyspnoea when the respiratory muscles, particularly those of the belly, are brought into play. Rigidity of the right side, particularly of the rectus muscle, is seen in peritonitis or appendicitis. The manner of observing this should be as follows : With the thumbs of both hands pressure should be made upon each rectus, beginning at the symphvsis pubis and following the line of Poupart's ligament. Starting again from the symphysis pubis, both recti muscles should be palpated up to and beyond the umbilicus. In examination of the belly the hand should be warm, as a cold hand will often cause, particularly in women, a momentary contraction of the muscles which may mask any diseased condition beneath. Observe whether the patient or the belly itself shrink at the approach of the examining hand. This is of value, par- ticularly in deep-seated pain. Often the stomach may be partly out- lined, particularly in thin subjects, and its size may be noted, as, for instance, an increase due to pyloric obstruction. A sausage-shaped 250 SURQrCAL PROCEDURES. tumor in the right inguinal region, chiefly seen in infants, is due to intussusception of the bowel. The general contour of the belly should be observed. The pouting of the navel in anasarca, the lack of this in ovarian tumors, the ball-shape of ascites, the general distention of the peritoneal cavity observed not only in the foregoing disease, but also in cancer of the peritoneum itself or of the colon or liver otten a symptom of hydatid cyst— these are all of importance. Marbling of the belly, due to obstruction of the venous flow, is seen in pregnancy, liver diseases, ascites, and tumors pressing on the deep veins. Enlargement of the spleen, which can be easily distinguished, may be due to malignant disease, to leukaemia, or to malaria. In local enlarge- ments between the costal borders and below the xiphoid cartilage, if hard, cancer of the stomach, usually pyloric, is thought of, but when soft, pulsating, and expansile, they are caused by aneurism. General protuberance of the bowels is often a most characteristic symptom of tumors of the kidney, which push the bowel forward ; hence one should not be deceived by tympany on percussion. Tumors of the right hypo- chondrium, are usually of the liver and gall-bladder ; of the left hypo- chondrium of the spleen or a distended stomach ; renal tumors may be found on either side. In the right iliac region tumors may be caused by disease of the csecum and appendix, by pelvic abscesses, fecal accumulations, or cysts of the ovary and broad ligament ; in the left iliac, by tumors and cysts of the ovary, pelvic abscess, or volvulus. In the umbilical region we may find tuberculosis of the mesentery, and tumors may present themselves here which spring from other regions. In the hypogastric region the most common tumors are pregnant uteri, distended bladders, and fibroids. Lumbar tumors spring from the kidneys, or are cysts, perinephritic abscesses, or occasionally perityph- litic abscesses. When peristaltic motion is observed from without it is often due to obstruction of the bowels. Board-like rigidity with distention is seen in tubercular peritonitis. One may meet with the pelvic enlargement of ovarian tumors, the general bloating or distention of peritonitis and intestinal obstruction ; the doughy, brawny swelling, spreading from the pubis, of extravasated urine ; scars along the side indicate previous pregnancies or the results of great abdominal distention. Occasionally one sees, particularly at the navel, a persistent omphalo-mesenteric duct which may discharge a purulent material or even intestinal contents. A dis- charge at this point may be from a persistent urachus. In these latter conditions there will be more or less excoriation around the umbilicus. Observe the middle line particularly for old scars of previous operations, for hernia at the umbilicus, or separated recti muscles, and particularly, in the inguinal region, the condition of the inguinal rings. Pulsating swellings may be observed which if in the longitudinal axis of the body might indicate aortic aneurism, although aneurisms of the superior mesenteric artery are not infrequent. A flask-shaped tumor arising in the middle line from the pelvis, which often may reach the umbilicus or even beyond, and which fluctuates and is elastic, is prob- ably a distended bladder, which may be mistaken for a more serious condition. A tumor in either flank about the size of one's fist, which possibly can be grasped by the hand, with the history of movement, change in position, sharp colicky pain, and a lessened secretion of urine, usually indicates a floating kidney. This is particularly true of the right side. An elastic, flask -shaped tumor of the right hypochondrium may be a dilated gall-bladder or a hydatid cyst. Swellings in the ileo-costal space almost always originate from the kidney or surrounding structures. For instance, a dense, brawny infiltration on one side, with other characteristic SURGICAL DIAGNOSIS. 251 indications of pus, would show the presence of perinephritic abscess, in which fluctuation is rarely detected. The diagnosis is made upon its pitting, the indura- tion, and the history. Tumors here with unchanged skin, particularly in the young, almost always spring from the kidney proper, and, if in the very young, of rapid growth, and of large size, with the other associated symptoms, are chiefly due to sarcoma, although cysts are not infrequent. The spine should be examined for any local enlargement, beginning at the atlas and going down to the coccyx ; as to its general contour, whether there be kyphosis, lordosis, or scoliosis ; and as to its mobility, as shown by movement. An undue rigidity of the spine is brought out by asking the patient to pick up an object on the floor. The influence of extension in the correction of deformity should be tried in all curva- tures, and in lateral curvatures measurements should be made of the legs for inequality. Cold abscesses lie always to one side of the spine and below the affected region. In the very young certain tumors present themselves, particularly around the sacrum, the lumbar region, and the coccyx, which are placed centrally, which are deeply connected, may or may not fluctuate, are oftentimes transparent and usually congenital ; as, for instance, spina bifida and the sacro-coccygeal tumors and der- moids. In many patients at the lower portion of the sacrum a small sinus, one to two millimetres in diameter, is found, with an intermittent discharge of unpleasant odor — called the pilo-nidal sinus — which, while congenital, yet often does not begin to be annoying until early manhood. In the inguinal region many tumors present themselves for diag- nosis, and this is a common seat for error. A hernial protrusion, whether direct or indirect, of the inguinal variety always presents itself in this region, and the diagnosis should be easy by its reducibility or the presence of the characteristic impulse on coughing. A hernia may be confused with the shot-like nodes of syphilis, which are always bilateral, and with the large immovable swellings of Hodgkin's disease or, if unilateral, with bubo from infec- tion from the foot or from the urethra, whether the latter be gonorrhceal or chancroidal. The nodes also enlarge in tuberculosis, epithelioma of penis or leg, etc. The Genito-ubinaey Teact. — Kidney. — Constant pain in this region may be due to cancer or to tuberculosis ; paroxysmal pain, to stone and foreign bodies. A tearing pain is felt in hydronephrosis and pyelitis ; a dragging pain which at times is paroxysmal, attended by nausea, is characteristic of floating kidney. Tumors of the kidney are not affected by respiration. In perinephritis the patient lies on his back turned toward the affected side, with his legs flexed. It simulates, on the right side, appendicitis. Sudden increase in the amount of urine passed, following suppressed urination, is pathognomonic of hydrone- phrosis. The penis should be observed for the presence or absence of scars — for discharges, which are very important, particularly when associated with a painful knee-joint. In elderly people, particularly after fifty- five years of age, a muco-purulent discharge, commonly seen a short time after defecation, is complained of, which they attribute to former disease, but which is simply due to enlarged prostate. The normal pros- tatic discharge is squeezed out by the act of defecation. The presence of a pin-point meatus or adherent foreskin in children may give valu- able aid in many conditions. 2o2 SURGICAL PROCEDURES. Testicles. — In any abdominal tumor in the male the presence of the testicles should be sought for, as a retained testis is very liable to undergo sarcomatous change. The absence of one or both is important, particu- larly in painful swellings in the groin or about the rings. A nodular tumor of the epididymis in conjunction with a thickened vas is charac- teristic of tuberculosis. The testicle is uniformly large in sarcoma and luetic affections. The scrotum is always large, pear-shaped, and fluctuates (or if the tunica albuginea be greatly distended an elastic feel may be substituted for the fluctuation) in cases of hydrocele and hematocele. A worm-like condition of the left side of the scrotum which subsides in the recum- bent posture, and which may be prevented from recurring when the patient is standing by pressure upon the external ring, is due to vari- cocele. This is chiefly seen on the left side. Perineum. — The drawers of the patient should be examined in every case when pain is complained of in this region for the presence of pus and blood, which oftentimes are significant, though not noticed by the patient. If present, gonorrhoea, anal fissure, hemorrhoids, fistula in ano, and epithelioma may be the cause. Urinary fistulse are common in this region following stricture and urinary extravasation. A brawny, painful mass in the ischio-rectal fossa shows abscess. In this condition fluctuation cannot be detected. Hemorrhoidal tags denote past and possibly present hemorrhoids. The groin is the common seat of hernias, both inguinal and femoral, which are oftentimes difficult to differentiate. It may be said that if the finger be placed upon the spine of the pubis, any hernia which points externally to the finger is femoral — internal to it, inguinal. In fat people the spine of the pubis is found with difficulty, but may be easily reached if the leg be abducted and the finger run along the tendon of the abductor longus where it is inserted into this bony landmark. A large fluctuating swelling which may point above or below Poupart's ligament, externally or internally to the femoral vessels, or between the tuberosity of the ischium and the great trochanter, with a history of long duration, is possibly a cold abscess, and is very suggestive of spinal or hip-joint tuberculosis. Enlarged, iender lymph-nodes follow infected wounds of the foot, epithelioma and infection of the penis. They may also be enlarged from tuberculosis. With the history of an injury in elderly people when fracture of the femoral neck is suspected, resistance felt in Scarpa's triangle is very important as an aid in diag- nosis, particularly when there is flattening of the trochanter on the same side and a puckering above the patella, which latter is due to a shortening of the quadri- ceps extensor tendon. The Lower Extremity. — The knee is flexed and everted in tuber- culosis ; flexed and fixed in shortening of the hamstrings ; slightly flexed in every joint-effusion, as in this position the joint may be distended to a greater degree with less pain. In "joint-mice" and dislocation of the semilunar cartilages the knee is often flexed and locked. In hydrops articuli the joint is much swollen, but its contour is preserved and the lines of the capsular ligament are sharply defined. In all effusions in the knee-joint the patella is said to float, whether the effused fluid be blood, pus, or serum. Sinuses about the joint are commonly due to SURGICAL DIAGNOSIS. 253 neighboring tuberculosis. They are small, often multiple, and present the usual granulations of this condition. All joints should be examined for muscle-spasm, which is characteristic of tuberculosis. The Leg. — The anterior surface and shin are favorite seats for the tertiary lesions of lues. Tenderness on percussion and old sears have great diagnostic significance as to a previous active process. Varicos- ities, chiefly seen in women, are due to venous obstruction, whether just above the knee, pelvic, or thoracic, and follow the course of the internal saphenous vein, and often are associated with an obstinate pig- mented ulcer on the shin. The Foot. — Pain felt in the arch, with no perceptible injury, maybe due to flat-foot. Distention of the ankle-joint, whose normal structure will not admit of much fluid, is seen in tuberculosis ; tenseness of the tendo Achilles in talipes equino-varus. The Diagnostic Significance of Pain. The writer is indebted to Dr. J. H. Musser for the following classifi- cation and paragraphs on Pain : Pain is primarily due to either functional or local causes, the func- tional being illustrated by the headaches of anaemia or the heel-pain of gout, while local causes may be due to hyperemia, inflammation, or injury. Pain is shown (1) by facial expression ; (2) by posture. It is often pathognomonic, as, e. g., the doubling up in cramps ; the bent knee of arthritis ; the retracted head of meningitis ; the straining attitude of dysuria ; the support of the arm in clavicular fracture ; flexion of the thighs in peritonitis ; the ape-like posture with general tremor seen dur- ing micturition with vesical calculus ; the sudden upright posture in angina pectoris ; the support of the head in cervical caries ; the eversion of the leg in fracture of the cervix femoris ; the rigidity of the injured side in fracture of rib ; the immobile side in pleurisy. (3) By reflex actions — as, e. g., stiffening of the belly-wall in peritoneal inflammations, especially upon palpation by examining hands ; the erections of urethral irritation and frequent urination of bladder disorders ; and the brassy cough of aortic aneurism. (4) By the associated phenomena of disease, injury, etc. According to Musser, pain should be studied for the following aspects : First, the mode of onset; second, duration; third, time of occurrence; fourth, character ; fifth, seat ; sixth, whether affected by heat, cold, pres- sure, posture, or rest. (1) Mode of onset oftentimes gives clue to morbid processes. Sudden onset points toward inflammations of serous membranes, as in perito- nitis ; or to obstruction of some normal mucous canal, as in appendicitis, obstruct- ing gall-stones, or vesical calculi ; or to rupture of an organ or part, as sudden pain in an aneurism or in perforation of the stomach and intestines : sudden pains are also observed in neuralgias, particularly in the branches of the fifth nerve. Slow pain usually betokens slow development, as, for instance, painful urination due to enlarged prostate. (2) Duration shows the acuteness or chronicity of the cause. Pain of long duration is always associated with a long-standing cause. It 254 SURGICAL PROCEDURES. should be noted whether it is temporary or constant, as from this one may be able to judge of the disease : temporary pain may indicate either relief or a cessation of the disease, while constant pain points to a constant cause. As an example a temporary pain is felt in the passage of hard feces, yet constant pain during the passage points to some organic lesion of the rectum, as fissure or hemorrhoids. The duration may indicate the prognosis, as when in a strangulated hernia the pain ceases gangrene may have occurred. Pain following shock shows that reac- tion has set in, and hence is a favorable sign. " The abdominal surgeon should welcome its presence after operation" (Musser). Comtant pain is seen particularly in organic lesions, in inflammations of all the tissues, particularly those of bone. It may be reflex in cha- racter, as the pain and uneasiness felt in the right shoulder which is more or less constant from gall-stones. Paroxysmal pain is usually associated with nerve-lesions or neuralgias, and also with obstruction to some canal by a foreign body. Periodical pa ins are chiefly due to malaria or syph- ilis or to some atmospheric influence, or are in relation to some physio- logical process. The Time op Occubbence of Pain. — Nocturnal pains are com- mon in lues, in all inflammations of bones, as seen in the night-cries of children with hip-joint disease. Pains in the day are oftentimes due to the position of the patient, such as pain in the instep due to flat-foot. The time and the relation to some function are often very important. Gastric pain coming on before meals means gastralgia ; that occurring after meals is due to some organic lesion of the stomach, as cancer or ulcer, or at times to dyspepsia. A common example is the pain in cystitis which is felt before urination, and which is relieved by this act. This pain is due to the contact of the urine with the irritated and sensitive mucous membrane. Pain occurring during micturition points toward stone or inflammation of the urethra ; pain occurring after it often is due to stone, when the bladder contracts upon its rough surfaces. This pain is usually relieved as the urine accumulates and lifts the bladder-wall away from the calculus. The Chaeactee of Pain. — Pain may be spoken of as being due to .soreness, tenderness, aching, lancinating, or throbbing, and from each of these characteristics one is able to learn much of its cause. Soreness, particularly on movement, often indicates muscular or ligamentous origin. An aching pain is due to nerves or muscles. Aching pains may be gen- eral, and often usher in more serious general constitutional diseases, as the general pains in the bones preceding influenza. Throbbing pain is often an accompani- ment of acute inflammation, which, if it has been of several days' duration, points many times toward abscess-formation. Sharp and lancinating pain is seen in obstruction to canals by some foreign bodies, particularly calculus, and also in inflammation of serous membranes. A dull pain, particularly in bones, betokens a chronic, slow inflammation. Pain accompanied with tenesmus is usually asso- ciated with foreign bodies, as blood and stone, and is noted chiefly in the rectum and the bladder. The character of the pain often indicates the structure involved — as, e. g., itch- ing, burning pain in skin and mucous membranes, while the soreness which is increased on movement and pressure is characteristic of muscles. A deep-seated, boring pain is characteristic of bone-lesions. A sharp, lancinating pain points toward nerves. A dull, constant, aching pain is often associated with disease of some viscera. If the lightest contact to any part elicit pains, it points toward affections of the cutaneous nerves. If the skin can be freely handled without causing pain, this source can be eliminated. If deeper pressure on the groups of muscles be made and soreness be complained of, it points toward muscles. If, on making deep palpation over the location of a bone deep-seated pain is elicited, while the skin and muscles are free from pain, bone-lesions, chiefly of inflamma- tory nature, may be thought of. SURGICAL DIAGNOSIS. 255 The location of pain may be said to point fairly accurately to the lesion, providing that the nerve-distribution is recalled ; but one should always remember the possibility of referred pain. Examples of this are very common and frequently overlooked, hence the disease is not treated. Mention is made here of some of the commonly referred pains which are apt to mislead. Pain over the right shoulder is associated with gall-stones by means of the vagus and the third or fourth cervical nerves. Pain back of the ear may be due to mastoid disease, particularly if there be tenderness over this region ; but the mouth should always be examined for carcinoma of the tongue. Knee-pains often mean hip-joint disease. Pain in angina pectoris radiates down both arms. In renal disease it follows Poupart's ligament or is felt in the bladder or the testis, or may radiate down the inner surface of the thighs. In vesical calculus pain is felt at the end of the penis. In diaphragmatic pleurisy it is located above the umbilicus and to the front. In Pott's disease anywhere in the spine it is always referred to the anterior surface of the body. The high cervical Pott's lesion will give pain in the throat, with irritation which is too commonly treated for a cold. In disease at the junction of the cervical and dorsal vertebras pain is referred to the intercostal nerves and their distribution, and is often called " intercostal neuralgia ;" mid- dorsal pain is referred about the belly, and in small children is frequently thought to be due to colic. In disease of the lumbar spine pain is referred down to the pelvis. Pain between the shoulders oftentimes is due to aneurism or to cancer of the oesophagus ; pain in the neck may be transmitted by the phrenic nerve and be due to pericarditis or diaphragmatic pleurisy. So-called sciatica is often caused by a fissure of the anus, by cancer of the rectum, or by ulcer, and may be cured by treating these conditions. The pain of hip-joint disease may not only be felt in the knee, but may extend to the heel. Never make a diagnosis of " rheumatic " and "growing pains" in a child without a thorough examination, looking par- ticularly for tubercular disease in some joint or joints. Pain Modified by Pressuee and Movement — Pain increased by pressure is due to inflammation ; if relieved it is either neurotic or func- tional. Pain that is relieved by pressure, particularly around the belly, often is due to a reposition of some organ which has been dislocated : this is chiefly seen in the kidney, as when a patient himself can replace a movable kidney and thus relieve the characteristic sickening pain of this affection. Pain that is increased by pressure at "nerve-points" means neuralgia. If by pressing upon the head or by having the patient jar himself by his feet pain be elicited along the spine, it is characteristic of Pott's disease. The influence of movement is very suggestive. The contraction of an inflamed muscle is painful. If it be found that certain active movements are painful, but that the movement can be made passively without causing pain, it may be put down as muscular. It is not the position of the limb which is painful, but the method of obtaining it. Ligamentous pain, whether active or passive, is elicited by any movement which stretches the ligament; hence in moving any joint, if it can be done passively to its normal degree without causing pain, the articular surface composing that joint may be said to be free from disease ; but the moment the joint and the ligaments about it are put upon the stretch and pain be elicited, it is ligamentous in origin. Pain in Special Regions. — Pain in the extremities, if bilateral, may may be due to disease of the spinal cord or to neuritis, toxaemia, or pressure ; if unilateral, to injury, inflammation, or pressure, or to transmitted sensations. Pain in the foot is usually caused by flat-foot; in the heel, by gouty or rheu- matic conditions, although it may be caused by aneurism of the popliteal artery pressing on the popliteal nerve. Pain in the space between the third and fourth 256 SURGICAL PROCEDURES. metatarsal bones is due to pressure on a small branch of the plantar nerve, which is nipped between the articular ends of the two contiguous bones. Pain is usually- located in the shoulder when due to liver disease; in the back, when due to dis- orders of the stomach ; in the interscapular region, in ulcer of the stomach. Pain behind the sternum, common in gastric disorder, may also be due to aneurism, tumor, or angina pectoris. Pain in the sternum or ribs may be due to syphilis or periostitis. The pain in the loins, when acute, may be due to a dislocation of the kidney, to calculus, to uterine disorders ; when chronic, to uterine and renal dis- orders and varicocele. Coug-h. — In aneurism of the carotid, and even of the aortic arch, a peculiar metallic, brassy cough and irritation of the throat are com- plained of. The dry, constant, hacking cough due to irritation, which by turn is caused by pressure, is often seen in women with thyroidal enlargements and in many tumors of the neck. The constant cough of irritation due to enlarged uvula, and a cough similar to that described above as due to pressure of tumors, may be found associated with car- cinoma of the oesophagus. Cough may be also caused by the presence of a foreign body in the auditory meatus. It is transmitted along the auriculo-temporal branch of the fifth nerve. In infants cough may be due to irritation of the stump of a tooth. PART IV. INJURY AND REPAIR. CHAPTER XXI. WOUNDS. By Chas. B. Nancrede, M. D. Subcutaneous Injuries, Contusions, Lacerations, etc. Subcutaneous Injuries, Contusions, and Lacerations vary in severity from the pain and swelling of the skin, which promptly appear and as promptly disappear, for example, after a cut from a whip — i. e. a wheal — to complete disorganization of a limb, the skin alone remaining intact. The most common causes are blows from or falls upon blunt objects, the passage of wagon- or car-wheels, and entanglement of a limb in ropes or machine belting. The connective tissue with its vessels always suffers. When only a few vessels are ruptured an ecchymosis or bruise results, with pain, tenderness, swelling, and discoloration of the parts, the effused blood as it reaches the surface changing its purplish hue to a brownish, green, and yellow tint as it fades away. The effusion may either be evenly distributed throughout the damaged tissues — hem- orrhagic infiltration — or form circumscribed collections — ecchymoses or sugillations. In lax tissues, as the axilla, or where a limb has been traversed by a wagon-wheel, the major part of the skin may be stripped off from the deep fascia, and the cellular tissue and the intermuscular spaces be distended by such an enormous extravasation that death results from the sudden abstraction of blood from the circulation, or gangrene occurs because the pressure upon the small vessels is such that the collateral circulation cannot be set up. These accidents rarely occur except as a result of the giving way of a large vein — e. g. the axillary or external iliac. When the larger blood-collections become circum- scribed by condensation of the surrounding tissues, they are called hcema- tomata. Occurring in certain regions, a prefix or suffix is added to indi- cate the locality — -cephal when occupying the scalp (cephalhcematomata) ; arthrosis when a joint is concerned (hamiarthrosis). The pressure exerted by the effused blood usually arrests the bleeding, and coagulation gen- erally sooner or later occurs. The clot eventually breaks down into a thick, reddish fluid which often assumes a brighter tint when exposed to the air. Repair takes place without true inflammation unless infection occurs. The coloring matters of the disintegrated clot diffuse into the 17 257 258 INJURY AND REPAIR. surrounding tissues, and with the liquid portions are removed by the lymphatics. Symptoms. — Pain, except when a nerve-trunk is damaged, is de- pendent upon and proportioned to the tension resulting from the swelling, which varies with the amount of effusion and the laxity of the tissues : when confined beneath tense, unyielding structures, as fasciae, a small effusion may be productive of severe pain, while a large one in lax tissues, as the scrotum or eyelids, may cause nothing beyond slight discomfort. Discoloration shows promptly if the bruise is superficial, but may not appear for many days if the deeper parts are those injured or the effusion occurs beneath an unruptured fascia. At first of dark purple, the color changes to green, then to yellow, finally fading out. Constitutional reaction — "aseptic fever," so called — is proportioned to the extravasation and laceration ; i. e, the amount of fibrin-ferment and nucleins available for absorption. When the injury is super- ficial the overlying skin presents the evidences of plastic exudation — viz. normal reparative processes — -which soon disappears unless infection occurs. Treatment. — Rest must be secured for the part by splints, position, or both. Even where no appreciable lesion of the epithelium is dis- cernible, it is better to carefully sterilize the surface and employ subse- quently only aseptic applications, because portions of the skin may have been actually killed, and yet no evidence of this appear until later : these precautions are imperative if abrasions do exist, lest infection occur. Cold may be employed to check effusion by applying ice-bags, iced lotions, or aseptic lotions so disposed as to permit constant evapora- tion taking place, especially for the more superficial injuries. Alcohol- and-water is one of the best evaporating lotions, to which morphia may be added if desired. The value of lead-water is doubtful. Irrigation with cold sterilized water may sometimes prove useful in certain severe contusions, but all cases where any form of cold is used must be care- fully watched lest gangrene be precipitated. Massage has been recom- mended for slight contusions, because it favors rapid disappearance of the effused blood by distributing it over a greater area, but a judicious selection of cases must be made, lest more harm than good result. In the more severe injuries the effusion may be checked and absorption hastened by gentle, elastic pressure, such as can be secured by the careful application of bandages over many layers of cotton, first having aseptic- ally emptied all blebs and protected them by proper dressings. If the tension comprises the integrity of the parts, aseptic aspiration, followed by gentle pressure to prevent fresh hemorrhage, usually suffices, although incision may be requisite to satisfactorily evacuate large collections if much clot be present. When coldness and oedema of the part show that the collateral circulation is seriously interfered with by the pressure of the effused blood, as this probably comes from a large vessel or ves- sels, aseptic incision, ligature, perhaps packing and proper drainage are indicated. Injuries of Vessels. Arteries.— Mere contusion, if the vessel be superficial, compression against a bone if deeper, or overstretching during the production or WOUNDS. 259 reduction of dislocations, may cause partial or complete rupture of an artery. In the former variety the internal or middle and internal coats yield, usually in such a manner that, curling upward and downward because of their normal elasticity, they partially or completely occlude the vessel, thrombosis soon rendering complete any partial blocking. Even when the incurved coats do not seriously interfere with the blood- current thrombosis often results. Symptoms. — Unless the incurved coats at once block the vessel, no symptoms appear until thrombosis diminishes or cuts off the blood- supply, when the pulse in the distal segment of the artery either becomes feeble or is arrested, according to the rapidity of clot-formation : the part becomes numb, powerless, pale, and cold, with neither swelling nor extravasation to explain the condition. Sometimes severe pain is com- plained of. Later, if gangrene does not occur, enlarged collateral vessels may be detected. When the rupture involves all the coats and the opening is large, if the surrounding tissues are lax, an enormous soft, fluctuating, imperfectly circumscribed swelling forms in a few moments, and the loss of blood from the circulation may be so great as to produce syncope. The distal portion of the limb becomes swollen, pale, and oedematous, and no pulsation can be detected in the vessels below the injury. Extreme .pain is common. Pulsation is absent in the swelling or can onlyTxTdetected over a small area : it is not expansile, nor is there usually bruit nor thrill. If a bruit be present, it is not conducted along the vessel. If the surrounding tissues are dense enough to resist the effusion, a small rent in even a large vessel may give rise, for a time only, to more or less vague symptoms of traumatic aneurism, and then, after some days, perhaps quite suddenly, the barrier yields and the blood spreads widely through the limb, forming a cha- racteristic arterial hcematoma. Diagnosis. — When immediately after injury a diffuse, fluctuating swelling, perhaps pulsating over a small area, with bruit and thrill, appears in the course of an artery, with cessation of the pulse below, the diagnosis is clear enough ; but when the vessel is deep-seated and much inflammation exists, the condition closely simulates acute phleg- mon or even a rapidly-growing sarcoma. If neither thrill, bruit, pul- sation, nor alteration in the distal pulse can be detected, exploration with a grooved needle or aspirator must precede any active interference in doubtful cases. Traumatic aneurism, arising from yielding of the partially ruptured arterial wall, appears some time after injury and presents the ordinary symptoms of aneurism. Treatment. — When that surgical rarity, simple occlusion, results from contusion of a large vessel, carefully sterilize the skin, dress with abundance of sterilized cotton, place the limb in an elevated position, and wait to see if gangrene ensue. The gangrene, if it occur, may prove to be less extensive than at first appeared probable, one or more toes perishing instead of the extremity, so that before operating it is better, if possible, under aseptic dressings, to allow the line of demarcation to form and not amputate at the level of arterial occlusion. Traumatic aneurism must be treated as indicated by the locality and calibre of the vessel. An arterial haematoma — i. e. a diffused traumatic aneurism — re- quires prompt intervention. As the condition is really a wounded artery, 260 INJURY AND REPAIR. it should be treated as such if the vessel be of any size. In addition to the danger from mere loss of blood, the effusion often interferes so seri- ously with the collateral circulation that gangrene will occur unless the pressure be relieved. Gentle compression has been recommended when the extravasation tends to cease spreading and the collateral circulation is fair. This is questionable practice, except for the smaller arteries. When the diagnosis is clear, ligation should be done as directed for traumatic (circumscribed) aneurismT The efficiency of modern methods for controlling hemorrhage, the immunity conferred by asepsis against secondary hemorrhage and septic inflammation, and the certainty of remedying the effects of the injury, all indicate that this is the proper course to pursue. Moreover, the necessary incisions will permit of the removal of so much of the effused blood as will materially relieve the collateral circulation. While amputation at the level of the rupture is the only resource if gangrene of the segment of the limb actually occur, either before or after ligation, the emphatic warning must be repeated that with aseptic methods the surgeon can usually safely wait until no doubt exists as to the extent of the destructive process. Veins. — Contusion occasionally produces rupture of the internal coats, initiating a thrombosis which blocks the vein, but even when the main vein of a limb is concerned the free anastomosis prevents gangrene. The extent of extravasation in subcutaneous rupture of veins is rarely serious in itself, but if one of the main veins be ruptured or a branch be torn off close to the parent trunk, where the surrounding tissues are lax, as in the axilla, the amount withdrawn from the general circulation may threaten life or cause gangrene by interfering both with the direct and collateral circulation. Treatment. — Elevation of the part, coupled with cold and equable pressure, usually suffices, but where the effusion causes so much com- pression as to threaten gangrene incision and suture with catgut for small wounds and ligation for transverse wounds should be done, after turning out all the clots. While pressure combined with elevation is often sufficient, suture or ligation is perfectly safe, and more reliable when the effusion tends to spread. Lymphatics. — In all contusions lymph is extra vasated, and in some cases much of the effusion is composed of lymph. It may even form a fluctuating tumor containing yellowish or reddish fluid. These lymph-effusions most often result from laceration of the lymphatics tra- versing the subcutaneous cellular tissues, and are therefore most apt to occur when the skin is extensively displaced from the subjacent parts. These tumors form rapidly at the outset, to soon become stationary (lymph-cysts). When they progressively increase, rupture with the for- mation of a lymph-fistula may result. Injuries of Nerves. Experiment shows that slight blows inflicted upon nerves produce extravasations of blood into the neurilemma and between the nerve- fibres. The fibres are contracted at the point struck and irregularly enlarged above and below. In the more severe rases the Wallerian degeneration sets in within a few days, but where the hemorrhage is WOUNDS. 2(51 very slight and only a few fibres are torn, the paralysis rapidly disappearing, most of the fibres undergo, according to Mitchell, only a mechanical disturbance, and a rcslihilio ail inliyraiii rapidly occurs. Symptoms. — These vary with the severity of the injury. In the slighter eases pa.in will be felt at the point of injury, immediately fol- lowed by niini/nirsH and fit rmiiuii ion in the peripheral distribution of the nerve. A sensation of burning or heat is often experienced, and even actual flushing of the skin has been occasionally observed. All these sensations usually disappear in a few minutes, but the tingling may per- sist for several days. In more severe eases the punestliesut and paresis continue, neuralgic pain appears, and a distinct chronic neuritis, tending to spread and resulting in various trophic lesions, occurs. After the most severe contusions immediate and complete paralysis of both motion and sensation ensues. This may pass away with great rapidity : improvement may not set in for weeks or months, or tin: paralysis may be permanent. Tt is well to note that the peripheral areas supplied by nerves may vary in different, individuals, and that anastomoses occur with other nerves: ignorance of these facts lias led, and again may lead, to the most erroneous conclusions. Com- plete rupture of a nerve is of course accompanied by initial pain and immediate sensory and motor paralysis in the area supplied by the severed nerve, the changes consequent upon nerve-section following later. Treatment. — When seen early an attempt should be made to limit the effusion of blood and the exudates of repair by perfect rest of the part: morphia is often demanded for the pain. Later, counter-irritation, blistering, massage, and galvanism are indicated. When a well-grounded suspicion exists that the nerve has been actually severed, and no improvement in the paralysis takes place in from eight to ten months — symptoms of neuritis being absent — an exploratory operation may be done, the nerve examined, and if found severed the ends must be fresh- ened and sutured together: if markedly reduced in size at the point of injury, in extreme eases, resection of the damaged portion and suture is indicated. If, despite of appropriate treatment addressed to the neuritis 1 when this occurs, the disease continues to extend, Bowlby suggests that the nerve should be exposed and stretched to free it from adhesions to and pressure by the surrounding inflamed tissues : nutritional changes are also set up in the thickened nerve, tending to remove the compress- ing inflammatory exudate. Injuries of Muscles. Much pain, effusion of blood, and loss of power may result from contusion of muscles, but these symptoms are usually only temporary. Sometimes permanent . Alveolar Sarcoma. — This is a rare form, in which the cells, con- trary to the general rule of sarcomata, assume an alveolar arrangement strongly imitating that of epithelial cells in carcinoma. Almost invari- ably, however, on minute examination it will be possible to distinguish a delicate reticulum between individual cells, which is never met with in cancer. By some the alveolar sarcomata are grouped as belonging to endotheliomata {q. v.). On this point we need further light. Their common situation is in the skin, especially in connection with congenital defects, such as hairy and pigmented moles. E. Melano-sarcoma, sometimes known as Melanoma. — This refers to the deposition of pigment, rather than to type or shape of cell, the dis- tinguishing feature of these growths being the presence both in the cells and in the intercellular substance of a variable quantity of blackish pigment. Of all the forms, the melanotic growths are generally con- sidered the most malignant. They invariably recur after removal, they lead to secondary deposits at long distances, and they present the most intractable and incurable form of cancer. Deposition of pigment in carcinomata is most rare, if ever met with, and the growths heretofore 324 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. spoken of as melanotic cancer should be relegated entirely to the class just under consideration. ( Vide Plate XIII.) General Characteristics of Sarcomata. — The vascular supply of sarcomata varies within wide limits. In nearly all instances it is of capillary character, the blood circulating rather through vessels with well-marked walls. While large vessels may be found about and in the periphery of these tumors, distinct vascular structure is usually absent from the more internal vessels ; all of which will explain the frequency of hemorrhage, its persistency after operation, and the ease with which large extravasations occur. True hsematocele may thus take place within sarcomatous tumors with the usual later cystic alterations, and thus in one way we have the condition frequently spoken of as cysto-sarcoma. In attacking these growths the most vascular and bloody area may be met with just about their margins, the blood-vessels expanding as they arrive at the tumor, and bleeding sometimes furiously. Under most circumstances, however, this hem- orrhage can be controlled by packing or by operating at a little greater distance from the circumference of the growth. Metastasis in sarcoma is common, dissemination occurring mainly along the veins, since these growths often penetrate into .the venous channels and permit of easy detachment of fragments, which are then carried along as emboli. These emboli pass naturally to the right side of the heart, and thence to the lungs, where it is most common to find secondary growths, except in areas emptying into the "portal veins, in which case the liver will be the most common site. Sarcomata are destitute of lymphatics, and dissemination does not occur through these channels. Infiltration is also a common phenomenon with these growths. This is perhaps most often seen in muscular tissue, particularly with growths proceeding from the periosteum and projecting into it. Sarcomata, like other tumors, tend to grow along the lines of least resistance. Hence processes of these tumors will insinuate themselves into fissures and interspaces, and penetrate perhaps even into the cavi- ties, from which it is hazardous or impossible to remove them. Thus, sarcomata springing from the head of a rib have been known to extend through an intervertebral foramen and give rise to an intraspinal tumor, causing fatal pressure. Secondary changes are commonly met with in sarcomata, the most frequent being hemorrhage. Myxomatous degeneration is also frequent, and gives rise to cystic conditions. Calcification is common, particu- larly in the more slowly-growing tumors which arise from bone. Upon the other hand, necrosis (i. e. ulceration) is common in growths which project upon the surface or into any of the open cavities of the body. Ulceration here is simply an expression of growth at a rate relatively faster than the possibilities of nutrition permit, and gangrene is to be Angiosarcoma: blood-vessel with coagu- lated blood (X %"; Spencer). PLATE XIII. Melano-Sarcoma of Skin; a, Stroma with Pigment Cells; b, Endothelial Cell Nests with Migrated Pigment Cells. (Klebs.) CYSTS AND TUMORS. 325 regarded as a failure to supply sufficient blood. It may also mean infec- tion, of which it is, indeed, a usual expression. Tumors of this character, which luxuriate upon reaching the surface, and which bleed easily upon the slightest touch, were known in time past as fungus hcematodes. The name may be preserved for the sake of con- venience, but should be held to mean in almost every instance a rapidly- growing, round-celled sarcoma. Sarcoma is common in the lower animals, particularly so in horses — most common in those of gray color. It is met with also in cows and various other domestic and undomesticated animals. Glioma. Glioma, by some regarded as a variety of sarcoma, is by others (e. g. Sutton) considered as a distinct variety of tumor. Inasmuch as the nervous system is really of epiblastic origin, it is questionable whether gliomata may not, after all, belong in Group VII., Tumors of Epithelial or Hypoblastic Origin. For purposes of simplification, at least, it may be well included here as a type of sarcoma. It consists of delicate con- nective tissue, identical with that which is known in the histology of the nervou,s system as neuroglia. It bears the same relation to the central nervous system that plexiform neuroma bears to peripheral nerves. It occurs only in the former — that is, in the brain, in the spinal cord, and perhaps in the optic nerve. Structurally, it consists of cells with delicate ramifying processes held in place by fibrous tissue. Gliomata are usually quite vascular, the vessels being even sometimes sacculated. For the most part these tumors are solitary — i. e. do not give rise to secondary deposits. When near the surface of the cortex such a tumor may appear like an enormous convolution (Virchow). In the basal portions of the brain these tumors may attain considerable size. Gliomata in the spinal cord are rare, occurring twenty times as often in the brain as in the cord. In the latter location they are usually indistinctly outlined and cause a general enlargement of the cord. They may occur anywhere along its length, but are most common in the cervical portion. They are most common also between the fifteenth and thirtieth years of life, but may be met with in old age. The symptoms of these growths consist usually of pressure-effects, and it is ordinarily impossible to diagnose them before either operation or autopsy. If attacked at all, they need to be most radically extirpated, else these, like sarcomata in general, are most prone to return. 5. TUMOES OF SIMPLE MESOBLASTIC-TISSUE TYPE. Lipoma. Lipomata, or tumors composed of fat, are the most commonly met with of all neoplasms. Their normal type is the ordinary adipose tissue of the body, while, anatomically, they may be divided into the encap- sulated and the diffuse, the former of which are surrounded by more or less of an investment of fibrous tissue by which a certain form and integrity are preserved. The diffuse lipomata are those which are pos- sessed of no capsule, where the pathological collection of fat merges into that normally present — in other words, they are not circumscribed. 326 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Subcutaneous Kpomata are perhaps the most common of all, and are usually irregularly lobulated and encapsulated, adherent rather to the skin than to the deeper tissues. Usually but one is found in a given individual, though instances of multiple lipomata are not rare. They develop sometimes to enormous size, cases being ou record where the tumor has even weighed one hundred pounds. They may be met with at any point on the surface of the body. The lobules often burrow between the muscles, and those found in the palm of the hand penetrate even beneath the palmar fasciae. They are sometimes markedly pedunculated, and hang often by a small stem. The diffuse subcutaneous lipoma is most common about the neck ; next most common in the groin and axilla. Subserous lipomata are for the most part retroperitoneal, and very large tumors of this character, mistaken for ovarian tumors, have been successfully removed by operation. In the hernial canals and spaces they also are met with. They develop, moreover, beneath the peritoneum covering the intestines, and in this location they give rise occasionally to intussusception. Here they have the general form and significance of appendices epiploicx in their pathological development. Subsynovial lipomata occur about various joints and tendon-sheaths ; especially within the knee they assume a distinctive type which has been called lipoma arborescens, where they take on a dendritic appearance and arrangement. Submucous lipomata are rare. Intermuscular fatty tumors are occasionally met with, an inter- esting variety being that which develops between the masseter and buccinator muscles. Intramuscular forms are also rarely met with, as well as a variety known as parosteal, which arise in connection with the periosteum. Fatty tumors also occur within the spinal dura, as well as outside of it within the spinal canal, and more or less lipomatous alterations are common in connection with spina bifida. Lipomata are ordinarily easy of recognition, save when deeply located. The subcutaneous forms are intimately related with the overlying skin, and have a dough-like consistence which is usually pathognomonic. Those tumors, suspected to be fatty, which are met with in the middle line of the back or cranium are always to be viewed with suspicion, since they are often connected with congenital meningeal protrusions. An encapsulated lipoma, when thoroughly removed, will not return. It is when one deals with the diffuse variety that he often finds inter- ference unsatisfactory or regrets that he has attempted it, the difficulty being in knowing where to stop. Mixed forms of fibrous and fatty neoplasm are not infrequently met with, which may be spoken of as lipoma fibromatosum or fibroma lipoma- tosum according as one or the other tissue predominates. These growths are innocent in their character, but call for thorough extirpation. They frequently give rise to considerable discomfort or pain — so much so that they have been spoken of as lipoma dolorosa. Pibeoma. Fibromata are tumors composed of fibrous tissue, which, when of pure type, are found to be not so common as was formerly supposed, the majority of tumors hitherto roughly grouped as fibromata containing either muscle-tissue or sarcomatous elements, which takes them out of the category of pure fibroma. A typical fibroma is ordinarily dense, and is composed of wavy bundles of fibrous tissue whose cells are long and slender and closely packed together, the mass being permeated by distinct blood-vessels. Fibroma occurs most commonly in the ovary, the uterus, the intestine, the gum (epulis), in nerve-sheaths, and in the skin in the form of so-called PLATE XIV. ' - ; i -':i^ Keloid of External Ear. «, Dense Tissue of Skin; A, Fibrous Connective Tissue; r. Epidermis. (Klebs.) CYSTS AND TUMORS. 327 painful subcutaneous tubercles and molluscum fibrosum. There is also a fibrous tumor of the skin, known as keloid, sustaining to fibroma the same relation that obtains between exostosis and osteoma. The painful subcutaneous tubercle of many writers is a sample of pure fibroma in the shape of a small, flattened pea-like tumor which never attains great size. It is situated loosely in the subcutaneous structure and may form a visible prom- inence. Insignificant as it would thus appear, it becomes the seat of exasperating pain, particularly when touched or handled : this may radiate to considerable dis- tances. The etiology of these little growths is absolutely unknown. In the ovary, the uterus, the intestine, and the larynx pure fibrous tumors are pathological curiosities rather than common lesions. Epulis means, in effect, any tumor growing upon the gum. The term was formerly applied in an indistinct and too comprehensive way, although it is still retained in literature. But pure fibromata do spring from the fibro-osseous struc- ture of the gum and alveolar process. They are covered with the gingival mucous membrane and seem to spring from the periodontal membrane. They seldom attain large size; then only through neglect. By the pressure of such tumors teeth may be separated and no little distortion of the mouth produced. Keloid is a fibrous neoplasm arising, for the most part, in cicatricial tissue, which is essentially fibroid in structure. It is a neoplasm which often follows the general outline of the scar in which it grows, consists in elevation of the surface, ordinarily quite smooth, sometimes of a delicate pink from the dilated vessels which it contains. Keloid is the bite noir of surgeons, since it frequently complicates and disfigures scars which have been at first perfectly satisfactory, and since it indicates a condition which it is discouraging to deal with, because when it is removed there is usually recurrence of growth within a few months after cicatrization. It occurs often in stitch-hole scars and upon the site of extensive burns, may be met with after puncture of the ears for ear-rings, and has also been observed in scars left by smallpox, acne, etc. It is more prevalent in the col- ored than in the white race. In negroes FlG - 9l multiple keloid tumors are often seen, occasionally even in large numbers. Their explanation is unknown, and it may be that some trifling injury has preceded each individual tumor. Vide Plate XIV. Chondroma. The true chondroma is a tumor composed of hyaline cartilage. It occurs most often and typically in the long bones, usually in relation with epiphyseal cartilages, and, con- sequently, is most often noted during the earlier years of life. While it is usually a solitary tumor, multiple chondromata are often seen, especially upon the hands. These tumors are often encapsulated, and form deep hollows in which they rest. Unless pressing upon nerve-trunks, they are painless and slow of growth. They are exceedingly dense and hard, and ordinarily immov- Enchondroma from inner aspect of pelvis (contributed by Dr. Holloway). 328 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. able. Mucoid softening (i. e. cystic degeneration) is common, and the softened areas may give rise to fluctuation. There may be coincident calcification or ossification in any of these growths. It is noted as a curious circumstance, by Sutton, that their tissue resembles histologi- Fig. 92. Multiple enchondromata (contributed by Dr. Holloway). cally the bluish, translucent epiphyseal cartilage which is seen in pro- gressive rickets. To the small local hypertrophies of cartilage which are seen especially about joints, about the laryngeal cartilages and the triangular cartilage of the nose, are given the term ecchondroses. They are most common in the knee in connection with rheumatoid arthritis, and occur as prominences along the margins of the joint- cartilage. They may project to such an extent as to be detached by accident, after which they become movable and floating bodies in the joints. Many of the float- ing cartilages or bodies found in joints are, in other words, detached ecchondroses, CYSTS AND TUMORS. 329 which may be smoothed off by attrition, and which may be found singly or multi- ple, even several hundred existing in one joint. Chondromatous changes as occurring in sarcomatous tumors have already been alluded to. It seems to be easy for connective tissue to form hyaline cartilage, and mixed tumors may thus be met with in connection either with sarcoma, fibroma, or other forms. The treatment of chondroma is solely operative. Unless the integrity of a member or a limb be compromised, such a tumor can usu- ally be shelled out from its location, but requires that the matrix be completely extirpated ; all of which may call for the use of powerful bone-instruments. At other times amputation is the only measure which may relieve from deformity, pain, and disability. The eechon- droses occurring within joints call usually for incision and evacuation with the most rigid aseptic precautions, with or without drainage, as the case may be ; when practised according to modern technique this is almost invariably successful. In former times many lives were lost because of septic infection, which is now avoidable. Osteoma. Under the head of Nomenclature I have already endeavored to dis- tinguish as between exostosis, or irregular bone-outgrowth, and oste- oma, as a distinct tumor which is composed of bone-tissue, with the subvariety odontoma, or tumors of dental origin and structure. Oste- oma is regarded by some as ossifying chondroma, since it is nearly Fig. 93. Double osteoma of skull (Musee Dupuytren). always found near epiphyseal lines, and is always covered by hyaline cartilage when thus found. Nevertheless, it is not invariably such. We speak of compact or ivory osteoma and of a cancellous form. The former is identical with the compact tissue of the shafts of long bones, and may occur anywhere, but is most common about the cranium, at the frontal sinus, the external meatus, and the mastoid process. Osteomata growing into the frontal sinus of oxen, for instance, form large lobulated bony masses, sometimes weighing several pounds and as dense as ivory. Some of these tumors growing into the cranial cavity have been absurdly regarded as ossified brains. Osteomata in connection with the external auditory meatus partially or completely obscure this channel and cause deafness. They constitute ivory-hke growths, which defy sometimes the finest steel instruments with which the surgeon can sup- ply himself. 330 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 94. A s 'di-'- ^V / ' '■' ~~~ .■ . . 4 - ' ' '■^L ■ ■ . ; > ■■-■'" Osteoma of frontal sinus (Neisser). Cancellous osteoraata grow in the cranium as well as in the long bones, and, like the compact forms, only occasion pain by pressure upon nerve-trunks. Exostoses are classed by Sutton as — (1) Those formed by ossification of tendons and their attachments. One should exclude from this group such natural or evolutionary processes as the superior condyloid process, the third trochanter of the femur, etc. Over or around such exostoses bursse will form to mitigate as much as possible the effect of friction. (2) Subungual exostoses, occurring usually beneath the nail of the big toe. (3) Exostoses due to calcification of in - flammatory exudations, incl uding the rare condition known as myositis ossificans. When a true osteoma is once thoroughly removed there is no tend- ency to recurrence. Thorough removal, however, calls sometimes for serious and often mutilating operations, which may become dangerous when the growth involves the curve of a rib or a large portion of the skull. At other times amputation is rendered necessary. Special forms call for special treatment suitable to the case in hand. Odontoma. 1 The odontomata are tumors composed of one or more of the dental tissues, arising either from tooth-changes or teeth in process of develop- ment. They may be divided, according to Sutton, as follows : (a) Epithelial Odontomata. — These are provided with a capsule, and present usually as a series of cysts separated by thin septa, containing mucoid fluid, while the growing portions have a reddish tint not unlike sarcoma. They are most frequent about the twentieth year of life, but may occur at any age. They probably arise from persistent remains of the epithelium of the original enamel-organs. (6) Follicular Odontomata. — These are often spoken of as " dentiger- ous cysts," a term used altogether too loosely. They arise in connection with permanent teeth, and especially with the molars, sometimes attain- ing great size and producing conspicuous deformity. The tumor con- sists of a wall representing the expanded tooth-follicle, and a cavity containing viscid fluid, with some part of an imperfectly developed tooth, occasionally loose, occasionally more or less displaced in location. The cyst-wall always contains calcareous material. These tumors rarely suppurate. They occur also in animals. 1 These tumors are really of epithelial origin, since the teeth are epithelial products. They therefore really belong in Group VII., but are retained here because of their clini- cal resemblance to the osteomata, and lest previous classifications suffer too violent a shock. CYSTS AND TUMORS. 331 (e) Fibrous Odontomata. — These consist of condensed connective tissue in a developing tooth, and presenting as a tumor with a firm outer wall and a loose inner texture, blending at the root of the tooth with the dental papilla and indistinguishable from it. The developing tooth thus becomes enclosed within the capsule before it protrudes from the gum. These tumors are most common in ruminants, being often mul- tiple. (d) Cementoma. — This refers to a tumor of fibrous character whose capsule has ossified or calcified, the developing tooth thus becoming imbedded in a mass of dental cementum. These tumors occur most frequently in horses. (e) Compound Follicular Odontomata. — These are tumors containing a number of masses of cementum resembling small teeth, or even amounting to well-formed but ill-shaped teeth composed of all three dental elements. In such a tumor teeth may be found by the score. They are met with in the human subject as well as in animals. (/) Radicular Odontomata. — These are tumors which arise after the crown of the tooth has been completed and while its roots are yet in process of formation. The crown, being unalterable enamel, does not enter into the composition of these growths, which then consists of dentine and cementum in varying proportions. These tumors are rare in man, but frequent in other animals, and often multiple. (g) Composite Odontomata. — These are hard tumors, bearing little or no resemblance in shape to normal teeth, occurring in the jaws, consist- ing of a conglomeration of enamel, dentine, and cementum, presenting abnormal growth of all the elements of the tooth-germ. So far, this has only been found in man. So little is said about the odontomata in general surgical literature that I have devoted some space to the subject here, since these tumors, as they grow, are often regarded as due to necrosed bone or to unerupted teeth, while fibrous odontomata have often been regarded as myeloid sarcomata. No tumor of the jaw, especially in young people, should lead to excision of the jaw until it has been fairly demonstrated that the tumor is not one of the above forms, and that it really is something call- ing for so severe an operation. When one has to deal with a true odon- toma its complete removal is all that is called for, and no further sacrifice of tissue is necessitated. Myxoma. The myxomata are composed of mucous tissue, whose best^known normal representative is the Whartonian jelly of the umbilical cord. True myxoma should be distinguished from myxomatous degeneration, which occurs frequently in cartilage, fibrous tissue, and sarcoma, and which brings about a similar condition of affairs, though of essentially different origin. Myxomata appear under the following forms : (a) Polypi, growing most often in the nose. The pure form of nasal myxoma proceeds from the mucous membrane of the nasal passages or sometimes from the accessory sinuses. The polypi hang usually as gelat- inous tumors of grayish-yellow tint, being present sometimes singly, sometimes in clusters or in large numbers. Their principal effect is to produce nasal obstruction, with, perhaps, subsequent serious disorder 332 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. due to decomposition or to extension into the pharynx or other cavities. Similar growths also occur from the mucous membrane of the tympanum, and constitute the common variety of aural polypi. (6) Cutaneous myxoma is not common. It presents usually as a ses- sile tumor, although about the perineum and labia the tumors may become pedunculated. It is often difficult to distinguish between a myxoma of the skin and a sarcoma of the same which has undergone myxomatous degeneration, and which then should be strictly called sar- coma myxomatoses. The latter tend to recur after removal ; hence the importance of exact diagnosis, if possible, in which the history of the case will largely aid. (c) Neuromyxoma is a similar condition involving the nerve-trunks, and is dealt with rather under the heading " Neuroma." Myxomata require complete removal, and in the nose especially cau- terization or destruction of the surface from which they spring. When this is thoroughly done they do not recur ; otherwise, they are quite likely to require subsequent operation. Myoma. The true myoma is a tumor composed of unstriped. or involuntary muscle-fibre. Until, very recently it has been customary to divide the myomata into the leiomyomata in contradistinction to the rhabdomy- omata, the latter being supposed to be tumors of voluntary muscle-fibre. The latter, however, are now known to be spindle-celled sarcomata (q. v.), in which a certain striation of spindle-cells is often observed, and have been already spoken of in their proper place. Myomata, then, are met with only where involuntary muscle-fibre is found — namely, in the uterus and adnexa, the vagina, the oesophagus, alimentary canal, the prostate, the bladder, and the skin. They form encapsulated tumors composed of fusiform muscle-cells with a rod-like nucleus, the size of the cells vary- ing greatly in different specimens. The bundles of muscle-fibres are much contorted, and it is often difficult in a single section to decide to just what class of cells they really belong. These tumors are by all means most common in and about the uterus, and are spoken of as intramural when developing in the true uterine tissue, and submucous and subserous when situated closely beneath one or the other of the adjoining mem- branes. They differ greatly in their rate of growth, are, as a rule, quite firm in composition, and are moderately vascular, sometimes containing areas of softening and becoming even cystic. In rare instances they become enormously vascular, and have then been spoken of as cavernous myomata. Aside from mucoid or col- loid changes, such as referred to, they occasionally undergo fatty metamorphosis or calcareous infiltration. The latter is possible even to such an extent as to lead to the condition formerly spoken of as uterine calculi. Uterine myoma is quite liable to septic infection, which frequently follows exploration of the uterus o r the changes incident to pregnancy or parturition. It then becomes a case for immediate and most radical surgical attack. Uterine myomata do not occur before puberty, rarely before the age of thirty-five, and are most common between the thirty-fifth and forty-fifth years of life. More definite information concerning the enormous size which they attain or the special cha- racteristics which they display must be sought in the special treatises on Gyne- cology. They produce disaster not alone by their size, but by hemorrhage, by pressure on adjoining viscera (rectum, kidneys, etc.), and occasionally by torsion of a long pedicle. The operations, including myomectomy and hysterectomy, which are necessary so often for their complete removal, will be treated of at PLATE XV. ■ \<\T.> ,' '' '■■■.■■ V.: ti <■?, - -mm. . . . 7 L % Cavernous Angeioma of Liver; a, Vascular Portion; b,e,d, Growing Neoplasm; c, Hepatic Tissue. (Klebs.) CYSTS AND TUMORS. 333 greater length elsewhere, while for full information the reader must necessarily be referred to the special treatises. Myomata are found in the oesophagus anywhere along its course, in the walls of the stomach, where they are frequently confounded with malignant tumors, and in the prostate and wall of the bladder. Also in connection with the skin they are occasionally met with. Wherever met with, so soon as they give rise to incon- venience or to dangerous symptoms they are to be dealt with surgically, since no other treatment has been proven to be of lasting benefit. 6. TUMORS OF COMPLEX MESOBLASTIC TYPE. Angeioma. Angeiomata are tumors composed, in whole or for the most part, of blood-vessels, and naturally group themselves under three headings, in accordance with the structure of the vascular system : Fig. 95. (a) Capillary angeioma or nsevus, the most com- mon form of all, and frequently seen in the skin and subcutaneous tissue. When the condition is spread over a relatively large area it gives rise to a discol- oration known to the laity as port-wine mark. This is spoken of by pathologists as a telangiectasis, referring to vessels which are present in abnormal number and of abnormal size. The condition is often congenital or begins soon after birth. Accord- ing to the color of the affected area it may be deter- mined quickly whether the vessels belong mainly to the venous or to the arterial system. These tumors may be found in all parts of the body, upon the sur- face, and less often are seen upon the submucous sur- faces of the tongue, the inside of the mouth, the con- junctiva, and the vulva. The tendency is toward gradual increase in size ; rarely spontaneous contrac- tion and obliteration occur. (6) Cavernous Tumors — These are similar in structure to the corpus cavernosum, and are often spoken of as erectile tumors. They are most com- mon in connection with the skin, and are simply exaggerated forms of the variety first described, the vessels becoming not merely dilated, but cavernous in arrangement. They occur occasionally in the tongue, in the voluntary muscles, and in the liver, and are noted very rarely in the mammae, in the larynx, and subperitoneally. (Vide Plate XV.) A similar condition, but much more exaggerated, is met with in the so-called cavernous tumors which involve various organs, especially the thyroid and the liver. In these instances Angeioma; medullary a part or the whole of the organ may be involved, and pre- tu mor in shaft of hu- ■enta .great increase in size and evidences of excessive vas- ESSSii taSg£ "111 culanty, which one cannot fail to distinguish sometimes ceraux). even at a distance. In cavernous growths of the thyroid, tor instance, one may meet with vessels, veins especially, the size of his thumb, while with the ear not touching the body of the patient a distinct venous mur- mur may be appreciated. 334 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. (c) Arterial or plexiform angeiomata, which when of any particu- lar size are ordinarily spoken of as cirsoid aneurism or aneurism by anastomosis. This form consists of arteries abnormal both in number, length, and diameter, tortuous in arrangement, occurring perhaps most often in the scalp, rarely in the perineum or genitalia, and exceedingly rarely in other parts of the body. They will be spoken of at greater length under the heading Aneurism in Chapter XXXI. These tumors are exceedingly liable to rupture from external injury, and call usually for ligation of the main arterial trunks, with perhaps extirpation of the tumor-mass. Recognition of angeiomata is never difficult unless they are deeply concealed. The effect of intermitting pressure, the emptying and refilling, and the distinction between arterial and venous growths by the result of alternating pressure and relaxation, either above or below the growth, coupled with the discoloration of the skin, and, in the larger growths, the very audible murmur, — all these signs should leave one ordinarily in little or no doubt as to the character of the growth in hand. When such growths are small they may be dealt with by electrolysis, the needles from both poles being introduced, or only from the negative, the positive being applied upon some neighboring portion of the body — perhaps with the understanding that the treatment may have to be repeated once or oftener in order to bring about final obliteration of the tumor. The effect of the electric current is to determine the coagula- tion of the blood in the tissues acted upon, and this, in turn, is followed by organization of thrombus, conversion of vascular into cicatricial tissue, shrinkage, and possible eventual disappearance of the mass. It is good treatment with many forms of these growths to make a radical excision under an anaesthetic, dissecting out the mass as one would any other tumor, securing bleeding vessels, and reuniting the parts by sutures, with the expectation of securing primary union. This is the quickest and in many cases the least disfiguring method. Old methods of ligation or surrounding vessels or the subcutaneous ligature are now practically discarded. Still worse, and to be most severely condemned, are the injection methods as formerly practised, especially the use of iron salts in solution. Death has promptly followed resort to this expedient, and it is now never justifiable. With the two expedients of electrolysis and excision the surgeon has at hand nearly all the measures which he will ever need to practise for the medical treatment of angei- omata. In exceptional cases other methods may be resorted to which it is not necessary to discuss here. Lymphangbioma. Lymphangeiomata are tumors composed of lymph-vessels and bearing an exact resemblance to the tumors just above considered. They may likewise be divided into three varieties : (a) The lymphatic nsevus, composed for the most part or entirely of lymphatics nearly normal in size, but abnormal in number, occasion- ally colored red by the presence of blood-vessels. When pricked, pure lymph or blood-stained lymph will flow. They are for the most part quite small, and are noticed during the earlier years of childhood. They may occur anywhere upon the surface of the body or in the mouth, most frequently in connection with the tongue, where they appear most often CYSTS AND TUMORS. 335 Fig. 96. Lymphangeioma of lip ; macrocheilia (Neisser). as large papillae involving a portion or all of the dorsum. When all the lymphatic structures of the tongue are thus abnormally enlarged and involved, the condition is known as maeroglossia, and consists of more or less enlargement of the organ, some- times to a degree not permitting its retention in the mouth, but leading to its constant protrusion. (6) Cavernous lymphangeioma corresponds to cavernous angeioma, and is a condition in which the lymph- vessels become positively cavernous and sacculated. (e) Lymph-cysts are the still more aggravated form which lym- phatic dilatation may attain, and are usually encapsulated, complicated with more or less tense tissue, and produce a condition of the parts, espe- Fig. 97. Fig. 98. Congenital lymphangeioma (original). Lymphangeioma of lower extremity (original). 336 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. daily about the scrotum and labia, to which the term elephantiasis is often applied. The old question of congenital occlusion or dilatation of lymph-channels is one which has been made the subject of large separate monographs (especially by Busey), and, while deserving of the greatest consideration, cannot be more than touched upon in this place. Suffice it to say that numerous tumors, essentially of lymph- vascular origin, are found upon the lips, in the neck, and elsewhere, which grow slowly, are more or less elastic and spongy upon pressure, are frequently covered by skin from which hair grows most luxuriantly, and in which pigment or papil- lomatous structures are dispersed, and by which diagnosis may be aided. These tumors are often spoken of as cavernous tumors, are of slow growth, and occasionally undergo spontaneous involution, but usually eventually call for surgical relief. They are often confused with branqhiogenic and other congenital cysts of the neck. The treatment for the smaller lymphatic tumors is simple, but here electricity is less to be relied upon and excision is more urgently called for. Electrolysis will cause coagulation of blood, but not of lymph — at least not to nearly the same extent ; consequently its useful- ness is restricted to blood-vascular tumors. Excision, then, is almost the sole, at least the best, remedy. When this is impracticable much can be done by galvano- or ignipuncture, the cicatricial contraction following multiple punctures leading often to reduction in size of the affected part. The enlargement of the tongue spoken of above as macroglossia may be treated by ignipuncture or by electrolysis, if neces- sary under an anaesthetic, the effect of the electric current here being not to produce coagulation, but apparently absorption of fibrous tissue and changes which come slowly rather than by obliterative processes. 7. TUMORS OF EPITHELIAL TYPE OR OP EPIBLASTIC ORIGIN. In this general group of tumors epithelium or epiblastic tissue is the essential and distinctive feature. According to differences in shape and disposition of epithelial cells, or according to the embryological origin of certain complex tissues (nerve), these tumors may be arranged as follows : 1. Neuroma. 2. Papilloma. 3. Epithelioma. 4. Adenoma. 5. Carcinoma. But of these the first, though often considered by itself, essentially belongs here, while the fourth and fifth may be advantageously considered by themselves as Tumors of Glandular-tissue Type. Neuroma. The entire nervous system is produced by infolding of the epithelial or epiblastic layer of the embryo. Hence the consideration of neur- omata in this place. True neuromata spring from the structures of nerve-trunks, which trunks may also be the site of other tumors, mainly fibromata and sar- comata, with which neuromata may easily be confounded. The most common nerve-tumor is the neuro-fibroma, which grows from the struc- CYSTS AND TUMORS. 337 ture of a nerve-sheath, its long axis usually coinciding with that of the nerve-trunk. Tumors of this class vary greatly in size, are often mul- tiple, and in other instances affect nearly all the nerves in the body. They are extremely liable to my.coiutitous degeneration, which will account for many of the instances reported as myxo-neuroma, etc. They attack cranial and spinal nerves alike, and no nerve or nerve-root in the body is necessarily exempt. The sensory nerves appear more liable to attack than the purely motor. The nerve least often attacked is the optic. They are not rare upon the roots of the spinal nerves, in which location one may attain to such size as to press upon the cord and induce paraplegia. Multiple neuromata are often associated with molluscum fibrosum (g. v.). There is one instance on record in which one thousand six hundred of these tumors were found after careful dissection of the neuro-skeleton, and another in which at least two thousand were found, sixty of them involving the pneumogastric trunks and their branches. Plexiform neuroma is relatively rare. This means a type of nerve- tumor in which all the branches, for example, of a given nerve which are distributed to a particular area become enlarged and elongated, the overlying skin being stretched and thin. Such a tumor seems like a loose bag containing a number of vermiform bodies, resembling the sensation given when palpating a varicocele. On section each of the affected nerves reveals a quantity of myxomatous tissue replacing the nerve-sheath. They are in large measure congenital. Malignant neuroma (so called) will usually be found to be a true sar- coma of nerve-structures, usually of the spindle-celled variety. Trau- matic neuroma is most often seen in amputation-stumps, where the ter- minations of the divided nerves become bulbous, attaining the size of cherry-stones, the tumors being composed of a mixture of connective tissues and nerve-fibre, from which in time the true nerve-structure usually recedes or vanishes. They seem to form more often when sup- puration has been profuse or healing long delayed, and most often when sufficient care has not been exercised to prevent entangling of the nerve- ends in the scar of the wound. They give rise to a great deal of pain, and often necessitate re-amputation. The bulbous enlargement seems always the result of prolonged irritation in a nerve, and has been noted around various foreign bodies. True neuroma is innocent in tendency, though often extremely pain- ful. It is the sarcoma of nerve-tissue which produces signs of malig- nancy. A true neuroma which causes unendurable pain should be removed when accessible. It is sometimes possible to separate the tumor-mass from the balance of the nerve-trunk, and thus to remove it without excision of the nerve. At other times it is impossible to avoid division and ensuing paralysis. Whenever possible divided nerve-ends should be brought together by catgut suture, by which means it may be possible to avoid permanent loss of function. Nerve-grafting is also resorted to for filling such defects. Removal of painful neuromata due to injuries to the head has more than once been the means of curing traumatic epilepsy. Papilloma. The type of papilloma is the common wart, consisting of a central stem of fibrous tissue and blood-vessels covered by epithelial projections 22 338 AFFECTIONS OF THE TISSUES AND 1 ISSUE-SYSTEMS. and proliferations. Papillomata are mainly sessile and villous, as well as occasionally met with in other forms. (a) Warts. 1 — These are sessile papillomata, most common on the skin, often seen on mucous surfaces, and occurring sometimes singly, often in crops. They are exceedingly common about the perineum, where skin and mucous membrane meet, and are regarded as, for the most part, due to the irritation of specific discharges. The papillomata occurring about the genitalia are ordinarily spoken of as condylomata. The growths in these instances are frequently so luxuriant and proliferative that they assume fungoid shape, and are often spoken of as mulberry growths. Warts grow slowly or rapidly according to circumstances not easily appreciated. Warty growths may attain relatively enormous size and become very vascular. Late in life they are frequently the starting- points of epithelial in-growths, and then become true epitheliomata — i. e. cancer. Warty growths sometimes line the buccal cavity and com- plicate cases of macroglossia. They are also met with in the larynx, and when situated near the glottis may cause dyspnoea or even fatal obstruc- tion to respiration. It is claimed by some that cutaneous warts will disappear with con- tinued small internal doses of Fowler's solution. Fig. 99. Papilloma of bladder. (6) Villous Papillomata. — These are met with most commonly in 1 The warts are by many pathologists considered as mere evidences of hypertrophy from persistent irritation. They are here retained among the tumors lest too much vio- lence be done to formerly received notions. CYSTS AND TUMORS. 339 the bladder, occasionally in the pelvis of the kidney. They are strictly identical with chorionic villi. They occur for the most part singly. It often happens that long fine tufts are detached and carried away with the escaping urine : their presence when recognized should be pathogno- monic. Another form of villous growth arises from the choroid plexuses of the lateral ventricles in the brain. These may grow and attain a size sufficient to produce disturbance. (c) Intracystic Villous Gro-wfchs. — These are seen, for example, in mammary cysts. These, of course, are lined with epithelium, which acts here as it does in other localities, and proliferates under unknown circumstances more or less rapidly. In dealing with paro5phoritic cysts the presence of these growths has also been alluded to. (d) Psammomata. — These are peculiar epithelioid tumors composed of a globular arrangement of epithelial cells in layers, enveloped by con- nective tissue and usually calcined. They are met with exclusively in the pia mater of the brain and cord. In the former case the epithelium comes from the neighboring choroid plexus. Calcareous degeneration is a marked characteristic, and these little tumors often feel like stone. In this respect the arrangement is identical with that in the pineal body. Psammomata never grow to large size : they are for the most part no Fig. 100. Nail horns (original). larger than peas or small cherries. They are somewhat common in horses, developing from the surrounding plexus, as in man. Here they may attain the size of a walnut and still produce no recognizable dis- turbance. Psammomata of the spinal pia are much more serious, since here they will probably produce disastrous pressure-effects. (e) Cutaneous Horns. — These are also epithelial outgrowths, and are met with in four varieties (Sutton) : (1) Sebaeeom horns, quite common, arising by protrusion of contents of a seba- ceous cyst through a rupture in its wall or through its duct, with consequent desic- 340 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. cation by exposure to the air, while fresh material is consequently added at the basis so long as sebaceous secretion continues. These growths quickly soften when soaked in weak liquor potassse. (2) Warty horns, structurally identical with the above, but growing from warts instead of from sebaceous cysts. Both these forms are found most commonly about the head. Cutaneous horns are also met with in ovarian dermoids. They are com- mon in the lower animals and may attain large size. (3) Horns growing from cicatrices, especially of bones, are rare, but a cornified condition of the cicatrix itself, with formation of scales resembling those from horns, is not uncommon. (4) Nail-horns are simply overgrown nails, occurring for the most part on the digits and toes of bed-ridden patients who never walk. Treatment. — All these forms of epithelial outgrowth call for radical removal, after which, if effected, there is no recurrence. Radical re- moval, however, implies complete extirpation of the membrane or tissue from which the growth occurs, since if even a little be left there is tendency to recedive. Epithelioma. Epithelioma is common, especially where there is transition from one kind of epithelium to another, and, of all other localities, particularly where skin and mucous membrane meet — e. g. the lips, the vulva, and the anus. Epithelioma differs from papilloma in that the former is no longer limited by basement-membrane, but passes beyond it into the underlying connective tissue and presents down — rather than up — growth. Characteristic of epithelioma are the so-called eell-nests or pearly bodies, where there seems to be tendency to a globular arrangement of cells with such condensation or alteration that they lose their ability to take stains, and appear as a more or less lustrous mass, showing off by con- Fig. 101. Fig. 102. Epithelioma of face (XK"'> Spencer). Epithelioma of face, with "pearly (XK" i Spencer). body trast among the standard surrounding tissue. On this account they are often spoken of as pearly bodies. Recognition of these is tantamount to diagnosis of epithelioma. This form of neoplasm is essentially the same, no matter what its clinical varieties. These comprise a wart-like growth or nodule, which quickly becomes CYSTS AND TUMORS. 341 an ulcer with elevated edges, ulceration being due to necrosis of cells farthest from the periphery ; or, again, the disease may start as an ulcerated fisxure, ulceration and infiltration keeping pace, in which case we have a sharply defined ulcer with undermined edges. A third variety, often seen upon the lips, comprises a. projecting mass, often with more or less horny surface. In all of these, however, the charac- teristic cell-nests with their onion-like arrangements of cells will be found. Epithelioma, especially when exposed to the air or to surface-irrita- tion, quickly ulcerates and tends to involve all the surrounding tissues, while occasionally the distinctive cells proliferate so rapidly as to give the ulcer more or less of a bursal or a cauliflower-like arrangement. From such a surface there is a constant discharge of foul-smelling detritus or even of sloughs. Even bone cannot resist progressive invasion and Fig. 103. Fig. 104. Epithelioma of forehead and eyelid (Neisser). nit-';,: ii;b>'- ■■ Epithelioma of lip (Neisser). slowly disintegrates before the advancing mass. Cartilage is most resist- ant, and usually preserves its integrity to the last. In other words, the tendency of epithelioma is toward constant encroachment and infiltra- tion, and toward a fatal termination from hemorrhage by ulceration, from septic infection, exhaustion, or other accidents. The wart-like forms run the slowest course of all, but even here the malignant ten- dency is most evident. Lymph-node Infection. — A striking characteristic of epitheliomata is the usually prompt invasion of the adjoining lymph-nodes, which attain a size astonishingly disproportionate and bearing no necessary relation to the size of the primary growth. This constitutes one of the most serious complications of the condition. This lymphatic invasion par- takes of the distinctive malignant character of the disease, and from every focus of this character infiltration and destruction proceed. Infected nodes show also early a tendency to central degeneration and 342 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. to spurious cyst-formation. When the overlying skin becomes involved we have extensive sloughing and the conversion into large malignant ulcers. Dissemination to a distance (■/. e. metastasis) is rare in epithe- lioma — much more so than in carcinoma. About the mouth epithelioma is not common before the thirty-fifth year of life, though I have seen it on the lip of a twenty-year-old woman. It is vastly more common in men than in women, and more frequent on the lower than the upper lip. In the tongue it seldom occurs before the fortieth year of life. It seems to be more common both in the lip and tongue in men with bad teeth and in confirmed smokers, thus giving rise to the view often held that it is purely a matter of irritation. It may, however, with equal truth be laid to contact infec- tion should one regard it as of parasitic origin. In one-fifth of the cases of epi- thelioma of the tongue there are preceding lesions, usually described as leucoplakia or ichthyosis of the tongue — conditions characterized by epithelial reduplication and the formation of dense plaques or scales. These lesions are for the most part regarded as pre-cancerous conditions. The disease often starts near the stump of a carious tooth, in which case infil- tration and erosion begin promptly and progress rapidly. Epithelioma of the tongue has been known to follow down along the obliterated track of the thyro- lingual duct, and in this way to bring about a perforating uleer. Epithelioma of the oesophagus is a common cause of stricture of this passage- way. It leads always to ulceration, and usually eventually to perforation into the trachea or some other cavity or passage (i. e. a blood-vessel). In the larynx the disease is well known, and gives rise to intense, and finally fatal, symptoms, but has been dealt with successfully by radical operations for extirpation of the entire organ. . Occurring upon the scrotum, epithelioma has been in time past spoken of as chimney-sweeper's cancer or soot-warts, and has been usually ascribed to the irrita- tion of foreign material. Ulceration and infection of the inguinal nodes proceed usually rapidly and disastrously. There is much reason also to believe that tar and paraffin may produce similar irritation, and paraffin cancer has been described by various writers. It occurs also usually upon the scrotum. The skin-lesions which precede the formation of paraffin cancer resemble very closely those seen in chimney-sweeper's cancer. The skin becomes dry, thickened, parchment-like, while the openings of the sebaceous glands become obstructed by the tar or other material, producing acne-like lesions. Warty outgrowths then occur, and these become the seat of malignant ulceration. In chimney-sweeper's cancer the scrotum is usually first affected in a chronic dermatitis, to which warty outgrowths succeed, these enlarging and growing down- ward as ulceration takes place. About the external genitalia epithelioma is not uncommon, particularly in and about the prepuce. Such a degree of phimosis as leads to retention of smegma is certainly a predisposing cause, not only in man, but in the lower animals. Epithelioma of the vulva has been described under the name esthioniene, and requires to be recognized and dealt with promptly if one would attempt a radical cure. In the vagina and about the cervix uteri it is common, a large proportion of cases of cancer of the uterus being essentially epitheliomata of the cervix. In and about scars epithelioma is quite common ; also upon granulating ulcers. One danger to which a chronic ulcer is always exposed is that of epitheliomatous transformation, and in time past disaster has been the penalty of lack of early recognition. These growths also attack lupus-scars, or even any tissues actively involved in the lupoid process. This is particularly true between the fortieth and sixtieth years of life. Among the viscera, the gall-bladder is probably more often involved in distinct epitheliomatous changes than any other. It presents as a pretty uniform thick- ening, and causes augmentation in size, so that a distinct tumor projects from beneath the liver. In this location dissemination is rare. Epithelioma is to be regarded as having an essential and too often a rapidly malignant tendency, and should be attacked from the very out- set with determination and without mercy. Its successful treatment CYSTS AND TUMORS. 343 demands early and wide removal of diseased parts and complete extir- pation of all involved lymph-nodes — both of these to be carried out without regard to anything but complete removal. The involved tissue being excised, the question of plastic closure of defect or operative atonement for loss of tissue may call for the best of judgment and the highest degree of operative skill, in order that the best cosmetic results may be obtained. It is only the very small and incipient growths which ought to be ever attacked by such destructive agencies as cancer- pastes or the electrolytic current. While these occasionally give satis- factory results, their use is for the most part unscientific, and therefore barbarous. Rodent Ulcers. — Under the name of rodent ulcers, herpes exedens, lupus exedens, noli-me-tangere, etc. writers, for the most part English, have described a variety of epithelioma commonly met with upon the face to which in time past a separate classification has usually been assigned. Until recently it has been generally regarded as a local ulceration, distinct from cancer. In most of the older text-books it is referred to as lupus exedens. It is preceded usually by a nodular con- dition of the skin, quite vascular, breaking down into a regular ulcera- Fig. 105. Fig. 106. Rodent ulcer (original). tion, but little, if at all, elevated, the base of the ulcer deeply excavated, with a striking disproportion between ulceration and new growth. In this particular variety infiltration seems to be continuously in advance of the rodent process, the former being excessive, the latter but slight. This variety of epithelioma rarely, if ever, produces lymphatic involve- ment; the discharge is slight, the pain complained of inconsiderable. Occasionally it entirely alters its aspect, and in whole or in part presents features of the conventional epitheliomatous type. Rodent ulcer allies itself rather with the type of tubular epithelioma springing from the outer sheath of the hair-follicle, sending out cylin- drical processes which freely blend with one another. Rodent ulcer is to be regarded as an equally malignant type of ulceration with other cancerous ulcers, and demands the same thorough 344 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. and radical measures for its relief as do any other forms of epithelioma. It is perhaps the most favorable one to deal with, because of the usual freedom, from involvement of deep lymphatics. No distinctive meas- ures are necessary for its relief — only those which are thorough and merciless. 8. TUMORS OF GLANDULAR-TISSUE TYPE. These include adenoma and carcinoma. Adenoma. Adenoma is a tumor whose type is the normal secreting gland, from which it differs in being an abnormal outgrowth or product, but par- ticularly in that it has no power of producing the secretion peculiar to the gland-tissue or type from which it grows. The adenomata occur for the most part as circumscribed tumors in the mammas, parotid, thyroid, liver, and in the mucous membranes of the bowel and the uterus. They may be single or multiple; in the intestine they are usually multiple. In certain locations (e. g. the mamma) they attain occasionally enormous dimensions, and in the ovary tumors of this character may be met with weighing forty or fifty pounds. The true adenoma shows no tendency to infection of neighboring lymphatics, and gives rise to no secondary deposits, and when it causes death it is usually because of size or pres- sure upon important organs. It displays a marked tendency to cystic alteration, while the relative proportion of epithelium and connective tissue or stroma, varies within wide FlG - 107 - . limits. In certain cases, where the former is small in amount, the great preponderance of the latter has caused the use of the term ad 'e no-sarcoma., which is really a misleading name. The distinction between adenoma and true carcinoma is in some respects but slight ; and this fact will account for the conversion which many in- nocent gland-tumors seem to undergo from adenoma into carcinoma. So soon as the epithelial cells lose their regularity of disposition and collect in groups or make their way outside of the acini into the tissues, then the change from the benign to the malig- nant tumor has begun and the entire clinical aspect of the case has altered. This change may be the result of external irritation, of such tissue-changes as pregnancy and lactation, or of the undefined influence which advan- cing years seem to produce. Adenoma occurs in the breast as cystic adenoma or fibro-adenoma. The former attains often large size, are encapsulated, the acini are much dilated, and from the walls of the epithelium-lined cavities frequently project papillomatous processes, forming what are called intracijstic growths. Cystic adenomata grow slowly, pro- duce atrophy of mammary tissue by pressure, occur after puberty until the meno- pause, and rarely give rise to pain until they become large. As they grow they distort the breast until it may become very pendulous. Adenoma (rectal polyp) (Spencer, J" obj.). CYSTS AND TUMORS. 345 Fibro-adenoma occurs also in the breast as a small tumor, encapsulated, usually superficially placed, movable in its site, often multiple ; most common between the twentieth and thirtieth years of life ; often painful, especially during menstrua- tion ; tender upon pressure. Both forms may occur in young men. A form of fibro-adenoma in which fibrous tissue is greatly in excess, which never attains great size, is common in the breasts of unmarried women. They give rise to much pain and distress, but are clinically not malignant. Adenoma occurs frequently in sebaceous glands, as — (a) Sebaceous cyst, ordinarily known as "wen." These tumors commonly begin as retention-cysts, the duct of the sebaceous gland becoming occluded. But in many cases there is no occlusion of the duct, and the secretion may be easily expressed on pressure. They occur wherever sebaceous glands abound, but especially often upon the scalp. They are usually multiple, vary greatly in size, are easily movable over the bone, and are intimately related to the skin, while the duct-orifice is frequently recognized by a black spot, on removing which sebum can be expressed. These cyst-adenomata are encapsulated, and can be easily shelled out of their matrices, save when inflamed ; in which case fhev are often astonishingly adherent. Their contents consist of pul- taceous debris resembling old epithelial scales, fat, cholesterin, etc. The contents of these cysts are very prone to decompose, and they become as offensive as anything with which the surgeon has to deal. Putrefac- tion may be independent of inflammation or coincident with it. When irritated these gland-cysts become inflamed and may suppurate, suppu- ration being tantamount to cure by spontaneous processes. They may also ulcerate, without suppurating, and form foul-smelling ulcers, or give rise to cutaneous horns, as already mentioned. Fig. 108. Fig. 109. -. < I Adeno-careinoma ; x 65 (Spencer, i" obj.). Adenocarcinoma of breast; x 170 (Spencer, i" obj.). (6) Sebaceous Adenomata. — These spring from the sebaceous glands, which are lobulated like those about the nose and ear. Ade- nomata from this source are extremely liable to ulceration, may under- go calcification, and are often mistaken for epithelioma beoause of the fungous ulcerations to which they give rise. (c) Sutton has also described an adeno-carcinoma of the pecu- liar sebaceous glands named after Tyson. These are found particu- 346 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. larly at the base of the prepuce, this form of tumor being exceedingly rare. Adenomata springing from the mucous glands, which are usually quickly transformed into cysts, are also known, as well as other gland- tumors springing from the glands of Bartholin, Cowper, etc. They are, however, so infrequent as to not deserve further mention here. Adenoma of the thyroid body is described in Clinical Surgery usu- ally as cystic goitre or bronchocele. It constitutes for the most part an encapsulated tumor containing structures similar to that of the nor- mal tissue, forming tumors of various sizes, usually single, sometimes double, and occasionally occurring in the isthmus of the thyroid. These tumors contain central cavities with colloid fluid often heavily loaded with cholesterin. As they grow older and larger all traces of original thyroid tissue disappear, and we then have to deal with a cyst with a toughened, often calcified, wall. Thyroid adenomata usually are easily enucleated, even when they attain large size. When small they usually cause little trouble or pain ; when large they may give rise to alarming dyspnoea, and may thus jeopardize life. The pituitary body, which is analogous to the thyroid in structure, is occasionally occupied by an adenomatous tumor closely corresponding to that just considered. In the prostate adenoma is not rare, since its structure is composed of mixed involuntary muscle and glandular Fig. 110. tissue. Many instances of the senile enlarged prostate are due to adenomatous alterations. The so-called third lobe of the prostate, as found enlarged in old men, is usually an adenoma of the portion posterior to the vera montanum, which has grown into the prostatic urethra or toward the bladder, because this is | the direction of least resistance. In the parotid and other salivary glands I true adenoma is occasionally observed. Almost always it is distinctly encapsulated, but may have undergone marked cystic changes. Adenoma is common in the liver, either as la single or multiple lesion. Its pseudo-ducts often contain inspissated material of bile-green I tint. In the kidney adenoma presents for the I most part as a congenital adeno-cystic lesion, which is by no means rare. Both kidneys are usually eventually involved and the outlook is most unfavorable. By this lesion the kid- Ineys are converted into cystic masses, and most resemblance to original structure is lost. They may, when thus affected, attain great size. These renal adenomata are now usually spoken of as hypernephromata (or sometimes as Grawitz's tumors of the kidney), and constitute a distinct form of neoplasm peculiar to the kid- ney, and due to the overgrowth of foetal inclusions of -adrenal tissue. Congenital adenoma (cystic) of kidney (original). CYSTS AND TUMORS. 347 They attain often considerable size, and display in their course ten- dencies which make them, clinically at least, malignant. In the ovary we meet with adenoma, in which, however, there will be seen but little imitation of true ovarian tissue. In the testicle there is known to be a form of adenoma originating in the paradidymis, in no way connected with the secreting structure of the testis, but leading often to cystic alterations. In the mucous membrane of the stomach and bowels adenoma presents usually as an ovoid tumor, attaining possibly such size as to give rise to mechanical obstruction either by pressure or by traction. Adenoma of the pyloric region is a repetition in structure of the pyloric glands. In the rectum it presents, for the most part, as a polypoid outgrowth, most often met with in young children. Such tumors are generally small, and when solitary they often hang by a distinct stalk. Similar polypoid tumors present in the cervical canal of the uterus, where also are found sessile and racemose tumors ; all of which are structural repetitions of the glands met with in the cervix uteri. Ade- noma of the uterine cavity is most rare ; it is also rare in the Fallopian tube, but occasionally presents as a dendritic outgrowth from the mucous membrane distending the tube. Carcinoma. Carcinoma is a tumor always springing from pre-existing gland- tissue, which it more or less closely resembles in type, save that the structural mimicry is incomplete, the epithelial cells now collecting in irregular clusters, or filling the acini and obstructing the ducts, or bursting beyond the basement-membrane and invading the surrounding tissues. They frequently so fill the ducts as to appear in columnar arrangement when seen under the microscope, and this has given rise to the use of a term so vague as to have no place in pathology — i. e. cylin- droma. Carcinomata may arise from any of the secreting glands, but much more commonly from some than from others. They have no cap- sules ; they infiltrate the surrounding tissues, usually involve the lym- phatics early, are prone to spread to the superficial tissues and to ulcerate, and to undergo various degenerative changes. Nearly all cancerous tumors abound in lymphatics, which will explain the rapidity with which the lymph-nodes become infected, as well as the tendency to dissemi- nation which is characteristic of these growths. Dissemination leads to so-called secondary or metastatic growths, which may make their appear- ance in any organ or tissue, even in the bones, where they give rise to changes of texture that make spontaneous fracture easy. It is charac- teristic of carcinoma that the metastatic tumors which it may produce will reproduce almost perfectly the type of the primary tumor whence the embolic fragments which have produced them spring. The amount of dissemination varies exceedingly : it may even become so marked and so widespread as to produce a condition analogous to that met with in miliary tuberculosis, and consequently spoken of as miliary carcinosis. A similar condition, much more rare, is met with in dissemination of sarcoma, and is known as miliary sarcomatosis. A constantly-spreading cancerous infiltration of the superficial tissues, which is noted most often alter mammary cancer, is described under the form of cancer en cui- 348 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. rasse, or jacket or corset cancer. Sad instances will be seen in which this infiltration of the surrounding structures has extended nearly el- even completely around the thorax. It gives rise to a brawny indura- tion which is most unyielding, and which is studded here and there by nodules that tend to ulcerate, to fungate, and to bleed easily. It is per- haps the most hopeless form of cancerous disease. The older writers have constituted two or three clinically distinct forms of carcinoma, based mainly upon the relative hardness or softness of the tumor and the invaded tissues. The term scirrhus is, e. g., thus applied to a tumor in which connective tissue preponderates and epithelial cells are relatively deficient. On the other hand, the term encephaloid. has been applied to a tumor in which the connective tissue seems barely sufficient to hold the mass together, while the epithelial cells are in vast preponderance. These are all tumors of the round epi- thelial-celled type, and these distinctions are of clinical interest, yet have no great pathological import, save that in a general way the greater the proportion of epi- thelial elements the sooner will life be terminated by destructive processes. In other words, the more the tumor may partake of the encephaloid type the worse the prognosis or the shorter the probable duration of life. Again, these tumors pursue a widely varying clinical course. In those, particularly of the scirrhus type, where the connective tissue largely preponderates, there is often an eventual reduction in the size of the part involved, and such reduction of vascularity and of nutritive activity that the rate of growth is thereby very perceptibly checked. The so-called atrophying cancers of the breast are the best examples of this type of cancerous disease. Here the volume of the gland is ^^^^—fJft^slL-^^^^^^^^— diminished rather than augmented, and P^^^B tt^^^_ t '"' disease may Inst fur a number of years, ^A B^. even s " man y as twenty. It is question- ■k I able whether in the presence of this type j of disease it is well to operate. It would scarcely seem so, at least, in old and more or less enfeebled women, for it has usually been found that these live longer and in greater comfort if treated symptomatically. The so-called colloid forms of cancer are simply the expression of pathological changes occurring in growths of more dis- tinct type. Thus, colloid softening may occur in any tumor in which cancer-cells predominate, and the so-called colloid cancers of the peritoneum, the ovary, etc. are either examples of such alterations or are possibly endothe/iomata arising in I these locations. The term villous cancer, ^""Tener/tfo'nTx^rfpe^e?? 1101 " 6 - with other terms like it, should be ex- punged Irom all scientific literature, unless these terms be used in a purely adjective and clinical sense, for they imply noth- ing accurate as to the histological structure, and are too often misleading and inaccurate. Carcinoma is most common in the following regions : In the breast it appears particularly in two forms (Sutton) : (a) Acinous Cancer, and (b) Duct Cancer. (a) Acinous carcinoma is most often of the scirrhous type. It may arise at any portion of the breast ; and if anywhere near the nipple, it will early cause retraction of that prominence, which is always pathog- nomonic when noticed. AVhen elsewhere situated it leads early to pucker- ing and adhesion of the overlying skin. These tumors infiltrate widely, especially along the connective-tissue stroma and the fibrous tissue which CYSTS AND TUMORS. 349 intersperses the fat of the breast. They are always firm, sometimes ex- ceedingly dense, in consistence. A particular form of scirrhus, known as atrophying scirrhus, consists largely of strands of fibrous tissue injected F 1G - In- here and there with epithelial cells. It is the most slowly growing of all the forms of cancer, and by its con- traction tends to reduce rather than augment the size of the mamma. Acinous cancer is rare before the age of thirty, most common between forty and fifty. It occurs in women in all walks and conditions of life, married and single, and ' is rarely noted in the male breast. The most dangerous form of all is that which appears during lactation. Ordinarily its progress is comparatively slow. As it augments in volume it infiltrates all the surrounding tissues, becomes adherent to the pectoral fascia, infiltrates the muscle- fibres, and finally attaches itself to the "Pig-skin" appearance of cancerous breast periosteum of the ribs. The infiltrated (original), tissues tend to shrink rather than to increase in volume. Lymphatic infection occurs early in this form, and is a pathognomonic sign. It is most common in the axillary lymphatic nodes, but may often be detected in the neck above the clavicle. When the skin is completely involved there is a tendency toward ulceration and fungoid condition. This is always preceded by the purplish appearance of the tense skin. Pain is a very uncertain and variable feature. It is important to emphasize this fact, since in time past many of these conditions have been lightly regarded because of freedom from pain. Pain is by no means a constant phenomenon in any form of cancer, and the sooner old notions regarding it are discarded the better. On the other hand, pain is sometimes intense, either localized or radiat- ing and referred to distant points. Pain is particularly noticed in cases which assume the form of cancer en cuirasse. Secondary deposits in viscera are fre- quently met with, particularly in the abdominal organs and the lungs ; but any organ may be the seat of secondary infection, and this is found occasionally in the bone-marrow, not alone of the sternum or ribs, but of distant bones. This is spoken of as marrow infection. As the result of cancerous affection of serous mem- branes we frequently get effusions of fluid, as in the pleura, peritoneum, and peri- cardium : and this fluid is often blood-stained. In consequence of pressure upon the venous trunks in the axilla there is often a swelling of the arm upon the affected side, dropsical in character, known as lymphatic oedema. It is one of the most distressing features of some of these cases: the arm grows heavy, the patient loses control of it, and the skin may become so distended by effusion as to cause the limb to resemble a cast rather than a living member. This is due not alone to pressure upon the veins, but to involvement of the lymphatics, and upon careful examination positive dilatation of the lymphatic vessels may be noted. Pain is a usual accompaniment of this form of oedema. (6) Duct Carcinoma. — This appears especially about the time of the menopause, when glandular structure has disappeared and only ducts remain. It is common, without reference to cancer in these instances, to find cystic dilatation of numerous ducts which vary in size from a mustard-seed to a cherry. These are spoken of by Sutton and others as involution-cyst*. They are filled with mucoid material and have a bluish tint. They are most common upon the under surface of the gland, ouch cystic breasts are common, and when appearing in diffused form may be easily mistaken for cancer. Pain is rarely complained of. This 350 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. condition is certainly a pre-cancerous stage, since the dilated ducts are often the starting-points of cancer, and occasionally of papillomatous or villous outgrowths from their walls. Bud cancer implies the form which arises in these dilated ducts, most commonly in the terminal branches, appearing ordinarily as a single tumor, but sometimes as a mass of separate nodules. Intracystic and intracanalicular growths of this character will often be found. When assuming the truly cancerous phases they may be spoken of as duct can- cers ; otherwise, as duct papillornata. In time past these have, for the Fig. 113. Recurring carcinoma of male breast (original). most part, been spoken of as intracanalicular fibromata. Duct cancers are less tense than the preceding variety, and when situated near the surface often discolor the skin quite dark. It is from these cases that we often see a more or less abundant discharge of fluid resembling bloody milk. These tumors grow relatively slowly, lymphatic involvement is late, and in general they present the least malignant forms of breast cancer. Carcinoma of sebaceous glands is by all means most common in those specialized glands named after Tyson, met with about the prepuce. They give rise to the common forms of cancer in this locality. Carcinoma in the prostate is not common, and is usually confined to old men. Infiltration proceeds around the base of the bladder at the same time and binds the pelvic viscera together. The pelvic lymphatics become early infected and dissemination is frequent. In the salivary glands carcinoma is not common ; it is most so in the parotid region, occurring at middle life, growing rapidly, infiltrating surrounding parts, and tending early to ulceration. CYSTS AND TUMORS. 351 Carcinoma of the liver varies not a little in its arrangement and appearance. Sometimes it appears in the form of nodules ; at other times, as a more diffuse malignant infiltration by cells relatively abun- dant in number, so that the clinical aspects of the case conform rather to the encephaloid or medullary type. Carcinoma of the kidney was formerly ordinarily described as en- cephaloid, meaning thereby simply a malignant tumor of soft structure. It is probable that a large proportion of these tumors were sarcomata. Nevertheless, true carcinoma of the kidney is possible, though rare. Concerning carcinoma of the ovary, we must also remain in some doubt until the subject has been more thoroughly studied. That malignant tumors appear here is unquestioned ; and that many of them infect the peritoneum and disseminate widely is also true : that some of them are of distinctly epithelial type may not be doubted, and yet there can be no accurate description to-day of true cancer of this organ. On the other hand, in the testicle such tumors are common — more common, in fact, than sarcomata. It is quite likely that many of them arise from the paradidymis. Even here, while recognizing their clinical frequency, we need more light. Carcinoma of the stomach is a common disease. It involves the tubular glands, especially in the pyloric region, and conforms to them in type. After involving, first, the mucosa, it spreads to the entire coats of the stomach and infiltrates adjacent structures, while the mesenteric lymphatics are usually early and notably involved. Were it possible to recognize this involvement early in the course of the disease diagnosis of pyloric cancer and operative interference would be much more com- mon and hopeful. Secondary involvement is most common in the ad- joining viscera, but may be seen at a distance. Miliary carcinosis has been noted after pyloric cancer. This form is most common between the fortieth and sixtieth years of life, the duration of the disease not being long. In the intestine, and particularly in the rectum, carcinoma proceeds also from the mucous glands, and tends constantly to extend at its periphery and involve the entire lumen of the bowel. It seems to be inseparable from a tendency to contraction of the gut and consequent annular stricture. Ulceration, favored by surface-irritation and infec- tion, occurs almost always early. Above the rectum it is most common in the neighborhood of the sigmoid flexure. Cripps has observed that when cancer of the rectum spreads downward and involves the anus, it loses its typical glandular character and assumes the type of epithelioma or squamous-celled cancer. In all of these cases the pelvic and mesen- teric lymphatics are early infiltrated and secondary and metastatic affec- tions are common. Carcinoma may appear in any portion of the uterus, but is more com- mon in the lower than in the upper half. It assumes the type of the cervical glands, spreads rapidly, infiltrates widely, ulcerates early, and disseminates frequently. By extension of ulceration the formation of urinary and of fecal fistulse is common. Pysosalpinx and hydrosalpinx are also favored, because of infection from putrefying malignant tissue, while the spread of the disease is, in fact, more common when it involves the cervix than when it involves the uterine fundus. 352 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 9. ENDOTHELIOMA. This is spoken of by Snow as the cancer of endothelial cells. It has gone under various synonyms in past time, and, while undoubtedly a pathological possibility, is somewhat rare in occurrence and difficult of recognition. Endothelioma is, as its name should imply, a tumor distinctly of Fig. 114. 1 JS.V sKJ&V * . ■ * * t&T " e K«S« I ' ■iSf- ',y? ' ' ■ ..'■''.■ ■ ■ it J > % Endothelioma (of skull) (Volkmann) : a, cell groups ; b, cylindrical arrangement of cells ; c, blood-vessel. endothelial tissue. The possibility of such neoplasms has been for a long time recognized, yet, in spite of arduous study of these growths, we are not yet in position to speak as accurately concerning them as we could desire. They are, first of all, rare, and usually by the time they come to operation and subsequent examination have undergone changes which to some extent at least obscure their original characteristics. Considered from the developmental standpoint, they are to be considered as atypical proliferations of flat endothelial cells, springing either from connective-tissue interspaces or from the inner wall of blood- and lymph-vessels, on serous membranes, or else from the so-called perithe- lium of the capillaries. In one respect they may be regarded as con- nective-tissue tumors. Nevertheless, they are to be pathologically, if not clinically, sharply distinguished from tumors proceeding from the other connective-tissue elements. Endotheliomata are, in fact, to be abruptly separated from carcinomata and epitheliomata, although tran- sitional forms may be observed. They are so nearly allied to certain of CYSTS AND TUMORS. 853 the sarcomata as to be often included or more often confused with them. The greater part of these tumors proceed from the endothelial lining of lymph-spaces ; less often from the other areas mentioned above. They undergo many degenerations and metamorphoses. Thus, cartilaginous, myxomatous, and hyaline changes may be noted in them, as well as formation of lymph-dilatations, alveolar arrangements, or even semblance of cylindrical or tubular construction. Some of the tumors heretofore vaguely termed cylindroma in all probability belong in this class. At other times they have been confused under such names as angeio-sareo- mata or ple.riform or alveolar sarcomata, or they appear as villous out- growths ; and it is largely owing to this confusion that we are now cer- tain that these tumors are of more frequent occurrence than was formerly recognized. Even psammoma is by some regarded as calcifying endothelioma. For example, most of the tumors of the salivary glands and of the soft palate belong to this class. It has been shown, e. g., that 28 out of a consecutive series of 29 parotid tumors were really endothelioniata. It also appears that they may develop within the bones — for example, in the skull, in the neck of the femur, etc. — as well as in the cervical and dorsal lymphatics. 1 The endotheliomata also include the choksteatomata or pearly growths met with in the cerebral pia mater. Clinically, these tumors have no certain characteristics by which they can be separated from the sarcomata. It requires practically minute and microscopic examination to clearly place them where they belong. It will be enough, then, to say of them that they possess the ordinary clinical features of malignancy, including liability to recedive when not thoroughly eradicated, and that they call for exactly the same treatment as any other neoplasms presenting similarly malignant features. GENERAL DIAGNOSTIC FEATURES OF MALIGNANT GROWTHS. The following tables are here inserted, trusting that they may aid the young practitioner in distinguishing in a general way between benign and malignant tumors, and even in making a diagnosis between sarcoma and carcinoma. I have also inserted a table differentiating the clinical appearances of epithelioma and of lupus. In these tables com- prehensiveness has not been aimed at, rather simplicity, while it is not denied that cases are met with in which diagnosis may be exceedingly difficult, and in which the common signs herein mentioned maybe found either absent or misleading : Table \— Differentiation between Benign and Malignant Growths. Benign and Malignant. Common at all ages. Bare in earlv life. Usually slow in growth. Usually rapid in growth. Ao evKlenoes of infiltration or dissemina- Infiltration in all cases, dissemination in • many. Vnlt^J a "- "H™ i he most able P a P er which has appeared upon the subject is that by \ olkmann in the Deut. Zeit.f. Ohir., 1895, vol. xl. p. 1. * 23 354 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Benign Are often encapsulated, nearly always cir cumscribed. Rarely adherent unless inflamed. Earelv ulcerate. and Malignant. Never encapsulated, seldom circumscribed. Overlying tissue not retracted. No lymphatic involvement when not in- flamed. No leucocytosis. Elimination of urea unaffected. Always adherent. Often ulcerate — nearly always when surface is involved. Overlying tissue nearly always retracted. Lymphatic involvement an almost constant feature. Leucocytosis often marked. Deficient elimination of urea (?). Table II. — Diagnosis between Sarcoma and Carcinoma. Occurs at any age. Disseminates by the blood-vessels (veins). Arises from mesoblastic structures. Distant metastases are more common. Contains blood-channels rather than com- plete blood-vessels. Less prone to ulceration. Involvement of adjacent lymphatics not common. Secondary changes and degenerations are more common. (Sugar present in the blood ?). Rare before thirtieth year of life. Disseminations by the lymphatics. Arises from glandular (epithelial) tissues. Less so. Contains vessels of normal type. More so. Almost invariably adjacent lymphatics are involved. Degenerations not common ; other second- ary changes rare. (Peptone present in the blood?). Differential diagnosis between epithelioma and ulcerating gumma will be found in Chapter X. Table III. — Diagnosis between Epithelioma and Preceded usually by continued irritation or warty growths. Diathesis plays no known part. Rarely multiple. Area of thickening ahead of ulceration. Ulceration advancing from a central focus. Border usually raised and everted, regular in outline. Often assumes fungoid type. Base may be deeply excavated. Usually painful. Bleeds easily. Never tends to cicatrize. Most rare in the young. Discharge is very offensive. Lymphatic involvement nearly always. Tuberculosis (Lupus). Irritation plays no figure. Preceded usu- ally by nodules. Diathesis evident. Coincident evidence of tubercular disease elsewhere. Often multiple. Extension of ulceration not preceded by thickening. Various foci, which may coalesce. Border abrupt, eaten, irregular, thickened, firm, often inverted, irregular in out- line. Never fungoid. Base nearly level with surface. Seldom painful. Seldom bleeds. As marginal ulceration proceeds there is often cicatrization at centre. Common in the young. Discharge rarely offensive. Rarely. General Remarks on the Treatment op Cancer. Aside from the remarks already made in the earlier portion of this chapter on the general topic of Treatment of Tumors, it is best to em- phasize here that the treatment of cancer is too often hopeless because instituted too late. It must be part of the teaching of modern surgery CYSTS AND TUMORS. 355 to indicate to the laity in every possible way and through every legiti- mate channel that it is the greatest mistake which they can possibly make to conceal the existence of tumors or to put off operative or other treatment. Little as there is to be said of cancer that can be inter- preted as favorable, it must yet be acknowledged that in at least the majority of instances carcinoma originates in localities which are more or less accessible and as a local lesion, which, if radically attacked early, before the disease has spread beyond possibility of extirpation, would give vastly more favorable results. I hold, in other words, that in cases of cancer in accessible parts of the body, when operation can be made early enough and when tissues are sacrificed in a perfectly merciless man- ner, there is a large possibility of cure. This involves sometimes opera- tions which are too frightful for the average patient to contemplate. Nevertheless, the fact remains that even the pylorus may be successfully extirpated if only the operation be done at a time when disease is limited in extent and patients are not debilitated by its ravages. That carcinoma so frequently returns after operative attack, and that the outlook for these cases is so often hopeless and discouraging, are largely due to the fact that the general practitioner, under whose observation most of these cases first come, is slow to recognize the malady, timid to advise radical methods, and too frequently finds patients to whom the fatal policy of delay is more attractive than early and prompt interference. It is not, then, so much to the discredit of surgery that cancer appears in its present hopeless light as it is to the discredit of those who fail to recog- nize it early enough and to appreciate the urgent necessity for surgical procedures. Enough, it would seem, has already been said to insist upon more than the expediency — the absolute necessity — of wide extirpation ; and the surgeon should feel in attacking all cancerous growths that the tis- sue which is not plainly healthy is of suspicious character and should be removed. The mistake rarely is made of doing too much, while with unfortunate and fatal frequency its counterpart is made — i. e. the mis- take of doing too little. Within the past few years has come into notice the plan of treating malignant growths by the toxins of the streptococcus erysipelatis and the bacillus prodigiosus mixed, a plan based upon the original researches of Fehleisen, and in this country associated with Coley's name. It depends upon a clinical phenomenon occasionally noted, that certain malignant growths have receded or disappeared after an attack of erysipelas. The treatment consists in the hypodermatic injection of these toxins in small and gradually-increasing doses. It has been fol- lowed by marked benefit in a small proportion of cases ; but as a method ot treatment is hardly to be thought of save in non-operable cases, and these of the mesoblastic or sarcomatous type. In an occasional instance of this type it has produced remarkable results. CHAPTER XXVI. SURGICAL DISEASES OF THE SKIN. By W. A. Hardaway, M. D. Milium. — A milium is a small, whitish body commonly found on the face ; it may occur upon other parts of the body, notably the penis and scrotum of males and the labia minora of females. Milia are usually about the size of grains of sand, but may attain the dimensions of peas. If the very thin layer of skin covering a milium be incised, the mass can be turned out : it is generally soft and easily crushed, though in long-standing cases a calcareous change may occur. One or many milia may be present, and in certain regions, as the eyelids and cheeks, there may be groups of the little tumors. Milia cause no trouble beyond a slight disfigurement. A simple manner of curing milia is to incise the tumor, squeeze out the contents, and touch the little cavity with nitrate of silver. Another satisfactory method is to pierce each growth with a fine needle attached to the negative pole of five or six cells of a galvanic battery. In chil- dren frequent washings with soap and water are usually all that is required. Acne and Comedo. — Acne is an inflammation of the sebaceous glands and of the minute hair-follicles. To acne many sub-titles have been given, most of the names used being founded on clinical differences. Acne is essentially a disease of the young, often coming on at puberty. It usually disappears at the age of thirty or before. The sites on which the malady most commonly manifests itself are the sides of the brow, the cheeks, the shoulders, the back, and the chest. The lesions which make up the eruption of acne are comedones, papules, and pustules. The comedo is a sebaceous plug filling the orifice of a seba- ceous gland ; when expressed the comedo resembles a small white worm, but when in situ it has the appearance of a black point, from the dirt which has adhered to the end of the greasy mass. It is about the comedo that the inflammation commonly begins, leading to the forma- tion of the acne-papule, though papules may form independently of comedones. The papule is at first red, conical, and firm, but in a short time suppuration sets in, and a pustule situated on a red base results. In a few days this dries into a crust which falls, leaving a slight purplish stain and eventually a small pit. Since acne is universally associated with the second decade of life, it would seem that age must be regarded as in some way an etiological factor. Many have thought that menstrual disorders play an important part in the causation of acne, and it is often noticed that in those suffer- ing from acne new crops of lesions appear about the menstrual epoch. 356 SURGICAL DISEASES OF THE SKIN. 357 A thick oily skin, especially if associated with a sluggish circulation, acts as a predisposing cause. But the most important etiological factors are no doubt certain reflex circulatory disturbances of the skin caused by lesions of the stomach and intestines, such as neuroses and catarrhs. The fact that a form of acne may be caused by the ingestion of drugs, such as iodide and bromide of potassium, is well known. Whether it be treated, or not, acne will usually terminate sooner or later, but there is no doubt that by proper treatment the course of the malady can be stayed and much of the unsightly scarring prevented. In the wav of internal treatment it may be said that there are no drugs which exert a specific influence on the affection, and yet in nearly every case one must use some internal medication. If anaemia exists, tonics, especi- ally ferruginous preparations, will do good ; if the patient is strumous, fresh air, sunshine, and cod-liver oil are indicated. In the vast majority of acne patients a careful investigation will prove the presence of some gastric or intestinal affection. This should be treated by regulation of the diet and habits and by such remedies as seem appropriate. When every fault in the general health of the patient is as far as possible cor- rected, we proceed to the local treatment of the acne. It is impossible to catalogue all the methods which have been used, and only the plan of treatment which has been most successful in the hands of the author will be mentioned. A thorough washing of the face with hot water night and morning is of prime importance. White castile soap, or if something more stimulating seems desirable Bagoe's prepared olive soap, may be used. All comedones should be pressed out : this is best done after the use of hot water. A comedo-presser is necessary, and the one recom- mended by Piifard is the best for the purpose. It is only a modifica- tion of the watch-key with the sharp cutting edge replaced by a bevelled surface. When pustules have formed they are promptly opened with the acne-lancet. In acne indurata and in all cases where large, hard papules are present it hastens their disappearance to incise them even before pus has collected. Of all drugs to be used locally, sulphur or some one of its prepara- tions is best. Precipitated sulphur or equal parts of sulphur and boric acid can be used in powder form, being dusted on the affected region each night. An excellent stimulating lotion is the lotio alba, the formula for which is — Zinci oxidi, 31J ; zinci sulphatis, 3ij ; potassii sulphureti, 3ij _; glycerini, gij ; Aquae ad giv, — M. Sig. Apply at night. This lotion is mopped on at night after thoroughly shaking the bottle. The next morning it is washed off with hot wat?r. After this lotion has been used for a time it will generally be found necessary to use a stronger preparation. Vleminckx's solution is a valuable remedy. It is made thus : Calcis, Iss ; sulphuris sublimat., §j ; aquae, gx. — M. Boil to six ounces and filter. Vleminckx's solution is at first diluted with five parts of water. After this strength has been used for several nights less water is added, till finally the pure liquid is used. It is mopped on the affected regions and allowed to remain over night, when it is to be washed off with soap and hot water. In addition to the measures indicated it is well to order the following lotion : Acidi borici, giij ; alcoholis, 5 v. — M. Sig. Shake and apply. 358 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. This should be mopped on the face several times a day. By the evap- oration of the alcohol a thin layer of the boric acid is deposited over the surface, thus keeping up a constant antiseptic effect. Sebaceous Cyst. — Sebaceous cyst, also known as steatoma and atheroma, is a cyst which is filled with sebaceous matter. ( Vide also Chapter XXV., Adenomata.) The cysts may occur singly or there may be a number present. They are seen upon any part of the body, but occur with great frequency on the face or scalp. As usually observed, a steatoma presents as a tumor from a cherry to an egg in size, partly buried in the skin. In rare cases the tumor is peduncu- lated. The skin over the growth is usually normal in appearance, but it may be very thin and atrophic, or, on the other hand, thickened and somewhat reddened with dilated capillaries. The consistency may be hard or soft and doughy : this will depend in a great measure on the thickness of the cyst- wall. In some steatomata a small depression can be found through which on pressure the thick, butter-like contents can be forced. These cysts are likely from time to time to empty a portion of their contents through the opening. In other cases the tension in the cyst becomes so great that it ruptures and afterward fills again. After sebaceous cysts of the scalp have existed for a long time the hair over them falls out. It sometimes happens that sebaceous cysts become inflamed and suppurate, and occasionally this results in a cure by destruction of the cyst-wall. Sometimes an ulcer with infiltrated base is left, resembling an epithelioma. In the treatment of sebaceous cyst the one thing to be aimed at is complete destruction of the cyst-wall, for if even a small part of this remains recurrence is very likely to take place. The most generally applicable way of accomplishing this is to dissect out the entire cyst with the knife. The skin should first be anaesthetized by cocaine injections or by the ethyl-chloride spray. In dissecting out the sac the success of the operation is ensured by taking pains not to rupture the cyst before it is completely removed. The operation must of course be done anti- septically. Furuncle. — A furuncle is an acute inflammation of a hair-follicle or gland of the skin which usually terminates by necrosis of the central part of the affected region with suppuration. A single boil only may be present upon the body, but very commonly several boils in rapid succession or simultaneously affect a region. In some cases one crop after another without limit attacks a person, and this condition is designated as furunculosis. A boil commences as a small, red, painful, very tender papule, protruding from which a lanugo hair may generally be detected. Often at the apex of the nodule a small vesicle of cloudy serum may be seen. The papule rapidly enlarges into a conical swelling from a pea to a pigeon's egg in size. The surrounding area becomes red and infiltrated, while the skin over the boil assumes a dusky hue. At the end of three or four days the skin at the apex of the boil softens, gives way, and a small amount of pus exudes. At the opening a piece of white pultaceous necrotic tissue is now visible, which is thrown off in a day or two, leaving a granulating cavity. With the opening of the boil the intense throbbing pain is relieved, and with the separation of the core it ceases. After healing a small bluish-red scar SURGICAL DISEASES OF THE SKIN. 359 remains, which gradually fades to a dead white, or a slight amount of pigmentation may remain for years. A boil may not run through all these stages, but may stop short of suppuration and disappear without opening. "With large boils or where many are present a certain amount of febrile dis- turbance is noted; the patient loses appetite, and sleep is interfered with on account of the pain. The lymphatic ganglia in the neighborhood are often en- larged and tender, and may suppurate. A form of boil originating in the sweat-coil, and first described by Verneuil, differs from the ordinary furuncle. It affects especially the axillce, and the genital region. The process commences in the subcutaneous tissue as a small firm nodule. This enlarges till a raised, red, pea-sized mass is formed, which is soft and little painful. If left alone, these little abscesses burst, giving issue to a drop or two of pus, and a crust forms, under which healing occurs. Treatment. — Though many internal remedies have been recom- mended in the treatment of boils, it may be said that beyond putting the general health in the best condition possible, and correcting any constitutional vice which may be present, there is nothing which wo can accomplish by dosing the patient with drugs. In the earliest stage there is a chance of aborting a boil if only a means of destroying the germ in the hair-follicle can be used. For this purpose two methods commend themselves : The first was introduced by Tuholske, and consists of passing a needle attached to the negative pole of a galvanic battery down into the follicle and destroying it and its contents by electrolysis. The other means has been advocated by Lowenberg, and consists in destroying the affected follicle by thrusting into it the fine point of the actual cautery at a white heat. In the treatment of boils none of the ordinary poultices should ever be used, since they favor the development of other boils in the neighbor- hood of the first. If a poultice is deemed necessary, cotton wool wrung out of a 2J per cent, carbolic-acid solution and covered by rubber tissue and a bandage is the best application. This gives much relief, and often seems to limit the suppuration. In those cases where crops of boils succeed each other Yan Hoorn advises this plan of treatment : The entire skin is washed with a warm bath and soft soap. The boils and the surrounding skin are washed with 1 : 1000 bichloride solution. The boils are covered with mercurial-carbolie-acid plaster mull and the patient puts on clean linen. Twice a day fresh plasters are applied, and if the boils have opened, the pus is gently squeezed out and the region disin- fected with the mercuric solution. As soon as fluctuation can be made out, or as soon as pus is thought to have collected in aboil, a free opening should be made with antiseptic precautions and antiseptic dressings applied. After the separation of the core, if an ulcer is left which is indolent, iodoform dusted in often serves to hasten cicatrization. In the condition known as furunculosis it may occasionally happen that the patient becomes so reduced as to demand a change of climate, a course of tonics, and such other measures as are applicable after any debilitating disease. Carbuncle. — A carbuncle is a severe localized inflammation of the skin and subcutaneous tissue which, results in necrosis, usually at several distinct points. It is sometimes difficult in the inception of a carbuncle 360 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. to distinguish it from a boil, but usually the greater gravity of the malady is announced from the beginning. Not infrequently the disease is ushered in by a chill, and there is nearly always considerable fever and constitutional disturbance. The site of the carbuncle is red, swollen, cedematous, and quickly gets of a peculiar brawny hardness. There is pain of a burning or throbbing character. The redness grows more dusky, the swelling extends, and several pustules appear upon the sur- face. In eight days to two weeks the process has attained its maximum, and the carbuncle is two to three inches in diameter. Softening now commences, but instead of pointing at one place, as occurs with an abscess, the skin gives way at several points, emitting small quantities of sanious pus and exposing a white mass of necrotic tissue. These masses gradually come away through the openings, and leave deep, ragged ulcers. As soon as the openings have formed pain grows less and the constitutional symptoms grow better. The most common site for carbuncles is the back of the neck, but they may occur upon the face and other parts of the body, attacking most often the extensor surfaces. It is said that patients never recover after carbuncle upon the upper lip, but the author's experience is quite to the contrary of this statement. , Prognosis. — A carbuncle is always a dangerous affection, and especi- ally so in the aged or those debilitated from any cause. A carbuncle on the head or face is more dangerous than on other parts of the body. Tbeatment. — In all cases of carbuncle attention should be directed to keeping up the strength of the patient. To this end morphia must usually be given to secure rest, the hygienic surroundings must be made the best possible, a nutritious and easily digestible diet arranged, and alcoholic stimulants and tonics must frequently be administered. In very mild cases those local means which have been recommended in furuncle may be used, but in the majority of cases more radical measures will be called for. The method that is perhaps most generally useful is a crucial incision through the entire thickness and width of the infiltration, followed by the removal with the sharp spoon and scissors of all necrotic masses as far as possible. A moist, antiseptic dressing should then be applied and changed daily. A method which is much used on the Continent consists of the parenchymatous injection of a 5 per cent, carbolic-acid solution. A number of injections are made, and the operation is repeated if necessary, the aim being to saturate the carbuncle as thoroughly as possible short of producing carbolic-acid intoxication in the patient. The most radical of all methods thus far proposed is that of Riedel, by which the entire affected tissue is removed by the knife just as though it were a malignant tumor. The method is highly spoken of, but its use will probably be confined to those cases in which urgent symptoms are presented, as, for example, profound sepsis. Clavus ( Corn). — A corn may be either hard or soft. A hard corn is really a callosity with the addition of a peg of horny scales which pro- jects from its under surface and causes pain by pressure upon the sen- sitive tissue beneath. A soft corn differs only in that it occurs in situations where it is kept sodden by moisture. Corns nearly always occur on the feet, and are the result of ill-fitting shoes. Their usual SURGICAL DISEASES OF THE SKIN. 361 situations are the joints of the toes, especially the outer side of the little toe. It sometimes happens that a corn becomes inflamed, and this may lead to the formation of an abscess or ulcer, or even to caries of the bone. In the treatment of corns the first thing is to remove injurious pressure and to see that a properly-fitting shoe is worn. Hard corns may be treated just as if they were ordinary callosities. It is well, in addition, to place a felt corn-plaster over the corn in such a way as to prevent pressure. In the case of soft corns the feet should be washed twice a day, using plenty of soap. As much of the thickened epi- thelium as possible should be removed with a knife, and then the fol- lowing pigment painted on three times a day : Acidi salicylici, gr. xv; ext. cannabis Indie., gr. viij ; alcoholis, TTLxv; aetheris, Ttlxl ; col- lodii flex., Tfljxxv. — M. At the end of a week the corn can be pulled away with the layers of collodion. Verruca. — Warts have been variously named according to certain characteristics which they present, and for clinical purposes it is well to retain these titles. Verruca Vulgaris. — This is the form of wart so commonly seen upon the hands of young persons. Generally, a considerable number are found upon the body. They are sessile growths, from a pinhead to a pea in size, either with a smooth surface or beset with numerous little elevated points. Usually of a yellowish color, they may from accumu- lation of dirt become blackish. These warts are most frequently found on the hands, but may be seen upon any part of the body. The Seborrheic Wart. — This form occurs quite frequently upon the faces, backs, and arms of elderly persons. They are usually pigmented of a brown or black color, and present upon their surface a certain amount of scaling. They often itch intolerably. Verruca Digitata. — In this form the development of the individual papillae is great, giving rise to several long, finger-like processes seated upon a common base. These warts are found especially on the scalp, and one or several may be present. When only a single papilla is specially enlarged, the name verruca filiformis is given to the wart : it is found frequently on the eyelids. Verruca Acuminata. — This form of wart, to which the term venereal is also applied, occurs with much frequency about the genital organs and the perineal region of both sexes, but may be found in almost any other situation. The growths are pointed or sessile, and are often com- pared to various vegetable growths, as a cauliflower, a mulberry, etc. On parts of the body where they remain dry they are the color of the surrounding skin, but in the region which they most often affect they are constantly moist and become covered with a whitish, mucus-like coating and exhale a very disagreeable odor. If the coating is wiped off, bright-red, easily-bleeding tufts are 'exposed. These warts some- times develop with great luxuriance, forming masses as large as the fist. Until recently we have been entirely ignorant as to the etiology of warts, but now the opinion that they are due to a parasite is becoming more and more gen- eral. A number of instances of contagion can be cited in support of this belief. I erruca acuminata occurs especially where regions are kept moist by a chronic, discharge ; for instance, gonorrhcea, or during pregnancy, when an unusual activity ot mucous secretion occurs in the female genitals. Anatomically, all warts con- sist of a central vascular connective-tissue covered by more or less epithelium. 362 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Until recently the treatment of warts has been purely local. Col- rat made the observation that magnesium sulphate, given for some time in doses of ten to thirty grains three times a day for adults, was capable of curing warts. Other observers have borne witness to this, and the method is certainly worth a trial. A great many methods for the local treatment of warts have been advised. Some one of the caustic agents may be used. One of the best methods is by applying salicylic acid in the form of a plaster or in collodion, as recommended for corns, or, where the warts are very close together, by applying a saturated solu- tion of salicylic acid in alcohol several times a day. It is often neces- sary to resort to stronger remedies, among which may be mentioned chromic acid, acid nitrate of mercury, and trichloracetic acid. The fili- form warts may be snipped off with scissors and the base cauterized. An excellent manner of removing warts is by means of the electrolytic needle. The needle attached to the negative pole of five to ten cells of a galvanic battery is passed several times through the wart just above the level of the skin. It is better not to attempt to complete the ope- ration at one sitting, but to operate at intervals of a week or two, as in this way scarring is. best avoided. In the treatment of acuminate warts the chief point is to keep the parts dry and clean. Frequent washings are necessary, followed by dusting with a powder, such as this : Acidi borici, 3j ; hydrarg. chlor. mit, gr. x ; acidi salicylici, gr. x ; zinci stearatis, 3ij. — M. Where two surfaces which lie in apposition, as the glans penis and preputial sac, are affected, a piece of absorbent cotton should be interposed. When the growths are very luxuriant, they may first be trimmed away with the scissors and then the bases touched with pure carbolic acid or some other caustic. When these warts arise dur- ing pregnancy it is not necessary to treat them, as they nearly always disappear after delivery. Nsevus Pigmentosus. — A pigmented neevus is a congenital deposit of pigment in the skin which may or may not be accompanied by other changes in the integument. Moles have been variously named according to their clinical appearance. Ncevus spilus is the name given when noth- ing more than an abnormal pigmentation is observed. Such moles vary in size from a pinhead to a dime or even larger, and in color from fawn to black. Though most common on the back, they may be found on any part of the skin. If the surface of the mole is thrown into folds and ridges, it is called ncevus verrucosus. Very commonly a number of hairs, fine or coarse, spring from the nsevus, and the name ncevus pilosus is given. If soft, papillary growths cover the surface, the mole is termed ncevus papillomatosus. Some large moles contain a good deal of fat, and may resemble dermatolytic growths, thus receiving the name ncevus lipomatodes. Lesions occur in all respects similar to raised pig- mented neevi, except lacking' the color, and are spoken of as white moles. Moles vary much in size and number in different individuals. They are especi- ally often found on the face, neck, and back. Sometimes a pigmented nsevus covers a large region of the body ; again, a number of pigmented nsevi may be found in the course of some nerve. Sometimes a sarcoma or a carcinoma springs from a pigmented nsevus, and this renders the affection of more surgical import- ance than it would otherwise be. SURGICAL DISEASES OF THE SKIN. 363 If the surgeon is asked to remove a mole for cosmetic purposes, it is well for him to be quite sure before undertaking the operation that the resulting scar will be less disfiguring than the mole. If a mole with hairs is to be dealt with, the hairs should first be removed, and then, after sufficient time has elapsed for the full effect of the operation to become evident, what remains of the mole can be dealt with. The elec- trolytic needle gives the best results. In its use it is best to proceed carefully, doing a little at a time, as in this way scarring will best be avoided. Generally it will not be possible to remove all the pigment, but usually its amount can be much lessened and the mole can be brought to the level of the surrounding skin. If removed by the knife, as a rule too much scarring results. The caustics are unsafe. If a mole is where it is constantly irritated, as by the clothing, especially in advanced life, or if a mole shows a tendency to grow rapidly or to ul- cerate, it is wise to remove it without delay. Nsevus Vascularis and Telangiectasis. — By a vascular ncevus we mean a growth which is characterized by an increase in number and size of the blood-vessels of a part of the skin. If the blood-vessels have become dilated after the individual has reached adult life, they are usually spoken of as telangiectases. {Vide Chapter XXV., Group VI.) Telangiectases develop as secondary phenomena, although it may be at times difficult to ascertain the cause. The usual sites for telangiec- tases are the face, the neck, and the upper part of the trunk. One of the most common clinical forms exactly resembles the nsevus araneus. In other cases small red or bluish vessels are seen coursing over the skin. These are frequently seen in elderly persons upon the cheeks and in those suffering from rosacea. In other instances the telangiectasis occurs as a smooth red or purplish elevation, the surface of which may in the course of time become tuberculated, so as to resemble a raspberry. In some rare instances almost the entire surface has been occupied by telangiectases. Telangiectases are not infrequently seen upon mucous membranes, as about the nares, in the conjunctiva, and in the pharynx. Sometimes a telangiectasis spontaneously disappears, but more commonly it increases in size and others develop in its neighborhood. Treatment. — In some of the more formidable vascular nsevi serious surgical operations, such as ligature of the large vessels or even ampu- tation of the affected part, may be necessary, but here only those cases suitable for treatment by the ordinary means of the dermatologist will be considered. The methods of treatment which have been found most generally useful are — destruction by chemical agents, extirpation by the knife, and coagulation and inflammatory obliteration by electricity. 1. Destruction by Chemical Agents. — In the case of superficial nsevi the application of some caustic agent may suffice for a cure. Ethylate of sodium has been recommended, because it leaves only a superficial scar. Its use is tedious, as it must be repeated several times, and it is a preparation difficult to obtain. Nitric acid, acid nitrate of mercury, and chloride oi zinc are other caustics which, properly used, give good results. In using them the application should be carefully made, lest more destruction of tissue and scarring result than is necessary for the cure of the nsevus. The sloughs which form should be allowed to 364 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. separate of themselves. The injection of irritating chemicals into ele- vated nsevi has often been practised, but this is not a safe method and should not be used where other means will answer. 2. Extirpation by the Knife. — If the nsevus is small and so situated that tissue can be spared, probably no other method is more satisfactory than excision, as there is thus left only a linear scar. In removing a nsevus by the knife the incision should be made well outside the affected area, as otherwise the hemorrhage may be great and the growth may recur. 3. Coagulation and Inflammatory Obliteration by Electricity. — For the cure of vascular nsevi electricity may be used in two ways — as elec- trolysis or as the galvanic cautery. Electrolysis is perhaps the most generally useful method at the disposal of the dermatologist for treating vascular nsevi. In the case of small nsevi it is ideal : if the nsevi are large, its usefulness is limited by the fact that, since the area of vessels affected by each thrust of the needle is small, the sittings are long and must be repeated. The operation is performed in this way : A slender needle is attached by a suitable holder to the negative pole of a galvanic battery, while to the positive pole is connected an ordinary sponge elec- trode. The needle is passed into the nsevus and the positive electrode applied to some convenient part of the body. The tissue immediately surrounding the needle soon commences to assume a whitish color, which gradually extends, and this, together with the amount of destruction occurring about the needle, will be the index of the length of time the current is to be allowed to pass. The depth to which the needle is to be passed, the number of insertions of the needle, and the strength of the current used must all be determined by the size and nature of the growth. Usually the current supplied by twenty cells of an ordinary battery is amply sufficient. Lymphangioma. — By lymphangioma is meant a growth made up of lymphatic vessels. The form which most often affects the skin is lym- phangioma circumscriptum, and even this is a rare disease. It usually makes its appearance in the early years of childhood, and may attack almost any region of the body. When fully developed the appearance presented is striking. One or more patches, varying in size from a silver dollar to an area larger than the palm, will be seen raised above the level of the skin. At the first glance the patches seem to be made up of small closely-packed warts. The surface is uneven and rough in aspect, and varies in color from a dirty gray to black. On more careful examin- ation the seeming warts are found to be really vesicles from a pinhead to a pea in size, and so closely pressed together that their form is very angular and irregular. The vesicles are very deep-seated, their roofs being formed of the whole thickness of the epidermis. Some of the lesions are semi-transparent, but the epidermis of others is so thick that the lesions are opaque : it is the predominance of such lesions that gives to the patch its warty look. Small dilated blood-vessels can often be seen coursing over the vesicles. By a careful examination the impression is conveyed that the lesions are not vesicles in the ordinary sense, but rather that they are cavities deep in the skin filled with fluid. The lesions are firm, tough, and not easily ruptured. Around the edges of the main plaques are generally lesions that have thinner coverings, and therefore appear more as simple vesicles than those described. In color they may be pink, SURGICAL DISEASES OF THE SKIN. 365 red, or yellowish. If one of the lesions be pricked, a variable amount of clear fluid containing lymphatic corpuscles escapes. This may amount to only a few drops or the discharge may last several hours. In some cases the part upon which the lymphangioma is situated is increased in bulk. Lymphangioma persists indef- initely, tending to increase slowly in size by the formation of new vesicles and plaques. Some mention should be made of the acquired dilatations of lymph- channels to which the name lymphangiectasia has been applied. In its most frequent form it constitutes elephantiasis. ( Vide Chapter I.) Aside from elephantiasis, lymphangiectases are rare. They are always the result of antecedent causes which it is often difficult to discover. It is probable that both an acute and a chronic form exist, but nearly all cases described belong to the latter class. As an example of the acute form may be mentioned Trelat's case, in which eight days after an injury to the penis there occurred, besides an ordinary lymphangitis of the fore- skin, prominent vesicles which discharged lymph. Chronic lymphangiectases develop slowly, their progress sometimes being marked by paroxysmal erysipelas-like attacks, such as are fre- quently seen in elephantiasis. The lower extremities are usually attacked. The skin lesions consist of nodosities often arranged in rows corresponding to the course of lymph-vessels. The skin is glazed, cedem- atous, and of violaceous hue. The nodules, at first hard, break down and discharge lymph, with the consequent formation of lymph-fistula. Various secondary lesions accompany this condition, such as oedema, dermatitis, pachyderma, phlegmon, and lesions of the periosteum. In the treatment of lymphangioma the only procedure is destruc- tion of the growth. Where scarring does not matter, the cautery is the best method, as by it the vessels are sealed for some distance beyond the portion actually destroyed. When a limited area is involved and scar- ring is to be avoided, excision with the knife is advisable. Chemical caustics have not given good results. Whatever method is employed, the removal must be thorough or the growth will re-form. In lym- phangiectases elastic support should be used as for varicose veins, and compression applied to prevent lymphorrhagia. If only a few super- ficial vessels are involved, they may be dissected out. In chronic cases with ulcers and fistula? deep cauterization with such active agents as chloride of zinc or Canquoin's paste has resulted in cure. In cases where the lymphangiectasis is the result of tuberculosis of the lymph- vessels all sinuses as far as possible should be laid open, the diseased tissue should be removed, and the wound thoroughly cauterized with zinc chloride. In severe cases, with large growth of the bones and tis- sues and exhausting lymphorrhagia, amputation may be demanded. Keloid and Hypertrophied Scar (vide Chapter XXV., Group V.). — It is often of the utmost difficulty to make a clinical diagnosis between true keloid and the much commoner hypertrophied scar. The two affections are therefore classed together, and in many essential points they are identical. Alibert regarded the true keloid as a growth springing from the uninjured skin, but it is doubtful if an absence of a history of injury could be taken as implying the non-traumatic origin oi keloid, since in many cases growths indistinguishable from keloid have followed injuries so trifling as to have been readily forgotten had not some accidental circumstance fixed the occurrence in the memory. 366 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. True keloid may present itself as a single tumor, or many may be seen upon the body. In a negro recently seen by the author there were hundreds of tumors scattered all over the body. (Plate XVI.) In young subjects there is always some prospect that spontaneous involution may occur. As a rule, no operation demanding the use of the knife is permissible in true keloid, as there is a strong probability that the growth will recur. In hypertrophied scar, if deformity is caused or severe pain is present, removal may be necessary, but particular care should be taken that immediate union in the wound is obtained. The incision must be wide enough to embrace not only the scar, but also a portion of the surrounding tissue. Where there is not sufficient tissue to permit of this, skin-grafting by Thiersch's method should be employed at the time of the operation to cover in the defect. In this way recur- rence will best be avoided. Fibroma. — Fibroma of the skin manifests itself by the presence of variously sized tumors made up of fibrous tissue. Clinically, at least two varieties of fibromata can be recognized. In the first a small, firm, round tumor is present covered by normal skin. As a rule, these little growths are single, and are most commonly found on the face, trunk, or extremities. In the second form, known as mollusoum fibrosurn, the growths are multiple, hundreds being sometimes present upon the body. The tumors vary in size from a pea to masses weighing many pounds. The growths do not feel firm to the touch, but lax, and can be rolled between the ringers. The skin in the smaller tumors is normal in color, but upon the larger ones telangiectases are often seen, as well as more or less hyperpigmentation. In the case of single tumors excision may be practised where there is sufficient reason, such, for instance, as pain from pressure on a nerve. With the multiple tumors it may become necessary to remove the larger growths or the pendulous masses of skin. In such cases the hemorrhage is often alarming on account of the large vessels, and the surgeon must be prepared to meet this emergency. Epithelioma. — Three forms of epithelioma are usually described, and, though this division is purely artificial, it is retained for conveni- ence of description : (1) The superficial or discoid form of epithelioma often commences as a small pearly or waxy-looking papule, upon the apex of which usually a few thin scales collect. On removing the scales after the lesion has existed for a time there are exposed red granulations. The papules may remain for years without any further change, but more commonly they become very gradually infiltrated at the base, while the top assumes more and more the character of an indolent ulcer. The amount of tissue destroyed by the ulcer is variable. Sometimes, after a course of years, the epithelioma has only eaten away a small area, involving no more than the tops of the papilla of the skin, while in other cases great disfigurement and death may result from the amount of tissue lost. In this variety of epithelioma it is rare to find the lymphatic ganglia involved, except in the very latest stages of the disease. It is also a very rare occurrence to find other organs' affected by metastasis. PLATE XVI. Keloid. SURGICAL DISEASES OF THE SKIN. 367 (2) Papillary epithelioma is the name given to a form of epithelioma in which from the first there is a marked tendency to the formation of hypertrophied papillae. This type of epithelioma is must prone to affect the border where mucous membrane and skin join, the mucous mem- branes, the extremities, and the scrotum. Not uncommonly the affec- tion starts where a wart or other benign papilloma has existed for a long time. (3) Deep-seated epithelioma may develop as a recurrence after the removal of one of the other forms, or it may be a primary growth. It is the latter which is here described. The tumor occurs most often in the mucous Fig. US- membrane, and particularly the tongue. It occurs also upon the skin. This form of epithelioma commences as a small, hard nodule deep in the submucous or subcu- taneous tissue. The growth enlarges, and the tissues covering it may for some time remain normal, but eventually adhesions occur, so that the skin or mucous membrane is no longer movable. The skin covering the growth is often florid and shows dilated ves- Epithelioma, sels. After a variable time an ulcer forms, or the necrosis may occur more rapidly and a considerable portion of the growth may come away as a slough. A deep, irregular ulcerating cavity is left with hard edges. The progress of this form of epithelioma is more rapid than those already described, and sometimes in the course of a few months death may occur from dissemination or from marasmus. Mention must be made of a form of epithelioma which goes by the name of rodent ulcer. It is now agreed by most dermatologists that the significance of this name is purely clinical, there being no patho- logical grounds for separating rodent ulcer from other epitheliomata. This form of the malady is said to commence usually as a small brown- ish, rather soft nodule, generally found upon the upper two-thirds of the faces of elderly persons. After this has remained quiescent for a long time ulceration occurs. Though ulceration progresses slowly, its ravages may in the end be extreme, as the disease remains purely local, and thus does not readily terminate the life of the patient. After the affection has fully developed it presents the appearance of a crateriform ulcer with slightly everted edges, the great distinction of rodent ulcer being that the amount of induration is insignificant as compared to the extent of ulceration. Diagnosis. — As a rule, the diagnosis of epithelioma is easy. The age at which it develops, the chronic ulcer with indurated edges, and late in the disease secondary adenopathy, all help to establish the true nature of the affection. The maladies with which epithelioma is most apt to be confounded are syphilis, lupus, and rhinosderoma. A chancre might resemble an epithelioma, especially when it is found on the lower lip of an elderly man; but with the chancre there is a history dating back at most for only a few weeks, while that of an epithelioma covers months ; in chancre the lymphatic ganglia are involved early in the course of the sore, but in epithelioma only at a late date ; in chancre the induration is apt to be much larger in compar- 368 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. ison to. the ulcer than in epithelioma; and finally, if doubt still remains, it will be settled in a short time by the occurrence with a chancre of a roseola. A gumma of the tongue might closely resemble a deep-seated epithelioma of that organ, but the course of the gumma is more rapid, there are other signs of syphilis, and the lymphatic ganglia are not involved, as they are at a very early date with this form of epithelioma. When the gumma has broken down, the ulcer left is more undermined at the edges than the epitheliomatous ulcer: it has not much, if any, infiltration at the base and edges, and does not show the fungous growths which are usually a conspicuous feature of epithelioma. It is hardly likely that the ordinary form of lupus vulgaris could be mistaken for epithelioma. There is, however, one form of cutaneous tuberculosis (t. verru- cosa) which somewhat resembles the papillary epithelioma, but the situation of the lesion, the history, the absence of induration and of tendency to ulceration in tuberculosis verrucosa, and, finally, a microscopical examination, ought to decide the question. ( Vide Chapter XXV.) The differential diagnosis of epithelioma and rhinoscleroma will be considered under the latter disease. Paget's Disease (vide Chapter XXV., Group VII. ; also Chap- ter L.). — Paget's Disease most frequently attacks the breasts of women in the middle period of life, but it may affect other parts of the body, and the male sex as well. Croker has seen it upon the scrotum, and a case has been reported in which the affection attacked the nose. The malady usually begins upon the nipple of one breast, and looks at first like an ordinary eczema. There is more or less crusting, and when this is removed a raw, red granular-looking skin is exposed from which exudes a glairy secretion. The area involved slowly extends, the border remaining sharply defined and often a little raised. The base of the inflamed skin usually presents a thin infiltration, and scattered over the surface a few small islets of a pearly-looking epidermis can often be seen. It is com- mon to find the nipple gradually retracting. The malady may not extend much beyond the nipple or it may attack the skin of the whole breast. In a case recently seen the skin of a large portion of the anterior aspect of the thorax had become affected. There are itching and burning from the beginning. At the end of a few months, or in some cases only after many years, the disease enters upon its last stage, that of cancerous degeneration. This manifests itself either by the appearance of epitheliomata on the affected area or by the formation of an ordinary scirrhus of the breast. Microscopical examination of the affected skin shows that the super- ficial layers of the epidermis are thinned or wanting, while there is a decided down-growth from the deeper layers, and in some places alveoli of epithelial cells can be found. Thin states that the first cancerous changes occur in the lactiferous ducts. Darier has recently described certain bodies which may be seen in the epidermis in Paget's disease. These bodies are two or three times the size of the surrounding epidermic cells, and consist of a double-contoured cell-wall, within which is a mass of protoplasm containing several nuclei. Darier supposes that these bodies are psorosperms, and that the irritation of their presence causes the changes noted. The bodies may be found in scrapings which have been soaked in liquor potassse. The importance of an early diagnosis cannot be over-estimated. The affection which Paget's disease most resembles is eczema of the nip- ples. Paget's disease usually develops after the menopause, eczema during lactation. The surface exposed on removing the crusts in Paget's SURGICAL DISEASES OF THE SKIN. 369 disease is of a brighter red and more granular than that of eczema, while the border is more sharply defined. In eczema there is not the infiltra- tion noted in Paget's disease, and scrapings do not show the peculiar bodies described above. Treatment. — When seen in its early stages or before the diagnosis can be established soothing applications should be made just as though one were treating an eczema. When we are quite sure of the nature of the malady, energetic treatment should be resorted to. We may scrape away the diseased tissue with the curette and then apply a strong (30 per cent.) solution of zinc chloride for several hours, afterward dressing antiseptieally. A zinc-chloride paste may be used instead of the solu- tion, or an ointment containing 30 per cent, pyrogallol may be applied for two or three days until a sufficient destruction has been accomplished. When malignant growths have formed excision of the whole breast must be performed. Carcinoma Cutis. — Besides epithelioma, there are two varieties of carcinoma of the skin — the lenticular and the tuberose forms. Some authors recognize a pigmented form also, but it is to-day generally thought that most of these cases are really sarcomata. Lenticular Carcinoma. — Lenticular carcinoma nearly always develops secondarily to a primary carcinoma ; for instance, of the breast. The first evidence of the affection is the appearance of a number of white or pale-pink papules of a firm consistency, from a shot to a pea in size. The skin upon which these papules are situated may retain its normal color or may be of a violaceous hue and present dilated capillary vessels. The papules gradually increase in number, and coalesce to form larger nodules and plaques. In some cases large areas of skin become thick- ened and hard, constituting the cancer en cuirasse. The lymphatics may be so obstructed by the growths that the limbs become much swollen. The patient falls into a state of profound cachexia, and usually dies in a comparatively short time. If life is sufficiently prolonged, some of the nodules may ulcerate and fungous granulations may form. In a case of the author's the microscope showed that the nodules were made up of masses and bands of epithelial cells lying apparently in the lymphatic spaces of the skin. Carcinoma Tuberosum. — This form of cutaneous cancer is rarer than that just considered. It occurs upon any part of the body in the form of hard, nodular masses from a marble to a small apple in size, and of a brownish or purplish color. There are usually many such nodules on the body. In a case of the author's there were fully a dozen nodules situated upon a dense mass lying in the subcutaneous tissue of the back, and conveying to the finger the sensation that a flat mass of wood was being felt through the skin. The tendency of the tumor is to break down into fungating ulcers which rapidly exhaust the strength of the patient. Sarcoma Cutis. — Sarcoma of the skin presents so many clinical varieties that it is extremely difficult to give a general description of the affection. Cutaneous sarcoma may be primary or secondary ; one tumor may be present or many ; the growth may be pigmented or non-pig- mented. Melanotic Sarcoma. — This is the most frequent form of sarcoma, and 24 370 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. usually has its origin in a pigmented mole. From the mole a spongy, fungating, black tumor develops. In the course of a few weeks or months, generally first in the neighborhood of the original growth, Fig. 116. Fibrosarcoma of hands. numbers of small, firm, pigmented masses appear. These small tumors coalesce into large masses, ulceration occurs, the lymphatics become involved, and, after having become more or less generalized over the skin, the sarcoma attacks internal organs. The course of this form of sarcoma is usually rapid. Hutchinson has described a special form of melanotic sarcoma under the name melanotic whitlow which commences as a chronic onychitis with a faint pigmentation ; gradually a slightly pigmented, fungating tumor develops, and then the sarcoma becomes generalized. Histologically, these tumors are very vascular round or spindle-cell sarcomata, with giant cells in some parts of the growth. There is also always more or less pigment to be seen both in and between the cells. Idiopathic Multiple Pk/nwnted Sarcoma. — This form of the disease was first described by Kaposi : it is very rare. It generally occurs in middle-aged males, and first manifests itself as reddish-brown or plum- SURGICAL DISEASES OF THE SKIN. 371 colored, pea-sized tumors, which are tender on pressure and are accom- panied by spontaneous pain. The growths occur on the flexor or extensor aspects of the hands or feet. The tumors increase in number and run together to form plaques. In addition to this, the hands, feet, and eventually the limbs, fall into an elephantiasic condition on account of a diffuse, board-like infiltration in the skin. The treatment of pigmented sarcomata after dissemination has occurred is futile. If the primary growth is removed thoroughly at an early date, there may be some chance of cure. No treatment has suc- ceeded, in the great majority of cases, in curing idiopathic multiple pig- mented sarcoma, but the author has seen a case recover spontaneously, and Kohner claims to have brought about a cure by the use of arsenic. Arsenic administered hypodermicallv in gradually increasing doses has cured a number of cases of multiple non-pigmented sarcoma. The local sarcomata should be removed as soon as the diagnosis is made. Reference has already been made to the employment of erysipelas toxines in carcinoma. It has been used apparently with some benefit in inopera- ble cases of sarcoma. Tuberculosis of the Skin. — To-day no one doubts that the tubercle bacillus is capable of causing grave troubles in the skin. It is still a question as to where the limit of the various clinical forms which are in reality tuberculous should be drawn. Already it is shown that most cases of what was called papilloma are in reality tubercular infections. The same has been shown for many apparently simple chronic ulcers. Many are contending to-day for the tubercular nature of lupus ery- thematosus, and there, can be no doubt that there are cases of tuberculosis of the skin which are clinically indistinguishable from it. ( Vide Chap- ter IX.) At present there are at least four well-recognized clinical forms in which tuberculosis of the skin may occur ; Lupus vulgaris, tuberculosis cutis, tuberculosis verrucosa, and scrofuloderma. Symptomatology. — Lupus vulgaris, as a rule, commences in child- hood and upon the face. Often the first evidence of the disease will be two or three small red-brown spots upon the cheek. They may be slightly raised, on a level with the skin, or depressed. Slowly these spots enlarge and take on a semi-transparent " apple-jelly " look. These are the well-known lupus tubercles, and it is by variations in their size and course that all the clinical manifestations of lupus are formed. The tubercles are much softer than the surrounding tissue, as may be ascer- tained with a blunt probe. Gradually more and more tubercles appear, and in the course of months, or more often years, by coalescence, a brown- red patch is formed, somewhat raised, thickened, and covered with a cer- tain amount of thin scales. In the border of such a patch it is nearly always possible to distinguish typical lupus-tubercles. From this point the^ lupus pursues one of two courses. It may break down and ulcerate. 1 his is especially liable to happen when any of the mucous orifices are involved in the ulceration : all the soft parts down to the bone may be destroyed, but the bones are hardly ever attacked. The ulcers heal, usually after having existed for a long time, and scars of various sorts, from a thin to a much-banded scar, result. After the apparent healing has lasted a long time it is very common to see lupus-tubercles again 372 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. making their appearance in the scarred area, and the process again runs through the course described. While the ulceration is going on at the central portion of the patch the border has been slowly extending by the growth of new tubercles. Fig. 117. Lupus vulgaris. In some cases or in some parts of a patch ulceration does not occur, but interstitial absorption in the lupus-tissue oqcurs, and gradually the area becomes atrophic, covered with the scaling epidermis, and depressed below the surrounding level. Tuberculosis Cutis. — The affection to which this appellation has been given has been seen only in persons affected with tuberculosis of some internal organ, and is rare. The disease occurs as chronic ulcerations at muco-cutaneous junctions, as the mouth or anus. The ulcers are shallow, with ragged borders. The floor is filled with granulations which secrete a thin, purulent material which may dry into crusts. At times small yellow miliary nodules can be seen scattered over the lesion. This form of cutaneous tuberculosis does not always come on late in the course of the general infection, but may at times be one of the earliest signs, and some cases of ulcers of this class have been reported in which the skin-trouble seems to have been primary and tuberculosis of internal organs secondary. Often these ulcers are extremely painful. They SURGICAL DISEASES OF THE SKIN. 373 may continuously enlarge, or, having reached a diameter of an inch, stop there. They show no tendency to heal. Tuberculosis Verrucosa. — This affection was formerly known as ver- ruca necrogenica. It occurs usually upon those who handle dead per- sons or animals or those who have come in contact with the secretions of patients affected with tuberculosis. The early appearance of the lesion may vary considerably, but as it develops a marked tendency to papil- lary hypertrophy is noted. The common sites of the affection are the knuckles, backs of the hands, elbows, and knees. In a well-developed lesion which is still extending there is an erythematous zone outside the patch. The patch is covered with a crusty-looking growth, often with pustules between the excrescences. The area may be small or it may be large enough to cover the back of the hand. There is little tendency to ulceration. Sometimes spontaneous involution occurs, but usually the lesion slowly extends. At times the centre becomes atrophic, while the circumference is still extending. Beyond the local trouble this form of tuberculosis is not, as a rule, serious, but a few cases are reported in which generalization occurred. The course of the affection is very chronic, the lesions frequently lasting many years. Scrofuloderma. — This term is applied to certain lesions originating in the subcutaneous tissue in scrofulous subjects, and involving the skin secondarily. The lesions usually commence in lymphatic ganglia, es- pecially those of the neck. A doughy, painless swelling is formed. After a time the skin assumes a bluish hue, and finally breaks at one or more points, giving exit to a sanious material and leaving an ulcer with ragged, undermined edges. At other times the origin is not from a lymphatic ganglion, but from a nodule in the subcutaneous tissue. The ulcer is extremely slow in healing, and may last for years. In some cases the patient is exhausted by the protracted suppuration, more es- pecially as accompanying this condition there are usually other affec- tions present to which the strumous are liable. After the ulcers have healed scars remain, usually traversed by bands and ridges. Prognosis. — All forms of skin-tuberculosis are characterized by a tendency to recurrence even where a cure seems to have been effected. This is especially true of lupus. Tuberculosis verrucosa and scrofulo- derma give a better hope of permanent cure. If left alone, lupus nearly always slowly extends, causing hideous deformities, but rarely complete involution has occurred. The prognosis of tuberculosis cutis is that of the tubercular affection which it complicates. Treatment. — Since it is almost universally admitted that tuber- culosis of the skin is acquired by direct inoculation, it becomes of the highest importance to use every prophylactic precaution, especially with those who are supposed to be predisposed to tuberculosis. This includes avoidance of exposure, careful attention to all wounds, especially when they are known to have been exposed to tuberculous secretions, and care- ful and prompt cleansing of the unbroken skin when it has come into contact with any tuberculous matter. Internal treatment can be of avail only in so far as it improves the general condition of the patient. In this way climate also may exercise a beneficial effect. Thus far, we have no specific treatment. Tuberculin has been by 374 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. many discarded. Thiosinanim, much lauded in certain quarters, has proved inefficient in the author's hands. The true treatment of skin- tuberculosis is local. Caustic agents have been used lor a long time in the treatment of lupus. This method is not so much used now as surgical means. Only a few of the caustics will be mentioned here. Arsenical pastes (such as Bougard's, for which see Epi- thelioma) are valuable because they have a selective action, destroying diseased tissue more rapidly than the healthy. The paste should be applied on cloth, removed in twelve hours, and applied" again if necessary. Pyrogallic acid has a selective action, and may be used in an ointment, 3j to §j, spread on cloth and applied fresh twice a day till a sufficient effect has been produced. Nitrate of silver is useful, and with some dermatologists it is the favorite caustic ; the solid stick should be used, boring it into the soft lupus tissue. Pure lactic acid applied to ulcerated lupus on lint, the surrounding skin being protected by an ointment, has frequently yielded excellent results : the applications last half an hour, are frequently painful, and must be repeated. Salicylic acid, either in plaster mulls with creosote added, as recommended by Unna, or made into a paste with glycerin, often gives good healing, especially in the more superficial forms of the disease. Elsenberg has reported favorable results from the use of parachlorophenol. The area affected is first washed with alcohol and ether, and then pure parachloro^ phenol, heated till it melts, is painted on : this is somewhat painful. An ointment composed as follows is then applied : Parachlorophenol, lanolin, vaseline, powdered starch, da. 3iiss. — M. After ten or twelve hours this is removed and an iodoform salve substituted. In two days the parachlorophenol may be applied again, and so the treatment continued till cicatrization occurs. Of the various surgical methods of treatment, excision is the one which theoretically should yield the best results, but its use has been restricted in past years on account of the large wounds which it neces- sitates. Thiersch's skin-grafting has alone a great deal to obviate this dif- ficulty. This is the best treatment for tuberculosis verrucosa and for the enlargements of the lymphatic ganglia which lead to scrofuloderma. The method which is most generally used in treating lupus is no doubt curetting. A sharp spoon is used, and all the lupus tissue is scooped away as thoroughly as possible : the surface should then be cauterized with carbolic acid or zinc chloride. A great portion of the affected area usually heals after such a procedure, but some nodules will appear again, and must be scooped out again or treated in some other way. Multiple incision of the lupus area has been strongly urged by Vidal. The incisions should be made very close together, and usually two series of cuts are made at right angles. The theory of cure by this method is, that the vessels which nourish the new tissue are destroyed. The operation must be frequently repeated, and generally produces healing in a large part of the patch. The few"remaining nodules are usually best treated in some other way. The actual or the galvanic cautery may be used with advantage after curetting in place of a chemical caustic. This method may be also primarily used to destrov the lupus tissue either by puncture or by scarification. It is of special value iii treating single lupus nodules. The galvanic cautery forms an excellent means of destroying tuberculosis verrucosa and for cauterizing the ulcers of scrofuloderma. Electrolysis forms a convenient method for destroying nodules that have formed in the scars after any of the above-mentioned methods. A needle, affixed to the negative pole of a twenty-cell galvanic battery, is repeatedly thrust into the nodule till its destruction seems accomplished. In treating an ordinary case of lupus it often happens that we get the best and most rapid results by a combination of these methods, using at some stage, for example, a chemical caustic, and then one of the sur- SURGICAL DISEASES OF THE SKIN. 375 gical procedures, or vice versd: what combination of procedures is best for each case must be determined by the judgment of the surgeon. The treatment of the ulcerous lesions of scrofuloderma will depend somewhat upon the condition of the patient, as well as upon the nature of the disease. It is advisable, if possible, to curette the ulcers, to lay open all sinuses, to cauterize with carbolic acid or chloride of zinc, and then to dress with iodoform. Where such severe means cannot be under- taken, the ulcers may be dressed with a paste made of salicylic acid and glycerin, to which has been added 1-2 per cent, of carbolic acid. Chaul- moogra oil internally and also as an ointment is recommended by Crocker. Erythema Induratum. — Under the title erytheme indurc des scrofu- leux Bazin has described a malady which most often occurs in young girls of a scrofulous habit. The disease first manifests itself as one or several hard, pale indurations in the skin, which can be more easily felt than seen. The indurations are most usually found on the legs, and a favorite site is just below the bulge of the calf. When a number of lesions are present they may coalesce into brawny patches. In the course of time the skin over the nodules becomes red and then violaceous. Involution may occur after a considerable time, or the indurations slough out, leaving deep indolent ulcers, which are very slow in healing. There are no symptoms of constitutional disturbance, but there are often severe pains in the limbs. Its chronicity, the small number of lesions present at first, and the absence of fever distinguish this affection from erythema nodosum. The disease is most often mistaken for syphilitic gummata, but the absence of a syphilitic history, absence of other syph- ilides, the evolution of the disease, and finally the failure of specific treatment, should determine the diagnosis. In the way of treatment all these cases demand tonics, cod-liver oil, and good hygiene. The patient should be placed at rest with the legs elevated. When ulcers have formed, dressing with stimulating powders, such as iodoform, and the application of antiseptic dressings with firm bandaging, are most appropriate. In any case the healing is slow. Rhinoscleroma. — Rhinoscleroma is a parasitic lesion commencing as a painless induration, usually situated at the edge of the alai nasi or upon the upper lip. It grows very slowly, and there is no tendency toward involution. The skin over the growth may be unchanged or it may present dilated blood-vessels or may have a dark reddish color. To the touch the mass has a peculiar wooden hardness. The tumor has a lobulated appearance. Between the lobules the skin may crack, giving exit to a thick yellow discharge which dries into crusts. The affection may occur in the palate, pharynx, or trachea. It causes usually no sub- jective sensations, unless by its increase in size it interferes with respi- ration. In some cases pressure on the growth causes exquisite pain. The disease is rare, but in some portions of Russia is almost endemic. There is little encouragement to operative interference, as thus far after removal the growth has always recurred. Lang seemed to get good results in one case by the internal administration of salicylic acid, and at the same time injecting the drug into the tumor. In case respi- ration is interfered with, a part of the growth may be removed or a hole may be drilled through it to permit breathing. ( Vide Figs. 9 and 315.) 376 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Actinomycosis. — Actinomycosis is another parasitic disease rarely involving the skin primarily. (Vule Chapter VIII.) The affection is most commonly seen in the subcutaneous tissue of the jaws, though other regions may be affected : for example, in certain tropical countries one variety of actinomycosis is not uncommon affecting the feet, constituting the malady called podelcoma. After an incubation-period which is not determined, the disease commences as one or more hard, lumpy tumors about the jaw. As they enlarge and approach the surface the skin over them become violaceous in appearance, and finally breaks down, often at several points. The sinuses thus formed discharge a sanious pus, float- ing in which may usually be found the actinomycotic granules, small, yellowish bodies composed of the ray fungus. Not long since it was thought that the only treatment consisted in total extirpation of the diseased tissue. Where this was impossible in- cision of the sinuses, with subsequent scraping and cauterizing, was recommended. Recently it has been shown that potassium iodide, administered as in syphilis, is almost a specific, and a number of cures by this means have been reported from various parts of the world. Cysticercus Cellulosus Cutis. — The cysticercus of the taenium solium is occasionally found in the subcutaneous tissue, where it forms tumors from a pea to a marble in size, round, and covered by unaltered skin. In the early stages the tumors are tense and elastic, but in time may undergo calcareous change. Usually several tumors are found, most commonly on the back. The diagnosis is often impossible to make except by removing one of the tumors and puncturing the sac and examining the fluid for the hooklets. Echinococcus-cysts have been found in the skin, where they form fluctuating tumors. Guinea-worm (Pilaria Medinensis). — The Guinea-worm is a white worm one-tenth of an inch in diameter and from two to three feet long. It is found in a great many tropical countries. The embryo probably enters the body in the drinking-water, and passes from the intestines to the skin, under which it develops. This applies only to the female worm, the male never having been discovered. When fully developed the worm can be felt like a string coiled up. Inflammation more or less intense is excited, and a vesicle forms which breaks, allowing the head of the ivorm to protrude. The time-honored treatment for Guinea-worm consists in gentle traction performed by winding as much of the worm as protrudes each day about a bit of stick. This method is tedious, and recently means which would seem better have been suggested. Christie has recom- mended the destruction of the worm while still under the skin by elec- trolysis. Emily recommends injecting into the worm as it lies under the skin a solution of bichloride of mercury. The worm is killed and absorbed without further trouble. Onychia. — The term onychia is applied to any inflammation of the nail-matrix. The inflammation may be associated with some lesions of the nervous centres, as in Morvan's disease. There is an onychia which is of syphilitic origin. The most important and the only phase of the affection that will be discussed here is onychia maligna. This is an acute phlegmonous inflammation of the matrix which is most commonly seen SURGICAL DISEASES OF THE SKIN. 377 in ill-nourished children of strumous habit. The affection commences with throbbing pain in the finger. There is a sero-sanguinolent exuda- tion under the nail, which becomes of a dull, opaque color, is lifted from its bed, and curls up at the edges. It usually separates, leaving a sloughy surface which cicatrizes with the formation of a deformed nail. The inflammation may spread to the tissues about the nail, constituting a paronychia, which may result in the loss of the last phalanx. The tkeatment consists in such general measures as the condition of the patient demands, together with appropriate local applications. At first cold-water compresses give relief. As soon as fluid has collected beneath the nail the pain is best relieved by splitting the nail : if it is loose, it should be removed, as recovery is thus hastened. The surface left is to be treated with antiseptic dressings on ordinary surgical prin- ciples. CHAPTER XXVII. BURNS, SCALDS, AND FROST-BITES, AND THEIR TREATMENT. By John Parmentee, M. D. Bubns and Scalds. To the old classification of burns and scalds, which regarded the depth only of the destructive effect, should be added another which takes cognizance of the superficial extent as well. It is a well-known clinical fact that a deep burn of limited extent is far less serious than one quite superficial, but covering a large area. Furthermore, there does not seem much justification for clinging to the elaborate classification of Dupuytren, who divided burns into six groups according to the depth of the lesion, for from a practical standpoint the surgeon knows how difficult it is to estimate the depth of a burn at the time of its occur- rence. As burns and scalds differ only in causation and appearance, it will be understood that what applies to one is equally true of the other, and therefore, to all intents and purposes, the terms may be used inter- changeably. Definition. — A burn is the lesion remdting from the application of concentrated dry heat; a scald, from the application of hot or boiling liquids or steam. Corrosive fluids cause lesions very similar in many respects to those produced by dry or moist heat. Classification. — Burns and scalds may be divided into three groups : (a) Burns of the First Degree. — These may have hyperemia and swelling for their chief characteristics. The skin becomes more or less reddened from capillary dilatation, followed by a serous exudate, which is ordinarily slight in amount. These phenomena may last for a few hours and entirely disappear. Occasionally, in persons with a delicate skin, desquamation occurs. (6) Burns of the Second Degree. — To the hyperemia and swelling are added vesication. The blebs vary in size and contain serum clear or light in color, and lie between the horny layer and the rete Malpighii. The time of their appearance varies from a few minutes to some hours. The swelling is greater than in burns of the first degree. The pain is also more marked, especially when the vesicles are opened and their covering removed. (e) Burns of the Third Degree. — These include all lesions involving the entire thickness of the skin, with or without the underlying tissues. They vary, therefore, from partial destruction of the skin to complete charring of all tissues. An eschar is formed which may be dry or moist according to the individual case, and possessing varying shades of color from gray to black. BURNS, SCALDS, AND FROST-BITES. 379 General Considerations. — These injuries, where at all extensive, even though .superficial, are peculiarly fatal, and have always been justly dreaded by the surgeon. The young and the old, delicate women and drunkards, are more prone to die than healthy adults. Few live when more than one-quarter of the body surface has been burned. Burns involving the thorax or abdomen are particularly fatal, owing to the shock and to sequels to be mentioned later. In cases dying within a few hours after injury no characteristic post-mortem appearances have been discoverable, so that numerous theories have been advanced to explain the lethal action of burns. We may mention only a few : (a) Destruction of Red Blood-corpuscles. — These being essential to respiration and metabolic activity, these processes are hindered by their diminution, or else, having given up their haemoglobin, this latter may destroy the white blood-cor- puscles and produce an excess of fibrin-ferment, with subsequent coagulation of the blood in the vessels. This theory is in accord with the post-mortem findings in certain cases where an excess of haemoglobin was found in the kidneys, these organs being hyperaemic and studded with necrotic foci. The more or less com- plete anuria so often observed in these cases can thus be explained by the lesions in the kidneys. (b) Over-heating of the blood, with subsequent cardiac paralysis. (c) Excessive irritation of the nervous system, with resulting reflex diminution of vascular tone. (d) Thrombi and emboli from the blood-plaques, which, added to the increased adhesiveness of the blood-corpuscles, cause stoppage of the circulation. (e) Ptomaine-poisoning, the ptomaines being ibrmed from the products of decomposition which have escaped destruction by the burn. But it is now well proven by various researches that the effects of burns in this respect bear a. close relation to ptomaine-poisoning. An amorphous ptomaine, with a sharp, disagree- able odor, has been isolated from the blood under these circumstances, which when injected into animals produces all the symptoms caused by burning. A poison can also be isolated from burned flesh, which makes it probable that this poison is first there generated and thence disseminated throughout the system. It is probably to be regarded as the product of high temperature upon albumin, and of the direct importation of bacterial poison from without. Its formation can be materially reduced by removing the burned portions of the body before the ptomaine has entered the circulation. Accordingly, prompt amputation of the destroyed mem- ber is indicated. If delayed twenty-four hours, it may be too late. The poisoning is so similar to that produced by muscarine that atropine — as an antidote — will often be found most serviceable. (/) Noxwus chemical substances formed by the action of heat upon substances within the skin and then absorbed. It has been alleged that hydrocyanic acid is produced in this way, and the resemblance between the symptoms of fatal burns and poisoning by this acid have been adduced in support of the theory. It is much easier to explain the cause of death when this follows after three or four days, but, as this properly belongs to the sequelae of burns, it will be considered elsewhere. Symptoms. — These vary with the situation, extent, and the time following the receipt of the burn, and with the age, bodily vigor, and temperament of the individual. Given a case of extensive superficial burn involving a third or more of the body-surface, we shall find symp- toms of shock the most prominent feature. Usually there is great pain, although in very bad cases this may be absent. The patient complains of great thirst and is more or less completely prostrated. The skin- surface is cold and clammy, the face pale, the temperature subnormal ; the mouth and tongue are dry ; the pulse is small and thready ; the respiration shallow and panting ; the mind may be clear, but commonly delirium supervenes, followed by stupor and coma. The rigors and 380 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. cramps frequently seen in adults are increased to convulsions in children. Should the patient survive the following twenty-four to forty-eight hours, the phenomena of shock are succeeded by those of reaction and inflammation. In this stage the temperature rises, the pulse becomes fuller and more bounding, the respiration more regular, but hurried — symptoms which are due to the pain and reflex irritation, and also to the absorption of decomposition products. It is in this stage that the more dangerous complications arise which so commonly cause a fatal issue. These will vary with the situation and extent of the burn. Chief among these may be enumerated the following : pleurisy, pneu- monia, pericarditis, meningitis, cerebritis, peritonitis, duodenitis, and intussusception. The third stage usually begins after the second week, and is charac- terized by suppuration and septic phenomena. This stage acquires signif- icance in proportion to the extent of the surface injured and to the inefficiency of the treatment employed, as, for instance, where septic pus is allowed to remain in contact with a granulating surface, which it quickly erodes and deepens. Should the patient survive the many com- plications which belong rather to this than to the preceding stage, he may finally succumb from pyaemia, amyloid changes, and resulting exhaustion. Among the important complications of this stage may be found — (a) Tetanus. — This may occur in the preceding stages, but most often appears at this time. ( Vide article on Tetanus.) (b) Arthritis occurs where the burn has extended to the region of the capsule, through which, by extension of the sloughing, the joint becomes invaded and sub- sequently inflamed. That this inflammation does not always of necessity follow is well illustrated by a case now under the writer's care, in which, following a burn from a sky-rocket, the capsule of the metacarpo-phalangeal articulation of the left index finger was opened some weeks after the injury through ulcerative action. The joint was thoroughly washed out and the capsule stitched. Union was imme- diate, and perfect joint-action followed, and has so remained. Ordinarily, how- ever, the loss of the joint may be expected to ultimately occur. Here, as else- where, an antiseptic regimen helps in preventing ulcerative action or mitigates it when fully established. In other respects the treatment is that of joints suppu- rating from other causes. (o) Hemorrhage from ulceration extending into some vessel sufficiently large now and then causes serious and fatal results. When a burn occurs over import- ant vessels the possibility of hemorrhage should always be borne in mind, and measures taken to prevent it from becoming excessive. For instance, when upon an extremity the patient should be shown where and how to compress the vessel until aid comes. Other expedients will suggest themselves in individual cases. ( d) Cicatrices and their diseases. Cicatrices are the most common sequelce. of the third stage. They not only produce frightful deformity, but they may also impair the function of the afflicted part, so that extensive operations are often necessitated for their removal. This portion of the subject will be treated, elsewhere in this work, so that we shall content ourselves here with a word as to their prevention. Rigid asepsis from the beginning should be aimed at. Unfortunately, only too frequently this must of necessity be imperfect or wellnigh impossible to attain, but this should not deter us from doing our best along these lines. Early skin-grafting by Thiersch's method should be resorted to. This measure, when done in a timely and proper way, is a most efficient one in preventing cicatricial contraction. Where BUBNS, SCALDS, AND FROST-BITES. 381 and when feasible the part should be systematically moved, the natural motions being imitated so far as possible. Proper posture during sleep is a most important, but usually neglected, prophylactic measure. Cicatrices may undergo various changes of a pathological nature. Among these is ulceration. This is not infrequent in scars from burns occurring in tuberculous, syphilitic, or even badly-nourished individuals. It may occur years after the formation of the cicatrix. As such cicatrices usually depend upon some depraved constitutional state, the indication is to build up the general health with tonics, nourishing food, and an existence as hygienic as possible. Locally they may be treated with solutions of nitrate of silver, 5 grains and upward to the ounce. Alum (one teaspoonful to a goblet of water), alcohol, port wine, and other astringents may be used with advantage. Carcinoma, especially epithelioma, is comparatively frequent in scars following extensive burns. The writer has had occasion to amputate the lower extremity three times for such cause, and has seen a few cases in the practice of other surgeons. Treatment. — This is both constitutional and local. Constitutional treatment in cases of severe burn, with symptoms of shock and collapse, resolves itself into judicious stimulation, alleviation of pain, and later the use of tonics and restoratives, together with improved hygiene. Diffusible stimulants, such as alcohol and ether, may be given hypo- dermically, by rectum, or by mouth where the patient can swallow. External warmth, particularly the hot (100°-104° Fahr.) bath, aids these stimulants. Strychnia and digitalis, in appropriate doses (gr. ^ of the former and 15 minims of the latter), to be repeated in two or three hours if necessary, may be advan- tageously used. Where the collapse is less marked and the pain excruciating it is good practice to immediately anaesthetize the patient, and then administer mor- phia in doses of from i to J grain subcutaneously. The morphia can thus be given in smaller doses and renders more efficient service than when its effects are offset by the pain. In some cases auto-transfusion and the subcutaneous injec- tion of normal (0.6 per cent.) salt solution does great service. Local Treatment. — The kind and amount of treatment varies with the kind and degree of burn. The burns caused by corrosive chemicals may be in part neutralized by agents having an opposite chemical reaction or a mechanical effect. This, however, is only true when treatment can be instituted immediately or very soon after the receipt of injury. Burns of the first degree require little or no treatment. Cooling applications, such as cool water, lead-water, starch-water, a saturated solution of sodium bicarbonate, and the like, form the most soothing applications. Powders, in the form of starch, dermatol, zinc oxide, flour, fuller's earth, and many others may be used, but ordinarily are not so grateful as lotions. Flexible collodion makes an admirable dressing, and is especially useful about the more mobile parts of the body, such as the neck, face, etc. A domestic remedy of great efficiency in burns of even the second degree is molasses, which is best put on by soaking bits of blotting-paper about £ an inch by 2 inches in it before laying them evenly upon the entire surface. They must overlap each other, and when sufficiently dry an excellent covering is obtained 382 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. for the part. Any excess of molasses at the edges may be wiped away and dry powder dusted upon them. Thus applied, molasses excludes the air, is soothing, and prevents decomposition, sugar being an excellent antiseptic. Burns of the second degree may be effectually treated by the means first mentioned. In addition, the blebs frequently require attention. As a rule, they may be left for a few days (three or four) without treat- ment, as the raised epidermis and serum protect the underlying sensi- tive surface. When, however, blebs form from the action of corrosive fluids, the serum will be found of an irritating character and should be evacuated early. How this is to be done has been already explained in Chapter XVII. under the Management of Blisters. For burns of the third degree, where they are at all extensive, no single procedure compares in value with the hot bath (100° Fahr.). It may be continued for days, and even weeks or months. It gives instant relief from pain by protecting the burned surface from the air, and for a similar reason it tends to prevent decomposition. When pus is formed it is washed away immediately, and thus a fairly aseptic condi- tion of the burned surface is maintained. Above all, in the early stage it vigorously combats the collapse which is so often present. For lesions of the third degree, but comparatively local in extent, the first indication is to carefully disinfect them with solutions of bichloride 1 : 2000 or carbolic acid 1 : 40, and to cut away all tissue actually dead. To do this effectually an anaesthetic is usually required. Indeed, the anEesthetic should be given before the removal of the clothing — which, in passing, it may be said, should be removed with the utmost care, in order that the epithelial covering may be preserved as far as possible. In the majority of cases the use of some antiseptic powder is preferable to ointments as a dressing. Powders are more apt to remain antiseptic, and their power to prevent suppuration is certainly greater. An excellent powder for this purpose is one containing iodoform 1 part and boric acid 7 parts. It should be sterilized before using by steaming for fifteen to twenty minutes. It can be used generously, with- out fear of iodoform-poisoning, except, possibly, in the more extensive burns in young children, where the hot bath is usually indicated. Zinc oxide, bismuth, and other similar powders have been used and praised. If ointments are used, a good formula is one containing equal parts of the ointment of oxide of zinc and of naphthaline, to which may be added 5 per cent, of iodoform. Picric acid in 1 to 3 per cent, ointment, or in saturated watery solution, makes a very soothing and excellent dressing. Whether powder or ointment be used, over all a thick layer of anti- septic gauze and cotton should be applied and bound firmly to the part. The dressing should not be disturbed until loosened bv the discharges. In the less extensive burns oftentimes a single dressing will suffice, a dry aseptic scab having been formed, under which healing goes on without incident. The prevention of scars has already been alluded to in a previous paragraph. Burns from Lightning. — These vary from mere reddening of the skin to the most severe forms. Coexisting with these are usually found pathological conditions of even more importance which scarcely come within the scope of this chapter, and the subject may be dismissed with the statement that, so far as the burns are concerned, what has already been said upon the subject in general applies equally to similar lesions due to lightning. BURXS, SCALDS, AND FROST-BITES. 383 Frost-bites. Frost-bites result from the application of cold of an intense degree for a time sufficiently long to arrest the circulation. They may be divided, like burns, into three degrees, and have a striking similarity to them. The first degree is characterized by superficial erythema; the second, bv the formation of resides ; and the third, by eschars. Symptoms. — These are both constitutional and local, varying with the degree and duration of exposure to cold. Constitutional Symptoms. — In extreme cases these are manifested by a subnormal temperature, difficult respiration, slow pulse, dilated pupils, which react sluggishly, incoordination, apathy, and a tendency to sleep, which is so irresistible that the individual will consciously lie down to certain death. Local Symptoms. — The first degree is characterized by a deep-red color and more or less evident swelling in the affected tissues. The retarded circulation is shown by the slowness with which the color returns after its dissipation by pressure. The part may become more or less painful as warmth is applied ; usually only itching is present. This degree of frost-bite, frequently repeated, leads to the well-known con- dition of chilblains. In frost-bite of the second degree the color becomes of a deeper red or bluish tint, and the part is more or less covered with blebs. These may break, leaving ulcers which are extremely slow in healing. Indeed, frost-bites of the second degree are usually more intractable than burns of the same degree — i. e. the vitality of the tissues is more depressed. In the third degree the part becomes dark blue in color or marble- like, is anaesthetic, and is covered with blebs. Soon gangrene, local or general, supervenes, followed frequently by sepsis, producing general disturbance. Treatment. — This will vary according to the extent of surface in- volved and the degree of the freezing. The treatment when a large portion of the entire body is frozen con- sists in the gradual application of watmth. This is done by putting the patient in a cold room, rubbing him with a sponge soaked in cold water, later putting him in a cold bath (60° F.), the temperature of which is gradually raised to 90° in the succeeding three or four hours. Stimulants may be given subcutaneously, or, in cold water, by mouth where the individual can swallow. (Large, hot enemata should not be used, as thrombosis and gangrene of the bowel may be easily induced.) Vertical suspension of the part (the extremities, for instance) should be resorted to early. When pain is severe it may be mitigated by the appli- cation of cold in some form, as the snow-poultice, ice-bags, or cold wet cloths. Artificial respiration should be practised, and continued for a long time, even though its effects are not at first apparent. Local Treatment. — The treatment of a part is conducted along lines similar to those just considered as applicable to freezing of the entire body. The restoration to a normal temperature must be gradual ; therefore snow or ice should be first used and followed by warmer appli- cations. Dry rubbing of the part is also useful. When ulceration has occurred, it may be treated as in the case of burns with any of the vari- 384 AFFECTIONS OF THE TISSUES AND TJSSUE-SYSTEMS. ous antiseptic powders or ointments previously mentioned. Where the frozen surface is extensive, the continuous bath may be used with great advantage, and for the same reasons that indicated its use in burns. Its temperature will of course be regulated by circumstances. We have in mind here the bath as used after reaction has been finally estab- lished. When the part becomes gangrenous we should redouble our antiseptic precautions, and when a line of demarcation has formed between the living and dead tissue, remove the latter. In the case of an extremity this means amputation or disarticulation. Where suppura- tive cellulitis occurs it must be met promptly with free incisions, disin- fection, and thorough drainage in the usual way. CHAPTER XXVIII. THE MUSCLES, TENDONS, AND TENDON-SHEATHS, BTJKS^E, AND FASCIAE. By Herbert L. Burrell, M. D. Malformations. Congenital muscular deformities are met with occasionally. They are always due to either the absence of certain muscles or to the pres- ence of supernumerary muscles. The absence of the pectoral muscles is recorded. Webbed fingers, or syndactylism, is a congenital fusion, more or less perfect, of two or more digits. It is not very rare ; it often occurs in more than one member of a family, and frequently recurs in succeed- ing generations. It is due to the grooves in the hand of the fetus fail- ing to become clefts. The " webbing" may involve two or more fingers in one or both hands, the union being partial or complete. The indi- Fig. 118. Webbed and supernumerary fingers. vidual fingers in form are frequently perfectly normal. They may be joined in three ways : first, by a narrow or wide web of skin and connective tissue ; second, they may be in close apposition ; and third, the bones of two "fingers may be fused together either partially or throughout their length. The usefulness of the hand is often but little 25 385 386 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. impaired. Supernumerary fingers not infrequently occur in conjunction with syndactylism (Fig. 118). Treatment. — If the bones of any two fingers are united through- out their length, it is unadvisable to attempt to separate them. The old operation for this deformity consisted in merely dividing the web from top to bottom, and in trying to prevent the fingers from reuniting. This method has been practically abandoned, because it is impossible to prevent a portion of the web from re-forming, and, on account of Fig. 119 Showing operation for webbed fingers : (1) and (2), incisions for before and after suture. cicatricial contraction, separation of the fingers is incomplete. A good method of treatment is to first make a small permanent opening between the bases of the fingers. This opening may be established by keeping in it an elastic ligature or a silver wire, with the ends attached at the wrist until the edges are united. After these edges are well covered with epithelium the remainder of the web is simply cut through. The best operation, and the one generally used, is illustrated in Fig. 119. Two flaps are taken, one from the palmar surface of the first finger, and the second from the dorsal surface of the next, by incisions made along the median line of the fingers («). By so doing two flaps are obtained, each of which is of the length of the finger and in width equal to a quarter of the whole circumference of one finger with the added width of the web (6). These flaps are freed so that the palmar flap of the second finger remains attached to the first finger, while the dorsal one from the first finger remains attached to the second finger. The flaps are then brought around each individual finger and sutured into position (o). Care must be taken to adjust the flaps and sutures accurately at the base of the fingers, and the fingers must be kept well apart by the dressing ; otherwise a partial failure may occur. In case the bones are only united for a slight distance they may be cut or sawed apart. Other methods of treatment are sometimes described, but they do not differ essentially from those given here. Webbed toes are less frequently seen than webbed fingers. As the deformity interferes but little with the usefulness of the foot, and as the MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 387 parts are concealed from sight, operations are unnecessary. Should an operation be desirable, however, it would be done in the same manner as for webbed fingers. Webbed knee is a very rare condition. The femur and tibia are not fused, but the knee-joints are flexed by a web of skin and connec- tive tissue in the popliteal space. In one instance, where both knees were in this condition, a typical plastic operation corrected the deformity, but it was necessary to divide the outer and inner hamstrings. Surgical Injuries of Muscles and Aponeuroses. Muscular hernia is the protrusion of a limited portion of the mus- cular substance through its ruptured fascia or aponeurosis. This occurs only during contraction, forming an elastic tumor which disappears dur- ing relaxation. It results in "impairment of muscular powers. The diagnosis is easily made and the wounded edges of the tear in the aponeurosis can be readily felt. Treatment. — In recent cases rest and pressure generally result in a cure. If necessary, the edges of the opening in the fascia should be freshened and brought together by sutures. If the discomfort caused by a muscular hernia is only slight, an improvised pad or truss may relieve the patient. Injuries of Muscles. Contusions may be slight or severe. A slight contusion, if it occurs in a healthy muscle, may be quickly recovered from. Severe contusions are accompanied by swelling and discoloration of the overlying skin. Inflammation, suppuration, and atrophy may ensue, the latter probably being the result of accompanying nerve-injury. Hematoma of the sterno-mastoid muscle is a condition which is sometimes seen in apparently healthy children at birth or shortly after. It is usually a localized swelling in the body of the muscle, but the whole length of the muscle may be involved. It is thought to be due to pressure or to partial rupture of the muscles from traction during birth. It is always unilateral, and it disappears spontaneously in from two to six months. A strain is a stretching of a muscle, with probably always a small amount of rupture of muscle-fibre. Strains are often followed, espe- cially when they occur late in life, by troublesome pain resembling rheumatism. Strains occur most frequently in the muscles of the back, hips, shoulders, arms, and legs. They occur often as a result of violent muscular efforts. Treatment. — During the acute stage of either a contusion or a strain, rest to the affected parts is imperative. Hot fomentations or evaporating lotions are adjuvants to be used. As soon as the pain and tenderness diminish, massage, passive motion, liniments, and electricity may be applied. Subcutaneous rupture of healthy muscles and tendons is of com- paratively common occurrence ; for example, in most cases of strain some rupture of the muscle ensues. Complete rupture of a muscle is rare. Rupture generally takes place 388 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTE3TS. Fig. 120. in the tendon near the union with the muscles or at its insertion on the bone. The power of resistance of a healthy muscle is very great, and it is said that rup- tures occur only as the result of some invol- untary action and when the muscle is taken unawares. Rupture of either a muscle or tendon is accompanied by sudden, violent pain and loss of power. A distinct snap is almost always heard. There is usually, unless the affected muscle or tendon lies deeply, a marked depression between the severed ends. This depression, which is easily felt at first, is often masked by the accompanying swelling which quickly comes on, and is due to the extravasation of blood in the surrounding parts. The tendons of the biceps, the triceps, the deltoid, and the pectoralis major have been torn apart by violent exercise, in lifting or clutching at some object in falling ; the sterno-mastoid from violent vomiting or ex- cessive traction in childbirth ; the pronator radii teres and plantaris in lawn-tennis ; the rectus abdominis and the internal and external oblique muscles in tetanus and from falling across iron bars ; the tendo Achilles and gas- trocnemius on alighting suddenly from a height ; the quadriceps extensor tendon, the ligamentum patellae, the biceps femoris, and rectus femoris by falling backward or forward on the ice; adductor longus in horseback ^ichtaamptaSSfaSdiSS ridin g; semimembranosus in lifting; and the formed a ne W attachment in muscles of the perineum and sphincter ani in the bicipital groove. ... -n 11 ■ i 1 i i- parturition, r oilowmg long and exhaustive illnesses, such as occur in typhoid, typhus, and scarlet fevers, the mus- cles and tendons lose their power of resistance and often rupture from the very slightest muscular force. The flexor and extensor tendons of the hand are ruptured at their insertions. This accident occurs frequently to ball-players. In violin- playing the extensor tendon of the middle finger of the left hand has been torn away. Treatment. — In the simple forms of rupture the treatment consists of absolute rest in a position which gives the greatest degree of relaxation to the injured part and approximates as closely as possible the ruptured ends of the muscle and tendon. Compression by bandages and splints is used when necessary. The application of ice or anodyne lotions has- tens the absorption of the effusion and promotes early repair. When the function of the ruptured muscle or tendon is one of considerable importance, or it is obvious that the ruptured ends will not unite, it is necessary to suture the same by open incision under antiseptic precautions. The flexor and extensor tendons of the hand, the quadriceps and patellar tendons, and the tendo Achilles are the principal ones which require MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 389 operation. Catgut, or silk is used for the suture and the wound is closed without drainage, the limb being placed in the most favorable position for relaxation of the aifected part. Contractures sometimes develop sub- sequent to muscular ruptures. This is due to the action of antagonistic muscles, as in congenital torticollis from rupture of the sterno-mastoid, or to contraction of the cicatricial tissue. Dislocations of muscles and tendons are caused by the laceration of their fascial and synovial sheaths. They are not frequently seen, and those tendons most liable to dislocate are the long head of the biceps from the bicipital groove, the peroneus longus, the peroneus brevis, the tibialis posticus, and the plantaris in severe sprains of the ankle-joint ; the sartorius and quadriceps in severe sprains of the knee ; and the extensor tendons on the back of the wrist, as well as the flexor carpi ulnaris in sprains of the wrist. The latissimus dorsi muscle may become displaced where it passes over the lower angle of the scapula, and is rec- ognized by the prominence of that portion of the bone. Dislocation of a muscle or tendon is recognized by acute pain, by a certain amount of loss of function in the part, and by the jumping of the tendon from its anatomical position on contraction. Diseases op Muscles. Myalgia is often known as muscular rheumatism or neuralgia, neither term being strictly correct. It is a painful affection of the voluntary muscles, and oftentimes dates from some strain or blow. It is charac- terized by sudden pain and is intensified by strain or exposure. It occurs most frequently in the muscles of the back and in the neck. It is occasionally found to depend upon some specific cause, such as syph- ilis, tuberculosis, lead-poisoning, or malignant disease. Tkeatment. — Subcutaneous injections of one-sixtieth of a grain of atropia into the body of the muscle are said to give prompt relief. Other remedies are massage, electricity, hot baths, dry heat, and the administration of salicylic acid and iodide of potassium. Functional Disorders of Muscles. — Temporary loss of muscular power, with or without spasmodic contraction, is a condition occasionally seen. It comes in muscles which have been overworked, subjected to any unusual strain or position, or exposed to cold. A common example is writer's cramp, in which the muscles of the hand are affected only when holding a pen. Myositis and Inflammation of Muscles. — Hypersemia in muscles may be due to traumatism, inflammation, to extension from contiguous inflammation, or to an infection from the presence of micro-organisms. In muscle as well as in other tissue inflammation results in effusion, sup- puration, ulceration, and necrosis. The limited amount of inflammation of muscle which follows a simple contusion is characterized by an exu- date of serum and by cellular infiltration around and between the mus- cle-fibres. If the trauma is sufficient to do permanent injury to the muscle-tissue, and there is no infection to produce suppuration, cloudy swelling and coagulation-necrosis follow. The defects caused by this necrosis in the muscle-tissue are to a certain extent replaced by the proliferation of muscle-cells, as has been described under Regeneration 390 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. of Muscles. If this necrosis be extensive, there is a considerable forma- tion of fine connective tissue in the muscle-substance. These simple forms of hyperemia are known as myositis serosa and myositis fibrosa. Myositis purulenta is the suppurative and gangrenous form of in- flammation, which is always due to bacterial infection. It may be either acute or chronic, occurring in the form of abscesses or as diffuse sup- puration. It occurs in the course of compound fractures, in general septic infections, and in endocarditis, erysipelas, typhoid fever, and tuberculosis. Myositis ossificans is a peculiar form of inflammation in which plates of bone are developed in the substance of the muscles. It may occur in connection with the formation of callus in the bone after frac- ture and as a result of continued or frequently repeated irritation or traumatism. Rider's bone is a small plate of bone in the adductor longus muscle of the thigh, forming as the result of knee-pressure against the saddle. Drill bone is a similar condition in the deltoid muscle, and is occasion- ally seen in soldiers. Treatment. — Complete excision of the deposit is called for if the symptoms produced are annoying. There is a more general form of muscular ossification known as progressive myositis ossificans, in which a large number of muscles in the body gradually become the seat of extensive bone-deposits. This may come on as the result of a slight blow or even without apparent cause. Calcification of Muscles. — This is a condition in which there is a deposit of lime salts in the muscles. It may occur in two forms : first, as masses which are known as concmnents, which merely lie in the body of the muscle, or, second, as a general infiltration into the muscle-fibres. The first form is the ultimate result of tubercular necrosis and abscess- formation. Only a part of the necrosed mass is absorbed : the re- mainder becomes caseous, then calcified, and is enclosed in a capsule of connective tissue. If this inspissated substance gives rise to trouble, it may be readily excised. The second form, which is more properly spoken of as calcification, is a genuine infiltration, and is exceedingly rare in muscles. It has been found in the muscles of the legs. Degeneration of Muscles. — The muscles, like other tissues, are the seat of various forms of inflammatory degenerations. Some of these constitute definite surgical lesions, others are the sequelre or manifesta- tions of general disease, while still others may be the result of poison- ing by arsenic, phosphorus, etc. Syphilis of Muscles. — Syphilis of the muscles is not rare. It may manifest itself at any time in the course of the disease, especially in the tertiary stage. It may appear localized as a gumma or as a diffuse syphilitic myositis. G-ummata are found generally in the muscles of the legs, arms, and neck. The muscles of the tongue are frequently involved, and even the heart and diaphragm may be invaded. They occur as distinct rounded tumors in the body of the muscle, varying in size up to a pigeon's egg or even larger. Three have been observed in one sterno-mastoid muscle. These swellings are frequently so hard and so well defined as to lead to an operation, and excellent surgeons have MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 391 erred in attempting their removal. These syphilitic growths are usually of an unstable nature, there being an extravasation of leucocytes without the formation of granulation- tissue. The leucocytes perish by fatty degeneration ; suppuration and ulceration ensue ; small areas may be reabsorbed. In larger gummata there may be a central zone of casea- tion, surrounded by granulation-tissue which becomes transformed into connective tissue and causes the common depressed cicatrix of syphilis. The diagnosis is at times very clear, but gummata are frequently confounded with malignant growths ; in fact, not infrequently the diag- nosis is established by the success of the syphilitic treatment. Syphilitic myositis may, as a rule, be differentiated from ordinary myositis by the history, by the less acute course of the symptoms, and by the peculiar swelling and induration of the affected muscles, usually spoken of as " woodeny." It is characterized by an exudation into the interstitial connective tissue and the sarcolemma. Syphilis of muscles, as a rule, runs a chronic course. In adults it occurs as a tertiary lesion, but in children, especially in infants, it may be one of the earliest manifestations of the disease. In addition to the above forms of muscular syphilis there is occasionally seen a form of syphilitic contracture of the muscles. It occurs chiefly in the flexors of the arm and forearm, but occasionally it is seen in the biceps. It begins insidiously with slight pains in the fleshy part of the muscle, soon accompanied by weakness and unsteadiness of action. Later there occurs a slowly-progressing contraction of the muscle itself. Occasion- ally the first symptom noticed is stiffness in the elbow-joint, extension becomes limited, and the forearm remains partially flexed, and, if the arm be forcibly extended, the muscle is found to be tense or prominent and in a state of spasm. There are no other distinguishable changes in the muscle than its shortening and tension. Muscular contractures may be of two distinct varieties — the first a simple muscular rigidity or spasm, and the second a permanent non- relaxing muscular contraction. The former is nothing more than a spasm of the muscles set up by extrinsic causes, either traumatic or inflamma- tory. An example of the traumatic form occurs in fractures, and disap- pears ^vhen the fracture is controlled. Rigidity and spasm, which always accompany joint diseases, especially in the acute stages, are examples due to inflammation. This spasm and rigidity are the cause of the charac- teristic deformities in hip-, knee-, and elbow-joint diseases and of the limitations of motion found in the early stages. There is a rare form of permanent congenital contraction of the muscles of the fingers and toes which may involve several digits of either the hands or feet. Gen- erally, these contractions are in the position of flexion, but there may be hyper- extension. In some of these cases there seems to be a distinct hereditary history of such deformity. Defective development of the bones may accompany muscular contraction. Treatment should consist of massage and manipulation, to be followed in case of failure by forcible extension under ether and retention by splints. Finally, division of the muscle or tendon, or even amputation, may be required to relieve certain cases. Permanent muscular contractions are acquired as the result of many causes. A mild form follows prolonged rest in a constant position, lhis takes place when an arm has been confined for a long time, with- 392 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. out passive motion, on an internal angular splint. This temporary- acquired contraction is not at all uncommon following the treatment of fractures involving the joint, and massage, passive motion, and, if neces- sary, active motion under an anaesthetic, are indicated. Severe and pain- ful contractions of the muscles often follow the various infective inflam- mations. Every surgeon not infrequently sees extensive and permanent contraction of the muscles of the hand and forearm following an infec- tive cellulitis which may have come from a small wound on one finger. The inflammatory process in these cases has penetrated to the muscle itself, and has caused an atrophy of the muscular fibres and an adhesion between the muscles and tendons themselves. Treatment sometimes seems almost hopeless. Massage and forcible extension, persisted in for a long time by surgeon and patient, result in some improvement ; even repeated etherizations are at times necessary. Cicatricial contractures of muscles follow injuries, loss of substance, or burns, and the deformity is due to either the injured muscle itself or to the superior strength of the antagonistic muscle. In adults contrac- tions of the muscles are seen as late results of hemiplegia paralysis. They occur commonly in the flexor muscles of the arm and leg. These flexions can be partially overcome by passive or active motion, but can- not be permanently relieved by any treatment. Traumatic Muscular Paralysis. — Persistent paralysis of one or more muscles may occur as the result of direct violence to the muscle itself or to its nerve-trunk. The former is not common, but a patient is occasionally seen who, after a violent blow on the belly of a muscle — for instance, the biceps — has considerable contraction, followed by paralysis and atrophy. The more common form of muscular paralysis is a result of injury to the nerve, and it is seen in the arm following pressure upon the circumflex and musculo-spiral nerves. Examples of this occur in erutch paralysis from the continued use of crutches, from pressure during sleep caused by the weight of the body or head resting on the arm, from the arm hanging over the back of a chair, following dislocations at the shoulder-joint, and after fracture from the involvement of the nerve in the callus. Direct muscular action, as in throwing a ball, may cause the same thing. When the trouble is occasioned by the use of a crutch it usually may be recognized in time to avert serious trouble. It begins with numbness and tingling in the fingers, soon followed by muscular weakness and paralysis if the cause is not removed. The treatment is rubbing, massage, hot and cold douching, elec- tricity, and passive motion. The recovery is usually very slow, and months may pass before the patient shows any improvement. Dupuytren's contraction is the name given to a condition not infrequently seen, principally in men of middle age, in which there is permanent flexion of one or more fingers, usually the third and fourth. It is due to a contraction of the palmar facsia, It has no English synonym, and ever since Dupuytren first demonstrated that the deformity was due to contraction of the palmar fascia, and not to the flexor tendons, the disease has been identified with his name. It is a condition which is seen in men much oftener than in women, and, while it may affect either or both hands and any finger, yet the ring and lit- tle fingers are usually the ones involved, and often the two together. MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 393 It is an acquired disease, and, although the etiology is. still a mooted point, as widely different views of its origin are held, yet it is certain that different conditions bring about the same disease. It seems to be most frequent in people of a rheumatic or gouty diathesis, and especially where it is hereditary. The disease has been ascribed to repeated slight traumatisms to the palm of the hand, such as occurs in the use of par- ticular tools ; again, to nervous and inflammatory causes. A few cases can be traced to syphilitic origin in which treatment begun early in the contraction ' '■■ ! '-' J has resulted in cure without operation. It seems probable that it arises as the result of a chronic inflammatory pro- cess which attacks the palmar fascia, and that various constitutional conditions may be responsible for its occurrence. Why the palmar fascia is singled out, and the reason that some of the fingers, and not all, are attacked, are not manifest. It has been clearly demonstrated by many dissections that the fingers are held flexed by tight bands of fibrous tissue which are some- what enlarged continuations of the palmar fascia, and which are attached to the skin of the finger at various points. It should be re- membered in this connection that the palmar fascia normally is not sharply defined, but that it becomes lost in the integument along the fingers in close connection with the skin. Dupuytren's contraction appears first as a small lump or band which can be felt in the palm near the base of the phalanx. This gradually becomes more evident ; occasionally stiffness of the fin- gers is the first symptom observed by the patient. The condition devel- ops slowly, without pain or discomfort, and, if allowed to progress, as is usually the case, continues until the finger-tip is drawn into the palm and other fingers begin to be involved. It is a characteristic deformity not readily mistaken. The marked flexion of one or more fingers, its progressive character, strongly resisting all efforts of extension, its slow development without evidence of inflammation, the prominent band felt in the palm, the ability to flex the finger still farther, and the absence of cerebral or spinal disease, taken together, make the diagnosis com- paratively simple. Cicatricial contractions from wounds, burns, and palmar abscess and rheumatic ankylosis with contraction, all somewhat resemble Dupuytren's contraction. The efficiency of the hand is much impaired late in the disease, but a thorough opera- tion relieves completely. The present treatment of Dupuytren's contraction is wholly ope- rative, and is either by subcutaneous section or by open incision, with •or without removal of the contracted fascia. Massage, forcible exten- sion, and apparatus have been abandoned as slow, tedious, and inefficient. By operation the contracted bands are divided subcutaneously with a Dupuytren's contraction of palmar fas- cia, showing contracted fingers. 394 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. tenotome at a large number of points, beginning as high up in the palm as they can be felt and continuing the incisions along the palm out on to the fingers. If the deformity is extensive, as many as ten or even twenty punctures may be necessary. The advantages of the subcu- taneous method are that it may be readily done under cocaine and the resulting scar is slight, while it has the disadvantages of all subcutaneous operations. The open operation is the best, for by this means the deform- ing bands can be clearly identified. One method is by making one or more incisions through the skin and fascia, straightening the finger, and allowing the wounds to heal by granulation. The best way of operating is to expose the contracted fascia freely by making a V-shaped incision in the palm, removing by careful dissection all of the bands, and suturing the V flap of skin back into position. The fingers should be put on a splint, which is slightly flexed to avoid pain, for a few days. Then the fingers should be completely straightened and the splint worn continu- ously until the wounds are healed. For several weeks, even after heal- ing, the splint should be kept on part of the twenty-four hours — during the night if it is more convenient. Hammer-toe is a peculiar deformity characterized by a permanent flexion of one or more toes : the first phalanx projects upward, while the second and third phalanges are drawn downward, so that the tip of the toe sustains the pressure on the ground. An annoying callus resembling a corn usually forms over the joint, which projects above. In many instances it is supposed to be the result of continuously wearing too short shoes, the toes being held cramped in this position : the fibres of the plantar fascia attached to the lateral ligaments become permanently shortened. In some cases the condition seems to be hereditary. The condition often begins in childhood, and continues until the deformity becomes pronounced, giving rise to much inconvenience and annoyance. If treatment is begun before the flexion becomes rigid, the trouble may often be remedied without operation. The toes should be strapped by firm adhesive plaster to a stiff plantar splint of wood or tin, the plaster passing over the crest of the projecting joint and being renewed frequently. A slight gain over the deformity is acquired each time. The lateral ligaments and plantar fascia have been divided subcutane- ously and by open incision, with satisfactory results. Excision of the joint seems to promise a better result than amputation, for the latter to be effective must be near the metatarso-phalangeal joint. Lock or trigger finger is the name given to the peculiar and rare condition in which free flexion and extension of the finger is prevented and the finger is brought to a sudden stop while in motion. On extra effort being made, with an appreciable jerk the obstruction is overcome and the flexion or extension is completed. The condition may be due to a circumscribed thickening of the tendon, causing for a short space a disproportion between the size of the tendon and its sheath, or it may be due to a small fibroma formed on one of the synovial fringes, being caught between the tendon and its sheath. Strains and injuries, as well as gouty and rheumatic inflammations, are regarded as etiological causes. If after the usual means of treatment by passive motion and rub- bing relief is not obtained, an incision should be made and the cause of the trouble excised. MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 395 Inflammation of the Tendons and Tendon-sheaths. — The sheaths of tendons are synovial membranes which resemble very closely in structure and pathology the synovial sacs of the joints. Inflammation of a tendon is usually identical with, and occurs at the same time as, inflammation of its synovial sheath. The most frequent source of simple hyperemia in a tendon is a sprain or wrench in the neighborhood of a joint, or it may follow long-continued and excessive muscular exertion. This hyperemia is usually of a subacute character and is known as the- citis, simple teno-synovitis, or teno-synovitis crepitans, from the peculiar well-marked crepitating or creeping sensation which is often felt over the tendon while the muscles are in action. If the injury is severe, there is an acute effusion of a considerable quantity of serous fluid into the tendon-sheath and surrounding tissues. The location of the trouble is marked by an ill-defined swelling, often elongated and cylindrical in shape, which is more or less painful and is sensitive on manipulation. Muscular action causes pain and is accompauied by the soft crepitant feeling. In less severe ca^es there may be a history of slight sprain, no distinguishable swelling, pain during fatigue or on beginning motion, which largely wears away as the movements increase and the patient becomes accustomed to them. In such instances the diagnosis is made largely by the crepitation, which is apt to be more pronounced than in those cases where the effusion is considerable. This form comes on in the tendo Achilles and in the front of the ankle after long walks. The crepitation corresponds to a pleuritic rub, and is the result of a fibrinous deposit in the tendon-sheath, which becomes roughened when the tendon is moved. The tendons of the forearm, wrist, and hand are frequently the seat of the trouble. Here it is often started up by severe muscular exercise, as in ball-playing or rowing or by sprains. Synovitis of the wrist- or ankle-joint may be mistaken for thecitis. In the former the pain and tenderness are diffuse, while in the latter they are elicited by direct pressure along the course of the tendon. The treatment is rest and immobilization by splints, with mode- rate pressure if there is swelling ; later, massage and passive motion. In light cases, partial rest, tincture of iodine, blisters, douches, and light rubbing will give relief. The duration of the trouble may be from a few days to three or four weeks. A teno-synovitis not infrequently arises in the course of acute or chronic rheumatism and in gout. Should the trouble not yield readily to local treatment, salicylic acid and potassium iodide should be admin- istered. In connection with a post-gonorrhceal arthritis the neighboring tendon-sheaths are often more or less involved. Chronic teno-synovitis is probably in nearly every case a tubercular disease of the tendon-sheath. It may develop as a primary disease or secondarily to tuberculosis of a neighboring joint. Like tuberculosis in a joint, chronic teno-synovitis develops after some traumatism, as a sprain or contusion, and it is seen most commonly in adult life in labor- ing people. The great majority of cases develop in the tendons of the flexors of the forearm, while it is not of infrequent occurrence in the hand and in the vicinity of the knee and ankle. There are two patholog- ical forms of the disease. The one is a fungous form, distinguished by 396 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. the growth of exuberant granulation-tissue of a gelatinous appearance, surrounding the tendon on the inner side of its sheath. In the other form, known as hygroma, the inner surface of the tendon-sheath is covered with small growths which become detached, forming small, hard kernels, known as rice-bodies. These rice-bodies are the result of a fibrinoid degeneration ; that is, the degenerated villous growths, which are fibrinous in character, become loosened, forming free kernels. Until recently this form of disease was supposed to have no connection with tubercular disease. It is now distinctly established that these bodies contain tubercle bacilli. The same condition may be found in tubercular joint disease, where they develop from a fibrinoid degeneration of tubercular granulations on the synovial fringes. It is said that these small tubercular nodules never become caseous. Their structure is that of fibrous tissue with few nuclei and an occa- sional giant cell with tubercle bacilli. Their separation is due to the fact that they project from the surface of the sheath as small, hard nodules, and by rubbing of the tendon are gradually separated. Localized tubercular areas are sometimes seen in the tendons and tendon-sheaths. If the disease is allowed to run its course, suppuration ensues, forming sinuses involving the skin which eventually break down. These, with the resulting cicatrices, greatly impair the usefulness of the hand. The treatment of chronic teno-synovitis may be of two kinds — conservative and operative. The essential features of the former are rest, immobilization by suitable splints, and moderate pressure. If the disease occurs in the forearm, the arm should be placed upon a splint, bandaged with not too great pressure over wadding, and carried in a sling. While the disease very rarely disappears spontaneously, yet this treatment, if persisted in for a long time, together with careful atten- tion to the general physical condition, which is of the greatest import- ance, and the administration of tonics, iron and cod-liver oil, will often result in permanent improvement. The writer believes that this method should be first tried in all cases which are seen sufficiently early and in which the disease has not made such progress that already an operation is indicated. This applies espe- cially to such cases as are able to give up their occupation temporarily and devote themselves to the eradication of the disease. The operative treatment is more efficient in the majority of cases When there is no marked thickening of the tendon-sheath and its con- tents are fluid, an aspirating needle may be inserted into the sac, the fluid drawn away, and an emulsion of iodoform injected. The emulsion should consist of a 10 to 20 per cent, mixture of iodoform in glycerin or olive oil, both ingredients being sterilized separately before being put together. This method of preparing the emulsion is said to prevent the dangers of iodoform-poisoning. This method of treatment will fre- quently result in a cure of the disease in the right class of cases. When an incision is made the part should be rendered bloodless by an Esmarch bandage ; the sheath should be laid open throughout the whole length of its diseased portion, even if it is necessary to divide the annular ligament, in order to thoroughly evacuate and cleanse the walls. Efficient treatment must mean the complete removal of all tubercular deposit by scissors and a sharp curette. Recognition of diseased from healthy tissue is often extremely difficult, but everything of a suspicious nature should be dissected out. This is especially true when the condi- tion is secondary to joint disease. If necessary, the diseased tendons MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 397 should be removed, and if a large portion of tendon is destroyed, the space may be filled in by splitting a portion ofi' either end of the healthy tendon, turning the ends up and down, and suturing them together. By so doing the function of the tendon is not greatly impaired. If the operation has not been an extensive one, after thorough cleansing of the wound it may be dusted with iodoform and closed. After a radical ope- ration the wound may be partially sutured together and packed with iodoform gauze. While the prognosis is usually favorable in primary tuberculosis of the tendon-sheath, yet relapses occur and the patient may succumb to general tuberculosis. Felon, or whitlow, is an acute infectious inflammation involving the deep tissues of the terminal phalanx of the fingers or thumb. It may originate in the soft tissues, the ten- dons or tendon-sheaths, the perios- ! '• ! ' ; teum, or even the bone. At the start it is always a circumscribed inflammation on the palmar aspect of the finger, and it is more frequent Felon of thumb. Suppurative thecitis of thumb. in women than in men. It usually appears to originate spontaneously, but is probably the result of some injury so slight as to escape unno- ticed. The symptoms of a deep felon are almost unmistakable. The pain is excruciating ; there is persistent throbbing which is increased by motion, pressure, or a dependent position. The finger is swollen, hot, tense, and of a livid hue. Fluctuation is not obtained, because of the limited space in which the suppuration occurs, Treatment consists in prompt incision at the earliest moment to relieve tension by laying open the inflamed focus. This treatment should not be delayed in order to try abortive measures when once the diagnosis is clearly established. It is very rare that septic inflammation when once established can be aborted. Applications of tincture of iodine, nitrate of silver, and liquor plumbi subacetatis are recommended 398 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. as abortive treatment, but the disease when recognized must be promptly relieved, for delay is dangerous. The incision may be made after applying a small elastic tourniquet around the finger and injecting a few minims of a 2 per cent, solution of cocaine into the base of the finger on either side. The incision should be made over the point of great- est tenderness, and should be carried through the soft tissues down to and through 'the periosteum. Oftentimes not any or not more than a single drop of pus will be obtained, but the pain and tension will be relieved and further spread of the disease will be prevented. The incision should be made promptly, even before suppuration has been established, and the dressing should be an antiseptic one for a few days, after which the wound may heal very quickly. It is remarkable with what little discomfort the operation may be performed under cocaine, and how quickly relief is obtained. The variety of felon known as shirt-stud or collar-button abscess should not be forgotten. It is a small collection of pus lying just beneath Fig. 124. Fig. 125. Neglected suppurating thecitis resulting in palmar abscess. Same, dorsal aspect. the skin, connected by a small sinus with a large abscess beneath the deep fascia. The danger lies in the fact that the superficial abscess may be opened while the deep one is unrecognized and continues to extend. Pus extends readily in the finger, owing to the anatomical arrange- ment of the fibres, the connective-tissue fibres running perpendicularly inward to the deep fascia, and when the pus reaches the tendon-sheath it extends without opposition along its channel. MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 399 Fig. 126. Inflammation of the thumb or little finger is much more likely to extend into the palm and up the forearm than if situated on either of the other three fingers. The tendon- sheaths of the first three fingers are closed sacs and extend only to the base of the fingers, while those of the thumb and little finger are continuous with the synovial membrane which encloses the tendons of the palm and passes beneath the annular ligament, extending for some distance up the forearm. The importance of thorough and prompt attention to a felon can scarcely be overestimated, for an important mem- ber is involved and the function of a hand or arm may be lost, and lives have been destroyed by neglect. Palmar abscess occurs either as the result of a suppurative lymphan- gitis or a thecitis of the flexor tendons of the fingers travelling upward, or it may be the result of direct local in- fection. A favorite seat for infection is the cal- losities almost invariably seen in the palms of working-men over the heads of the meta- carpal bones. The broken skin over a blis- ter or a small crack in the surface of the skin, together with the presence of infectious matter, furnishes the soil and material for abscess-formation. This mode of infection is rather more likely to result in a superficial than a deep palmar abscess. The latter variety occurs commonly secondarily to suppuration in the tip of the thumb or little finger, where the pus has travelled along the tendon-sheaths into the syno- vial sac of the palm. The dense palmar fascia above, presenting a barrier to the exit of the pus, favors its spread along the tendons. If the pressure be not relieved and an exit given to the pus, it may extend between the bones of the hand to the dorsal surface, or it usually finds its way under the annular ligament into the wrist, and frequently involves the muscles of the forearm. The pain and tension are always very great, while redness and inflammatory swelling are not pronounced symptoms because of the deep location of the suppuration. There is always, however, a characteristic oedematous swelling of the whole hand, which is described as a porky or boggy swelling. The fingers are stiff and held partially flexed. Fluctuation may or may not be obtained, but the other symptoms as described, of an acute nature, are sufficient to establish a positive diagnosis. There are usually considerable constitutional disturbance, temperature, anorexia, etc. Nowhere is an early operation of greater importance, and neglect leads frequently to the loss of function or complete loss of the hand. Surgi- cal anaesthesia is necessary for the operation. Incisions in the fingers and in the palm should be made parallel to the axis of the bone. Short, Permanent contraction of fingers after palmar abscess. 400 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. deep incisions are the rule, in order that the vessels may be more readily avoided. The palmar arch crosses the hand nearly opposite the web of Diagram of palmar incisions. the thumb, and if incisions are made beyond this, no difficulty will be met with. It is better to avoid cutting the arch, but if cut it should be ligated. If the inflammation has spread extensively, the sinuses should be Fig. 128. Diagram of dorsal incisions. followed out and several short counter-openings made to secure thorough drainage. After prolonged irrigation with a hot antiseptic solution narrow strips of iodoform gauze should be inserted into each opening. The after-treatment should consist of a prolonged hot antiseptic bath daily in a vessel capable of admitting the whole hand and forearm. Large antiseptic poultices applied clear to the elbow should be changed frequently enough to keep them hot, and the arm should be raised on a pillow. Careful attention should be paid to the general condition of the patient, and stimulants and quinine adminis- tered as required. In very acute types of the inflammation it may sometimes be- necessary to make a number of long parallel incisions, regardless of all anatomical structures, and even to cut the annular ligament. Permanent contractures of the fingers result, due to adhesions between the tendons and to cicatricial formations. Manipulation and massage, continued for a long time after recovery, aid somewhat in reducing the contractions. Ganglion. — In connection with the tendon-sheaths of the forearm and hand there occurs a small, rounded, elastic swelling which is known as a ganglion. It was first thought to be a localized dropsy of the tendon-sheath ; hence as such it received the name of weeping sinew. Recently ganglia have been classed with the hygromata of the tendon- sheaths and bursse, and now are believed to be outgrowths from the syno- vial fringe or follicles of joints, occasionally from the tendon-sheaths, and are regarded as a kind of new growth. The fluid which they contain is- MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 401 a sort of thickened synovial fluid, and usually does not communicate with the fluid of the tendon-sheath or joint. Another theory is that the gan- glion is a hernia of synovial membrane, occurring through a rent in the tendon-sheath, forming a closed sac. Ganglion is most common on the dorsum of the hand, but may occur on the foot or on the flexor tendons of the forearm. It is a small, oval, fluctuating tumor, causing no pain and very little inconvenience, except that there is slight pain when the arm is fatigued. Treatment. — This is by rupture of the sac by pressure or treatment of the sac by operation. Where the ganglion is small the time-honored method of rupture of the sac by a blow from the back of a book may be tried. A simpler method is to superimpose the thumb over the tumor and by sudden pressure to rupture the sac. A splint and pad-pressure should be kept applied for ten days to a fortnight. A cure by forcibly rupturing the sac is not certain, but the method has the advantage of not injuring the patient. The treatment of the sac by operation may be carried out in several ways — by aspiration with a fine, hollow needle, with or without the injection of an emulsion of iodoform. In the larger tumors and in those where the simple methods of cure have failed the very sat- isfactory operation of excision of the sac by dissection may be done. In all of these methods it is necessary to apply a splint and pressure to the part in the after-treatment. Affections of the Burs^. Acute bursitis is due ordinarily to external traumatism or excessive muscular exertion. It is an acute hypersemia of the bursal sac, giving rise to increased secretions which may be either serous, sero-fibrinous, or purulent. It gives rise to a superficial, rounded, more or less prominent fluctuating tumor. If the inflammation is not of a purulent nature, the symptoms are slight and are the result of physical discomfort from the presence of the swelling. When the bursitis results from a blow, the swelling comes on rapidly, with pain and tenderness, and there may be considerable blood poured with the effusion into the sac, causing so-called hsematoma of bursse. When the inflammation is suppurative, which occurs only from infection, there are rapid swelling, redness, tenderness, and pain, with often considerable constitutional disturbance. Unless promptly arrested there is danger of extension to the surrounding tissues and the joint may be invaded. The location, extent, and shape of the swelling are sufficient to distinguish the disease from ordinary cellulitis. The general treatment is rest to the part, uniform pressure, and cold applications, together with aspiration if the effusion and swelling do not diminish. If pus is present, the sac should be freely laid open, curetted out, and packed to secure obliteration of the cavity by granula- tion healing. Chronic bursitis is not the mere continuation of the acute variety of the disease until it becomes chronic, but it is a distinct type of the disease which is known as hydrops or hygroma. It occurs usually as a painless, fluctuating swelling of slowly increasing size, with thickened walls due to a growth of villous or granulation-tissue, and containing a thick mucoid liquid. This villous growth at times undergoes a fibrin- 402 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. oid degeneration, the degenerated portions breaking loose, giving rise to the rice-bodies which are found in chronically enlarged bursas. The number of these small bodies is often very large ; as many as several hundred may be found in one sac. The whole process, in many instances at least, is essentially a tuberculosis, and in the rice-bodies are found tubercle bacilli. ( Vide Chapter XXXII.) Hygrornata of the bursoe are said to be caused by growths of cartilage and by sarcomatous tissue. Chronic bursitis is often due to injury or mechanical irritation, and in rare cases it is ascribed to rheumatism or syphilis. There are many cases of tubercular disease of the synovial bursse which are secondary to a tuberculosis of a neighboring joint, and which on that account fail of recognition. It is of special importance that they be not overlooked in operations upon the joints. The diagnosis rests mainly upon the nature of the swelling, the slow chronic course of the disease, and the location of the trouble. In many instances when it occurs at the wrist-joint it cannot be distin- guished, except by operation, from chronic disease of the tendon-sheath. Occasionally the rice-bodies may be felt like small shot in the sac. Treatment other than operative is merely temporizing with the trouble, although there may occur instances in which rest of the part on a splint, with application of moderate pressure and counter-irritants, may be advisable at first and may result in temporary improvement. The operation consists in incising the sac, evacuating its contents, thoroughly curetting out the interior, and irrigating with a 1 : 1000 corrosive-sublimate solution. If practicable, it is better to dissect out the sac. Packing with iodoform gauze secures permanent closure of the cavity by granulation. Over the hyoid bone a cystic tumor of a size requiring removal is rarely met with ; it is a chronically enlarged bursa of the hygroma type. Simple Enlarged Bursas. — There are a number of bursa? which are often enlarged. Several of them are of sufficient importance and fre- quent occurrence to receive distinguishing names. Enlargement of die prepatellar bursa, commonly known as housemaid's knee, is the most oommon form of enlarged bursa. It occurs as a prominent fluctuating swelling directly over the patella, painless unless inflamed, and is caused by the pressure incident to kneeling. It sometimes occurs in both knees at the same time, and its appearance is very striking and perfectly characteristic. It should be treated by aspiration followed by rest and pressure. When inflamed it must be incised. A bursa over the anterior aspect of the upper end of the tibia, between the patellar tendon and the tubercle of the tibia, is sometimes enlarged, and may be mistaken for synovitis of the joint. It may communicate with the joint and must be aspirated with care. A bursa over the tip of the olecranon process corresponds to housemaid's knee, and is known as miner's elbow from its frequency in that class of work- men. A subpatellar bursa has recently been described as occurring in football-players, supposed to arise from excessive exercise in kicking. Bursse in the popliteal space beneath the tendons have been mistaken for aneurism as well as intra-articular disease. They are also likely to communicate with the joint, and must be operated upon with caution. There is a deep bursa beneath the deltoid muscle which causes pain, MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 403 swelling, and crepitation on motion when inflamed. A bursa under the tendo Achilles over the tuberosity of the os calcis causes pain and lame- ness when inflamed. A bursa occurring under the psoas tendon, between it and the edge of the pelvis, may communicate with the hip- joint ; also one between the great trochanter and the gluteus maximus is sometimes seen : both of these when enlarged and inflamed give rise to symptoms which simulate hip disease in its early stages. Enlarged bursa? are also seen once in a great while in various other parts of the body ; for example, over the tuberosity of the ischium, between the latis- sirmis dorsi and the angle of the scapula, in the palm, and in the calf of the leg. As a general rule, there should be but little difficulty in distinguish- ing bursa?, but when they lie in close proximity to a joint, the diagnosis may occasionally be quite obscure and can be made only by careful dif- ferentiation. Bursse of New Formation. — The number of normal bursa? in the body is very large, and is not by any means constant, even in healthy adults. As many as eighteen have been found in the vicinity of the knee-joint and fifteen in the dorsum of the hand. New bursa' develop in locations where the tissues are subjected to constant pressure or fric- tion, usually over bone-prominences. They are formed in the soft con- nective tissue between the skin and underlying tissue, beginning at first as small, irregular cavities with a lining of atrophied connective-tissue fibres. The space develops slowly in size until finally it has a complete sac with a smooth-walled endothelial lining. Bursse are seen in various places on the body — on the outer side of a club-foot, where the pressure is borne in walking; over the projecting spines of the kyphosis of a spinal caries ; .on the ends of stumps after amputation when an apparatus has been worn. All of these are liable to become inflamed and cause serious inconvenience. A bursa forms over the sternum in shoemakers ; over the head of the fibula in tailors, constituting tailor's ankle, from pressure caused by sitting on the floor with the legs crossed in front. A bursa? forms over the first metatarsal bone in the deformity known as hallux valgus. This latter bursal tumor is commonly known as bunion, and always occurs as the result of wearing tight, improperly fitting, or improperly made shoes. It may be caused by the shoe being too loose, allowing the foot to slip back and forth, or more frequently it is due to a narrow-toed shoe causing the tip of the great toe to bend toward the outer side of the foot, thus bringing unusual pressure on the joint. A mild degree of bunion is present in many people who suffer very little inconvenience. There is usually slight tenderness in the part, and the swelling is quite likely to become acutely inflamed, in which case the skin becomes much reddened ; there is constant pain with excessive tenderness, walking is very difficult, and it is impossible to wear a boot of any kind. Suppuration takes place in the bursa, which, breaking through the sac, invades the joint and other tissues and often starts up a cellulitis in the foot. Persons having bunions should not wear nar- row-toed shoes, but shoes with broad, rounded toes and a straight inner border. Bunions which are slightly inflamed and in which there is some pain and dis- comfort are relieved until the acute symptoms have passed off and the inflamma- 404 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. tion has subsided by wearing over the part a small, circular felt pad cut out in the shape of a washer. " The pressure of the shoe comes against the pad, which sur- rounds the sensitive area. If the bursa is thickened and not inflamed, blisters and iodine may be applied to reduce its size. When the bursa is inflamed rest and cooling applications are indicated and may prevent serious trouble. Suppuration demands incision and antiseptic treatment, and if the joint is invaded partial or complete excision of the joint will be required. The removal of a bursa before any inflammation has occurred is the best treatment, and frequently it is necessary to combine with its removal a resection of the underlying joint. Parasitic cysts of muscles are rare. The trichina spiralis, the eehinococcus, and the cysticercus are the three species of animal parasites which occasionally occur in muscles. Trichinosis originates from eating underdone pork which contains the trichinae spiralis. These parasites develop in the intestines, penetrate the walls, and enter the circulation, or by a direct passage find their way into the muscles, where they remain. By their presence a myositis develops, resulting in exudation, which becomes encapsulated and forms a permanent cyst. The symptoms are pronounced : there is a muscular stiffness, with pain, swell- ing, and tenderness. The constitutional symptoms are high temperature, chills, delirium, and gastro-intestinal disturbance. The mortality is high, but undoubt- edly many mild cases recover. The diagnosis is confirmed only after abstracting a piece of the muscle with a small punch and subjecting it to a microscopical examination. The treatment consists of the employment of purgatives ; sedatives, ample nourishment, and stimulants are required. The eehinococcus, or hydatid, and the cysticercus are seen even less frequently than the trichinae, which they closely resemble in character. They result from infection by taenia through the intestinal tract. Their presence in the tissues through irritation results in the formation of cysts. These parasites are not confined to muscles, but are found in any tissue or organ of the body. Tenotomy and Myotomy. These should be recognized as important surgical operations, as upon them depend largely the correction and removal of many deformities. They form a considerable proportion of the operative surgery of ortho- paedics, but are frequently very useful to the general surgeon. Myotomy and tenotomy will be treated as one subject, because the method of ope- rating is essentially the same. It is always advisable to cut the tendon when possible, and only in instances where the muscle has no tendon or the tendon is too short is the muscle itself divided. Tenotomy is indicated in all cases where there is permanent contraction or shorten- ing in a muscle or fascia, resulting in deformity which interferes with the usefulness or beauty of the part. In fractures occurring in the neighborhood of a joint persistent muscular spasm may interfere with maintenance of apposition of the fragments. This may readily be overcome by subcutaneous tenotomy. This is often true of the tendo Achilles in fractures about the ankle-joint. There are two ways of per- forming tenotomy — one by an open incision, the other subcutaneoudy. In general, it may be said that the open operation is desirable in dangerous localities and where there are several tendons to be cut, as in the case of contraction at the wrist-joint. The advantages in favor of subcutaneous tenotomy are its simplicity, greater rapidity in securing firm union, and minimum danger from infection by the small puncture. MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 405 The operation of subcutaneous tenotomy is easily done, and there is little danger if a thorough knowledge of anatomy is possessed by the ope- rator, in order that important vessels and nerves may be avoided. The only instruments needed are two delicate knives, known as tenotomes, with straight blades about a half inch in length and an eighth of an inch broad — one sharp-pointed, the other blunt. Longer blades are unnecessary, except in rare instances where a muscle is to be divided. The curved tenotomy knives, while theoretically applicable to the curved surface of the tendon, are, in the experience of the writer, never neces- sary. The sharp-pointed instrument should be introduced through the skin near the tendon, and above or below it according as one desires to cut in or out. By cutting the tendon outward the skin is more likely to be punctured, while by cutting downward there is more danger of injur- ing adjacent and underlying structures. Lengthening of Tendons. — In certain cases where the contracted tendon is to be divided it may be advisable to lengthen it a certain def- inite amount. This may be done, as illustrated, by an incision along the middle of the tendon, which should be one-half as long as the required distance. The tendon is then cut through at either end of the middle incision and the ends sutured together. Another method of lengthening, especially applicable to old cut tendons where the ends are retracted and cannot be brought into apposition, is by splitting off a por- tion of one or both ends of the cut tendon, turning it down, and suturing together the ends thus split off. Fig. 129. Showing methods (a) and (6) of lengthening tendons. Transplantation of muscles and tendons, in the absence or loss of tissue, has been proposed, and experiments have been made on animals with this end in view. It has been shown that such implanted tissue a ™ays becomes absorbed, but it is possible that such tissue may assist and hasten regenerative changes. Gluck has inserted strands of catgut 406 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. to replace the loss of muscle, of tendon, and of nerve-tissue, with partial success. Dr. J. E. Goldthwait of Boston has recently suggested a new method of tendon transplantation or grafting, and several cases have been operated upon and reported by him. It is made use of in the treatment Fig. 130. A B Illustrating transplantation of tendons in paralytic valgus (case of Dr. J. E. Goldthwait) : A, before operation, with patient standing naturally, bearing weight on both feet ; B, after operation, snowing patient standing and bearing all of weight on left foot. of some cases of infantile paralysis for the purpose of furnishing better mechanical support to certain partially paralyzed groups of muscles. The method consists of cutting the tendons of certain muscles and attaching them to others, and thus transferring the action of the muscles to other more important tendons. From the few cases which have already been operated upon the writer believes this to be a surgical procedure of considerable promise in the treatment of deformities resulting from infantile paralysis. CHAPTER XXIX. INJURIES AND DISEASES OF THE LYMPHATIC VESSELS AND NODES. By Frederic Henry Gerrish, M. D. Wounds of Lymphatic Vessels. Probably every cut into the tissues beneath the epithelial surfaces lays open minute lymph-vessels, and in amputations tubes of consider- able size are always severed. But almost never does any trouble ensue from such injuries alone. If a superficial vessel does persist in leaking through a wound, a delicate touch with a mild caustic and firm com- pression with pad and bandage will usually speedily end the trouble. But when a yreat trunk is incised or otherwise opened, the surgeon has to deal with a lesion of the gravest kind. The thoracic duct is so deeply located that it is very seldom wounded, but when it is punctured the very inaccessibility which is ordinarily its protection interferes with, though it may not absolutely prohibit, direct treatment. Its contents escape into the whole surrounding region, causing chylous hydrothorax or chylous ascites, or both, or the fluid may distend the areolar tissue outside of the pleura and peritoneum or fill up the mediastinum. Possibly a cure may be effected by an abdominal section with drainage, adhesion of the lips of the duct resulting from the irritation occasioned by the necessary manipulations during the operation and by the presence of the drainage-tube. Suture of the opening in the thoracic duct seems not to have been attempted in the abdominal region, but it has been tried with success in the case of wounds close to its central extremity at the base of the neck. In this locality forcipressure and compression with a pad of gauze have yielded good results. Wounds of the right lymphatic duct are far less serious than those of the larger trunk, and, from its readier accessibility, are much more amenable to treatment. Inflammation of Lymphatic Vessels. Lymphangitis, as this disease is technically called, need not be de- scribed under several different heads, as has usually been the case, for we now know that all inflammation of lymph-vessels is of microbic origin, and may therefore drop the terms " idiopathic " and " traumatic " as being no longer descriptive. Lymphangitis is almost always secondary to some traumatism, but it may depend upon the passage of septic mafc- 407 408 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 131. Connects with Superior Mediastinal Nodes Connects with Axillary Nodes Diagram of the nodes and vessels of the head and neck, showing the regions that are drained into each group of nodes. Deep structures in red, superficial in black. (F. H. G.) INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 409 Fig. 134.— Diagram of the nodes of the trunk and their tributary vessels. (F. H. G.) 410 INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 411 ter through the unbroken integument. It may be induced by various micro-organisms. At first a thrombus is formed in a vessel ; then pus- cells are seen in the walls, the epithelium is swollen or peeled off, the lymph is thick with desquamated cells and fibrinous clots, leucocytes and exuded lymph surround the tube, and the neighboring structures are inflamed. In tubercular inflammation characteristic deposits occupy the lumen. The process may terminate in complete resolution or abscess or occlusion. The related nodes are usually implicated. Clinically, we observe in mild cases of the tubular variety faint red lines in the skin coursing up the limb, which are felt to mark the location of beaded cords. From these a bluish tint diffuses laterally, and the nodes soon become swollen and tender. Little pain is experienced if entire quiet is maintained. In severe cases all these symptoms are aggra- vated. Pain is acute, fever is high, oedema is marked, and in some sit- uations is very perilous. Later on pus forms in the nodes and areolar tissue, and in the worst cases there occur rigors, excessive thirst, difflu- ent abscesses in distant parts, restlessness, delirium, and death from sep- ticceniia. The termination of a case depends upon the nature and amount of the toxic material introduced, the condition of the patient, and the promptness and wisdom of the treatment. In the reticular form the inflammation shows itself in red, tender, cedematous patches, which may succeed each other up the limb, one fad- ing as a neighboring area blooms out. It is to be remembered that the inflammation of a vessel, superficial or deep, does not always pursue a course from periphery to centre : it sometimes works back in the opposite direction. Tbeatment must be both local and general. If there be a wound, thorough disinfection of it must be effected at once. Irrigation with an antiseptic wash may accomplish this, but if this is doubtful the wound should be laid open to give opportunity for perfect cleansing of the parts. For a surface application a hot antiseptic, pack is best in the early stages ; for example, a corrosive-sublimate solution, 1 : 2000. A blister around the limb at a level proximal to the disease was much esteemed formerly — i. e. fighting fire with fire. If pus forms or is suspected, incise freely and let it out. Meantime the systemic condition must be regarded, the bowels and kidneys kept active, pain checked with anodynes, and the strength held up with easily digested food and other supportives. Occlusion of Lymph-vessels. A considerable number of the most serious affections of the lymphatic system are caused by interference with the normal flow of lymph ; and, as many of these diseases have features in common, it will be well first to study the general subject, and then to consider in detail the specific manifestations, varying as they do according to their etiology, their situation, the size of the vessel involved, and the kind of tissues con- cerned. Various conditions occasion occlusion, as thickening of the walls of the vessels fro . m , inflammation, the deposit of plastic material about the tube, the pressure of neighboring tumors, the presence of a morbid growth within the lymphatic, or the 1. f en ? en , t of a P arasit e in its lumen. Anything which arrests the current dams back the lymph upon the region which the vessel normally drains, unless the fluid 412 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. can escape by some side channel; and this interference results usually in one or both of two principal changes. The first of these is dilatation of the vessels from the increased pressure of lymph within, and the other is saturation of the tissues on the distal side of the obstruction with lymph, and their consequent hyperplasia from over-nutrition. Dilatation may be displayed over a minute area or in the vessels of an entire limb — there may result small vesicles or large cystic tumors; it may affect deep structures or superficial ; its effect on health varies from the inappreciable to the destructive ; and its amenability to treatment ranges between the facile and the hopeless. If the case is one of pure dilatation, the vessel assumes a beaded appearance when the valves hold, and a cylindrical when they do not. The latter variety readily changes into the cystic when the inward pressure is concentrated upon a limited area, and causes a bulging of a part or the whole of the circumference. When a cluster of dilated vessels lie in contact, increasing pressure may cause such atrophy of their contiguous walls that ultimately perforations occur, and the mass of tubes becomes a sac with imperfect septa which are the remnants of the vessel-walls. Inflammation of a dilated vessel is a much more serious matter than the same process in normal conditions. The hyperplasia resulting from the constant overfeeding of the parts, which are flooded with lymph in cases of occlusion, is not observed in all of the tissues ; but the white fibrous — the classical " connective-tissue proper," the material which nature uses so largely in reparative pro- cesses and which is produced so readily — gluttonously appropriates as much as it can of the excess of nourishing material, and, having a greater capacity for growth than its neighbors, crowds them to such an extent by its augmented bulk that they are not able to take even their wonted quantity of aliment. As a consequence they suffer atrophy, while it undergoes hypertrophy. It is a case where the greedy avarice of the rapidly-breeding plebeian starves out the refined and sensitive, but necessary, patrician, with the usual result of fatal disaster to the community. Lymphcedema. Interference with the normal passage of lymph often results in its transudation in large quantity into the areolar tissue. This condition is called lymphcedema or solid oedema. It is distinguishable from the oedema which results from venous obstruction by its extreme density and persistence. Areolar tissue is so almost universally a constituent of the soft parts that lymphcedema may affect a whole limb, which then becomes brawny, inflexible, and enormously swollen. If this condition exists a long time, permanent enlargement ensues from the growth of white fibrous tissue, and the part becomes not only useless, but an intol- erable burden. The treatment should aim to remove the obstructing cause, if practicable. If this cannot be done, firm, equable compression with an elastic bandage should be applied. This failing, nothing remains to be done short of removal of the affected part. Amputation-flaps may heal promptly, even though lymph oozes profusely from their cut surfaces at the operation. INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 413 Fig. 135. Macromelia. Sometimes we see cases in which there is no typical lymphangeioma, varix, oedema, or lymphorrhcea, but for which we can account only on the ground of occlusion of lymph-chan- nels, as there is a monstrous growth of one or more members, obviously from such excessive nutrition as is a characteristic feature of this obstruc- tion. This condition is known as macromelia, but special names are used for the designation of the disease in different parts, as macrodactylia, mac- ropodia, macroglossia, and macrocheilia, wherein the digits, the foot, the tongue, and the lips are respectively affected (see Fig. 96). The patient shown in Fig. 136 was affected in two fingers of one hand and three of the other, and in one leg, the part of the limb most overgrown being the great toe. The cause of the disease is un- known, and the only satisfactory treat- ment is amputation. ( Vide also Chap- ter I., Tissue-Alterations due to Change in Nutrition.) Macroglossia (Neisser). Macromelia (original). 414 affections of the tissues and tissue-systems. Chylocele. This disease resembles ordinary hydrocele in all of its clinical aspects with a single exception, which is rarely, if ever, recognized before operation. The fluid contents, instead of being clear, are milky, and failure to find translucency in a case supposed to be one of hydrocele should excite suspicion of chylocele. A positive diagnosis, however, can hardly be made, as the rare disease, spermatocele, presents a non-translucency with the candle-test. The fluid in chylocele is milky, and if allowed to stand cream rises to the surface. The lining of the sac may exhibit distended lymph-vessels, or at some point the mouths of several large channels connected with spaces of areolar tissue. Apparently the disease is due to an obstruction on the proximal side of some lacteal, but the pathology is not clear. Further observation may show this to be of filarial origin. Treatment for hydrocele is generally that appropriate for chylocele ; but in cases where milder means fail it will be well to lay open the vaginal tunic and ligate the enlarged and leaking vessels. FlLARIASIS. Most prominent among the causes of serious obstruction of lymph- channels stands filariasis. The diseases which it induces are uncommon in this country, but it has already obtained a foothold in some of our Southern States, and the possibility of its wide dissemination gives a peculiar interest to the study of its history and manifestations. It is essentially a parasitic condition. In a typical case of filariasis the blood contains a multitude of worms of the nematoid class of the variety called filaria sanguinis hominis — the thread-like worm of the blood of man. The creature is sexless, one-eightieth of an inch long, not quite as wide as a colored corpuscle of the blood, and wriggles incessantly like a snake. The worm appears to be enveloped in a filmy, transparent sheath, within which the body is alternately extended and retracted with great rapidity, so that the impression is produced of the animal's being furnished with a lash. This action does not cause locomotion, but makes little currents in the blood, by which the recognition of the parasite is facilitated. Many millions of these microscopic beings may exist in one patient. A most peculiar characteristic is their alternate presence in and absence from the blood. During the daytime the blood is free from them, bat as night approaches they begin to appear, their numbers rapidly increase, and by midnight the blood swarms with them. From this hour they gradually disappear, and few, if any, can be discovered after six o'clock in the morning. Habitual reversal of the periods of waking and sleeping determines a corresponding change in the time of appearance of the parasites, and fever inter- rupts the regularity of their manifestations. The cause of the periodicity of their migrations is not known. The method by which filarise are propagated is of practical interest. A female mosquito abstracts from a person who has filarial disease a meal of blood in which are many of these embryos. Several days are consumed in the digestive process, but a small proportion of the parasites not only escape destruction, but even undergo some development. The insect, led by instinct to deposit her eggs on the surface of some pool, ends her brief life by falling into the water, and the tenants of her frail body emerge into a medium exactly suited to their needs. In this they may attain a length of half an inch. If now they are swallowed by a human being whose thirst for water exceeds his discretion in the selection of it, they work their way, probably by boring through the intermediate structures, from the ali- INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 415 mentary canal to some large lymph-vessel, in which they find the environment best adapted to their comfort. They then steer against the current of lymph, and continue until they enter a vessel too small to permit further passage. Here a permanent lodgement is effected, and the creatures grow, develop, and breed in their snug quarters for years, setting up serious structural changes in the neigh- boring parte by the irritation of their presence. Several mature worms have been discovered in a single case. It is imaginable, however, that one of these helminths could produce pathological results of the gravest sort. While it is unquestionable that nearly all cases of the various dis- eases which are called filarial are really inaugurated by these parasites, it is pos- sible, on the one hand, that some other equally obstructive agency may produce identical results, and, on the other hand, it is known that filariasis may exist for a long time without serious interference with health. Both of these occurrences are, however, exceptions to a very general rule. No evil results are to be expected from the mere presence of the embryos in the blood, but the parents are terribly mischievous in their effects. Hyperemia, organization, and consequent stenosis, of the invaded vessel are soon occasioned ; the lymph is dammed back, the tube dilates, the walls burst or become hypertrophied, the whole region which was formerly drained by the occluded vessel is saturated and distended with the fluid, and the tissues undergo characteristic changes. Lymphangitis, lymphadenitis, lyrnph-varix, lymph-scrotum, chyluria, elephantiasis, phle- bitis, hcematuria, hydrocele, fever resembling malarial, — one or several of these are to be anticipated in such a case. It is useless to direct any medicinal agencies to the cure of filariasis. Even if we knew how to destroy and remove the unwelcome visitor, its extirpation would do no appreciable good, for the lesions produced by the presence of the worm would remain. Something of alleviation may perhaps be accomplished by rest, elevation of the affected part, the lowering of tension by the use of saline laxatives, a spare diet, and abstinence from liquids as far as possible. Operative procedures are sometimes available, and these will be mentioned when considering the separate diseases caused by filariasis. Our greatest reliance in our efforts to rid the community of the evils dependent on this parasitic condition must be placed on sanitary measures. If all drinking-water in filarial regions were to be subjected to thorough filtration and boiling, or to either of these processes, the further exten- sion of the condition would be effectually prevented. We now proceed to the consideration of the chief diseases produced by filariasis. ELEPHANTIASIS. No one who has seen a pronounced case of elephantiasis of the lower limb — a favorite seat of the disease — would think of questioning the fitness of the name, for the resemblance to the leg of the greatest of quadrupeds is instantly suggested. The disease is not common outside of the tropics, and yet cases are seen now and then in northern climes. As our knowledge of filariasis is quite recent, it is impossible to state whether or not most of the sporadic instances apparently originating in the temperate zone have had a filarial source. As the mature parasite has a marked preference for the lymphatics of the lower part of the body for residential purposes, the disease is rarely seen above the navel, 416 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. and the lower extremities and the external genitals are the members usually affected. When the malady attacks the lower limb it commonly begins with an outburst of erysipelas in the toes. The manifestations are not unusual — pain, swelling, inflammation of lymph-nodes, systemic dis- turbance. Subsidence leaves the integuments thicker and harder than normal. After a variable period a second attack of erysipelas occurs over a wider area and disappears, and then another and another, and so on for many times, each leaving its mark in a contribution to the thickness of the skin and subcutaneous tissue, until the hypertrophied parts may be four inches thick. The limb is rarely involved above the knee. When the disease is well marked the skin is seen to be thrown into many ridges, the surfaces concealed in the intervening furrows being eczematous ; foul and indolent ulcers are numerous ; and cracks, oozing lymph, appear at many points. The skin may be smooth or rough, hard or soft, and gray, brown, black, warty or knobbed, and a single case may display several of these peculiarities. The suffering of the patient is mainly due to the great weight of the member, but in some cases the pressure upon included nerves adds an element of very acute pain. The condition now established is a true hyper- » Aplasia of the white fibrous tissue of the corium Fig. 137. Fig. 138. Elephantiasis of leg;, scrotum, and penis (original). Elephantiasis of hand, acquired (Park). of which is a copious albuminoid deposit. The papillae are immensely enlarged. A section shows a white, homogeneous mass, moist with INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 417 lymph, which leaks from every point, and almost as dense as cartilage. The blood-vessels are notably enlarged. Pressure and enforced inac- tivity have caused degeneration of the muscles, and the over-nutrition of the periosteum has resulted in abnormal growth of bone, usually in disfiguring protrusions. There is, however, a form of congenital elephantiasis which is now known to be due to the constriction of amniotic bands or Fig. 139. a misplaced cord upon the growing limbs of the foetus. This pertains almost invariably to a single extremity, usually the lower. Save in appear- ances this form has nothing to do with the com- mon parasitic form, and is to be regarded as a hyperemia due to distended veins and lymphatics. Fig. 140. Elephantiasis of scrotum (original). Elephantiasis of scrotum and penis (original). Treatment of the erysipelas should be conducted on the lines already prescribed for that disease, and the other incidental ailments are to be managed as when they occur in other circumstances. For the tully-developed elephantiasis numerous therapeutic recommendations have been made. Rest, elevation of the limb, and fomentations contribute to the comfort of the part; compression with a rubber bandage may retard the growth and afford some relief for a time; anodynes and supportives to the general system are often manifestly demanded. But among real operative measures amputation alone is worthy of serious consideration, and must be resorted to if the disease is to be extirpated. 418 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The results are generally all that could be expected. The Esmarch bandage is of conspicuous value in these cases. Elephantiasis of the external genitals stands next in order of frequency to that of the leg, and, allowing for the structural differences in the organs concerned, the symptoms and the tissue-changes are substantially identical in the two localities. If only the scrotum be involved, its integuments so far outgrow the length of the penis that the latter may become lost to sight at the bottom of a conical pit. The super- ficial lymphatic vessels are apt to become varicose, and, being rupt- ured, discharge so much fluid as to keep the skin moist. Ulcera- tions are common, and mortification of the mass may occur. The chief danger seems to be from septic infection. The greatest discomfort experienced is due to the bulk of the tumor and its weight, which may exceed that of the individual who bears it. The severe dragging on the inguinal structures not infrequently causes hernia. When the penis is the part principally affected, which is rather un- common, it may grow to a monstrous size. In Fig. 137, which exhibits a typical enlargement of one leg, the patient's penis, measured around the curves, had a length of twenty-seven inches and a circumference near the scrotum of fifteen inches. This case and that represented in Fig. 139 belonged in Barbados, where the disease is so common as to have derived one of its names (Barbados leg) from the place. Fig. 140 is drawn from a photograph of a New England case in which penis and scrotum are about equally diseased. In females elephantiasis is far less frequent than in males. The genitalia involved are the homologues of the scrotum and penis — namely, the labia majora and the clitoris. The TREATMENT OP ELEPHANTIASIS OP THE GENITALS does not differ from that appropriate to the disease in other localities. Only complete ablation affords anything more than transient relief. The main peril is from shock, for hemorrhage, which formerly was most dreaded, is largely controllable by the Esmarch bandage. For some hours before the operation the parts should be elevated in order to drain them of fluids, hernise should be reduced, and hydroceles emptied. The neck of the tumor is to be constricted with the elastic band and provision made for compression of the aorta. The incisions are made along the dorsum of the penis and over the course of the cords, and these organs, with the testes, are dissected out and turned up on the abdomen. Wounding of the vaginal tunic is to be avoided. The per- ineal connections are then severed and the mass removed. Veins, as well as arteries, ought to be tied. LYMPH-SCROTUM. This is a form of elephantiasis, and often develops into the commoner variety. It generally is ushered in with fever, which is quickly fol- lowed by acute inflammation of the scrotum and of the lymphatic ves- sels of the groin. The skin is thickened and becomes peculiarly corru- gated, and its lymph-vessels dilate to such an extent as to constitute a set of large intercommunicating sinuses, with so little epidermal cover- ing that spontaneous or artificial perforation often starts a dangerous INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 419 lvmphorrhagia. The scrotal enlargement is more due to dilatation of lymph-vessels than to hyperplasia of connective tissue. Usually there is intermittent leakage of lymph, and the bulk of the tumor may lessen during the discharge and increase during the interval. After the drain has continued for many years it may cease, and the scrotum gradually assume the characteristic appearances of ordinary elephantiasis. Filariae may be absent from the blood, even though constant in the voided' lymph — a condition brought about by the lodgement of a worm in a vessel in or near the upper part of the scrotum. The inflammation which the parasite awakens extends to the nearest related nodes, the channels of which consequently become occluded, and thus the embryos are confined in the lymph on the distal side. Ablation is the only suitable treatment. CHYLTJRIA. This is a condition characterized by the presence of emulsified oil in the urine. There is usually no warning of its approach, but the onset is sudden, the urine assuming a milky look and becoming extremely abun- dant. Simultaneously there may be discomfort in the region of the urinary organs, with general depression and debility. The urine coagu- lates quickly, but the clot soon disintegrates, a layer of cream forms on the top, and rapid decomposition ensues. There is sometimes coincident hematuria. Chyluria may continue many months, and then cease as abruptly as it began. It is often associated with lymph-scrotum, and the discharge of milky fluid from the ruptured vesicles may alternate with the appearance of chyle in the urine. The condition of the gen- eral health varies greatly, but marked debility is common, due probably to the waste of a large amount of the digested materials which the lac- teals have absorbed. The pathology is obscure. Doubtless the disease is of filarial origin, for its geographical distribution is identical with that of other diseases of this class, and the embryos are almost invariably to be found in the blood and in the chylous urine. No other feature of the malady is as constant as their presence. Supportive measures are almost always demanded, but beyond this treatment nothing avails. Prognosis should be guarded. Inflammation of Lymph-nodes. — Now-a-days we have discarded the words " idiopathic " and " diathetic " as applied to this disease, for we recognize no spontaneity of cause to justify the first, and know that the cases which formerly seemed to warrant the second are started by material particles brought through lymph-channels from an infected area to a node. The microbes which set up inflammation in vessels excite the same process in nodes, and almost always lymphadenitis (the technical name of the disease) is caused by extension of the lymphangitis of some tributary. When this is not the case the cause is usually to be sought in infection from a more or less distant point, the poison being conveyed to the node through vessels which may receive no harm from the toxic agent to which they give passage. Nodes are very prone to take on inflammation, and this generally spreads to the areolar tissue in which they are imbedded. As acute inflammation of lymphatic nodes usually differs from the 420 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. chronic form in etiology, course, and indications for treatment, the two will be considered separately. Acute Lymphadenitis. — A previously unnoticed node displays the classical signs of inflammation. The pain is not great if the adjacent parts are kept entirely quiet, and there may be absence of fever. If the inflammation is not checked, suppuration occurs. The node and the skin covering it soften, and when a cluster of nodes is concerned they may form a single abscess by confluence. Evacuation of the pus is suc- ceeded by rapid healing, but in depraved conditions of the system an ulcer, or even a sinus, may remain and be unresponsive to treatment for a long time. Rarely acute inflammation terminates in the chronic form or in fibrous induration, caseation, calcification, or gangrene. Generally acute lymphadenitis is caused by the introduction to the node of some irritant material brought by lymphatic vessels. The principal pathological change observed is a vast increase in the number of cells, which block up the chan- nels, and thus make the node more than ever a catch-basin for particles floating in the current of lymph. Treatment must be prompt and active if the integrity of the node is to be saved. First, remove the cause if possible, seeking it at the periphery of the tributary vessels. Keep the inflamed part perfectly still. Reduce congestion by leeching or apply freely several times a day equal parts of carbolic acid and glycerin, or inject carbolic acid. The last method has won much favor. Its value seems to depend less upon the strength of the acid than on the exact manner of its employment. Some surgeons use a 2 per cent, solution, others the liquefied acid, but all recommend the injection of all parts of the node. The needle of a hypodermic syringe is thrust nearly through the node lengthwise ; it is then slowly withdrawn, and the acid is deposited all along its track — perhaps thirty minims if a weak solution is used, three or four if the strongest. Then firm pressure is applied. None of these measures are efficacious after pus has formed. When this stage is reached incision must be resorted to. If there are fibrous bands or adherent pus, curette the cavity, swab it out with a strong antiseptic, and pack it with gauze. When granulation has well begun healing may be expedited by a deep suture. The routine treatment of inflamed nodes with tincture of iodine is most undesirable. Iodine in any form probably does no good in acute lymphadenitis. Constitutional treatment, although of secondary importance, may be needed, and the careful practitioner will not forget the possibility. It is probable that a node is never thoroughly restored after having been inflamed. Its stroma is increased, it remains harder than is normal, and it has contracted adhesions to circumjacent parts. Chronic lymphadenitis may be, though it rarely is, a sequel of an acute inflammation. Almost always it originates in the entrance of bac- teria from the peripheral area drained by the affected nodes. These directly or indirectly excite inflammation of so low a grade that it often seems to have qualities which entitle it to be regarded as chronic from the outset. So deliberate is this process that it may consume many years before it runs its entire course, including its sequels. Its most characteristic feature is perverted growth of the connective tissues, which so hypertrophy as to destroy or crowd out the cellular elements and INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 421 sometimes reduce the node to the condition of a fibrous lump. At other times the node attains a great size, in which case large cells are found to have developed. Many nodes in a locality are apt to be diseased at the same time, and often coalesce into hard, lobulated masses, which are always disfiguring, frequently cause suffering, and occasionally interfer- ence with important functions by pressure upon nerves, vessels, and other organs. These nodes, which are almost always the seat of tuber- culosis, undergo the degenerative changes incident to that disease, and with especial frequency caseation. The cluster of nodes is converted into a cheesy mass, which may long remain unaltered or rapidly soften and be partly discharged, the remainder acting like a foreign body and maintaining suppuration. When spontaneous healing takes place the resulting scar is large, puckered, and unsightly. Chronic lymphadenitis is most common in the poorly nourished, espe- cially those of tuberculous or syphilitic parentage. It is very insidious in its approach, and the fact that a node is in trouble may not be sus- pected until an abnormal bulging is noticed on some part of the patient's neck — the favorite locality of the disease, because the mucous surfaces of mouth, nose, and ear offer so much more extensive opportunities for the admission of septic germs than are available for the inguinal and axillary nodes. There is no pain, as a rule, and the growth may remain unaltered for a long period. Treatment must be both constitutional and local, the former being much the more important. Hygienic measures are most to be depended on — abundance of pure air and nourishing, easily-digested food, cloth- ing adapted to the seasons in turn, baths, suitable exercise, favorable climate. Unhappily, however, the majority of cases occur among people to whom such prescriptions are a mockery, to whom the exact antipodes of these conditions have constituted the entire environment and the most urgent invitation to the disease with which they are afflicted. Penury establishes the physical state which favors the development of the malady and an insurmountable obstacle to the adoption of the necessary means for its removal. Only the opulent can command the best constitutional treatment. We are driven, therefore, in a large proportion of cases, to depend upon medicinal remedies, and these are principally in the directly sup- portive class — tonics and stimulants, as cod-liver oil, iron, and the alcoholics, the last to be used with extreme caution. Arsenic, mercury, and iodine, of course in minute doses and in forms which are easily tolerated, have often seemed to aid in the correction of the constitutional perversity. Local treatment should vary according to circumstances. If the node is hard, some good may come from the application with gentle friction of some ointment containing iodine, iodoform, iodide of lead, or iodide of potassium. When this device causes soreness of the skin, its use should be left off until the skin is restored, and then renewed. Pus should be given vent as soon as detected, and the incision would better be small. The cautery knife at a dull red heat is preferred by certain surgeons. One advantage of early opening is the probability of a less offensive scar than follows spontaneous evacuation of the pus. With a view to the substitution of harmless cicatricial tissue in the place of the morbid deposit, the centre of the node may be injected with a caustic, as two minims of a 10 per cent, chloride-of-zinc solution once a week or so, or three minims of equal parts of carbolic acid and glycerin. Puncture with the thermo- 422 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. cautery will sometimes answer the same purpose, causing induration of the entire node. Particular caution should be observed in the local treatment of ingui- nal tumors, which are supposed to be chronically inflamed lymphatic nodes. In two patients I have found hernia which had been diagnosti- cated by the attending physician as lymphadenitis, and in one of these a small knuckle of intestine was gangrenous. When the tumor causes suffering by compression of nerves or ves- sels, or menaces life by interference with breathing or deglutition, nobody hesitates to advise removal. But these cases are infrequent, and concerning a cutting operation in the majority of cases the highest surgical opinion is divided. Of course every one would be glad to rid his patient of a mass which is probably tubercular, for infection of the system from the degeneration of these nodes may occur in any given case, though it certainly is not common. If there is only slight mobility of the tumor, nobody can tell how extensive a dissection may be necessary to remove it; and perhaps more harm than good comes from taking only a part away, for experience shows that such interference often excites more rapidity of growth in the remainder. There is a lack of information relative to the results of extirpating operations : the reports of them have been made too soon to justify conclusions as to their value. It is probably a safe rule to ablate masses which are freely movable, in order to prevent extension to neighboring nodes. Such operations are not difficult, as a rule, but when the tumor is not freely movable the case is far different. Then it is generally best not to use the, cutting edge of the knife after the nodes are reached, for the vessels and nerves, and especially the jugular vein, are often so displaced, stretched, and obscured that they are apt to be mistaken for fascial bands and wounded in consequence. The fingers and blunt instruments are the safest imple- ments in these circumstances. Piecemeal removal is often most expe- ditious, and by far the best. Hodgkin's Disease. There are not many diseases which have been called at one time by as many different names as that which we are about to consider, and its current titles are herewith presented, not as an illustration of the fertility of terminological inven- tion, but that the reader who has known this malady by any one of these appella- tions may be made aware of the subject of this section. Here are the names : lymph- adenoma, generalized lymphadenoma, lymphadenosis, lymphoma, adeno-lymphoma, malignant lymphoma, malignant multiple lymphoma, infective lymphoma, adenia, ade- nosis, progressive glandular hypertrophy, hyperplasia of lymph-nodes, lymphosarcoma, multiple sarcoma, lymphatic ancemia, splenic anosmia, pseudo-leucncytha>mia, pseudo- leukmmia. Unfortunately, some of these are used to designate more than one dis- ease, and their employment is, consequently, very confusing ; and others, while affecting to give pathological information, are really misleading. It has seemed wiser, therefore, m spite of well-grounded objections to eponyms, to call the affec- tion by the name of the observant physician who first gave an account of it, until a concise and correct descriptive title can be agreed upon. Hodgkin's disease is more frequently seen in the young, and espe- cially males. Its first manifestation is the enlargement of some super- ficial nodes, generally in the cervical region. They are not painful or tender, do not adhere to the skin or to each other, and show no tend- ency to caseation or suppuration. The spleen is a little enlarged and the INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 423 Fig. 141. general vigor impaired. There is a suggestion of ana-mia, but the only observable alteration in the blood is a slight diminution in the number of the colored corpuscles. The case can cer- tainly be made out to be neither cancer nor tuberculosis, and arouses but little | suspicion of sarcoma. The enlargement of the nodes pro- gresses — if slowly, the tumor is prob- ably hard ; if rapidly, soft. Those in I the arm-pits and groins are affected next after the cervical, and other groups fol- low suit. The only suffering comes from debility and depression of spirits, which are constant, and from fever, which is frequent. The blood may lose three- quarters of its colored corpuscles, but the colorless are not diminished. The skin is pallid and waxy and the mucous membranes are blanched. Variations in appetite are observed from anorexia to voracity. In a year or two every node in the body I is enlarged : the neck has ceased to be a constricted part and bulges hideously; the axillae are stuffed with tumors ; the groins protrude and the lymphatic col- onies in the great cavities are correspondingly affected. Pressure produces results which vary according to the organ involved, and is responsible for pain, paralysis, perverted respiratory action, and interference with digestion and circulation. Death is due to exhaustion. Post-mortem examination shows no formation of pus, no caseation, no breaking down of any kind. The nodes composing each separate group have become fused, the lymphoid tissue between them having in- creased and banded them together. They display increased vascularity and hypertrophy of tissue, the cellular elements being overgrown in the soft masses and the fibrous in the hard. Small, irregular lumps of new lymphatic tissue are scattered abundantly throughout the spleen, and the lungs, liver, kidneys, stomach, and intestines may contain similar deposits. This is the history, in brief, of a pronounced and clear case of Hodg- kin's disease, but deviations from this type are not uncommon, and the future may prove that some of the so-called varieties are really different diseases. The most confusing (alleged) variety is that in which there is not merely a relative, but an actual increase in the number of leucocytes in the blood. The difficulty in interpreting this condition, so opposed to that which is usual, is at least diminished by observing that this multi- plication of colorless corpuscles is coincident with that form of hyper- trophy of the spleen in which there is not only the typical, characteristic overgrowth of the lymphatic elements, but also an augmentation of the pulp; and this change in the pulp is the cause of the leucocythsernia. Hodgkin's disease (Park). 424 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Thus we have developing in the same patient Hodgkin's disease with its loss of colored corpuscles, and splenic leucocythsemia with its vicious gain of colorless corpuscles. Occasionally there is no enlarge- ment of the spleen. It would be (interesting to know if the other I viscera, which are usually affected I in advanced stages, are equally ex- lempt. Sometimes the disease begins I in the deep nodes, and then an early diagnosis is wellnigh impossible. Diagnosis cannot be made until I the appearance of enlargement of nodes. The principal differences between Hodgkin's disease and leu- cocythsemia (with which, as we have seen, it is at times associated) are, ; first, that in the former anaemia is not pronounced until after the lym- phatic hypertrophy, but in the latter anaemia is the first thing noticed ; second, in Hodgkin's disease the splenic enlargement is slight until that of the nodes is very great, but in leucocythamia the spleen is the first organ to show increase in size. The recent discovery that the blood-leucocytes are not of one kind, but of five or more varieties, may be the key which is to unlock some of the mysteries of this disease, which needs to be studied anew from the point of view of this addition to our knowledge. In the treatment of Hodgkin's disease almost all drugs which have been tried have proved to be worthless. Arsenic alone seems worth a trial, as some tumors have diminished during its administration and a number of complete cures have been reported. As large doses as can be borne without toxic effects should be given. The general strength must be upheld in every possible way. Local treatment does not promise much, if any, more than medicinal. Injec- tions, massage, inunctions, compression, and blistering have all been tried fruit- lessly. The propriety of operation always comes up for discussion. If the diag- nosis has been made early — when, for instance, only a single and accessible group of nodes is involved, the spleen apparently normal, and the anaemia slight-^ removal of the mass should be practised ; for, while this procedure cannot be warranted to exempt the patient from extension of the disease, it is usually attended with little peril, and it gives him the chance of benefit possibly resulting from the extirpation of a tumor which if allowed to remain may cause infection of the entire system. In order to do any good the removal must be thorough. If the disease has become general, operation is not to be thought of, except for the removal of such masses as mechanically cause suffering or interference with vital processes ; and always in such a case it should be plainly stated by the surgeon Hodgkin's disease (Park). INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 425 that nothing curative can be hoped for from the operation, but merely temporary palliation. Sarcoma of Lymph-nodes. Although the cases are very rare, it seems to be fairly settled that sarcoma may affect lymph-nodes as a primary affection. The diagnosis is not always easy — in fact, may not be possible until the node has been removed and subjected to microscopic examination. The treatment is, of course, ablation. CHAPTER XXX. SURGICAL INJURIES AND DISEASES OF THE VEINS. By Jambs M. Holloway, M. D. Hyperemia of Veins. This condition is a consequence of trauma, not only of the walls of the vessel, but of the adjacent or surrounding tissues. Contusion, punct- ure, or laceration of a vein, if not treated preventively, will be more or less speedily followed by swelling, induration, plugging, discoloration, and decided tenderness. If circumscribed, the elevation of temperature will be strictly local, and not always appreciable except by a surface thermometer. The surgeon rarely encounters such a case, because of its seeming insignificance. When called he finds that the hyperemia has extended upward along the course of the vessel quite a distance from the site of the injury. The vein can be outlined by the swelling and discoloration, and the pain and fever indicate a constitutional disturb- ance. Hypersemia of veins is a prominent feature in the clinical course of a sprain in which preventive measures have not been employed or have failed. All of the structures about the joint are more or less involved ; there is a general discoloration of the skin, the hue deter- mined by its natural pigment. The veins are usually, in such a case, outlined by their fulness and the darker arborescent streaks. After the hypersemia has subsided the mottled skin oftentimes remains to indicate the effusion of blood and the enfeebled venous flow through these super- ficial vessels. Frequently clotting occurs during the active hyperaemic state, and the vein is obliterated, leaving indurated masses that are likely to be mistaken for lymph-nodes or fibrinous deposits. These phenomena, observable upon the superficial, occur as well in the deeper parts, and may be properly cited as one of the causes of nutritive dis- turbances, pathological degenerations, and the formation and growth of neoplasms. The treatment of hyperemia of veins demands physiological rest, support by dry or wet, warm, hot, or cold compresses of cotton or wool, and the supporting effect of concentric compression by bandages. Anodyne and astringent lotions may be added to these when pain and tenderness exist. A lead lotion with opium, an evaporating or stimu- lating lotion — e. g. distilled extract of witch-hazel, tincture of arnica, or the balsam-apple in rectified spirits — may be substituted. Compres- sion by cotton batting or wool and the bandage supports, eases and favors resolution and the return circulation. Phlebitis. Inflammation of Veins (Sepsis). — Wounds of veins are the most frequent direct cause of this condition. The absorption of septic fluids 426 SURGICAL INJURIES AND DISEASES OF THE VEINS. 427 from contiguous structures that are septic is the common indirect cause. Oftentimes, in either case, the lymphatic system is considerably affected, so as to render it difficult to decide as to their causal relation. The walls of the veins become swollen and less resistant, the serous coat is congested, the valves are less mobile, and the blood clots readily from stasis and the admixture of septic fluids. The parts directly within the area of the septic state become boggy, discolored, and more or less ten- der, the pain being burning and lancinating. The tendency is toward the formation of diffuse collections of pus in the adjacent structures. The constitutional disturbance is alarming ; the asthenic state is present ; all the essential signs of fever are manifest ; the pulse soon becomes feebler and less regular than in the sthenic fevers ; the respira- tion is sighing ; the skin is frequently bathed in profuse sweats ; the countenance expresses concern ; and the secretions from the intestinal tract and the kidneys are scanty. There is a general sepsis that may terminate more or less speedily in death by asthenia or by the formation of septic abscesses in the lungs or liver or brain. On the other hand, the patient may recover by elimination of the septic matter through intestinal drainage and free diuresis and diaphoresis, or by the formation of conservative dep6ts of pus in the cellular planes. Treatment of Phlebitis (Sepsis). — The preventive treatment should be the aim of the surgeon — viz. when possible remove all for- eign substances, blood-clots, etc. that will act as local irritants, establish and maintain free drainage, and employ aseptics and antiseptics. The technique will be suggested by each individual case. Should, however, these precautions have been neglected or have failed because of incom- pleteness in their application, no time should be lost in the thorough removal of the cause when practicable, and in the employment of con- stitutional treatment to lessen the gravity of the sepsis, and at the same time sustain the patient against the asthenic state so likely to prove fatal. Free Incisions where the parts are boggy and tense, irrigation with sterilized carbolized water, the bichloride solution ; after, drains of gauze or tubing, dusting with iodoform and boric acid, and over all aseptic and antiseptic gauze, the object being to prevent those putrefac- tive changes that result in the production of ptomaines and toxins. These for the local condition. For the constitutional state, already present, free drainage by the intestinal tract and kidneys is to be secured by small doses of calomel repeated at intervals of a half hour or hour, to be followed by small doses of Rochelle or Epsom salts until free pur- gation and diuresis occur. At the same time milk, broth, eggs, and wine or whiskey should be judiciously administered. Special attention should be given in such cases to the administration of from one-thirtieth to one-twentieth of a grain of strychnine hypodermically every four or six hours, to which may be added, when required, digitalin and nitro- glycerin. In cases of recovery the area of the local septic state is recognized by a persistent swelling and induration, upon the subsidence of which, under appropriate treatment by bandages, massage, and the hot and cold shower, the superficial veins may be outlined by irregularity and cordiness. 428 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Varicose Veins (Varices). There is no doubt about the dilatation of the calibre of the veins that are in a varicose condition. Nevertheless, veins that are dilated are not necessarily varicose. A difference between varicose and dilated veins is therefore recognized. This consists in the condition of the valves. In the former (varix) the valves are insufficient ; in the latter (dilatation) they are not. In the former the walls are irregularly thinned, length- ened, and tortuous ; in the latter the walls are more or less thickened. Insufficiency of the valves is caused by a stretching of the wall of the veins so as to separate the thin free edges, leaving an interspace that permits of regurgitation of the blood in a direction opposite to the nor- mal current. In consequence the column of blood has no longer sup- port against gravity, and does not flow normally into collateral channels when interrupted in its more direct course. This valvular insufficiency is a potent factor in progressively thinning the vein-walls and adjacent skin, and increasing the danger of their rupture subcutaneously or through the attenuated overlying skin or mucous membrane. Short of this, the pressure-effects of varicosities are liquid or semi-solid oedema; pain due (1) to the sense of fulness where stasis (congestion) results ; (2) to pressure upon filaments of nerves or nerve-trunks ; (3) to disturbances of nutrition, causing eczema, ulceration, overgrowth, more or less permanent pigmenta- tion, the formation of thrombi and their degeneration into phleboliths. Causation of Varicose Veins of Lower Extremities. — (1) Thrombosis of large veins following an attack of typhoid or other long- continued fever ; (2) injury of pelvis or thigh or leg, lessening nutritive powers; (3) local pressure of pelvic or abdominal tumors or fecal accumulations (the latter affecting the left limb) ; (4) long-standing occupation, affect- ing the long superficial internal saphena ; (5) congenital defect in the arrangement of the valves, as noticed in the paragraph on the Anatomy and Physiology of the Veins, as recorded by Bennett. Constipation and, pregnancy, especiallv the latter, aggravate the varicosity, the former being questionable as an exciting or aggravat- ing cause. Occupation is not usually an ex- citing cause, but persons who are compelled to maintain the erect posture during long watches, during great heat, or are subject to frequent slight injuries have a tendency to varicosity very much aggravated. Ag3 is not a determining cause, for in many instances the presence of varicosities is not discovered until far advanced. The disease is rarely !\ noticed in persons under twenty-one years i Si unless abdominal obstruction exists — a very congenital varices (Park). ™ re occurrence. The tendency to the affec- tion increases under certain limitations after adult life, and is much more common in old age in both sexes. Fjg. 143. SURGICAL INJURIES AND DISEASES OF THE VEINS. 429 The complications of varicose veins of the lower extremities, as given by Bennett, are hemorrhoids, varicocele, varix over pubes, labial varix in female, ulceration and eczema, persistent solid oedema (lymph- oedema), recent thrombus, old thrombus, valgus. Varicose veins of the upper extremities are caused by occupations requiring over-use — e. g. in washerwomen who work daily and use their hands instead of wringers, men who work at brick-kilns pitching the brick in the erect position, and, after burning, loading wagons ; tennis- and baseball-players can be named. The early symptoms are pain in a muscle or group of muscles in unusual localities of the arm, usually attributed to sprain. To diagnose such a case slight compression with a bandage around the arm near the axilla will speedily bring to view conspicuous varicosity. To prove the correctness of the opinion, apply a roller bandage and the movements will be made without pain ; afterward direct the patient to wear an appropriate elastic stocking. In extreme cases the same treatment may be resorted to as is applicable to veins of the lower extremities. Symptoms of Varicose Veins of Lower Extremities. — Incipient. — Crampy pains upon rising, passing off, and late in the afternoon a sense of ful- ness and heaviness, with more or less dull pain in one or both legs. Inspection rarely reveals varicosity of the superficial vessels, except perhaps a few slight varicosities near the saphenous opening, upon the outside of the thigh, in the popliteal space, on the fibular side of the leg, or behind the ankles. These may be altogether absent. In some cases slight oedema of the foot or ankle comes on later in the evening, enough only to be noticed because a loose shoe then feels too tight. Varicosities of the deeper veins are more commonly recognized now than formerly. When elderly laborers or women who are multiparous are able to pursue their usual vocations without much pain, the inference is warranted that their varicosities are confined largely to the superficial veins. Pain in the vicinity of superficial varices is commonly due to pressure upon filaments of nerves, not to any disturbance of the main branches. The sense of fulness and heaviness that is experienced is due to the general stasis in the foot and leg. The eczema and itching are due to the effusion disturbing the function of innervation in the sensory branches distributed to the skin. The ulceration and resultant ulcer are due to the bursting of a vein, to the wound of the cuticle by the finger-nails employed to allay or modify the itching after lying down, to an accidental contusion or abrasion, to the presence of a phlebolith that causes molecular death by pressure or by becoming septic. Treatment of Varicose Veins of the Lower Extremities. — Support by the perfect elastic stocking or by the roller bandage is sufficient to ease the crampy pains upon rising and prevent the heavi- ness and fulness and slight oedema of the early or incipient stage. More radical treatment should be resorted to after the condition has advanced. Multiple ligation of the prominent veins, either subcutaneously or through incisions in the overlying skin, has proven effectual in many instances. But under the present aseptic and antiseptic method nothing short of excision of the internal saphena and prominent tortuous groups oi veins below the knee can be recommended. 430 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The technique, simple but tedious, is as follows : "While the patient is standing encircle the upper third of the thigh by a rubber cord, tight enough to obstruct the venous flow, but short of compressing the artery. While an anaesthetic is being administered, the internal saphena and veins below the knee, that were not easily outlined before, now become prominent. As soon as the parts have been thoroughly cleansed and protected by sterilized towels, an incision through the skin, six or eight inches long, should be made parallel to the internal saphena, but not directly over it. This precaution is taken to avoid wounding the vessel by misdirected pressure upon a blade of uncertain keenness. When the incision through the skin has exposed the subcutaneous cellular tissue, the knife must be laid aside or its handle only employed. With it and the fingers the vein and its variable number of branches must be teased out of their bed, and so thoroughly exposed that each branch and the proximal and distal end of the main vessel can be ligated. After the vessels have been secured they are excised by the scissors. Then, after cleansing the parts by wiping, not by irrigation, the edges of the skin-wound should be accurately coapted by silkworm-gut or catgut sutures. Under extraordinary circumstances, not likely to occur often, liga- tion of the femoral vein or one or more of the venae comites of the leg is suggested when the method named above has failed to cure the vari- cosity. When the disability can be clearly attributed to a varicose state of the deeper veins and the subcutaneous veins are not plainly apparent, the writer would advise ligation of the deeper veins. Under the improved and constantly improving methods for doing thoroughly clean surgery this advice is deemed proper. It is given without hesita- tion since the experiments of Trzebicky and St. Karpinski in 1893 on the ligation of femoral veins. The operation of Schede has the same idea in view — cutting off the column of blood from above — but does it more effectually than any of the other methods. It is simply a circumcision of the entire leg at about the junction of the upper and middle thirds, dividing the skin and subcutaneous tissues down to the deep fascia, tying the bleeding points, and then sewing up the incision. Treatment of Varicose Ulcer. — Palliative. — The various methods commonly employed are intended to arrest the ulcerative process (first stage), or to stimulate it in the stage of arred (second stage), or con- duct it steadily through the stage of repair (third stage). These methods have been considered fully elsewhere. Whatever plan of treatment suc- ceeds in aiding the ulcer to heal leaves the limb in such a condition, on account of the varicosity, as to render reopening of the ulcer or the formation of others, under very slight exciting causes, probable. There- fore the only radical method by which a cure may be effected is to first excise or obliterate the main trunks that are varicose. Then the most effective plan is thorough curettage, loosening the edges of the ulcer with the handle of a scalpel, and aseptic and antiseptic dressing with proper support. If so large a portion of skin has been destroyed as to pre- vent contraction, skin-grafting will hasten cicatrization. The eczema and weeping that cause so much itching and distress in such cases before operation for radical cure can be lessened, and some- SURGICAL INJURIES AND DISEASES OF THE. VEINS. 431 times be made to disappear temporarily, by elevation at night and skilful bandaging during the day, the parts having been dusted with boric acid, bismuth, iodol, aristol, iodoform, oxide of zinc, or admixtures of these in proper proportions. The globular vari.v that occurs oftenest at or near the saphenous opening is not always a dilatation of the saphena. Bennett describes two kinds that are dilatations of smaller collateral vessels — viz. (1) the subcutaneous, that is the more globular in shape and, under the thinned skin, is darker ; (2) the subfascial, that is flattened by the denser fascia lata, its color being less dark because of its depth. Neither kind can be emptied by pressure, rebounding when digital compression is withdrawn. When these give rise to pain by pressure upon minute filaments of nerves, removal is the proper treatment. A curvilinear incision half around the tumor will expose it readily, and in the subcutaneous variety will lessen the danger of cutting into the tumor. Landerer's method of treating varicose veins has not been sufficiently employed in this country to determine its value. Its simplicity is con- spicuous, and if successful, even as a palliative measure, deserves prompt recognition in dealing with a class of cases that are not to be operated upon for a radical cure because of old age, visceral degenerations, preg- nancy, or those necessities of life demanding continuous occupation. It consists in the pressure on the saphena above or below the knee by a "parabolic spring carrying a cushion filled with glycerin or water," attached to a garter that fits so loosely as not to constrict the limb. Rupture of varicose veins is sometimes attended by profuse hemor- rhage, and death has resulted. It always causes alarm to the patient and those around. To arrest the bleeding, elevate the limb and apply pressure with the finger until a compress and bandage can be applied. The flow of blood is mainly from the distal end, but, it is asserted, the proximal end also bleeds. Venous N^vtrs. This is one form of erectile tumor. It is usually congenital, but quite often acquired. It involves the skin and mucous membrane, and is Congenital venous nsevus (original). found in the subcutaneous and submucous tissue. Nffivi are discovered post-mortem in the liver and some other internal organs. They are 432 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. situated more commonly on the head and face and in the cavities of the nose and mouth, pharynx, and nasopharyngeal space. The upper and lower lips, the tongue, the orbit, and the scalp are frequently the seat of the affection, and the dark claret stains or port- wine marks in the skin of the face and neck and upon the eyelid, usually called mother's marks or birth-marks, and attributed to maternal impres- sions during intra-uterine life, are true venous nsevi. They vary in size from the head of a pin to masses of relatively large size and dif- fused over large surfaces of skin, or form large tumors of divers shapes. Fig. 144 represents a subcutaneous nfevus of the arm of a young lady, who stated to the writer that it was congenital and had increased with the growth and development of the arm. Until examined carefully it resembled a mass of tortuous varicose veins. Some of these tumors pulsate; others do not. Some of them can be emptied by firm pressure ; others are elastic, and the blood can only be dis- placed, owing to the thickness of the walls of the caverns and the amount of inter- vening hypertrophied connective tissue. Certain forms of carcinoma and sarcoma resemble venous nsevi in appearance, density, and anatomical arrangement, while distinct naevi form a part of such malignant growths. Many venous nsevi (the smaller varieties) disappear spontaneously after birth, the blood-supply having been cut off; others increase in size, many of them outstripping the nor- mal growth of the structures containing them. In some the growth is so rapid as to injure by pressure-effects, by closing more or less com- pletely the cavities — e. g. obstructing one nasal cavity or lessening the calibre of the pharynx, thereby causing difficult deglutition. Lennox Browne reports varices of the throat and under the tongue, the former causing overgrowth of adenoid tissue and giving rise to tenesmus similar to that from piles in the rectum. Treatment of Venous JST^vi (vide Chapter XXV., Angei- oma). — For the smaller circumscribed variety, that tends to disappear spontaneously, painting with collodion will so constrict the growth as to lessen its size and finally cut off the blood-supply. For the claret stains tattooing offers a method of cure that will reward the patient one. For the circumscribed increasing tumors on unexposed parts of the body and upon the scalp the ligature, inserted subcutaneously and made to transfix and surround the mass so as to cut off the blood-supply, will effect a cure without disfigurement. The injection of coagulating agents is only named to be condemned. The writer was present many years ago when an unsightly nsevus of the upper lip was injected with a solution of persulphate of iron. The tumor solidified with wonderful quick- ness, and then afforded favorable opportunity for excision and a subsequent plastic operation to restore the lip. This suggestion was disregarded, and the patient died ten days afterward from tetanus. Excision offers a means for the cure of nsevus, especially in those that do not pulsate and are situated under the skin. The bulbous cau- tery, after applying or injecting cocaine, is applicable to nsevi on the tongue. The safest and least destructive method is electrolysis. CHAPTER XXXI. SURGICAL INJURIES AND DISEASES OF THE ARTERIES, INCLUDING ANEURISM. By Duncan Eve, M. D. Malformations and Malpositions. "Defects of development in the large arterial trunks " (Ziegler) "are of grave import." Thus, e. g., absence or imperfection of the septum of the aortic bulb, the aorta and the pulmonary artery arising from a single stem, or abnormal position of the septum, the aorta being displaced to the right or in extreme cases arising from the right ventricle ; perma- nent patency of the ductus arteriosus — a defect at one point being to a certain extent compensated for by an abnormality at another. Simple atrophy of the walls of arteries is observed in connection with general marasmus and atrophy of individual organs. After ampu- tation of a limb the arteries usually become smaller. Thrombosis. The circulation through the arteries being so active and energetic, a coagulation from stagnation is not likely to occur. A change in the inner wall of an artery is the commonest cause of thrombosis, but this is a matter of degree ; and if the circulation remains vigorous, even a considerable change of surface will not necessarily produce coagulation. When the circulation is sluggish it is more apt to occur. In atheroma, subsequently to be considered, calcareous plates are often found which, in some cases by absorption of the inner coat or its destruction or disap- pearance, come into contact with the blood-stream and result in a deposition of fibrin thereon. This is most frequently noticed in the aorta, but it may occur, though more rarely, in smaller arteries, and cause complete obstruction of them ; the consequences of which in the arteries of the brain or heart are very important or even fatal. This process is with difficulty to be distinguished from embolism, which will subsequently claim attention. Thrombi are spoken of as " (1) parietal, and (2) obstructive, accord- ing as they are attached to the wall of a vessel or occupy its whole lumen. The one kind may, of course, pass into the other, but the structure of those which are at first parietal is different from that of those which are formed by coagulation of the whole column in a vessel." "1. Parietal thrombi are always formed of successive layers. The first layer (as Zahn has observed during life in the transparent part of frogs) is formed of leucocytes with a little fibrin ; on this another layer 28 433 434 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. is deposited, and so on. For some reason, not yet understood, the suc- cessive layers are often different in color, some consisting entirely of leucocytes and fibrin, others containing red corpuscles also, producing an appearance like the structure of an agate. This laminated structure is traceable to the last in such thrombi, and is often obvious to the naked eye — for instance, in the layers of clot inside an aneurism. Some parietal thrombi are almost wholly composed of fibrin and leucocytes, and are known as ' white thrombi.' Some layers may be transparent or hyaline, but generally there is a large quantity of a finely granular substance known as molecular fibrin. " 2. Obstructive thrombi, consisting of the whole mass of the blood, will at first precisely resemble ordinary clots formed out of the body, but undergo certain changes. " These changes are : In the first two or three days the thrombus becomes firmer and drier from loss of the serum squeezed out of it in contraction. Next it becomes somewhat adherent to the wall of the vessel. Later on the blood-pigment diffuses out of the corpuscles, and the whole clot becomes tinged of a reddish-brown color from altered haemoglobin or hsematoidin. This is, however, absorbed, and the clot becomes partly decolorized, especially in the central portions. The loss of color is good evidence of the age of the clot. " What may be considered a natural or healthy end of this process is the so-called ' organization of the thrombus.'' It becomes gradually replaced by a mass of connective tissue, which either converts the vessel into a fibrous cord or else becomes channelled and allows it to become pervious again." l However, another transformation of the thrombus may occur, or what is known as softening. The fibrin and leucocytes disintegrate into a fatty mass, which forms a slimy fluid of pulpy or creamy consist- ency in the inner layers of the thrombus, and it is thus broken up. The microscope shows this to be granular matter with shrivelled and degenerated leucocytes. Rarely, the number of the cells is so great as to present an appearance very similar to pus, pus itself only developing under septic influences. The result of this softening is, that (1) the softened matter may pass into the blood without injurious consequences, the only result being that the channel of the vessel is opened up ; (2) a fragment may be carried on into some smaller vessel, which it will obstruct, forming an embolus ; (3) the matter may contain septic material (pus), producing general dis- ease or setting up suppuration or necrosis at the point where it becomes ultimately lodged. Fragments of thrombi may be detached by the force of the blood-stream, by movement or some mechanical accident without softening, and be carried off to be lodged elsewhere as an embolus. Emboli may be formed from other substances than a blood-clot. When tissues containing fat are broken down by injury or disease, drops of fluid fat enter the circulation, and may be lodged in the branches of the pulmonary arteries and capillaries. Emboli are simple or mechanical and specific, the one producing only the effect of obstruc- tion, the other general or localized septic infection. Simple obstruction 1 Manual of General Pathology, John Frank Payne, M. D., 1888. THE ARTERIES, INCLUDING ANEURISM. 435 of an artery by an embolus is generally indicated by the suddenness of the symptoms, referred to the part beyond the obstruction. In most cases the obstruction is increased by the extension of a thrombus from the embolic mass. The column of blood both in front and behind the embolism is brought to a state of rest and coagulates. This also occurs in partial obstruction. The embolus is most frequently arrested at the bifurcation of an artery, and secondary thrombi may extend into the branches. Vegetations carried away from the aortic valves, lodging in the middle cerebral artery, with or without subse- quent thrombosis, suddenly developing hemiplegia, aphasia, and other symptoms showing a morbid condition of that part of the brain supplied by this arterial branch, constitute a by no means uncommon form of cerebral embolism. In the same condition of the aortic valves there may be sudden and painful obstruction of the femoral artery, the embolus lodging at the giving off of the profunda, the limb becoming cold, pulseless, and subsequently gangrenous. " If the main artery of a iiinb be blocked," says Payne, " the anastomosis may be perfect enough to restore the circulation after a time, so that no permanent effects follow. If the anastomosis be insufficient, we get, in the external parts, gangrene." If an artery going to an internal organ is blocked, there will in many cases be sufficient lateral anastomosis to restore the circulation ; but if a terminal artery is occluded, the consequences are very apt to prove serious by reason of rapid necrosis (softening), slow necrosis (wasting), or a hemorrhagic infarction. Emboli only move in the direction of the blood-current in the arteries. The treatment of thrombosis and embolism is mainly prophylac- tic. Their thorough consideration is of importance in the treatment of surgical diseases and the pathology of the arteries. 1 In some instances the production of a thrombus is essential. Care should be taken, how- ever, in all cases that the thrombus does not give rise to embolism. The parts therefore should be kept perfectly at rest, with as slow and easy pulsation as possible, until organization or absorption of the thrombus occurs. Arteritis. Inflammation of arteries as a result of extension from the tissues adjacent is of common occurrence ; however, they are more resisting than many other tissues ; thus in hospital gangrene, now rarely seen, they are the last of the soft parts to yield to the destructive invasion, and have been often seen completely uncovered or lying loosely in a mass of necrotic and sloughing material, still serving the important purpose of carrying the vital fluid on to more distant parts. In malig- nant disease the walls of the arteries may be thickened even to the extent of occlusion by irritative hyperplasia, or blocked by clot, thus preventing serious hemorrhage in many instances as the process of ero- sion advances. It is yet an open question whether acute arteritis occurs as a primary affection. A few doubtful cases have been recorded in which severe pain and tenderness existed along the course of an artery, in some instances accompanied by a certain degree of redness and swell- ing. The diagnosis has been made, but, a favorable termination occur- ring, pathological proof demonstrating its existence is wanting. Each coat of an artery may be separately involved ; thus we have periarteritis, mesarteritis, and endarteritis, these distinctions being more For more thorough consideration of the pathology of thrombosis and embolism see P. 29 et sej., Chap. II., "Surgical Pathology of the Blood." 436 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. important in a pathological point of view than for curative treatment at the hands of the surgeon. Mesarteritis is generally an accompaniment of endarteritis, fibrous deposits taking the place of normal elements and muscular fibres as they gradually disappear in the middle coat. The changes rarely extend to the same Fig. 145. degree in the intima, but here and there the normal tissue may be com- pletely replaced by cicatricial or fibrous tissue. Periarteritis, usually secondary in character and due to extension from surrounding lesions, results in fibrous thickening and condensation of the outer coat. The thickening may be diffused or ag- gregated into coarse bands or nodes — periarteritis nodosa of Kussmaul and Maier — or destructive ulceration may occur. In destructive inflam- mation and ulceration of the arterial coats the lumen of the vessel is gen- erally occluded by a thrombus before perforation occurs. Should throm- bosis not develop, severe and some- times fatal hemorrhage may arise if the artery be of sufficient size. Acute arteritis is a rare surgi- cal disease, and is due to infectious material or to toxic embolus lodged in the vessel. The internal coats Arteritis and periarteritis nodosa ; small artery from peritoneum : 6, thin mus- cular layer; c, adventitia ; k, thrombus (Fletcher). Cross-section of same artery : a, thickened and confused intima and media ; e, zone of leuko- cytic invasion, at /merging into surrounding connective tissue (Fletcher). become swollen and infiltrated with pus-cells. The suppurative pro- cess may extend to the other coats of the artery and surrounding parts, and may result in abscess. Syphilitic arteritis may occur, either as an independent disorder or as part of a local syphilitic affection. The intima and adventitia are THE ARTERIES, INCLUDING ANEURISM. 437 thickened by fibrous hyperplasia or diffused cellular infiltration. The media may be but little altered, or here and there atrophied and fibrous. The thickening of the coats may be so extensive as to almost or entirely occlude the lumen of the vessel. Tuberculous inflammation is very common in arteries running through organs or tissues involved in tuberculous infiltration. Tuber- cles and diffused patches may appear in their walls, and if the granu- lomatous focus becomes caseous, the vessels undergo the same changes, rupturing or giving rise to hemorrhage, unless prevented by a previously formed thrombus. Patty degeneration occurs in the inner coats of arteries, especially the aorta, carotids, and cerebral arteries, developing small, rounded or angular whitish spots, which are elevated slightly above the surface, the fatty changes first taking place in the connective-tissue corpuscles, and subsequently the intermediate substance softening, the masses of fat- granules falling apart and being carried away by the blood-current, leaving velvety-looking depressions. Calcification, most frequently met with in the peripheral arteries, occurs chiefly in the middle coat, and consists of a deposit of earthy matters, mostly calcium phosphate, with a little carbonate, forming plates, rings, or tubes, known as laminar, annulur, and tubular calcifica- tions. The result is a deficient supply of blood, owing to a narrowing of the lumen of the vessel and want of contractility. When it is exten- sive enough to entirely occlude the vessel, gangrene may result. It is often readily detected in superficial arteries, as the radials, by the finger placed on the vessels, which feel hard, rigid, and Unyielding. Calcifi- cation occurs chiefly in cases where the nutrition of the cell-wall is impaired and when degeneration of tissue has already taken place. It is a very common sequel of fatty change, and also of atheroma or scle- rosis. The calcareous matter is deposited in the intima as well as the media. In the former it is mainly the atheromatous patches which become calcified, forming definite and cohering plates which may be removed entirely. When in the media the whole vessel may be con- verted into a hard and rigid tube, noticed most frequently in the larger and middle-sized arteries of the trunk and limbs, the inner surface often having a ribbed or corrugated appearance, from which, if the intima is peeled off (which may be readily done), it is seen that the ridges spring from the middle coat, the intima being more or less atheromatous. The deposit of ossific matter in the arterial coats — ossification — occurs but rarely. Atheroma, also known as arterio-sclerosis (chronic arteritis?), is a degeneration of the arteries, fatty and atheromatous, usually attended with thickening of the intima, later also of the media. It is a process common to age, when it is found attended with other evidences of senility, as the arcus senilis, atrophy of the kidneys, and general atrophy, and is an expression of involution. Atheroma occurs in two forms, nodular or localized — mostly seen in the aorta and larger vessels— and the diffused. In the iwdular form there are seen upon the inner lining of the artery grayish or yellowish elevations presenting an appearance not unlike cartilaginous plates, the edges either abrupt or gradually sloping. 438 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. In size these sclerosed spots vary from small points to that of an inch or more in diameter, and may be so numerous as to thickly stud the intima. Later, degenerative changes or necrotic softening occurs within the plates, and they are then composed of soft, grumous, molecular mate- rial, developing into atheromatous abscess, which may rupture on the sur- face of the' intima, discharging its contents, leaving an irregular necrotic area, the atheromatous ulcer, often covered with fibrinous deposits ; the final change being calcification, which may occur in the base of the atheromatous ulcer or in the plates before rupture. True ossification has occasionally been observed. The media and adventitia may be thicker than normal, the former presenting more or less calcareous infiltration. In other instances, especially when localized dilatations of the vessel are present, the middle and outer coats are thinned and degenerated. Fibrin- ous thrombi are apt to form on the ulcerated surfaces. The diffused form of atheroma is most often met with in the smaller arteries, being frequently seen in strongly-built, muscular men whose work has been laborious and who have been much exposed. The arteries are thickened and dilated, and at the same time lengthened, so that they become more or less tortuous. The intima presents spots of a dull-white appearance, but not distinct nodules ; and there may also be areas of degeneration. The subendothelial tissue is greatly thickened : and the muscle-fibres in the media variously degenerated, sometimes dis- tinctly fatty or necrotic, at other times converted into hyaline material, all resemblance to muscular tissue being lost. The adventitia is thick- ened and dense. Taking the well-known etiological factors of atheroma, dissipation, excesses, errors in diet, rheumatism, gout, syphilis, etc. and toxic conditions of the blood, thereby interfering with perfect nutrition of the intima, developing excessive and possibly defective cell-proliferation of the subendothelial tissue, and imperfect development of the endothelial cells, are of paramount consideration. Laborious work, excessive muscular effort, with or without exposure, increasing the cardiac force, also interfere with the proper nutrition of the intima. Strain is very gen- erally accepted as a sufficient cause for the production of changes in the vessels, whether it results from the repeated and sudden increase of blood-pressure incident to excessive muscular effort, or from the repeated overfilling of the blood-vessels, due to excessive alimentation of the bon vivant. Mental strain and anxiety may also have a like influence. Symptomatology. — Degenerative changes may be shown in autopsy which were unsuspected during life, owing to the mildness or indefinite- ness of the symptoms. So few of the arteries involved are within reach of tactile investigation, and early diagnosis is of such importance, that it is necessary to carefully consider even slight changes in any clinical phenomena in order to arrive at a correct conclusion. We may first find indications from the pulse : its tension may be high, although the hard- ening of the artery may amount to nothing, but sometimes we find the one accompanying the other, the radial being felt as a hard, rigid cord, which can be traced up the arm to the brachial and axillary. The pulse- wave is rather slow from want of elasticity of the vessel* the sphygmo^ graph showing a short up-stroke with broad summit, and slow, gradual descent. The loss of elasticity and increased blood-pressure may also be indicated by the tortuous character of the temporals, and sometimes by the radial and brachial. Hypertrophy of the left ventricle is early manifested by increased area THE ARTERIES, INCLUDING ANEURISM. 439 of cardiac dulness and augmented force of the systolic sound. The second sound of the heart heard over the root of the aorta is decidedly- accentuated and ringing — a natural result from increased arterial pres- sure, or, more properly, resistance. Dilatation may follow hypertrophy with its usual train of symptoms. Treatment. — It is generally accepted that organic changes in the arteries, as elsewhere, offer but little if any promise as regards curative treatment. However, Bartholow, with others, has claimed that the double chloride of gold and sodium has the power of absorbing connec- tive-tissue growth, and hence is useful in arterio-sclerosis. Others have claimed benefit from iodide of potassium, whether due to syphilitic lesion or otherwise. Billings claims that Basham's mixture, or tr. ferri alone or with dilute phosphoric acid and glycerin, has given good results ; with Huchard he also places stress upon milk as a diet. Prophylactic measures and means to stay further invasion are of greater import- ance. Of the utmost necessity is the avoidance of those diseases, habits, and customs which have been known to be productive of this condition. A quiet, well- ordered life, free from mental and bodily strain, avoidance of excesses in eating and drinking, as well as excesses in muscular exertion, are essential, together with good hygienic surroundings and a sufficiency of sleep at regular hours. Complete attention to the eliminalory organs, clean and freely-acting skin, and proper work on the part of the kidneys and bowels must not be lost sight of, and the patient should be thoroughly instructed as to the details of his daily life. If the heart's action should seem to be excessive as a result of high arterial tension, it may be modified by a cautious use of the nitrites, amyl, nitro-glycerin, etc. Bleeding may prove beneficial in some instances. When the heart's power shows indication of failure cardiac stimulants may be resorted to, but with the utmost caution for fear of rupture of the cerebral or other weakened vessels. Aneurism. An aneurism is a tumor filled with blood and communicating with the lumen of an artery. With this general definition we have several material modifications. A true aneurism is one in which the walls of the sac are formed by the coats of the vessel, of which one at least is intact. It may be sac- cular, sacculated., or sacciform, consisting of a pouch projecting from one side of the vessel and communicating by a small or large opening with the latter. It may rupture and become diffused. A hernial aneurism is one in which the inner coat or the inner and middle coats are pro- jected through the outer coat ; it may be sacculated or may rupture and become diffused. A cylindroid, tubular, or fusiform aneurism is formed by a uniform dilatation and growth involving the whole circumference of an artery ; it may rupture and become sacculated or diffused. A dissecting aneurism is one making its way between the coats of the artery ; it may be sacculated, may rupture, and be a diffused or false aneurism, and yet again become circumscribed. A traumatic aneurism is one produced by a wound, traumatism, or injury of an artery from within or without, and may be diffused or circumscribed ; or arterio- venous, constituting aneurismal varix, in which the blood is poured into an adjoining vein ; or a varicose aneurism, through an intervening aneur- ismal sac, and then into the vein. Nearly all traumatic aneurisms and all diffused aneurisms are false aneurisms, having no arterial coat around 440 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. them. Arterial varix is a simple dilated and tortuous condition of smaller arterial vessels and capillaries. Aneurisms are thus, from an etiological standpoint, divided into trau- matic and spontaneous or endogenous. They all present certain clinical phenomena in common : (1) The development of an elastic pulsating tumor, which is diminished in size by pressure on the tumor or the artery on the proximal side of it, and increased in size by pressure upon the artery on the distal side ; (2) aneurismal murmur or bruit, heard over the tumor ; (3) signs of pressure, as absorption of neighboring parts and tissues, even bone; pain' and paralysis from pressure by the tumor on adjacent nerves. Results of Aneurism. — An artery involved in aneurismal dilatation never returns to its normal state ; the dilatation, if changed at all, tends steadily to increase. The walls become thinner and weaker, and, while the irritation may develop an increase of tissue in the vicinity, it is unable to furnish an efficient substitute for the loss or attenuation of the original arterial coats. The sac ultimately gives way at some point, and in the case of aortic and other dilatations affecting the larger vessels fatal hemorrhage ensues. Fatal cerebral hemorrhage or apoplexy, and haemoptysis in pulmonary tuberculosis, may result from the rupture of minute or miliary aneurism. An untreated aneurism may also cause death by pressure on important parts, by inducing syncope or by causing gangrene. Spontaneous cure — unfortunately, a rare termination — may be effected in several ways, and the modes of treatment subsequently to be considered are but imitations of nature's methods : (1) The most frequent method is by the gradual deposit and subse- quent consolidation of laminated coagula, and is seen almost exclusively in sacculated aneurisms and arteries of the second or lesser magnitude, the dilatation forming a diverticulum in which the blood circulates more slowly, and the morbid condition of the intima in addition favor- ing the formation of a coagulum in successive layers, thus encouraging the separation of fibrin and the consequent formation of a laminated clot. Stanley observed an aortic aneurism spontaneously cured in this way. This mode of cure is imitated in the medical treatment of aneurism, as well as the surgical treatment by pressure on the cardiac side of the aneurism, by flexion, and to a certain extent by Wardrop's operation. (2) The artery below the sac may be plugged by an embolus from the previously formed coagulum, or the artery above the sac may be occluded by an embolus from the heart or another aneurism, the former being imitated by Brasdor's operation and the treatment by manipula- tion ; and the latter by Anel's method. (3) Irritation of the sac may cause coagulation within, and is imitated by direct pressure, galvano-puncture, and the injection of irritating fluids. The clot formed in this way is apt to be soft, and may subse- quently disintegrate. (4) Finally, by suppuration and gangrene previously occluding the artery and extruding the sac as a slough. This is the method of the "ancient cure," or the operation of Antyllus, which practically is an excision of the aneurism. THE ARTERIES, INCLUDING ANEURISM. 441 When spontaneous cure results the sac becomes firm and contracted, the pul- sation and bruit disappear, the circulation being carried on by collateral branches. It is only in comparatively small arteries that we may expect complete oblitera- tion spontaneously by filling up of the sac with cicatricial tissue, the formation of such tissue probably being preceded by the occurrence of a thrombus in the sac, subsequent organization of the thrombus, and the development of collateral cir- Fig. 147. Chronic endarteritis: a, media of obliterated vessel; I, elastic tunic (media); e t interna; cv } fibrous connective tissue occupying original lumen ; a', a", inflamed nerves ; n, healthy nerve ; v, arteriole with vegetating endarteritis ; set, sclerotic tissue (Letulle). culation. In large aneurisms we frequently find large, firm, laminated, partly decolorized or mottled thrombi more or less completely occupying the cavity. At various points we may find evidence of partial proliferation of the elements of the intima in contact with the thrombi, leading to the development of fibrous tissue ; but such thrombi rarely if ever undergo complete organization, affording but an imperfect defence against rupture, as the blood may find its way between the thrombus and the vessel-wall, and the thrombi may undergo softening, disintegra- tion, and even liquefaction ; sometimes calcareous salts are deposited, and they become calcified. In rare and occasional instances of fusiform or tubular aneurisms, even in comparatively large arteries, observed principally in the aorta and the larger branches, laminated thrombi may also entirely fill the cavity of the aneurism, leaving a canal for the passage of the blood, and by hyperplasia and hypertrophy the different tunics become greatly thickened and increased in strength and density, the effect of gradual and long-continued interstitial deposits of fibrous tissue, resulting in spontaneous cure. Etiology. — The development of an aneurism is due invariably to pre-existent disease or injury of the arterial coats, sclerosis or atheroma being the commonest cause. Sacculations are especially apt to occur when the intima and media are simultaneously affected by active disease or degeneration. Affections of the adventitia may lead to aneurism when they are such as extend to the media and occasion muscular degeneration there. These conditions all diminish the elasticity and strength of the arterial wall, so that the pressure of the blood causes it to stretch and give way. We usually find the intima wanting or highly atheromatous, the muscular elements of the middle coat being lost altogether or fatty and degenerated, the elastic fibres showing granular 442 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. change. The intima or media, or both, may here and there be wanting entirely, while the adventitia is usually thickened and infiltrated with a\ %?■■ Six- '-^' &. ■ - -**-«~.--.-.\»*r . 'Times fll. Aneurism of an artery from the pia mater, of mycotic-embolic origin : a, adventitia ; h, hyaline intima covered with thrombi ; r, red thrombi (Eppinger). exudations. According to the Ponfick, 1 emboli consisting of calcified endocarditic vegetations may lodge in the wall of an artery — possibly of the brain, for example : there they work or bore their way into the tissue of the wall until it at length gives way and a sacculation is formed. Age has an important influence on the occurrence of aneurism. We find by far the majority of cases occurring about the middle period of life, the decade from thirty to forty years of age being that in which we have by far the greater frequency of occurrence of atheromatous degeneration, while at the same time the heart has not lost any of its impulsive force ; there are more frequent calls upon the entire muscular development for periods of increased and extraordinary exer- tion, and when the degenerated vessels, enfeebled and inelastic, becoming exposed to powerful causes of distention, may readily give way or be dilated at some one weakened point. After the age of forty the heart's action, as well as general muscular force, gradually becomes weakened, and we find the frequency of occur- rence gradually decreasing. Aneurism is rare before the age of puberty, the few occasional cases being rather surgical curiosities. Erichsen says that "Syme mentions a case of popliteal aneurism in a boy of seven ;" Hodgson had a prepara- tion of a carotid aneurism in a girl of ten, and Schmidt a case of spontaneous aneurism of the radial artery in an infant eight weeks old. E. W. Parker, after a careful search of medical literature, only found 15 cases recorded as occurring under the age of twenty. Gross says that " men suffer from aneurism more fre- 1 Virch. Arch., vol. lviii. THE ARTERIES, INCLUDING ANEURISM. 443 quently than women, but in what proportion has not been determined." The same principles influenced by age govern sex. Occupation also has its bearing, and we find a greater frequency of occurrence in those subjected to occasional over-exertion of muscular and cardiac force. Climate also has its influence, and we find a greater frequency in cold than in hot countries : it is not so much locality and meteorological influences, however, as it is the habits of the people that predis- pose to it. Cachexy, induced by any cause, as syphilis, rheumatism, gout, errors and excesses in diet having a tendency to develop structural changes in the arterial coats, is of importance as a factor. Embolism is an occasional cause, noticed most frequently in the popliteal artery, producing first obstruction in the calibre of the vessel, and then softening, disintegration, and dilatation of its walls. The direct and exciting causes are limited to bloivs, wounds, violent muscular strains, or increased cardiac impulse even from mental excitement or other causes. The degenerated coats may give way under the influence of a direct blow or concussion, or severe muscular exertion or inordinate force of ventricular contraction unduly stretching the inelastic vessel. Varieties. — Various classifications have been observed by different authors. I can but regard the following as being full and complete, and more in accordance with the general features presented, simple, and readily understood : 1. Sacculated or Sacciform Aneurism : This may result in — A. Hernial aneurism; B. Diffused aneurism, the latter being a form of False aneurism. 2. Cylindrical, Tubular, or Fusiform Aneurism. 3. Dissecting Aneurism : This may become — 1. Sacculated ; B. Diffused and false aneurism. C. Circumscribed aneurism. 4. Traumatic Aneurism. This may be — C. Circumscribed, ~\ t\ i t ■ ' f f. Aneurismal varix, > e. False aneurisms. D. Arteno-venous, < J TT . ■ ' ' [ g. Varicose aneurism, 5. Arterial Varix and Cirsoid Aneurism. 6. Aneurism by Anastomosis, or Angeioma. (1) Saccular Aneurism. — Of the two grand divisions, according to this classification, we find the saccular the most frequent. It essentially consists of a formation of a pouch, bag, or sac connected with the side of the aifected artery. It may even develop from some point of a cylin- drical or tubular dilatation or aneurism. It is capable of assuming a great variety of forms, the most common being globular or ovoid — in rare cases, conical, elongated, or irregularly flattened. It may vary materially as regards dimensions, in some instances not being larger than a hazel-nut ; in others it is as large as the fist or even the head of the patient; in general, however, so long as it remains a simple saccu- lated aneurism it is not larger than an orange. l-i AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The attachment of the tumor to the artery is commonly by a narrow footstalk, t in some instances it is by a broad and extended base, in which case it is not usual for the artery to suffer serious compression during the progress of the mor. The orifice of communication in the first method of attachment is pro- rtionately small, with smooth and well-defined margins. In the latter it is ivays much larger, its edges irregular, sometimes quite shreddy and ragged, as if b vessel had been rent or torn. The internal and middle tunics may terminate ruptly at the margins of the sac or may extend into its cavity, and serve for, at ist, a partial lining. By the rapid proliferation of tissue in the adventitia and idia there is usually such a blending of the various elements that the separa- m of the several coats in an aneurism of large size becomes very difficult if not possible. So long, however, as the external coat remains intact, it may be ;arded as a simple sacculated tumor. The first thing that happens is the loss of tensile strength of the middle coat rough pre-existing disease of it and the intima, or possibly a rent, fissure, or ;vice, which gradually enlarges under the influence of the impelling current of x)d, and thus permits the corresponding portion of the elastic adventitia to be nverted into a pouch. This pouch, originally composed exclusively of the adven- ia, would be very weak and unable to withstand the shock of blood driven into Nature, however, comes to the rescue, and under the influence of irritation, used by pressure of the developing tumor, pours out both in the adventitia and jacent tissues plastic matter : this effusion rapidly becomes organized, blending e tissues together in a firm and more resisting mass. Under the same influences ere may be more or less proliferation of the muscular elements belonging to the sdia, as well as, in some cases, the interior being lined, if not with a perfect, yet fair ensemble of the intima. " Such aid, then," says Gross, " is wise and need- 1, and, fortunately, always comes into play at an early stage of the disease," the elding of the arterial coats, the pressure of blood within, and the pressure of the mor on adjacent structures developing sufficient irritation from the rapid effu- m of plastic exudates and the proliferation of cellular and other elements. 'oss further says: "When the periosteum contributes to the formation of the c, as it occasionally does in aneurism of the thoracic aorta, the walls of the tumor ay be partly earthy, or even partly osseous." The sac varies in thickness, in different cases and under different nditions, from the fourth of a line to the fourth of an inch thick, or ■en thicker, at some points as the tumor develops the sac becoming uch thinner than at others. Usually the sac is quite tough, and in ses of long standing is composed of various strata, grayish, whitish, ■ drab-colored, consisting of fibres intersecting each other in all direc- Dns. The outer surface is rough and irregular ; the inner, if at first nooth, subsequently becomes rough and encrusted with fibrinous con- etions. Notwithstanding the thickness of the sac and the reparative fects of nature by means of plastic exudation, owing to the absence • deficiency of the muscular fibres it gradually dilates under the con- aued influence of the inflowing blood-stream, and at one or more points anifests a disposition to yield, and at length gives way, the activity ' the absorbent vessels, according to some writers, exceeding those of pair. The sac always contains, even at an early period of formation, fibrinous masses, at not only strengthen the tumor, but aid in its obliteration, and in rare instances i spontaneous cure. They are arranged in concentric layers or lamina? piled one )on the other, and closely connected with one another and with the wall of the c. Their color and density vary according to age of development, the outer and der being pale and yellowish and of a firm, fibrinous consistency, while the inner ies, of more recent date, resemble very much an ordinary blood-clot ; in thick- iss they range from one-fourth of a line to that of a sheet of paper, and may imber several hundred in an aneurism the size of an orange. The diminished ovement of the blood in the sac, and the altered conditions of the sac-wall jm that of normal endothelium, cause the deposition of fibrinous material in PLATE XVII. Large Aneurism of Aorta, showing Lamination of Clot in the Effort at Consolidation. (Specimen in Museum of the Medi- cal Department, University of Buffalo.) THE ARTERIES, INCLUDING ANEURISM. 445 which are entangled both white and red blood-cells, and, as the fibrin contracts after deposition, the red corpuscles are squeezed out or disintegrate and again mingle Fig. 149. ifv i.) ,*y? « j .V A , > r ,,., : \x k( ;S *» ■ Multiple aneurisms of the mesenteric arteries (Eppinger). with the fluid blood, the leucocytes, or a part of them, and the fibrin remaining, to subsequently become organized into a lamina. In the older layers no corpuscles are distinguishable, but much fatty and granular matter is found, the result of their disintegration. In fusiform aneurisms, in which the flow of blood is rapid throughout the dilatation, adhesion takes place with difficulty, while in sacculated aneurisms, the movement of the blood being retarded, laminated fibrin is nearly always deposited. It will afterward be shown that modes of treatment by which the flow of blood in the sac is retarded are of the greatest importance. (A) Hernial aneurism, or aneurismal hernia, is of so rare occurrence that its existence has been questioned. Among the older writers, Haller, Dupuytren, Breschet, and others have given particular descriptions of it. It is saccular in form : the outer and middle coats having yielded to erosive or other destructive action, the inner coat is pushed out in the form of a thin translucent cyst. Pressure on adjacent tissues occasions interstitial plastic deposits, strengthening the sac. Soon, however, under the influence of continued blood-pressure from within, it will burst and result in a diffused or circumscribed hemorrhage, Avhich subse- quently may be walled in by adventitious material, forming (rts of the surgeon at reduction. (C) Circumscribed Traumatic Aneurism. — The blood, extravasated as >ve, may become surrounded and limited by plastic exudation ; this gradual development of fibrous tissue, after the nature of cicatricial sue, may be sufficiently firm to prevent further diffusion, but not THE ARTERIES, INCLUDING ANEURISM. 447 strong enough to resist the distending force of the cardiac contractions, and it steadily increases in size — not by a process of stretching, as it does not become uniformly thinner in proportion to its increase in size, but by a constant growth of new fibrous tissue. As the aneurism in- creases, however, the growth of fibrous tissue becomes less perfect, and eventually too soft to withstand the pressure of the blood, and the sac may rupture and the aneurism again become diffused or fatal hemor- rhage result. Circumscribed traumatic aneurism most usually occurs from injuries to the smaller arteries, as the temporal, facial, palmar, plantar, radial, and ulnar. Another form of circumscribed traumatic aneurism occurs but rarely, and is due to a small puncture of a large artery, as the carotid or axil- lary. At first the hemorrhage may be quite free, subsequently arrested by pressure ; the external wound as well as that in the arterial coats may heal by cicatrix. This, being weaker than the normal arterial tis- sues, may, after several weeks or months, yield to the pressure of the blood, and a distinct sac, formed by the yielding of the cicatrix in the external coat and the arterial sheath, results, with no effusion of blood into the surrounding tissues, this being the only form of traumatic aneur- ism that possesses the features of a true aneurism. Fig. 150. Traumatic aneurism of axillary artery (Park). (B) Diffused traumatic aneurism exists when the blood forced out is only limited in extent by the resistance of the surrounding tissues and coagulation in the network of areolar tissue. It has no sac, its boundary is ill defined, and it has a constant tendency to extend under the pres- sure of the fluid blood, which is continuously forced into the interior of the mass. (D) Arterio-venous Aneurism. — In former days, when general vene- section was so frequently resorted to, it was by no means uncommon for 448 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. the adjacent artery as well as the vein to be wounded. When a con- tiguous artery and vein have been perforated, Fig. 151. adhesion may take place between the two ves- ted sels at the site, the communication between filfeki, I hi them remaining pervious; a portion of the arterial blood is thrown directly into the vein at each pulsation, the vein being dilated into a fusiform pouch with thickened coats. Com- municating veins may also become enlarged, nodulated, tortuous, and thickened, constitut- ing (/) aneurismal varix. In some instances the openings in the artery and vein are not directly in communication, and a diffused or circumscribed aneurism, with its sac formed by plastic effusion and develop- ment of fibrous tissue, is formed between the two vessels, into which the blood is poured before reaching the interior of the vein, form- ing a varicose aneurism, which is a traumatic aneurism to which is added the conditions of aneurismal varix. In some instances the open- ing into the vein becomes closed, and the tumor is converted into a circumscribed traumatic aneurism. (5) Arterial Varix and Cirsoid Aneurism. — This is a peculiar dilatation occurring in the scalp, and next in frequency in the hand, although other parts, as Arteriovenous aneurism at bend of elbow : a, brachial artery ; b, radial artery ; c, basilic vein ; d, median basilic vein ; c, an- eurismal sac; /, dilated vein (Lenoir). Fig. 152. Cirsoid aneurism (Bruns). the tongue, viscera, bones, etc., may be involved. The artery is THE ARTERIES, INCLUDING ANEURISM. 449 dilated, elongated, and tortuous, very much like a varicose vein. True aneurismal pouches sometimes form as large as the end of the finger or thumb. If a single artery is involved, it is known as arterial varix, and if a number of arteries, held together by connective tissue, are so affected, it is termed cirsoid aneurism. The structure of the arterial walls in the beginning shows no change, although subse- quently they become thinned during the process of dilatation and elong- ation. Some authors have argued that this is not properly an aneurism, but, having some of the peculiarities pertaining thereto, it is deemed best to consider it in connection therewith. It is especially the middle coat which is most affected, becoming pale, soft, and thin, the artery now resembling a vein in structure. The dilatation is commonly sym- metrical, so that the circumference of the artery is uniformly dilated ; in other cases, however, this not being the case, we have pouches and unequal saccular dilatations. As the artery elongates it becomes tortu- ous and serpentine, sometimes even spiral. It is rarely limited to a single trunk, several trunks and their branches being involved. These growths rarely occur in infancy, generally making their appearance in early adult life as the result of a bruise or injury, causing, as some sup- pose, a paralysis of the vasomotor nerves. The tumor is irregular in shape, compressible, bluish in color, and pulsating. (6) Aneurism by Anastomosis, or Angeioma. — While not properly a neoplasm, but rather a morbid change affecting a vascular area in which the arteries become dilated and convoluted and the intervening tissues subject to atrophy, its consideration here is proper, although by some it is not considered as an aneurism. The tumor pulsates, and feels under the fingers like a knot of moving worms. In some instances it originates in congenital defects, and at times leads to erosion of bone ; in other cases it is evidently the result of mechanical injury. The walls of the dilated arteries are thickened. It differs from cirsoid aneurism in that the capillaries are dilated and the skin is involved. It will generally be noticed that the arteries leading up to it, though at a considerable distance, are tortuous and dilated, with thin and distended coats, pulsating forcibly, constituting the condition of cirsoid dilatation. The temperature of the part may be somewhat elevated. Symptomatology and Diagnosis. — The leading symptoms in exter- nal aneurisms are usually sufficient for a ready diagnosis. The devel- opment of a tumor in the course of an artery, ovoid or globular, except in the case of diffused or tubular aneurisms, soft and elastic to the touch, is usually well defined. This, if taken in connection with pulsa- tion and a well-marked bruit, forms pathognomonic phenomena not likely to be mistaken for anything else. However, if the tumor is not of recent formation, it may be firm and resistant from accumulation of more or less organized coagula within and density of the sac. The fluid nature of the contents is usually perceptible. A cystic or other tumor, located over the course of an artery may receive an impulse therefrom, which, however, would be likely to disappear if placed in a dependent position, or, if it is lifted up from the artery, the impulse in such case being more of a lifting, heaving character, in a line drawn from the centre of the artery to the centre of the most salient point of the tumor ; while in aneurism it is eccentric, expansive, and centrifugal, being felt 29 50 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. nth almost equal force over the entire circumference of the tumor. In ase of a tumor over a large artery the impulse usually increases with tie size of the tumor, and in aneurism it naturally decreases. In grasp- ig the tumor between the ends of the fingers applied to both sides its xpansive character in aneurism is quite apparent. The^pulsation is lore forcible in an aneurism in which' there is but little laminated brin, and as this increases the pulsation loses its expansile character, eing converted into a dull thud, and in some cases is lost entirely. V"hen pulsation is ill denned it may be increased by elevating the limb r compressing the artery below the tumor. Firm pressure above the amor will cause the pulsation to cease, and the size of the tumor may e somewhat reduced by pressure at the same time over the tumor, 'aking the pressure from the artery suddenly, the blood will rush into be tumor and distend the sac by a sudden stroke more or less expansile i character. The bruit or murmur accompanies the pulsation, and may vary mate- ially in different instances, as was first noticed by Ambrose Pare, and i caused by friction and ricochetting and tumult of the blood passing lto and out of the dilatation. It is usually loud, rasping, and blowing -loudest and roughest in tubular aneurisms. Occasionally in sacculated neurisms the bruit is double, and in cases of aortic regurgitation we lay have a diastolic murmur in fusiform aneurism from the backward ow of blood in the large vessels. In many cases the bruit is entirely r occasionally absent, especially in sacculated aneurisms with small louths, in those that are distended with coagula and blood, and in more uiescent states of the circulation. In the latter case exciting the circu- ition by muscular exertion or otherwise may develop a bruit that at ther times may not be detected. Elevating the limb may slightly xluce the quantity of blood in the sac, and render perceptible a bruit jo feeble to be detected otherwise. Pressure over the artery leading to le sac will usually cause cessation of bruit. The skin over an aneurism may be healthy or natural in color, though i is stretched : as the aneurism grows it may become discolored, thinned, ad even ulcerated, and suppuration may occur in the subcutaneous reolar tissue. Muscular weakness, stiffness of the part, and a tired ?eling are accompaniments. Venous congestion and oedema from compression of the deep-seated eins, and in some cases a varicose condition of the superficial veins, nd even gangrene and superficial sloughing from obstruction to the 3turning circulation, are among the effects sometimes present, the tend- ocy to gangrene being increased by the pressure of the sac upon its own r neighboring vessels. Pressure upon nerves not only gives rise to mcinating pain, but also to interference with the functions of important arts, as hoarseness and spasmodic dyspnoea from compression of the ecurrent laryngeal, dyspnoea and uncontrollable eructation from pres- ure on the pneumogastric, and facial paralysis, deafness, ptosis, strabis- ius, and blindness in cases of intracranial aneurism. Pressure upon screting glands or their ducts may cause trouble from interference with lieir functions, death from asthenia and progressive emaciation having ccurred from pressure upon the thoracic duct prior to rupture of the ac. Serious consequences may ensue from pressure upon important THE ARTERIES, INCLUDING ANEURISM. 451 viscera, or dyspnoea and cough from compression of the trachea, bronchi, or lungs ; dysphagia from pressure on the oesophagus ; or hemiplegia as a result of an intracranial aneurism. Serious consequences result from pressure upon bones and joints ; the flat bones, as the ribs and sternum, and even the bodies of the vertebrse, may be eroded, or caries and destruction of an articulation may ensue. The erosion of bone by an aneurism is usually attended by a distressing sensation of boring or burning pain, as in the vertebral column in cases of aortic aneurism. When an aneurism becomes diffused by rupture of its sac the tumor loses its defined outline, rapidly becomes much larger, and the pulsation and bruit may become weak or disappear. The part becomes cedematous, cold, and livid from venous congestion ; pain is suddenly increased, and syncope may occur. The swelling becomes hard from coagulation, and in some rare cases consolidation of clot, condensation of areolar tissue, and plastic effusion may limit its further extension, and so grave a result has resulted in spontaneous cure. Generally, however, the swelling increases, with or without pulsation, and the case ends in gangrene or external hemorrhage from giving way of the superjacent tissues. In other cases rupture of the sac leads to wide extravasation of blood into the tissues, with shock and pain, faintness and syncope from loss of blood from the general circulation, and death at no distant day from exhaustion or gangrene. Diffused traumatic aneurism is, as Gross remarks, a collection of blood in the tissues of the part, differing only from a wounded artery in there being no exter- nal communication. The diagnosis can usually be readily made by reason of the oblong, somewhat pyriform swelling, elastic and fluctuating, and, if the opening into the artery is large, we may have well-marked pulsation, thrilling, purring or jarring, and bruit, although in some cases one or both may be wanting ; the pul- sation of the artery beyond the wound is either diminished or wanting. At first the skin over it is natural in color, but gradually becomes bluish, and thinned by pressure. Circumscribed traumatic aneurism in the clinical phenomena presented differs but little if at all from the forms already given. In all cases we may expect to find the pulsation in the artery beyond the aneurism diminished. General Treatment. — Measures to prevent further increase of the dilatation, the formation of organized coagula, and the obliteration of the sac pertain to the domain of therapeutics as well as surgery, and surgical means may be greatly enhanced thereby. In some instances they constitute the sole reliance, the object being, first, to lessen the force of the cardiac impulse, and so diminish the eccentric pressure of the blood ; and, second, to modify the condition of the blood so as to dispose 1x> the deposition of fibrin. Perfect rest, in bed if possible, and a limited diet, avoiding irritation or indigestible food and stimulants, with a restricted quantity of liquid, as well as mental quiet, are of the greatest importance. Iodide of potassium, from its effect of increasing the deposition of fibrin, has been largely used by various reliable observers, and it has evidently been productive of good even in cases not due to syphilitic disease of the artery. Given in doses of from 5 to 30 grains three times a day, alone or combined with the bromides, suffering has been relieved, there has been diminution in the size of the sac, and in some cases a cure has been apparent. Operative Measures. — First in importance is ligation, whether by the 452 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. " old method " of Antyllus, extirpation and ligation of all vessels be- longing to the sac ; Anel's operation, or proximal ligation in the imme- diate vicinity of the sac ; Hunter's method, or proximal ligation at a distance from the sac ; Brasdor's procedure, of distal ligation below the sac ; or Wardrop's modification of the same, by ligature of one or more of the principal branches given oif from the artery below the sac. In all cases a proper preparation of the patient by rest, attention to diet and the emunctories, should not be lost sight of, and an effort to estab- lish in advance the collateral circulation by compressing for a few hours daily the artery involved should not be neglected. Dr. Joseph Kansohoff of Cincinnati, in a short paper contributed to the Am. Med. Ass'n., June, 1893, on "Extirpation of Aneurisms," gave the following con- clusions : " 1. Extirpation is the ideal method. It should be resorted to unless there are weighty reasons against it. " 2. In aneurisms of the forearm and legs no other method should be adopted. " 3. Aneurisms which have suddenly grown large from subcutaneous rup- ture of the sac, and those in which rupture is pending, should be subjected to extirpation. "4. In recent traumatic aneurisms the injured vessel should be divided be- tween ligatures ; when a sac has formed it should be excised. "5. When other methods have failed, extirpation should be tried before resort is taken to amputation. "6. In arterio-venous aneurisms extirpation should be practised if any opera- tion is indicated. " 7. Proximal ligation is to be reserved for cases of idiopathic or spontaneous aneurisms in which the age of the patient or an enfeebled condition from other causes would make a prolonged operation hazardous, and for cases in which the position of the tumor precludes the possibility of extirpation." Nearly forty years ago Mr. Syme suggested that in aneurism of the carotid, axillary, gluteal, and iliac arteries, in which the Hunterian method is not admissible, the sac should be freely opened, its contents turned out, and the artery ligated above and below. In several in- stances following the suggestion he was brilliantly successful, the last one being an aneurism involving the external iliac, his incision into the sac extending for six inches, and six pounds of blood and fibrin were turned out; the common, external, and internal iliacs were ligated, with recovery of the patient. As regards effectiveness, extirpation has many advantages, but is, unfortunately, not admissible in some cases. Hunter's method, although claimed as a modification of Anel's, but originated independently, is next in value. One of its advantages over the latter is that we are more likely to find sound arterial tissue at a distance from an aneurism than in its immediate vicinity. These two methods, as well as extirpation, are often excluded by reason of the site of the aneurism and the vessel or part of it involved. In ligation in the immediate vicinity of the sac we are less apt to have maintenance of the circulation in the tumor by development of the collateral circulation, and as a result rapid but imperfect coagulation. In the Hunterian method we may have secondary hemorrhage at the site of the ligation, return of pulsation from too free development of collat- eral circulation, including the sac, sloughing of the sac, and gangrene of the limb. Brasdor's operation aims to produce entire arrest of circulation in the sac, and Wardrop's modification a partial arrest. In addition to the THE ARTERIES, INCLUDING ANEURISM. 453 (same risks pertaining to Hunter's method, we are liable to have further distention of the sac or rupture of the sac or artery. It is limited to particular cases, as aneurism at the root of the carotid or of the innomi- nate. The conditions and relations of each particular aneurism and the vessels involved are to be thoroughly and carefully considered, and the most suitable method resorted to. Ligation is indicated in cases in which the trouble is active and pro- gressive, in locations in which pressure and flexion are not applicable, in any cases in which other less dangerous modes have been tried unsuc- cessfully, in cases where a sacculated aneurism has suddenly become diffused or opened into an articulation, or where it has opened or is about to open externally, and in traumatic aneurisms. It is contraindi- cated when other methods, as pressure, flexion, etc., offer a reasonable hope of core ; in the presence of any complication, as extensive cardiac or arterial disease ; the prevalence of erysipelas, which would likely affect the wound, or other circumstances incurring too great a risk ; and by the locality of the aneurism being such that from the proximity of anastomosing branches or from any other cause the operation would be unsuccessful. Multiple aneurisms, though usually, are not always a contraindication : two aneurisms occurring in the same artery may be cured by the single operation, or a double popliteal by operation on both femorals. Their occurrence, however, suggests extreme caution. Recurrent pulsation usually occurs after ligation within twenty-four hours, though sometimes not for four or five weeks, and still more rarely at an interme- diate period. It usually disappears as consolidation takes place, though a fatal result may occur from sloughing of the sac. It is generally satisfactorily treated by elevating the limb, with moderate pressure over the sac. Enlargement of the sac without pulsation may result from reflux of blood on the distal side. If exces- sive, it may lead to gangrene, but generally coagulation occurs, converting the aneurism into a solid tumor. The treatment of hemorrhage at the point of liga- tion, sloughing, or rupture of the sac is by elevation of the limb, careful pressure, mechanical or digital ; this failing, cutting down on the bleeding point and liga- tion above and below, or ligation of the main artery at a higher point, or amputa- tion, must be resorted to. Suppuration of the sae may occur in from a few days to several months after ligation. We first have heat, pain, pulsation, and discol- oration of the skin : the latter, becoming thinned, at length gives way, and the contents of the tumor, softened, broken down, and mixed with pus, are discharged through the aperture in the form of a dark, purplish- brown fluid mixed with masses of soft dark coagula or drier laminated fibrin. The escape of this matter may be accompanied by a sudden gush of fluid arterial blood, carrying off the patient at once, or it may occur in small quantities, ceasing and recurring from time to time, grad- ually producing fatal exhaustion. It is most liable to take place between the third and eighth weeks, though in one case recorded by Sir A. Cooper it took place so late as the eighth month. If unaccompanied by hemor- rhage, it requires only the treatment of an abscess, proper precaution being made to arrest hemorrhage should it occur during evacuation. If accompanied by hemorrhage, the case is quite serious. Evacuation of the sac by free incision, clearing out the cavity, and packing with iodo- form gauze, held in place by graduated compress and roller bandage, may serve to permanently arrest the flow of blood, and will in all events give 454 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. time to resort to more effectual means if needed. Ligation of the bleed- ing vessel is of doubtful utility ; the softened and disintegrated vessel would be apt to give way. A ligature applied nearer the centre of cir- culation also is doubtful in its results : the circulation below, already embarrassed by the previous ligature and by suppuration and distention of the sac, may be so interfered with as to result in gangrene, or else the collateral circulation, if of sufficient activity to maintain vitality in the parts beyond the sac, will also keep up the hemorrhage from the artery or the sac. More certain results are offered by amputation of the limb if the aneurism is so situated that it can be done, or control of the hemorrhage by means of the actual cautery in other cases. Compression as a means of cure may be instrumental or digital — directly over the tumor or indirectly over the artery above or below (proximal or distal), or by means of the elastic bandage. In either event proper and careful precautions to favor occlusion should precede and accompany the effort. The irritability of the heart and general system should be controlled by anodynes and sedatives, and the patient placed in a comfortable bed and his position secured by well-adjusted pillows and mattresses. In irritable and uncontrollable patients it is not advisable. Various instruments for this purpose have been devised, or the sur- geon may improvise one to suit the special indications of the case. Direct pressure, for obvious causes so dangerous and uncertain, and distal pressure, are now rarely resorted to, but both may prove valu- able adjuncts to proximal compression. Before applying the instru- ment the part should be well shaved and dusted with talcum or other powder, and if an extremity is involved a soft roller should be carefully applied. In order to keep up continuous pressure, at the same time prevent the skin from being chafed or the soft parts beneath the pad from sloughing, it is best, if applicable, to adjust two instruments, the one above the other, a little distance apart, so that one can be tightened and the other temporarily loosened. The more continuously the pressure is kept up the greater certainty of effective results. It must be main- tained carefully for a variable period. In some instances the tumor has solidified in a few hours, in others in two or three days, and it has been protracted from time to time for two or three months before cure has resulted. Barwell gives the longest period at seven weeks, and the shortest twenty-four hours. In all cases of instrumental compression it is well to secure complete distention of the sac by a few minutes' distal compression. Careful elastic pressure over the sac during the whole course of treatment bv compression is advised. Compression has its disadvantages. It is sometimes unbearable by reason of pain, tedious in protracted cases, and occasionally fails. If venous congestion, great oedema, and pain are markedly increased, it should be abandoned if satisfactory results are not obtained in three or four days, and in exceptional cases in even a shorter time, and the Hunterian or other method resorted to. In the event of its failure the chances of cure by ligation may have been enhanced by the partial or complete development of the collateral circulation while being tried. The elastic bandage and tourniquet have been successfully used in some THE ARTERIES, INCLUDING ANEURISM. 455 cases of aneurism of the extremities. The bandage is tightly applied from the fingers or toes up to the aneurism, lightly over the sac, and tightly again above it; then the elastic tourniquet is secured, which should be removed before the bandage, and instrumental or digital compression kept up for three, six, or twenty-four hours afterward, even if all pulsa- tion in the tumor has ceased. The elastic bandage should be kept on for about an average of one and a half hours : it has been kept on for three to five hours without serious results. The limb must be kept warm by enveloping it in wool and the application of external heat to about 100° F. If the bandage be kept on longer than an hour, an anaesthetic or a full morphia hypodermic may have to be used. It effects a cure by causing stasis of blood in the sac and adjoining portions of the artery. It may fail from want of coagulability of the blood, and may result in gangrene from blood-stasis in the limb, venous thrombosis, or embol- ism from subsequent washing away of the clot or a part of it. It is not applicable to aneurisms that are large, have thin walls, containing fluid blood with no laminated clot, or are rapidly increasing in size. Flexion, by bending the limb on itself, is limited to arteries low in the popliteal space or below in the leg, or in the arm below or at the bend of the elbow, and is further limited by pain and the insupportable annoyance due to confinement of the limb in one position. Although occasional temporary relaxation has been permitted, it has sometimes even then effected a cure. The limb is carefully bandaged as high as the knee or elbow, and then the extremity forcibly flexed upon the joint and maintained in position by a few secure turns above the joint or secured by a strap. It should be kept up for several days or a week or longer, and may precede or alternate with digital or instrumental compression in suitable cases. Galvano-puncture, first employed by Phillips some sixty years ago, was but little resorted to until recently, when it has been warmly advo- cated by French and Italian surgeons, the object being to decompose the blood in the sac by means of galvanism, and thus secure its coagu- lation. Injections into the sac of perchloride of iron, ergot, and other reme- dies have been used in some cases with success, but the dangers from inflammation, gangrene, rupture, and embolism are far too great. Manipulation, by kneading and squeezing the tumor in order to break up coagula that may have formed with the hope that a fragment may effectually plug the distal side of the artery, is both dangerous and uncertain : the embolus is not under control, and may lodge where it will do serious injury. Esmarch, Teale, and Tillaux have mentioned such results from the necessary manipulations during the examination of an aneurism. Acupuncture and the introduction of foreign bodies from without, coils of horsehair, catgut, and iron wire, to secure the formation of coagula, are also of questionable propriety, and should never be resorted to if more certain methods are available. Macewen's method of irritating the interior of the sac by means of a sharp needle, and thereby inducing the formation of white thrombi, has sometimes proved successful, the effort being to induce infiltration of the sac-wall with leucocytes from the blood-stream, and their segregation at the Doint of irritation. 456 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The irritation should be evenly applied over as much of the interior of the sac as possible, and at times, the needle being held lightly with its point impinging on the opposite surface so as to allow the current of blood to play on it, shifting to other positions at intervals of a few minutes. The time required to irritate the entire sac varies from a few hours to forty-eight hours. It may be necessary to repeat the operation at intervals for weeks or even several months. The latest suggestion in the way of treatment is subcutaneous injection with a 2 per cent, solution of gelatin in normal (6 per mill.) salt solu- tion. From six to eight ounces have been introduced at one time, and repeated as often as necessary to accomplish coagulation. This method is only of value, however, in sacculated aneurisms. It depends for its success upon the increase in coagulability of the blood which the gelatin produces. (It has been suggested also to utilize this property by using similar injections for relief of haemoptysis.) It is not without its danger, nevertheless, and at Iteast one patient has died after its use. Fig. 153. Thoracic (aortic) aneurism (Park). Special Aneurisms. — Thoracic aneurism presents symptoms that are far from uniform, being due to pressure upon surrounding struc- tures, and influenced by location, form, size, rapidity of formation, and direction of growth ; being liable also to materially change during its progress. The symptoms are not in proportion to external manifesta- tions : the more an aneurism tends in an inward direction, the greater the degree of suffering and disturbance, which may be intensely aggra- vated prior to any external manifestations. In some cases these may be very indefinite, with no physical signs whatever. Erosion of the THE ARTERIES, INCLUDING ANEURISM. 457 sternum or ribs occurring, it may be readily apparent. Abnormal local sensations are usually present, such as pain varying in character and intensity ; heat, weight, and fulness with throbbing ; cutaneous tender- ness and hyperesthesia being common. When pressing backward the pain may be gnawing or grinding, owing to destruction of the vertebrae. Pressure-symptoms, occasioning interference with nervous and other functions, are to be closaly studied. Aphonia, dyspnoea, or dysphagia may be manifested earlv or late. The general system may suffer mark- edly, and we may sometimes have a striking appearance of illness, com- bined with anaemia or a sallow, cachectic look, distressed and wan expression, without positive diagnostic phenomena. Gastric disturb- ance from pressure upon the pneumogastric or sympathetic nerves, and dysphagia, if oesophageal stricture and organic disease can be eliminated, are important symptoms. Head-symptoms with disturbed sleep may also occur. Local bulging is dependent upon the site involved. If in the as- cending or transverse portion of the arch, the prominence will be in front and to the right or left of the manubrium, occupying the re- mainder of the arch and the descending portion ; the bulging will be posteriorly, generally to the left of the spine and occasionally to the right, and may become quite extensive. In shape it tends to be rounded and conical, and involves the ribs and spaces equally. Pul- sation, if expansile, heaving, and throbbing, with or without enlarge- ment, and synchronous with the cardiac systole, is an important sign : it may be markedly undulatory, and sometimes a thrill is felt ; it is some- times double, and occasionally is mainly diastolic. If the patient is made to sit up with the head inclined forward, and the cricoid cartilage is grasped firmly between the index finger and thumb and drawn forci- bly upward, putting the trachea on the stretch, a distinct and well- marked tugging sensation is felt, originally described by Surgeon-major Porter as tracheal tugging. Dulness upon percussion of a dead, putty- like character, extending beyond the cardiac areas, may be elicited over an aneurism, which is also to be discriminated from other mediastinal growths by exclusion or other characteristic phenomena. This is but one link in the chain formed by other symptoms. Auscultation may reveal nothing or only indefinite sounds. The most important is a rough murmur, usually systolic, sometimes double, and in rare instances only diastolic. Gross says that " it is more like the purring of a cat than the clear murmur of the first sound of the heart, and it is still further defined by the presence of a peculiar tremor or vibratory movement." In the treatment little is to be hoped from surgical interference, and our main reliance is upon therapeutic measures. Ligation on the cardiac side of the tumor is out of the question : an operation on one or more of the branches after Wardrop's modification of Brasdor's opera- tion has not been as yet attended with results sufficiently satisfactory to justify very urgent recommendation, nor does acupuncture or galvanism offer encouragement. Should spasmodic closure of the glottis threaten to suddenly cut short the patient's life, opening the larynx or trachea is justifiable, as would be an opening into the stomach for the introduc- tion of food in the event of distressing dysphagia. The Innominate Artery. — Aneurism of this artery usually pre- 458 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. sents a pulsating, globular tumor behind the right sterno-clavicular junction : in addition to pain, we may have oedema of the right side of the face and arm, laryngeal cough, dyspnoea, and dysphagia. The tumor will fill more or less the hollow above the sternum, rising as high as the lower margin of the cricoid cartilage ; the sternal part of the sterno-mas.toid is first pushed forward and subsequently the clavicular portion: The upper part of the sternum, the clavicle, and costal carti- lage of the first rib may be pushed forward without the development of a tumor in the neck. Dulness on percussion around the sterno-clavicular articulation and pulsation of the first intercostal space are apparent. Bruit may be absent or very variable in character ; the cardiac sound may be projected well up into the anteroinferior triangle of the neck. The pulsation in the carotid and radial on the right side is less than on the left, in many cases before the appearance of tumor. Enlargement of the superficial veins of the neck and upper extremities is a frequent accompaniment. Pain is not limited to the tumor, but may radiate into the neck or arm, over the shoulder and upper part of the chest. En- trance of air into the right bronchus may be interfered with. The muscular power of the right arm may be impaired. Pressure upon the sympathetic may occasion turgescence from dilatation of the vessels, and sweating on one side of the face. Treatment. — In addition to a thorough attention to therapeutic measures, distal ligation only is admissible, limited to ligation of the subclavian alone, the carotid alone, or consecutive ligation of both ; or galvano-puncture or acupuncture may be tried. In subclavian aneurism the tumor extends externally to the clavic- ular origin of the sterno-mastoid muscle, reaching the posterior triangle of the neck : it becomes more elongated transversely than vertically ; the bruit is propagated more toward the axilla than the neck, and re- mains the same on compressing the carotid ; the radial pulse is enfeebled, and the limb painful, oedematous, and incommoded in its movements. Ligation of the innominate, first practised by Mott, was successfully done by Smyth of New Orleans, who also tied the carotid and vertebral. Ligation on the proximal side and immediate amputation of the arm have been advised, and are perhaps justifiable in so grave a condition. The N. Y. Med. Record of Aug. 17, 1895, has the following : "A man was recently on exhibition in London whose innominate artery was tied by Mr. Coppinger, at the Mater Misericordise Hospital in Dublin, in January, 1893. The operation was for the relief of aneurism of the subclavian artery. He was exhibited shortly after the operation in Dublin, and later at New- castle-on-Tyne. The man is now fifty-nine years of age, and is in excellent health. It is claimed for him that he is the only living example as yet exhibited in Europe of cure of subclavian aneurism by innominate ligature." Ligation of the innomi- nate has also been recently done by Burrell of Boston, with temporary success. Axillary aneurism, either idiopathic or traumatic, from the laxity of the surrounding tissues is prone to development and liable to become inflamed. Venous congestion and oedema of the forearm are likely to ensue. Delayed radial pulse on the side involved and severe pain from pressure on the brachial plexus are features. Ligation of the axillary has been done, yet the statistics of ligation of the third part of the subclavian have been more favorable, the first method being more after Anel's, the latter the Hunterian, method. Syme and Morton removed the arm at the shoulder-joint for hemor- rhage and gangrene of the subclavian at the second part. Proximal THE ARTERIES, INCLUDING ANEURISM. 459 pressure before resorting to ligation should be faithfully and carefully tried. Aneurism of the common carotid presents a considerable degree of difficulty in its diagnosis, having in more than one instance been mis- taken for aneurism of other vessels, solid cysts, abscesses, or other tumors by careful and experienced surgeons. Dilatation of the internal jugular vein, which may receive a pulsatory movement from the heart or the vessel, is distinguished by its softness and compressibility, the lack of expansile impulse, its situation, rather behind than in front of the mas- toid muscle, and pressure upon its distal portion effacing it. In aneur- ism of the aortic arch, innominate, and subclavian the delayed impulse at the radial should aid in the diagnosis. Ligation of the common carotid has been attended with a considerable degree of mortality, in many cases death resulting from cerebral or pul- monary sequelse. If the aneurism is located low down, the proximal operation may be impossible, and ligation of the innominate for cases occurring on the right side is far too serious. Digital compression may be unavailable, and the only resort is to the old operation, the distal ope- ration by Brasdor's method, or Wardrop's modification, one of the latter methods being preferable from the possibility of mistaking aneurism of the arch or the innominate for one of the common carotid. Galvanism and acupuncture are worthy of consideration. Aneurism of the external carotid, from the shortness of this vessel, rarely occurs without involving as well the upper portion of the common artery at its division. The tumor will be found under the angle of the jaw about level with the cricoid cartilage. Paralysis of the tongue on that side and aphonia and dysphagia have been met with. Ligation of the common carotid, or the external on its proximal side, is likely to be followed with failure on account of the extent of anasto- mosing vessels. Morris advised as well ligation of the principal branches of the external on the distal side of the tumor — an exceedingly diffi- cult measure. Digital compression, galvanism, or acupuncture may be successful. Aneurism of the internal carotid external to the skull presents but little difference from it at the point of bifurcation or the upper part of the external, the tendency being to extend inward toward the pharynx rather than outwardly. If digital compression, medical treatment, and other milder means fail in giving relief, ligation of the common carotid, although extremely unfavorable, may be resorted to. Intracranial aneurisms are usually formed by dilatation of the whole calibre of the artery rather than a saccular development. Pres- sure-effects upon the soft and yielding brain-tissue show themselves prior to giving way of the bony encasement. The symptoms are quite equivocal : an aneurism of large size may exist at the base of the brain without any symptoms whatever. " The most reliable " symptoms, according to Gross, " are apoplexy and hemiplegia, buzzing noises in the ears, deafness, dizziness, vertigo, and pain in the head, circumscribed or diffused, intermittent or continued, increased by motion, and accom- panied by peculiar morbid sensations," coming on suddenly without pre- monition or arising gradually and imperceptibly. A loud rough or 460 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. whizzing noise, heard by the patient on one side of the head and by auscultation, has in a few instances served for diagnosis. Operative measures are limited to ligation of the carotid when diag- nosis is satisfactory. Intraorbital aneurism frequently first manifests itself by a loud snap or crack felt in the orbit or head as if something had given way. _ Con- gestion of the conjunctiva, difficulty in opening the eyelids, a feeling of tension or pain in the orbit, a loud whizzing noise, increased on stoop- ing or lying down, more or less exophthalmos, and pulsation of a throb- Fig. 154. Aneurism of right internal carotid (Peacock). bing character, with loud whizzing bruit, may serve to distinguish this affection. If digital compression should fail to relieve, ligation of the common carotid should be resorted to, the exigencies of the case and clearness of diagnosis justifying it. Aneurism of the vertebral artery is of extremely rare occurrence, and the symptoms quite obscure, a pulsating tumor situated in the course of the vessel, not commanded by pressure on the lower part of the caro- tid, being somewhat distinctive. If pressure, etc. fail to cure, ligation of the artery near its origin is the only resource. Aneurism of the Abdominal Aorta. — Pulsation is more distinct than in thoracic aneurism : pressure-effects are less marked, from the yielding character of the abdominal viscera and walls. The tumor is THE ARTERIES, INCLUDING ANEURISM. 461 immovably fixed, dull on percussion, and gradually increases in size and firmness with its age. The pain, at first slight, gradually becomes more severe, especially in the vicinity of the cceliac, solar, and hypogastric plexuses, and maybe quite neuralgic — pain of a boring nature, burning, more fixed and attended with sympathetic disturbance when the verte- bras are involved. It must be discriminated from solid or other growths of the pancreas, malignant and other growths of the omentum, stomach, colon, or mesentery, hydatids of the liver, intestinal concretions, indu- rated faeces, abscesses of the abdominal walls, and abnormal pulsations of the aorta from anaemia, neuralgia, or inflammatory reaction. With the bowels thoroughly emptied and abdomen relaxed, examination in the recumbent position on a firm table, and also with the patient placed on the hands and knees, if carefully done, may serve for diagnosis, especially if the expansile character and distinct bruit over the inferior dorsal or lower lumbar vertebrae or the tumor direct is present. Although ligation has been resorted to, it is out of the question, and our reliance is entirely on therapeutic measures, with or without com- pression, in the latter event anaesthesia for several hours being essential. Aneurisms of the hepatic, gastro-epiploic, and mesenteric arteries are extremely rare, yet it is important to make a correct diagnosis to at least prevent erroneous measures of treatment. In aneurism of the hepatic artery the tumor is fixed, and in the two latter forms more or less movable from side to side, the pulsation being maintained. The latter are usually circumscribed and more or less globular, and may be accom- panied by bruit. From pressure upon the liver or gall-bladder jaundice may occur, and pressure on the pancreas may result in phenomena of imperfect digestion, pain, eructation, flatulence, and vomiting ; in some instances hsematemesis existed. Fra. 155. Sacculated aneurism of femoral artery (Parmenter). Inguinal Aneurism.— Aneurism of the common iliac is extremely rare, it being much more likely to develop from the external iliac or upper part of the femoral. It is usually circumscribed, though some- times tubular, rarely diffused. When first noticed it is small, soft and compressible, attended with pulsation and bruit and but little pain or tenderness. It rapidly enlarges, and may seem lobulated from con- striction by the fascia under which it lies. Increasing in size, oedema 462 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. of the limb will arise from pressure on the saphena and femoral veins, and pain occasionally in the thigh and leg from pressure on the anterior crural nerve. Pulsating tumors of bone must be excluded by careful examination. In no case should thorough treatment by pressure, etc. be omitted; and in the event that the external iliac or the common iliac can be reached above the sac, ligation may be attempted. If Syme's procedure, after the " old method," is deemed advisable, firm pressure on the abdominal aorta during the operation should not be neglected. Aneurisms of the Internal Iliac Artery and its Branches. — Erichsen has only recorded one instance of aneurism of the internal iliac and one of the pudic, so rarely have these vessels been involved. Gluteal and sciatic aneurisms, both traumatic and idiopathic, have occasionally been observed, the former more frequently than the latter. Erichsen says that " gluteal aneurism has generally been found situated at the upper part of the great sciatic notch, but may extend over a large portion of the buttocks. Sciatic aneurism lies more deeply, and a por- tion of the sac may be within the pelvis." They vary in size from a slight swelling to a tumor as large as a child's head — are accompanied by strong pulsation, whirring and buzzing murmurs, sciatic pain, and possibly local paralysis. The diagnosis is somewhat difficult, and abscess, soft sarcomata, cysts, and sciatic hernia must be eliminated. Various methods of treatment have been suggested, as opening the sac and ligation of the vessels, ligation of the internal iliac, injection of coagulating fluids, or galvano-puncture. Pressure on the cardiac side of the tumor is impossible. Cirsoid aneurism and angioma present clinical features that are quite definitive, yet the treatment is in many cases unsatisfactory. If detected early and while small, thorough removal by incision, the lines of incision being carried wide of the tumor, or the thermo- or galvano- cautery, should be resorted to. In other instances the ligation of the afferent vessels may succeed; the injection of coagulating fluids after the method of Broca, who used perchloride of iron, preventing the passage of the styptic beyond the desired area by pressure with a leaden ring, attacking the tumor in sections by dividing it into lobes by means of rubber tubes ; or the nitrate of silver, as suggested by Bigelow ; coagulation by electro-puncture or ligation of the main vessel. Two or more of these methods may be combined. CHAPTER XXXII. INJURIES AND DISEASES OF THE JOINTS AND JOINT STRUCTURES. By Joseph Bansohoff, M. D. Injuries op Joints. Contusion. — The simplest injury to a joint is the contusion result- ing usually from direct violence, such as a fall or a blow. Very rarely, as in the case of the small joints of the hand and wrist, is it the result of indirect violence. When severe, contusion often makes itself mani- fest by hemorrhages into the periarticular tissues, which may, in the course of twenty-four hours, permeate the subcutaneous layer and appear in the form of ecchymoses of greater or less extent. In the severer forms of contusion considerable hemorrhage into the interior of the joint takes place. Swelling of greater or less extent, with loss of the normal joint outline, will make easy the recognition of the condi- tion. Pain, as a rule, is not very severe, the inconvenience of the joint movement and tenderness on pressure being the only subjective symp- toms complained of. In extensive hemorrhages into the joint slight rise of temperature may result during the first twenty-four or forty- eight hours. The treatment of contusions consists of rest, evenly applied band- ages, and elastic compression. If much pain be complained of, appli- cations of ice during the first twenty-four or forty-eight hours will often give great relief. After the lapse of two or three days passive move- ments should be made and systematic massage of the joint practised. Sprain. — A sprain is always the result of indirect violence, and is produced when the movements of a joint are carried beyond their physio- logical limits, but stop short of a permanent displacement of the articular ends — that is, dislocation. A sprain may thus be said to be the pro- dromal stage of a dislocation. Excessive muscular action may likewise produce a sprain. In many individuals the presence of a sprain pre- disposes to recurrence of the condition from apparently trivial causes. In the majority of sprains there is a stretching of the capsule and of one or more of the ligaments. In severe cases there is a rupture of one or both of these, with consequent laceration of blood-vessels, and often nerves. Hemorrhage into the joint and the periarticular structures is almost always present. The ligaments, as a rule, if torn, give way at the point of insertion rather than in their continuity. This is made manifest in milder cases, not by tenderness to pressure over the articu- lar line, but at some point above or below, corresponding to the point from which the ligament was torn. In the tearing of a ligament from 463 464 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. its osseous attachment particles of bone are not infrequently brought away with the detached fibrous structure. In severe cases the bone may be denuded of its periosteum for a considerable distance. The symptoms of a sprain are — pain, swelling, ecchymosis, and limitation of joint-function. The pain at the moment of accident is often very severe, leading at times to syncope. When an examination of the joint is made the tenderness will be found most marked over the articular line and over the insertion of the ruptured ligament. The swell- ing varies greatly in different cases, since it depends upon the hemor- rhage within and about the joint. In mild cases it is limited to the periarticular structures, appearing in the form of ecchymoses within the course of two or three days. The ecchymoses, owing to ruptures of muscles, are often found at points considerably removed from the affected joint. The ecchymosis following a sprain is often found at a distance far removed from the joint without rupture of muscle. Often the only ecchymoses seen in sprains of the shoulder appear after the lapse, sometimes, of many days at the point of insertion of the deltoid. As a rule, the swelling attains its maximum within the course of twenty-four hours. In many cases, however, the hemorrhage into the joint produces a reactional hydrarthrosis, which reaches its maximum in from a week to ten days. The degree of periarticular or intra- articular swelling depends entirely upon the extent of damage done to the ligaments and the joint-capsule. The clinical history of a sprain varies with the conditions pro- duced by it. In some cases, characterized by the stretching of the lig- aments without laceration, the pain and swelling speedily subside, and after a few days or a week the joint- functions are restored. In severer cases, where hemorrhage into the joint and periarticular swelling indi- cate extensive laceration, the progress toward recovery is often very tedious, and months may pass before a final restitution to the normal condition takes place. In the severest cases circumscribed tender areas, thickening of the joint-capsules, or chronic hydrarthrosis may leave the joint permanently impaired. Atrophy of the muscles is often found to follow upon severe sprain during the first two weeks, and is the result of the injury to the articular nerve-filaments. This condition is often irreparable. Extensive hemorrhage into a joint is always significant of a tedious recovery, and frequently renders unfavorable the prognosis, so far as complete restoration of joint function is concerned. In subjects 'with a tendency to diathetic, and par- ticularly to tubercular, disease a sprain is often the exciting cause of chronic joint disease. Treatment. — In the treatment of sprains absolute rest should be at once secured. Elevation and suspension of the affected limb at a right angle will often relieve the pain at once. This position conduces to the arrest of hemorrhage and, by rapidly depleting the veins, facilitates the absorption of the already effused blood. To further hasten absorption compression by an elastic bandage may be considered as of prime importance in the treatment of sprains. Cold applications are often of value for the relief of pain. To these may be added the lead and opium wash, or a solution of chloride of ammonium and opium, or an ichthyol ointment. Internal administration of opiates may become necessary when pain cannot be INJURIES AND DISEASES OF THE JOINTS, ETC. 465 otherwise alleviated. To secure absolute rest immobilization of the joint by means of plaster-of-Paris, starch, or silicate-of-sodium bandages is often indicated. The indiscriminate use of fixed dressings must, however, be condemned, since their unnecessarily prolonged use may lead to irreme- diable stiffness of the joint. It is preferable to resort to the use of splints, which can be removed daily if required. After the subsidence of the acute symptoms of the sprain the main object of treatment must be that of the restoration of joint function. Efforts in this direc- tion should never be delayed beyond the second week. The chief agents in attaining this end are passive movements and massage methodically applied. In the severest forms of sprains, in which the intra-articular effusion is not absorbed by this treatment, recourse must be had to aspiration of the joint. In sprains which are not relieved by one or other of these methods of treat- ment, singly or combined, counter- irritation by means of blisters, or, preferably, by ignipuncture, often answers admirably. When there is any thickening under an especially tender point recourse should be had to free incision. In a few cases hemorrhagic cysts have been drained or granulation masses removed with a curette, thereby permanently relieving the symptoms. The writer recently drained with success such a subfascial cyst as large as a hazelnut. It was over the trochanter, and directly under a point which had been extremely tender during two years fol- lowing a sprain of the hip. Penetrating- "Wounds. — The injuries of joints hitherto considered may prove serious to the function of a limb, but being subcutaneous they never, per se, jeopardize either limb or life. In strong contrast to these, therefore, are the wounds in which communication is established between the external air and the joint interior. Penetrating wounds, particularly of the larger joints, like the knee, the hip, the shoulder, and the ankle, may and often do become among the gravest of the injuries to which the body is subject that are not immediately fatal. Penetrating wounds of the joint may be divided into the incised, the punctured, the lacerated, and the gunshot injuries. In very many instances the wound is complicated with more or less extensive injury to the surrounding structures, particularly the bones, the larger blood- vessels, and the nerve-trunks. For practical purposes simple incised wounds may be differentiated from the complicated forms, for in the latter the opening of the serous cavity is less significant than the con- comitant injury to bone, blood-vessel, or nerve. In civil practice the injuries most frequently seen are of the punctured or incised variety. The shoemaker thrusts an awl into his knee or the woodman sinks his axe into ankle or knee ; the mechanic occasionally thrusts a pointed instrument into the wrist-joint. The loound of communication, it will therefore be seen, varies very much in its size, being often so small as to be just perceptible, or large enough, on the other hand, to afford a view of the joint interior. In the latter instance the diagnosis is, of course, simple ; in the former, on the other hand, it may be difficult to recog- nize the penetrating nature of the injury, and often it is impossible. Symptoms. — Cardinal signs indicative of penetrating joint injury have been said to be the outflow of synovial fluid, pure or mixed with blood, and in the absence of this the rapid filling up of the joint-cavity with blood. Neither of these signs is pathognomonic. The opening of a periarticular bursa or of a tendon-sheath will permit the outflow of a 30 466 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. fluid closely allied to the synovial. When the perforation is small the opening in the joint closes, and will allow no permeation of fluid through the wound tract. The accumulation of fluid within the joint, on the other hand, will often attend contusion of the joint without perforation. It is not uncommon, for example, to find, in consequence of falls upon the knee, a contused and lacerated wound of the periarticular structures, followed by hsemarthrosis without penetration of the joint. In compound fractures of the epiphyses joint penetration may often be suspected, but is rarely subject to demonstration until, in neglected or badly treated cases, the joint reacts to septic infection. When the diagnosis cannot be otherwise established, the careful use of a steril- ized probe may bring certainty. In small punctured wounds the dis- placement of the tract between muscles and tendon-sheaths will often render the search futile. If indications arise demanding a positive diagnosis, an enlargement of the wound under anaesthesia and explora- tion of its course must be made as the preliminary step of the proper operative treatment. Punctured and small incised wounds of even the largest joints are not, as a rule, attended by severe constitutional disturbance. A man with a punctured knee may follow his vocation for a day or two without any marked local or general disturbance. In the lacerated wounds, on the other hand, there is, as a rule, very great depression. Being often associated with fracture or dislocation and accompanied by profuse bleeding, the shock manifested is often extreme. The clinical course of these injuries depends wholly on the presence or absence of primary wound infection. In the latter even large wounds heal per primam without local or general reaction. The continued outflow of synovia for several days, while it jeopardizes so fortunate a result, does not annul it. In the cases of grave infection, with insufficient drainage, the joint structures soon undergo changes that place them beyond repair. The synovial membrane becomes greatly thickened, the surrounding liga- ments become softened, the cartilage covering the bones raised at first in areas, then separated altogether from the underlying bone. The joint structures thus become almost altogether unrecognizable. Communica- tions are established between the pus-cavity into which the joint has been converted and the bursse originally communicating with the joint tendon-sheaths overlying them. In this way a joint abscess finds its icay to the surface, often in as many as from three to six places removed from each other by considerable distances. While this process in and about the joint is going on the limb becomes often enormously swollen, the general septic manifestations are very marked, and, unless relief is afforded, death may sooner or later occur. But even in such unfortunate cases life and limb are often preserved after protracted suppuration, last- ing at times for many months. In penetrating wounds of the smaller joints, particularly of the hand and foot, owing to their greater simplicity the local and general manifestations are proportionate to the size of the joint injured. Whereas, as a rule, the function of the joint involved is permanently restricted, the infection remains localized and limited, and life is rarely threatened. But even in this regard caution in prognostication is essen- INJURIES AND DISEASES OF THE JOINTS, ETC. 467 tial, since the extension of disease to parts far removed from the pri- mary injury occasionally ensues. The treatment of penetrating wounds of the joint must have for its objects — first, the securing of primary union through the prevention of infection ; and, second, the treatment of the traumatic arthritis when the infection has already taken place. To meet the first condition is simple when the diagnosis is clear. Like wounds in other parts, joint wounds must be thoroughly cleansed. Unevennesses of the surface and contused edges must be removed by clean incisions, and the joint should be thoroughly explored for parts of the vulnerating body which have possibly remained imbedded in it. To accomplish this the wound into the joint may without fear be very much enlarged. The joint-cavity is then to be thoroughly irrigated with a sublimate solution of 1 : 1000. If there has been much oozing, a silkworm-gut strand may be left for drainage. The wound is closed by sutures and the joint, being asepti- caily dressed, kept at rest. When the diagnosis of joint penetration is in doubt, the treatment should depend largely upon the facilities for aseptic exploration at the command of the surgeon. Without such facilities it is probably wiser to await the development of symptoms indicative of infection before resorting to operative interference. When the surgeon has control of his surroundings it is advisable, as in cases of doubt pertaining to pen- etrating wounds of the abdomen, to enlarge the punctured or incised ivound, to trace it to the joint-capsule, and, if this be found to be pene- trated, to treat it as in the cases just considered. With the first evi- dences of septic, infection, in either class of cases, the treatment must consist of the antiseptic management of the joint interior. By this is meant a free incision for the removal, through drainage, of the contents of the diseased joint and antiseptic irrigation of the joint interior. In proportion as these objects are sought early or late the integrity of the joint will be more or less maintained or entirely lost. For the drainage of joints that are already suppurating, nothing excels rubber drainage- tubes of considerable calibre. In the management of traumatic suppurative arthritis regard must be had to the position of the limb with a view to probable future ankylosis. Left to itself, a suppurative arthritis of the knee will invariably leave the limb much flexed ; of the elbow, the arm slightly so. An early regard for the position to be attained is therefore an essential element of treatment. When the penetrating wound of a joint is only one feature of a com- plicated trauma, the question of primary excision, or even of amputation, may arise. For uncomplicated wounds of the joint neither of these ope- rations is primarily indicated. In cases of compound dislocation with fracture into the epiphysis, particularly in the upper extremity, a pri- mary excision will often save a useful limb. The same is true of com- pound dislocations of the ankle. In compound dislocations of the knee the force producing it is necessarily so great as to make the joint injury of secondary importance. In these cases primary amputation must, as a rule, be resorted to. 468 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Gunshot Injuries. Gunshot wounds of the joints are always lacerated and contused, and for this reason alone afford a better soil for infection. In the wounds made by larger missiles there is always added considerable injury to the epiphyseal ends of one or both of the contiguous bones. In these wounds the epiphyses are often shattered beyond repair, and the larger vascular or nerve trunks are often involved to a degree calling for im- mediate amputation. A gunshot wound of a larger joint by a ball of large calibre, when left to itself, often pursues a rapidly fatal course. Of 271 joint injuries in the Russo-Turkish war, tabulated by Reyher, 146 proved fatal ; mortality, 54 per cent. From the very first day the joint becomes tender, the slightest movement giving rise to excruciating pain. The integuments become discolored, the veins are distended, and gas- formation in and about the joint rapidly takes place. The constitutional symptoms accord with the degree of the local infection : the temperature ranges between 103° and 105° F., the sensorium becomes obtunded, delirium develops, and the patient, if unrelieved, often dies, in from three to five days, of acute septicEemia. In the gunshot wounds of joints made by small-arms, as seen in civil practice, the symptoms are far less pronounced. They accord with those described of the milder infected wounds that are penetrating from other sources, but even in these, owing to the damage done to contiguous bones and the presence of foreign substances, the symptoms develop more rapidly. In wounds produced by the larger missiles fired from modern arms there is usually perforation, under which circumstances, as in gunshot injuries elsewhere, the wound of entrance is smaller than that of exit and has a tendency to contract. The wound of exit is larger, often gaping, and on explo- ration presents detached spiculse of bone. In wounds made by missiles of small calibre perforation of the larger joints is not common. The missile may rarely be found loose between the joint surfaces. Often it is found firmly imbedded in the epiphysis after having produced more or less splintering. Wounds of the joint made by the larger projectiles of war, propelled with great force, and particularly those of modern pattern, are almost always per- forating. In joints with subtendinous pouches, like the elbow and the knee, joint penetration not infrequently occurs without injury to the bone. A similar penetration may occur, for example, from a wound in the antero- posterior axis of the knee without injury to bone when the leg is flexed at an angle of about 140° against the thigh. Treatment. — The course of a wound is mapped out by the hands of him who first sees it. This is particularly true of gunshot wounds of joints. Except when profuse hemorrhage calls for immediate care the first attention should be limited to the application of an antiseptic dress- ing. More should not be done until the best possible facilities are afforded for antiseptic and aseptic manipulations. Above all things, probing with, finger or instrument can only be harmful unless every pre- caution toward surgical cleanliness is observed. Conservatism in the sense of antisepsis and immobilization is indicated in eases of smaller wounds, such as are seen in civil practice. In all other gunshot injuries INJURIES AND DISEASES OF THE JOINTS, ETC. 469 of joints conservatism is probably most favored by primary operative treatment. Delay until the manifestations of infection compel a tardy interference entails disaster to life and limb more often than in joint wounds from other causes. This has been established beyond a reason- able doubt. Of 46 gunshot injuries of the larger joints treated antiseptically primarily, 6 ended in death ; mortality, 13 per cent. This primary treatment included anti- septic occlusion, immediate drainage, and primary excision. _ In 78 cases treated by antiseptic means after infection had occurred the mortality was 54 per cent. (Eeyher). According to the varying conditions found, recourse must be had to exploration and lavage of the joint, atypical excision, or amputation. In civil practice the latter would rarely be demanded ; even in military practice it will probably be reserved for the complicated injuries, of which the joint penetration is only one element. Extensive injury to to the soft parts, comminution of both epiphyses and fracture extending into the diaphysis, injury to larger nerve and vascular trunks, are the conditions demanding primary amputation. As for severe injuries from other causes, amputations of the lower extremity, other things being equal, will be oftener demanded than those of the upper. In the smaller wounds seen in civil life, when the diagnosis is clear the facili- ties for asepticism should determine the course ; without them, an expect- ant treatment limited to thorough cleansing of the wound and immo- bilization should be trusted to rather than exploration. With facilities for aseptic work at hand even the smaller wounds seen in civil life should be subjected to immediate exploration. The wound should be enlarged and the site of joint penetration thoroughly exposed. When it is required for further manipulation a free incision into the cap- sule must be made. With the parts so exposed the course of the ball can ordinarily be easily followed. If it has ploughed its way into an epiphysis, the canal should be enlarged with chisel and sharp spoon until it is found and dislodged. Loose spiculse of bone are to be removed with the forceps and uneven projections chiselled away. An atypical resec- tion may thus be made. Particular care must be given to the removal of foreign substances carried in with the missile. If in perforating wounds the manipulations have brought the operator near the distal side of the joint, a counter-opening should here be made. Ample facility for drainage is the condition on which success depends. After such atypical resection fair joint motion is often retained. If both epiphyses are injured, it is probably wiser to make a formal excision with the view to obtaining ankylosis. Diseases of Joints. Diseases of joints which result from irritation or infection may be divided into the acute and the chronic. The division can also be made according to their primary or secondary development, and, finally, according to the end-product of the process into the serous or purulent on the one hand, and the dry or plastic on the other. Exact differentiation between the various types is often a matter of considerable difficulty. As elsewhere, an acute disease of a joint often retrogrades slowly, 470 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. becomes the subject of exacerbations, and eventuates in a chronic disorder. In point of pathology, differentiation is also at times difficult. As in cases of pleurisv with effusion it is at times impossible to state just when the serous becomes converted into a purulent exudate, so in inflammatory or subinflammatory diseases of the joint the differentiation is often im- possible. Furthermore, as in the intrathoracic disease just referred to, the disappearance of the serous effusion will leave a jibro-plastic material as the only vestige of pre-existing disease, or, as we may have a fibro- plastic disease of the pleura unchanged at any time, so we may have inflammatory diseases of the joint converted from the serous into the plastic, or one that remains plastic throughout the entire course of the disease. Again, as elsewhere, differentiation between lesions of the joints that are purely the result of irritation — mechanical, as from injury, chemical, as from a deposit of uric-acid salts — or the purely infective is difficult to make. For practical purposes, therefore, the best division possible of acute diseases of joint structures under the circum- stances given is into — (a) The simple serous synovitis. (b) The simple purulent synovitis. (c) The dry synovitis. (ct) Acute suppurative arthritis. Simple Synovitis -with Effusion. — Acute serous synovitis is the commonest form of joint disease. As a rule, it is the result of a con- tusion, but may arise without any known cause. In point of frequency the joints involved are the knee, the elbow, and the ankle. Among the joints less frequently involved are the hip, the shoulder, and the small joints of the extremities. The pathology of the disease is limited to changes in the synovial membrane in which the usual manifestations of irritation and inflammation develop according to the cause producing the disease. In mild cases of synovitis the condition described lasts from a week to ten days, when, by the gradual absorption of the exudate and the return of the distended vessels to their natural condition, the joint resumes its normal appearance and function. In other cases absorption goes on very slowly, or it may altogether fail to take place, under which circumstances we have established the condition known as hydrarthrosis, the chief feature of which is the effusion into the joint. Simple Purulent Synovitis (Synovitis Catarrhalis Purulenta).— In less_ favorable cases or in consequence of improper management the exudation increases often to enormous proportions. Its character may also change : turbid at first from the admixture of few cellular elements, these increase until the exudate assumes a purulent character. The rapidity with which the effusion becomes purulent is at times so great that the synovitis in these cases seems to be purulent from the beginning. Except for the latter, the condition of the joint interior does not vary at first in the simple purulent form of synovitis from the serous. Particularly in children, as Volkmann and Krause have shown, there may be a purulent effusion into the joint without destruction of the articular surfaces or permanent impairment of synovial membrane, joint-capsule, or ligaments, pro- vided spontaneous perforation occurs or an early outlet be made for the discharge. INJURIES AND DISEASES OF THE JOINTS, ETC. 471 Dry Synovitis. — In certain cases of acute synovitis the fluid exuded may be very small in quantity or altogether absent. In proportion the flakes of fibrin are greatly increased, until they may appear as a con- tinuous layer covering the articular surfaces and forming a deposit of varying thickness on the synovial membrane and cartilages. The fibrin thus thrown out shows remarkable tendency toward organization. The smooth, glistening character of the serous surfaces is lost. In its place there are masses of fibrin, often unevenly disposed and by joint move- ment often drawn into shreds of unequal length and adherent at one or both ends. If ankylosis do not occur, these shreds may speedily become detached and present themselves in the form of many small bodies the size of a pea or bean, round or ovoid, and consisting of con- centric rings of fibrin — rice-bodies. In other cases the joint surfaces are speedily welded together by the organization of the exuded lymph. Ankylosis may sometimes follow these acute dry synovitides with remarkable rapidity. Acute Suppurative Arthritis. — The conditions above described are superficial, and do not involve, even if long continued, the integrity of the joint structures. Acute suppurative arthritis, however, being always an evidence of grave infection, is almost from the first destructive in its tendency. Although in the beginning the lesions are limited to the synovial membrane and the product may be but a serous effusion, there soon follows purulent distention of the joint. In addition to the syno- vial lining the cartilages participate in the morbid process. They lose their pearly hue and assume a reddish or even blue tinge. Blood- vessels appear within them, and absorption, often in patches, takes place, the subjacent bone thereby becoming exposed. Shreds of car- tilage are often raised in areas, become necrotic, and are thrown off into the joint-cavity. The ligaments become softened and permeated by small purulent foci ; the joint becomes loosened and devoid of function. Displacements of the articular ends of the bones are therefore of early and frequent occurrence. Caries of the articular ends, extending for a greater or less distance into the epiphyses, results. The periarticular structures, bursa?, and tendon-sheaths take part in the suppurative pro- cess. Abscesses communicating with the joint occur and develop in different places. They are often far removed from the part primarily involved. Unless adequate treatment is instituted the destruction of the joint invariably follows. If the limb is saved, the suppurative pro- cess gradually subsides through the drainage given by fistulous forma- tions or by surgical treatment. The joint-cavity is almost always obliterated. Ankylosis, fibrous or bony, is an almost inevitable result. Symptoms. — The superficial position of most of the joints facilitates the recognition of a simple synovitis. Except in the joints deeply seated, like the shoulder and the hip, the four cardinal symptoms of inflamma- tion can be easily recognized. In the latter joints only are we called upon to look to other than the characteristic symptoms for recognition of the condition. As has been said in the symptomatology of joint injuries, the patient first complains of pain, which, as a rule, is propor- tionate to the rapidity of the joint distention with fluid. Generally the pain is complained of in the joint itself. Only in exceptional cases, as in the hip, it is felt in a part far removed. With the pain there is associ- 472 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. ated more or less tenderness, often felt at one or more points along the articular line rather than over the entire area. In cases of traumatic origin the reason for this is apparent. In other cases Volkmann has ascribed these special points of tenderness to the deposit beneath them of fibrinous material. It is more probable, however, that these special points of tenderness correspond to the attachment of ligaments or dupli- catnres of the synovial membrane, which are stretched by unequal ten- sion of the effusion in the joint when pressure is made over them. Where pain is not complained of when the limb is at rest, it will often be found to be very severe when any effort at motion, voluntary or passive, is made. The swelling is the most marked feature of a simple synovitis. Often within twenty-four or forty-eight hours it is sufficiently developed to have effaced all of the normal outlines of the joint. The development of an acute synovitis is very frequently, although not always, associated with definite change in the position of the limb. For the most part, one midway between flexion and extension is assumed, and maintained throughout the entire course of the disease. The knee becomes flexed upon the thigh, the foot becomes placed in the position of talipes equinus, the hip becomes flexed and abducted. When the shoulder is involved the arm is held close to the side of the body ; in disease of the elbow the forearm is extended at an angle of 140°; in disease of the wrist there is a slight drop, the fingers are maintained almost in extension, and the hand somewhat flexed on the forearm. The assumption of these positions has been accounted for through the fact that by them an equal pressure on different part of the joint surface is secured, since they are positions taken by the joints when injected experi- mentally. This explanation does not obtain in cases of synovitis, since in some of great distention with serous fluid no faulty position is assumed. In every case of purulent synovitis this tendency to contracture makes itself apparent early, as it does also in cases of tubercular disease, to be hereafter considered. It is exceedingly probable, therefore, that the contracture is a reflex phenomenon manifested only when, from the nature of the disease, prolonged fixation, in the position in which exten- sors and flexors are equally favored, is to be maintained for a long time. The symptoms hitherto considered are far more important than the remaining cardinal symptoms of redness and heat. In simple serous synovitis redness, as a rule, is altogether absent. In the purulent form it is present only when preparations are making toward spontane- ous perforation. When synovitis is the result of joint contusion the reaction following periarticular injury is often causative of a redness far in excess of that which follows the synovitis alone. In joints super- ficially placed, like the elbow, the knee, and the wrist, a local elevation of temperature of from one to two degrees may usually be recognized. In cases of suppurative synovitis the general symptoms reflect the greater gravity of the local condition. With the systemic absorption of the products of inflammation the usual accompaniments of toxaemia, chills and continuous fever, coating of the tongue, and anorexia, are found. The general symptoms of acute suppurative arthritis are proportionate to the severity of the local condition. Almost from the beginning the temperature rises from three to five degrees, and continues with morning INJURIES AND DISEASES OF THE JOINTS, ETC. 473 remissions until vent is given to the inflammatory products or until death ensues from exhaustion. The fatality of this condition has already been referred to in the section on Penetrating Wounds of the Joints. In the dry form of synovitis many of the local symptoms of the serous and purulent variety are absent. Pain and tenderness are often very marked, and out of all proportion to the swelling, which, as a rule, is slight. In these cases the tendency to faulty position is very early developed. When efforts at motion are made crepitus is felt. Move- ments of the patella upon the front of the femoral condyles may like- wise elicit such joint crepitus. When the latter is insufficient to be felt it is distinctly audible when the ear is placed over the joint and the articular surfaces are moved upon each other. Passive movements are more painful than in the synovitis with effusion, and the pain associated therewith increases with the tendency to the formation of adhesions. The latter may form as early as the first week, and be firm enough to demand the anaesthetizing of the patient for their severance and the correction of the concomitant deformity. The general symptoms in cases of acute dry synovitis are often out of proportion to the severity of the local condition. Etiology. — The etiological factors of acute diseases of the joints may be divided into the traumatic and the non-traumatic. The former have been sufficiently considered under the head of Joint Injuries. Without the history of a trauma, acute inflammation occasionally devel- ops without any recognizable cause. Non-traumatic joint inflammations are often secondary to lesions in the vicinity of the joint. Acute inflam- mations of the joint-structures also often develop by extension from disease in the vicinity. Chronic osteitis, periarticular abscesses, epiphyseal osteomyelitis, or erysipelas of an extremity may by extension of the process involve a joint in the vicinity. Suppurative disease in the lendon-sheaths of the hand and foot are not infrequently the cause of acute destructive inflammation of joints. Direct perforation of the joint-capsule from the outside does not ordinarily take place in this process, but it is through the slow invasion of the capsule by the pus-formers from without that the disease is grafted on the joint interior. A tubercular nodule in the epiphyses by breaking into the joint will speedily set up a synovitis which at first is serous. Many of the non-traumatic inflammations of joints are but the manifestations of systemic involvement, and may therefore be called infective. Pyaemia, puerperal fever, gonorrhoea, the acute exanthemata, rheu- matism, and gout, all have, as frequent complications, one or other form of acute joint disease, limited according to the severity of the local infection either to the synovial membrane or deeply involving the structures entering into the joint formation. The synovitis of pycemia and puerperal fever is ordinarily characterized by the involvement of more than one joint, either simultaneously or in succession. The joints affected are usually the larger ones, like the knee and shoulder. Generally the joint effusion is purulent from its inception. The pus when evacuated is usually thin and flaky, but often is very foul. The acute exanthemata— with which for present purposes might be classed typhoid fever — which most frequently are followed by synovitis in their relative order are variola, scarlet fever, measles, and typhoid fever. As a rule, the joint complication develops during the period of convalescence, and, except in the case of variola, is ordinarily serous in its character. In variola, however, suppuration of the joint is not at all uncommon. In the suppurative processes of joints which occasionally accompany the acute infectious diseases the specific microbe of the individual disease has not been found in the joint effusion. The staphylococcus aureus has been most frequently observed, and in graver infections the streptococcus. In the arthritis following typhoid fever) 474 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. the hip is more frequently affected than any other joint. Occasionally suppuration does not take place and complete recovery may ensue. More frequently, however, the joint lesions leave in their wake ankylosis or spontaneous dislocation. In 43 cases of joint disease from typhoid fever collected by Keen, 30 were subjects of spon- taneous luxation, of which 27 were of the hip, 2 of the shoulder, and 1 of the knee. The synovitis which is the chief symptom of rheumatism is sufficiently characterized by the rapidity of the joint effusion, its serous character, and, above all, by the periarticular swelling and redness and the number of joints that are simultaneously or successively involved. Gouty synovitis is but a manifestation of the general condition. It is serous, limited, usually to the metatarso-phalangeal joint of the left foot, associated with extensive periarticular swelling and redness. Through the soft parts, after the subsidence of the acute disease, nodules of calcareous deposit can often be felt within and about the joint structures, more or less defacing the joint outline and limiting mo- tion to a varying degree. The subjective symptoms of pain and of tender- ness are far in excess of the local underlying conditions. Both rheu- matic and gouty synovitis are further characterized by their tendency to become subacute and even chronic. The structural changes involve the cartilage, ligaments, and periarticular structures. Both of these forms of synovitis, but particularly the gouty, are characterized further by their tendency to recur. Post-go7iorrhceal synovitis, when it develops, usually appears during the period of greatest activity of the primary urethral disease. In the great majority of cases, therefore, it will be found before the end of the third week. Immunity from a synovitis, however, does not exist until the complete cessation of the discharge. Closely allied etiologically to gonorrhoeal synovitis is what might be termed urethral synovitis. Occasionally the passage of a sound or a catheter in a urethra apparently normal is followed by a joint affection indistinguishable from that under consideration. The diagnosis of gonorrheal synovitis is not difficult when the presence of the primary disease is known. From ordinary rheuma- tism it may be recognized by its being mono-articular, by the low range of temperature, the absence of the profuse sweating and heavilv-loaded urine characteristic of rheumatic disease. Gonorrhoeal rheumatism (as it is too often misnamed), as a rule, retrogrades slowly toward recovery. Often, however, the effusion becomes permanent. In other cases the plastic material thrown out tends toward the formation of fibrous anky- losis. Most ankyloses of the knee that are not the result of tubercu- losis or trauma in young male subjects owe their origin to gonorrhoeal infection. Syphilis very rarely produces primary acute articular disease. Occasionally during the eruptive stage joint pains are complained of. Serous effusions do not occur frequently, and are almost altogether limited to the knee. Ordinarily, the joint complications of syphilis are secondary to gummatous deposits in the epiphyses. In the hereditary syphilis of early life multiple joint lesions of this nature are often seen. Treatment. — The treatment of acute inflammation of joints has a fourfold object : First, the limitation of the inflammatory process ; sec- ond, the removal of the products of inflammation; third, the prevention of deformity ; and fourth, the restoration of full physiological function. (1 ) Among the methods of curtailing inflammation mav be mentioned, INJURIES AND DISEASES OF THE JOINTS, ETC. 475 in the first place, position and rest. In inflammation of the larger joints of the upper, and of necessity of the lower extremities, the patient must be put to bed. In diseases of the knee, the ankle, the elbow, and the wrist the limb should be suspended at nearly a right angle. The disad- vantage given by position to the arterial circulation is often of itself suf- ficient to cut short an attack of synovitis. Unfortunately, in inflamma- tory conditions of the hip and of the shoulder these advantages cannot be obtained. Rest should further be secured by placing the part upon a proper splint, and the circulation should be as far as possible controlled by the application of an elastic bandage. As elsewhere, this should not be directly applied to the skin, which would speedily macerate, but over one or two thicknesses of gauze. When the tenderness and pain will not admit of such pressure the application of an ice-bag or astrin- gent lotions, sugar of lead and tincture of opium or the chloride of ammonium, will be of service. The general condition of the patient in the simple form of synovitis rarely requires any special attention. (2) For the removal of the products of inflammation the preparations of iodine, of mercury, and of lead have been used from time immemo- rial, but with rather doubtful results. The repeated use of blisters and of the hot iron will not infrequently, in cases that have passed through the acute stage, cause a speedy and permanent reduction of the joint swelling. To further facilitate the removal, and at the same time ensure joint fixation, fixed dressings, like the plaster-of-Paris, the starch, and the silicate-of-soda bandage, have been highly recommended. Their use, however, should be limited to ten days or two weeks at a time, after which an inspection of the joint is necessary to forestall the development of ankylosis. Very effective in hastening absorption of serous products of inflammation is massage. When methodically applied once or twice daily, and followed by the use of elastic compression, it will remove the great majority of synovial effusions. As auxiliary to the local treatment very great faith may be placed in the internal administration of the iodide of potassium. When, notwithstanding the procedures here de- scribed, the effusion continues, recourse should be had to aspiration of the joint. This should not be delayed more than two or three weeks, lest the relaxation of the periarticular structures leaves the joint in a per- manently weakened condition. The aspiration should always be done with the strictest aseptic precautions, a large needle being used and an oblique puncture being made through the overlying soft parts. All of the fluid of course cannot be removed by aspiration. The removal of only a part, however, will relieve the intra-articular tension to a degree compatible with the function of absorption by the synovial membranes. In not a few cases, particularly of the subacute variety, the tendency to the reaccumulation of fluid is great. When one or two aspirations have failed, a permanent cure can ordinarily be secured by the injection into the joint-cavity of two or three drachms of a 5 per cent, solution of car- bolic acid. This injection should preferably be made through a large trocar, the joint being distended with as much of the solution as it will hold, when all but two or three drachms are allowed to come away through the cannula. In cases of pyoid effusions relief will not ordi- narily be obtained without this treatment. In cases of suppurative arthritis efficient drainage must be secured at 476 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. the earliest possible moment. It is only by early and efficient drainage that the joint function can in a measure be saved. In very many instances the removal of the entire synovial membrane and as much of the articular ends of the bones as may be diseased (arthrotomy) would prove the best conservatism practicable. It is only in the exceptional cases of acute articular suppuration that recourse must be had to amputation. (3) Deformity is to be prevented by giving the limb a proper position from the very beginning, and one which, in the event of ankylosis, would leave it most useful. The knee should therefore always be kept extended, the elbow at nearly a right angle, and the wrist midway between prona- tion and supination. In diseases of the hip the leg is to be extended. As the tendency to deformity often manifests itself early, it may be already present when the case first comes under observation. At any cost this should be corrected as soon possible, either by gradual exten- sion or, if need be, forcibly under general anaesthesia. By the use of proper support the recurrence of the deformity can ordinarily be ob- viated. (4) Restoration of function is the most difficult achievement in the treatment of acute joint diseases. It can be met only by properly con- ducted passive movements, instituted as soon as the height of the inflam- matory action has been thoroughly passed. The restoration of joint function must be particularly cared for in cases of synovitis which early manifest a tendency toward joint fixation. Such are the dry synovitides and those which complicate gonorrhoea and the acute exanthemata. In these cases the use of an immobile dressing for two or three weeks will often permanently impair joint movement. Where it is already impaired passive movements and massage are most serviceable in restoring joint function. Oheonic Diseases. Hydrarthrosis. — This term is used to designate a serous effusion into a joint with a tendency to chronicity. Strictly speaking, it is not a dis- ease, but a result common to many conditions in and about the joints. Often in its inception it is the result of an irritation or an inflammation, the acute synovitis having become chronic. On the other hand, the effusion is often the result of changes in the vicinity of joints. Larger joints, like the knee, the elbow, the shoulder, and the hip, are often the seat of hydrarthrosis, although the knee is affected more frequently than all of the rest of the joints together. The character of the effusion is ordinarily serous ; occasionally it is tinged with blood, and contains at times shreds of fibrin, free globules of oil, and, in old- standing cases, fat-crystals. In its amount it varies materially. In the knee there may be just enough of an effusion to efface the patellar grooves, or, in old-standing cases, as much as a pint. With the long continuance of hydrarthrosis, irrespective of its cause, certain structural changes result. The synovial membrane in its deeper layers becomes very considerably thickened; the folds or reflections show marked induration, and can often be felt in distinct ridges. The synovial fringes become enlarged, cedematous, and by proliferation far more numerous than in the normal condition. The articular surfaces of the INJURIES AND DISEASES OF THE JOINTS, ETC. ATT bones are ordinarily unchanged. The important ligaments do not usually become relaxed, so that pathological displacements are never seen. Although in long-standing cases of hydrarthrosis appreciable muscular atrophy ensues, contractures are very uncommon. Only so far as the presence of the fluid acts mechanically is the joint function restricted. When the accumulation is large, the bursa? with which the joint is in communication ordinarily participate in the effusion, thereby giving to' the joint surface an uneven, at times lobulated, appearance. When, as at times occurs, the hydrarthrosis disappears spontaneously the bursal effusion may remain unchanged. The diagnosis of hydrarthrosis of the knee, the elbow, the wrist, or the ankle is easily made. Effusions into the shoulder and hip can only be recognized directly when they are quite large. The wave of fluctuation in extensive effusion is distinct. The articular outlines are effaced, and in the knee the ballottement of the patella can be easily demonstrated. The chronicity of the condition, its slow development, the absence of rise of temperature and of pain, confirm the diagnosis. The prognosis of hydrarthrosis is largely that of the under- lying condition. In the simpler forms spontaneous cures occasionally result. As a rule, considerable fluctuation in the quantity of the effusion is manifested. A partial or total absorption will often be fol- lowed by an increase and reaccumulation of the fluid. Treatment. — In comparatively recent cases of hydrarthrosis absorption may often be secured by the treatment advocated for acute synovitis with serous effusion. Friction, methodical massage, repeated blisters, and the continuous application of an elastic bandage will often effect a permanent cure. In the failure of these measures recourse may be had to immobilization, from which the danger of ankylosis is not so great as in the cases of acute disease. In the majority of old-standing cases, however, recourse must be had to aspiration of the joint, to be followed by irrigation with a 5 per cent, solution of carbolic acid, of which from five to ten cubic centimetres may be allowed to remain within the joint. To make the injections painless, a \ per cent, solution of cocaine may be injected before introducing the carbolized water. In cases where even this has failed the draining of the joint may be resorted to. A few cases have recently been recorded in which free incision of the joint has been made, the synovial surfaces thoroughly rubbed with pledgets of gauze, pro- liferated and hypertrophied synovial fringes removed, and the joint closed. A simpler method is what the writer would call that by subcutaneous drainage. A strand of silkworm gut is passed by means of a trocar through the affected joint : the ends of the strand are then carried subcutaneously through the periarticular tissues to a small incision made midway between the points of entrance and exit. After being tied the knot is buried and the wound of incision and, if need be, the punctures, are closed by sutures. The drainage is thus carried into the peri- articular subcutaneous tissue, which does the absorbing, and through which and through the joint there passes a strand of silkworm gut. After a cure has been effected the silkworm gut, if need be, can be readily removed. Chronic Articular Rheumatism. — This is a condition of advanced life and often found in the lower social strata. Individuals who have always been well nourished are not often subject to this disease. It occurs oftener in men who have led exposed lives : the earlier decades of life are, as a rule, exempt. The disease may follow in the wake of an acute rheumatic attack ; generally it is subacute or chronic from its inception. 478 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Like its acute prototype, it is polyarticular. The pathological changes of chronic articular rheumatism vary with its severity and duration. Joint effusions are ordinarily limited in amount, if at all present. Pri- marily, the synovial membrane, the capsule, and the periarticular struc- tures are involved. The synovial membrane becomes thickened, the ligaments indurated, and periarticular fasciae show a tendency to become fixed. Consequent upon this irritative hyperplasia, the joints often become fixed and a fibrous ankylosis results. The cartilages and the articular ends of the bones remain unchanged for a long time. It is only after prolonged fixation that cell- proliferation in the cartilaginous covering takes place, followed by abnormal bone- formation. This metamorphosis of bone occurs relatively often in the small joints, particularly in women over thirty. The SYMPTOMS AND COURSE OF CHRONIC ARTICULAR RHEUMATISM correspond to the morbid conditions described. Mild or severe pain in one or more joints will be complained of. This is associated with restricted movement in the respective joints. There is usually an absence of redness over and about the joint, and tenderness is never excessive. Joint motion is very often associated with a distinct crepitus. With the continuance of the process restriction of motion and faulty position will often eventuate in the disability of an entire limb. It is in this way that, by the multiplicity of joints involved, the subject of chronic articular rheumatism is often permanently invalided. Acute exacerba- tions of the chronic disease are of frequent occurrence. The diagnosis is ordinarily easily made. The conditions with which it may be confounded are arthritis deformans and the articular affections consequent on diseases of the spinal cord. The treatment of this condition is chiefly general. During the acute exacerbation sodium salicylate is as serviceable as in the typical acute articular disease. During the intervals alkaline waters, particu- larly those containing lithia, have been found efficient. Sulphur and mud baths, when long continued, seem also to have proven serviceable. Methodical massage may accomplish much in overcoming joint fixation, hastening the absorption of effused fluids and reducing the thickened capsule and periarticular structures. Osteo-arthritis. — This is a condition of degeneration and prolifera- tion of the structures entering into a joint, the morbid anatomy of which forms a distinct entity. The causes which bring about the changes are far from being clearly apprehended. It is for this reason the disease has been variously named rheumatoid arthritis, arthritis de- formans, dry arthritis, trophic arthritis, according to the views enter- tained concerning its nature. For the most part it develops by predi- lection in individuals past middle life, many of whom present evidences of arterio-sclerosis. Occasionally it develops in young subjects, prefer- ably in girls after the appearance of menstruation. As the immediate cause of osteo-arthritis trauma plays a most im- portant role, particularly about the hip, rapid changes of an osteo-arthri- tic nature following contusions of and about the trochanter. Within three or four weeks most extensive changes may occur which simulate the conditions following a fracture. Medico-legally, the knowledge of a trauma as the exciting cause of an osteo-arthritis is of signal importance. INJURIES AND DISEASES OF THE JOINTS, ETC. 479 In its clinical manifestations osteoarthritis, except in the rarest cases, is characterized by its chronicity and the tendency to joint-fixa- tion, not by obliteration of the joint-cavity, but by the development of osteophyte processes which me- chanically impede motion. Pain Fig. 156. is one of the chief symptoms of this disease. The joint, as a rule, shows early the deformation of its contour. The ligaments are thickened, prominent, and indu- rated ; often bony deposits can be felt within them and continued into the periarticular fascife and tendons. In the early stages joint distention by fluid can occa- sionally be made out, although, as a rule, the process is one in which synovial fluid is rather reduced than increased in quan- tity. In accordance with this, the patient often experiences a dis- tinct creaking or grating when he makes an attempt at motion, and therefore stiffness and pain in the part will be complained of in the morning until the joint has been considerably used after a night's rest. Acute exacerbations follow- ing a trauma, for example, or a breaking ofi° of one of the osteo- phytic growths, may be followed by hemorrhage or serous effusion into the joint. This condition usually subsides more readily in cases of this character than in joints that are otherwise nor- mal. Morbid Anatomy. — Al- though all the structures entering into the joint are ultimately in- volved, the first changes are observed in the articular carti- lages. The disease begins usually with a proliferation of the deep layers and a rapid multiplication of the cells within the capsules. Where the joint surfaces must press upon each other the matrix of the cartilage becomes fibrillated, almost velvety. Where there is less pressure on the joint-surfaces the proliferation of the cartilage-cells proceeds, while the matrix remains intact. In the periphery, therefore, General .osteoarthritis, with multiple synostoses ("ossified man") (Park). 480 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 157. the process is formative. Thus there are formed ecchondroses, which are most marked along the borders of the joint surfaces, with a distinct tendency to outgrowths into the synovial membrane and the capsule where it joins the epiphyseal margin. The process of destruction pro- ceeds in the central portions of the joint, where, by attrition, the fibrillated portions of the cartilages are removed and the underlying bone-tissue becomes exposed. The changes in the latter tend toward a complete obliteration of the meshes of the uppermost lamellse, a com- pact layer of unusual hardness taking the place of the normal cancellous bone ; thus the eburnated surface of one bone grates against its fellow. Any unevennesses which may have been present soon cut furrows into the yielding surface opposed to them ; therefore in many cases osteo- arthritis is characterized by grooves and ridges alternating with each other on the surface of a bone involved in the disease. Their presence ex- plains why in joints so deformed motion is often limited to a single plane. The proliferation of the cartilage along the periphery of the artic- ular surfaces and into the margins of the joint-capsule presents marked tendency toward ossification. Osteophytic growths develop along the margins of the articular surface, thereby producing a dis- tinctly lipped appearance. Often the entire circumference of a joint will thus be en- sheathed by new bone-formation. Frequently these processes entirely change the outline of the joints, as will be seen by reference to illustrations, wherefore the name of arthritis deformans happily designates the morbid con- dition, as seen in advanced cases (Fig. 157). The capsule and ligaments often present osseous plates within them, the joint-fringes are early enlarged, often presenting infiltra- tions with various forms of connective tissue, fat, cartilage, or bone. The eating away of one or more of these processes is a fruitful source of the development of foreign bodies within the joint. The synovial membrane never becomes entirely obliterated, wherefore ankylosis does not occur in this disease. A vestige of the joint-cavity is always present. The joint becomes locked by proliferation of bone about it; a true ankylosis, however, rarely, if ever, takes place. By attrition, absorption of existing and deposition of new layers of bone go on synchronously. It is in this manner that, as the head of the femur, for example, in morbus coxec senilis (which is arthritis deformans of the hip) becomes absorbed, the acetabular rim is widened and made shallower by deposition of new layers of bone. In this process of absorption the head of the femur may almost disappear, the neck be reduced to a right angle or less, and the entire length of the femur shortened by from three to four inches. Arthritis deformans, knee (original). INJURIES AND DISEASES OF THE JOINTS, ETC. 481 Symptoms. — The beginning of arthritis deformans, except when it follows a trauma, is ordinarily insidious. Pains varying in their inten- sity, but often severe and associated with creaking of the joints and moderate joint effusion, are among the earliest clinical manifestations. Very frequently the pains are of a neuralgic character. In the hip, for example, they are referred to the sciatic nerve. The joint deformity, however, usually manifests itself early. Irregular nodules appear, grow slowly, and show no tendency toward absorption. With the temporary joint effusion and the pain, muscular contraction often manifests itself early, fixing the joint in an abnormal position. The course of the disease is ordinarily chronic, continuing at times for from three to ten years or more. Exacerbations consequent on trauma are frequently shown ; severer injuries may produce fracture or dislocation. Treatment. — -The treatment of osteo-arthritis is extremely unsatis- factory. In every feasible way joint movement should be maintained by active and passive movements. Massage may also be advantageous. Fixation by immobilizing dressings is to be strenuously avoided. Operative treatment is not often called for, although in younger individuals, and particularly when the disease affects only one joint, excision may be resorted to in cases where the pain is very severe or the limb rendered useless. In a num- ber of cases in which Kbnig made excision recurrence of the disease did not ensue during six years after the operation. A resected elbow-joint performed its func- tion well, although the arm was weak. A knee united firmly, although the patient was over sixty years of age. In two excisions of the hip of patients, aged respect- ively seventeen and twenty-eight years, the result was very satisfactory. Neuropathic Diseases of Joints. Although M. T. E. Mitchell called attention to the joint complica- tions of nervous diseases in 1831, it was not until their classical descrip- tion by Charcot in 1868 that they were given a fixed position in articular pathology. Whereas joint complications may follow injuries of the peripheral nerves or of the spinal cord, they are for the most part asso- ciated with the chronic diseases known as locomotor ataxia and syringo- myelia. Notwithstanding great variations in the mode of development and the rapidity of their course, neuropathic arthritis appears under two forms clinically, the benign and the malignant. The former begins as an acute or subacute swelling of the joint and the periarticular joint struc- tures. There is a serous effusion iuto the joint, which may after a short time be absorbed, the disease being unmarked by either fever, pain, or redness. _ The malignant type, according to Charcot, is found exclusively in tabetic subjects. With or without absorption of the serous effusion the joint-capsule remains relaxed and weakened, the ligaments show a tendency to undergo softening, and the articular ends of the bones are rapidly destroyed. The morbid anatomy would permit the logical division of neurog- enous arthropathies into the atrophic and the hypertrophic. In the latter proliferative processes in the cartilages, the capsule, and the periarticular structures predominate, since, as in cases of arthritis deformans, extra- capsular stalactitic growths and exostoses are of common occurrence. Atypical bone-formation is also found in the contiguous tendons and fascia. In the atrophic arthropathies, on the other hand, the degenera- 31 482 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 158. tive process predominates and leads to the destruction of the bony components of the joint. Often the entire epiphysis is changed in its conformation. Where, after destruction of the cartilaginous covering, attrition takes place, absorption follows, the process being one of rarefying osteitis. The head of the femur may be absorbed, leaving scarcely a trace (Fig. 158). In the knee absorption causes the disappearance of the condyles and of the head of the tibia. Thus a disproportion is established between the area of the joint surface as a whole and that of its com- ponent bony parts ; thereby is produced a flail joint, and as characteristic of this condition the tendency to luxations and subluxations. The arthropathies of nervous origin affect chiefly the knee. In 56 observations by Barry the knee was affected in 33, the hip in 15, the shoulder in 10, the joints of the foot in 11, the elbow in 8, and the joints of the hand in 1. In 66 cases the arthropathy was mono-articular; in 25 more than one joint was affected. As a rule, joint compli- cations do not supervene in tabes until the latter is well marked and has existed for from three to five years. It may develop before the tendon reflexes are lost, and occasionally it appears as the initial symptom. Symptoms. — The onset of the disease v ,,. '-a*»—*._.- is ordinarily sudden. Without apparent t-'flP exciting cause the joint and periarticular structures are swollen, and oedema may involve the entire extremity. The latter usually disappears rapidly, leaving the hydrarthrosis (Figs. 159 and 160). In a number of cases the joint effusion is preceded for a number of days by a grating sensation. The periarticular oedema has been ascribed by DeBove to a detachment of the joint-capsule from the bone, and the consequent effusion of the synovia into the periarticular tissues. In 23 out of 56 cases the onset was gradual. Most of the cases are marked from beginning to end by complete absence of pain and of local and general manifestations of inflammation. Except for the abnormal mobility of the joint and the consequent tendency to faulty position, the patient need not be embar- rassed by the presence of the arthropathy. In a few cases, spontane- ously or through trauma, the joint has been opened. The joint perfora- tion in these cases has not been followed by the disastrous consequences of like lesions in normal joints. Preternatural mobility is characteristic of this condition. The knee, when the patient is erect, is thrown back- ward, with the receding angle in front ; in the hip external rotation can be carried to the point of bringing the heel forward. Except for the often enormous joint distention in tabetic disease of the shoulder, the upper extremity assumes the position of one in which excision of the shoulder-joint had already been made. The diagnosis of neuropathic arthritis is ordinarily easily made. Aside from the symptoms of the parent affection, the rapid course of Disappearance of joint end of femur in neuropathic atrophy (original). INJURIES AND DISEASES OF THE JOINTS, ETC. 483 the disease, the relative freedom from pain, the large joint effusions, the local anaesthesia, the muscular atrophy, the relaxation of the ligaments, and particularly the age of the patient, are sufficiently diagnostic. The condition with which it may most Fig. 159. readily be confounded, osteo-arthritis, afflicts for the most part older individ- uals, is associated with severe pain and joint fixation, and is essentially slow in its development. It is only in the Fig. 160. Charcot's disease. Charcot's disease of elbow. hvpertrophic form of neurogenous joint disease that the diagnosis can become difficult. Treatment is palliative. When the effusion is extreme temporary benefit may be obtained, as in a case recently operated on by the writer, by tapping and injection of carbolic acid, as in the treatment advocated for hydrarthrosis. Joint fixation by proper appliances or retentive dressings may be of avail in locomotion. When the disease is limited to the knee, recourse may be had to excision with a hope of securing a firm limb. Rotter has thus excised the knee in 4 cases, with fair results in 2. Hysterical Joints. — As a result of slight trauma or over-exertion — as, for example, in dancing — and very frequently without any exciting cause, there develops in hysterical subjects a train of symptoms which, to casual observation, may closely simulate organic joint disease. From the time of Brodie the joints thus apparently affected have been des- ignated as hysterical joints. The individuals usually afflicted are girls and young women, sometimes pregnant, otherwise well nourished, and generally in the higher walks of life. They may or may not display other phenomena of hysteria or allied neuroses. The joints most fre- quently involved are the hip, the knee, and the ankle. Clinically cha- racteristic of an hysterica] joint is the disparity between the intensity of pain complained of and the local manifestations. 484 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Another clinical characteristic of the condition is the variability of the position assumed by the limb. The variations often follow each other at short intervals. A sign to which Brodie called particular attention is the intense hyper ozsthesia of the joint and of the overlying integument. This is more marked even than the tenderness of the joint in organic disease, in acute articular rheumatism, or in an acute periarticular abscess about to rupture. The pain of hysterical joints manifests itself only during the waking hours. The starting-pains complained of at night, so characteristic of some forms of organic disease, are seldom seen in hys- terical joints. In very rare instances organic diseases have been com- plicated by the exaggerated suffering of hysteria, but here the permanency of muscular contractures, joint fixation in one position, and the test by anaesthesia will make the diagnosis clear. The treatment of an hysterical joint should be directed toward the psychical condition of the patient. When once thoroughly assured that that there is no serious disease present, applications of electricity and massage will ordinarily speedily cause the symptoms to disappear. Too much attention should not, however, be given to local treatment, and retentive appliances and dressings should be strenuously avoided. Loose Bodies. In previously healthy joints or joints that have been diseased there are not infrequently found bodies varying in size, number, and histolog- ical construction, either loose and contained within the joint-cavity or adherent at some point by a pedicle of varying length and thickness. The joints oftenest the site of loose bodies are the knee and elbow. The former is involved in nearly 86 per cent, of all cases. In the remaining joints foreign bodies are only exceptionally found. In joints that have been free of disease these loose bodies— or floating cartilages, as they are often termed — are invariably the result of a trauma. Allied to this class of cases is that known as the internal derange- ment of the knee, where, in consequence of a violent wrench, one of the semilunar cartilages, preferably the internal, has been loosened from its moorings to the tibia and the coronary ligament, and is deflected toward the joint interior. First described by Hey, the subject has been investigated particularly by Allingham and Bruno. Of 43 cases exam- ined by operation or autopsy, the internal cartilage was luxated in 27 ; the external in 13 ; not stated, 3. Primary laceration of the synovial fringe, or its infiltration with blood and consequent exfoliation, may likewise be the source of a foreign body in a hitherto normal joint. According to Hunter, Shattuck, and Fisher, the organization of an intra-artioular dot will sometimes give rise to a loose joint body. Finally, the penetration and encapsulation of a foreign body, like a needle, may, though rarely, be the nucleus of a loose body. In diseased joints foreign bodies may develop as a consequence of fibrinous deposits on the joini surfaces. By organization and long-continued attrition the deposits are broken up, as a rule, into large numbers of minute bodies varying in size from a grain of mustard to a bean. They compress each other into ovoid biconvex forms, and occasionally fill the joint-cavity. These corpora oryzoidea, or rice-bodies, have been so called from their shape, size, and pearly appearance. INJURIES AND DISEASES OF THE JOINTS, ETC. 485 The hyperplastic synovial fringes observed in many of the diseases of the joints form another common source of these loose bodies, many of them floating frsely within the joint, others fixed by more or less attenu- ated pedicles to the joint-wall. These synovial fringes may present all the histological variations of the connective-tissue types found in the make-up of the joint ; therefore, these foreign bodies may be cartilag- inous, contain true bone, consist of a mass of fat, present a cyst within their interior, and, in very rare cases, a mass of mucoid connective tissue. Symptoms. — The symptoms of loose bodies vary with their size, situation, mobility, and the conditions under which they were developed. When they are small and numerous, as in cases of hydrarthrosis, tuber- cular disease, and arthritis deformans, they produce few symptoms and rarely of themselves require attention. In the larger bodies — which, as we have seen, are directly or indirectly of traumatic origin — the symp- toms are far more pronounced. Frequently their existence does not make itself manifest until the immediate results of the accident to the joint have largely disappeared. Thus, after a fall upon the knee, for example, a loose cartilage will occasionally be discovered a week or ten days after the injury and after a partial subsidence of the articular dis- tention with serum and blood. In other cases months and years may pass after an accident before the loose body is discovered. In the largest number of cases the symptoms manifest themselves in conse- quence of the locking of the foreign body between the articular surfaces and the consequent violent stretching of the joint ligaments. An individual makes a misstep or an awkward movement, and suddenly feels an excruciating pain which compels him to stand where he is or possibly to sink to the ground. The limb itself usually remains fixed nearly in extension in the knee ; in the elbow, at an angle of 130° or 140°. By a little manipulation the patient, or some one assisting him, brings the joint surfaces again into apposition, and except for some tenderness of the part and temporary effusion into the joint a return to an approximately normal condition follows. This incarceration of the foreign body occurs at intervals varying between a few weeks and as many years. Between the attacks the joint function, however, is rarely normal. Limitation of motion is very common. In the knee, the foreign body being usually in the anterior portion of the joint, or in the subquadricipital pouch, complete extension is not easily accomplished. In the elbow, the foreign body lodging more frequently in the anterior pouch, flexion to a right angle cannot be made. In cases of partial detachment of the semilunar body it can often be felt in its abnormal position and is but slightly movable. A positive diagnosis of a loose body can only be made when it is subject to palpation. When felt it appears as a hard round body under the soft parts, usually over the interarticular line or in relation with the external condyle of the femur. Its position can ordinarily be shifted, and as a rule it disappears from observation, often for long periods. Through long experience the patient himself is often more successful than the surgeon in bringing it to the surface. As to the nature of the foreign body, pre-operative diagnosis cannot be made. Treatment. — The multiple bodies which belong to the graver joint diseases, like tuberculosis and osteo-arthritis, very rarely require sur- 486 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. gieal intervention. In the larger bodies, which are the important factors in a diseased condition of the joint, the treatment is palliative or radical. The former consists in the wearing of an elastic bandage, which will, in a measure, keep the foreign body from between the joint surfaces. The radical measure applicable to-day is extirpation. To transfix them by needles and bury them without the joint by subcu- taneous measures must not be practised to-day. The excision, as a rule, should be made by an ample incision directly over the foreign body, whicli is held by an assistant, or, for the time being, transfixed by a needle. When, after the incision is made, the foreign body is not visi- ble, manipulation of the joint surfaces will either bring it to the surface or expose it somewhere in the interior. In the latter event it can readily be drawn into the wound by means of forceps or blunt hook. If there be a pedicle, this should be cut off as close as possible, and preferably without previous ligation. It is always wise as far as pos- sible to explore the interior of the joint for other foreign bodies, one of which might be readily overlooked in its more hidden recesses. When the foreign bodies are small and numerous a very free incision must be made for their dislodgement. and only in these cases is lavage of the joint requisite. In the pedunculated growths from the synovial fringes many may unfortunately escape removal, and, growing, require subsequent operation. The operation itself must be done with the strictest precautions as to asepticism. The fatality of the operation in pre-antiseptic days was nearly 40 per cent. It has been reduced to almost nothing. With the removal of the foreign body the irritative changes pro- duced by it rapidly subside, and joint function is almost completely restored. This applies partieularly to the operative removal or fixation by suture of a ruptured or dislocated semilunar cartilage. Tubercular Arthritis. Pathological Anatomy. — Tubercular arthritis in advanced cases includes in its destructive tendencies all of the joint structures. In its inception, however, it begins either in the epiphyseal ends of the bone, when it is called osteopathic, or in the synovial membrane, when it is known as arthropathic. According to the investigations by Miiller of specimens obtained in Kbnig's clinic, of 232 cases the primary seat of the disease was the bone in 158, the syn- ovial membrane in 46, the origin was doubtful in 28. Of 61 cases involving the hip the disease was osteopathic in 47, arthropathic in 3, and doubtful in 11 cases. Of 118 cases of disease of' the knee the bone was first involved in 69, the synovial membrane in 33, the origin of the disease unknown in 16. Of 53 cases of disease of the elbow the bone was first involved in 42, the svnovial membrane in 10, doubt- ful 1. Volkmann believed that in children the disease was almost invari- ably of osseous origin, whereas in adults the synovial type predominated. Nevertheless, according to the investigations of Miiller, 76 per cent, of the cases occurring after the thirtieth year were probably developed in bone. (a) Osteopathic Arthritis. — This begins, as a rule, as a well-out- lined nodule of reddish-gray or yellowish color in the epiphysis. It may be situated near the epiphyseal cartilage or directly underneath the articular line. In very many instances it is first found near the periosteum or in proximity to the capsular attachment. Whereas, as a rule, it at first presents itself as a single nodule, there may be many. In the severest types of the disease the entire epiphysis is evenly occu- INJURIES AND DISEASES OF THE JOINTS, ETC. 487 pied by the infiltration. The bone about the nodule is distinctly hyper- sernic, thereby accentuating the more subdued color of the tubercular nodule itself. In the hypersemic area the bone trabecular are somewhat thickened, the cancellous spaces are devoid of fat-cells, and within them are often found miliary tubercles. These are often the means of the extension of the disease. As the central focus increases in its dimen- sions it becomes yellowish in spots from deficient nutrition and fat- necrosis. Thus there are found nodules varying in size from a pea to a nut, consisting of a soft cheesy material, early containing spiculse of bone that have resisted absorption. Older nodules are made up alto- gether of this cheesy debris, and can readily be washed away or removed as an entity with the finger. This material has often been called tubercular pus, although it bears only a physical resemblance to the latter. At this early stage the nodule is contained within a cavity lined with granulation-tissue, thus constituting what is sometimes called the tubercular epiphyseal abscess. Very frequently the tubercular nodule, as has been shown by experiment, is of embolic origin. As in infarctions of the viscera, there then results infection of a wedge-shaped segment of the epiphysis, the base of the wedge being directly under the articular cartilage, the apex toward the epiphyseal line. The result Fig. 161. Central sequestrum (original). of this is an epiphyseal necrosis, which, while it may be as small as a bean, may, on the other hand, be as large as the epiphysis itself. In very many cases such small epiphyseal sequestra may remain for years im- bedded within the epiphysis, or, being absorbed by granulation pro- cesses, leave a cavity filled with serous exudation, or one that even- tually closes by the formation of cicatricial tissue. So fortunate a termination, however, is the exception. As a rule, a tubercular nodule becomes surrounded by a layer of granulation-tisme, which in turn be- 488 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 162 comes invaded with miliary tubercles, and it is through the growth of this granulation-tissue that bone absorption takes place. ( Vide Chapter IX.) Through the growth of the primary focus in the direction of the encrusting cartilage the joint itself, sooner or later, becomes involved. Even before a perforation of the encrusting cartilage has taken place there is a reactionary inflammation within the joint, as has been shown by Lannelongue, Volkmann, and many others who have operated early for tubercular disease. Before perforation ensues the synovial membrane becomes thickened, the car- tilage over the tubercular epiphyseal focus shows signs of proliferation, and the vascular offshoot from the synovial mem- brane intervening between the articular surfaces in part causes adhesion between them with a tendency toward partial ob- literation of the joint-cavity. This reaction may prevent joint infection or limit it to a part thereof. This is not infrequently seen in the knee. Generally, however, this takes place through direct communication of the epiphyseal tubercular focus with the joint interior. The granulations undermine the articular cartilage either in limited and numerous areas or as an entity. In the former the cartilage, having lost its pearly- white appearance, is cloudy, yellow, and presents numerous erosions, the floors of . :. ' -• : which are made up of fungus-like granu- 1 "*' vfe ,J ^vt" J '■ ■■■9r'J< lations. In other cases the entire encrusting * • v "'•'' cartilage, exfoliating as a mass, can be stripped from the underlying granulation- layer like the cuticle from a bleb (Fig. 162). With the penetration of the tuber- cular focus into the joint a panarthritis is speedily developed. The capsule becomes thickened, the synovial mem- brane injected ; it loses its smooth appearance and becomes covered with fungous granulations, within many of which will be found a miliary tubercle, as first described by Koster. With the thickening of the capsule there is infiltration of the periarticular struc- tures, which in the more superficial joints may extend into the subcuta- neous cellular tissue, binding down the skin, the fascia, muscles, and ten- dons to the joint-capsule. This infiltration is largelv of a gelatinous nature, and but the result of the retarded circulation' produced by the distended capsule. Within the joint there is, as a rule, found a little fluid, which is not pus in a strict sense, but is the product of the lique- faction of the cheesy substance in the depots and the cellular output of the fungous granulations (pyoid or archepyon). At this time there is a manifest enlargement of the joint, which is emphasized usually by the wasting of the muscles above and below. Usually spindle-shaped, covered by an ansemic, often glistening, and r . . ■ BUS * Tubercular panarthritis (original). INJURIES AND DTSEASES OF THE JOINTS, ETC. 489 adherent skin, underneath which a few of the larger veins will be seen, the joint now presents the typical appearance of tumor albus, or white smelting, the fungous or gc/a'tinoid joint-disease. In the majority of cases the capsule itself is softened at one or more places, whereby the granulation-process becomes extra-articular. Sooner or later the skin becomes involved from underneath, and the products of the tubercular disease escape through what is incorrectly called a tubercular abscess. From the absence of acute inflammatory signs such abscesses are some- times designated cold abscesses. Such a periarticular abscess may develop without involvement of the joint. A subperiosteal nodule not infrequently makes its way to the surface, undergoes caseation, and remains extracapsular to the end. As in other abscesses that have discharged, contraction usually takes place until a fistulous opening is left. The sinus leading to the tubercular focus is very often tortuous, and its cutaneous aperture far removed from the site of the disease. In long-standing cases of tubercular arthritis many sinuses are found, often under- mining the periarticular tissue over large areas. With the formation of abscesses the process ceases to be strictly tubercular, for the infection with ordinary pus- formers, as a rule, takes place soon after the tubercular depot has been discharged through the skin. In the prognosis of tubercular arthritis this secondary infection is of the greatest moment, since it is more destructive to the joint, and even to life, than the primary disease. (b) Arthropathia Arthritis. — When the synovial membrane is pri- marily attacked the tuberculosis may be diffusely disseminated over more or less of the entire area or be limited to one portion thereof, preferably one of its reflections or a synovial fringe. In the diffuse form there may be deposited a large number of miliary tubercles, without much change in the intervening tissue. The joint itself is not much altered. It is occasionally found in general miliary tuberculosis, of which it is only one of the many manifestations of infection. In other cases the diffuse tuberculosis of the synovial membrane is associated with increased vascularity, as a product of which an extensive serous or sero-fibrinous exudation is found within the joint. This latter, which is known as hydrops tuberculosis, must always be taken into consideration in the etiology of chronic articular effusions. The capsule itself is very often thickened by excessive vascularization, and as a product of this a more or less extensive deposit of fibrin will be found covering the synovial membrane and the articular cartilages. This may be extensive enough to completely cover the tubercular nodules. The partial organization of fibrinous deposit from proliferation of endothelial layers underneath will often give rise to the development of rice-bodies in large numbers, to which consideration has already been given. In the majority of cases the synovial membrane is very much thickened and softened, and within it there are disseminated tubercular depots of larger size, which also invade the subsynovial tissues. Commonly, there is only a slight increase of the synovial fluid, which soon becomes turbid and pyoid. As in the osteal form of tuberculosis, granulation-tissue develops from the sur- face of the synovial membrane and soon occupies the joint-interior. From it are invaded the encrusting cartilages. Ordinarily these present a distinctly worm-eaten appearance, and it is from the periphery toward the centre that the process of invasion takes place (Fig. 162). 490 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Repair in tubercular arthritis follows the paths by which recovery takes place in tuberculosis elsewhere. Its first evidences are found in the granulation-tissue, which loses its succulence from decreased vascu- larity and shows a tendency toward conversion into fibrous tissue. In this process small caseous depots are often left for years, and account for the tendency to recurrence of the disease. While it is certain that the bacilli do not live throughout such long periods, it is probable that their Fig. 163. Bony ankylosis of knee (original). spores live and develop actively after a slight trauma sustained some- times years after an apparent cure has been effected. (Although this explanation is hypothetical, it best accords with the clinical facts as often seen.) In the process of cicatrization joint surfaces are often welded together by fibrous bands, thereby reducing the joint-cavity in size, and particularly obliter- ating the subtendinous joint-pouches. It is in this way that limitation of joint movement remains as a permanent result. When the disease has destroyed both encrusting cartilages, fibrous bands firmly unite the articular ends, constituting a common source of fibrous ankylosis. With long continuance of this condition the fibrous bands undergo ossification until, where the condition has lasted for many years, the cancellous systems of contiguous bones are merged into each other, often without more than a vestige of the pre-existing interarticular cleft, thus producing bony ankylosis (Figs. 163 and 164). Symptoms. — The early stages of a tubercular arthritis are, as a rule, vaguely indicated by symptoms. Occasional pains, felt particularly during sleep, and in the lower extremities a passing lameness, are the earliest indications of the disease. With its progress the symptoms become more pronounced. Those to which attention is earliest directed are defective movement, swelling, deformity, and muscular wading. The INJURIES AND DISEASES OF THE JOINTS, ETC. 491 first of these is among the most valuable aids in diagnosis. There is early seen a limitation of movement, which is most marked in the Fig. 164. Section of bony ankylosis of hip (original). shoulder and in the hip, almost always present in the knee, and to a less extent in the wrist and ankle. Tubercular hydrops, which is oftenest found in the knee, may exist without limitation of joint movement. Swelling and deformity are early seen in all cases of tubercular arthritis except, in the cases of the deep-seated hip and shoulder. The swelling depends on the pathological conditions above described. Though seem- ingly the deformity may be due to an enlargement of the bones, this in reality rarely takes place, and then only as an excessive repair. In very exceptional cases there is an absolute elongation of bone in consequence of tubercular arthritis. The deformity is very frequently enhanced by partial or total luxation. In the knee there is a tendency toward sub- luxation backward of the tibia on the femoral condyles, the latter becoming abnormally prominent. In the hip, what is left of the femoral head often leaves the deformed acetabulum, thereby producing great deformity with shortening. The deformity is almost always enhanced by vicious joint fixation. Reflex contractures, invariably of the stronger flexor muscles, and angular deformity speedily ensue. The knee is flexed upon the thigh ; the elbow becomes fixed at an angle of 120° to 130° ; the wrist drops; the hip is flexed upon the abdomen ; and the foot assumes the talipes- equinus position by the contracture of the stronger muscles which act upon the joints named respectively. The contracted muscles can always be felt early as well-defined ridges in close proximity to the angle in which the limb is fixed. With the contracture there is often associated an crtrophy of the muscles as an early evidence of the disease. 492 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Although the degree of atrophy may not at first be measurable, the flabby condition of the muscles is significant of its presence. Pain varies materially at different periods of the disease and in the various types. It is most marked in the osteopathic form of the disease. In the synovial type, even when associated with large effusion, it may be slight or altogether absent. Whereas, as a rule, the pain is experi- enced in the joint involved, it may be reflected, as is the case notably in the hip, to parts far removed. Through fixation of the limb by mus- cular contracture motion does not necessarily increase pain. Children with advanced disease of the hip or of the knee often do not suffer at all, even from violent exercise. By substituting the functions of other joints for that of the one diseased motion in the latter is involuntarily reduced to a minimum. The constitutional complications of tubercular arthritis are rarely marked in the early stages. Adults and children are seemingly in per- fect health except for the local condition. In proportion as this extends the general condition suffers. Careful observation will reveal an evening rise of temperature, although in the morning it returns to the normal. Particularly in the lower walks of life, where the disease is long neglected, the pain and the consequent loss of sleep will frequently give the children a haggard appearance, which, however, may be made to disappear with the institution of proper treatment. When the disease has pro- duced extensive destruction of the joint and periarticular abscesses have devel- oped, the temperature, as a rule, is continuously elevated, and the constitutional manifestations are not unlike those of visceral tuberculosis. The diagnosis of tubercular disease is, as a rule, easy. In fully 90 per cent, of the cases it is almost self-evident. Far more diffi- cult is it to distinguish the individual types of the disease. The fun- gous variety of the superficial joints, like the knee, elbow, wrist, and ankle, is very easily recognized by the swelling, the deformity, and the sense of false fluctuation. More difficulty attaches to the recognition of a deep-seated tubercular nodule within the epiphysis. The condition with which this is most easily confounded is the epiphyseal gumma of late inherited syphilis. The presence of corroborating evidences of syphilis, rapidity of development, and, above all, the therapeutic test, will, as a rule, make the diagnosis clear. Treatment. — The treatment of tubercular arthritis must be based on the natural tendency of the disease toward recovery. With or with- out deformity such recovery ensues — in disease of the spine, for example, where operative interference cannot be resorted to early. Conservatism, therefore, must be the keystone of treatment, and only in the failure of this must resort be had to active interference. Since tubercular arthritis is but the local expression of an infectious disease, general measures are not to be overlooked. An abundance of fresh air, a suitable diet, and attention to cleanliness are of first import- ance. The internal administration of gualacol and of creosote has been found to be beneficial. In the hands of very many Continental sur- geons the modified tuberculin treatment has also been followed by excel- lent results. The local treatment of tubercular arthritis should, in the first place, be directed toward securing absolute rest to the joint. A prolonged rest in bed will often at once relieve pain and swelling, and even if prolonged INJURIES AND DISEASES OF THE JOINTS, ETC. 493 through many months will not interfere with the nutrition of the patient. Local rest is best obtained by the use of a retentive dressing of plaster of Paris, of starch, or of silicate of soda, applied with sufficient snug- ness to distinctly compress the distended joint. In the joints of the lower extremity, except the hip, and of the upper limb, except the shoulder, and in tuberculosis of the spine, such retentive dressings are often the most serviceable of the methods of treatment to be invoked. In the inception of the disease traction (extension) is also very service- able, particularly in overcoming the tendency toward the contracture of the flexor muscles. During the acute stages such traction can be best maintained with the patient in the recumbent posture, whereas later some form of traction splints can be successfully used. In tubercular arthritis of the upper extremity the use of extension is far less valuable. When the contractures are firm enough to resist traction an open division of the contracted parts should be made. In very many cases it is advisable to attack the tubercular disease directly by agents which distinctly destroy the bacillus or unfit its soil for necessary sustenance. Such agents are zinc chloride, balsam of Peru, and particularly iodoform. The direct injection of either of these agents into a tubercular focus at intervals varying from four or five days to as many weeks will often obviate the necessity of a more or less crippling operation. The zinc chloride may be used in the saturated or 50 per cent, solution, and from four to five minims injected. The balsam of Peru is injected undiluted. The iodoform may be employed in 10 to 20 per cent, solutions in sterilized glycerin or olive oil, and injected in quantities varying from one drachm to two ounces. To avoid iodoform intoxication it is best to begin with a smaller quantity. While the injections are being made the urine should be carefully examined, since the gravest result of such intoxication has been parenchymatous ne- phritis. The iodoform solution should always be sterilized by submer- sion of the iodoform during four days in a 1 : 1000 solution of corrosive sublimate ; it should then be thoroughly washed in sterilized water. The glycerin, and particularly the oil, should also be sterilized by boiling. When many fibrinous shreds come away through the cannula it is 1 advisable to freely incise the joint, with proper aseptic precautions, and to thoroughly irrigate it with a saturated boric solution before making the iodoform injection. If need be, the incision can be sufficiently enlarged to make the operation exploratory, the incision being closed immediately after the injection has been completed. For the cure of a tubercular arthritis from three to twenty injections may be necessary, and the time required to effect a cure varies from two months to one year. Hydrops tuberculosus will often disappear under rest and compression. In the failure of this, aspiration should be resorted to, and this be fol- lowed by the injection of carbolic acid or iodoform. The so-called cold abscesses require special attention in many cases, although when they are limited in size they may be allowed to take care of themselves. Through defective operative treatment, septic infection, which may rapidly be destructive to joint and life, has often been induced in the past. 494 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Here also the injection of iodoform, after the preliminary tapping and irriga- tion, is frequently followed by a brilliant success. The size of the abscess is no indication of the extent of the lesion which gave it origin. Its walls are lined by a quasi-pyogenic (pyophylaetic) membrane which, as Volkmann has shown, is studded with miliary tubercles. When the iodoform injection, after repeated attempts, has failed of success, the abscess should be thoroughly incised, its walls cleared of the tubercular lining with a sharp spoon or, what is preferable, the operator's finger wrapped in sterilized or iodoform gauze. This operation should be considered incomplete until the aperture of communication, which usually though not always is present between the abscess and the joint interior, has been discovered, enlarged if need be, and the joint treated by injection. These conservative measures will frequently fail of encompassing a cure or even of stemming the progress of the disease. In cases from the lower walks of life the conditions when first seen may altogether preclude conservatism. Operative measures of greater or less extent are then called for, the object of which is the mechanieal removal of the tubercular tissues and of carious bone, and the procuring of a surgically clean wound with its natural tendency to immediate union. Sometimes there can be detected in the head of the tibia, the femoral condyles, and the ulna a tuberculous nodule which can be removed through an incision that does not involve the joint. In the removal of such a nodule the chisel should be carried through sound bone, and as far as possible the infection of this from the tuberculous centre is to be avoided. In the great majority of cases the operative treatment cannot stop short of a free incision into the joint, thus making it in a measure explor- atory. Such free incision, technically termed arthrotomy, is, of itself, with proper precautions, devoid of danger. When thus thoroughly exposed the tubercular foci can be readily removed, and, if the pro- cedure has not been too long delayed, without seriously affecting the outlines of the joint surface. This operation, known as arthrectomy or joint evasion, means the removal usually of fungous masses from the synovial membrane, of the encrusting and interarticular cartilages, so far as they may be diseased, of the synovial membrane and capsule, if need be, and of the evacuation with the chisel or sharp spoon of tuber- cular foci in the epiphysis. The operation is therefore, in reality, an atypical resection. In joint erasions recourse should be had to cutting rather than to scraping instruments, since the danger of infecting the wound with tuberculosis is thereby reduced to a minimum. After the erasure has been completed sterilized iodoform is to be introduced into the wound, the articular wound closed by deep sutures, and the cutaneous wound in the ordinary way. Drainage is ordinarily not called for, although when oozing has been checked with difficulty a silkworm-gut strand, drawn through the wound and to be removed with the first dressing, will answer well for drainage. Many surgeons pack the wound for two or three days with iodoform gauze, after which the sutures introduced at the time of opera- tion are tightened. Even the heads of the humerus and of the femur have thus been successfully freed of tubercular nodules and of their encrusting cartilage, returned to their respective sockets, and excellent results obtained. INJURIES AND DISEASES OF THE JOINTS, ETO. 495 A further advantage of arthrectomy is the ease with which the operation can be repeated if necessity arises, and the important fact that by not interfering with the epiphyseal cartilage the growth of the bone in length is not curtailed. Resection, for tubercular arthritis, formerly very extensively prac- tised, is for good reasons less and less employed. Until the period of puberty has been reached a formal excision should rarely be performed, since the removal of the epiphysis is invariably followed by very great shortening of the extremity. It is only after arthrectomy, as above described, has failed in children and in young adults that formal excision should be at all practised. In persons who have arrived beyond the age of puberty, the same objection not obtaining, excisions are more frequently to be made. At this period of life repair, so far as bone is concerned, is less easily accomplished, and the uneven surfaces which remain after arthrectomy might fail to unite; therefore — as in the knee, for example — we are sometimes compelled to make a formal excision in order to ensure the speediest recovery with a useful limb. As a rule, however, excision for tuberculosis of the larger joints should be reserved for the correction of deformity after the tubercular process has healed spontaneously or through the methods of treatment, operative and otherwise, above described. In tuberculosis of the wrist and of the foot total excision of the bones involved is to be resorted to rather than the excision of the tubercular focus and its evacuation by curette or chisel. It is particularly in these cases that operative infection of con- tiguous joints and of overlying tendon-sheaths is likely to occur. Even in the absence of such infection the shell of bone which is left after the evidement of the tubercular focus is filled with a clot which readily becomes infected, and in the contrary event is difficult of organization. In severer cases of tuberculosis of the bones of the wrist, and par- ticularly of the tarsus, amputation will often afford the patient the quickest and safest road to recovery. Amputation must likewise be resorted to at times in children in whom the tubercular and secondary suppurative processes have left the region of the joint riddled with sinuses and the bones destroyed over extensive areas. In the lower extremity such amputations must be made oftener than in the upper, but in both, with the improved surgical technique of recent years, the mortality following them has been reduced to a minimum. Ankylosis. This signifies, literally, a crooking of the joint. In a general sense it is, reserved for fixation of the joint, with which there is often associated an angular deformity. The diseased process may be in the joint proper, in the periarticular tissues, the overlying muscles and tendons, or even in the integument. Every joint fixation has thus often been included in the term ankylosis. A division has likewise been made into the fibrous or false, and the bony or true, ankylosis. A better division is that by which the term (a) contracture is used to designate joint fixation by abnormal- ities of the soft parts, and (b) ankylosis from fibrous or bony union of the articular surfaces proper. a. Contractures. — Acute inflammations of the joints and tubercular processes are, as we have seen, very often early associated with muscular 49G AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. contraction, which, from the inception, immobilizes the joint absolutely except to examination under anaesthesia. After the subsidence of the primary disease the contraction may continue and simulate the lock- ing of the joint. The periarticular swelling and the thickening of the capsule attending rheumatism will often leave a joint in a similar appar- ently ankylotic state. The cicatricial contraction which follows severe burns may likewise produce an apparent ankylosis. In the last-named condition the interior of the joint may remain, except for dryness, com- paratively normal. The continuation of joint fixation of this nature will slowly, by the growth of new connective tissue from the periphery of the joint, eventually lead to a true ankylosis. In cases of severe spastic paralysis the condition of ankylosis is likewise simulated. b. True ankylosis has been properly divided into the fibrous and the osseous, although in long-standing cases a combination of both forms will be usually found, and only in very chronic cases does it ever come to a complete bony union of the articular ends with total obliteration of the Fig. 165. Bony ankylosis of hip (original) : external view of specimen shown in Pig. 164. joint-cavity (Fig. 166). The diseases which are most productive of true ankylosis are — acute suppurative arthritis, to a less extent tubercular disease, and chronic rheumatism. In the latter ankylosis of many joints is often seen. Post-gonorrhmal arthritix, the non-suppurative complica- tions of puerperal septicaemia, and the acute infectious diseases are less often followed by bony ankylosis. The diagnosis of the conditions which fix a joint is' ordinarily easily made. That of fixation from extra-articular causes must always be dif- ferentiated from that of true ankylosis. The clinical history of the case and the condition of joint movement under an anaesthetic would make the recognition simple. The differentiation between the fibrous and the INJURIES AND DISEASES OF THE JOINTS, ETC. 497 bony ankylosis is, as a rule, also easily established. A bony ankylosis will absolutely prevent joint-motion, whereas in the fibrous varieties the patient himself, or with a little assistance, can always elicit a certain de- gree of motion. The knee forms an exception to this rule : notwith- standing an osseous ankylosis, some degree of motion can be elicited. Fig. 166. Bony ankylosis of knee (original). The writer has in two cases seen an osseous ankylosis of the patella to the anterior surface of the femoral condyle with slight joint motion. The operation revealed the joint interior free except where the patella had formed attachments. Treatment. — The treatment of joint fixation necessarily varies with the conditions which produce it. If the result of cicatrices, fascial or muscular contractures, attention must be directed to them rather than to the joint itself. The former must be remedied by plastic operation. Contractures of muscle and fascia can often be overcome under an anaes- thetic. If this fails, success must be expected from a division of the tendons and fascia, either by subcutaneous operation or, preferably, by open division. In cases of true ankylosis that are known to be fibrous, operative measures are called for only after a milder treatment by baths, massage, and active and passive joint movements has been tried without effect. Mechanical appliances to stimulate motion may also be tried. Very fre- quently, indeed, by the combined use of massage and weight-extension, the deformity which so often accompanies ankylosis can be overcome. In the failure of these methods recourse may be had to forcible breaking 32 498 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. up of the fibrous adhesions which fix the joint, always under an anaesthetic (brisement forcS). The less the number of adhesions broken up at a sitting, the less is the reaction ; therefore anaesthesia may be resorted to at intervals of a week or ten days, and thus gradually the deformity be overcome and an opportunity given for the little that is gained each time to be maintained. By this method there is avoided the Fig. 167. danger of lacerating a large vascular or nerve-trunk running in close prox- imity and adherent to the joint- capsule. Particularly in attempt- Fig. 168. f it Bony ankylosis of nip with deformity. Bony ankylosis of hip with deformity (original). ing to overcome long, old-standing angular ankylosis of the knee have ruptures of the popliteal artery, vein, or accompanying nerve-trunk been produced. In severing adhesions the force should always be so applied at first as to increase the deformity. The angle of flexion of the knee and elbow should by the first movement be even more reduced. Upon this flexion should follow the first attempt at extension. Unfortunately, even with the most careful and oftenest repeated attempts to overcome a fibrous ankylosis, failure to restore, even approximately, normal joint function is the rule. The fibrous bands which have been broken up reunite and the ankylosis is speedily re-established. If, therefore, the ankylosis is left in the most favorable possible position, it is all the patient can hope for. The treatment of bony ankylosis must be limited to the correction of the deformity. When bony ankylosis has occurred and the disease which INJURIES AND DISEASES OF THE JOINTS, ETC. 499 produced it has disappeared, the danger of operative interference is only that which would follow a like operation upon a healthy bone. The cumbersome appliances which in former years have been resorted to for overcoming osseous ankyloses are no longer to be used. The osteoclast, which played an important role before the days of antiseptic surgery, is only of historic interest. If the position of the limb is a correct one, osseous ankylosis is not to be interfered with. In the overcoming of deformity the operation may be done through the joint or in close prox- imity to it. In ankylosis of the hip, in which there is often extensive new bone-formation, it is better to divide the bone below the trochanter. When the neck of the bone has not been destroyed by disease, its sub- cutaneous division with a saw, after the method of Adams, may be resorted to. In ankylosis of the knee recourse must usually be had to the excision of a wedge, with base anterior, before the deformity can be corrected. Bony ankylosis at the elbow is best treated by excision, which will leave a very serviceable although an abnormally movable joint. CHAPTEE XXXIII. OPERATIONS ON JOINTS. By Joseph Ransohoff, M. D. Arthrotomy. — By this term is meant an incision into the joint, either for the purpose of establishing drainage or for purposes of exploration. It is indicated in chronic serous and purulent effusions where other measures have failed. For the removal of foreign bodies and loose cartilages, arthrotomy offers the only radical relief. Since the operation is always to be done under anaesthesia, the incision through the integu- ment and the capsule should be ample enough to freely permit thorough exploration of the joint interior. Arthrectomy. — Arthrectomy, or joint erasure, reserved almost alto- gether for the treatment of tubercular processes, has for its preliminary step an arthrotomy. The operation consists of the removal of the syno- vial membrane, of the encrusting cartilages, and of the superficial laminae of bone so far as they may be diseased. In an arthrectomy, or joint erasure, nothing is sacrificed except that which is the seat of disease. The operation is therefore less severe than is an excision, can be per- formed earlier, and when successful may retain much of the joint func- tion for the patient. To be entirely successful the incision into the joint must be large enough to permit its thorough exploration, lest a hidden focus of disease escape detection and appropriate treatment. Resection or Excision. — Although these terms are used synony- mously, the former applies to the removal of portions of bone in their contiguity — the latter to the removal of the articular surfaces and soft parts that enter into the joint formation. Since the latter complete operations are not often demanded, the terms may properly be consid- ered synonymous. Joint excisions are called for in compound dislocations when reduction cannot be otherwise made, in gunshot injuries where there is much shat- tering of bone, and for the relief of angular ankylotic deformities. Sup- purative processes consequent on penetrating wounds or general septic infec- tion likewise demand resection. The great majority of cases in which joint excision is demanded belong to the class of tubercular arthritis. The indications for the operation in this class of cases have been consid- ered in the paragraphs on tubercular arthritis in the preceding chapter. Excisions made for injury are, like amputations, divided into the primary, the intermediary, and the secondary, the first of these being made within the first twenty-four or thirty-six hours and before wound- infection has occurred. Wherever possible excisions for injury should be primary. The intermediary excisions are made during the height of infective inflammation, and consequently of the general septic infection. It is for this reason that the mortality of these operations on the larger joints is enormously high. Secondary excisions are made after the de- 500 OPERATIONS ON JOINTS. 501 cadence of the infective process, and have for their object the removal of dead bone and of pyogenic surfaces, and such preparation of the articular ends as will ensure an ankylosis in a good position. Arthrodesis. — Allied to the excision of a joint is the procedure which contemplates its destruction and the production of an ankylosis. The operation having this for its object is termed arthrodesis, and is applicable especially in cases of infantile paralysis, in consequence of which the usefulness, particularly of the knee and often of the ankle, has been lost. When in these cases orthopaedic appliances fail to give relief or the financial condition of the patient precludes his obtaining aid therefrom, joint excision often restores the usefulness of the limb. In excisions of joints the incision should be as nearly linear as possi- ble ; tendons should be preserved in their attachments to the soft parts, and bruised as little as possible. Attention to the making of a clean wound is one of the essentials of healthy repair. Since the labors of Oilier of Lyons and the younger Langenbeck of Berlin and Larghi of Bologna, much attention has been given to the saving of the periosteum as a single layer, which, subsequently ensheathing the denuded bone sur- faces, is believed to further the development of new bone to take the place of that which has been removed. The subperiosteal method, as this has been designated, is feasible only in cases of disease where the thick- ening of the periosteum permits its being stripped away from the bone before it is divided. Large blood-vessels are never endangered in excisions ; the use of the Esmarch bandage is therefore unnecessary. The bleeding is ordinarily so slight during the operation that with competent assistance it does not obscure the field of operation nor make the overlooking of a nidus of disease probable. SPECIAL EXCISIONS. Shoulder. Resection of the shoulder is ordinarily partial, in that the head of the humerus alone is removed, the glenoid head of the scapula being usually left in situ. The operation can be made by a straight incision over the anterior surface of the joint, beginning at the acromio- clavicular junction and passing over the anterior convexity of the joint for a dis- tance of three to four inches. ( Vide Fig. 169.) The incision may likewise be made from a point above the coracoid process obliquely across the front of the joint in the direction of the fibres of the deltoid muscle. Charles Bell and Morel practised a U-shaped incision with the concavity upward, making a flap of the deltoid muscle. Konig exposes the joint through a posterior longitudinal incision. Whatever the incision, the capsule is opened, the wound margins separated by broad retractors, and, while the assistant rotates the arm Fig. 169. Excision of the shoulder (Oilier) : A , reg- ular incision ; B, supplementary. 502 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. outward, the knife is carried over the lesser tuberosity, dividing the cap- sular ligaments and the attachments of the subscapulars muscle. The arm being then rotated inward, the attachments of the supraspinatus, infraspinatus, and teres minor are divided. Wherever feasible in this step of the operation, the practice of Vogt should be followed of retaining the greater and lesser tuberosities with the muscular attachments. The head of the humerus is now forced out through the wound, seized with the forceps, and removed with the saw. The best functional results are obtained when the section is made through the anatomical neck. The line of section must be determined, however, by the extent of the lesion which demands the operation. This is completed by the removal, if it be necessary, of the glenoid fossa with saw or forceps, although in this event the attachment of the long head of the biceps to its upper end should be preserved in connection with a few bony laminae with the periosteal covering. Elbow. Indications. — Partial or complete excision of the elbow must be resorted to for compound dislocations, ankylosis, suppurative arthritis, gunshot injuries, and chronic articular disease. It is likewise indicated in chronic dislocations in which milder operations, like osteotomy of the olecranon, fail to make reduction possible. The various methods of operation have in common a long posterior incision, to which, according to various operators, may be added a par- allel lateral incision, a transverse incision, or both. In almost all cases the posterior longitudinal incision suffices (Figs. 170, 171, 172). It should be in adults at least four inches long, with its centre opposite the base of the olecranon. The incision should run a little to the inner side of the axis of the olecranon and be carried along its entire length down to the bone. The soft parts — and, if possible, the periosteum — are first elevated toward the inner condyle by longitudinal incisions carried down to the bone. In this manner the ulnar nerve is pro- tected. The incision is carried around the epicondyle, carefully pre- serving, if possible, its muscular and ligamentous attachments. The dissection is next carried in the same way toward the outer condyle, equal attention being given to the protection of its muscular and liga- mentous connections. Particular attention should here be given to saving the anconeus muscle. Through forced flexion the lower end of the humerus is then dislocated into the wound and sawed through on a level with the base of the condyles. The radius and ulna are next brought into the wound, and, if need be, divided on a level with the base of the coronoid process of the ulna. When the dissection is made for bony ankylosis the bones of the forearm must be divided first, and with them there is brought through the wound the lower end of the humerus, which is divided below the epicondyle. Oilier employs a "bayonet" incision, which is a modification of the external late- ral incision advocated by Chassaignac. The incision begins on the external border of the arm, three inches above the articular line, and is placed between the supinator longus and the outer border of the triceps tendon. It is carried down to the level of the epicondyle, when OPERATIONS ON JOINTS. 503 it turns downward and inward to the olecranon, the posterior border of which it follows to its base and onward as far as need be toward the Fig. 171. Fig. 172. fl Excision of the elbow- joint : A, Von Langen- beek ; B, Oilier. Excision of the elbow- joint: A, Nelaton; B, C, Hueter. Osteoplastic method : A r by external incision ; B, Von Mosetig-Moor- hof. ulna. The incision over olecranon and ulna is at once carried to the bone. In the upper portion of the incision the periosteum is reached between the supinator longus and triceps and the capsule opened. In the middle portion of the incision the cleft between triceps and anconeus is followed, and the triceps tendon separated from the olecranon. After the detachment of the external lateral ligament the lower end of the humerus is dislocated outward and removed with a saw. Radius and ulna are subsequently removed in the same way. The ulnar nerve is not seen in this operation. The Wrist. The complexity of the wrist-joint, the number of bones entering into its formation, the firmness with which they are held in relation to each other, and the number of the overlying tendon-sheaths have made ope- rations on it difficult of accomplishment. Post-operative extension of the disease, protracted suppuration, and a result which is, as a rule, far from good, have made many operators question the usefulness of excis- ions. With improved technical resources, however, better results are being obtained, and particularly after partial excisions, and to a consid- erable extent after total excisions, a hand that is fairly useful may be retained. An excision should be considered complete only when at least the extremities of the bones of the forearm and all of the first row of the carpus, with the possible exception of the pisiform, are removed. Any operation short of this should be designated a partial excision. The conditions requiring excision are gunshot injuries, compound frac- tures of civil life, suppurative arthritis, and tuberculosis. In the com- 504 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. plicated injuries of the wrist and hand as sustained in factories, and as often seen in civil life, partial and informal excisions should always be given preference to primary amputation, unless it is evident from the complicated nature of the trauma that gangrene would follow. It is particularly in this class of cases that conservative resection is followed by excellent results in cases apparently hopeless. For disease, resection is rarely called for before puberty, the cases being amenable to the milder measures of removal of individual bones. It is during the third and fourth decades of life that excision is most frequently demanded. Methods. — The operation most frequently performed by English and American surgeons is that described by Lister in 1865 (Fig. 173). The incision begins over the middle of the dorsum of the radius on a level with the styloid process. It Fig. 173. is carried downward in the direc- tion of the inner edge of the joint of the thumb and first metacarpal bone, from which point it is deflected downward along the radial border of the hand about the mid- dle. This, which is known as the radial incision, divides only the tendon of the short radial exten- sor of the wrist. The tissues upon the radial side of the incision are raised, the tendon of the long ra- dial extensor of the wrist is divided at its point of insertion, and all the soft parts are retracted outward, thereby exposing the trapezium, which is cut off from the rest of the carpus, but left in place to be removed later. By extending the hand the tendons are relaxed and the carpus cleared in the direction of the ulnar border of the hand. A free ulnar incision is then made, the knife being entered two inches above the styloid process of the ulna directly in front of the bone, and carried downward between it and the flexor carpi ulnaris in a straight line as far as the middle of the fifth metacarpal bone on its palmar surface. The dorsal lip of this incision is then raised, the tendon of the extensor carpi ulnaris cut at its insertion and dissected up from its groove in the ulna. The extensors of the fingers are then lifted up and the dorsal and inter- nal lateral ligaments of the wrist-joint divided. The flexor tendons are next separated over the front of the carpus, to accomplish which the unciform process of the unciform bone must be cut with the forceps. In this dissection the knife ought not to be carried below the bases of the metacarpal bones, to avoid injuring the deep palmar arch. The anterior radio-carpal ligament is then divided, the carpo-metacarpal articulations opened, and the carpus is extracted through the ulnar incis- ion with suitable sequestrum forceps. The ends of the radius and ulna can then be easily protruded through the ulnar incision, and as much as ;/)-^'7\ Excision of the wrist: A, Lister's radial incis- ion; B, Lister's ulnar incision; C, Oilier; D, Von Langenbeck. OPERATIONS ON JOINTS. 505 may be necessary can be removed with gouge, chisel, or saw. The ends of the metacarpal bones are sawn off or at least deprived of their artic- ular facets. The operation is completed with the removal of the tra- pezium, which, being seized with a strong pair of forceps, is readily dis- sected out without necessitating the division of the radio-carpal flexor or the radial artery, The Fingers, Thumb, and Metacarpus. Formal excisions of the bones and joints of the hand, although formerly described in works on operative surgery, are rarely required. The operations are for the most part limited to the removal of necrotic sequestra or of fragments in compound wounds of the fingers and hand. The formal excision of the metacarpal bones, with the possible exception of that of the thumb, will usually leave a flail-like finger, which may be- come a source of inconvenience to the extent of necessitating a second- ary amputation. Therefore, as a rule, with the exception of the thumb, the formal excisions of phalangeal or metacarpo-phalangeal joints of the hand are largely tentative. In most cases primary amputation is to be preferred. The Hip. The operation is indicated in tubercular arthritis when,. notwithstand- ing conservative measures, the destruction of the joint progresses and the vitality is undermined by long-continued and profuse suppuration. As will be seen from the chapter on tubercular arthritis, a formal excis- ion should be reserved for extreme cases, and particularly in children and in youths below maturity should the operation be limited to the removal of diseased structures, the operation being made an atypical resection or an arthrectomy. The excision of the entire epiphysis of the femur in a growing child means a shortening of from five to six inches when the subject has reached full development. In patients past the fifteenth year and in adults the same limitations do not exist, and formal excisions can be oftener made. Excisions are likewise called for in rare cases of arthritis deformans, for bony or fibrous ankylosis where simple osteotomy has not availed. Old-standing and painful dislocations of the hip and congenital dislocations may likewise call for operations upon the hip, although in the latter condition an osteoplastic operation looking to the formation of a new acetabulum should be given the pref- erence over the removal of the femoral epiphysis. Methods. — The simplicity of the hip-joint makes it approachable for operative interference from all sides except the inner. Many methods of excision have therefore been suggested and practised (Fig. 174). Longitudinal, curvilinear, and transverse incisions have been recom- mended for opening the joint, and flap operations with upper or lower convexity have likewise been practised. Of the various incisions, the longitudinal are unquestionably those best adapted for saving as much as possible of the ligamentous and muscular structures. The more complicated the incision, the greater the wounding of the soft parts and the less the probability of a good primary result. The longitudinal 506 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. incision that is most often practised is that originally made by White, but now known as the Langenbeck incision. The patient being placed upon the sound side, the limb, if it be not already so from disease, is flexed at an angle of 45°. An incision from three to six inches in length, according to the age of the patient, is made over the centre of the trochanter and in the axis of the femoral shaft. It should begin just above the trochanter, and in its upper two-thirds be placed in the gluteal region. Over the trochanter the incision passes at once to the bone, whereas the gluteal muscles are divided layer after layer. When the capsule is reached it is divided in the direction of the original incision from the acetabular margin to the femoral neck. Two transverse incis- ions made close to the acetabulum by cut- ting the cotyloid ligament and admitting air into the joint will open this freely for inspection and manipulation. The mus- cular attachments to the great trochanter are next divided close to their insertion, the periosteum as far as possible being preserved. The limb is rotated inward to expose and facilitate the divisions of i i the posterior muscles, and rotated out- . ' ' „ „,„ ward to divide the anterior. The capsule Excision of theinp^.Sayre; B, Olher. ^ ^^ ^.^ ^ ^ J ^ femur is readily dislocated and brought into the wound. The ligamen- tum teres, having usually disappeared, demands no attention; when present it must be divided. The soft parts being thoroughly protected by retractors, the saw is applied at the base of the femoral neck or, if need be, at the base of the trochanter. A very serviceable method is that of dividing the femoral neck at its base with a chisel, and subse- quently removing the trochanter, if need be, with a saw. Wherever pos- sible the trochanter should be saved. The operation is completed by removing the foci of disease from the acetabulum with bone gouge or chisel. As much of the capsule as can be should be removed and all of the joint interior cleansed with a sharp spoon or the finger covered with gauze. Before closing the wound the sinuses which are present should be thoroughly opened up or scraped. Tubular drainage being provided for, the wound is closed with sutures. Operation by Anterior Incision. — Luecke and Schede, and more recently Barker, have employed an anterior incision. It begins below the anterior spine of the ilium half an inch to its inner side, and runs downward and a little inward for three inches. It passes to the inner side of the sartorius and rectus femoris, and exposes the external border of the ilio-psoas. The further steps of the operation are similar to those above described, although the neck of the femur may be divided in situ with a keyhole or chain saw. The incision of Barker is to be preferred. It is made near the external border of the limb, passes between the tensor vaginae femoris and gluteal muscles on the outside and the sartorius and rectus on the inside, until it reaches the neck of the femur. The operation is simpler than that of Luecke and Schede, and closely OPERATIONS ON JOINTS. 507 resembles the incision made by Hueter. The position of an anterior incision sim- plifies the use of a posterior splint and does not interfere with drainage. The advantages are such that English writers believe the method to be that which should always be practised unless contraindications exist. Oilier has recently advocated an osteoplastic excision in which, through a curved incision with downward convexity made over the top of the trochanter, the latter is exposed and divided with the chisel, turned upward with a flap, and reunited by sutures to the femoral shaft after the excision of the neck and head has been completed. The management of the trochanter in excisions of the hip should not be routine. Although, on the one hand, Sayre and Volkmann made it a rule to remove it with the femoral neck, on the other hand Langen- beck and Hueter have advised supratrochanteric excision wherever feasible. The latter operation necessarily is followed by the least degree of shortening. Circumscribed disease of the head and neck requires the removal only of these parts. Whenever it is necessary, on the other hand, to thoroughly expose the joint interior and the disease requires the removal of the synovial membrane and parts of the acetabulum, excision of the trochanter becomes necessary. After-treatment. — In an adequately equipped hospital the patient can be placed in a wire cuirass, the limb in extension. A very effective dressing is the fenestrated plaster-of-Paris breeches, with extension by means of weight and pulley, as after the method of Gurdon-Buck. Counter-extension is not often required. Particular attention must be given to overcome the tendency to adduc- tion, and many operators advise placing the limb from the beginning in slight abduction. Since in most cases fibrous or bony ankylosis is sought for, passive movements are not ordinarily to be employed after excisions of the hip. In the few cases in which, from the local conditions existing at the time of operation, the preservation of joint movement can be hoped for, passive movements should be instituted as soon as the wound is thoroughly united. The greatest mortality follows operations performed in the first five years of life. It decreases from that period on up to the full development. In operations done in adults, and particularly in older subjects, the mortality is again very great. Regarding the usefulness of the limb after excision, the statistics of Baer show that in 8 out of 46 cases free active movement of the joint could be made; in 23 movement was limited, in 11 cases ankylosis resulted, and in 1 a flail joint remained; 12 were able to stand without support upon the resected limb. The Knee. Resection of the knee may be demanded for gunshot or other injury, for deformity, ankylosis, for neuropathic arthritis, and particularly for tubercular disease. Resection for gunshot injury has in past wars proved so fatal that unless the dangers of death from sepsis can be materially decreased, choice should be made between conservatism and amputation. The mortality following resection for gunshot injury is placed by all writers at about 90 per cent. For ankylosis with angular deformity resection is a safe and almost uniformly successful procedure. In tubercular disease the easy accessibility of the joint fits it particularly for the more conservative operation of arthrectomy and informal or partial excisions. In the failure of this recourse may be had to formal excision. The latter is not called for in young children, and even in youths and in adults should rarely be resorted to as the primary opera- tion, except in cases of most extensive destruction by disease. Methods. — The anatomical relations of the joint make it approach- 508 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 175. Excision of the knee-point A, semilunar incisioD B, Ollier's' incision. able by transverse, curvilinear, or longitudinal incisions made over the front and sides of the joints (Fig. 175). The transverse incision is made directly across the centre of the joint down to the patella, which is divided with the saw. The flaps thus made are reflected upward and downward, and the joint interior is reached. Usu- ally the semilunar incision with upper concavity is resorted to. The knife, being entered at the pos- terior extremity of one condyle, is carried down- ward and forward below the patella across the patellar ligament near its insertion, and thence upward to the posterior end of the inner condyle. The incision is carried into the joint. The flap containing the patella, being grasped with a sharp retractor, is drawn upward by an assistant, the knee being flexed to a right angle. By transverse incisions the lateral ligaments are divided and the crucial ligaments are severed close to their tibial insertions. In this step of the operation, to avoid injury of the popliteal vessels, the point of the knife should be directed toward the inner condyloid depression. The articular ends of the femur and of the tibia are now sufficiently separated from each other to permit their free protrusion from the wound and, after periosteal decortication around the periphery, their removal with saw or broad chisel. When the saw is used the femoral epiphysis may be divided from before back- ward. To remove the upper end of the tibia it is advisable for the pro- tection of the popliteal vessels to saw from behind forward. The opera- tion is completed by the removal of the patella if it be involved in the disease, and the extirpation of the subquadricipital pouch. The extir- pation of the capsule completes the operation. The proximity of the vessels makes the removal of the posterior wall of the capsule a delicate procedure. E. Hahn and, following him, a number of operators have reversed the semi- lunar incision, giving it an upper convexity and dividing the tendon of the quad- riceps femoris instead of the ligamentum patellae. The, advantage of the procedure is the ease with which the subtendinous pouch of the joint is reached. Volkmann and others open the joint by the transverse incision and the division of the patella, the latter being reunited, if it is to be saved, with catgut or wire sutures after the completion of the resection. Moreau, Ferguson, Butcher, and Oilier employ an H-shaped incision, the hori- zontal portion of which is carried through the ligamentum patellse. It has no advantage over the transverse or the curvilinear incision. When a longitudinal incision is made it may be in the axis of the limb and through the centre of the patella, which is then divided vertically with saw or chisel. As in transverse divisions of the patella, suture may be practised after the excision is completed. Langenbeck made an incision upon the antero-internal aspect of the joint. The methods by longitudinal incision have only the doubtful advantage of leaving the ligamentum patellse intact and serviceable in case joint-function is retained. For fixation of the bone surfaces Gurdon Buck in 1 853 resorted to bone suture. Many operators have since resorted to catgut or wire suture, or to the even firmer fixation by means of steel or ivory pegs. As a rule, such procedures needlessly complicate the operation, since OPERATIONS ON JOINTS. 509 fixation is readily maintained by closely applied retentive dressings and proper splints. With careful attention to hsemostasis during the operation drainage will be sufficiently provided by a strand of silk- worm gut passed through the most pendent portion of the wound. Ordinarily even this is superfluous. After-treatment. — Accurate apposition of the bone surfaces is best main- tained by means of a posterior concave splint, which is retained in place by plaster-of- Paris bandages applied above and below the line of incision. If desira- ble, the limb can be maintained suspended during the first twenty-four or forty- eight hours to reduce oozing to a minimum. When such a retentive appliance is used, it should be fenestrated over the wound to make the parts easy of access. When properly applied the first dressing need not be changed in less than from two to four weeks. The Ankle. Methods. — Many methods have been devised for excision of the ankle, but they are mostly modifications of the original procedure of Moreau by reaching the joint through external and internal lateral incis- ions. In 1865, Langenbeck modified it for the purpose of making the operation subperiosteally. The external incision, about three inches in length, is made over the lower end of the fibula and its malleolus beyond its tip. The incision is carried down to the bone : by means of an elevator the fibula is separated from its periosteum and divided with a chain or keyhole saw an inch above its lower end. The lower bone segment, being grasped by forceps, is drawn out of the wound, turned from side to side, and with short cuts of the knife severed from its liga- mentous attachments. In this step of the operation the external lateral ligament should be injured as little as possible. The second step of the operation, according to Langenbeck, is the removal with the saw of the upper articular surface of the astragalus. The third step is constituted by an incision over the internal malleolus, of equal length with the external, and likewise reaching down to the bone. The periosteum, being divided vertically, is peeled as far as possible from the inner and posterior surfaces of the bone. The internal lateral ligament is next divided and the tibia protruded through the inner incision by forcibly everting the foot. The articular end of the tibia is then removed with a saw. If need be, the whole of the astralagus can be removed from the external incision. The supposed imperfect exposure of the joint interior through lateral incisions has led many operators to resort to more or less transverse incisions across the front of the joint, either dividing the tendons and subsequently suturing them, or partly cutting and partly forcibly retracting them during manipulations upon the joint surfaces. These methods are, as a rule, to be condemned. Konig in 1885 modified the operation by longitudinal incisions, placing them respectively over the anterior borders of the tibia and fibula (Fig. 176). From these two incisions all of the soft parts between them are raised as a flap from the anterior surface of the joint. This is now opened and the interior exposed. With a broad chisel the outer lamellae of the malleoli, together with their ligamentous attachments, are sev- ered. The soft parts being then retracted, the lower end of the tibia is divided with a broad chisel and removed with forceps. When it is the seat of disease the fibula is removed in the same manner. The astragalus is next cared for, its upper sur- face being removed with the chisel, or, if necessary, the bone is entirely taken away. A unilateral external incision recommended by Chassaignac and Erichsen 510 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. gives valuable results if, after the opening of the joint and division of the external lateral ligament, the foot be forcibly dislocated inward. With almost the same object in view Kocher resorts to a semilunar incision from the outside of the tendo Achilles to the outer border of the extensor tendons and passing underneath the Konig's incision for excision of the ankle. external malleolus. The joint is thus easily and widely opened, the peroneal ten- dons alone being divided. After the completion of the operation these are readily sutured. This method is particularly applicable to children. After-treatment. — The wound is closed after ample drainage has been pro- vided for. Any tendency to a talipes-equinus position should be overcome by the use of a well-padded leg-and-fbot-splint made of perforated tin, felt, or plaster of Paris. During the first twenty-four hours the limb is to be retained at a right angle, after which it should be kept suspended. Osteoplastic Excision op the Foot. For tuberculosis of the ankle-joint and of the bones of the tarsus Wladimirov and Mikulicz, in 1871 and 1880 respectively, advised a pro- cedure by which the ankle-joint and as many of the bones of the tarsus as may be necessary can be removed with the retention of the anterior por- tion of the foot, which is fixed in an extreme equinus position. The operation is performed with the patient in the prone position. An incision is carried from the tubercle of the scaphoid bone across the sole of the foot to an inch behind the base of the fifth metatarsal bone (Fig. 177). From each end of this incision another is made longitudi- nally to the base of each malleolus, the ends of the lateral incisions being united by a cut across the ankle dividing the tendo Achillis. All incisions having been carried to the bone, the quadrangular flap is dissected from above, the joint opened from behind, the lateral ligaments divided, and the astragalus and calcaneum separated from their attach- ments and removed. The lower extremities of the tibia and fibula and OPERATIONS ON JOINTS. 511 the articular surfaces of the scaphoid and cuboid are next removed with the saw. The foot is then brought back, the divided surfaces care- Fig. 177. Osteoplastic excision of the foot (Mikulicz). fully adjusted, and the wound closed. Wire suture or bone pins may- be used to ensure fixation, although the procedure has been shown to be superfluous. Buntz has recently tabulated 34 cases of osteoplastic resection of the foot, in none of which death was attributable directly to the operation. Of 26 cases operated upon for tuberculosis, 18 were cured— 1 1 with a very good and 7 with a useful foot ; 2 died of tuber- culosis, and in 5 a secondary amputation had to be made. The result in 1 was unknown. Of the remaining cases, the result in regard to usefulness was good in 4, fair in 3, and bad in 1. CHAPTEE XXXIV. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. By Roswell Park, M. D. At the very outset of a study of surgical diseases of the osseous system it is necessary to emphasize a fact which students and young practitioners are often prone to forget — namely, that bone, even the densest, is a tissue, and that as such it is liable to infection, suppuration, gangrene, etc., just as is any other tissue; that all infectious processes are identical in general character, their gross mani- festations varying only by virtue of the peculiar characteristics of the tissue in which the infection occurs. Bone is always vascular, and even that exceedingly hard variety which is met with in the petrous portion of the temporal, or the ivory exostosis, has sufficient connection with the vascular system to permit of its proper nutrition. The firmest and hardest bone will bleed when divided or injured, and any tissue which will thus bleed can react injuriously to various irritants. All bone marrow begins as red marrow, with 1 or 2 per cent, of fat, and ends by becoming yellow, with 60 or 70 per cent, of fat, and whether this change shall take place suddenly or rapidly depends upon diverse conditions. Many years ago it was claimed by Bourgery that bone is simply a large cavernous arrangement where stagnation of the blood-current favors the deposition of fat. Fatty altera- tion progresses from periphery to centre, and the bones of the hands and feet undergo fatty alterations before those of the trunk and pelvis. In other words, the truncal skeleton remains as "red bone" longer than the balance of the osseous system, and he whose sternum has become a really "yellow bone" must have reached a ripe old age. So in long bones distal extremities first become fatty. Individual peculiarities seem to govern these changes. Thus, the neck of the femur will sometimes be fatty and friable at the fortieth year, or reasonably firm and still red at the eightieth. This fatty condition is not to be confounded with true osteoporosis or rarefaction in bone, though it is often associated with it. When the two conditions are combined we have osteoporosis adiposa. Into this condition immobilized limbs pass more easily than those which are used. Their weeks have been equal to years of ordinary inactivity. Red bone seems to be too highly vascular to be a favorite site for tubercle, and distinctly yellow bone too non- vascular. Consequently, bone tuberculosis is less often seen at the very extremes of life. White bone, as those who make anatomical preparations call it, is most favorable for tubercular infection on account of its minimum contents both of blood and fat. These bones come most commonly from phthisical subjects. Acute Osteomyelitis. This condition was never accurately recognized until described by Chassaignac in 1853, and even he missed many of its distinctive features, although he gave to it a most descriptive name, "typhus of the limbs." Pathology. — The disease is a distinctly infectious process, limited sometimes to the bone marrow and internal portion of the bone, some- times apparently involving every particle of the osseous structure. Its onset is sudden, its manifestations most acute and serious, and its rav- 512 SURGICAL BTSEASES OF THE OSSEOUS SYSTEM. 513 ages, when not promptly checked, most extensive. The following more or less distinct varieties may be distinguished : A. The Staphylococcus. B. The Streptococcus. C. The Pneumococcus. D. The Tubercular. E. Miscellaneous other Infections, including the Colon Bacillus, the Typhoid Bacillus, etc. Be the organism what it may, the mechanism of the infection and the lesions produced by it are essentially similar, and may all be de- scribed together. These consist of rapid thrombosis, coagulation-necrosis, and suppuration, along with the local destruction incident thereto, and with unlimited possibilities in the way of auto-intoxication, both from the local lesions and from the disturbance of the general economy and interference with excretion. Every severe case is accompanied by more or less of general septic intoxication, presumably from the ptomaines produced by the bacteria, while in many instances, particularly those where the bacteria at fault seem extremely virulent, the intoxication is> overwhelming and the course a rapidly fatal one. Death has been known to follow within thirty-six hours after the first symptom of ah acute osteomyelitis. For the average case three more or less distinct stages can usually be distinguished : first, a period of purulent infiltra- tion, with the formation of local foci in the bone marrow and speedy secondary involvement of the periosteum and synovial membrane ; second, a period of sequestration or formation of a sequestrum inside of an abscess-cavity ; third, the stage of repair. First Stage. — During this there occurs most violent inflammatory infiltration, localized areas becoming at first hyperaemic, then infiltrated with hemorrhagic exudate, whose rapidity of production will indicate the intensity of the infection, since often at the same time one finds enlargement of the spleen and hemorrhagic exudations in distant serous cavities, such as the pleura and pericardium. The locally infected areas of bone marrow quickly break down into depots of pus, which spread either toward the epiphyseal line or else along the Haversian canals toward the periosteum, which becomes both infiltrated and loos- ened. The loosening is particularly marked about the shafts rather than the joint ends, while, as a rule, that end of the bone toward which the nutrient artery is directed is the one whose epiphysis is first loosened. Nevertheless, about the knee it would seem as though the lower end of the femur and upper end of the tibia are the particularly predisposed localities. In many instances obliteration of nutrient vessels and thrombosis are very early features of the case. The area of separation of the periosteum is usually an index of the extent of deep destruction. From the periosteum the infection may extend toward the covering soft parts, in which case we may have a parosteal abscess, or it may perforate toward the joint-cavity, leading quickly to pyarthro- sis and destruction of joint structures. It would appear in children, particularly that the epiphyseal cartilage forms often a barrier to the advancement of the lesion in the direction of the joint, and thus it happens that we have acute necrosis of the shaft of a long bone, with perforation through the periosteum at both of its ends. In adults this takes place less often, the joint ends being- often primarily involved. Softening and separation of cartilages are usually secondary to the other processes. It is possible even- to have the primary infec- 33 514 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. tion in the joint end proper, and extension therefrom to the epiphysis permitting of epiphyseal separation and extrusion of this fragment as a sequestrum. This separation occurs in many instances rapidly and before the attendant is alive to what has really happened. Second Stage. — The second stage includes, coincidently with the occurrence of suppuration, the proliferation of considerable granula- tion-tissue, by which more or less protection is afforded ; also, when time is afforded, the rapid formation of new bone, whose effect is to wall off the scene of conflict and death from the surrounding tissue, by which event prognosis, so far as the patient's life is concerned, is very much improved. Intraosseous abscesses may quickly coalesce, and the result may be one long tubular abscess extending through the shaft. At other times both bone marrow and the cancellous tissue are bathed in pus, while if the periosteum has been totally separated the conse- quence will be a sequestrum whose dimensions correspond with those of the shaft. When periosteum is not loosened the necrosis will prob- ably be central and more or less circumscribed. ( Vide Plate XVIII.) Third Stage. — The third stage is the period of efforts at spontaneous repair. There is a natural effort toward elimination of the sequestrum by the process of softening or liquefaction in the direction of least resist- ance. This process may extend over months when surgical relief has been delayed, and may be accompanied by so much other disturbance as to completely ruin a bone or limb for further use. In neglected cases several sinuses may lead down toward the central sequestrum. On the other hand, once this sequestrum be eliminated an extraordinary amount of activity is usually displayed in the direction of repair. Symptoms.— In a general way the signs and symptoms of all acute infectious lesions in bone are strikingly similar, and are most significant when construed aright. Patients complain usually first of exhaustion, followed quickly by pain, which may speedily become agonizing. This is often accompanied by an introductory chill with high fever, after which the general character of the disease quickly assumes the typhoid aspect. Evening temperature may rise high and be followed by some morning remission. The spleen is usually enlarged, the primse vise disturbed, and often we have to do with a fetid diarrhoea. In the young the sen- sorium is early affected and children quickly become delirious. The pain, at first vague, quickly focuses in the particular bone or bones most involved, and as it increases in intensity there is a more and more signif- icant tenderness, which becomes exquisite. Ordinarily there is also early and characteristic reddening and swelling of the affected parts. With all these evidences goes also a characteristic muscle-spasm, by which cer- tain posture signs will be produced varying with the bone involved. Pain is always intensified by the slightest degree of disturbance. In consequence, the limbs (for it is the limbs which are usually involved) are contracted, and every effort to overcome the contractures is followed by aggravated pain. The more acute the pain the more vivid the exter- nal evidences of inflammation and the oedema of the parts, especially below and about the lesion. Thus it may happen that within forty-eight hours we have not merely swelling, but actual oedema of the part involved, which should be always regarded as pathognomonic. A little later, superadded to the other signs of inflammation, we find PLATE XVIII. .,' n £ ■%j6s_^'~' Acute Osteomyelitis; Showing Purulent Foei and Accompanying Dis- turbances. (Kocher.) SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 515 fluctuation if parosteal abscesses have formed, or possibly the evidences of epiphyseal loosening or complete separation. When the disease is pri- mary in an epiphysis the corresponding joint will be early involved, and the joint symptoms will take on rapidly the type of an acute purulent synovitis, only with a much more significant degree of pain. It is prob- able that under few, if any, circumstances is pain complained of more serious or aggravating than in cases of acute osteomyelitis of the fulmi- nating type. So far, only local symptoms have been described. To these there must be added the list of those pertaining to thrombosis and metastatic infection, with their septic and disastrous consequences. The disease is frequently so acute and rapid that even within the first day or two there is not only extensive thrombosis in and along the bones, with rapid purulent degeneration and thrombi, but that even more serious general condition to which these lesions so easily give rise — i. e. unmistakable pycemia. The general symptoms are common to the disease, no matter what bone be involved. Local symptoms will, of course, change in accord- ance with their location. While not so common, the flat bones, like the pelvis, cranium, and sternum, may be involved in most active manifes- tations of this disease. The same is true even of the vertebras, but, as a rule, it is in the long bones of the extremities that its ravages are most frequently seen. Prognosis. — The prognosis depends in large measure upon the early recognition of the disease and the prompt affordance of surgical relief. There is perhaps no disease less amenable to purely medicinal treatment, and, if bones are to be saved in their entirety, early and free incision is called for. Consequently, when the case is seen late it almost invari- ably entails necrosis with more or less disturbance of function, or pos- sibly such a serious condition as to call for amputation. The fulminant cases when not early recognized and promptly operated often prove fatal, and death has been known to follow within thirty-six hours after the onset of the first symptom, the fatal result being due to overwhelming septic infection with thrombosis, etc. Almost every case, however, if seen early enough, can be saved. Complications. — The complications are to be divided into the con- stitutional and the local. The former refer rather to the spread of septic infection and its more or less disastrous and remote ravages. Metastatic infections may produce serious or fatal complications, while, when less acute, important functions may suffer a serious impairment. Among the local sequelae are to be considered mainly the results of destruction of bone-tissue and neighboring joint structures. When the disease occurs in young and rapidly-growing children partial or complete arrest of development in the bone involved is not infrequent. This may lead to inequalities in length of the femora or humeri. It may lead also to compensatory hypertrophy of bone, with perhaps considerable distor- tion during subsequent growth. An entirely distinct, much less serious, consequence of osteomyelitis is the condition usually known as bone-abscess, in which the acuteness of symptoms has long since subsided, but in which a distinct local focus remains. This will be considered by itself. 516 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Etiology. — That the disease is an infection from the very beginning is settled beyond a doubt. The source of the infection, however, is not always easy to trace. Two distinct causes seem to conspire to produce the majority of these bone infections — micro-organisms of more than ordinary virulence, and a predisposing condition of the system, due sometimes to constitutional weakness or inherited taint or at other times to the results of exposure and fatigue. The causes of suppuration in general have been much more elaborately discussed in Chapter III., and it is hardly necessary to reiterate them here. It is a fact, however, that the majority of cases occur in children and after a combination of exposure and fatigue — as, for instance, sitting upon the ice afterbeing exhausted in skating — all of which, however, would be inoperative to produce an infection were not the germs at hand ready to assail every tissue whose resistance is thus temporarily lowered. The actual infection may occur from within or from without — from within per- haps through the alimentary canal or the respiratory tract, most probably in most instances from the tonsils and the pharynx. Infection from without may occur through a little abrasion or scratch, the blister upon the foot made by an ill-fitting shoe or by a skate-strap, or something of the kind. These cases occur almost always in "the young, more often in boys than girls, probably because in the former more opportunities for infection are permitted. Bone infections, however, are possible even in the new-born, in which case the infection may occur through the pharynx or through the umbilicus, while the local resistance may have been lowered by the injury due to mechanical delivery, turning, etc. In elderly people the disease is almost unknown. Diagnosis. — The disease for which this is most commonly mistaken is acute rheumatism. There may have been some excuse for this in time past, because of the lack of general knowledge of bone infections ; now there is none. The majority of cases of necrosis following osteo- myelitis which have come under my observation were the result of errors in diagnosis at the time when surgical relief might have prevented any local disaster. Rheumatism is never followed by suppuration, nor does it produce, except in the rarest instances, a septic type of disease; its painful lesions are rarely so painful as those due to osteomyelitis, and the clinical picture is almost always easily dis- tinguished. Lesions of rheumatism are usually multiple ; those of bone infection, for the most part, single. The first complaint of pain in the latter is more likely to be along the shaft of a bone than at the joint end, while this is not true of rheumatism. Moreover, in acute osteomyelitis the disease assumes from the very outset a seriousness and gravity which is seldom if ever approximated by acute inflammatory rheumatism. Tkeatment. — As stated, the treatment for acute osteomyelitis is essentially surgical. Anodynes may be necessary for relief of pain, but no time should be lost, when once the diagnosis is made, in making incisions sufficiently long and deep to expose the bone involved, and then, by means of suitable instruments, opening to its interior in order to relieve tension and to remove septic products. The incision required may possibly be ten or twelve inches in length, as over the femur or tibia. In almost every instance the tissues as we go deeper will be found more and more oedematous or infiltrated, with every evidence of the proximity of pus ; the periosteum will be thickened and infected, and between it and the bone we may find collections of pus, as well as outside of it. If seen late, the characteristic muscle appearances already SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 517 described may be noted. The periosteum should be incised completely down to the bone throughout the length of the incision, and then an ordinary bone-drill may be used to perforate the bone for exploratory purposes, just as the aspirating needle is used in the soft tissues. From every puncture in the bone thus involved will exude purulent fluid, often sanious, thus indicating the condition within. It is now necessary, with the bone-chisel or other suitable instruments — made for the special purpose— if at hand, to cut a deep groove or channel, perhaps from one bone end to the other, completely opening into the marrow-cavity, in which numerous foci will be discovered or in which all distinctive struc- ture of bone marrow may be lost, the cavity being filled with pus. The entire pus-containing cavity, being thus freely opened, should be scraped and disinfected with hydrogen peroxide and cauterized with zinc chloride or its equivalent, and packed, the wound being left open. Even this may not always be enough, but if there be epiphyseal separation, or, more unfortunate yet, if there appear evidences of joint infection, the neighboring joints must be explored, first under aseptic precautions, while if pus be found within, they must then be freely opened, washed out, and drained. Meanwhile, if in the soft tissues exposed by the incision the parosteal veins be found filled with septic thrombi, they should be opened so far as exposed and their contents removed. These operations are often severe, perhaps prolonged, but nothing in the way of operative treatment can be so severe nor so serious as the disease itself when left unoperated ; and the rule then is stringent and far-reaching that every infected tissue, and especially every infected bone interior, must be thus exposed without mercy and thoroughly cleaned out. Only in this way can lives be saved which would other- wise be certainly lost. Moreover, it is necessary to carry out this treat- ment in the fulminant cases as early as possible; and, consequently, errors in diagnosis by which it may be postponed until metastatic infec- tion or grave pulmonary and cardiac complications have set in are most unfortunate. So long, then, as the local indications are as above described surgical treatment is loudly called for, whether the systemic complications be pronounced or not. The immediate effect of the ope- ration having passed away, the relief thus afforded will often prove amazing — to such an extent that within twenty-four hours patients may be comfortable and evidently out of danger who were at the time of operation in the gravest danger of a speedy fatal termination. The later results of this operation are a wound which will discharge at first freely, and which, so soon as septic material is out of the way, will begin to granulate. Ordinarily, no attempt should be made to close such a wound, though much may be done to favor rapidity of granulation. While some antiseptic dress- ing is always employed, it will be of advantage occasionally to change the charac- ter of the same, and to alternate between perhaps iodoform with boric acid and acetanilid, the effect of any one drug being apparently lost after it has been used for some time. There are some cases where an entire diaphysis or bone-shaft will be found separated from one or both epiphyseal terminations, lying in a subperiosteal abscess-cavity, bathed in pus, and dead beyond possibility of repair. This is total necrosis of the shaft from an acute infectious process, and is to be treated by complete removal of all dead and dying tissue. In the case of the forearm or leg it may be that the remain- 518 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. ing bone, when only one is involved, as is usual, will be sufficient to maintain the integrity of the limb until new bone can be reproduced within the periosteal bed occupied by the old one. More or less com- plete regeneration of bone is possible, particularly in the young, and in connection with compensatory hypertrophy of the parallel bone will permit the restoration of the leg to partial or complete usefulness. On the other hand, should this prove later a complete failure, amputation and substitution of an artificial limb may be called for. When the disease has involved the articular side of an epiphyseal line, and when we have complete epiphyseal separation with consequent pyarthrosis, the probable consequence will be necessity for a complete or partial resection of the joint and the probability of subsequent ankylosis. Patients may find later that a modern artificial limb with its possibilities will be much preferable to such a con- dition, and may readily consent later to an amputation which they would at first refuse. Acute Infectious Periostitis. — This is an infection of the same general character and type as the osteomyelitis just described, but refers to those cases where the disease apparently is confined to the periosteum and the outermost layer of the bone. In its possibilities for harm it is scarcely less serious, although in its tendency to spontaneous perforation and escape of pus it is less likely to prove fatal. The causes and the general clinical manifestations are practically identical. The disease is perhaps a little less grave in its acute mani- festations, the localization of pain more exact, with ordinarily less tend- ency to serious joint complications. Local tenderness is exquisite, and particularly in those bones which lie near the surface — e. g. the tibia — and early recognition of fluctuating areas is easy. It may be localized over a small area or the entire periosteum of the shaft may be involved ; in which case, so soon as pus forms and the periosteum is separated from the bone, there is probability of acute necrosis of the shaft. Here, again, there may be a tendency to mistake at least the first signs of the disease for acute rheumatism, from which it must necessarily be early differentiated as above. Treatment. — Here also there is the same necessity for immediate intervention, if possible before pus has formed, in order that there may be little or no periosteal separation and encouragement to necrosis. Anaesthesia is necessary, with prompt incision, the use of the sharp spoon, and disinfecting agents : no attempt should be made to close the wound, but drainage should be favored in every way. The intensity of the pain is promptly relieved and the whole clinical picture immediately changed by such a procedure. The ordinary bone-felon upon a terminal phalanx is practically an expression of this type of disease, and universal experience corroborates the wisdom of deep and early incision, even in the case of so small a bone-entity as a phalanx. Acute Epiphysitis. — This is a term applied rather indiscriminately to a form of acute osteomyelitis involving primarily and especially the the epiphyseal lines, or to a condition of hypersemia and neuro- vascular excitement at _ epiphyseal junctions, stopping short of suppuration, but giving rise to intense pain, muscle contraction, joint tenderness, etc. It is most often seen at the upper end of the tibia. Sympathetic disturb- ance may extend even to serous effusion into a joint, although this is SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 519 not necessarily the case. The limbs are early drawn up, and e very- attempt to extend them simply aggravates the distress. So long as there be no evidences of suppuration, it is sufficient in these cases to apply a sufficient degree of traction to overcome muscular contracture and to completely straighten the limbs. This must probably be applied first under anaesthesia, and the patient be kept under anodynes for a few hours thereafter. So soon, however, as the muscles are tired out by the steady traction, pain subsides, and the intensity of the condition may be thus relieved within forty-eight hoars or less. It would be well to continue physiological rest and traction so long as there remains the slightest tenderness. Should evidences of suppuration supervene at any time, incision and evacuation of pus and exudate must be practised. Periostitis Albuminosa. — This is a quite rare manifestation of bone disease, only given an identity of its own since 1868, when Oilier first distinguished it, and since which time it has been the subject of consid- erable controversy. The name refers to a condition less acute than the infectious periostitis just described, localized for the most part in a single bone, calling almost always for incision and evacuation of a fluid which is gelatinous or mucoid in appearance rather than purulent. It is because of the peculiarity of the subperiosteal collection of fluid that it has in time past received the name periostitis albuminosa, and it was not generally regarded until recently as a variety of the infectious form of periostitis. It is, however, now generally conceded as being a mitigated form of infection in which the products of exudation assume the serous rather than the purulent type. In certain instances it appears to be the tubercle bacilli which are at fault. At all events, the organisms which produce the disease are more or less virulent, else the clinical form of the disease would be less serious than it really is. Cultures made from these subperiosteal collections have in almost all recent instances revealed the presence of some one of the numerous pyogenic organisms. Within the past year Dor has described a polymorphic microbe in instances of this kind which he has called the bacillus eereus dtreus, with which he claims to have been able to reproduce the disease in animals. Chronic and Latent Osteomyelitis. — So far, I have described only the most acute manifestations of bone infection. As in the lungs, how- ever, very chronic lesions are met with, and as in the lungs, again, it is possible for collections of micro-organisms to become more or less encapsulated and for a long time to lie latent until some provoking cause excites them again into activity. In this way are to be explained the numerous instances of recurring abscesses within the bone neces- sitating repeated operations, often at long intervals (Plate XVI.). Possible Consequences of Any or Aee of the Bone Infec- tions. — Keeping ever in mind the fact that bone is a living tissue, calci- fied and stiffened by inorganic material simply for the purpose of giving it strength, we must not forget that as such it may sutler remotely from the consequences of local infections, as may any other tissue. Thus it may have its nutrition impaired so as to produce atrophy on the one hand, or increased so as to lead on the other to hypertrophy, either regular or irregular in outline. Again, in its texture it may be altered to a very wide extent between the degree of extreme sponginess or porosity on one side (osteoporosis), or to the greatest degree of density ever attained by ivory 520 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. (osteosclerosis) on the other. Similar changes are also noted in cases of Done tuberculosis, which is to be considered by itself. The densest bone has sufficient vitality to permit its nutrition and life, and may assume dimensions much larger than that of the Fig. 178. m original, and a hardness which will defy the best steel instruments should it become necessary to operate upon it. The other extreme of osteoporosis' includes a condition where the bone has barely sufficient inor- ganic material to permit it to retain its shape and ordinary proportions. Such bone is fragile in the extreme, and scarcely ser- viceable as a supporting tissue. The prin- cipal portion of its bulk is constituted by marrow-tissue, which make it extremely vascular, but far from strong. When spongy to this degree, it is ordinarily unserviceable for its proper function. Astonishing pic- tures of osteosclerosis and osteoporosis side by side are present in many instances of disease, the latter being often evidence of more or less ossification of new-formed granulation-tissue. This is often a happy combination, because the bone, which for the most part has been sadly weakened by disappearance of its calcareous material by liquefaction and by absorption, is reinforced along some of its lines by a pillar of osteo- sclerotic tissue, by means of which it still functionates as a more or less useful sup- port, (Vide Fig. 178.) The operating surgeon has to familiarize him- self with the density of normal bone in various locations, since in many operations upon the deeper bones he detects healthy bone rather by the sense of touch and of hearing, and the resist- ance which it offers to his instruments, than by sense of sight. Osteogenesis and osteosclerosis ii slow infective processes (original). Tuberculosis of Bone. In Chapter IX., on Tuberculosis in general, the writer went into considerable detail with regard to the nature of tubercular lesions, which were stated to be essentially the same whether occurring in hard or soft tissue, the active agent being the now well-known bacillus tuberculosis, which, finding lodgement, for instance, in the osseous tissue, acts as a specific irritant, and so provokes the production, first, of a typical tubercle, and, later, of typical granulation-tissue, by whose ravages the distinctive signs of bone tuberculosis are produced. This process, then, is in no respect different in bones from similar lesions in other parts, though modified to a slight extent pathologically, to a greater extent clinically, by the dense environment. Nevertheless, trifling or most extensive destruction of bone substance is produced by this tissue, while PLATE XIX. VS Tubercular Disease of Hip Joint and Pelvis, involving the muscles (rare); o, Rarefying Ostitis, i.e., Osteoporosis; /', Fungous Granulation Tissue. (Unnelongue ) SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 521 by continuity or by metastasis there is more or less involvement of the adjoining textures, either parosteal or articular. It is by granulation- tissue that so-called caries is produced, and it is by the same tissue that distinct portions of bone are sometimes completely segregated from their vascular surroundings and shut off from nutrition, so that they die and form what are known as sequestra. Necrosis may, then, be the result of tubercular disease. So long as the process be active, this granulation-tissue tends ever to enlarge its boundaries, and, like pus, to spread in the direction of least resistance. When produced in the shaft of a long bone this may lead to involvement of the entire shaft, or there may be liquefaction and absorption of dense bone and the formation of a sinus from the marrow- cavity to the periosteum, beneath which the granulation-tissue will spread, and through which it will sooner or later perforate, to resume its progress toward the surface, always in the direction of least resistance. In this progress tendon-sheaths or bursa may be involved, or dense aponeuroses may turn the granulation column aside, causing it to per- forate toward the surface at some remote point ; while, in the end, it may spread out more or less beneath the skin before finally causing its de- struction. Sooner or later, if uninterrupted by treatment, this escape will occur, and then we have the condition of a tubercular ulcer of the skin, from which leads down, by a devious path, a sinus toward the original focus. When this original focus has been juxta-epiphyseal, we see speedy involvement of the epiphyseal cartilage and a pathological diastasis which may early lead to spontaneous or pathological luxation. Or, again, a focus, having once originated at an epiphyseal extremity, tends usually to perforate quickly into a joint-cavity, after which a consider- able length of time is usually expended in filling up this joint-cavity with exuberant granulation-tissue. This is the material so often found in tubercular joints, and is well characterized by the name given to it by the Germans, fungous tissue, they calling such joint affections fungous joint inflammations. Seen thus in joints, after it has been long exposed to friction and to more or less pressure, it may have lost some of its original luxuriant features. It is best seen when it is freshest and has been exposed to least disturbance. Under these circumstances it is vascular, dark red in appearance, friable, and easily removed from the tissue upon which it has grown. Ordinarily it is infectious, and by its inoculation into animals is capable of reproducing the disease. The pathology of tuberculosis of bone may, then, be virtually summed up in saying that it consists of the ravages produced by the presence of this granulation-tissue, with the irritative hyperplasia of surrounding tissues which its presence always excites, even though they be not actively infected. This is, then, the explanation for the majority of cases of caries, of tumor albm, of Pott's disease, of spina ventosa, and of the condition which at various times has been known under many other names. Varieties. — Acute Miliary Tuberculosis of Bone. — This corresponds to a similar invasion, for instance, of the lungs. It might be fittingly described as an acute tubercular form of osteomyelitis. It may run its destructive course within a short time, and cause such involvement of structures as to necessitate amputation of a limb, or it may appear in 522 AFFECTIONS OF THE TISSUES ASD TISSUE-SYSTEMS. Fig. 179. the truncal skeleton as a primary disease, spreading rapidly therefrom and involving the viscera or the cerebro-spinal membranes, and causing an early death, perhaps within a few weeks after its onset. This con- dition has been in time past more prevalent than generally understood, and has not even yet received the attention it deserves. It is perhaps less painful than the pyogenic forms of osteomyelitis, and may assume less of the septic, and more of the typhoid or meningeal, type of dis- ease. The pain also may be less severe, though reflex symptoms, especially muscle-spasm, will be an early and marked feature of these cases. Involving a limb, the case may not be hopeless ; but when involving the cranium, spine, or trunk it is fatal, and little, if anything, can be accomplished by treatment. The operative treatment for parts which are inaccessible is virtually that already given under Acute Osteomyelitis, to which the reader is referred. Chronic Tubercular Osteomyelitis. — This is the ordinary form of the dis- ease, and is exceedingly common. In certain parts of the world it constitutes nearly one-third of the diseases calling for surgical treatment in clinics and hospitals. This is particularly so in the most thickly-settled portions of the Eu- ropean continent. In Buffalo it consti- tutes from 15 to 20 per cent, of cases found in my wards and in my clinic. In fact, the proportion during certain years has been larger. Symptoms. — The essential symptoms of bone tuberculosis are muscle-atrophy, muscle-spasm, and pain , direct or referred, and upon the existence of these, coupled perhaps with local tenderness and local swelling, a diagnosis can almost always be made. Muscle-atrophy is distinct, and is not alone that of disuse, but is even a distinctive evidence of the tubercular process. It involves the parts above and below the lesion. Muscle-spasm is never lacking, but is most noticeable about the spine and the joints of the extremities. In Pott's disease, for instance, the condition causes a stiffening of the back and an inflexibility of the spine which are always recognized as distinctive. About the joints it leads gradually to fixation, usually in the condition of more or less flexion, the flexor muscles being ordinarily stronger than the extensors in all parts of the body. Thus we see the knee and the elbow drawn up, and most other joints in a condition of flexion so far as it may be permitted. It is characteristic also that muscle-spasm, is frequently exaggerated, Tuberculous disease of hip (original). SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 523 i>^ usually in a reflex way, by which pain is always augmented. These sudden but brief contractures occur more often during sleep than during the waking hours, and give rise to the so-called starting pains, usually nocturnal, which are noted in nearly every case of this kind. The pain is in large measure the result of contracted muscles pulling tender joint surfaces together, and is consequently augmented during the muscle-spasms just described to an extent causing the patient to cry out even during sleep. There is also usually a more or less deep-seated and constant pain or soreness, manifested in increasing degree as the lesion advances. These pains are also often referred, it being quite generally the case that lesions in the upper ends of long bones give rise to pain which patients refer to the lower ends. Thus, in hip-joint disease pain is often referred to the knee ; in Pott's disease, often to the anterior part of the trunk. Of all cases it may be said, in a general way, that slight but slowly increasing disturbance of function of a joint inaugurated Fig. 180. by trifling muscle-spasm, with complaint of aching or pain, is most significant, and should call for careful examination, it being a mistake to anaesthetize patients for this purpose, since by the anaes- thetic the pathognomonic muscle- spasm is abolished and mistakes in diagnosis favored. Tkeatment. — The treatment of tuberculosis of bone is both con- stitutional and local. The former consists in the best possible hygiene and in those measures which are everywhere recognized as helpful in similar conditions. I believe in the internal use of benzosol, or its equivalents, in doses large enough to quickly impress the tissues with its influence. I be- lieve also that the treatment by tuberculin, or its equivalent prep- arations, is helpful, although by no means self-sufficient. In addi- tion to these, the very best tonics and evacuants should be judici- ously used. But it is mainly with local treatment that we shall here have to deal. The local treatment may be divided into the non-operative and the operative. The former consists in enforcing the general principles of physiological rest, which is done partly by orthopwdic apparatus proper and partly by the general principles of traction, and is resorted to mainly in a class of cases treated of under Orthopaedic Surgery, the best methods for the purpose, apparatus, etc., being found under 'that heading. Healed tuberculosis of spine (original). 524 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Aside from this, a hopeful method has been that recently suggested by Bier, consisting of making an artificial chronic congestion, it having been long known that tubercles do not thrive when bathed in too much blood. The congestion is secured by wearing an elastic bandage above the point involved, elastic constriction being made to a degree as great as may be comfortably borne. The result is venous congestion, possibly oedema of the parts below, which to be made effective should be carried nearly to the tolerable extreme. Constriction, when applied for this purpose, may be at first enforced for only a short time, but can be later borne for longer and longer periods, until a time is reached when the patient can wear a comfortably snug bandage nearly all of the time. Marked improvement follows this method in many cases. The operative treatment consists in ignipuncture, curettage, or formal extirpation. Ignipuncture is the insertion into the bone-focus, no matter how deep, of the glowing point of the thermo-cautery. It is best prac- tised under an anaesthetic, and when the bone is superficial no hesitation need be felt in plunging the cautery directly through the skin, making it burn its way into the depth of the bone. This is easy when the can- cellous tissue is that at fault. If the bone be deep, an incision may be made down to it, after which the cautery is applied as above. The result in, almost every instance is relief from pain, frequently surprising in its rapidity and effectiveness. This effect seems to be brought about partly by relief of tension, partly by destruction of diseased tissue; again, in large measure, by the acute congestion which is the result of the most vigorous counter-irritation. It need occasion no fear nor difficulty, and is applicable to all accessible bones. It must not be expected to cure every case, but is a measure which may be confidently expected to relieve pain and to do good. The more radical form of treatment is always called for when one can determine in, any way that the carious process is advancing or that pus or caseated deposits are present. This is made known in various ways already indicated ; but when one is reasonably sure of their pres- ence it is best to begin the operation as an exploration, going so far as the findings may justify. This may include merely scraping out of a small focus, or it may entail removal of a large portion of a bone or resection of a joint, or even amputation, according to the severity of the deep lesion. It is best to do whatever may be necessary, and to do it all at once. The operator should not rest content with mere opera- tive attack, but should carefully disinfect the entire tract, cutting away or removing with the spoon all the sinus-wall and all fungous tissue, which he should follow wherever it may lead, disinfecting freely with hydrogen peroxide or caustic pyrozone, and then using some active caustic, like zinc chloride or the actual cautery, unless he have already used caustic pyrozone. In this way material may be destroyed which has escaped the instruments used ; and in this way, also, absorbents are seared or closed and protection afforded. My personal preference is for a packing made of iodoform gauze, soaked in a mixture of balsam of Peru containing 10 per cent, of guaiacol, which I find more advan- tageous than anything I have used. One should always add to these measures, however, whatever may be necessary in the way of after- treatment, both local and constitutional, and should be prepared to ope- SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 525 rate again should latent foci subsequently manifest themselves or should there be recrudescence of the active disease. Bone-abscess. Bone-abscess is a term applied to deep and circumscribed, collections of pus within the bone, for the most part within the shafts of long bones. They are due either to the acute ravages of pyogenic cocci or to the slower lesions produced by the tubercle bacillus. They are frequently evidences of return of disease of the acute type after a more or less long period of latency. The manifestations are usually quite local- ized, in this respect differing materially from those of acute osteomye- litis. The pain is deep-seated and boring, while there is local tender- ness, often with considerable enlargement of the overlying bone. The lesion occurs more often in the tibia than in all of the other bones put together — at least under those clinical conditions which entitle it to be called bone-abscess. The pain is frequently nocturnal or osteoscopic, and patients may endure it for weeks or even months before coming for operation or relief. One may always expect to find a layer of condensed, sometimes extremely hard, bone around these local foci, and it is due to this that they do not either perforate or diffuse and cause extensive trouble. Treatment. — Treatment is always operative; should consist in anaesthesia, exposure of the bone, effective exploration by means of the bone-drill, as one would use the hypodermic needle for exploration in the soft parts, and then the free use of the bone-chisel or other instru- ments by which the area may be widely exposed. The density and firm- ness of the bone under these conditions will sometimes almost defy the best-tempered instruments. Care should be taken to make the external opening as large, or nearly so, as the deep focus, in order that the surface may not heal too readily and before the deeper part is filled up. The same directions with regard to cauterization and packing the cavity obtain as given before. Syphilis of Bone. Syphilis of bone may assume the type of gummatous involvement of the periosteum or of the bone itself or of syphilitic caries and necrosis. The former appears usually as a distinct tumor, ordinarily tender and exceedingly painful, especially at night, it being characteristic of almost all cases of bone-syphilis that the pain, however great during the day, is exaggerated at night. The true syphilitic gumma, or syphiloma, of bone is but little, if at all, different from gumma in other tissues, which may become secondarily infected and then suppurate with the formation of sinuses, etc. Suppuration, however, is rare. Central gumma, like central osteosarcoma, is possible, and will probably lead to expansion of the surrounding bone. Syphilitic necrosis, so far ae the bone lesion is concerned, scarcely differs from the other varieties already described or to be described. It is, however, almost always of the slow form, and involves more often the flat than the long bones. It is especially seen in the cranium and the sternum. Syphilis of bone is often mistaken for 526 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 182. rheumatism or pseudo-rheumatism, because of the deep-seated, somewhat indolent, pain. Syphilitic disease of bone permits occasional spontane- ous fracture, the bone affected with this disease being always more friable than natural. There is also another form of bone-syphilis — namely, the Fig. 181. Syphilitic gummata of head and face (after Jullien). Syphilitic ostitis and osteosclerosis (original). hereditary — which deserves a moment's consideration. It leads, usually early, either to bone enlargement or to caries and necrosis, the latter most usually upon the cranium, where extensive ulceration and sequestrum- formation may be observed, even the dura being exposed by breaking down of fungous tissue. Hereditary bone-syphilis is also characterized by osteophytie formation, by the substitution of gelatinous for spongy bone-tissue in the neighborhood of epiphyses, and by early and easy epiphyseal separations. It is characterized also by irregu- larity of ossification of cartilage and consequent deformity of bone ends, especially about the phalanges and the metacarpal and metatarsal bones. In almost every case where doubt would in other respects arise, the other evidences of congenital or acquired syphilis are so plain as scarcely to permit uncertainty. ( Vide Fig. 182.) The possible combination of syphilis and tuberculosis in the same sub- ject must never be forgotten, the lesions partaking of one or the other character according as the tubercular or syphilitic taint may predom- inate. There is urgent necessity in all cases of syphilis in bone, whether operated on or not, for the combination of suitable internal treatment with surgical interference. Only by this combination can the efforts of the surgeon be crowned with ultimate success. In failure to appreciate this fact operation often seems to be almost futile. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 527 Caries. Caries is a terra applied to infiltration of and substitution in healthy bone by granulation-tissue, and has been in use for many centuries, from a time long before the pathology of the condition was understood. Caries never occurs except in the presence of a specific, irritant, which for the most part is tubercular, sometimes syphilitic, in character. The pure type of caries is connected entirely with the formation of granula- tion-tissue, already repeatedly described, and the slow ravages connected with its presence in and substitution for the original bone. So long as septic infection (pyogenic) be avoided, it assumes the dry type, as it used to be known, called by the older writers caries sicca. When the fungous tissue is invaded by putrefactive or pyogenic organisms suppuration of course occurs, and then we have the moist forms of caries, the caries humida of our forefathers, connected always with the presence of pus. When closed areas of bone, small or large, being thus shut off from nourishment, die as the result of its presence, the complicated condition used to be known as caries necrotica. Occurring under any circumstances, caries is a result and not a cause, and is to be dealt with accordingly. Peculiar alterations and markings in bone are the consequence of carious changes, and bones are given a most fantastic and peculiar appearance in consequence. The surface is almost always irregular, tunnels or canals are formed, and the bone is often honeycombed, as it were, by the excavations just made. Along with the process of osteoporosis and disappearance of bone at one point may be seen osteosclerosis in the adjoining area, and the bone, which is apparently much weakened by the destructive process, is strengthened in a compen- satory way by the artificial density of the tissue unde- stroyed. Caries, being but an expression of tubercular or syphilitic, possibly of other specific disease, has been thus sufficiently if briefly dealt with both from the pathological and the surgical standpoint. Its ' clinical evidences are those of joint and bone tuber- culosis or syphilis, which have been already dis- cussed^ and its operative treatment consists always caries of lower end of fe mur in surgical attack with bone-chisel and sharp spoon, (original). according to the rules already laid down. The bone which is completely carious calls for extirpation— i. e. usually amputation. In the carpus and tarsus resection will often suffice, as also when the disease is limited to joint ends._ Occurring in the pelvis, ribs, sternum, or cranium, more or Jess extensive resections of flat bones are called for, in the latter place leading often to exposure of the dura (of which one need have no fear) when necessary. -The same rules with regard to cleansing and packino- the wound are to be carried out as given before for operation on tuber- cular bones. 528 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Necrosis. Necrosis corresponds to gangrene of soft parts, and the term, when used by itself, is by common consent limited to death of bone-tissue. Necrosis by itself is never a distinct disease, but simply indicates the ter- mination of some preceding disease process. It may be considered as — (a) Traumatic. (6) Pathological — i. e. the result of disease ; or (c) Toxic, due to the presence of specific poisons in the system. (a) Traumatic necrosis is, for the most part, due to the shutting off of blood-supply by accident or by separation of the whole or a part of a bone in the same way. Thus in consequence of multiple fractures fragments occasionally die and require later removal. The same result has been ascribed to traumatic or non-traumatic embolism, of the prin- cipal nutrient artery of a bone, but the possibility of this pure condition is very doubtful, bone being too well supplied by its surrounding perios- teum. Necrosis in connection with fracture is rare except in compound fractures, and, when a detached fragment can be seen, may and should be anticipated by removal of the same. (6) The pathological form is due almost entirely to the pre-exist- ence either of tuberculosis, syphilis, or an acute infection, such as osteo- myelitis in some of its expressions. It may also be the result of acute infectious periostitis, where the periosteum is completely loosened from the shaft of a long bone. These conditions have been already described at some length, and it would scarcely seem necessary to do more than allude to them as causes. They are connected either with the slow ravages produced by granulation-tissue, so often alluded to, itself being the result of the provocation of a specific irritant, or else to the acute septic processes by which infected exudates shut off large areas from sufficient blood-supply, or by which in consequence of septic thrombosis a similar result is brought about. In consequence, we may have bone dying in small visible particles, or the entire shaft of a long bone or several smaller ones may be at once involved in the destructive processes. The portion which dies, be it larger or smaller, is known as the sequestrum, which may assume most irregular and unusual shapes, varying entirely with the area involved. The general character and size of a sequestrum will depend, for the most part, upon the nature of the cause. In acute osteomyelitis it is usually either an entire bone- shaft or an entire epiphysis which thus suddenly dies. In the slower processes, connected really with caries, the fragments may be of almost any imaginable size and form — irregular with jagged ends, or long, extending completely through a bone, either from end to end or from side to side. (c) The toxic forms of necrosis are due mainly to two substances used in the arts — mercury and phosphorus — whose use seems to be inseparable from the manufacture of many modern industrial products. Mercurial necrosis may come either from the volatilization of the metal in factories where mirrors are made or from refineries where amalgam is distilled. It may also come from the internal vse of the drug. Its effects are seen rather in the alveolar portion of the lower and upper jaw than anywhere else. It is, in fact, through some unknown peculiarity that the jaws are the bones commonly involved in both of these forms. PLATE XX. Necrosis of Shaft of Femur with Sequestra, life size. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 529 Phosphorus-necrosis, on the other hand, manifests itself almost entirely in the lower jaw, and is met with, usually among the young, in factories where matches are made. It is due to the vapors of phosphorus, which cause a form of nearly distinct maxillary necrosis— a fact which has been so widely recognized as to lead to state legislation preventing the employment of the young in such work. Phosphorus-necrosis begins as a periostitis with the production of osteophytes, Fig. 184. 14 %t&. Phosphorus-necrosis of lower jaw (Musee Dupuytren). and is completed as a nearly total necrosis of the entire bone. Treatment of the Toxic Forms. — The preventive treatment must consist of careful supervision of the teeth, the use of alkaline mouth-washes, inhalation of terebinthinate vapors, which neutralize those of phosphorus, and always the perfect ventilation of establishments devoted to match-making. The curative treatment consists of buccal antisepsis, opening of abscesses, and the removal of diseased bone, especially of dead bone, upon the first provocation. The occur- rence of fistulae should always be regarded as pathognomonic of diseased bone. In aggravated cases, such as are rarely if ever seen to-day since legislation has been brought to bear upon the subject, practically complete necrosis of the lower jaw, either en masse or in portions, was far from unknown, and the possibilities of regeneration of the bone was for a long time discredited, until the late James R. Wood of New York exhibited a specimen, both at home and abroad, which proved its possibility. Since then we have learned that it is possible for bone thus to regenerate, the cause of the disturbance having been removed. Sequestrum-formation. — To the portion of bone which dies, be it large or small, regular or irregular, is given the name sequestrum, while multiple sequestra are by no means uncommon. The sequestrum is white and ivory-like in hardness — at least when it consists of original compact structure. It is rare to find a distinct sequestrum of spongy tissue, simply because this yields so readily to the presence of granula- tion-tissue and of pyogenic infection. A sequestrum may include an entire bone, shaft, or epiphysis, or only a small fragment. A given portion of the bone, having lost its vitality, becomes properly a foreign body which the surrounding tissues endeavor to extrude or to wall off and surround. The extrusive effort is the one which is usually seen. This is done by the continued presence of granulation-tissue, which gradually perforates the surrounding bone at places of least resistance, the result being the slow formation of a sinus or several sinuses, ulti- 34 530 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. mately connecting with the surface, and in which in neglected cases the dead fragment of bone can be seen or felt, or from which it can be with- drawn almost without operation. While this weak- Fig. 185. ening of bone is going on in certain portions a cor- responding strengthening process is also being put into effect ; and the result is a quantity of new bone, Fig. 187. J \ Central necrosis of tibia, long central sequestrum (original). Sequestrum inside of a core of new bone-tissue, ar- ranged much like a puz- zle (original). Necrosis of tibia, showing seques- tra after removal (original). which is often wrapped around the sequestrum or which is simply the effort to atone for its pathological weakness and to strengthen it, some- times to an amazing degree. This new osseous tissue which so often surrounds the sequestrum is called the involucrum, and in many instances it is necessary to remove more or less of the involucrum before the sequestrum can be lifted out of its bed or removed. The whole necrotic process is perfectly intelligible if simply read aright as an endeavor on the part of nature to get rid of dead and irritating material. When this effort is properly interpreted and early enough, the natural efforts can be seconded by the interference of the surgeon at a time when disturbance shall be limited to the minimum and before external sinuses have had any opportunity to form. On the other hand, ignorance and neglect may lead to the extreme condi- tion, and most fantastic arrangements of sequestra and involuera are seen in all pathological museums, some of which seem to partake almost of the perplexities of Chinese puzzles. The explanation, however, is always as above afforded. Treatment. — This is always surgical, and consists in removal of SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 531 the dead portions and restoration of the parts to a condition favoring rapid regeneration. The treatment must always be radical, and is made difficult sometimes by the inaccessibility of the fragment or by the density of the involucrum and the necessity for large external openings in order to remove the sequestrum. Large and powerful forceps and strong and well-tempered bone- chisels are usually necessary, while, after making the necessary opening for removal of the sequestrum, the sharp spoon should be used thor- oughly to scrape away all the lining material of cavities in which frag- ments have been lying or all fungous tissue which may fill sinus tracks. It will be well after this to thoroughly cauterize the wall of the cavity, after which it is to be packed. The packing of old bone-cavities is of importance, and operators should appre- ciate the reason for so treating them. The packing is essentially a foreign mate- rial which the tissues will naturally endeavor to extrude as they did the seques- trum. The method of extrusion is by filling up beneath and around it with granulation-tissue, which later may ossify. The packing is therefore a constant provocation to the formation of this tissue, which is now desirable and is used mainly for this purpose. It is antiseptic material, and will serve always to pre- vent decomposition of the pyoid material which would otherwise fill such a cavity as the result of waste — Nature's effort at formative material gone to waste. A number of years ago Gunn suggested the use of wax for this purpose, wax being plastic and incapable of absorption. A piece of white wax was heated in hot water, moulded with the fingers to fit the cavity, where it served the purpose of a packing, and was reduced in size with each dressing, as was necessary to permit it still to remain. It is not now used as much as it deserves to be. In favorable cases it may be possible to so thoroughly cleanse the bone-cavity without the use of caustics as to justify the attempt, after rigid asepsis, of allowing it to fill with blood which shall coagulate and organize directly into connective tissue. When this effect is desired the wound should be covered with green silk protective, over which the other dressing may be snugly applied. This healing by the aseptic blood-clot is the ideal method when possible. The extent to which regeneration of bone is possible is often amazing, espe- cially in the young. Thus, after removal of the entire shaft of a tibia there may be in time not a complete restoration to former integrity, but, nevertheless, the formation of so much new osseous material as to restore a great degree of strength, and which shall, with the compensatorily hypertrophied fibula, make the leg as useful as ever. In the thigh, however, complete necrosis of the femur will almost always mean amputation, as it will also in the arm unless the necrotic portion be but a small proportion of the length of the humerus. The treatment of necrosis of the skull, or, in fact, of any bone in the body which is accessible, is based prac- tically on the principles already laid down. Other Parasitic Affections of Bones. These are mainly of two varieties — hydatid disease and actinomycosis. Hydatid disease of bone consists in the development of hydatid cysts which may be either of primary or secondary origin. Almost all the bones of the skeleton are liable to cyst-formation, save only the very short bones of the carpus, tarsus, and digits. In the very long bones they occur most frequently in the region of the epiphyses. The partic- ular vascularity of this region is the main factor in their location at this point. The cysts may be unilocular or multilocular, and around them may be a thin or a large area of infiltration. In other words, their 532 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. boundaries may be abrupt or not. Their volume is exceedingly varia- able, unilocular cysts sometimes attaining considerable size and distend- ing the bone beyond its normal proportions. (See Chapter XXV. for further reference to the pathology of hydatid cysts.) The treatment is purely operative. The contents of the cysts must be evacuated and its walls radically destroyed by caustic, spoon, etc. All sequestra must be removed ; in the limbs amputation is sometimes necessitated by the extent of the affection. Actinomycosis (see Chapter VIII.). — The general character of this parasitic disease has been already considered. It should be remembered here, however, as one of the possible, though in this country rare, affec- tions of the bones. The peculiar fungus may be found in the periosteum, in the compact outer layers of the bone, or within its more spongy depths. When the lesion is large enough to be recognizable to the naked eye it assumes, for all practical purposes, the appearance of caries like that due to tubercular or leprous diseases, while in the pus or debris discharged from the same or contained within the invaded bones the characteristic yellow, cheesy, or calcareous particles will always be recognized. In this disease there never seems to be the slightest tendency to encapsulation, nor to protect against further spreading by any process of repair. The diseased area constantly enlarges its dimensions, involving everything as it spreads, it being limited by no membrane nor tissue of the body. Occurring in the bones, it is for the most part a secondary or metastatic infection, and may be found in any part of the body. The symptoms will be those of osteoperiostitis occurring first in the jaws, as it nearly always does in cattle and often in man ; it will be accompanied by loosening of the teeth and involvement of the submax- illary tissues in a way scarcely imitated by any other disease. The course of the disease is always slow, with little or no tendency toward spontaneous recovery. Trophoneurotic Diseases op the Bones. Under this general heading it is proposed to group a number of dis- eases whose clinical manifestations are distinct or classic, but whose underlying causes are as yet more or less obscure, in most cases more so, and about which we can speak with but little definiteness ; neverthe- less, the diseased conditions are distinctive and important. Achondroplasia. — This is a lesion of intra-uterine life which includes a softening of primary cartilaginous structures and curvature or malfor- mation of the bones which should be formed from them. It concerns that period of foetal life between the third and sixth months. It has been sometimes spoken of as intra-uterine rickets. (In fact, the term rickets has been made to cover many different conditions.) Under this name it was first described by Miiller in 1860, and since then by vari- ous authors under various names, most commonly as fcetal rickets. It appears that in this disease the foetal cartilage contains mucus abnor- mally collected, for the most part, in minute cavities or cells just at its borders. The chondroblasts and osteoblasts are not regularly dispersed, and the development of the growing bone is thereby much interfered with. The periosteum appears to have nothing to do with this condi- tion. In consequence the cartilage does not do its proper duty. The SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 533 long bones fail to attain their proper proportionate length, but become thicker than normal, the periosteum being unaltered. On the other hand, those bones into whose Fig. 188. formation cartilage enters but slightly, such as the clavicle and the ribs, retain their normal pro- portions : the consequence is a peculiar malformation and dis- proportion of the whole skeleton (Fig. 188). These deformities are sym- metrical, and pertain for the most part to the bones at the base of the skull and to the long bones of the limbs; therefore the distinctive appearance may Fig. 189. Achondroplasia skeleton (Porak). Achondroplasia (Lugeol). be recognized even at the birth of the child. The head is dispropor- tionately large, the spinal column short, the lumbar curvature exag- gerated, all of which is rather the reverse of the ordinary rachitic manifestations. The disease is not common (Fig. 189). Prognosis is unfavorable, because it seems impossible to undo the faults of the intra-uterine condition. The disease, however, is not incompatible with a long life. Rachitis. — This also is a constitutional condition, and has been already described in Chapter XIV. So far as the manifestations in the bones are concerned, it is a constitutional dystrophy caused by improper depo- sition of calcareous material in the softened and somewhat perverted foetal cartilages. It is a condition, however, pertaining rather to post- 534 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. natal life, and while inconspicuous at birth becomes more and more marked as the child develops. It is essentially a disease of malnutrition, and consequently may be seen in all walks of life, as well in the bottle-fed babies of the wealthy as in the best-nourished children of the very poor. The lesions are widely distributed. The disease is divided by some writers into three periods: (a) rarefaction of bone-tissue •; (6) softening of same ; (c) re-ossi- fication. The first stage is the intra-uterine part ; the second and third stages are post-natal. To fetal rarefaction have been attributed intra-uterine fractures, even by Hippocrates. The general dyscrasia and visceral alterations of rachitis interest us here less than deformities of the various bones. The head is dispropor- tionately large, the vertex flattened, the frontal and parietal eminences pronounced ; the anterior fontanelle closes very late. To the atrophic alterations of the head have been given the name eraniotabes. The face is disproportionally small, the lower jaw assuming a polygonal shape. The palatal vault is of the Gothic type, dentition irregular and retarded. In the thorax the clavicular curves are exaggerated, by which the bones are shortened and the shoulders made narrow. The costo-chondral junctions are enlarged, the result being the so-called rachitic rosary. The sternum projects and gives the peculiar appearance known as pigeon-breast. The pelvis is often deformed, frequently distorted to such an extent as in after- years to make normal delivery impossible. The spinal column may either be distorted very early, or is likely to undergo alterations of curvature due to the combined results of pressure and traction upon softened vertebra. The joint ends of the long bones are enlarged or clubbed, this being true even of the phalanges. Joint movements are often accompanied by crepitation. The axes of the long bones are distorted, and more or less marked deviations and curvatures result, giving rise to such deformities as knock-knee, bow-leg, etc., Osteomalacia. — As rickets is essentially a disease of the very young, osteomalacia is practically confined to adults. The name implies a peculiar softening of the bones by which their resistance and rigidity are weakened and deformity permitted. The disease is common to man and animals in confinement, and is frequently noted among wild animals dying in zoological gardens. It is perhaps most often noted in pregnant women, where it would appear as if the mineral elements needed for the growing foetus were abstracted from the mother's bones rather than from the food ingested. It is brought about also by starva- tion, possibly by lactation, especially among those who nurse their children for unusual periods. Spontaneous fractures, especially of the long bones, are frequent. These may refuse to unite properly, and false joints may result. The urine will under these circumstances contain an excess of mineral salts, carbonates, phosphates, and oxalates, and when these are discovered in the urine of those suffering from fractures it should always be a warning to administer calcium salts and mineral acids internally, preferably phosphoric, and to carefully watch the excretions. The progress of the disease is slow, yet steady, and often not easily checked, if at all affected, by mineral acids. Occurring in pregnant SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 535 women, it may be checked after delivery, especially if the child be not allowed to nurse from the mother. In some instances it occurs with each successive confinement in the same patient, and makes distinct advance with each fresh attack. The prognosis is therefore unfavorable, least so in puerperal cases. An infantile form, as well as & foetal, form, has been described, but it is doubt- ful whether these forms really come under the same category, and whether they are not manifestations of rickets. A senile form has also been described which affects for the most part the sternum and thorax, which is characterized by excess of nervous excitability and by bone-pains, as well as by liability to multiple frac- ture upon the slightest provocation. This form, however, differs but little from the osteoporosis of advanced years, and scarcely deserves distinct consideration. Certain writers have also spoken of a symptomatic form observed in cases of cancer, syphilis, scurvy, etc., which, however, is entirely unnecessary, since the fractures occurring in cases of cancer or syphilis are due to secondary lesions of the same character, while those occurring during scurvy are simply an expression of star- vation and weakening even of the bones. Cases of cancer, for instance, where bones have broken without being previously weakened by secondary growths, have been described, but are exceedingly rare and need only to be mentioned here. Fig. 190. Osteomalacia : celebrated case of Moraurt, 1753.-Skeleton now in Musee Dupuytren. The treatment for all these conditions must be removal of the cause if dis- coverable, and the administration of calcium salts in accessible shape, as in cases or riC-KGos. Osteopsathyrosis, or Fragility of Bones.— This seems to be a con- dition distinct from osteomalacia, just described, it being, more than the other, a condition due to trophic nerve disturbance. The condition seems to be hereditary, often extending through several generations It is cha- racterized by fracture of long bones upon the slightest provocation and is a disease common to all ages. While apparently congenital in origin 536 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. it persists often throughout life, no impression being made upon the con- dition by medication. It is not characterized by distinctive histological changes, and all theories heretofore advanced toward its explanation are disappointing. We are as yet in complete ignorance as to its cause. It is seen, at least in this country, most often in paretics and annates of insane asylums. The ease with which the bones of such patients are broken has given rise to repeated charges of violence or homicide. From one case in which this charge was made I secured specimens of the ribs, which were so fragile that they could be easily crumbled between the fingers. Such patients might easily sustain serious fractures when undergoing necessary restraint, even of the gentlest nature. Fig. 191. w Osteopsathyrosis (Blanehard's case). Osteopsathyrosis of this congenital type is peril aps best illustrated hy a case reported by Blanchard,of Chicago, 1 in the case of a woman twenty-seven years of age at the time of his report, who up to that time had sustained over one hundred fractures. In her case it was sufficient to merely gently slide from the sofa to the floor to break some bone. Treatment in her case had been of no avail (Fig. 191). It is important to impress these facts upon the mind of readers, because allegations of undue violence are frequently made in these cases, which, especially in asylums, may be most unjust and difficult to prove or disprove. Senile Fragility of Bones. — This simply means weakening of the bones, which is incident to advanced age in either sex due to and com- prised under the term osteoporosis. Added to this, in certain places is a positive change in shape, also characterizing the senile condition — e. g. the neck of the femur. Under these circumstances bones will break 1 Trans. Am. Orthopcedic Assoc. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 537 with a minimum of violence and without invoking any theory of osteo- malacia, osteopsathyrosis, or the like. As bone disappears under these circumstances, fat usually takes its place, so that while the volume of the bone may be not particularly diminished, it weight and density are materially altered. ( Vide also introductory remarks to this chapter.) Atrophic Elongation. — This is a term first applied by Oilier, and refers to a distinct type of alteration in long bones by which their actual volume is relatively diminished, although they increase in length. It is produced largely by lack of pressure, and is seen in many amputated stumps, in which it has much to do with the conicity of the same. It is seen in another expression in certain cases of typhoid fever or in forced confinement of the young to bed, where the bones appear to grow at a much more rapid rate than normal. It may also be due to unequal amounts, or defects, of nutritive supply, especially that furnished by the periosteum, and in certain other cases seems to be a purely reflex or trophoneurotic change which is always inexplicable. Frequently accom- panying it is muscular wasting, which is to be explained rather by reflex action through the cord, produced perhaps through the mechanism of the terminal filaments of the articular nerves. Ostitis deformans, or, as it is often called, Paget's disease of the bones, is a condition found alike in long and flat bones, the osseous tis- sue being condensed in texture and increased in amount, or at other times the osseous tissue becoming quite porous and the spongy tissue rarefied without alteration in the marrow. It is due to the unknown causes which may be summed up in the expression trophoneurotic, a painful and & painless form having been described, the former the more frequent. It produces deformities, disfigurements, and hypertrophies of the long bones. It is distinguished from arthritis deformans, described in Chapter XXXII., which is a distinct malady, this under consideration having no particular reference to joint structures. In the skull it is usually the face bones which are most involved, although the disease often commences in the cranial bones. The skull proper may be thickened even to three centimetres. The thorax becomes globular or cubic in form ; the arms are relatively too long, and there is usually dorsal kyphosis ; the pelvis is thickened and distorted ; the ribs are augmented in size, the femora irregularly curved ; the patellae enlarged ; the tibise more massive and their curves exaggerated. The disease is essentially a symmetrical one, commencing for the most part in the cranium and radius. Fractures are rare, because the bones become stronger rather than weaker. In many instances these changes are accompanied by severe pains, sometimes exaggerated by pressure. The malady is usually regarded as rheumatism, but it must be said that, even were accurate diagnosis made early, it would scarcely avail in treatment, since there is none for it. It may require to be distinguished from hereditary syphilis, in which the tibiae have more of the sabre shape ; from acro- megaly, soon to be described, or leontiasis, which begins in the bones of the face and involves the cranium only secondarily. Osteoarthropathie hypertrophiante pneumique. — Under this title which has no exact equivalent in English, was described in 1890, by Marie, a peculiar affection, often wrongly spoken of in this country as Marie's disease. This is for the most part a pulmonary affection 538 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. accompanied by enlargement of the extremities. There is some reason to think that, whatever it be, there are present some micro-organisms giving rise to products that are absorbed into the general circulation, the result of whose presence is an irritative hypertrophy of certain parts, particularly the joints and ends of the fingers, the elbow-, shoulder-, and knee-joints, and often the wrist. There is also ordinarily dorso- lumbar kyphosis, which in acromegaly is usually cervico-dorsal. The cranium remains intact; the borders of the jaw are sometimes involved. Acromegaly is so named from its tendency to increase the volume of the bone extremities or apices. The first case of this disease was pub- lished by Marie in 1885. It is characterized by progressive increase in Fig. 192. Fig. 193. Osteoarthropathy (Marie). Acromegaly (original). weight, by enlargement of all the extremities, bones and soft tissues alike ; but the most characteristic involvement is that of the lower jaw, the upper jaw being little if at all affected. The lower jaw assumes enormous size and projects so that its teeth are far in front of those of the upper. The supraorbital ridges enlarge, as do also the sternal ends of the clavicles and costal cartilages. As the disease progresses the ribs SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 539 are widened and the scapulae enlarged, the vertebrae and the interverte- bral cartilages thickened and fused together, causing usually cervico- dorsal kyphosis. The long bones of the limbs suffer later, especially at the lowermost joint ends — i, e. hands and feet. The viscera are rarely affected, but there is a peculiar and characteristic enlargement, usually of the thyroid and pituitary bodies. The lower cervical ganglion of the sympathetic is also sclerosed ; the mucous membrane of the nose is usually hypertrophied ; the uvula is enlarged, while often the larynx participates in the changes. Acromegaly is essentially symmetrical, and for each change upon one side of the body we notice a corresponding alteration upon the other. Particular features are observed in individual cases, but the above are practically common to all. The underlying pathological condition is as yet undetermined, though most indications point to late alterations along the original cran.io-pharyngeal tract of the young embryo, whose remains are best known in the pituitary body and the thyroid. The greatest complaint usually is of headache, which is difficult or impossible of relief. The disease is steady, progressive, unaffected by treatment, and the prognosis bad, though its course be slow. Leontiasis. — A diffuse, bilateral, symmetrical hypertrophy of the bones of the face and later of the cranium, described first by Virchow, the real origin appearing to be in the superior maxillae, the result being a peculiar leonine appearance of the face, whence the name given to the disease. There is no distinct tumor-formation in the bone, but rather Fig. 194. Leontiasis : skull of a Chinese woman (U. S. A. Museum, No. 10,620). the entire structure of the bones involved is affected. As it advances for this it always does— function of the parts is interfered with, masti- cation becomes impossible, headache and pain are constant, The special senses are disturbed because of involvement of their nerves, and patients die usuallyfrom inanition, because no longer able to chew and swallow food. It is distinguished from Paget's disease, because it shows no tendency to involve the rest of the skeleton ; from acromegaly, in which 540 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. the general shape of the jaw is preserved, though its dimensions are magnified ; from tumors of the jaw or face, because of its symmetrical enlargement. Its pathogeny is as obscure as that of the other bone affections mentioned in this list, and its treatment as unsatisfactory. Tumors of Bone. As between the various hypertrophic conditions of the bones just above catalogued we must distinguish the true neoplasms, which answer all the requirements of the definition given in Chapter XXV., but which deserve special consideration here because of their importance. There are few if any of the true tumors which may not be met with in bone, including the periosteum. Fibromata of even large size spring from the periosteum, especially about the jaws and from the base of the skull, from which latter place they may project into the nasopharynx and seriously interfere with the welfare of the patient. Some of these tumors are soft and succulent, as well as extremely vascular, and I have seen death occur upon the table in an endeavor to remove a growth of this kind, hemorrhage being simply uncontrollable. Cartilaginous tumors, as stated in Chapter XXV., are not often found outside of the bony skeleton. They may spring from cartilaginous extremities of growing bones, from epiphyseal cartilages, or from the interior of long and short bones, where Fig. 395. their origin is probably due to inclusion of cartilaginous elements, as compre- hended in Cohnheim's theory. In young children they are often multiple and involve various parts of the body. Occurring in adults, they are less often multiple, but may attain considerable size. They are found most often about the ribs, sternum, pelvis, and femora. If the entire structure of a given bone be involved in a growth of this kind, its eradication — that is, amputation — will probably be called for. When otherwise, complete removal with care- ful cauterization of the base of the growth or surface from which it sprang will usually be enough. These carti- laginous tumors tend on the one hand to mucoid softening and cystic forma- tion, and on the other to calcification or ossification, by which the original carti- laginous character of the growth may be concealed. Osteomata are by some writers made to include exostoses and hyper- ostoses. In accordance with the system adhered to in this work, only those growths are considered as tumors Exostosis bursata {Orlow). SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 541 which are of no physiological usefulness, and I should prefer to maintain a distinction between osteomata and the exostoses or bone-hypertrophies, Fig. 196. Cancellous osteomata springing from the diploe {Musee Dupuytren). which pertain either to evolutionary relics or to constitutional affections. There is, however, a peculiar form of exostosis which becomes covered Fig. 19 Fig. 198. Sarcoma of femur (original}. ['"ungating osteosarcoma of cranium (Pemberton). by an adventitious bursa, whose walls become in time quite thick and which now goes everywhere under the name exostosis bursata. In the 542 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. cavity of this bursa will be frequently found rice-grain or other fibrinous concretions. This lesion is common in the neighborhood of joints, and the new bursa frequently communicates with the joint-cavity (Fig. 195). Myxomata are rare in bone, and are seen usually only as degen- erated forms of cartilaginous bony or malignant growths. They lead to cystic degeneration. A primary growth of this kind must have for its origin the bone-marrow, such cases having been described. Sarcoma of bone is often spoken of as osteosarcoma, the former term, however, being preferable. This occurs most commonly in the long bones, although none are exempt; usually single, it nevertheless may be multiple. It occurs frequently in the young, is seen even at birth, and in these instances is supposed to take its origin usually from epiphyseal structures. No period of life is, however, exempt. Tumors attain sometimes enormous size. Marsh has recently described such a tumor weighing thirty-three pounds. Microscopically, these tumors may assume either of the varieties, those of the most rapid growth being found rather of the round-celled type, while those of slow growth are usually myeloid or contain giant cells. Sarcomata frequently rise from the periosteum. Commencing in the interior of a bone, they are known as intraosseous, and as they develop, for the most part very slowly, they expand the bone more or less sym- Fig. 199. Osteosarcoma of humerus (Pemberton). metrically, in distinction to those growths of external origin which are in evidence on one or another aspect of the bone involved. The former are also sometimes spoken of as central sarcomata. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 543 Sarcoma not infrequently has its origin from the callus of a delayed bone-union, and I have had repeatedly to amputate for this most unpleasant sequel of fracture. (See Fig. 202.) As the disease advances there is increase of pain, usually with increasing cachexia, while augmentation in size of such a tumor may make a limb not only useless, but the Fig. 200. source of greatest annoyance and , difficulty in management of the case. j?^ Treatment. — There is but one treatment in cases which will permit it — amputation of limbs, extirpa- tion of tumors from certain bones, or Fig. 201. ^5 ■:'* gP^ Sarcoma of periosteum of humerus (Pemberton). Cystic osteosarcoma of tibia (original). excision of entire bones. Thus for sarcoma of the scapula we extirpate the entire bone ; for sarcoma of the skull we make extensive resections of the same, removing the underlying dura when involved ; for sarcoma of the upper or lower jaw we remove it in whole or in part. Sarcoma of the spine is inoperable, that of the pelvis for the most part equally so. In absolutely inoperable cases treatment by the toxines of erysipelas may be tested. In all the cases where pain is severe it is only humane to administer opiates, which under these circumstances are both anodyne, 544 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. stimulant, and almost nutritive. Patients in this desperate condition should not be allowed to suffer, and opium in assimilable form should always be administered to any amount necessary. Fig. 202. Sarcoma developing in callus (Haberen). Endothelioma. — We are hardly yet in a position to speak very def- initely with regard to this growth, especially in bone, where, by the time it comes under observation, its original characteristics will have under- gone more or less alteration. There is, however, good reason to think that some of the growths, especially of the softer variety, described as the central sarcomata, belong really among the endotheliomata. At all events, they are essentially malignant, and are to be treated in exactly the same way as the growths for which they are mistaken. CHAPTEE XXXV. FRACTURES. By H. H. Mudd, M. D. The term fracture, in surgery, is applied to a break or solution in the continuity of a bone or cartilage. Fractures are said to constitute one- seventh of all injuries. They are ten times as frequent as dislocations. This break may be a dent or an irregular depression, as frequently occurs in the flat bones. The bone may be compressed, as happens in the irregular bones, or the break may be a complete separation of the frag- ments of a bone with displacement. In order to give accurate meaning to the term fracture one must modify it by a qualifying adjective or distinguish it by some phrase or name that will designate its characteristics. Thus we classify fractures, first, as Incomplete and Complete. Incomplete fractures may be sub- divided as follows : (A) The separation of an apophysis, the detachment of a fragment by a cutting instrument, or the fracture of the malleolus, which, although exhibiting complete detachment of a portion of bone, is classed as an incomplete fracture because the body of the bone remains intact. (B) The green-stick fracture, which is the bending of a long bone, notably of the radius and ulna. This occurs only in young sub- jects. (C) The fissured fracture, which is a line of fracture extending partly across a flat bone, as the parietal, or a fracture in a long bone which does not completely sever a fragment from the body of the bone. In the long bones this fracture usually begins at the expanded end and extends into, but not through, the shaft. The line of a fissure may be spiral in its course. (D) A depressed fracture is a dent in the surface of a bone which is produced by direct violence. It may occur in the shaft of a long bone ; is more frequent in the spongy bones, but it is most common in the flat bones of the skull. (E) Partial fractures. The green-stick fractures, the fissured and depressed fractures, are par- tial fractures, but there is a fracture which, although it may possibly be complete, comes properly under the designation of partial fracture. It is a fracture without mobility and without displacement. Crepitus is absent, but an injury to the bone is evident by impaired function, pain and swelling. The swelling develops slowly as the osteoplastic deposit envelops the injured part. This partial fracture is frequently observed in the clavicle, but it occurs also in other long bones. Complete fractures may be classified as follows : (A) A transverse fracture is one in which the line of fracture makes a right angle wjth the axis of the bone or where it does not vary from it more than ten or twenty degrees. The surfaces must be so near a right angle that they 35 545 546 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. will oppose each other, and not slip so as to overlap after adjustment. Irregular serrated surfaces often aid in maintaining the adjustment. (JS) An oblique fracture is one in which the line of fracture is at an angle of not less than ten degrees nor more than seventy degrees with the axis of the bone. It is inter- Fig. 203. mediate between a transverse and a longitudinal fracture. The surfaces are at such an angle that even if Fig. '204. Transverse fracture, ununited. Oblique fracture, badly united. they are well adjusted there is a disposition to overlapping. Any force tending to shorten the bone, whether it be pressure or muscular contrac- tion, produces displacement with consequent shortening. The fractured surfaces are disposed to slip one on the other until there is overlapping. (C) Longitudinal fractures approach the axis of the bone, and may extend from one end of the bone to the other, or, entering at one end of it, may pass very obliquely through the bone to emerge at some distance from the point of entrance on one side of the shaft. (D) The epiphyseal fracture is of course found only in the young sub- ject, not after the twenty-first year. It is the separation of the articular end of the bone from the shaft ; the separation occurs at the cartilagi- nous junction of the shaft and the expanded extremity. This line is transverse, except as it finds irregularity in the overlapping of a portion of the shaft, as at the tubercle of the tibia. The cartilaginous lamina FRACTURES. 547 between the shaft and epiphysis is not suddenly obliterated at one time, so that where the separation occurs at a time when it is partly ossified portions of the shaft or epiphysis are broken off, usually as thin scales of bone. It requires considerable force to produce such a fracture, and the damage inflicted is often increased by the stripping of the periosteum from the shaft. (E) A multiple fracture occurs when there is a fracture at separate points of a bone or when there are several fractures in different bones at the same time. This term should not, however, be applied to the fracture of associated parallel bones, such as the radius and ulna or the tibia and fibula, when only one break in each is present, for they act as a common bone in resisting violence. A multiple fracture of a single bone implies that the fractured points are separate and are not close together. A bone may be broken into a number of fragments, but if the lines of fracture run one into the other and the fragments are comparatively small, it becomes a comminuted fracture. (F) An impacted fracture is where one fragment penetrates the other and becomes imbedded in it. This fracture may occur in any part of a long bone, but is most frequent in the expanded extremity, where a point of bone is likely to be entangled in the cancellated bone. The interlocking of the fragments must be firm enough to give sbme stability to the parts and to resist free movement at the line of fracture. This occurs not infrequently at the trochanter of the femur and the lower end of the radius. ((?) A compound fracture is one in which the broken bone has a more or less free communication through the muscles and fascia with a wound in the skin. An incomplete fracture may be compound. A" compound fracture may be produced by direct or indirect violence. Direct violence bruises and lacerates the tissues. Indirect violence forces the bone through the skin and soft parts. It is one of the most important complications of fractures. A gunshot fracture is, of course, always compound. If a gunshot fracture occurs in the shaft of a long bone, it is almost always accompanied with comminution of the bone, thus adding another complication to the fracture. If the ball enters the cancellated bone, the fracture may be very limited, and, notwith- standing it is a compound fracture, it may heal readily and inflict but little damage. The splitting and splintering of the shaft of a long bone by a bullet is a serious injury. (H) The intra-articular fracture passes directly into the articular surface of a joint. Etiology of Fractures. — The strength of a bone is determined by its texture ; hence the same bone in different individuals varies markedly in its resisting power. Compact bone substance is always stronger than spongy bone. The form of a bone may predispose it to fracture. The long bones and the flat bones are more liable to fracture than the irregular ones. The function of a bone may predispose it to the violence which results in fracture ; thus the forearm and leg are most exposed, but the single -bone, the humerus, transmitting the violence of many falls to the body, is often fractured. The clavicle is in the same way sub- ject to fracture. The habits of life of the individual have much to do with exposure to accidents the period of greatest activity being the time of the most frequent occurrence of fractures — viz. from the twentieth to the thirtieth year of life. Males are most 548 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. exposed, and, although their bones are stronger than the bones of the female, they surfer more fractures than females do. The age of the individual is a potent factor in the etiology of fractures. It is a well-known fact that the increased size of the medullary canal and the dimin- ished thickness of the cortex of the shaft of the long bones that occurs in old age are predisposing causes of fracture. The atrophic changes occurring in the aged affect alike both sexes, but with this fragile condition of the bones of the aged the relative weakness of the bones of females becomes more evident in the marked increase in the frequency of certain fractures, notably those of the neck of the femur and of the lower end of the radius. Rickets weakens very materially the bones and predisposes to fracture, though it so markedly limits the activity of the child that in many cases it protects from fracture by imposing conditions which prevent exposure to violence. The stumbling of rickety patients, however, inflicts many falls and consequent frac- tures. No doubt intra-uterine fractures are more frequent in infants where the foetal bones are diseased, as in congenital rickets. Various constitutional diseases, such as scurvy, syphilis, and struma, disturb the nutrition of the bones and weaken them. Trophic changes resulting from diseases of the nervous system may change the bone so as to predispose it to fracture. Kauber found that the tibia of a paralyzed extremity weighed 6.6 ounces, and of the healthy extremity of the same subject 9.4 ounces. Local inflammatory conditions of a bone, such as caries and necrosis, may materially weaken it. Atrophy of a bone, whether produced by disease, paralysis, senile, changes, or disturbed circulation, enlarges the medullary canal, increases the size of the interspaces in the cancellated bone, and thus weakens the cortex of the bones, so that they have but little resisting power. Mollities ossium or osteomalacia is a disease of adult life apparently dependent upon trophic changes due to nerve lesions, pregnancy, or cancer. The outline of the bone is not changed. The medulla changes in character, so that it does not renew the disin- tegrating bone. The cortex is largely replaced by fatty material and the bones readily bend or break. The bones also become fragile from a con- dition of osteoporosis which results from an inactive life or malnutrition. Syphilis, by the development of gummy tumors or a rarefying oste- itis, may predispose the bones to fracture. Thus it is manifest that physiological as well as pathological conditions predispose to fractures. The immediate cause of fracture is found in the violence of extra- neous force or muscular action. Fractures from external violence are caused either by direct or indirect force applied to the bone. Direct violence may produce a fracture at any point to which it is applied. Indirect violence usually produces a fracture at some particular point of weakness to which it is transmitted. It is apparent that the degree of violence necessary to produce a fracture will vary not only with differ- ent bones, but with the physiological and pathological conditions of the bone, together with the manner of the infliction of the violence. Direct violence may be inflicted either by the muscular action of the individual forcing the bone against a resisting body, or by an extra- neous force driving the foreign body against the bone. The calcaneum may be broken by the direct violence of a fall, the heel coming violently in contact with the ground. A wheel passing over a limb, breaking it at the point of contact, inflicts direct violence to the part. Indirect violence more frequently breaks the long bones than the short or irregular ones. It is evident that peculiarities in the mechan- ism of the violence are important factors in determining where the frac- ture occurs ; for instance, a fall upon the hand may break the radius, FRACTURES. 549 the ulna, the humerus, or the clavicle ; so also a fall upon the foot may break the fibula, tibia and fibula, or the femur. Weak points and curves in the bones help to determine the site of fracture. Certain important differences in the fractures produced by direct and indirect violence must exist. The damage to the soft tissues at the seat of fracture will be much less by indirect violence. The broken ends of the bones may lacerate the muscles, the skin, or the vessels and nerves, but the damage is not likely to be so great as in fractures produced by a violence which may bruise and crush all of the tissues surrounding the injured bone. Muscular action, unaided by external violence, may produce fractures. The olecranon and patella are the most frequent examples of this kind of fracture. The humerus and femur are not infrequently broken in this way. The humerus is thus broken in the act of throwing. It may also be broken by torsion, instanced by two men placing their elbows on a table with their fore- arms upright and interlocking hands, and each endeavoring to force the hand of his opponent backward toward the table. The femur may be broken by a twist in kicking. These fractures occur as a result of comparatively little force, as the bones have but little capacity to resist torsion. The compression of uterine contractions and external violence may produce an intra-uterine fracture. A congenital fracture is to be distin- guished from a fracture produced during delivery by the traction and manipulation of the attendant. The deformities produced by the displacement of the fragments of the long bones are designated as angular when the axis of the bone is bent at the break ; as lateral when the fractured ends are displaced to one side, so that the axis of the two fragments are not in the same line, though they may be almost or quite parallel ; as longitudinal when the ends overlap ; and as rotary when a segment of the bone is turned upon its own axis. A wide separation of the fragments may occur by mus- cular action, as in the olecranon process of the ulna, or in the os calcis when the posterior extremity is detached and pulled up, or in the wide separation of the fragments of the patella. The complications of fractures are of two kinds, immediate and remote. The primary local complications are numerous ; for example, the open wound, the extreme obliquity, the involvement of a joint in a fracture, injury to a contained organ, as in the fractures of the skull and thorax, comminution of the bone, or compound fracture with the impli- cation of a joint. To these we may add great destruction of adjacent tissues, the injury of arteries, veins, and nerves, the intervention of the tissues between the fragments, the wide separation of the fragments, emphysema, and free hemorrhage. The constitutional complications of shock and delirium may be present. The secondary complications may develop in simple fractures, but are more likely to follow complicated ones. These secondary complications are deformities, delayed union, and false joint or an ankylosed joint ; or trophic changes, together with sepsis, thrombosis, embolism, or tetanus. Symptoms and Diagnosis.— The diagnosis of a fracture is often very easy, though in some cases it is extremely difficult even after the careful consideration of every symptom. The symptoms are both sub- 550 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. jeotive and objective. Some of them are pathognomonic, others only suggestive. In many fractures all of the symptoms are easily elicited ; in others nearly all of them are absent. Even where most of them are absent the diagnosis may be positive. Symptoms such as pain, loss of function, and history vary in importance with different patients, though the fractures may be similar. The points to be considered in the diagnosis of fractures are as fol- lows : 1. The history ; 2. Loss of function ; 3. Pain; 4. Crepitus; 5. Mobility ; 6. Deformity ; 7. Ecchymosis ; and 8. Redisplacement. The history, to be complete, should include an inquiry into the exist- ence of predisposing causes and also that of previous injuries. The immediate history of the accident includes the manner and the points at which violence was inflicted, as well as a statement of the degree of violence and the recognition of an audible snap. Lt is generally impos- sible to estimate the degree of violence, and very generally the snap of a bone, if any is produced, is unrecognized in the excitement of the acci- dent. The character of the violence and the point of its reception are the most valuable items in the history. Loss of function almost uniformly accompanies fractures. Impacted fractures, as at the trochanter and an occasional simple fracture of the tibia or fibula arid the green-stick fractures, may exist without total loss of functional activity. On the other hand, it should be remembered that temporary loss of function is sometimes produced by contusion, fright, and nervous disturbances. Localized, pain and tenderness are often important symptoms of a fracture. Pain on muscular movements of the limb or at a point where no direct violence has been inflicted is a valuable aid to diagnosis. Pain at a point where direct violence has been inflicted may be due to con- tusion of the superficial soft parts or of the periosteum. If the pain is referred to a limited area, is elicited only on pressure, and always at the same point, but without apparent contusion of the parts, it is strongly suggestive of fracture. The pain of contused parts is more likely to be vaguely diffused and not so fixed in its location. Crepitus is the grating caused by rubbing the fractured ends together, and is recognized by the sense of touch as well as by being heard. It is pathognomonic of fracture, but is often absent, and in many cases should not be sought for, as the diagnosis is clearly established without it. The crepitus of rough bone surfaces rubbing upon each other is, in the neighborhood of joints, simulated by inflamed bursse and by tenosyn- ovitis. The crepitus of cancellated bone is softer than that of the dense bone of the shaft. Abnormal mobility in the shaft of a long bone is a positive symptom of fracture, but where the injury is near a joint it is sometimes extremelv difficult to differentiate between the motion of the joint and the mobility of a break. This is especially true about the elbow and the hip, and it may be only after repeated trials or by the existence of crepitus that one can say surely there is abnormal mobility. Abnormal mobility is determined by manipulation, unless spasm of the muscles or voluntarv movements exhibit it. It is absent in an impacted fracture and in a green-stick fracture, except where manipulation breaks the interlocking fragments apart. Roughly moving the fragments inflicts damage upon the contiguous tissues and pain upon the patient. FRACTURES. 551 Deformity is one of the most important symptoms of fracture. It may result from the swelling of the soft parts or be dependent upon the displacement of the bones. The swelling is due primarily to hemor- rhage, later to the infiltration with serum and lymph of the tissues sur- rounding the fracture. The deformity resulting from displaced bone may be a shortening, an angular or lateral displacement, a rotary dis- placement in the long bones, or an indentation of the irregular or flat bones. It is often pathognomonic, telling not only of the fracture, but suggesting more or less clearly its character. A wide separation of fragments may occur in certain fractures, as in those of the patella and the olecranon process. A careful inspection and palpation without movement of the injured parts, will often give the surgeon accurate knowledge concerning the situation of the fracture, the character of the violence, and the extent of the injury to the soft parts, and suggest the manipulation and the treatment required in a given case. The two sides of the body should be compared in order to make mea- surements, expose symmetrical parts, and define the relative position of important landmarks, so that the deformity may be fully appreciated, for, though often most palpable, it is frequently so slight that the most careful investigation is necessary to reveal its presence. Ecchymosh is sometimes distinctive of a fracture. An incomplete fracture may be suspected after injury if a point of pain exists where no direct violence has injured the soft parts, followed by the gradual development of ecchymotic areas at or some distance from the location of the pain. The blood follows the planes of the fascia, and is not evident until these lead it near the surface of the body. This symptom is especially valuable in the diagnosis of the fractures of the base of the skull, particularly of the posterior fossa. The existence of these symptoms may be more or less fully established without manipulation of the patient. It is important that all the facts in the case be made clear with as little handling of the parts as is compatible with security. It is a well-known fact that a dislocation once reduced generally keeps its place. This is not so with the majority of fractures, for they require extension and retentive apparatus to keep them in place. The re-establishment of a deformity after its correction is a valuable symp- tom and suggests the existence of a fracture. Treatment. — Bones so uniformly unite when properly treated that an exception to this rule needs explanation. The treatment of a frac- ture is a great responsibility, and every surgeon knows that in certain fractures it is difficult to get a perfect result ; hence dissatisfaction between the patient and the surgeon is not infrequent. Every effort must be taken to give each case careful attention, and the treatment must include both local and general conditions. The local treatment involves two most essential points — the reduction of the displacement or correction of the deformity, and the retention of the fragments in their normal position. The reduction of the fracture, the " setting " of the bone, should be accomplished as early as practicable. In many cases it may be done at once, but in others it is better to wait until the patient is at home, where he can be kept quiet and where efficient treatment may be enforced. It is very rarely necessary to wait for the swelling or tume- faction to subside. This traumatic swelling subsides much more quickly and certainly if the adjustment of the fracture is promptly accomplished. 552 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The perfection of the adjustment may be confirmed or established after the swelling has subsided, but it must, in part at least, be accomplished at once. Success in many fractures is best attained by prompt and efficient reduction. If the injury to the soft parts is excessive and danger of gangrene is imminent, it may be wise to limit the effort at reduction to simple con- tinuous extension with or without lateral support. The stability given to the injured parts by lateral supports is usually, even in these cases, a safeguard rather than a detriment, as its prevents excessive swelling, favors absorption, and diminishes the irritation produced by displaced fragments. Even in crushing injuries, when the extremity can be saved, it is extremely rare to find a case that demands a delay of several days in the adjustment. The effort to reduce displaced fragments or to set the bone should be carefully conducted. The surgeon should avoid in his examination undue manipulation, and above all things he must not add to the injury already inflicted. Muscular contraction is the first obstacle to the reduction of a fracture. This is to be controlled by traction and counter-traction, rarely by anaesthesia. Anaesthesia is more frequently demanded for diagnostic purposes than for the adjustment of fracture. The temperament of the patient often determines the necessity for its use. It is demanded in cases of doubt. The stage of muscular excitement which so often pre- cedes the relaxation of full anaesthesia is at times a serious disadvantage in treating patients. Gentle traction, often necessarily continuous, aided by the knowledge of the fracture obtained through inspection and the history of the accident, will enable the surgeon to set the bone without much pain and with a minimum amount of manipulation and injury. If the fracture is oblique with overlapping or transverse with angling, extension is often all that is needed. If it is transverse with lateral dis- placement, it will need not only extension, but careful manipulation with pressure. The interposition of muscle and fascia and impaction occa- sionally resist proper adjustment. The retention of the fragments in position after they are adjusted may be easy, but it will often tax the ingenuity and tact of the surgeon to the utmost to maintain even a fair approximation. Surgeons should remember that slight motion at the seat of fracture does not interfere with repair. Absolute immobility is not necessary for good and rapid union. The ribs, the clavicles, the femur, and the humerus are con- stantly in evidence on this point. Extension and counter-extension without lateral supports may be all that is necessary. Rest and an easy position secured by lateral supports and slight pressure are efficient in many fractures of the forearm and leg. A fractured bone may usually be kept in good position without being subjected to undue lateral pressure. The union will not be good unless the fragments when at rest are properly adjusted; hence the retaining apparatus must so utilize the principles of extension and lateral support as to accomplish this purpose. Repair of Fractures. The histological changes and clinical phenomena which accompany the healing process are uniform. The character of the bone fractured and the complications encountered may alter the orderly process, but not FRACTURES. 553 Fig. 205. the method, of repair. A fracture is uniformly accompanied by more or less hemorrhage from the bone and soft parts, the amount being de- pendent upon the location and character of the fracture and the extent of laceration of the contiguous tissues. This blood-clot plays a part in the generation of bone that is to follow only in that it gradually dis- appears, and is replaced by a soft vascular mass, the so-called germinal tissue, which envelops the bone at the seat of fracture. The cells in the vicinity of the fracture begin to multiply and new tissue is generated (see Fig. 205). This tissue is rapidly vas- cularized if the fracture is in cancellated bone, as in the flat and irregular bones and in the expanded ends of the long bones. Medullary tissue is found not only in the central cavity of a bone, but also distributed throughout the cancelli of bone, and under its influence and that of the periosteum a small amount of new material is converted rapidly into bone-tissue. It does not, necessarily, become first cartilage and then bone. The bone-cells, or osteoblasts, are found in small irregular cavities. Lime salts are deposited in the fibrous matrix of the new bone. The bone-tissue first formed is soft and coarse, taking a long time to become firm, hard bone of normal vascularity and density. The fibrous mass which develops about a fracture in the shaft of the long bones is quite abundant and forms a large plastic mass, which lifts the periosteum from the bone and envelops it both on its superficial and deeper surfaces. It forms a film be- tween the firm broken edges of the cortex which connects this external envelope with the plastic osteoid substance which fills the medulla. The part of this plastic mass which immediately surrounds the break is generally converted into cartilage before calcareous or ossific matter is to be found in it. This fibrous mass or callus envelops the bone, extends in a thin lamina between the ends of the bone, and occupies the medullary canal for some distance above and below the site of the fracture. The portion within tlu medullary cavity is called the internal callus, while that between the ends of the bones is the intermediate callus. The periosteum is buried in the new deposit. That portion of the periosteum near the periphery of the callus is the part which is vascu- larized first. Here the circulation is most perfect, and the osteoblasts are first found. The vascular supply from the periosteum is most free, and the blood-vessels extend from it into the callus. The blood-vessels from the bone emerging from the Haversian canals also permeate it. The periosteum is the most active osteogenetic agent, but the medulla is also very active. The thicker portions of the callus immediately surrounding the break where the blood-supply is slowest in being perfected becomes cartilaginous. The K it Fracture three weeks old ; periosteal and medullary callus partly ossi- fied, partly cartilaginous: P, peri- osteum ; A', bone ; M, medulla (Till- manns). 554 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. blood-vessels must permeate this cartilage before it is converted into bone. Osteo- blasts are not found in cartilage except under the direct influence of and in contact with blood-vessels. A zone of osteoblasts penetrates the cartilage about the blood- vessels, and then the osseous tissue is formed around them, so that, though neither cartilage' nor blood-vessels alone are capable of forming bone, the two, together with the aid of the osteoblasts, accomplish this end. The ossification of this callus occupies from four to eight weeks. During this time the broken ends of the bone still present a hard, rough line and have undergone but little change. The Haversian canals with their blood-vessels are, however, growing larger and the bone more porous. The spaces become large and irregular in outline and are filled with osteoclasts or giant cells. These large cells are destructive and not conservative. The bone-tissue is riddled with holes. A rarefying osteitis is established which continues until the ends of the bone are more like cancellated bone. The osseous tissue that still occupies the medulla and forms the mass which envelops the bone, and produces the thickening at the seat of the fracture, is now to be absorbed and removed. This is slowly accom- plished, the medullary cavity is re-established, the external callus is absorbed, rough points are rounded off, and the evidences of injury slowly disappear. If the fracture cannot be made immobile or is imperfectly adjusted, the orderly process described is interrupted. The amount of new material necessary to unite a fracture under these conditions is much greater and the time required is increased. The healing process is delayed or completely interrupted, just as it is in the soft tissues when they are pulled apart or disturbed by motion or imperfect adaptation. There is also more scar and the deformity is increased. The callus is thick and abundant when union occurs under such conditions. Osteophytes may develop during the healing of a fracture. They are most apt to spring from points of tendinous insertion or from mis- placed pieces of periosteal tissue. It must not be understood that the fractured surfaces are unchanged until the provisional callus which constitutes the primary union is fully organized. The rarefying osteitis which precedes the solid union of the cortex of the long bones begins soon after the injury, but the vascular canals are plugged with blood-clots and the process of vascularization is slow. The collateral circulation which is to be developed in the bone requires time. It is so slow that the bone is united by the surrounding callus, and is firm enough to resume its function before ossific matter lias transformed the intermediate callus into bone of normal structure to complete the repair. The repair of intra-articular structures is modified by the synovia and the cartilaginous lamina over the surface. Cartilage is not developed to repair the break in its surface. The line of fracture remains either as a sulcus with the bone at the bottom of it, or it has a thin fibrous band at the depth of the sulcus bridging the line of fracture. Intra-articular fractures are said to be more liable to non-union ; this, however, is not well established, for union generally occurs. The union of epiphyseal fractures takes place rapidly. The line of fracture follows generally the epiphyseal line, but frequently varies slightly from it, for scales of bone are found adherent to the cartilagi- nous line. If the irritation and inflammation are excessive, the cartilage FRACTURES. 555 may be destroyed or converted into bone. Hence the growth of the bone in lengthmay be arrested. This seems to be the exception, how- ever, and not the usual result. Compound Fractures. The treatment of compound fractures is of the greatest importance. Antiseptic and aseptic surgery has completely revolution- ized the practice of surgeons in caring for such wounds. The first essential in the treatment of such an injury is that the surgeon shall approach it with perfectly clean hands. The area about the wound should be rendered aseptic by the use of the razor, soap and water, and antiseptic washes. The wound should not be hermetically sealed when the injury is severe and complicated by comminution and contusions. Let the wound serve as an avenue for drainage. Gauze dressings may materially aid in making drainage free and safe. In a large percentage of cases produced by direct violence, where extraneous matter has been forced into the wound, it is better to anes- thetize the patient. The wound can then be more thoroughly cleansed and inspected. This inspection means that the opening should be enlarged or that other openings be made that will permit of a thorough recognition of blood-extravasation, of the laceration of the soft tissues, and of the degree of comminution of bone. Loose fragments of bone should be removed and lacerated tissues, if their vitality be much impaired, should be trimmed off. Large blood-clots should be evacu- ated, and especially is this true if they are in the subcutaneous tissue. The fractured ends of the bone are to be adjusted. The wounds are then to be partly closed, an angle usually being left for drainage. It is not often necessary to use drainage-tubes, and rarely for more than two days, if primary union is to be attempted. Even if the wound is clean, small, and the injury to the soft parts slight, it is safer to dress it as an open wound with an abundant pad of gauze over it. The dressing, no matter what material is used, should not expose a moist surface to the air, for this favors contamination and infection. Absorbent dressings should be abundant, for it is not wise to disturb unnecessarily the fractured bones if possible to avoid it, but cleanliness must be maintained. It is very rarely necessary to wire fractured bones together in order to maintain apposition in compound comminuted fractures. It may be necessary to remove fragments and cut off sharp ends of bone, so as to facilitate adjustment, but the fracture can usually be retained in position without sutures. There are many compound fractures of the extremities, especially when produced by indirect violence, which after cleansing, removing fragments of bone and blood-clots, can be safely closed, and union will occur promptly. However, in the hands of the average sur- geon drainage is a safeguard. * Delayed Union and Non-union. The formative power of bone is very great and repair is usually most perfect. Nutrition of bone, its normal waste and repair, as also its 556 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. regeneration after injury, are influenced by the general condition of the patient. Pregnancy, lactation, general debility, and acute diseases may interfere, just as an exhausting hemorrhage or a great physical drain may interrupt the process. There are certain local conditions which delay or prevent union — viz. marked displacement, the intervention of muscles and fascia, or a foreign body. Suppuration may destroy repara- tive material. Defective nutrition, either through innervation or deficient blood-supply or disease of the bone, may arrest the reparative process. Certain bones and definite parts of a given bone are more liable to such interruption than others. The humerus, the bones of the leg, the femur, and the bones of the forearm are, in the order given, most liable to non-union. A careful distinction must be made between delayed union and non- union. Union may be so delayed that at the end of the first, second, or third month the plastic deposit is deficient in amount and very soft. Stim- ulation of the nutritive process by rubbing the bones roughly together, or by puncturing the fibrous material as well as the ends of the bones with a drill, may arouse renewed action and secure solid union. The establishment of more perfect circulation or the improvement in the general health effected by getting the patient out of doors and by renew- ing his activity may start anew a halting reparative process. In non-union the ends of the bone are rounded off, the medullary cavity is closed, the blood-supply to the seat of injury is diminished, and the ends of the bone at times may be widely separated by the absorption of bone. Non-union occurs very rarely — according to Ham- ilton, not more than once in five hundred fractures. It must be ap- parent to surgeons of large practice who have studied the clinical his- tory of fractures that the treatment of the fracture has much to do with the failure to unite. Undue pressure, too light bandaging, over-anxiety about the process of union making the surgeon over-zealous in inspec- tion of the parts, imperfect adjustment, and undue mobility, are all ele- ments which should be considered. The surgeon should carefully con- sider every detail of his management of the case, as well as the local conditions pertaining to the fracture and the general condition and sur- roundings of the patient, before accepting the non-union as being pre- determined by conditions beyond his control. The purpose of treatment for delayed union or false joint is to re- excite the activity of the nutritive processes. The procedures adopted for this purpose are varied. If the mobility is slight, as is often the case in fractures of the leg and the thigh, lateral supports may be adjusted and the patient allowed to use the limb. The continued irri- tation of the intermittent pressure exerted in walking renews and main- tains active nutritive efforts until union is finally accomplished. Where there is much atrophy of the soft parts massage exerts a good influence. The Brainerd method — viz. boring the ends of the bone — is a safe procedure if performed as an aseptic operation. If these simple methods fail, then the false joint may be exposed by a free incision, the tissues, whatever they may be, that intervene between the ends of the bone cut away, and the medullary cavity opened by resecting the bones in such a way as to give good broad surfaces for FRACTURES. 557 approximation and easy retention. It is important in the operation so to arrange the local conditions as to give full approximation and easy Fig. 206. Flail-joint, with extreme angular deformity after compound fracture, result of neglect (Park . retention. This approximation may be secured by nails, wire sutures, ivory pegs, chromicized catgut or kangaroo tendon, or simply by a splint. The individual case must determine the necessity of the use of the suture. It is not always necessary. It usually requires a much longer time to secure union in such cases than it does in primary fractures. The peri- osteum from the portions of the bones excised must be saved. SPECIAL FRACTURES. Fractures of the Nose. The nasal bones increase rapidly in strength and resisting power as they approach the os frontis. The nasal spine of the frontal bone rein- forces them at this junction. Fractures of the base of the nose are infrequent, but quite dangerous. The cribriform plate of the ethmoid is very apt to be implicated in this fracture, the fragments of which very easily penetrate the brain. Inflammation and sepsis are apt to follow, for the spiculse of the cribriform plate are sharp and the communication with the nasal fossae offers a good opportunity for septic infection. The fracture may include the nasal process of the superior maxilla and the vomer. A broken nose is not dangerous to life, except when it is broken at the base and complicated with fracture of the cribriform plate. The 558 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. break in the lower segment is most frequent, the injury being to the nasal bones only, though the perpendicular plate of the ethmoid may be bent or broken. The fracture is always by direct violence, is frequently comminuted, and often compound both by wound of the skin and the mucous membrane. The cartilages of the nose are frequently separated from their attach- ment to the nasal bones. This accident is of the same clinical imports ance as a fracture of the nasal bones in their lower segment. Hemor- rhage is occasionally severe, recurrent, and prolonged. Deformity by deviation to one side or a flattening of the nose, crep- itus under pressure, mobility, obstruction to the nasal passages by blood- clots, swelling of the mucous membrane, and the history of the accident are the common symptoms of these fractures. Emphysema of the eyelids or cheeks also indicates fracture of the nose, and, although it may conceal the real deformity of the displaced bones, it is not a serious condition and rapidly subsides. It is produced by the escape of air from the nose in the act of sneezing or blowing. Bleeding into the subcutaneous tissue and the swelling from the contu- sion of the soft parts may also conceal the exact nature of the injury. The deformity produced by an irregularity in the outline of the nose makes these fractures of extreme importance, and an accurate adjust- ment of the comminuted bone is necessary to the symmetry of the part. Any irregularity in the outline is most obvious and changes the whole expression of the face. If the displacement is marked, the adjustment can be accomplished best by force applied from within the nostril, a firm knitting-needle or a small grooved director serving very well for accom- plishing this purpose. It is well to wrap it with iodoform gauze or plain sterilized gauze, which should be firmly applied to the bar, and the whole should not be more than three-sixteenths of an inch thick. This is to be carried upward and backward along the septum until it passes beyond the break, and then carried firmly and strongly forward until the bones are pushed and moulded into position. In order to accomplish this it should be carried forward along the septum parallel with the nasal bones until it rests in the groove between the plate of the ethmoid and the nasal bones. The wrapping of gauze should be held in position by the porte-meiche, the fingers, or the forceps while the smooth rod upon which it has been carried into place is withdrawn. Superior Maxilla. The nasal and alveolar processes are frequently broken. The nasal process suffers fracture in the crushed injury of a broken nose. The alveolar arch is broken by blows which loosen the teeth or break away the entire arch or a segment of it. Fractures of the body of the bone are the result of great violence. The blow may be transmitted through the malar bone. The injury inflicted in this way is to the wall of the antrum. Breaks in the body of the bone may separate the alveolar arch and the palate process from the upper segment of the bone. Patients bear these injuries wonderfully well. Repair is rapid and union by bone almost certain, though the deformity may be great. It is earnestly recommended that all fragments shall be left in place, as FRACTURES. 559 no portion of the bone, unless it be completely detached, should be removed. All the fragments should be saved and moulded into the best possible shape, and then given such support as it is possible to secure to keep them in place. Loose teeth should not be removed, for they will become fixed in position again. Notwithstanding the extreme vascularity of the parts, hemorrhage is not apt to be excessive. The cavities of the nose, the pharynx, and the mouth, as also wounds of the skin, are open avenues to infection. Phlebitis, lymphangitis, septicaemia, erysipelas, and necrosis are possible complications which make the injury a serious one. Suppurative inflammation of the antrum is also a trouble- some sequel which may develop. Partial fractures of the alveolar arch must be held in place, if mobility or displacement be present, by wiring the teeth in the fragment to the adjacent teeth in the uninjured portions of the arch. The frag- ment of the arch, either with or without the teeth, may be secured by an interdental splint of wire, gutta-percha, or other suitable material. The skill of the dentist is often required. Displacements of portions of the body of the bone are often difficult to treat. The displacement is generally downward and backward. The fingers in the mouth and a blunt hook to catch behind the palate or to hook over the orbital margin, or to pass from a wound or incision in the cheek about some point of the displaced bone, even when vigorously used, cannot always accom- plish perfect adjustment. This is especially true in fracture of the maxilla with depression of the malar bone. Malar Bone and Zygomatic Arch. The body of the malar bone is very rarely broken, for it is thick and strong and articulates with a bone which gives way and allows displace- ment inward before sufficient force has been applied to cause fracture. The wall of the antrum caves in or the bone is displaced toward the orbit. The zygomatic arch breaks under direct violence or as a compli- cation in the displacement of the malar bone. The break most fre- quently occurs in the temporal portion of the arch. The zygomatic arch may be elevated and the malar bone occasionally brought into position by passing a hook under the zygomatic process of the malar bone and pulling and lifting it into place. The incision through which the hook is passed need not make the fracture a compound one, and is not a dangerous pro- ceeding if made with aseptic precautions. If the injury is confined to the arch, the normal outline can usually be restored, but if the malar bone is fractured and displaced, even great force will not always correct the deformity. Inferior Maxilla. The position and prominence of the inferior maxilla greatly expose it to fracture. It is a dense, strong bony arch, compactly formed, some- what elastic, capable of free lateral movements, and well calculated to resist violence and maintain its integrity. It is, however, more fre- quently broken than any of the bones of the face. Fractures occur most frequently in the body of the bone. Compression at the angles or blows upon the angle may break it near the centre of the arch, but the symphysis and the anterior portion of the body are the parts most 560 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. exposed to direct violence, and are thus frequently broken. The ramus and the coronoid processes, though protected from violence, are generally broken by the direct injury of blows or by penetrating wounds. The condyle — or, more correctly, the neck — is broken by indirect violence transmitted through the body of the bone from the chin. The site of the most frequent fractures is at or forward of the mental foramen, often at the symphysis. The fracture is most frequently slightly oblique, extending downward and backward, and it is bevelled, so that the anterior fragment is longer on its internal surface. Fractures may occur at every part of the body of the bone. When they occur at the angle the obliquity is apt to be more marked. The bone is not infrequently, perhaps in one-fourth of the cases, broken at two separate points. The multiple associated fractures are situated, usually, one in the anterior portion of the bone, and the other at or near the angle of the opposite side, but the seat of the multiple fractures may vary from the condyle to the symphysis. Nearly all of the fractures are compound by communication with the oral cavity. This is especially apt to be the case where a tooth has been displaced. The general symptoms of a fracture of the jaw are pain, deformity, mobility, and crepitus. The pain is provoked by the movement of eat- ing and talking, and is often very great. The patient endeavors to miti- gate its severity by supporting the jaw. It should be remembered that the inferior dental nerve passes through the body of the bone. This nerve may be torn, but if not torn its encasement in a broken bony canal no doubt adds to the severity of the pain on any motion of the fragments. Fractures anterior to the mental foramen should not be so painful as those situated farther back in the body of the bone. The deformity is best recognized by observing irregularities in the teeth. The fracture rarely occurs in the body back of the molar teeth. The anterior fragment is apt to be displaced downward and inward. Where the fracture is well back toward the angle or in the ramus or neck, the deformity can sometimes be best detected by observing the symphysis. If this be displaced to one side of the central line of the upper incisors, and there be tenderness and pain in the region of the ramus on the same side, it is suggestive of fracture, and careful search should be made for it. Mobility may be very free, but slight mobility is most common. Mobility, when the fracture is in the neck or condyle, may be appreci- ated best during movements of the jaw. Crepitus is usually plain and easily detected, except in fractures of the coronoid process. The treatment required in the great majority of cases is simple. It is not easy to secure immobility, but the slight movement between the fragments does not appear to interfere with union. Many of these fractures recover with practically very little help from treatment. To secure as much stability as possible the body of the jaw should be sup- ported by a splint or bandage and held against the upper jaw, which serves as a splint. A moulded pasteboard, felt, or gutta-percha cup makes a good splint. This should be fitted to the chin and the body of the jaw, and serve as a cup in which the jaw rests, a padding of com- mon non-absorbent cotton being placed next to the skin. This splint is held in position by a four-tailed bandage. The sling or four-tailed bandage may be used without the splint (Fig. 207). Putting a vire or silk ligature about the teeth in many of the fractures is a simple and an efficient treatment if used in conjunction with an immobilizing cup. FRACTURES. 561 The wire loop should include at least two teeth on each side of the break, as con- stant tension on the teeth will soon loosen them. The wire should be silver, of medium size, and not too tightly drawn. If only the teeth next to the break are surrounded by the wire loop, their loosening is very apt to increase the irritation Fig. 207. Application of four-tailed bandage. about the fracture. If the break is markedly oblique, the difficulty in adjusting the fracture is often very great, and the retention in good position by a supporting splint is unsatisfactory. In these cases the tension on the wire loop is too great for the teeth to bear, and the tendency to displacement is so great that it will fre- quently break a wire if it is passed through drill holes in the bone. Interdental splints of heavy wire fitted to the teeth, formed from a plaster mould, are at times very valuable. The fastening together of the lower and upper jaw by wire loops about the teeth may offer material help during the short time it is necessary to immobilize the fracture. Union is rapid when necrosis does not occur. The bone is fairly firm in three weeks, though mastication of solid food should be longer delayed. Non-union is very rare. Fractures through the ramus of the jaw do not show much displacement. Immobilization of the jaw is all that is required in the way of treatment. The Hyoid Bone. The hyoid bone is broken by compression, either by direct force or by bending the head forcibly backward. Hemorrhage or marked inflam- mation, with collateral oedema, may render the injury serious. The swelling may impede respiration. The fracture ordinarily unites readily and without much inflammation, the union being either cartilaginous or bony. The result is usually satisfactory, as the displacement is generally slight. Dyspnoea, difficult deglutition, and pain on talking may be present as symptoms. The treatment is symptomatic. If the displacement is great, or if the cornua has penetrated the pharynx or been turned so as to be caught in the tissues, an attempt should be made to replace the fragment, and if this should be impossible it may be removed. The oedema of the glottis may demand tracheotomy, and the difficulty in swallowing might necessitate feeding by an oesophageal tube. 36 562 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The Ribs. Fractures of the ribs are frequent, but authorities differ as to the most common seat of these fractures. They are broken generally in the lateral wall of the chest (Fig. 208) at or between the angle and the anterior third of the rib. It is a very rare accident in the child, fre- quent in the adult and aged. It occurs from direct or indirect violence. It may result from a compressing force, one or more of the ribs being broken. Symptoms. — Collapse or profound depression may follow the violence inflicted. A weak and rapid pulse with dyspnoea and local pain are present in the graver injuries. Pain which is made worse by pressure at the point of fracture, or by pressure which will increase the arch of the rib, is an important symptom. Diaphragmatic or abdominal respi- ration is present. Emphysema beginning at the seat of the fracture may extend over the body. Hemorrhage from the wound, if the fracture is Fig. 208. Fracture of ribs ; synostosis. compound, may be either external or into the thorax. Haemoptysis from the wounded lung may occur. Crepitus may be distinct, but is often absent. The displacement is rarely enough to require attention except when several ribs are broken. It may then be necessary to correct the deformity by adjusting the fractures and securing them in position by fastening the ends together. Treatment is directed to the relief of pain, to limiting the motion of the chest-wall in breathing, to the arrest of the hemorrhage, and to the control of the irritation of the injured parts. Pain is relieved or controlled by a firm bandage or plaster strip applied so as to encircle the thorax and limit the movement of the chest-wall in respiratory efforts. This firm bandage helps to immobilize the fragments. Anodynes are also most useful, and in many cases must.be resorted to. Relief from pain favors reaction and shortens the depression following the injury. Hemorrhage from an external wound may be controlled by direct ligature or by pressure. A pouch of gauze may be carried through the bleeding wound into the cavity of the thorax and stuffed with small strips of gauze, so that a knob of gauze can be firmly pulled against the inner thoracic wall. This prevents hemorrhage into the thorax, and by its pressure arrests it in the intercostal space. Haemoptysis is not often very free. Hemorrhage must always be carefully considered and con- trolled. FRACTURES. 563 The Steenum. The sternum is an open cancellated bone composed of several pieces which unite at different periods of life. It may be broken or separated at the junction of the manubrium and the body, or the break may occur at the cartilaginous junction of the separate pieces of the body of the bone. According to Hoffa, statistics show that the sternum is broken less often than any of the bones, making only about 1 per cent, of fractures. The sternum is fractured most frequently by forcible flexion of the spine. A fracture induced in this way is most apt to occur in the upper section of the bone. Muscular action must also be recognized as a source of fracture. The great muscular effort used in lifting heavy weights has produced this fracture. Blows upon the sternum by a pole or club may induce fracture by direct violence. By far the larger num- ber of fractures result from the forcible bending of the body, either from a fall upon the head or the buttock, or by being caught while in a sitting posture between a moving wagon or car and a beam overhead, and thus forcibly bending the spine. The xiphoid cartilage may be luxated or broken. This is sometimes a painful and dangerous accident, as it may induce spasm or irregular action of the diaphragm and violent vomiting. If its symptoms should be violent and serious, it can be exposed and fastened into place or removed. The Clavicle. The clavicle is exposed to both direct and indirect violence. It is a curved slender bone, aud to it or through it is transmitted the force of falls upon the hand, the elbow, and the shoulder. Direct blows upon the upper surface of the shoulder or upon the anterior surface of the base of the neck are also received by the clavicle. It is a very com- mon break, constituting 15-16 per cent, of all fractures. It occurs most frequently in children under five years of age. It is compara- tively rare in the aged, but frequent in middle life. The common seat of fracture is in the body of the bone just outside the middle, near the junction of the external with the middle third. The fracture at this site is generally the result of indirect violence. It is produced by a blow or a fall upon the shoulder or by violence transmitted through the arm. Any portion of the bone may be fractured by direct violence, though the external end is rarely the seat of fracture. It is rarely a compound fracture, although the bone is superficial, being covered only by the skin and subcutaneous tissue. Complications in the way of dam- age to adjacent important structures are also rare, the subclavian vessels, the plexus of nerves, and the pleura almost uniformly escaping injury. The displacement in fracture of the clavicle is very uniform — viz. the internal fragment is pulled upward by the sterno-mastoid, and the external one depressed and carried inward by the weight of the shoulder and by muscular action. Dis- placement of the fractured ends is less marked if the seat of fracture be near either end. The SIGNS AND SYMPTOMS OF A FRACTURED CLAVICLE vary with the seat of fracture. The deformity and disability are less marked when the break is in the outer third. If it be in the body of the bone the shoulder drops downward, and if the displacement be marked, it 564 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. comes forward and inward. The head is turned toward the affected side and the patient seeks to support his forearm and elbow. The irregu- larity at the seat of fracture is easily discerned. The pain on motion is acute and the loss of power in the arm is complete. These signs are nearly all well marked in the adult, but in children a break in the clavicle often occurs with little displacement. The periosteum may remain untorn and the ends of the bone remain in good position. This modifies the deformity and lessens the pain, and the loss of function is not so complete, so that it is not an infrequent thing to have the injury overlooked by the mother for several days. Treatment. — Cases of the character last mentioned need but little treatment. A well-adjusted sling, giving support to the forearm and the elbow and confining the hand and arm of the child, will often answer all the indications. Strenuous but injudicious efforts to immo- Fig. 209. ft Moore's dressing for fracture of the clavicle. bilize the shoulder in these simple cases may provoke further displace- ment and add to the deformity and pain. The multiplicity of the plans suggested for the treatment of fractures of the clavicle testifies to> the inadequacy of the methods in vogue. The results of treatment in cases in which the deformity is marked are usually not perfect. There is gen- erally a little shortening and a well-marked callus. A comfortable and fairly-efficient method of treatment is the " double figure of 8 " sug- gested by Dr. E. M. Moore of Rochester, New York (Fig. 209). The illustration shows the bandage applied. It is as follows : A strip of muslin a little over two yards in length and wide enough to be folded four times upon itself until it is a strip eight inches wide is held on the surgeon's hand ; the hand is placed under the elbow of the injured side ; the folded strip with ends of unequal length crosses the under surface of the flexed forearm at the elbow. The longer end, which is to the FMACTURES. 565 inner side, is passed upward inside and in front of the arm and is car- ried over the shoulder across the back and through the opposite axilla. It is brought over in front of the sound shoulder and meets in the back the short end, which is carried first up over the outside of the forearm and backward across the spine. These ends are secured to each other in the back and about the sound shoulder. The hand is supported in a sling which is attached to the bandage as it passes over the injured shoulder. The efficiency of Moore's dressing depends on a recognition of the position of the fibres of the pectoralis major. Those arising highest are inserted lowest on the humerus, the tendon making a half turn as it descends to its insertion. Hence the farther back the elbow is held, the more are the clavicular fibres pulled upon — i. e. the fragments held in place. The figure of 8 crossing over the spine with a loop around each shoulder is fre- quently used. The loop placed about the injured shoulder should fit rather snugly, so that it will not slip too far inward from the point of the shoulder. If the loop is too large, it makes a downward pressure on the outer fragment, and tends in that way to increase the deformity. The most efficient treatment is attained by placing the patient in the recumbent position on his back, with a firm support under the spine. This should be so adjusted that the injured shoulder is allowed to hang free, its weight carrying it upward and backward. This treatment enforced for three weeks gives very good results. It is simple and effective, but irksome, and very few patients will submit to the position aud the long restraint. The Scapula. The acromial process of the scapula is usually broken by direct violence. The break is most often near the end of the process. The mobility of the fragment is easily detected, so that the diagnosis is not difficult. The outline of the spine can be followed, for it is subcutane- ous throughout the entire length. The pain and contusion confirm the diagnosis. The union is usually ligamentous, rarely bony. The treatment consists in holding the head of the humerus well up in the glenoid fossa and immobilizing the arm. This is most com- fortably accomplished by a broad strip of folded muslin (or cheese cloth), which is so placed that its central portion passes under the elbow. The ends of the strip are carried upward to the shoulder and crossed over it, and carried across the chest in front and behind to the opposite axilla, and secured to each other as they meet. The hand should be secured in a sling fastened to this bandage at the crossing above the shoulder. A pad of cotton or wool should be put in the axilla, thick enough to keep the arm from the body, so that the humerus may be nearly vertical. The next most common fracture of the scapula is of the surgical neck. In this fracture the break passes from a point below the glenoid fossa upward to the suprascapular notch, including the coracoid process. The symptoms are lengthening of the arm, flattening of the shoulder, an unoccupied space below the acromion, loss of function of the arm crepitus, and an easy reduction, with immediate recurrence of the de- formity as soon as the support under the elbow is removed. There is unusual passive mobility of the arm in this fracture. The union is usually bony and occurs promptly with restoration of the function of the arm. 566 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 210. The treatment enforced should support the arm firmly, so that the head of the humerus is pushed up against the acromion process. The head of the bone and the neck of the scapula should be held out from the body by a pad. This may be accomplished by the support given to the elbow by a broad strip of adhesive plaster (moleskin), which should pass about the body and up over the top of the sound shoulder. It should be firmly applied. The arm is thus immobilized after carrying the elbow forward on the chest. The angles of the scapula, and also the spine and the body of the bone, are broken by severe direct violence. There is not much displace- ment except where the fracture involves the inferior angle, which may be carried forward and upward. The fragments can generally be moved, so that crepitus is evident. The bone is well protected with muscles, and it is not easy to detect irregularities of outline. The treatment consists in padding the scapular region and binding it firmly to the chest-wall. The arm must be immobilized by fixing it in a sling. The Humerus. The humerus is not broken as often as the clavicle or the bones of the forearm. The fractures of this bone are to be considered in groups — first, of the upper end ; second, of the shaft ; and third, of the lower end. Fractures of the anatomical neck, fractures through the head or through the tuberosities and the head, may well constitute one class of the first group, as the clinical history is much the same. A fracture of the anatomical neck- is very rare. The line of the break gen- erally follows the groove between the tuber- osities and the smooth cartilaginous head. Fractures through the head rarely occur, except as a complication of the more ex- tensive fractures through the tuberosities and the surgical neck. Fracture through the tuberosities does not occur frequently. These breaks are generally produced by di- rect violence, rarely from uncomplicated indirect violence. The symptoms accompanying these frac- tures are not so distinctive as to permit a differential diagnosis. The shoulder is swollen and generally flattened over the joint. Crepitus is present and the function is lost, while pain is quite marked, especially on motion. Fracture of the surgical neck is the most frequent and the most important of this group of injuries. The line of fracture is below the tuberosities and above the insertion of the pectoralis major and the latissimus dorsi (Fig. 211). It results from either direct or indirect violence. This fracture usually presents a well-defined group of symptoms. The head of the bone can be felt in its proper place. The axis of the Fracture of the anatomical aeck of the humerus (Hoffa). FRACTURES. 567 shaft points inward toward the coracoid ; the upper end is almost always pulled inward by the pectoral muscle and by the latissimus dorsi. It makes a slight angle with the head ; crepitus is distinct, and can be elicited by traction and rotation ; the arm is shortened and hangs power- less at the side ; and mobility is marked. The head of the bone is in the proper position, but does not rotate with the shaft ; voluntary move- ments are lost, while passive movements are free. Fractures at the upper extremity of the bone may be impacted, and are then rendered still more obscure. The violence producing this fracture is well cal- culated to produce separation of the epiphysis in young subjects. The displacement is, however, different. Fig. 211. Fracture of the surgical neek of humerus (Hoffa). After the reduction of the displacement present in this group of injuries the treatment which is adapted to the most common frac- ture — viz. that of the surgical neck— answers the indications that should be met in the others. The deformity present in the fracture of the sur- gical neck may be corrected by traction downward, outward, and for- ward until the shaft comes into line with the head. Direct pressure of the hand aids the movement of coaptation. If the patient is able to sit up, the dressing is more easily applied. The elbow should be held just away from the body and the forearm flexed at right angles. The splint most universally applicable for these fractures is the plaster-of-Paris folded con) press or a plaster roller. It should extend from the lower part of the forearm to the top of the shoulder, enveloping both the elbow- and the shoulder-joint. The entire arm should be first wrapped in cotton. During the application of the plaster splint extension from the elbow is continued. 568 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. If these fractures be complicated by dislocation of the head of the humerus, they are of much more serious import. Reduction of the dis- location must at once be attempted by manipulation. If this fails, then either at the first dressing or at some time within a week or ten days, as indications may suggest, the reduction must again be attempted by cutting down upon the fracture and attempting reduction by McBurney's method — that is, with a hook passed into a hole drilled into the upper fragment. Traction and rotation through the medium of the hook, together with a more direct manipulation of the parts, should succeed in effecting a reduction of the dislocation. Reduction may possibly be accomplished by direct manipulation of the head Avithout the hook. After the reduction of the dislocation the treatment is to be directed to the cure of the fracture. If the local condition be such as not to per- mit the application of a splint, the patient should be placed upon his bed, and, while the arm is placed in a comfortable position on pillows, traction should be made by means of adhesive strips and weights and pulleys or by elastic bands until the swelling subsides. Two points must be clear to the surgeon in treating injuries of the upper end of the humerus. These are usually easily determined, as they present distinctive diagnostic symptoms. The most important point is to know that the head is not dislocated ; second, that the injury is not co7ifounded with fracture of the neck of the scapula. The shaft of the bone is frequently broken by direct and indirect violence, but muscular action is not an infrequent source of fracture. Displacements in the broken shaft may be lateral, angular, rotary, or overlapping. Mobility is marked ; crepitus is easily obtained ; shorten- ing is not usually very marked ; swelling and pain are present. Injury to the. musculo-spiral nerve is one of the complications of this fracture, as is also injury of the brachial artery. The nerves may be injured by the violence of the accident or by involvement in the callus. Injury to the artery may be detected by a disturbance of the circulation and absence of the radial pulse. Motor and sensory disturbances indicate the extent of the nerve-injury. Plate XXI. Delayed union and non-union are said to be more frequent than in any other bone, but the fracture is easily managed and is almost uniformly satisfactory in result. If the circulation is free, the nutrition should be good and union fairly certain. This bone has, however, been known to disappear by absorption after fracture. Untoward results of this kind cannot be guarded against, so that, though it is an injury which usually results in union, it may be accompanied by grave complications. These fractures should be treated as are those of the upper end of the bone. The splint should immobilize the shoulder and the elbow, while it gives some lateral support to the break. A plaster-of-Paris or starch bandage or pasteboard splint should be used. Fractures of the lower end of the humerus are frequent, and are of the greatest importance, for imperfect adjustment is likely to result in permanent deformity and impairment of function. It is always desira- ble to make an accurate and exact diagnosis, though it is sometimes difficult or impossible to do so. The epicondyles are subject to fracture by direct violence. The line of fracture does not usually enter the joint. The internal epicon- PLATE XXI. Supra-Condyloid Fracture, child oi nine years; union with deformity, fragment so joined to lower end of shaft of humerus at an angle that when forearm is completely flexed upon this frag- ment, it yet is only at right-angle with arm. Operation indicated. (X-Ray picture.) FRACTURES. 569 dyle is the much more prominent and is most frequently broken. The fracture does not involve the joint, and the displacement is not usually great. The intermuscular fascia helps to retain these fragments in position, though they are occasionally torn loose from their muscular attachment. When this occurs they may be distinctly separated from their normal situation. If detached and in bad position, it is well to remove the fragments. The treatment is rest with the forearm fixed in a flexed position. Supracondyloid fracture and separation of the epiphysis are similar in some of their symptoms, their correction, and their treatment. They both ordinarily result from indirect violence. The epiphyseal sep- aration follows the line of the cartilage, and is nearer the articulation than the supracondyloid fracture. The position of the arm in each of these injuries is much the same, the arm being slightly flexed, with marked fulness in front of the elbow, and the olecranon more prominent posteriorly. The deformity is increased by putting the arm in an ex- tended position, and is diminished by flexion. Mobility is increased, the crepitus is soft in epiphyseal separation, and is easily elicited in supracondyloid fractures. The projection in front of the elbow-joint is sharp and more easily outlined in the fracture than it is in the epiphyseal separation. Here, as in all injuries about the elbow-joint, it is import- ant to determine the relation of the olecranon to the external and the internal epicondyles. They maintain their normal position in both of these injuries. If the arm be flexed, a line drawn from one epicondyle to the other in a vertical plane crosses the top of the olecranon. If the arm be extended, a line so drawn in a horizontal plane also touches the top of the olecranon. In a dislocation of both bones of the forearm backward, which simulates these injuries, this relation is altered. Either condyle may be broken from its fellow and from the shaft of the bone. A transverse supracondyloid fracture may be complicated by a fracture extending from the transverse line of fracture to the joint (Fig. 212). These fractures implicate the joint. They may result from direct or indirect vio- Fig. 212. lence. The fracture may be comminuted and compound, and the contusion and the lacera- tion are often extensive. The T-fracture above described is the intercondyloid fracture and is usually produced by direct violence. The sep- aration of either condyle is more frequent than the intercondyloid fracture. The lines of sep- aration in these injuries vary considerably, but the treatment is much the same. In fracture of the external condyle the fragment is more apt to be displaced forward. Fracture of the internal mav be associated with a backward displacement of the bones of the T " fraC (H r eiferichr erus forearm and with widening of the joint. In these fractures swelling, ecchymosis, marked mobility, and crepitus are present. The deformity may be marked in any of these injuries, but it is always great in the intercondyloid. The surgeon must bear in mind that a good movable joint is to be 570 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. sought in these fractures, and it is usually attained if the treatment is directed by tact and good judgment. It must not be conceded that frac- ture into the joint necessarily implies a bad result. The extent of the injury, the comminution of the bone, and the violence of the separative action, may result in a stiff and deformed joint, but this is not the usual result. Accurate adjustment is the essential to successful treatment. Maintenance in perfect position is not always possible, but may be attained in the majority of cases. An anaesthetic is here not infre- quently demanded in order to make an accurate diagnosis and to secure good adjustment. The surgeon must bear in mind the fact that the axis of the forearm and the arm are not the same when in a position of extension. They make an obtuse angle, the forearm diverging outward, so that when hanging at the side, in a position of supination, the hand is carried away from the body. It is also extremely important, both on account of symmetry and usefulness, to retain this outward deviation, which gives to the arm its carrying power. How may accurate adjust- ment and maintenance be best attained ? The fragments can be most accurately moulded into position when the arm is extended or when only slightly flexed. The extended position is often necessary to per- fect adjustment. If a splint is to be adjusted to the arm, and it is not thought best to flex it to a right angle, it should not be placed in full extension, but slightly flexed. The support may be a posterior splint or an immovable cast. Elastic extension or traction by pulley and weight is occasionally necessary if the swelling be too intense to permit the immediate application of a retaining splint. It has been a habit with me to treat these cases in a right-angled splint. Good results have been the rule, but in the condyloid fractures the position of very slight flexion is the best for accurate adjustment, and the arm may be secured in this position. It is, in my opinion, important that the recumbent position be assumed for a time in the cases dressed in full extension. I have in a number of cases, after using this position for a week, flexed the arm to a right angle and then continued treatment in a rectangular splint. Passive motion in order to retain mobility of the joint is out of place and dangerous. It is to be con- demned as pernicious. The joint is to be put at rest until the bone is consolidated ; then the patient will gradually recover motion if the adjustment has been good. The splints most useful in these fractures are those which can be moulded to the outline of the parts. Plaster of Paris, pasteboard, and starch are the most useful. If it be desired to inspect the arm, a section of the cast may be cut away. The cast can then be replaced and held in position by a roller bandage. It requires five or six weeks to secure good union in fractures of the humerus. There is but little danger of permanent loss of motion in the joint if the adjustment has been perfect, though every surgeon will meet cases in which even with the greatest care a deformity will occur that impairs the symmetry of the arm or the function of the joint. Fractures op the Forearm. — The Ulna. Fractures here, excepting Colles' fracture, most frequently involve both bones, but either bone may be broken without implicating the other. FRACTURES. 571 Muscular action sometimes produces fracture of the olecranon pro- cess, the fragment so detached being usually a thin portion, often only a scale from the tip. The process is more frequently broken by direct violence, which usually occurs in a fall with the elbow bent and strik- ing against a hard substance. The process is thus broken off near its junction with the shaft. In these cases the muscular contraction of the triceps materially aids the violence in producing the fracture. The joint is opened, and, the bone being so superficial, the fracture is easily rendered compound by the violence producing it. The contusion inflicted and the involvement of the joint result in rapid swelling. The tumefaction of the parts obscures the injury somewhat, but the diagnosis is not usually difficult, for the posterior surface of the process is subcu- taneous and the line of fracture can be felt on the sharp ridge which is continuous with the shaft of the bone. If the laceration is extensive, the detached fragment may be pulled well up by the triceps. In these fractures the tip of the process does not hold its proper relation with the epicondyles, and this relation is especially destroyed when the arm is flexed at a right angle. It is not always feasible to put the part in good position at the first dressing. It is well to put a splint on the arm while it is in a position of slight flexion, though later in many cases the arm may be safely flexed to a right angle. A plaster-of-Paris case makes a good splint for immobilizing the arm. After it hardens a large fenestrum can be cut in it, so as to expose the posterior surface of the joint. Then a compress can be placed above the olecranon process, and be made to pull it down- ward toward the ulna by a strip of adhesive plaster or an elastic band Fig. 213. Fracture of olecranon with fibrous union (Park). that should be secured to the anterior surface of the plaster splint some distance below the bend of the elbow. After a week or ten days the splint can be changed to a right-angled plaster cast and the same method of pressure continued. It is well to have firm pressure made over the subcutaneous surface of the process at the time of the bending to avoid a tilting or angling of the fragments. The result is usually good, a close fibrous or bony union being attained. Passive motion is to be avoided until the fragment has firmly united. The coronoid process is rarely broken, except in the backward dis- location of both bones by the combined force of the muscular action of the brachialis anticus and the pressure of the coronoid against the trochlear surface of the humerus. It must be a rare injury even under these circumstances, for a backward dislocation occurs most frequently from hyperextension of the arm. It should be treated by putting the arm at rest in the right-angled position. 572 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The shaft of the bone is broken singly almost always by direct vio- lence. Breaks are more common in the lower half of the shaft than in the upper part. The diagnosis is easy : crepitus, irregularity in outline, generally due to the violence producing the fracture, pain at the seat of fracture, swelling, and loss of power, with the history of the accident, make the evidence of fracture conclusive. Treatment. — The arm should be placed in a semi-prone position, and an anterior or palmar splint extending from the internal epicondyle to the fingers, and a posterior dorsal splint that should extend from the metacarpus to the head of the radius, should be used. These light wooden splints should be padded with cotton and should be a little wider than the forearm. A pad should also be placed against the ulna at the fractured point, if this be in the middle third of the bone, so as to keep it from sagging or angling. The splints are secured in position by a roller bandage. There is not much danger of loss of rotation by angling of the bone outward toward the radius in simple fracture of the ulna. The pronator quadratus, however, tends to pull the lower fragment out- ward toward the radius if the break be just above its attachment to the ulna. The Radius. This bone is more subject to fracture than any other except the clavicle. The head or the neck of the bone may be broken either by direct or indirect violence, though indirect violence is the most frequent source of the injury. Falls upon the pronated hand drive the radius against the capitellum, thus producing these fractures. Injury to the neak of the radius is frequent in children. The shaft of the radius is broken by direct or indirect violence. Fractures of the shaft of this bone are usually complicated with a break of the ulna. The biceps, the supinator brevis, and the pronator radii teres are to be considered in treating all fractures of the shaft of the bone. If the break is above the insertion of the pronator radii teres, the upper fragment is rotated into a position of supination, while the lower fragment is in a position of pronation. The fracture is best managed if the arm is kept supine. The usual symptoms of fracture are present. It is not easy to make the diagnosis when the fracture is in the upper part of the shaft, for it is deeply buried under the muscles. The failure of the head to rotate with the shaft of the bone in fractures of the neck and shaft is an important sign of fracture. It must, however, be remembered that when the fractured surfaces are interlocked the head may rotate with the shaft even if a fracture has occurred. Fractures of the shaft are treated, if in the lower half, by the same method used in treatment of injuries to the shaft of the ulna. If the fracture be above the pronator radii teres, it should be treated with the forearm supinated and flexed at a right angle. A posterior rectangular splint is best. It should immobilize the elbow and secure the arm and the forearm. The most common fracture of the radius is at the lower end, and is known as Colles' fracture, though the usual seat of the fracture is below the point indicated by Colles in his description. It results from a fall upon the palm of the hand, and occurs in childhood and extreme FRACTURES. 57; old age, but is most frequent in elderly females. The break is rather uniform in its symptoms, position, and line of fracture. It is situated in the expanded end of the radius at from one-fourth of an inch to one inch from the articular surface (Fig. 214). Fig. 214. •aseasassss- Colles' fracture (Anger). The deformity resulting from the fracture is very uniform. The lower fragment is displaced backward on the dorsum of the bone, the articular end is tilted backward, and the styloid process is carried up the forearm and backward, so that, instead of being well forward and below the level of the styloid process of the ulna, it is displaced upward and the hand is drawn toward the radial side. Crepitus is not easily elicited. The deformity, the history of the accident, and the mobility of the fragments are the symptoms. Impaction of the fragments is, I believe, not very common. If there should be impaction, and it be firm enough to resist the proper adjustment, it can be released by forcibly and strongly extending the hand until the fragments separate, and then the adjustment can be accomplished in the usual manner. The reduction of the fracture can usually be accomplished by the following method : An assistant holds the elbow by grasping the lower end of the humerus ; a second assistant grasps the hand as if to shake hands, and makes firm extension while the hand is prone. The surgeon then places the fingers of both hands on the palmar surface of the end of the upper fragment and presses downward and forward upon the dorsal surface of the distal fragment with his thumbs. Firm pressure will almost certainly carry it well forward into position. It is rare to have much difficulty in keeping it in good position. If the fracture is not com- minuted, but transverse, there is little tendency to redisplacement. Fracture of the styloid process of the ulna may also occur. The obliquity of the line of fracture and the occasional comminution of the distal fragments have much to do with the difficulty in keeping the fracture in good position. Among the complications attending this fracture is a rupture of the radio-ulnar ligaments. This complication makes the prominence of the ulna more marked than the slight shortening of the radius alone could account for. The injury is, moreover, often complicated by compound dislocation of the styloid process, with penetration of the internal lateral ligament. Fractures in this situation are safer and more comfortable if a splint be applied that will give rest and support to the hand and the forearm. These splints are of great variety, but the simpler ones answer every purpose. It is, I think, hard to devise one which will fulfil more of the indications than a plain straight wooden splint, properly padded, that will extend from the end of the fingers to the epicondyle. This splint should be fitted to the palmar surface, and should be so padded as to put the fingers in a position of slight flexion. Some loose cotton 574 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. may be placed under the radius to support the lower end of the upper fragment. A bandage is then applied to secure the hand and forearm to the splint while it is in a semi-prone position. It is a good plan to place a compress of cotton on the dorsum of the distal fragment. At the end of a week the splint should be shortened and the fingers made free, so that they can be flexed and extended. This is of extreme importance in patients above forty years of age. This plan of treat- ment secures comfortable quiet for the arm until the union is firm, and it provides for free movements of flexion and extension of the fingers after the first week. The fracture almost uniformly unites in five weeks. The sling to support the forearm should be a narrow strip, and it should exert its pressure on the forearm and not on the hand. An excellent splint is also made of lint soaked in plaster of Paris applied to the palmar surface while the parts are held in exact position. The results should be good so far as restoration of function is con- cerned, and the contour is very nearly perfect, except in cases where the comminution is marked and the retention of the fragments is difficult or impossible. A slight shortening may take place in these comminuted fractures of the end of the radius. The pistol-shaped splint and Levis's perforated moulded splint are frequently used. The deviation of the hand toward the ulnar side is not an efficient agent in maintaining the fragments in position, and should never be enforced to the dis- comfort of the patient. In the more common and simpler cases, where the line of Fig. 215. Fig. 216. Moore's dressing for Colles' fracture of radius. fracture is transverse or slightly oblique and not comminuted, a wide strip of adhe- sive plaster encircling the wrist gives sufficient support, or a firm compress made of FRACTURES. 575 a soft roller bandage may be fastened to the palmar side of the radius by the plaster strip to give more definite support. This treatment, devised by Dr. Moore of Rochester, is applicable to many cases and gives excellent results (Figs. 215, 216). Fracture of both bones of the forearm is frequent, but it rarely occurs in the upper third. It may follow direct violence, though it is more frequently the result of indirect violence. The displacement may be great and in any direction. Accurate adjustment is most important for overlapping ; rotary or lateral displacement or any angling of either of the bones outward or inward is likely to interrupt the rotary function of the forearm (Figs. 217, 218, 219). This function is best preserved if the forearm be kept in a position of supination or in a semi-prone posi- tion, for the bones are then widely separated. In cases where there is a marked tendency to a recurrence of the displacement it is perhaps safer to keep the forearm in full supination until union is at least fairly firm, for accurate Fig. 219. maintenance and good adjustment is best attained in this position. In a week or ten days the forearm may be put into a semi- prone position, as it is much more comfort- able for the patient. The semi-prone posi- tion is the one usually preferred in these Fig. 217. Fig. 218. vr Results attending angular frac- ture of the radius. Displacement in fracture of forearm. cases. The splints adapted to the treatment of fractures of the shaft of one or both of the bones in the semi-prone position are two straight boards of the width of the upper part of the forearm. The palmar splint should extend from the epicondyle to the ends of the fingers, and the dorsal from the head of the radius to the wrist. They should be £76 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. properly padded, but interosseous pads are not necessary. A simple roller bandage answers all the purposes for holding the splints in posi- tion. The hand is fastened to the palmar splint, and the roller then envelops both palmar and dorsal splints and is continued to the elbow. The forearm is then placed in a sling and kept at rest, care being taken to give its upper part good support. The sling should not exert traction on the hand and arm below the seat of fracture. The Wrist and Hand. Fractures of the carpal bones are rare, except when the wrist is crushed. The diagnosis is difficult and replacement uncertain. The treatment consists in rest and in controlling the engorgement likely to follow such injuries. Fractures of the metacarpal bones are more frequent, and may occur as a result of direct or indirect violence. The distal half of the bone is most frequently the seat of fracture. The fracture that follows indirect violence is usually situated within an inch of the articular sur- face of the head. The displacement is uniformly forward, with the head of the bone bent toward the palm of the hand. The diagnosis is best made with the fingers closed, so that the first row of phalanges are at a right angle to the metacarpal bones. If the symmetry of the row of knuckles is broken by one or more of them being less prominent than they should be, it is strongly suggestive of fracture. If there be also a sensitive point on the dorsum of the short- ened metacarpal, with slight irregularity at the point of tenderness, then the diagnosis is fairly certain. This may be confirmed by restoring the symmetry by traction on the finger and pushing the head of the bone toward the back of the hand. The treatment should be by traction on the extended finger with a firm pad or support under the head of the bone. ■ The hand should be placed upon a long palmar splint securely bound to the forearm by a bandage or by plaster strips, or both. The extension should be by adhesive plaster about the finger, attached to an elastic band fastened to the end of the splint. The splint should extend several inches beyond the fingers. Union always occurs, generally within three weeks. The phalanges are almost always broken by direct violence, so that the distal phalanx, being most exposed, is most often fractured. The violence causing the fracture frequently complicates it by an external wound. Suppurating fractures of the first and second phalanges expose the patient to the dangers of purulent infiltration along the sheaths of the tendons in the palm and the forearm. Extension of suppurative inflammation is especially apt to follow the tendinous sheath of the little finger, for the sheath of this tendon is continuous with the sheaths of the forearm. Prolonged suppuration is apt to destroy the bone, and it almost certainly entails impairment of function from adhesive or destruc- tive inflammation. These compound fractures often heal kindly and quickly, and the wound may be made to pursue an aseptic course if due care is taken. The soft tissues are often pulpefied by the crushing violence which causes the break. FRACTURES. 577 The diagnosis is usually easy. Mobility, crepitus, and the history of the accident are the cardinal indications. Adjustment of the fracture is not difficult, and maintenance is gen- erally effected by placing the hand on a padded splint with the fingers well supported in a position of partial flexion. The contiguous fingers are valuable supports in the proximal row of phalanges. Extension, as described in the treatment of the metacarpal bones, is sometimes essen- tial, and union is rapid and satisfactory except in suppurating fractures. It is a good rule not to amputate injured fingers unless they are hope- lessly destroyed, but the danger of long-continued inflammation in the arm must not be overlooked in the desire to save them. The Pelvis. Fractures of the pelvis are properly divided into two classes — those which implicate the ring of the pelvis and those which involve only some of the more exposed prominences of the ilium, the ischium, or the sacrum and coccyx. Fractures of the pelvic ring are always serious. They are produced by a crushing violence applied to the pelvis and sacrum, by lateral compression, or through yiolence transmitted through the femur or trochanter. A double fracture frequently follows a crushing injury, one line of fracture being through the pubic bone, and one through the ilium behind the acetabulum. It is also possible that both the pubic and sacro-iliac joints may be separated by violence transmitted through the leg. A break at the symphysis may also occur from internal violence, as in childbirth. Associated with other fractures Fig. 220. '*■ Fracture of pelvis. of the pelvic ring, and as a result of great violence, the sacrum is sometimes trav- ersed by a vertical fracture. One of the greatest dangers attending these injuries is found in the involvement of the viscera situated in the pelvis: in this way the urethra, the bladder, the blood-vessels, or the intestines may receive serious injury. The contusion of the soft parts by the breaking of these important bones, the laceration of the viscera, and the shock accompanying such violence render these fractures of the pelvic ring most serious accidents. The most common of the fractures of the pelvic ring are of the pubic bone. This may be a separation at the symphysis, but is more frequently a break that involves the horizontal ramus of the pubis and the ascond- 37 578 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Fig. 221. ing ramus of the ischium (Fig. 220). The urethra and the bladder frequently suffer injury in this fracture. Urinary infiltration is especially dangerous, and if it occur should be promptly provided with free exit and drainage. Fractures of the true pehw are determined by the history of the violence and by the disability they entail. The patient cannot walk, contusion is apparent, mobility is present, and the shock is marked. The viscera give special symptoms. Mobility, and occasionally crepitus, can be determined by pressure upon the anterior portion of the crest of the ilium. When the fracture is in the pubic portion, mobility and crepitus can be detected by direct manipulation. Fracture produced by violence transmitted through the femur may occur by the head of the bone being forced, through the acetabulum, or a line of fracture posteriorly may begin with the sciatic notch and extend through the ilium, and another involve the ramus of the pubis and ischium anteriorly, thus separating a section of the bone, including the acetabulum from the ring of the pelvis. These lines of fracture may extend through the sacro-iliac junction and the symphysis pubis. The treatment of either of the fractures last named must include extension applied to the leg. The treatment necessary in most of the fractures of the pelvic ring is rest in bed, with the support of a circular bandage about the hips. Visceral complications will require such attention as is needed to meet the particular indications. Fractures of the false pelvis or of the ilium are more frequent, and are not very serious injuries. It seems to me that a portion of the crest may be detached by muscular action in the young adult. The anterior spine may also be detached. A break in the ilium usually involves the anterior or the posterior portion of the crest, the line of fracture bea-innina; near the middle and extending in a curved line either forward Great deformity after multiple or backward, the concavity of the curve beinp - fracture of femur, with synos- i ' & tosis (Park). upward. Quiet without pressure is the treatment. Recovery is the rule, but it may occur with deformity. Transverse fractures of the lower portions of the sacrum and of the coccyx may occur. The pain is great; the displacement is forward, making an angle which presents posteriorly. Replacement can be accomplished by introducing the finger into the rectum and making backward pressure, but maintenance in a good position is difficult. It has been attained by stuffing the rectum with gauze or with a hollow tube wrapped with gauze. The rim of the acetabulum is sometimes broken, generally as a complication in dislocation of the femur. This is a rare injury. The violence producing it is probably applied directly to the trochanter while the leg is flexed and either rotated strongly FRACTURES. 579 outward or inward, the head of the bone being thus driven against the rim. The segment detached is a part of the posterior margin of the ring. The diagnosis is not easily made. The dislocation of the femur must be reduced and maintained in position by quiet and extension. A fracture of the tuberosity of the ischium is a rare accident, and is caused by direct violence which produces a severe contusion of the soft parts. The Thigh. Fractures ot the lower extremity are one-half as frequent as those of the upper. About one-fourth of such injuries of the lower extremity are of the femur. Fractures of the lower end of the femur are infre- quent, those of the upper end are more common, but the middle third is more frequently broken than any other part. The fractures of the upper end include those of the neck, epiphyseal separation, and those breaks which pass through the trochanters. The epiphyseal separation must be very rare as a result of violence. It occurs more frequently however, as a pathological condition. Fractures of the neck are such as are styled intracapsular and extracapsular or mixed. The intracapsular fractures are those involv- ing the narrow portion of the neck. These fractures occur most fre- quently in the aged. The increased amount of medullary substance and the diminished amount of cortical and trabecular bone-tissue in the aged weaken very markedly the neck of the femur. This fracture is by indirect violence transmitted through the shaft of the femur or through the trochanters Fig. 222. and the neck, or it is produced by a twist or strain upon the leg in the endeavor to avoid a fall. The capsule of the joint is not neces- sarily torn and the immediate displacement is not great. The fracture may precede the fall that accompanies it, the fall being consequent upon the fracture, though the reverse is most commonly true. Great vio- lence is not required to produce such a frac- ture. The loss of function is not necessarily absolute and immediate, patients having been known to walk with such an injury. The mixed or extracapsular fracture (Fig. 222) occurs in the same manner as the intracapsu- Extracapsular fracture of thigh lar fracture, though it may require a little more violence and the line of fracture is not so uniform. It extends through the broader portions of the neck at the base of the trochanter, and is partly within and partly, without the capsule of the joint. It may involve one or both trochanters. The line of fracture here, as in the narrow portion (or intracapsular), is more likely to be oblique when the violence is transmitted through the shaft of the femur to the tro- chanter and neck. This fracture is also most frequent in the aged. The most common break of this class is along the line of junction of the 580 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. neck with the trochanter. These fractures are frequently impacted, though not necessarily Aery firmly so. The deformity in fracture of the neck sometimes shows an anterior angle in the neck of the bone, the posterior portion of the neck being shortened and interlocked, while the anterior surface is separated or not so firmly impacted. This puts the femur in a position of outward Fig. 223. Fig. 224. Impacted fracture of neck of femur (Park). rotation. The deformity accompanying this fracture is more immediate and marked than in intracapsular fracture. In extracapsular fracture we may have the lesser trochanter attached to the neck. The diagnosis and the prognosis of fractures of the neck of the femur will be here considered, but the treatment is best considered in connection with the treatment of other fractures of this bone. The differentia! diagnosis between these two varieties is not clear, although now and then the diagnosis of an extracapsular fracture is plain and definite. The symptoms of a fracture of the neck, besides the history, are disturbed function, pain, crepitus, eversion, shortening, relax- ation of the fascia lata, the abnormal relation of the anterior superior spine of the ilium to the trochanter major, the rotation of the trochanter on a shortened radius, and a fulness of Scarpa's triangle. The diagnosis should be made with as little manipulation as possible ; hence the age of the patient and the history of the accident, together with th? position, the shortening, the fulness of Scarpa's triangle, and the relations of the trochanter, should be grouped and considered before manipulating the patient. The age is usually above fifty and the history often one of slight violence. The position of the limb is suggestive : it looks help- less, and lies usually in an everted position on the bed, with the muscles and fascia relaxed. The lessened tension of the fascia is noticeable above the trochanter. The function of the limb is impaired or com- pletely lost. The patient is sometimes able to flex the thigh and lift the foot from the bed without much pain. The individual can in excep- tional cases walk for a short distance after the injury has been received. The pain of this fracture is generally very severe. Any motion or mus- cular spasm causes sharp exacerbations, and there is a dull aching pain FRACTURES. 581 even when the limb is quiet. Crepitus is not uniformly present, but can generally be elicited if care be taken to bring the broken surfaces in apposition. It is not, however, necessarily essential to a diagnosis. Eversion of the limb is almost uniformly present, and is in many cases quite marked, for the foot often rests on its outer aspect. This ever- sion is produced partly by the violence inflicting the injury, partly by the muscles attached to the trochanter major, as well as by the psoas and iliacus. The natural disposition of the leg is to external rotation when in the dorsal decubitus. Inversion is sometimes present, due probably to the peculiar relation of the fragments induced by the violence fracturing the neck. The character and extent of the rotary movements are important in making the diagnosis. Rotation of the injured leg causes pain, often develops crepitus, and the trochanter moves in an arc with a shortened radius. This makes a diagnosis of a fracture of the neck of the femur clear. The radius of the arc may in isolated cases be increased, but it is rarely normal if a fracture exist. Where the femur rotates upon its own axis it is pathognomonic of fracture of the neck. This symptom can be easily recognized if the surgeon will follow the trochanter in its movements with the finger. Short- ening of the leg is produced by a change in the angle of the shaft with the neck or by a displacement upward of the trochanter and the portion of the neck attached to it. This shortening of the leg can usually be determined to be in the altered neck by verifying the length of the leg from the trochanter to the external malleolus. The extent of the shortening will vary from a fraction of an inch to three inches. The exact amount of shortening in a given case is not easily determined. For purposes of examination the patient should be either on a fairly firm bed or a table, and the legs must be symmetrically placed with ref- erence to the pelvis. The adduction or abduction, as well as the degree of flexion, must be the same in each extremity. A cord should be stretched between the two anterior superior iliac spines. This should be bisected at right angles by a line passing downward over the sym- physis, and the shortening will be determined by the relations of the malleoli with this downward line. It may also be determined by Bryants method, which is as follows : The legs are symmetrically placed ; a vertical line is dropped from the anterior superior spine of the ilium on each side, and a line is carried upward from the trochanter to this vertical line, intersecting it at right angles. The difference in the dis- tance from the trochanter to this vertical line gives the amount of short- ening of the leg. Fulness in Scarpa's triangle and a widening or a thickening of the trochanter are also worthy of notice as symptoms of a fracture of the neck of the femur. The diagnosis of fracture of the neck is often easy and positive, but there are cases where it becomes extremely difficult to determine certainly the existence of a fracture. The differential diagnosis between the intracapsular and the mixed or extracapsular fracture is often impossible. . Extreme age, moderate violence, a slight shortening with- out complete loss of function, suggest the intracapsular fracture. Com- minution or a thickening, either primary or secondary, of the trochanter, with marked shortening, indicates extracapsular fracture. Many cases will remain doubtful. The prognosis of an intracapsular fracture of the neck is not so favorable as that of a mixed or extrascapsular fracture. It was for a long time a mooted question whether bony union ever occurred in this 582 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. break, or whether it was always fibrous. It is now known, however, that bony union does occur. The mixed or extracapsular fracture is much more likely to give a good result, for bony union is the rule if the treatment is good. Most authors recommend a guarded prognosis, and admit the possibility of an imperfect result. The prognosis must in many cases be guarded, for it is extremely difficult, and often impossi- ble, to determine certainly whether it is an intracapsular or an extra- capsular fracture. Fractures of the neck, occurring as they do in per- sons of limited vitality, who are old in tissue if not in years, demand extreme care in treatment. The first consideration is, of course, the life of the patient, and, as confinement in a fixed position is not only irk- some, but is dangerous to the life of the aged, the prognosis will involve not only the usefulness of the limb, but a consideration of the danger to life. It is wise to treat these cases as if we expected a good result by solid union, for it can generally be attained. The teeatment must be so ordered as to save life even at the expense of an imperfect leg. (See Treatment below.) Fractures of the upper and middle thirds of the femur occur generally as the result of indirect violence. They are usually oblique, Fig. 225 Fig. 226. Fig. 227 Fracture of upper third of femur. Overlapping fracture of femur. the line of fracture being downward, forward, and inward or slightlv outward. Fracture in the middle third of the femur by muscular action is not very infrequent. The violence of the injury may help to deter- mine deformity, but the line of fracture, the contraction of the tibio- FRA CTUBES. 583 Fig. 228. pelvic and the ilio-trochanteric muscles, as well as the external rotators, are active agents in the formation of the external anterior angle (Figs. 225, 226). The natural eversion of the leg when the patient is in the recumbent posture is also a factor in producing this deformity in the thigh. The thigh is also shortened. This is partially due to the ang- ling, but an overriding or an overlapping (Fig. 227) of the fragments is also present. Spasm of the long muscles of the thigh is a very constant symptom, exciting pain and increasing the deformity and irritation of the soft parts. The mobility is easily determined, and crepitus is sharp and decided. The diagnosis can often be determined by inspection simply, with- out manipulation. The thigh is slightly flexed, everted, broadened, and shortened, with a distinct prominence on the anterior outer surface of the thigh, which exhibits a marked increase in the anterior curvature at the site of the fracture. Fractures of the lower end of the femur may be by indirect vio- lence, though they are most frequently due to direct violence. These fractures are classified as are those at the lower end of the humerus. A supracondyloid fracture is of the shaft within four inches of the con- dyles. It has generally a slight obliquity downward and forward, with the lower end of the upper fragment displaced anteriorly and the lower fragment pulled backward. This backward displacement of the upper end of the lower fragment may injure the blood-vessels, as the artery runs close to the bone here. The gastrocnemius, soleus, and plantaris help to increase the deformity. The rectus and the hamstring muscles pull the lower fragment upward, thus increasing the deformity and the danger to the popliteal vessels. The deformity is peculiar in this, that the patella, is made prominent by the flexion of the joint produced by the backward displacement of the lower fragment. There is a depression above the partially flexed joint. This supra- condyloid fracture is occasionally com- plicated by a vertical fracture into the joint, separating the condyles. This intercondyloid fracture is a serious injury, for it complicates a bad fracture with a lesion of a large articula- tion, and makes the fracture intra-articular. There is present in this fracture, in addition to the deformity noticed in a supracondyloid frac- ture, a widening of the joint, and the condyles are pushed apart by the fractured end of the shaft. The capsule of the joint is distended with blood and serum and the mobility is great. Fracture of either condyle may result from a fall upon the flexed knee, the violence expending itself on the condyle detached. It may also result from the violence of a twist transmitted through the lateral ligaments of the joint, thus tearing Fracture of lower en d of femur, with great displacement of condyles (Park). 584 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. off the condyle. The violence may also be transmitted through the head of the tibia to the condyle which suffers the fracture. The diagnosis of this fracture is not difficult. The undue freedom of the lateral movements in the extended limb is easily determined and crepitus can be detected. The detached condyle may be displaced for- ward and backward, but, as the shaft of the femur remains intact, there is no shortening of the leg. An epiphyseal separation of the lower extremity of the femur is a most serious injury, and not infrequently demands amputation. Treatment of the Various Fractures op the Femur. — The principles guiding us in the treatment of fractures of the different por- tions of the femur have been the subject of wide discussion and very diversified views. This has resulted in many methods of treatment and in a multiplication of apparatus designed to meet the supposed indica- tions. Dr. Allis has called attention to the difficulty in obtaining an accurate adjustment in fractures of the upper third of the femur, and also to the difficulty in maintaining the adjustment. It appears to me, however, that he has exaggerated the latter and underestimated the efficiency of proper extension in accomplishing the purpose. Permanent deformity often occurs in fractures at this site, but I believe that continuous extension will generally control the deformity. Imperfect extension will not do it. Dr. Allis suggests that we cut down upon the fractures of the upper third, adjust the fragments, and keep them in position by fastening the ends together with ivory pegs, steel pins, or wire. Oblique fractures in any part of the shaft may gradually find a per- fect adjustment under the influence of continuous traction, but the trans- verse fracture with lateral displacement and overlapping requires more than a complete extension to secure this end : it must also have direct lateral pressure to force the fragments into position. Failing in this way to accomplish the purpose, success may be obtained by increasing the angular deformity until the ends can be put in apposition, and then with extension and gradual straightening of the leg, while maintaining firm lateral support at the fractured point, the fragments may be set or prop- erly adjusted. It is not easy to determine that adjustment is good, for the bone is enveloped in a mass of muscles and so placed that it cannot be distinctly outlined. The intercondyloid fractures require not only extension, but lateral pressure on the condyles, in order to secure good apposition in the vertical line of fracture. Every form of splint devised for the treatment of fractures of the femur is designed to meet the acknowledged need for extension, and in addition to this some of them utilize lateral support. All surgeons admit the value of traction, although many deny the wisdom of relying solely upon its efficiency for the result desired. It is quite difficult to obtain good lateral support for its fractured ends through the great mass of muscles which envelop this bone. The soft mass of muscles prevents the lateral pressure from accomplishing the purpose for which it is intended. The muscles rapidly atrophy under the influence of rest and pressure, and the lateral support becomes inefficient unless it is reapplied. The problem in treatment is to secure the best extension, with such lateral support as is needed, with the least discomfort and the greatest freedom to the patient. The double inclined plane has been discarded. Buck's extension by weight and pulley with the leg and thigh in the extended position is adopted by many surgeons. It is also used in conjunction with some FRACTURES. 585 form of a long side-splint by surgeons who are not willing to rely solely upon extension. Lateral support is also given by sand-bags placed alongside the thigh. Buck's extension is applied in the following way : A strip of moleskin plaster four inches wide, and long enough to have the free ends extend above the knee when the centre of the strip passes loosely across the sole of the foot, is to be used as a Fig. 229. Extension-band and foot-piece. medium for making extension. A flat piece of wood, three by four inches, with a hole in its centre, is placed in the middle of the long strip. A cord passes through this wooden piece and also through the moleskin plaster. The adhesive strip is placed in contact with the skin along the sides of the knee, and is held firmly in Fig. 230. Same, folded and ready for use. position by a roller bandage which should envelop the leg as high as the plaster extends. The cord that passes through the foot-piece is carried over a pulley at the foot of the bed, and continuous extension is made by a weight, the leg and thigh resting on the bed or on cushions (Figs. 229-231). Hamilton uses, in addi- Fig. 231. Mode of applying adhesive plaster. (When the dressings are completed the limb is to rest on the bed.) tion to the extension, a long side-splint extending almost to the axilla, which is designed not only to give lateral support to the fractured bone, but also to prevent rotation and secure a good relative position of the body and leg. Lister's long splint is still used. 586 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. Simple and continuous extension was, I think, first obtained in oblique suspension by Nathan K. Smith when he introduced his anterior splint, of which the Hodgen suspension splint is a modification. The advan- tages of the Hodgen splint are— (1) The most equable perfect and com- Fig. 232. The Hodgen suspension splint. fortable extension yet devised. (2) Easy adjustment. (3) It leaves the thigh exposed for inspection. (4) The muslin supports on which the leg and thigh rest can be separately adjusted, so that the tension on any one of them can be easily changed and the normal anterior curvature can be Fig. 233. maintained, notwithstanding the rapid atrophy of the soft tissues. The fractures in the shaft and in the lower end of the femur can be very perfectly immobilized in this splint. Clinical results and theory confirm me in the belief that it comes nearer adjusting and immobilizing the fractured ends of a break in the neck than any other method of treat- ment devised. If the ends are in apposition, the movement should be easier at the head than in the fracture. The head of the femur should move with the neck if adjustment is good ; the swing of the leg does not imply that the movement is at the break. Moderate extension approximates and sets the fractures of the neck. The impacted fractures at the base are not disturbed by moderate equable extension. Displacement by rotation can be avoided in this splint. If pressure upon the trochanter is desired, it can be secured by a flannel bandage about the hips. The FRACTURES. 587 freedom of the motion allowed the patient does not interfere with the union of the broken shaft, as the splint and the leg are free to move with the body of the patient. The only motion is at the hip-joint, and there is no possibility of angling at the fractured point by the dragging of the leg on the bed as the patient moves from one side to the other. The patient can sit upright in bed or use the bed-pan without disturbing the fracture. The application of the Hodgen splint is simple and in skilful hands is painless. Suppose the leg with its fractured femur to be resting upon the bed. The adhesive strip with its foot-piece and cord is placed in .position : an assistant grasps the foot with one hand, and with the other hand under the knee lifts the leg from the bed, while at the same time he makes steady extension of the femur. The surgeon then applies the roller as high as the plaster extends, binding it to the limb. The leg is again allowed to rest upon the bed : the assistant maintains moderate traction on the foot so that the extending force applied to the fractured bone may be continuous. The splint is then put into position. The lateral arms of the splint are held apart by a metal arch ; one arm of the splint is placed upon either side of the leg, and the crossbar is brought close to the sole of the foot. No special or violent attempt to adjust the fractured bone is made except where there is lateral displacement of a transverse fracture. The free swing of the leg and the efficiency of the extending force secure adjustment of the ordinary oblique fracture in a few hours. The flexion of the leg on the thigh should be very slight, not more than an angle of 170° or 180° ; for if the bend approaches a right angle, the elevation of the knee is necessarily great, and most of the extending force applied to the thigh would be through the muslin strips on which the upper part of the leg rests (those just at and below the bend of the knee). The angle of flexion at the knee may be varied from that of the splint by lengthening or shortening the strips which support the thigh. The foot may be elevated or lowered, and the support rendered by the muslin strips under the thigh varied by sliding the loop at C downward toward the foot or upward toward the groin. The flexion of the knee is only sufficient to put the leg in a comfortable position, slightly relaxing the tension of the hamstring and gastrocnemius muscles. The slight flexion of the thigh on the pelvis with extension puts at rest the psoas and iliacus and the rectus extensor of the thigh. External rotation, if it occurs, can be obviated by securing the foot to a foot-piece or by a muslin strip passed around the outer border of the ball of the foot and fastened to the inner arm of the splint. A foot- piece can be easily adjusted to the splint if it is thought desirable to steady the foot in a fixed position. The degree of extension necessary to accomplish the result desired may be determined in part by the sensations of the patients. It is never necessary, when using this splint in the adult, to apply (as recommended by Hamilton when speaking of other methods of making extension) twenty pounds as an extending weight. An extension of twenty pounds, applied through an adhesive strip to the leg and pulling upon the knee-joint and femur, is a serious trial to the patient's endurance, and it taxes the surgeon's ingenuity to steadily maintain such a force. The amount of extension required in this suspension splint is much less, being from three to ten pounds. There is no friction to overcome, and so long as the patient remains in bed there is no appreciable variation in the extending force, provided the point of support is ten feet or more above the plane of the bed. It is a quiet, persistent, non-irritating, effective pull. There is no perineal band to fret and worry the patient. The extending force is determined by two factors, and these are entirely within the control of the surgeon— viz. the obliquity of the extending cord and the weight suspended. The first can be varied by the relative position of the bed and the suspending pulley, and the latter can be increased, if desired, by placing sand-bags across the lateral bars of the splint. It seems difficult for some surgeons to understand how extension can be applied to a fractured thigh by direct traction upon the leg 588 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. without counter-extension through the perineal band. They fail to recognize the efficiency of the weight of the leg as an extending force and the stability of the body as a counter-extending force. The amount of the extension in a particular case where the patient weighed one hundred and fifty pounds was calculated mathematically and estimated at 6.1 pounds. The suspending cord in this case formed an angle of 15° with the perpendicular, and the weight of the leg was estimated as being twenty-one pounds. The suspended limb should not be raised much above the bed, the heel remaining within two inches of the bed. If the pulley from which the splint is suspended is fixed in a ceiling that is nine feet to twelve feet high, a perpendicular line dropped from the pulley should fall beyond the foot of the adult patient. In the case of a child, where the weight of the leg is less, the obliquity of the cord should be greater. The obliquity of the cord should be sufficient to make an angle of from 15° to 35° with the perpendicular. The point of fixation for the pulley for suspension should not be nearer the plane of the bed than ten feet. This gives the patient the full liberty of the bed without changing materially the extending force. The inclination of the patient to slide toward the foot of the bed may be obviated by raising the foot of the bed by means of blocks. In the case of a child it may be well to pass a cord loosely about the body under the arms and fasten it to the head of the bed, to serve as a check to any great change in the position of the patient. The splint is well adapted to the treatment of all fractures of the femur, whether they are intra- or extracapsular, through the trochanters, the shaft, or the condyles. The results of the treatment of fractures of the neck of the thigh with this splint are very satisfactory in the major- ity of cases. Most of the unsatisfactory results obtained are probably due to imperfect adjustment of the fractured ends, or are found in the fractures that occur in the neck very near the head. The feeble, aged persons who are most liable to this injury derive comfort from the use of the Hogden splint, for the freedom of motion it gives is greater than they can obtain with any other apparatus, or than pain will permit if the injured member is allowed to go without treatment. The spasmodic or violent contraction of the muscles of the thigh when the fracture is in the shaft is sometimes so great in nervous children that Buck's exten- sion with the leg resting upon the bed, and the lateral support of sand- bags about it, is best for a few days. After this irritability subsides the leg is more comfortable and more efficiently treated in the suspension splint. This spasm subsides after a few days, but provokes by irritation an increased exudative deposit about the break. I find that a sand- bag partly full, placed on the thigh while it is in the suspension splint, materially mitigates the spasmodic action. Clonic contraction will, in isolated cases, occur with any splint and under any plan of treatment, for no lateral support nor compression can prevent the contraction which accompanies a muscular 'spasm. Sulphonal or, if necessary, opiates, will help to control this clonic spasm, and may be given to nervous children with advantage for a few days after such an injury. This method of applying extension affords a most perfect means of neutraliz- ing the tonic contraction of the muscles. The oblique suspension gives equable and continuous extension of an amount sufficient to accomplish FRACTURES. 589 a perfect . result without the waste of any force, and it ensures the patient the most perfect liberty attainable by any known means compati- ble with comfort and safety. The Patella. Fracture of the patella is the most frequent during the period of greatest muscular activity — that is, between the ages of twenty and forty years. The patella may be fractured by direct or indirect violence. Indirect violence is inflicted by muscular action. The fracture inflicted by muscular force is in the majority of cases transverse, and occurs in the lower half of the bone. The violence may be purely muscular, or, as often happens, may through a fall be combined with some degree of direct injury. The fracture is usually complete, and it is evident from the swelling, loss of extending power FlG - 234 - of the leg, and by the mobility and more or less marked separation of the fragments. The power of extension may not be completely lost, but it is always enfeebled. The fascia extending laterally from the patella over the joint may not be extensively torn, and through the influence of the vast! some degree of power of exten- sion may still remain. The swelling; is not onlv in the i , , i i i , i i (• A. • • . Comminuted fracture. tissues about the knee-cap, but the capsule ol the joint is distended by the hemorrhage resulting from the fracture and by a serous effusion into the irritated joint. This swelling may materially influence the degree of separation of the fragments. The transverse fracture may be compound from the violence of a direct blow. Fractures by direct violence are more uncertain and irregular than when caused by muscular action. The separation of the fragments in a fracture produced by a direct blow upon the patella is not apt to be so great as where the line of fracture is transverse and largely the result of muscular action. The lines of the fracture may be stellate or vertical, and the displacement very slight, for the tissues on the superficial surface of the bone may not be completely separated. A compound fracture of the patella is not very infrequent, and, as the knee-joint is in these cases exposed to the dangers of infection, it is a much more serious injury than a simple one. In such cases the utmost care is demanded to preserve aseptic conditions and avoid suppuration. The treatment of the fractured patella is generally conservative and efficient. Extensive effusion of blood and serum, with consequent distention of the capsule of the joint and marked infiltration of the sur- rounding tissues, sometimes delays the adjustment of the fracture, though immediate adjustment is generally possible. The preliminary treatment for the first three or four days should be such as to limit and control the reparative action. Equable and slight compression applied by a well- adjusted bandage and the use of cold applications should be resorted to at once. The treatment is most efficiently carried out by some firm or fixed dressing which shall keep the limb in an extended position, give complete rest to the joint, and limit the movements of the muscles .of the thigh. Hence the splint should include the whole length of the thigh as well as the leg. Moderate compression of the muscles of the thigh 590 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. lessens the contraction of the quadriceps extensor. The best splint to subserve this purpose is the plaster-of-Paris splint, which should steady the foot and extend to the groin and gluteal fold. It should be sup- ported and strengthened by tin strips incorporated in the sides of the splint. This splint should have a large oval fenestrum cut in its ante- rior lateral surface, in order that the region about the patella may be thoroughly exposed to the surgeon's view. The separated fragments of a transverse fracture may then be drawn together by strips of plaster passing over a compress placed above the patella. The two ends of the strips are carried obliquely downward toward the calf of the leg and secured to the splint. Traction is thus made upon the upper fragment, drawing it downward. Another strip may be carried across the ligament below the knee-cap and upward toward the posterior surface of the thigh, and likewise fastened to the splint. The traction upon these strips of plaster may cause some tilting of the fragments at the line of fracture. This can be controlled by a compress placed over the surface of the patella and held in place by a bandage about the splint. It is a great source of comfort and security to the patient to have this plaster splint suspended, so that the leg can move with the patient. The Hodgen splint should be used for this purpose. Many devices have been used for the approximation of the fragments. Mal- gaigne's hooks have been used for this purpose, as also subcutaneous ligature and the wiring of the fragments. The dangers attending operative measures have rather discouraged their general adoption. The results obtained by a conservative method are so good that the operative treatment is certainly not generally advisa- ble, though in proper hands many cases will justify operation. It is particularly applicable in refractures of the patella and in those fractures which have united badly, leaving the function of the limb much impaired. There is no question but what bony union occasionally results from conservative treatment, but close fibrous union is the usual result. A short ligamentous union gives the leg good functional activity. Good strength and good functional use of the leg may result even where the fragments are separated for an inch or more, if the ligament is firm. The leg should be kept at rest with the patient in bed for five weeks. He should then continue the use of crutches for six weeks longer. A limited use of the leg, aided by a cane, should be continued still longer. This carries the patient over a period of three or four months. Rubbing and moderate flexion of the knee in order to secure perfect function will have to be continued for a longer time. A compound fracture with suppuration requires free drainage and the best antiseptic precautions to limit the suppurative process. Com- pound fractures should be approximated by fastening the fragments together by wire or ligature. The wiring of the patella to secure union for a transverse fracture with wide separation may be used in simple fractures where every antiseptic precaution can be enforced. The union is more rapid and more certain than where treated in a conservative way. A patient who does well under operative measures mav return to work in two or three months. The wire loops used on the" fragments of the patella should not be passed into the joint, but should penetrate the fragment of the bone and emerge at the superficial surface, where they can be twisted together and flattened upon the bone. Strong kan- garoo tendon may be used for this purpose. FRACTURES. 591 The Leg. The tibia and fibula should be separately considered in the study of fractures of the leg. Fractures of the tibia are classified as of the upper and lower ends and of the shaft. Fractures of the head of the tibia are usually by direct violence. The fibula may be broken with it or mav be torn from its tibial attach- ment, The displacement is apt to be more marked if the ligaments uniting it to the tibia are broken. A transverse fracture below the tubercle (Fig. 23d) is not infrequent. Fig. '235. Fig. 236. Fig. : Fracture of upper end of tibia. w Transverse fracture, with anterior displacement. Line of fracture at junction of lower third and middle third of tibia. Fractures of the upper end of the tibia, implicating the joint, are slow in uniting. Fractures in the lower end and of the shaft of the tibia usually unite in five or six weeks, but in the upper end, even where the joint is not involved, they are slower and may require three or four months. Violence transmitted through the shaft of the tibia may detach a condyle. Swelling about the site of fracture is supple- mented by swelling of the distended sac of the joint when the fracture enters the joint. 592 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The knee-joint must be put at rest, hence the splint must include both the thigh and the leg. Some lateral support should also be given to the tibia at the site of fracture. The plaster-of-Paris splint is well adapted to the treatment of these fractures. If adjustment is good, even if the injury be compound, suppuration may be avoided by careful attention to antiseptic details. If suppuration occur in the joint, free drainage by incisions properly made must be obtained. The Hodgen suspension splint with oblique extension is admirably suited to the treat- ment of these cases. Extension is often essential to the most perfect results. The lateral support secured by a roller bandage or by a many- tailed bandage may be useful in conjunction with the Hodgen suspension splint. Fractures of the tibia may occur at any portion of the shaft, but are most frequent in the lower half of the bone. Fracture by indirect violence is frequent at the junction of the lower and middle thirds. It is said that torsion plays a considerable part in determining this fracture. The line of fracture in this part of the bone is downward and forward (Fig. 236), so that the end of the upper fragment has a sharp point ante- Fig. 238. Fracture-box suspended. riorly. The displacement is almost always of the anterior fragment forward and outward. The shortening is determined either by the violence inflicting the injury or by the contraction of the gastrocnemius and soleus muscles. The anterior projection of the upper fragment may be in part due to the action of the quadriceps extensor of the thigh. Fractures of the shaft are very generally accompanied by a fracture FRACTURES. 593 of the fibula at a point a little above the line of fracture of the tibia. (See Fig. 237.) The lower fragment of the tibia is frequently broken or split into more than one piece. The split bone sometimes enters the ankle-joint. Fractures of the tibia, whether by direct or indirect vio- lence, are apt to be compound. The symptoms are loss of function, pain, mobility, and deformity due to the anterior projection of the upper fragment. Injury to the great vessels in fractures of the tibia, whether of the upper end or the shaft, are not infrequent. Reduction of displacement in the shaft of the tibia can usually be ac- complished by traction upon the foot. The reduction is not always easily maintained where the obliquity is marked and the displacement great. The contusion and swelling which usually accompany these fractures often make it unsafe to put the leg into a plaster-of-Paris dressing at once. While these conditions exist and prevent the use of the plaster splint, the bivalve cushion or pillow makes a most admirable support for the fracture. A feather or moss pillow makes good padding for this purpose. The pillow should be placed about the leg, and the lateral support given by a fracture-box composed of three loose boards. The wooden strip on the posterior surface of the leg should extend from a point below the sole of the foot to the fold of the joint behind the knee. This board should not be wider than the leg at the calf. The two lateral boards should be wider, being about five inches in width, and should extend from below the sole of the foot to a distance of four or five inches above the knee-joint. The leg is placed in the middle of the pillow, and the sides of the pillow are brought up on its lat- eral surfaces. The lateral boards are now pressed against and give support to the leg and foot, the amount of pressure being determined by the tension put on the bandage strips which pass about and envelop the splint, the pillow, and the leg. If the upper fragment is disposed to push forward, it may be somewhat steadied in position by a firm compress placed over it and secured by a strip passing about the fracture-box at the site of injury. This splint may be replaced in a week or ten days by a plaster-of Paris splint. This fracture-box is very well adapted to the treatment of these fractures, for it fulfils the conditions to be met in compound fractures. The. leg can be inspected without disturbing it, and it can be kept clean. Good support is given by lateral pressure. Stability of position is almost essential to kindly healing of compound fractures. Hence the removal of a portion of the end of a bone, in order to relieve tension and to give easy adjustment, is justifiable in these compound fractures if the fractured surfaces cannot be held accurately in position by the fracture-box or by nails or pegs passed through the fractured sur- faces. This fracture-box may be suspended, and the patient can move without disturbing the fracture. If the injury to the soft parts be not too great, and the fracture be easily retained in position, a plaster-of-Paris splint may be at once adjusted. The danger of making the plaster splint too tight may be obviated by enveloping the leg in a thick layer of cotton batting : the common non-absorbent cotton is the best. A plaster-of-Paris roller is then applied. A stirrup made from strips of old sheeting into which the plaster-of-Paris is rubbed makes a good splint. This plaster stirrup should be about three inches wide and composed of six or eight thick- nesses of cloth. It should be placed outside the cotton and extend from a little above the knee downward across the sole of the foot and up on the other side of the leg to a position opposite the point of begin- ning. This is secured to the leg by a simple roller bandage. The band- age can be cut in front and the leg inspected at any time without disturb- ing the plaster stirrup. In the obstinate cases of anterior displacement of the upper frag- 38 >94 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. ment the tension exerted through the Achilles tendon may be relieved by subcutaneous division. Fractures of the lower end of the tibia may be either by direct crush- ing or indirect violence. Most frequently these fractures are produced by the transmission of violence through the foot. This fracture may involve both bones above the joint or make a comminuted fracture of the lower end of the tibia. The fracture, if above the joint, is to be treated much as a fracture of the shaft of the tibia. Fractures of the lower end involving the joint are inflicted either by eversion and outward rotation of the foot, producing a Pott's fracture, or by inversion with inward rotation, producing fracture of the fibula about an incli and a half above its lower extremity, as well as fracture of the tip of the internal malleolus. This fracture does not usually produce serious deformity. The displacement is easily corrected, and the result of treatment is generally good. Pott's fracture, the one produced by eversion and outward rotation of the foot, has three separate lines of fracture : one of the tip of the internal malleolus, another of the fibula two and a half inches above the lower end ; the third, not always present, is through the outer margin of the articular surface of Fw- 239 - the tibia. When the outer portion of the articular sur- face of the tibia is broken from the shaft, it may be pushed upward between the tibia and fibula. This frac- Fig. 240. Pott's fracture (Hoffa). Exaggerated deformity in Pott's fracture. ture, if complicated by the displacement of this wedge-shaped fragment, is a serious injury. FRA CTURES. 595 The symptoms of such a fracture are the outward eversion of the foot, the prominence of the internal malleolus, and tenderness at the site of fracture of the fibula, together with a widening of the articulation (Fig. 240). The adjustment can usually be accomplished by traction upon the foot with pressure upon the external malleolus. In these fractures the foot is often displaced backward, so that the anterior margin of the tibia presents forward on the astragalus. The treatment of these fractures is usually best accomplished by the application of a plaster-of- Paris splint. It will often be necessary to delay the application of the plaster splint until the swelling of the parts has subsided, but the adjustment of the displaced bones must be at once perfected. They can be retained in position by the fracture-box with lateral compression, as described above for use of fractures in the shaft, and by a plaster-of-Paris splint. Fractures of the upper half of the shaft of the fibula without a break of the tibia are by direct violence. Fractures of the lower half result most frequently from indirect violence. The upper end of the fibula may be broken by the action of the biceps muscle or by a twist or turn of the leg. Fractures in the lower end of the fibula frequently result from forcible eversion or inversion of the foot. The displacement of the fragments in fracture of the fibula is not usually very marked. It is more evident when the injury is of the lower third than when in the shaft or upper end. The attachments of the muscles and interosseous membrane prevent a very wide separation. The treatment of fracture of the shaft and lower end is by immo- bilization of the ankle and foot with a plaster-of-Paris splint. This treatment should also be followed in fractures of the upper end. Union is usually rapid and satisfactory. In fractures of the upper half of the fibula the splint may be removed in three or four weeks, but when the lower half is broken the splint should remain longer. Ambulatory Method of Treatment. Fractures of the leg and thigh are now not infrequently treated by the so-called ambulatory method. This means something more than permitting the patient to move around with crutches with some fixed dressing applied to the break. The object is to so arrange the dressing as to enable the patient to use the leg in locomotion. The various forms of hip-splints used for immobilizing and securing extension for hip dis- ease may be used in this way. The splint with a body band, a perineal band, or an inside steel bar, with ischiadic crutch and a cross-bar below the sole of the foot, on which the weight of the body falls in walking, is most useful. The fracture is to be enveloped by lateral supports, which should fit snugly and give some pressure to the soft parts. Extension is to be secured by fastening the foot to the cross-bar. The lateral support may be secured by a snug-fitting plaster cast. It is claimed by advocates of this plan of treatment that a simple plaster-of-Paris splint so adjusted as to have the thick sole of the splint separated from the foot by a layer of cotton (one inch or more), and made to encircle snugly the tuberosities of the tibia, will afford a good medium of locomotion and firm support for the break. 596 • AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The ambulatory treatment is valuable in exceptional instances, and should be used ; but in many cases an enforced rest for the body and the leg will be most advantageous to the patient. The advantages claimed for this method are, first, a more rapid and less uncertain union of the break ; second, a more satisfactory and perfect restoration .of function, since there is less atrophy of muscle and a diminished stiffening of the joints ; and, third, the value of the time secured to the patient by the short confinement to the bed or house. The Foot. The bones of the foot suffer fracture by direct and indirect violence. The astragalus may be crushed by a force transmitted through the tibia. There is no uniformity in the line of fracture through the astragalus, and the diagnosis is difficult, and is occasionally impossible unless the fragments are displaced. The displacement of one of the fragments, usually of the neck, is not infrequent. If it cannot be put into good position, it should be removed. If the fracture be compound and the bone be comminuted, or if the displaced fragments suppurate, it is best to remove them. The results of treatment of fractures of the astragalus when the dis- placement is not marked are good. The result, even when it is neces- sary to remove a part of the bone, is also good. Immobilization of the ankle in a position at right angles to the axis of the leg is the treatment to be pursued. This is best secured in a plaster-of- Paris splint. The caloaneum may be broken by a fall upon the foot or by the violence conveyed through the tendo Achillis in contraction of the gas- trocnemius and soleus muscles. Where the fracture is the result of a fall upon the foot the bone may be comminuted. Flattening of the sole of the foot, absence of the prominence of the heel, with pain and disability, constitute the symptoms attending such a fracture. The parts are to be moulded into as good a position as pos- sible and treated by immobilization. If the injury be compound and the fragments small and detached, they should be removed. Where the fracture results from muscular contraction the position maintained should be that of extension of the foot. The metatarsal bones are broken by direct violence. The first and fifth metatarsal bones, being the most exposed, are the ones which are usually broken. Contusion of the parts about the site of fracture is very common, and the fracture is frequently compound. The displace- ment is not apt to be very marked. The symptoms are pain, mobility, crepitus, and tenderness at the site of fracture. The treatment is immobilization of the foot. Fractures of the phalanges result from direct violence. The bones are often crushed by the violence producing it. Extension applied to the fractured bone may be necessary in isolated cases, but usually the support given by the contiguous toes and by a bandage which covers the foot and toes, putting the foot at rest, gives sufficient stability to the fracture after it is adjusted. CHAPTER XXXVI. DISLOCATIONS. By H. H. Mudd, M. D. The bones of the skeleton are joined by ligaments or by fibro-carti- lage. The union in some cases is so firm that separation cannot occur without fracture, and the resulting injury is to be regarded rather as a fracture than a dislocation. The separation of the smooth articular sur- faces of a joint that has a capsule., even if accompanied by a fracture of bony prominences, is a dislocation. The displacement need not be so com- plete as to entirely remove one articular surface from its opposing bone to constitute a dislocation, so that in the surgery of the joints a dido- cation is the complete or partial separation of the articular surface of the one bone from that of another. The partial luxation which accompanies a sprain is momentary, the displaced bone returning at once to its place. If the displacement by muscular action or the tension of the ligaments remains unreduced, even if the articular surfaces are not entirely sepa- rated, it constitutes a dislocation. Dislocations are less frequent than fractures, being in the proportion of one to eight or ten. Dislocations are traumatic, pathological, and congenital, occurring in frequency in the order named. Traumatic dislocations result from direct and indirect violence and from muscular action. We are chiefly concerned with this class. In the pathological dislocation the ele- ments determining the accident are slow changes in the ligaments and tissues of the joint, muscular action being the active agent in produ- cing the ultimate displacement. The congenital dislocations are those which occur in the child from errors in the development of the joint, and not such as are produced by the violence inflicted during the delivery of the infant. The distal bone forming a joint is the one spoken of as being dis- located ; rarely, as of the acromial end of the clavicle, is the proximal bone the one displaced. If there be a wound of the skin which communicates with the dis- located joint, it is characterized as a compound dislocation. Special indi- cations for treatment may arise from other important complications, such as laceration of nerves and vessels or fractures. If the dislocated bone remains at the point where it first comes to rest it is primary; but if after a time, under the influence of muscular activity or patho- logical changes, it shifts to another point, it is a consecutive or secondary dislo- cation. 597 598 affections of the tissues and tissue-systems. Etiology and Mechanism. Pathology of Recent Dislocations. — The laceration of liga- ments is determined by the mechanism of the joint and by the cha- racter of the ligaments. In the arthrodial joints the injury to the cap- sule may only be on one side, but in the hinge joints the ligaments are likely to be ruptured upon both sides of the articulation. The liga- ments may be stretched in some joints, so as to give complete displace- ment without laceration, notably in the dislocation of the lower jaw. The muscles are occasionally ruptured and the vessels and nerves com- pressed or lacerated, though the blood-vessels are rarely seriously injured. Bony prominences may be detached, as in the coronoid pro- cess of the ulna. The margins of the articular surfaces may be broken off, as the rim of the acetabulum. The tearing away of an apophysis may occur as a complication of a dislocation. These fractures of the bone are not apt to be extensive enough in dislocations to make special complications, though occasionally a complete break occurs. The disloca- tion may be compound — that is, the injury to the soft parts may expose the joint. The special pathology of unreduced dislocations is found in the change in the relations of the parts about the articular surfaces and in the changes which follow the pressure of the bone upon the contiguous tissues. The displaced bone becomes attached to the adjacent tissues. A new socket is formed of the soft parts, against which it presses or at its point of bony contact. If the capsule of the joint be stretched over the joint surface, it may become adherent to it and practically limit the formative processes and changes about the joint. The muscles and nerves may become adherent to the displaced bones and undergo atrophy or degen- eration. The viscera are rarely injured by dislocations, except in those that involve the vertebrae. Injury of the pelvic viscera is possible in dislocations of the femur where it penetrates the acetabulum and enters the pelvis. The displaced clavicle also may injure the vessels of the neck. If the reduction of the dislocation is promptly made, it is generally followed by repair and the function of the joint is restored, though limitation of free movement may exist and is especially apt to accompany undue inflammatory reac- tion. A good recovery follows even the compound dislocation if suppuration is avoided. The imperfect repair of the capsule of the joint or of the ligaments may lead to a condition which admits of a ready displacement of the bone. Fre- quent recurrence constitutes what is called recurrent or habitual dislocation. Injuries of nerves by laceration are frequent. An injury to the nerves may express itself by a loss of power in the muscles or by loss of sensation. Involvement of the nerves may occur from a neuritis, and be dependent rather upon contusion of the small nerves than upon direct injury to the nerve-trunk itself. Symptoms of a Dislocation. The symptoms of a dislocation are clear and well denned, but the possibility of the existence of a fracture, and the swelling that occurs about a deeply situated joint, not infrequently make the diagnosis diffi- cult. The general symptoms are — (1) Deformity, evident in contour and in the fixed position of the distal bone. (2) Pain about, the joint, DISLOCATIONS. 599 usually quite severe : as nerve-trunks are frequently subjected to pres- sure, this pain may extend to the points of distribution of nerve-fibres. (3) Voluntary movements are very much limited, and there is a rigidity of the injured parts which resists passive movements, except when lacera- tion of the ligaments and capsule is extensive. (4) The normal outline of the region about the joint is changed, and bony landmarks indicate the altered relation of the bone. (5) The dislocated bone can often be out- lined in its new position, and the injured extremity may be lengthened. (6) The direction of the axis of the dislocated bone is altered. The DIFFERENTIAL DIAGNOSIS BETWEEN FRACTURE AND DISLOCA- TION is determined by the elastic fixation of a dislocation, the absence of crepitus, and the fact that there is but little tendency to redisplace- ment in a dislocation. Each one of these symptoms may, however, be reversed. Mobility and redisplacement may characterize a dislocation where extensive injury to the soft parts is inflicted. Crepitus may be present when an apophysis is detached or when a prominence of bone on the margin of the articular surface is broken. Treatment. Laceration of nerve-trunks may result in permanent injury, and muscles that are torn may be so imperfectly restored that weakness of the joint continues. Compound dislocations with fracture may result in acute suppurative inflammation, leading to loss of function. Rest is essential to perfect restoration of the joint, and even if the primary disturbances have subsided, the joint should not be subjected to excessive motion in any direction until the parts have become thoroughly restored. The injured joint should be kept at rest from three weeks to three months. The acute inflammatory process is to be controlled by heat or cold and rest. Dislocations remain unreduced by reason of ignorance, inattention, the interposition of- muscles or tendons, a small opening in the capsule, or because a fracture of some of the bony prominences permits the bone to escape easily after reduction. Unreduced dislocations become irredu- cible after a period of time that varies with the anatomy of the joint and the degree of reaction that attended the injury. Adhesions form which make violent efforts at reduction dangerous. The limit of time when it is injudicious to make efforts at reduction cannot be said to be fixed. This is especially true since arthrotomy has become a com- paratively safe operation in the reduction of these ancient dislocations. The nearthrosis, or new joint formed by the displaced bone, may often become so perfect as to make it undesirable to attempt reduction by operative means. Reduction with good restoration of function is often possible after the lapse of a long time. The time at which this is pos- sible and advisable is greater in the ball-and-socket joints than in the hinge joints. Compound Dislocations. — This complication is infrequent, for the violence necessary to produce protrusion of the articular surfaces is necessarily great. The consequent injury to the surrounding tissues, including vessels and nerves, is serious and is apt to result in suppura- tion. The gravity of the condition varies, however, very greatlv in 600 AFFECTIONS OF THE TISSUES AM) TISSUE-SYSTEMS. different joints, the difference being found rather in the amount of injury to the contiguous tissues from the violence necessary to make it compound than to the special characteristics of the joint. It is an especially grave complication in the hip. The opening in the compound dislocation of the shoulder is usually in the axilla, and constitutes a serious lesion. Fortunately, it is a rare injury in these joints. It is much more frequent in the ankle, the elbow, the knee, and in the dislo- cation of the phalanges or the metacarpal bone of the thumb. Special effort must be made to attain a perfect aseptic condition. Good drain- age must be secured in selected cases by gauze packing. Special Dislocations. Simple dislocations of the lower jaw present only two forms — the unilateral and the bilateral tcith forward displacement. The double or bilateral is the most frequent. This injury is more frequent in women than in men. It is rare in children and in the aged. A dislocation backward and outward may occur, but it is as a complication of a frac- ture of the glenoid fossa or of the jaw, and is the lesser of the two injuries. The mechanism of the anterior dislocation, whether of one or both sides, is the same. It occurs when the mouth is widely open by the condyle slipping forward over the eminentia articularis. It is aided in this escape from the glenoid fossa by the external pterygoid muscles. The Fig. 241 . temporal muscle is made tense and firm, and helps to retain the bone in the abnormal position. The capsule is not necessarily torn. The interarticular flbro-cartilage is carried forward with the condyle (Fig. 241). The symptoms are the rigidity of the jaw with inability to close the mouth, a projection of the chin, and the presence of the condyle forward of its normal position. A deviation of the jaw toward the uninjured side is present in the unilateral dislocation. Treatment. — Reduction is ef- fected by depressing the angle of the jaw, the symphyses being at the same time supported, the object of the movement being to pull the condyle downward until it can be car- ried backward over the articular eminence and forced into the glenoid fossa. The joint should be put at rest for two weeks at least. The Sternum. — The dislocation of the body of the sternum from the manubrium and the xyphoid appendix from the body are the usual dis- placements. The dislocation of the body from the manubrium is pro- duced by muscular action, by strong flexion of the head and body, In- direct violence applied to the body, or by forced dorsal flexion.' In displacement produced by flexion or muscular action the displacement of the body is usually forward. It may be displaced backward by direct violence. Double forward dislocation of the inferior maxilla. DISLOCATIONS. 601 The pathology and treatment are the same as in fractures. Bony union occurs between the different pieces of the sternum at about the thirty-fourth year. (For dislocation of the ensiform cartilage, which is rare, see Fractures.) Dislocations of the Ribs. — Clinical records prove the possibility of a dislocation of a rib from the vertebrse. The dislocation is forward. This injury appears to involve the eleventh and twelfth ribs more often than the others. The chondral cartilage may be displaced from the ribs and from the sternum. These injuries are rare, and are to be treated as fractures. The Clavicle. — Both ends of the clavicle may be displaced simulta- neously, but more frequently only one end is dislocated. The sternal end is dislocated forward, backward, and upward. The forward dis- location is produced by forcibly carrying the shoulder backward and downward. The sternal end is lifted from its articulation, and when the shoulder is freed from its restraint the end of the clavicle is carried forward on to the sternum. The dislocated head is easily recognized by palpation, local pain is present, the shoulder is depressed, and the function of the arm is impaired. Dislocation backward is produced by direct violence forcing the bone into its new position, or by indirect vio- lence, when the shoulder is forced forward and inward. The bone can be felt in its new position, and the direction of the axis of the bone shows that it is displaced backward. The upward dislocation occurs when the shoulder is forcibly depressed. The end of the bone is then found above the sternum. The backward and the upward dislocations may disturb respiration, and the backward displacement may also inter- fere with deglutition. These dislocations are reduced by carrying the shoulder upward, out- ward, and backward, and by direct manipulation of the displaced end. The great difficulty is found in maintaining reduction, for it is difficult to hold the shoulder in a fixed and proper position. Direct pressure on the end of the clavicle may aid in keeping it in position. The bone should be frequently inspected, for the inclination of the articular sur- faces favors redisplacement, and treatment must be continued for several weeks. The arm should be used with caution for two months. The acromial end is rarely displaced except in an upward direction. This supra-acromial displacement is caused by a blow upon the shoulder or by a fall. It does not often overlap the acromion. The symptoms are impaired function of the arm, prominence of the end of the clavicle, and easy reduction and recurrence of the dislocation. Stimson's plan of treatment is very good. A broad strip of plaster is used. The middle of the band is placed under the elbow ; the ends are carried up the arm and over the shoulder so that they cross over the displaced end. A firm pad may be placed between the plaster strip and the end of the clavicle. Moore's dressing for fractured clavicle {q. v.) is also an excellent dressing. Total dislocation of this bone occurs from extreme violence, which pushes the shoulder inward, displacing the sternal end forward and the scapular end upward. Treatment is directed to keeping the bone in position by carrying the shoulder outward and backward and by direct pressure upon the 602 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. bone. The result in dislocation of either end of the clavicle is usually good, and, though perfect retention of the displaced extremity is not feasible except by operative measures, its function is generally not impaired by the remaining deformity. Dislocation of the Shoulder-joint. — The bony part of the shoulder- joint consists of the glenoid cavity and the head of the humerus. The articular surface of the glenoid cavity is oval in shape, with the small end pointing upward and forward, and is quite small in comparison with the head of the humerus. It serves merely as a point of support for the humerus in its movements. The head of the humerus is hemispherical in shape, is placed obliquely on the shaft so as to form an angle of about 140° to its axis, has a diameter of about two inches, and an articular surface three or four times as great as that of the glenoid cavity, although the articular surface of the cavity and the support it gives to the humerus in its movements are increased by a fibro-cartilaginous ring which is attached to its margin. The capsular ligament completely encircles the articulation, is attached beyond the glenoid cavity, and is remarkably loose, being much longer and larger than is necessary to keep the bones in position. The looseness of the capsule permits the bones to be sepa- rated from each other for an inch or more, and secures to the joint a gliding as well as a rolling motion. The capsule is also remarkably thin, so that the articular surfaces are readily displaced on the applica- tion of moderate violence. The prominence of the shoulder, the many functions of the arm, and its freedom of motion, the comparatively small size of the glenoid cavity, and the laxity of the capsular ligament so expose the shoulder-joint to dislocation that more than half of all dislocations are of this joint. It is worthy of note that these dislocations almost never occur in children, are rare in the aged, and are three or four times more frequent in men than in women. The humerus is held firmly in position when at rest by atmospheric pressure ; when it is in motion the action and counter-action of the various muscles attached about and passing over the joint strengthen the capsule greatly and prevent dislocations resulting from normal movements. The shoulder-joint being without bony protection in the greater part of its circumference, admits of a number of different dislocations. Keeping the glenoid cavity as a central point from which to designate these displacements, they may be spoken of in the order of their fre- quency as anterior, downward, posterior, and upward. In the anterior or subcoracoiel dislocations the head of the bone escapes through a rupture in the anterior and lower part of the capsule, and pushes forward before it the subscapular muscle or ruptures its fibres. The margin of the head or the anatomical neck rests against the margin of the glenoid cavity, and the head is under the coracoid process. If the bone is carried farther forward by the violence, more of the capsule is torn, the greater tuberosity may be torn from the bone, and the head finally rests to the inside of the coracoid process, and it becomes a sub- clavicular dislocation. The posterior portion of the capsule is stretched tightly over the glenoid cavity or is lacerated. The tendon of the biceps is sometimes torn from its groove. The downward or subglenoid dislo- cation occurs when the rupture in the capsule is at a lower point, and DISLOCA TIONS. 603 is apt to follow in cases where the elevation of the arm was very great when the violence was inflicted. The head of the bone escapes below the subscapular muscle, and rests against the border of the scapula rather on its ventral surface. The axillary vessels and nerves are more likely to be disturbed by pressure in this variety. The external rotators are more certainly ruptured or the tuberosity detached when the head is thus displaced. The posterior, subspinous, dislocation is more rare. It occurs when the arm is adducted and the elbow raised somewhat. The head of the bone passes backward under the spine or is arrested under the anterior extremity of the acromion process. The signs and symptoms of a dislocation of the shoulder are — pain in the region, flattening of the shoulder, prominence of the acromion (Fig. 242), with a depression at the glenoid cavity and lengthening of the Fig. 242. > i Exhibits a subcoracoid dislocation and the position of the patient in his endeavor to find relief from pain. arm in the forward, downward, and backward displacements. A short- ening of the arm occurs in the upward displacement. A change in the direction of the axis of the humerus, inability to bring the elbow to the side, loss of voluntary motion, with an elastic resistance to passive motion, and the presence of the head <>i the humerus in the new position, aid in the diagnosis. The elbow is not easily carried inward or forward on the chest, and the hand cannot be placed on the opposite shoulder while the elbow touches the thorax (Dugas). The differential diagnosis between a fracture and a dislocation at the shoulder depends upon the character f the deformity, the increased ease with which pas- sive motion can be made in a fracture, the resistance met with in a dislocation, and the ease with which extension and counter-extension reduce a fracture, unless it be an epiphyseal separation, while the dislocation requires certain well-regulated systematic movements to accomplish its reduction. The great readiness with which the deformity in a fracture recurs, and the presence of bone-crepitus in the fracture, which is not present in a dislocation unless there be also a fracture about the point. The fracture which most closely simulates a dislocation of the shoulder is that of the neck of the scapula, but the mobility of the part, the ease with which the deformity can be reduced, and the immediate recurrence of the deform- ity in the fracture should not make the diagnosis very difficult. The treatment of a dislocation at the shoulder should be the early 604 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. reduction of the deformity and the adjustment of the joint surfaces. An attempt should be made to do this without an anaesthetic. If this effort be ineffectual, then an anaesthetic must be given in order to over- come the muscular resistance incident to the new position and the irri- tation of the injury. Opposition to reduction may also be found in the difficulty experienced in freeing the head of the bone from the border of the glenoid cavity, in the small opening in the capsule, in the inter- vention of portions of the freely torn capsule, and in the peculiar rela- tions of the subscapular muscle and the biceps tendon. In attempting to reduce the dislocation the arm should be first car- ried in those directions in which it meets with least resistance. When force is to be used, we must be FlGi 243, guided in the application of it by our knowledge of the anatomy and physiology of the parts. The mechanism of the force necessary to be applied in order to reduce a dislocated humerus varies in the different dislocations and depends upon the form and extent of the displacement. Extension and counter-extension are, however, con- stant factors in all of them. In addition to the extending force, the desire is to use rotation and lever- age in such a way as to limit the power necessary to be expended. The anterior dislocations are by far the most frequent, and of these the subcoracoid makes a very large proportion, so that the manipulation necessary to reduce this form of dislocation has received the most attention at the hands of surgeons. Fig. 244. First position in Kocher's rotation method. Arm is being carried forward and upward toward second position. Quite a number of methods have been described, but the most efficient of them perhaps is the one known as Kocher's rotation method, which is DISLOCATIONS. 605 used in the following way : The elbow is carried firmly to the side, with the forearm at a right angle to the arm, and the arm is then forcibly rotated outward till the forearm points away from the body (Fig. 243). When this has been done the arm is carried up from the body till it is in the horizontal plane running through the glenoid cavity. The scapula is fixed and firm extension is made during these movements (Figs. 244, 245). When the arm comes to the level of the shoulder, it is gradually rotated inward, and is again brought to the side with the forearm across FlG ' 245 - the body. The head slips into place with the inward rotation and at the beginning of the downward move- ment. This method requires care in its use, especially in the aged, in order to avoid fracturing the bone in the effort to replace it, for the bone is under the strain of torsion. The method by perpendicular exten- sion, first used by Mothe in 1812, was for a time very generally used. It is applied in the following way: With the patient sitting upon a low chair or on the floor, a folded towel is put over the shoulder and is firmly held by an assistant in order to fix the scapula. Another assist- ant sits on the well side and pulls firmly on a second towel which passes under the injured shoulder. The surgeon now stands on a chair or table and grasps the arm at Completion of third movement in Kocher s the elbow, and makes firm perpendicular method, extension upon it till the head is brought into position. The arm is then brought cautiously to the side and held in a sling. In the axillary dislocation abduction, extension, outward rotation, and finally adduction, accomplish the reduction. Upward traction is here a valuable aid. The subspinous dislocation is replaced by raising the arm to a level with the shoulder, making extension in a forward direction, rotating the arm outward, and then bringing it to the side while direct pressure is made upon the head from behind. The upward dislocation is reduced by downward and outward extension. On analyzing the different methods which we have given, it is evident that they depend upon extension and counter-extension, rotation and leverage. In view of this fact, and inasmuch as that method which utilizes these forces in the simplest and most effective way and adapts itself to the greatest variety of cases is of the greatest value, it seems to me that the following method is good : The patient lies on his back on the floor or on a table. The operator, removing his shoe, puts his heel in the axilla or the foot against the ribs or the top of the shoulder, and, grasping the forearm and elbow with his hands, makes use of extension, counter-extension, rotation, and leverage in such a way as the character of the injury and the stage of the manipulation may suggest. Strong extension by an assistant can be made during manipulation by putting a clove hitch about the arm with a towel or sheet. This may 606 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. also enable the surgeon, by looping the sheet about his loins, to make extension upward, outward, or downward. Downward traction with the heel in the axilla is to be made in the subcoracoid dislocations. Out- ward traction with the foot against the ribs is used to advantage in the subclavicular dislocations. Upward traction in the subglenoid dislocation with the foot on the acromion to steady the scapula is generally successful, but is more dan- gerous than the downward pull with direct pressure on the head with the heel or hands. The movement, under traction, of the arm downward and forward to the chest, with inward rotation, terminates the effort. In the subspinous dislocation forward traction with rotation usually determines reduction. This combines extension and counter-extension with the rotation method and the lever method of Sir Astley Cooper. It is a very efficient method, and is to be recommended on this account, as well as on account of its simplicity and versatility. A ding which should embrace the forearm and give support to the elbow should be adjusted after the dislocation has been reduced. This gives sufficient immobility to the joint, which should be kept at rest for three weeks. Moderate use may then be made of the joints, but extreme movements should not be permitted. Special complications involving excessive reaction may require topical applications. The complicated cases are to be treated in accordance with general surgical principles. When a fracture and a dislocation exist together, an attempt is made to reduce the dislocation by the Avicenna impulsion method. If this fails, the parts should be cut down upon and the head replaced, and the fragments secured in position, if necessary, by sutures. The displaced fragment, if unreduced and if it be only the head and surgical neck, may be removed, or a nearthrosis may be permitted to form between the fragment and the shaft by separating them from each other by extension. The old rule, of first permitting the fracture to unite and then attempting to reduce the dislocation, has lost its favor since aseptic conditions make operations so promising. The injuries to nerves and vessels must be treated according to general surgical rules. The exact period of time after which it is impossible to reduce a dis- location of the humerus by manipulation cannot be given, for it depends upon the extent of the injury to the soft parts, the degree of fixation of the bone in the new position, the extent of the displacement from the normal position, and the degree of change in the size of the glenoid cavity. In old cases, up to an age of a year or more, one should, under an anaesthetic, attempt, to break up the adhesions, and by any of the methods of manipulation above described endeavor to replace the bone. If this effort prove fruitless and the function of the arm be greatly im- paired by its position or from pressure on nerves or vessels, a resection should be made, unless the glenoid cavity is but little altered and the head can be brought into position by a simple arthrotomi/. The relative results obtained by resection and arthrotomy are not clearly defined. Franz Smith has reported 32 cases of resection in old dislocation from Wolfler's clinic. In 20 cases (62 per cent.) a good result was obtained, while with arthrotomy only a moderately good result was obtained in 33 per cent, of the cases. From this he concludes that resection is a better operation than arthrotomy in these cases. Dislocations of the Elbow. — The elbow-joint, though its bony out- line is so arranged that the articular surfaces are snugly and firmly DISLOCATIONS. 007 opposed, is frequently dislocated. It is especially the dislocation of childhood. Both bones may be dislocated in any direction, and the end of either bone may be separately displaced, so that there are many forms of injury to this joint. The normal outline of the joint is distinct and the bony landmarks are clear and well defined, yet when swelling- and tume- faction are present it is often difficult to diagnosticate the definite injury to the joint. The most common dislocation of this joint is of both bones backward. It results from a fall upon the outstretched arm, the violence being transmitted from the palm of the hand through the forearm, which determines a hyperextension with rupture of the anterior ligament. If the bones are arrested at a point where the coronoid rests against the articular surface of the humerus, it is regarded as an incomplete disloca- tion, but if the coronoid be carried backward until it rests in the olec- ranon fossa, it is complete. Torsion of the forearm when in a position of semiflexion is also given as a method of producing this dislocation. The lateral ligaments are torn or detached from the bone. Symptoms. — The elbow is partly flexed and the outlines are ob- scured by swelling. The olecranon has lost its proper relation to the external and internal epicondyles; the head of the radius may be iden- tified, especially if the bones are also displaced outward, by rotating the forearm. The deformity upon the posterior aspect of the joint is more marked during flexion than in extension. The trochlear surface of the humerus can often be clearly outlined at the elbow in the extended arm. Treatment. — Reduction is, as a rule, easily accomplished without anaesthesia. Traction upon the extended or hyperextended arm should be made, and the forearm must then be moved to the right-angled posi- tion during the continuance of traction, with downward pressure on the forearm. This pressure may be secured by the hand of the surgeon or by the knee placed in the fold of the joint. Lateral displacements of both bones may be either outward or inward, and generally constitutes an incomplete dislocation. The lateral dislo- cations result from falls upon the extended arm. In outward disloca- tions the ulna rests against the articular surface of the humerus, and in inward displacements the head of the radius is in contact with the trochlear surface. Complete outward or inward dislocations are rare. Symptoms. — The width of the joint is markedly increased. The lateral projections of the humerus and those of the ulna or the radius are distinct. The motions of flexion and extension ai-e painful ; the forearm is slightly flexed, and the axis of the forearm is displaced to one side of its normal position or deviates from it so as to make an unnatural lateral angle. If these dislocations are complete, the symp- toms are exaggerated. Dislocations of the Ulna. — The only uncomplicated dislocation of the ulna alone is backward. It is very rare and is probably incomplete. The forearm is slightly flexed and adducted. The orbicular ligament is torn and the ulna and radius at the upper end are forcibly separated. The olecranon presents posteriorly, the head of the radius rotates in its normal position, and the forearm is inclined inward. The treatment of these lateral dislocations and that of the ulna are much the same. The reduction is accomplished by traction in the 608 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. extended or semiflexed position, with lateral angling at the joint, while direct pressure pushes the parts into position. It may be necessary to force the ulna downward and backward away from the articular surface of the humerus before it can be forced into position. Dislocation, of both bones forward is exceedingly rare, and may be complicated by fracture of the olecranon. It occurs by a fall upon the elbow when the arm is in extreme flexion. It is complete when the olecranon is fully displaced in front of the humerus. The forearm is lengthened and fixed. The posterior surface of the humerus presses against the skin, the condyles are more prominent, and the olecranon fossa is empty. Reduction is accomplished by extreme flexion and by pushing the forearm back into position. Dislocation of the Radius. — The head of the bone may be displaced forward, backward, or outward. The first form is not infrequent, the latter very rare. The anterior and posterior dislocation may be pro- duced by direct violence forcing the bone into its new position. The forward dislocation may be produced by hyperextension in a fall upon the pronated hand. The head of the bone slips forward in front of the capitellum. The orbicular ligament is torn or encircles the neck, the head being above or beyond it. The arm is slightly abducted, partly flexed, and pronated. The swelling is in front of the elbow ; the head can be felt in its new position, and there is a depression at its normal situation ; movements are painful. In some cases the entire bone shows a displacement upward. Reduction is accomplished by traction in the extended position with the forearm in forced supination. Direct pressure upon the head of the radius helps to force the bone into its natural position. In some cases there is a marked tendency to redisplacement ; hence the treatment should be such as to keep the arm flexed and in supination until the rent in the capsule and the torn ligaments are reunited and firm. This may be done by a plaster splint or by a right-angled posterior splint. The backward dislocation has much the same pathology. The rent in the capsule is behind. The orbicular ligament is torn. The head of the bone can be more distinctly felt and outlined in its new position. The position of the arm is much the same as in forward dislocation. The violence may be direct or by a fall upon the supinated and partially extended arm. Reduction is by traction in an extended position with direct pressure on the head. The arm should be flexed at right angles and carried in a sling after reduction. The outward dislocation is rare. It is difficult to retain it in position after reduction. The dislocations forward and backward, if they are also outward, are more difficult to maintain in proper position than if displaced directly in front or behind. Dislocation of the Head of the Radius in Children. — A displacement of the head of the radius in children under five years of age is a recog- nized injury. Unquestionably, a peculiar injury at this part is found in children. It is produced by a firm pull upon the wrist or forearm, as in lifting or jerking the child by the arm. Pronation is thought to be present when the injury is inflicted. It is probable that the head of the DISLOCATIONS. 609 bone is pulled out of the orbicular ligament and is displaced forward. The forearm is very slightly flexed ; movements of the elbow are fairly free, except that supination of the forearm meets with resistance. The displacement is rectified by forced supination, with extension and traction. An epiphyseal separation of the head may simulate this injury.. This demands a few days' rest in a splint, with the arm flexed and strongly supinated, though a good recovery often occurs without any definite restraint. The Wrist. Dislocations of the wrist-joint are rare. The backward dislocation is more frequent than the anterior. It is produced by a fall upon the palm of the hand, and the deformity simulates that produced by a Colles fracture. The deformity is, however, greater, and the abrupt line of the carpus can be somewhat distinctly outlined at the projection on the dor- sal surface. The sharp outline of the radius and ulna, anteriorly, is obscured by the mass of flexor tendons. The normal relations of the styloid process of the radius and ulna are, however, preserved and con- stitute a very important diagnostic sign. The forward dislocation must be extremely rare. It usually results from a fall upon the palm of the hand with the hand in full dorsal flexion, but it also follows a fall upon the back of the hand. The symptoms are the reverse of those that indicate a backward dis- placement. The projection in front presents its sharp angle at its upper border, and the articular extremity of the radius and ulna can be clearly outlined on the dorsum. Reduction in these cases is accomplished by extension with firm pres- sure on the displaced carpus. The hand should be retained on a splint for two or three weeks. The joint should be kept at rest until repair is complete. The fingers should be free from restraint after a few days, for it is important to avoid adhesion of the tendons to their sheaths. Dislocation at the Lower Radio-ulnar Joint. — The ulna is dislocated forward or backward in its relation to the radius. The backward dis- location is produced by exaggerated pronation of the wrist. This may be produced either by muscular action or by forced pronation. The forward dislocation is usually by direct violence. The reduction of these dislocations is not difficult. The hand and arm should be retained on a splint for several weeks, and only a moderate use of the joint permitted until the parts have regained full strength. The Carpus. — The os magnum is the only one of the carpal bones likely to be displaced. This bone is occasionally displaced backward, so that it is prominent on the dorsum. The bones of the carpus are closely bound together and are not often displaced, though a few cases of dislo- cation of the second row from the first are reported. This injury is usually an accompaniment of a crushing injury which breaks the bones and lacerates the soft tissues. Carpo-metacarpal Dislocations. — The thumb is most frequently displaced. It is usually a backward displacement, and results from extreme flexion or direct palmar pressure. Eeduction is not difficulty and is accomplished by traction and direct pressure. 39 610 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTE3IS. Dislocation of the bone forward is usually by direct violence. The axis of the metacarpal bone in the forward dislocation is inclined inward and forward, but in the backward dislocation it is outward and backward. The base of the metacarpal bone is prominent in its new position. After reduction the hand should be kept at rest on a splint for three weeks. Dislocation of the other metacarpal bones is produced by a degree of violence which inflicts other important injuries. Metacarpophalangeal Dislocations. — This joint in the thumb is not infrequently dislocated backward, less frequently forward. It is displaced backward by a fall upon the thumb bending it backward and pressing the base of the proximal phalanx on the dorsum of the meta- carpal bone. The proximal phalanx is bent backward at a right angle and the distal phalanx is flexed. The capsule is ruptured and the lateral ligaments are probably torn. Very great difficulty is sometimes experienced in reducing this dislocation. It is sometimes easily reduced, but the obstruction to reduction is very marked when the tendons of the short flexor of the thumb surround the head of the metacarpal bone. The lateral ligaments of the long flexor and the sesamoid bone may interfere with an easy and ready reduction. The surgeon may con- vert a comparatively simple dislocation into a complex one by flexing or extending the phalanx before the base has been brought well forward on the head of the metacarpal by forced dorsal flexion. This compli- cation is produced by the backward displacement of the sesamoid bone on to the head or dorsum of the metacarpal, and to the slipping of the anterior portion of the capsule between the base of the phalanx and the head of the metacarpal (Fig. 246). Treatment. — The reduction is to be accomplished by forced dorsal flexion and pressure on the base of the phalanx. This movement is Fig. 246. Metacarpophalangeal dislocation. best executed when the metacarpal bone is flexed and when the phalanx is grasped in a pair of forceps or in Levis's instrument. It should be clearly and distinctly understood that extension in a line parallel to the metacarpal bone is not admissible in the reduction of this dis- location. Dislocation of one or more of the second row of phalanges may occur. The injury is easily recognized, and can be reduced by traction and by -direct pressure. DISLOCATIONS. 611 All of these injuries of the carpal and metacarpophalangeal articu- lations need a rest of ten days or three weeks on a splint to secure a good result. If reduction is impossible, then arthrotomy is demanded. This is rarely necessary even in the dislocation backward of the pha- lanx of the thumb. The Hip. Dislocations of the hip are much less frequent than those of the shoulder. They constitute about 5 per cent, of all dislocations. They are more frequent in men than in women, and are most frequent between the twentieth and fiftieth years, though the femur may be dislocated at any age. The normal limits of motion are more restricted than in the shoulder. This ball-and-socket joint is well guarded against dislocation by the deep acetabulum which embraces a large segment of the sphere of the head of the femur, supplemented as it is by the cartilaginous ring which acts in the retention of the head in the socket by increasing the suction traction. The strong ligaments, the muscles which surround it, and the protection obtained by the mass of tissue that envelops the joint guard it against injury. The head escapes from the socket through a rent in the lower segment of the capsule, and may come to a rest at any point in the periphery of the acetabulum. The posterior dislocations occur during flexion, adduction, and inward rotation of the thigh. They are the most common of the dislocations. The anterior dislo- cations occur during abduction, often combined with outward rotation and exten- sion. The head of the bone, emerging through the lower segment of the capsule, does not necessarily remain on the margin of the acetabulum at the point it first reaches, but it passes in the backward dislocation to a point of rest in the sciatic notch, or on to the dorsum of the ilium, or even upward to the anterior inferior spine of the ilium. If an anterior dislocation of the head of the bone exists, it may pass from the thyroid foramen downward to the perineum, or upward to become a pubic or an intrapelvic dislocation. Each dislocation should in clinical work be classified as an anterior or posterior dislocation. The line of demarkation between these classes is drawn between the anterior superior spine of the ilium to the tuber- osity of the ischium and crosses the acetabulum. The symptoms and the treatment of the anterior are much alike and contrast strongly with the posterior dislocations. These two comprehensive divisions are also known as inward and outward dislocations. The head escapes at some part of the lower two-thirds of the segment of the acetabulum, and is carried inward if the displacement occurs when the thigh is abducted, and outward if it is in a position of adduction. According to prevalent classifications, we should include in the ante- rior or inward dislocation those on the tuberosity of the ischium, the perineal, the obturator, the suprapubic, the ilio-pectineal, and the sub- spinous. In the posterior or outward dislocations we should group the ischiatic, the iliac, the everted dorsal, and the supracotyloid. The classi- fication made by Allis in his recent monograph is suggestive, simple, and comprehensive. He recognizes the fact that all forms of dislocations primarily escape from the lower segment, and when inward are first thyroid and then are shifted upward or downward. If the primary dislocation is outward, it is dorsal, and is then shifted upward or down- ward. Allis's classification is into — 612 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. I All present j abduction I All present I adduction the general characteristics and rotation outward. of the and general rotation characteristics of inward. Fig. 247. (1 ) Lower thyroid (2) Middle « (3) High « (1) Low dorsal. (2) Middle " (3) High " The integrity of the inverted Y-ligament (Fig. 247) is recognized as an important aid in guiding the dislocated head into a position of rest. The position in which the head is found gives a name to the dis- location. The symptoms vary markedly with the different varieties of the inward and outward dislocations, as they also do in the outward or backward forms. There is, however, sufficient uniformity in the anat- omy, the pathology, and the clinical symptoms of each of these two groups to justify us in making it a broad basis of classification. The capsule of the joint is torn by the head of the bone as it escapes. If the rent in the capsule is made by simple abduction, it is apt to be less extensive than where rotation is the chief factor. In the latter instance the continued extreme rotation may increase the tear even after the head is already displaced. The inverted Y-ligament is, however, never torn entirely from its attachment to the femur. The posterior arm of this Y is occasionally lacerated. This ligament serves not only as a fulcrum for the leverage used in posterior dislocations, but it is the ana- tomical structure that limits the wandering of the head after the dislocation occurs. This ilio- femoral ligament passes from the upper margin of the acetabulum to the anterior surface of the base of the neck. It does not envelop the head in any of the dislocations. It steadies the tro- chanter, and the more tense it is made, either by muscular contraction or by the rotation move- ments of the surgeon, the more strongly it keeps the head away from the socket ; for when tense it holds the base of the neck against the margin of the acetabulum. This ligament must be considered in efforts at reduction. The torn portion of the capsule may overlap the socket and constitute an obstacle to reduc- tion and a complication in healing. This is especially apt to be the case if the capsule is torn near its attachment to the femur. Abduction and outward rotation are very constantly present in the anterior dislocations. Abduction may be very slight in the intrapelvic variety, and outward rotation may be very slight in the thyroid disloca- tion. The thyroid dislocation is the most frequent of the anterior dis- locations. The limb is flexed and appears to be elongated, while the trochanteric region is flattened and the trochanter lowered and displaced inward. The adductors are usually tense, and the head can be felt in its new position. The impossibility of adducting the limb and forcing it to complete extension aids in the diagnosis. These symptoms are modified if the dislocation is above or below the thyroid foramen. If Inverted Y-ligament. DISLOCATIONS. 613 it passes high up in front toward the spine of the ilium, then an excep- tion may occur and the symptoms be reversed and the leg be extended, everted, and slightly abducted. Adduction and inward rotation are the cardinal signs of the backward or outward dislocations. When the head rests in the sciatic notch or on the dorsum of the ilium the limb is flexed. The trochanter is elevated above Nelaton's line, and there is marked resistance to outward rotation, extension, or abduction. These symptoms are distinctly modified if the head passes upward and inward until it is above the inferior anterior spine. Here the leg may be abducted, everted, and extended. The differential diagnosis between the anterior and the back- ward dislocation is clear except in the subspinous (anterior) and the everted dorsal. In both the head is above the acetabulum. It is very essential to determine to which clans the dislocation belongs before under- taking reduction. The symptoms in these two special dislocations may be much the same. Dr. Allis contends, with reason, that the trochanter cannot be to the inner side of the line drawn from the spine of the ilium to the tuberosity of the ischium in the dorsal dislocations. Fig. 248. Fig. 249. 1 V Anterior dislocation of head of femur. Posterior dislocation of head of femur. Manipulation foe Reduction.— It is a recognized fact that in every dislocation the head should retrace the path along which it passed during displacement. It should be remembered that in the dorsal dis- 614 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. location the head escapes from the capsule in the lower posterior third of the margin of the acetabulum, and in the anterior dislocations it escapes from the lower anterior third. The head of the bone is to be brought to these points as a first step in reduction. It was plainly stated in the pathology of dislocations that strong rotation effected greater laceration during the escape of the head than when the head was lifted by leverage through the capsule ; so now strong rotation is a dangerous element in reduction. It must be carefully used when employed. Reduction of Dorsal Dislocations.— Kocher's Method. — The patient should lie on a folded blanket or mattress placed on the floor or on a table. The luxated thigh is rotated inward and flexed to a right angle. This brings the head to the acetabulum, and it is then lifted upward, the thigh rotated outward, and straightened as it is brought downward parallel with the other thigh. There is a purpose in each of these movements — viz. the inward rotation relaxes the capsule and ilio-femoral ligament, lifts the head from the posterior surface of the pelvis, and makes it movable. The subsequent flexion of the thigh to a right angle carries the head downward below the uninjured part and brings it opposite to the tear in the capsule. This is done without the application of force. One must be cautious in the forcible flexion, otherwise it may happen that the head will slip around the under mar- gin of the socket and produce a forward dislocation into the obturator foramen. With the upward pull the ilio-femoral ligament and the cap- sule, chiefly at its upper posterior circumference, are put on the stretch as the head is lifted up to the border of the acetabulum, while with out- ward rotation, through the tension of the ilio-femoral ligament, the tro- chanter is fixed and the head is forced into the acetabulum by the parallel extension of the leg. Middeldorpf's method of reducing posterior dislocations is the following: Strong flexion, abduction, and outward rotation of the extremity. The strong flexion lifts the head from the pelvis and brings it opposite to the tear in the capsule ; abduction puts the ilio-femoral ligament on tension and brings the head to the margin of the acetabulum ; and the outward rotation lifts the head into position. The leg is now extended parallel to the other. The ease with which passive movements in all directions can be made and the snap of the joint surfaces coming in contact with each other in both methods prove that reduction has taken place. The inexperienced operator must be careful not to mistake an obturator luxation which he has produced by his manipulations for an anterior displacement or a reposition of the bone. Allis's Method. — The patient lying supine, the surgeon kneels by his side, and if the right femur is dislocated he seizes the ankle with his right hand and places the bent elbow of his left arm beneath the popliteal space: (1) he now turns the bent leg outward (inward rotation) by means of the ankle and lifts upward (sky- ward) ; (2) then turns the bent leg inward (outward rotation) and brings the femur down in extension. The following is Kocher's method of reducing forward suprapubic dislocations : The patient is placed on a table. Hyperextension is then made, and followed by flexion with simultaneous pressure upon the head of the thigh, and finally inward rotation. The forward infrapubic dislocation of the thigh is reduced by Kocher by making flexion to a right angle, extension on the leg in this position, and strong outward rotation. The flexion of the thigh is necessary to relax the ilio-femoral ligament. Where the thigh is thus flexed to a DISLOCATIONS. 615 right angle no part of it is on tension. We now want to use the capsule in the rotation, and we make a strong pull on the leg, so that it will be put on tension. The thigh is now turned outward as far as possible, extension being made on it during the rotation. The result is that the ilio-femoral ligament draws the head into position. One reduces a perineal dislocation by Middddorpfs method by flex- ing the thigh to a right angle, following this by adduction and inward rotation. The flexion in the given .position of the leg relaxes the ilio- femoral ligament and makes the head free in its position. In order to prevent the following adduction from carrying the head around the acetabulum and producing an ischiatic dislocation, a folded towel is passed around the thigh at its upper extremity, and a strong pull up- ward is made upon it. The adduction brings the head to the margin of the acetabulum, and the inward rotation brings it into position. The dovmward or infracotyloid dislocation is reduced by extension in the given position of the leg — that is, in a flexed and an abducted posi- tion and then rotating the leg outward. The upward or supracotyloid dislocation is best reduced by a folded towel, and finally inward rotation completes the reduction. Dr. Allis directs for replacement of the head in the anterior or inward dislo- cations — 1, Flex and abduct the femur ; 2, make traction outward ; 3, fix the head by digital pressure and adduct. Dr. Allis strongly cautions the operator not to adduct until after he has made traction outward. He directs for reduction by means of external rotation — First step, flex the thigh, but not to a perpendicular ; second step, adduct, carrying the knee obliquely inward and downward ; third step, rotate outward. Reduction by Means of Rotation Inward. — Bigelow puts this manoeuvre at the head of his ten rules. His directions are — " Flex the limb toward the perpendicular, and abduct a little to disengage it from the bone ; then rotate the thigh strongly inward, adducting it and carrying the knee to the floor. The trochanter is then fixed by the Y-ligament and the obturator muscle, which serve as a fulcrum. While these are wound up and shortened by rotation the descending knee pries the head upward and outward to the socket." Rule. — First step, flex the thigh, but not to a perpendicular ; second step, rotate strongly inward ; third step, adduct and carry knee to the floor. All dislocations of the hip should be treated after reduction by rest and quiet. This is especially important in young subjects. The Hodgen suspension splint for a few weeks is most comfortable and efficient. The Patella. A dislocation outward results occasionally from a violent muscular contraction of the quadriceps extensor muscle. The patella is then slipped over the articular surface of the external condyle. It may also be dislocated outward by a blow upon the inner border of the patella. These dislocations occur when the leg is extended. If complete, the internal border is directed forward and the articular surface is directed toward the middle line of the leg, and the margin of the patella is against 616 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. the side of the condyle ; but in the incomplete dislocation the rotation is reversed, and the outer border is inclined forward, while a part of the articular surface is still in contact with the articular surface of the exter- nal condyle. Dislocations inward are very rare, and are always produced by direct violence. These dislocations are most likely to occur when the capsule is relaxed. Laceration of the capsule is generally present. Reduction is effected by flexing the thigh strongly on the body, and by pressing firmly on the sharp projecting edge of the patella so as to rotate its articular surface toward that of the femur. The edge against the condyle is freed and the muscle pulls it into place. Vertical rotation of the patella occurs from a blow when the leg is partly flexed. The rotation is usually outward, so that the articular facet looks inward. Manipulation while the leg is fully extended may reduce the disloca- tion. It may also be reduced by sudden and forcible flexion. This manoeuvre may increase the damage to the joint. The close investment of the displaced patella by a rent in the capsule may render incision necessary to effect its release and reduction. These dislocations are painful and the disability is complete. Recovery is, however, prompt and good after moderate rest. The Knee. Traumatic anterior dislocations of the tibia are more frequent than the posterior dislocations. The posterior dislocation frequently results from pathological changes in the joint-tissues. The ligaments soften and muscular action determines the gradual pathological displacement. The anterior dislocation is produced by hyperextension or by a blow upon the anterior surface of the thigh or the posterior surface of the leg. It is more frequently incomplete than complete. The capsule and the lat- eral ligaments are ruptured in the complete form. The pressure of the condyles of the femur on the vessels in the popliteal space is a serious and frequent complication in this injury. The leg is generally extended ; slight rotary displacement of the tibia is present. In the complete form shortening is evident. The projec- tion of the tibia in front of the condyle gives contour to this deformity. Reduction is easily effected by traction and coaptation. Flexion may also be used in effecting reduction, but hyperextension is dangerous. Compound dislocations of the knee-joint should meet with conservative aseptic treatment unless the popliteal vessels are completely destroyed. Dislocations backward are less frequent, and are produced by direct violence and also by indirect violence, as in cases where the leg is caught and held in a fixed position and the body pushed forward until the femur is carried forward by rupture of the capsule and partial or complete rup- ture of the lateral ligaments of the joint. Hyperextension is usually present. The contour of the condyle of the femur in front and of the tibia behind, with shortening in the complete form, indicates the diag- nosis. The vessels are not so likely to be injured in this form as in the forward dislocation. Traction with coaptation, and possibly flexion, will accomplish reduc- tion. DISLOCATIONS. 617 Lateral dislocation of the knee may occur by forced lateral flexion. Torsion also enters as a factor in producing these dislocations. They are most frequently incomplete. The outward dislocation is most common. The symptoms are found in the changed outline of the joint. The injury to the joint-tissues depends upon the extent of the displacement and the manner of production. Reduction is easy. All of these dislocations at the knee require a prolonged rest of six weeks to four months. A plaster-of-Paris splint is best suited to these cases. Immediately after the injury it may be necessary to use local treatment to control the inflammatory process. A posterior splint or the Hodgen suspension splint should be temporarily used to keep the injured joint at rest. The Semilunar Cartilages. — Dislocations of portions of the semi- lunar cartilages may occur. A fragment of the cartilage is displaced either toward the intercondyloid notch or it is displaced toward the periphery, so that it projects as a ridge at the border of the tibia. The explanations of its pathology are not full and complete. The symptoms simulate those of a loose cartilage in the joint. It is produced by torsion and flexion of the joint. The most serious disability is exhibited when the cartilage is displaced into the joint. The loose sec- tion is not infrequently pulled into the joint during flexion, but is apt to appear again at the margin when the leg is straightened. If it is entan- gled in the joint, the disability is complete until it is again freed from its abnormal position. This can usually be acomplished by rotation, sudden flexion, and extension. The symptoms vary. The cartilage may be outlined as a ridge along the border of the tibia, especially along the inner anterior border. A patient may be walking or kneeling and the luxated cartilage may be pulled into the joint. A sudden loss of function, with sharp pain "and perhaps swelling of the joint, discloses the condition. The only treatment available is to put a limitation on the flexion of the joint or an operative procedure to fasten the cartilage to the head of the tibia. The result of the operation is said to be satisfactory. The Fibula. The upper end of the fibula has been displaced forward by forcible inward rotation of the foot while in full extension. The extensor mus- cles are supposed to have pulled it forward out of place. It is also dis- located backward by the forcible contraction of the biceps. An upward dislocation may occur as a complication of fracture of the tibia or by an upward displacement at both ends. The displace- ments are easily reduced by pressure on the head of the bone with the foot at a right angle with the axis of the leg. It can be retained by pads and supports. The backward dislocation is more uncertain in sta- bility of position after reduction. Rest in a fixed position should be enforced. The lower end is rarely dislocated or detached, except as a complication of fracture. 618 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. The Foot. The dislocation may be backward, forward, or inward. The outward dislocations are associated with a Pott's fracture. The backward, dislo- cation is produced by extreme plantar flexion. The lateral ligaments are torn and the capsule more or less fully lacerated, and a fracture of the external malleolus is often present. The foot appears shortened in front, the heel is lengthened. An incomplete backward dislocation is a frequent accompaniment of Pott's fracture. A forward dislocation is produced by extreme dorsal flexion with forward pressure on the heel. The astragalus can be outlined in front of the tibia. The inward dislo- cation of the foot is most frequently produced by supination and adduc- tion of the foot. The astragalus has its external border displaced down- ward, and rests below and in front of the external malleolus. The external lateral ligament is torn, and the inner border of the astragalus is inclined upward against the tibia. The dislocation of the ankle is easily reduced by traction, pressure, and by dorsal or plantar flexion and by eversion of the foot. Rest in a plaster cast for a few weeks restores the foot and gives good functional activity. The foot is sometimes dislocated from, the astragulus. The displace- ment is backward and inward or backward and outward. It is exceed- ingly rare to have an anterior displacement. The backward dislocations are incomplete, for the articular surface of the astragalus remains in contact with some portion of the surface of the calcaneum. The head of the astragalus is on the dorsum of the scaphoid, or, if the backward displacement is very great, it may project forward so as to rest on the cuneiform bone. It shifts to the outer margin or on to the cuboid or inward along the margin of the scaphoid, with the character of the lateral displacement of the foot : these dislocations result from torsion of or wrenches of the foot. The foot is shortened anteriorly ; the head of the astragalus is prominent. If the foot is displaced outward, it is also everted, and the internal malleolus is prominent ; but if the foot is to the inside, it is inverted and the external malleolus is prominent. It is said that sometimes the tibial tendons grasp the head of the astragalus in such a way as to make reduction difficult, or the posterior margin of the astragalus may be caught in the groove of the calcaneum and be difficult to dislodge. The leg should be flexed on the thigh, and extension and manipulation of the foot resorted to in the effort at reduction. The astragalus may be dislocated from the tibio-fibular articulation as also from the calcaneo-scaphoid attachment. It occurs as a result of falls upon the foot or of twists or wrenches of the foot. The forward and outward displacement is most frequent. The foot is in full plantar flexion when it occurs. The head of the bone is prominent, the foot is inverted or everted, making prominent one malleolus or the other. Backward dislocation is very rare, and is produced when the foot is in extreme dorsal flexion. Outward and inward dislocation is very rare, as is also the dislocation of the astragalus about its own axis. In this displacement the version may be complete, the upper surface looking downward and the lower upward. Reduction of the dislocation of the astragalus is not always possible. DISLOCATIONS. 619 If it can be perfectly accomplished, the functional result may be good, but if it is not possible, primary resection is the safest procedure. Amputation may become necessary. Dislocation of the tarsal bones may occur. The diagnosis is not usually very difficult. If they can be pushed into place, they may recover their function, but if the injury is com- pound or if it suppurates, then the bone should be removed. The metatarsal bones may be dislocated. The first and second alone are in conjunction with the others. The third, fourth, and fifth are not separately dislocated, but may be associated in a dislocation. They can be forced into position, and if extensive injury does not complicate the case, the recovery is usually with a good foot. PART VI. SPECIAL OR REGIONAL SURGERY. CHAPTER XXXVII. INJURIES AND SURGICAL DISEASES OF THE HEAD. By Roswell Park, M. D. The Scalp. Erysipelas and cellulitis of the scalp are the result of the same infections and conditions as when met with in other regions, but are peculiarly prone to occur here because of the liability to infection from the hair with the material concealed in and upon the surface. They lead frequently to suppuration, in which case abscesses form that may extend inside the cranium, as into the frontal or other sinuses. These are common about the orbit and in the upper eyelid, and unless speedily incised may lead to gangrene. Multiple abscesses are also common. Disturbances of sight and hearing as sequels of these infections are occasionally met with. The principal danger from these purulent col- lections pertains to intracranial infection or general sepsis, usually of pyemic type. Gaseous Tumors of the Scalp. — The most common of these is ordi- nary emphysema, which may result from injury to the upper air-passages or even involving the lower. Thus, fractures of the nasal bones or of the base of the skull may permit the distention of the subcutaneous cellular tissue by forcible inspiration of air. Emphysema of the scalp may be a valuable diagnostic feature in certain instances. When con- nected with a wound it would best be enlarged in order to permit the escape of contained air. Otherwise, these puffy swellings usually dis- appear spontaneously by absorption of air into the veins. In cases of malignant or gangrenous emphysema, early and numerous incisions should be made, after which antiseptic solutions, etc. should be gener- ously resorted to. Pneumatocele. — A pneumatocele is a chronic gaseous tumor, being a cavity distended with air which has escaped from the cells of the underlying bone, bounded on the outside by the scalp, beneath by the cranium. They are met with about the mastoid or the frontal region. Not more than two dozen cases in all are on record. In consistency 621 622 SPECIAL OR REGIONAL SURGERY. these tumors are elastic, while the escape of air upon pressure is some- times to be heard upon auscultation. Their explanation is almost always a defect of the inner wall of the mastoid cells, through which air may be forced from the pharynx through the middle ear by violent effort. Bony defects which might permit this condition are met with in a small percentage of craniums. The best results in the way of treatment have been achieved by puncture, with the injection of weak iodine solution. Tumors of the Scalp. — These may be divided into the congenital and the acquired, as well as into the benign and malignant. Of the congenital tumors, the dermoids are of most interest. In order to fully understand dermoids of the cranium we must remember that originally the dura and the skin were in contact, and that the cranial bones develop as an after-thought. This will explain the occurrence of dermoids either beneath or outside of the bone or their simultaneous appearance and possible connection. Many of the so-called atheromatous cysts or wens are really of dermoid origin. Those which are extracranial need only antiseptic incision or excision. It will often be enough to split such a cyst with a bistoury, after which each half of the sac can probably be easily detached from the bed in which it has lain. Should intracranial con- nection be discovered, the bone-chisel and sharp spoon will be necessarily called into employment. Some of these dermoids perforate into the orbit, and may have to be followed into that location. Of the other tumors, benign or malignant, most varieties may be met with in this region. Subcutaneous collections of fat are not so common, nor are fibromata. Various bony growths may be met with, while in certain cases the signs of brain-pressure are to be explained only by their extension within the cranium. Malignant tumors are common about the scalp and the cranium ; they assume, however, no conventional appearance, and may be met with in any shape or form, those of the scalp alone occurring either as carcinoma or epithelioma from its epithelial elements, or as sarcoma from its meso- blastic elements. Tumors primary in the periosteum or bone must neces- sarily be of sarcomatous nature, while those of the type which perforate to the surface may be either sarcoma or possibly endothelioma. With regard to the general character of these growths enough has been already said. Concerning their extirpation (for there is no other treatment than this), operations of varying degrees of severity may be called for. The superficial epithelioma should be, if possible, attacked before it has become adherent, in which case everything should be removed down to the underlying periosteum, after which a plastic operation will permit the repair of the defect, so that primary union of the whole surface may be secured. Any malignant growth which is adherent to the underlying cranial bone calls not only for removal of its own substance, but for that of the bone to which it is attached. To fail in this is to invite recurrence. This may necessitate more or less extensive osteoplastic resections of the bone, but the condition permits of no middle course. Very extensive resections of bone have been made with success, and need not be abstained from unless there be good reason to fear involvement of the dura or cortex. In this case the advantages and dangers must be carefully weighed before proceeding to operation. During operations on the bone great care should be taken, especially in certain regions, to avoid injury to the intracranial sinuses, although we have learned that these may be ligated and intervening portions removed — almost with impunity when necessary. But the wounding of the sinus by the point of an instrument or spicule of bone may lead to a most hazardous and annoying complication, jind is to be prevented when possible. A small wound INJURIES AND SURGICAL DISEASES OF THE HEAD. 623 in a sinus may be plugged with gauze, which may remain for two or three days. There is always a possibility of air-embolism (Chapter II.) when the sinuses are opened, since their walls do not easily collapse. Hemorrhage from the soft parts maybe almost entirely controlled by the use of an elastic tourniquet stretched around the skull. Oozing veins in the diploe or in the bone may often be secured by pressing the tables of the skull together with bone-forceps, while at other times an antiseptic wax can be forced into the interstices of the bone and hemorrhage thus be checked. In certain cases where it seems impracticable to slide flaps and cover defects, the desired end may be obtained by skin-grafts after Thiersch's method. A rare and specialized form of blood-tumor, met with only on or within the cranium, is the so-called hernial dilatation of the superior longitudinal sinus. It may present through openings in the bone ; sometimes pressure upon it will cause vertigo and perhaps greater prominence of adjoining veins, even of the jugulars. Non-inflammatory Diseases and Congenital Conditions op the Skull. Incomplete formation of bone (aplasia wanii) is occasionally met with. The bone is a secondary formation in the skull, the dura and skin being originally in contact ; consequently, this condition can be easily explained as a failure to develop bone where it is normally met with. These defects are most common in the frontal and temporal regions. The bone may fail also to develop to ordinary thickness, and may be Fig. 250. Craniotabes (rhachitis) (Bruns). found as thin as paper or ossifying only in certain directions. Super- numerary bones may also develop, apparently to take the place of those previously lacking. Aplasia may also be a unilateral defect and con- tribute toward the formation of meningocele. Atrophy or anostosis— %. e. complete disappearance of cranial bones— is occasionally observed it may be an interstitial or an eccentric process, and may happen at any 624 SPECIAL OR REGIONAL SURGERY. point or at several spots. Up to a certain extent it is the rule in the skulls of the aged, where the bones become reduced to the thinness of paper or may in certain places completely disappear. Senile atrophy, in Fig. 251. Leontiasis : skull of a Chinese woman (U. S. A. Museum, No. 10,620). other words, is a normal process, and is to be expected after the sixtieth year of life, its possibility being not forgotten when operations are under- taken upon the skulls of those advanced in years. Eccentric atrophy Fig. 252. Osteoma of skull (Mudd). may also occur from pressure of soft or hard tumors, among them the so-called Pacchionian bodies. It is stated also that increasing hydro- cephalus may produce an internal and eccentric anostosis. INJURIES AND SURGICAL DISEASES OF THE HEAD. 625 Craniotabes or Cranial Rickets. — It is particularly in the skull Fig. 253. Same, seen from below. that the manifestations of rickets are most common, the bone becoming unduly thick and the general shape being changed. Usually there is Syphilitic caries of cranium (Bruns). flattened vertex with delayed ossification, with an abnormally firm union 40 626 SPECIAL OR REGIONAL SURGERY. along the suture lines. In spite of these changes, the bone often becomes affected by pressure to such an extent that a rachitic or hydrocephalic child, confined in bed and moving little or not at all, will develop a skull showing the effect of such pressure. Many rachitic skulls show areas of atrophic thinning, dispersed irregularly, while the inner surface may show the markings of the convolutions impressed upon it by the softness of the bone. Surgical Affections of the Cranial Bones. The acute affections of bones have been already dealt with at con- siderable length in Chapter XXXIV., and but little needs to be said here in addition to statements therein contained. Acute peri- ostitis is, for the most part, due either to syphilis or to an infection follow- ing injury. In the latter case it proceeds from the margin of the wound, and may spread to a considerable distance. It is in some instances secondary to deeper infection extending from the middle ear, and then is found posteriorly to the ear and externally to the mastoid cells. Con- genital openings or defects of the sutures about the mastoid seem to have much to do with the travelling of infectious lesions in these localities. Acute osteomyelitis is due to essentially the same causes as those just discussed. In this case it is especially in the diploe that the principal ravages are met with. Unless very promptly recognized and relieved by surgical measures, this is exceedingly likely to lead to sepsis of the pysemic type and at a relatively early period, the venous arrangement of the diploe favoring such type of disease. Necrosis of the skull is ordinarily the result, directly or indirectly, of injury, in which cases it is usually of the acute form, a fragment which has been too much separated from its surroundings to live, giving evi- dence of early and easily recognizable death. This necrosis is, for the most part, confined to the external table. Necrosis of slow origin is due either to tuberculosis or syphilis, perhaps more often to the latter. Under a cold abscess of the scalp or subperiosteal abscess will often be found at least a small area of dead external table which needs complete removal. Necrosis has also been observed to follow severe burns of the scalp. Injuries to the Head Previous to and During Birth. In utero the head is surrounded by amniotic fluid and is well guarded against injury. Nevertheless, as the result of penetrating wounds or of falls on the part of the mother such injuries do occasionally occur. Most of the cases of skull fracture reported as occurring before birth have really occurred during delivery. Multiple fractures of the skull of either character have been observed. During the process of parturition there nearly always appears a tumor of the scalp in the new-born, commonly spoken of as the caput succedaneum, at the point where pressure upon the head has been least. It usually disappears quickly after birth. It is due to a collection of blood, partly an extravasation, as the result of compression or injury. INJURIES AND SURGICAL DISEASES OF THE HEAD. 627 It is composed also of oedematous soft tissues of the surface. If incised, blood-stained serum is poured out. When this fails to rapidly resorb during the first days of the infant's existence, and especially if it fluctuate, it may be incised under antiseptic precautions and blood-clot be turned out or the necessary indication met in a judicious way. In rare cases it suppurates, by which is produced an acute abscess which naturally calls for prompt evacuation. A collection of fluid blood between the periosteum and the bone is known as the cephalhematoma neonatorum, such a lesion occurring Fig. 255. Fracture of right frontal Done in a new-born infant ; fracture extending into orbit (Bruns). on an average once in two hundred cases. It is met with most often over the fissures, and appears, at least in some cases, to be produced by the sliding of the bones. This collection also usually promptly disap- pears. In case of failure it may be aspirated or, if necessary, incised. Before resorting to any operative procedure it would be well to make a careful distinction between a possible meningocele or encephalocele as a congenital defect and cephalhematoma as an accident of delivery. A depression in the skull of a new-born child which does not quickly right itself or yield to expanding influences from within should not be long allowed to go uncorrected, since disastrous lesions, for the most part of paralytic type, may result therefrom. In these days of aseptic surgery there is no reason why such operation as may be necessary to elevate a fragment or an entire bone should not be performed with full precaution. Important Points in the Surgical Anatomy of the Skull. It must be remembered, first of all, that the young and the aged have no dis- tinction of tables of the skull, but that the diploe which separates the two tables is an affair of middle age, develops slowly, and disappears after the same fashion — sometimes to such an extent as to leave the skull of almost paper-like thinness. In all operations, then, upon the young and the old, one must proceed with extreme 628 SPECIAL OR REGIONAL SURGERY. caution, as expecting to find the skull quite thin. The lower limit of the squa- mous bone proper is the so-called masto-squamosal suture, and operations confined to the squamous plate alone are safe from injuring the sigmoid sinus on its inner side. The ridge at the posterior root of the zygoma indicates by its lower border the level of the mastoid antrum. A few lines above this, is the level of the base of the brain. The mastoid is present at birth and appears externally by the second year. Its antrum is present also at birth, though its air-cells do not develop until after puberty, their location being previously occupied by cancellous tissue. Most of these cells open into the antrum, a few directly into the tympanum. They are not always separated from the sigmoid sinus by bone. The partition between them is perforated by minute veins, forming an easy communication between the sinus and the antrum. Air escaping from the mastoid cells into the overlying tissue may cause emphysema from a basal fracture. In all operations upon the mastoid antrum one should keep to its outer side, and the higher and the more closely to the posterior zygomatic ridge he makes the first opening, the more sure is he to escape injuring the facial nerve. The groove for the sigmoid sinus extends to the jugular foramen from a point on the outside corresponding to the asterion. The lateral sinus may be indicated externally by a line from the superior border of the mastoid to the inion — i. e. from the asterion to the inion. The frontal sinuses are usually separated by a septum, which is often incom- plete or wanting. They are variable in size and outline, and do not develop until after the seventh year — in some cases to a relatively very large extent. The infundibulum, by which they empty into the nasal cavity, is often so small that when the lining membrane is involved it becomes closed, and retention with its accompanying symptoms — pain, tenderness, swelling, etc. — may ensue. Ulceration and erosion, however, may cause perforation internally to the supraorbital plates, so that pus may penetrate through the inner half of the orbit. Aside from its direct communication, the superior longitudinal sinus connects with the basal sinuses through the middle cerebral and the Sylvian veins, while communications with the middle meningeal veins are quite free. Where the frontal and diploetic veins enter the longitudinal sinus there are frequently dilatations in which marasmic thrombosis often originates. This sinus is also connected with the veins of the nasal septum, so that a septic phlebitis may be directly propagated from the nose. So much of the lateral sinus as is contained in the sigmoid groove is known as the sigmoid sinus, which connects directly with the exterior through the mastoid and the posterior condyloid veins. In sinus thrombosis this mastoid vein is usually likewise affected. One or more condyloid veins accompany the hypoglossal nerve through the anterior condyloid foramen, and may also serve for the propagation of infection or exit of pus. While septic particles may be carried — usually through the internal jugular — from any part of the lateral or sigmoid sinuses, they may also be carried by way of the other veins above mentioned or the occipital sinus ; all of which empty directly into the subclavian without passing through the internal jugular. These sinuses are all rigid tubes, always open, while the veins are thin and flexible, their calibre constantly varying with inspiration and expiration. The sinuses contain no valves, and these are very rare in the cerebral veins. So far as the lymphatics are concerned, there is free and easy communication between the internal and external plexuses and nodes. Into the superficial nodes, along the external jugular, outside of the deep fascia, empty all the external lym- phatics of the head. Intracranial infection shows itself in swelling of the deep cervicals beneath the deep fascia. Lymphatics are abundant in the dura, and pathogenic organisms, once housed within the dura, find it easily open to invasion. The potential interval between the dura and the arachnoid is termed the sub- dural space, where considerable effusion may occur without marked symptoms, owing to its easy diffusion, while blood poured out here may travel even to the lowest parts of the spine and cause death by pressure upon remote points. The arachnoid bridges over the convolutions and does not extend into the sulci. It is not vascular ; at certain points it is adherent to the pia, at others does not touch it. The subarachnoid space is formed in the latter way, and within it most of the cerebro-spinal fluid is contained. This space is unevenly distributed over the brain surface, most prominent beneath the posterior two-thirds of the brain, where there is a wide interval between the arachnoid and the pia, extending for- ward over the medulla and pons and as far forward as the optic nerves. This space connects with the ventricles by the foramen of Magendie, as well as with the INJURIES AND SURGICAL DISEASES OF THE HEAD. 629 sheaths of the cranial nerves. When these nerves escape from the brain or cord they are covered by all three membranes, the layers being most distinct along the optic nerves. Fluid injected into the subdural space may pass along the spinal nerves as far as the limbs. It is essential to realize this in order to appreciate how extensive is the surface exposed in leptomeningitis. Internal hydrocephalus is often the result of closure of the foramen of Magendie. The cerebro-spinal fluid is rapidly reproduced after traumatic escape. External hydrocephalus, or accumulation in the subarachnoid space, is a condition frequently due to tubercular infection. The pia is the vascular coat of the brain, supplied with an extensive network of fine nerve-fibres derived from the sympathetic and the cranial nerves, having intimate relations with the brain, to such an extent that leptomeningitis and encephalitis are almost inseparable. The nerve-supply to the cerebral membranes explains the severe pain of meningitis. Injuries to the Soft Parts of the Cranium. In direct connection with what lias just been stated above, it is well to emphasize that the venous communications between the exterior and interior of the cranium are numerous, and that the frequency of these anastomoses explains the ease with which extracranial infections are propagated within ; in other words, these explain the frequency of septic mischief in the brain from external injuries. Penetrating and incised -wounds are frequent about the head, their prognosis per se, as well as their proper treatment, varying but little from that of such wounds in other parts, so long as the skull proper and its contents escape injury. Hemorrhage from scalp wounds may be free, even fatal. The most dangerous hemorrhages occur from the tem- poral vessels. Penetrating wounds are short, and the periosteum and underlying bone are usually also injured. Such small articles as blades of penknives, particles of dirt, etc. will often be found when the parts are carefully inspected, a measure never to be neglected. Contusions of the scalp and skull are spoken of as subcutaneous, subaponeurotic, or subperiosteal, and are most frequent in the frontal and lateral regions. Ecchymoses following them may be extensive and discoloration may spread over a large area. In traumatic hsematomata resulting from various injuries incision should be early resorted to should blood-clot fail to resorb. Injuries to the Cranial Bones. All conceivable degrees of injury to the bones, from a trifling divis- ion of the periosteum down to most extensive denudation or mangling of the external table or the entire thickness of the bones, may be met with. These lesions may be spread over a large area or may be the result of penetrating wounds. In other words, we may have linear, penetrating, or large surface wounds with such injury to the scalp as perhaps to amount to a total loss of covering for the same. All of these moreover, may be complicated by fractures of the bone at the point of injury, with or without brain lesions, or by other and more remote lesions. In regard to most of these, it may be said that non-penetrating inju- ries, when promptly and properly attended to, have, for the most part a favorable prognosis. Every penetrating wound of the cranium is a condition justifying grave prognosis, on account of the great danger 630 SPECIAL OR REGIONAL SURGERY. incurred of infection. Other features of these wounds, with more in regard to prognosis and treatment, will be given under the head of Compound Fractures of the Skull, etc., with which they are usually connected. It is necessary, however, to say in this place that penetrating wounds of the cranium are often received in a way which does not permit actual diagnosis, as, for instance, when received through the nose, the orbit, etc. Every wound whose history and appearance indicate that penetration may have occurred should be, however, subjected to the most rigid scrutiny and care. Points of fencing foils, umbrella tips, etc. have been forced into the brain-cavity through the orbit and elsewhere, in a way which left little external evidence of the severity of the injury. Fractures of the Skull. Following the anatomists, and for general convenience, these are divided into fractures of the vertex, of the lateral region, and of the base, the former being the most frequent, since the vertex is the most exposed. A fracture in a given region may be confined to that locality or may radiate widely or extend nearly around the cranium. Of all the fractures of the bony skeleton, those of the skull constitute about 2 per cent. Fractures of the vertex are, for the most part, due to actual vio- lence, the force being often expended at the point of application or pro- ducing radiating fractures. Those which are limited to the neighbor- hood of the injury are spoken of as direct fractures, in distinction to which we have indirect or radiating, often producing remarkable results. Fractures may vary between the simplest crack or fissure, accompanied by but trifling brain-symptoms and never recognized, to the most extensive comminution and destruction of cranial bones which can be imagined. Splintered or comminuted fractures refer to the formation of numerous bony fragments which are often more or less loosened, some- times completely so, occasionally dovetailed together, and often driven in or depressed. Such fractures are direct. It is possible to have comminution without depression ; the latter makes it the more grave condition. Fractures with absolute loss of substance may be made by gunshot injuries or by any extensive splintering by a penetrating body. It is possible to have fracture of one table without that of the other, this being most often true of the external table. In isolated fractures of the inner table there is often dislodgement of small fragments which may injure the dura and possibly produce later epileptic or irritative disturbance. When the external table is chipped off the diploe is exposed, and this with its wonderfully fine venous communications opens up a wide area to infection and subsequent pyaemia. ^ Gunshot fractures are always depressed and almost invariably com- minuted. The bullet of the modern army rifle possesses a great initial velocity, and the cranium struck by it will probably be disrupted into fragments, with instant death. The majority of gunshot fractures of the skull seen in ordinary civil practice are due to revolver or pistol bullets from weapons of the prevailing type of to-day. In these instances there will usually be penetration, perhaps with perforation of INJURIES AND SURGICAL DISEASES OF THE HEAD. 631 the skull, and the formation thus of one or of two compound fractures, the wound of entrance being always comminuted and depressed, while 1 rag- Fig. 256. Gunshot fracture of skull (Helferich). ments of bone may be scattered along the course of the bullet, which may also carry in infectious material from without, such as hair, parti- cles of hat, etc. Whatever may be the wisdom of operating in other cases where there is room for doubt as to the proper course, there never is uncer- tainty as to the proper treatment of gunshot wounds of the skull, which should be invariably subjected to operation. It will thus be seen that fractures of the skull may be simple or compound, or complicated with other injuries, or depressed, without any reference to whether they are simple fissures or more extensive injuries. On the other hand, depressed and comminuted fractures may occur with- out being compound in a surgical sense, and with each one of these injuries there may be accompanying disturbance of the brain of any degree of severity, from the mildest concussion or shock up to rapidly fatal compression. Any imaginable complication of these head injuries is not beyond the bounds of possibility. The essential features in explaining the mechanism of fractures of the vertex are the area involved and the violence of the impact. The skull is often surpris- ingly elastic, even in the oldest individuals, and fractures occur ordinarily when the natural limits of elasticity have been exceeded and bone-cohesion overcome. Children particularly suffer from depression without fracture, which formerly was never operated upon, but which is now regarded as calling for operation. On the other hand, certain skulls are abnormally fragile (see Fragility of the Bones, Chapter XXXIV.), and, among the insane, may be found so porous and yielding as to be pressed out of shape without great difficulty. In injuries of slight extent it is enough that the skull be regarded as composed of an elas- 632 SPECIAL OR REGIONAL SURGERY. tic substance, while for injuries produced by greater violence the skull is to be considered rather as a globe or arch possessed of high resistance and elasticity, whose shape will probably yield more or less before a fracture results. Much may be learned from such experiments as those of Felizet, who filled skulls with paraf- fin and dropped them from varying heights, and then divided the bone, to note in numerous instances that, although the bone had not been fractured, it had yielded at the point of impact to a degree producing a marked depression in the parafHn beneath. It is, then, certain from observation, as well as from a multitude of experiments, that after various injuries, especially to the top of the head, the shape of the skull is momentarily altered and its diameters affected. Many frac- Pig. 257. Gunshot fracture of skull (Helferich). tures, then, are the result, as it were, of a bursting force, which may be shown by the fact that hair has been found included within closed fissures, as well as even the dura itself. Moreover, particles of bullets have been found within the skull without any visible opening through which they could have entered, showing that the bone has yielded under impact for a fraction of a second. It must also be remembered that in certain injuries to the head, as where a man is struck to the ground, there is injury at two points presumably nearly opposite. Fractures of the skull, especially of the vertex, possess surgical interest mainly as they are accompanied by more or less evidence of intracranial com/plications. So long as there is no evidence of hemor- rhage or laceration within, they are ordinarily regarded as a feature of the external wound with which they are usually found, and, unless there be comminution, depression, or some other good reason for operating, are covered over as the wound is closed, and are left to the natural pro- cess of repair by formation of minute callus or by the ossification of granulation-tissue. It is absolutely unfair to contrast the results of the surgery of to-day INJURIES AND SURGICAL DISEASES OF THE BEAD. 633 with those of the pre-antiseptic era. Kules then enforced are now entirely abrogated, and the methods of to-day would have made our surgical ancestors protest most loudly. One respect in which we violate precedent is in our disregard, to-day, of the periosteum, or pericranium. This is sacrificed without hesitation when found to be infected or torn or lacerated beyond capability of repair. A flap of scalp, it is known, will adhere as kindly to denuded bone as to periosteum, and we have even learned that skin-grafts can be applied and relied upon to adhere to this same bone— if not upon the first day, a little later when granu- lations have appeared. In the various plastic operations necessitated about the head we may also transplant flaps upon otherwise uncovered bone without the slightest hesitation. We have, furthermore, learned to treat fractures mainly in accordance with what we decide as to intra- cranial complications, or through what we can see either through the wound, if present, or through an opening intentionally made under anti- septic precautions for purposes of exploration. It is everywhere con- ceded to be better policy to remove fragments of bone whose vitality is uncertain, and to sacrifice ruthlessly any tissue injured or lacerated to such an extent that sloughing would probably follow, or so exposed as to have become necessarily infected. Diagnosis of Fractures op the Vertex. — In the absence of an open wound, and unless incision be made, this must often be con- jectural. In the presence of a wound diagnosis is usually easy, enlargement of the wound to any reasonable extent being perfectly legitimate for purposes of examination. In case of a small puncture with suspicion of fracture it will be usually better to enlarge it suf- ficiently to permit the introduction at least of the finger and of careful inspection. With the finger and the eye we seek to detect differences in level, depressions, fissures, etc. Mistakes often arise from the forma- tion of an exudate or a clot, by which a mere depression of the soft parts may be regarded as actual depression of the bone. Error occa- sionally arises from the existence of previous atrophy of the bone or any congenital defects in ossification of the skull ; also in the skulls of syph- ilitic patients where disappearance of a gumma is often followed by absorption of the underlying bone. In every case of doubt it will be wise to make exploratory incisions, of course under rigid aseptic precau- tions. These should not be made, however, unless the attendant is ready — i. e. has the facilities immediately at hand — for carrying out any further operative procedure that may be necessary, as elevation of frag- ments, removal of foreign bodies, etc. Areas of bloody infiltration often have abrupt margins which are calculated to easily deceive. In children, more especially, we often have a circumscribed bloody tumor which may contain cerebro-spinal fluid rather than pure blood. In some of these cases after exploration there will be found material resembling brain- matter, which, however, is not always such, although real brain-substance may escape, such escape necessarily implying rupture of the overlying membranes. Should it be noted that the fluid used for irrigating and cleansing such a wound begins to pulsate, it will almost always mean connection with the cranial cavity, and, obviously, fracture. A suture should not be mistaken for a line of fracture. This mistake is more easy when Wormian bones are present. One should not forget that 634 SPECIAL OR REGIONAL SUBGERY. blood may be wiped away from a suture line, but not from that indi- cating fracture. It is not often possible to diagnose an isolated fract- ure of the inner table. It happened, however, once to Stromeyer to notice that so soon as an injured patient assumed the horizontal position he began to vomit, which nausea subsided when he was placed in the upright position. On autopsy it was found that there had occurred a depressed splintering of the inner table with per- foration of the dura : less irritation was produced in the upright position than when the patient was lying down, which accounted for his vomiting when in the horizontal posture. When a comminution has been produced it is always of prognostic value to find an unbroken dura, since so long as its integrity is undisturbed the prognosis is better than when the reverse obtains. Prolapse of brain-substance is always a most serious complication. Escape of cerebro-spinal fluid is relatively rare. Treatment. — Treatment comprises attention to the local injury and the suitable dealing with the condition of the brain within when injured. The treatment of simple fractures is, for the most part, expectant. In the absence of indication for operation it should be exceedingly simple, and should consist of physiological rest, aseptic dressings, ice applications to the head, the administration of such laxatives, diuretics, antacids, etc. as may be necessary to favor free excretion and to guard against auto- intoxication. Whenever there is reason to suspect a depression, explora- tory incision at least should be made. Actual depression, whether the fracture be compound or not, calls always for operation, the opinions of surgeons of past generations to the contrary notwithstanding. This course is justified by the numerous instances in which later consequences have been noted, such as traumatic epilepsy, insanity, etc. Compound injuries call always for operation of some character, in- cluding the removal of loosened splinters, the elevation of depressed bone, the removal of all foreign matter, the checking of hemor- rhage, the excision of bruised and lacerated tissue, and the proper closure of the wound, with or without drainage according to circum- stances. In many serious and lacerated cases it is inadvisable to close the wound with the view of attempting primary union. It is much better to pack it with gauze and temporarily close it with secondary sutures. All of these surgical measures should be seconded by efforts which every judicious surgeon will always put into practice — namely, physiological rest (quietude of the head, which may even be enforced by the posterior plaster-of-Paris splint to the head and neck), attention to the primce put, the avoidance of transportation, the prevention of auto-intoxication, etc. The best judgment will often be called for in decision as to the amount of bone to be removed, the wisdom of opening the dura when not lace- rated, of examination of the brain with the exploring needle, the matter of drainage, the time during which it shall remain, etc. With reference to all these matters exact rules cannot be given, but every case must necessarily be decided upon its own merits. When drainage is made in recent cases it is usually sufficient to drain the scalp wound. Only in cases where there is probability of meningeal infection does it pay to INJURIES AND SURGICAL DISEASES OF THE HEAD. 635 deliberately attempt to drain the dural cavity. This is perhaps better done with gauze than with drainage-tubes. Skull-fractures where the injury is limited to a small area are now treated according to a bolder method than was in vogue a number of years ago, especially in cases where depression is recognized. I believe thoroughly in careful and judicious operating in every case where distinct depression can be made out, as well as in every case where indications point to injury of parts within the bone. The statistics of trephining in the pre-antiseptic era are valueless as arguments in this consideration. If done according to strict aseptic precautions and if good surgical judg- ment be used in every respect, the operation is per se almost devoid of mortality, and should not be regarded as a last resort, but rather in such cases as a first one. I have myself seen so many instances of later untoward consequences resulting from delay, which corroborate the expe- rience of others, that I would not be misunderstood in this matter. My advice might perhaps be summed up in the following words : Where there are no brain-symptoms and no skull-symptoms in fractures of the vertex leave the case alone ; when either of these is present, especially the former, it will always be wise to operate. Fractures of the Base of the Skull. In most of these fractures the violence is applied at some more or less distant point, and, by transmission through the arch-like structure Fig. 258. Fracture of base of skull (Brunsl. of the skull, expends itself in Assuring or comminuting the base. The most frequent location of the indirect injury is upon the convexity. The 636 SPECIAL OR REGIONAL SURGERY. mechanism of these fractures, indirect as most of them are, has been a vexed problem for many centuries, but has been cleared up mainly within the present century. Felizet has shown, for instance, how the handle of a hammer may be forced into its head by striking it in either one of two different ways, and has compared the mechanism of basal fractures to this fact. The secret of basal fractures probably resides in the elas- ticity of the skull, which varies within wide limits in different individ- uals, and which breaks, as do the ribs and the pelvis, at points more or less distant from that at which the injury occurred. Were the skull everywhere equally thick and elastic, there would be much less variation in these fractures, but we know that lacerations frequently extend be- tween the most resistant parts ; and when violence is applied upon the forehead we commonly find that the resulting fissure extends between the crista and the wings of the sphenoid upon the same side in its course toward the base : that when the lateral region of the skull is injured the fissure commonly extends between the sphenoidal wings and the occip- ital bone ; and that when the occipital region receives the first injury the fracture lies usually between the pyramid and the occipital crests. The analogy between fractures of the skull and cracks made in nutshells (cocoanuts, etc.) when struck with a hammer is too self-evident to be lost sight of. Many years since the French introduced the term fracture by contre-coup (counter-stroke) — a practical admission of the occurrence of fracture at a point more or less opposite to that struck. There is, however, no certainty about these fractures, and to spend further time in this connection in studying these minutiae would be of little avail to the student. It will be enough to add, then, that exten- sive fissures of the vertex are almost always extended to the base of the skull, while the reverse is seldom true. There are doubtless also many cases in which a bursting force compromises the bone rather than mere radiation of unexpended violence ; but so long as skulls conform to no fixed mathematical figures nor proportions, but are composed of bones varying in shape, density, and strength, it will be impossible to formu- late any laws which are comprehensive enough to be satisfactory. Frac- tures in the posterior fossa occur for the most part through violence applied posteriorly and from below. There is a ring-form of basal fracture produced mainly by the impact of the vertebral column, as when an individual falls upon the head, the weight of the body forcing the cranial base in upon the brain. Fractures of the anterior fossa may involve the roof of the orbit; even facial bones may participate in the injury. These considerations are not without importance, since if a patient presents symptoms of injury of the petrous bone, and if these be accompanied by injury to the lateral region of the skull, we are in position to make a diagnosis of fracture of the middle fossa. ( Vide Plate XXII.). V By all means, the majority of basal fractures are mere fissures which open and close instantly upon their production — close so quickly, in fact, as scarcely even to include blood between the broken bony surfaces. Prognosis. — The majority of basal fractures arc fatal, cither because of injuries to the brain, or of hemorrhage or violence along the nerve- trunks, or from infection extending along the newly-opened paths. Other things being equal, the longer the fissure the greater the danger, PLATE XXII. Fractures of the Base of the Skull. Illustrative Lines of Fissure or Fracture are printed in Red. INJURIES AND SURGICAL DISEASES OF THE HEAD. 637 particularly so when it takes its origin in the vertex, and because of greater ease of infection. Air-infection may incur in any basal fracture by fissures extending into the various air-containing cavities — nose, ears, sinuses, etc. They are then practically compound, though invisible. The general prognosis will depend, first, upon the injury to the cranial contents ; second, upon the possibility of infection. Statistics are abso- lutely unreliable, although always possessing interest. Numerous museum specimens show the perfection with which bony repair may occur and the admirable way in which compensation is afforded for defects. Suppuration after basal fractures is mainly that due to puru- lent basal meningitis, in which case the brain-symptoms dominate in the clinical picture, while the appearance of a single drop of pus in the ear or upon the surface is of the greatest significance. The conversion of a serous outflow (e.g. from the ear) into purulent fluid is also pathognomonic. Various paralyses, principally of the cranial nerves, may follow this injury and prove temporary or permanent. Diagnosis is often made by the study of these special nerve lesicns. Diagnosis. — The most significant diagnostic features are — 1. Spread of blood from the point of fracture until it appears as an ecchymosis at certain points beneath the skin. This will occur early in some cases, late in others. It may appear beneath the skin or beneath the conjunctiva or other mucous membranes, even in the pharynx. Occurring about the mastoid, it implies fracture of the middle or pos- terior fossa ; about the eyelids, of the anterior fossa. Beneath the bulbar conjunctiva, it means extravasation along the optic sheath, probably from within the dura. In fractures of the posterior fossa it will come to the surface of the neck, but only after two or three days. The ecchymoses about the lids or orbits occurring after two or three days mean more than those occurring within these days, since the latter may be caused by external bruising. The globe of the eye may be pushed forward by blood accumulating within the orbit. Exophthalmos thus produced is therefore most significant, though not common. 2. Escape of serous fluid, blood, or brain-substance from the cavities of the skull. Hemorrhages from this cause occur most often from the ear, the petrous bone being tunnelled with various canals through which blood may thus escape. One should, however, assure himself in every instance that the blood is really escaping from the ear, and not from some trifling wound of the external soft parts, the soft walls of the meatus, or the tympanum itself. Profuse hemorrhage can probably only come from a basal fracture. Escape of serous fluid is usually noted as a sequel to hemorrhage, although it may begin almost immediately after an injury. Earely more than twenty-four hours elapse before it begins to flow, if at all. The quantity of fluid discharged is sometimes aston- ishing. It may occur in frequent drops or during expulsive efforts, like coughing, or may ooze in such a way as to be insensibly collected by the absorbent dressings. In average cases the amount in twenty-four hours is from 100 c.c. to 200 c.c. : 800 c.c. have been noted in occasional instances, and in a very few still more. In other instances the fluid may escape through the Eustachian tube into the pharynx, whence it may escape by the nostrils or be swallowed. 638 SPECIAL OR REGIONAL SURGERY. . The escape of brain-substance is rarely noted, and obviously implies such serious injury as to make the prognosis of the worst. 3. Disturbance of function along particular cranial nerves, paralysis of which is often produced by fractures of the base, particularly those involving the foramen of exit of the nerve involved ; in which case the nerve may be lacerated or injured by the fragment of bone. 4. In addition to these distinctive features there will be in the majority of instances brain-symptoms, either of contusion or compression, varying in severity within all possible limits, but adding their weight to the value of the testimony. These will soon be considered by themselves. Other and unusual signs of basal fracture may occur, such as com- munication between the cavities of the petrous bone and the mastoid cells, and leading to the formation of pneumatocele, or emphysema of the overlying soft parts, observed mostly about the orbits, where the nasal cavity is as well involved. Treatment. — The treatment of basal fractures is mainly symptom- atic. The first effort should be to make antiseptic all those parts of the skull involved, which means to shave the scalp ; to thoroughly cleanse and irrigate the external ear and the auditory meatus, using a head mirror and ear speculum for this purpose, if possible ; to tampon the meatus with antiseptic cotton ; to provide a copious absorbent dress- ing for such fluid as may escape, and to change this frequently ; to cleanse the nasal cavity so far as possible, as well as the conjunctival sac when necessary, for all of which the peroxide of hydrogen is most serviceable. All of this should be done promptly, while at the same time studying the patient for evidence of brain injury or of involve- ment of special nerves. By the time these measures are thoroughly carried out a decision at least as to the necessity for immediate operation should have been reached. Evidence of brain-compression wanting, and in the absence of external or compound injury, the patient may be left at rest, with cold applications to the head and active purgation. In many of these instances benefit follows the application of a number of leeches to the mastoid region and to the occiput. Operation is called for later only when brain-symptoms supervene, these consisting for the most part of evidences of compression, either from blood or from pus, since com- pression from other causes must have been acting at the time of the first examination, and should have been recognized at that time. When direct fractures are evident the possibility of the entrance of foreign bodies must be also remembered. Thus, penetrating fractures of the base have occurred through the orbit as the result of accident or assault, and such weapons or implements as foils, ramrods, drumsticks, canes, umbrella points, etc. have been known not only to penetrate into the brain, but perhaps to leave some portion of their substance — e. g. a foil tip or an umbrella tip — within the cranium after their withdrawal. Separation of sutures, known also as diastasis of the same, is the occasional result of injury instead of, or complicated with, fissures or other fractures. It is the result of violence, and is virtually a specific form of fracture, from which it differs in no essential particular. Dias- tasis can only take place along lines of previous suture, but it is possi- ble that Wormian bones may be thus loosened. Sutures thus separated ordinarily heal by fibrous repair rather than osseous union. Diagnosis INJURIES AND SURGICAL DISEASES OF THE HEAD. 639 is ordinarily possible only as they are exposed to view, although dis- placement in the middle line or along known suture lines may be per- haps regarded as diastasis. The treatment differs in no respect from that of other fractures. Injuries to the frontal sinuses occasionally complicate fractures of the skull. These sinuses vary exceedingly in different individuals; are rarely truly symmetrical ; are not found in the very young ; they con- nect with the nose in such a way that emphysema of the frontal region is quite possible, while air may even be blown beneath the periosteum or may communicate with the interior of the cranium. In wounds of the frontal region the sinuses are occasionally opened — a fact of import- ance, since infection of the Schneiderian membrane may occur and endanger life, mainly because of the retention of infectious products within its cavities. Moreover, by such wounds the ethmoid may also be injured. Pus which escapes from these sinuses and from the ethmoidal cells is usually thin and bad-smelling. Long continuation of suppura- tion after such injuries probably means necrosis and formation of sequestra. INJURIES TO THE BRAIN AND ITS ADNEXA. With the recognition of certain portions of the brain whose function is now generally recognized and described, as well as with the more exact knowledge regarding the entire encephalon, the outcome of many recent studies, the teaching of the past with regard to the nature of various brain lesions has been essentially modified. Especially is this true with regard to the distinction formerly emphasized as between concussion and compression. In discussing brain injuries we must, first of all, distinguish between traumatic disturbances of the entire endo- cranium and localized injuries to the brain or particular vessels and nerves entering into its composition. With regard to the first, it is possible that the entire blood or lymphatic circulation within the cranium may be affected in such a way as to influence its nutrition and function, by which means activity and function are mildly or seriously perverted. The immediate effect of severe injury to any part of the body is reflex vasomotor spasm, which constitutes the essential feature of the condition known everywhere as shock. It is this condition, with its strong local expressions, which used to be known as concussion of the brain. When studied upon its merits, it is found to be indistinguishable from shock pro- duced by injuries to other parts. It will be correct, then, to make the general statement that the condition for so many years taught and recog- nized as concussion is but shock following injury to the head. This makes no further demands upon the question of pathology than those prompted by any traumatic disturbance. Through the mechanism of the cerebro-spinal fluid rapid alterations of pres- sure and of the volume of the brain are produced. There is an easy path between the inelastic cranial cavity and the exceedingly elastic and accommodating spinal canal, which latter serves as a reservoir for the fluid which may be pressed out of the cranium when brain -pressure is increased. And, while the subdural and sub- arachnoid spaces are each of them absolutely closed sacs and do not communicate one with the other, there, nevertheless, is ample accommodation within each to permit a constant equilibrium of pressure under ordinary circumstances as 640 SPECIAL OR REGIONAL SURGERY. between the spinal cord and the cranial canal. The brain expands in volume with every systole of the heart, while with every diastole it contracts. Its size is, moreover, modified by the motion of respiration. Under these extremely accom- modating conditions it is scarcely credible that external injuries which leave no internal marks of violence should do anything more than disturb the equilibrium of fluid distribution. Concussion op the Brain. We inherit the term concussion from the earlier masters of our art, by whom, however, it was used in a much broader sense than of late. Its modern significance was given to it by Boirel, who made it apply to a group of cerebral symptoms the result of injuries not accompanied by fracture or perceptible laceration of vessels — symptoms varying in inten- sity and duration. Our present position is practically this : The possibility of pure con- cussion of the brain — i. e. disturbance of brain function without gross mechanical lesions — is admitted, but its general frequency is denied. When present it must either pass away quickly, the condition being equivalent to that called " stunning " by the laity, or, if it assume dis- tinct form, its signs and symptoms are indistinguishable from those of shock, consisting essentially of rapid and feeble pulse, quick and shallow respiration, pallor of the skin, copious perspiration, complete or partial unconsciousness, muscle inco-ordination, with lack of sphincter control, occasional vomiting, the pupils usually reacting to light. The treatment for this condition is essentially that for shock, plus whatever may be called for in the way of attention to injuries about the head — e. g. sewing up a scalp wound, etc. Contusion. The condition of shock [cerebral concussion), when of pure type, passes away with reasonable promptness, especially when aided by sur- gical treatment. Anything which persists in the way of muscle-paralysis, disturbance of function of nerves of special sense, or other sign of any importance, indicates something more than mere vibratory disturbance : it implies mechanical lesion which could be perceived by the eye were the parts exposed, and constitutes the condition now generally known as contusion. This implies the existence of trifling exudates or hemor- rhages, which require not only absorption, but even cicatrization. Con- tusion pure and simple differs from ordinary laceration as a contusion else- where may differ from a wound. It cannot be separated, however, from conditions in which there are minute separations of continuity and actual lacerations. It may be divided into three post-mortem forms : general hyperemia, with or without oedema ; punctate or miliary hemorrhages ; and thrombosis of minute vessels, which may occur separately or together. Moreover, there may exist similar lesions in the meninges, constituting meningeal contusion. Ordinarily, minute vessels of the pia are ruptured and blood is effused in small and thin patches over various parts of the brain. The so-called compression apoplexies of certain authors are insep- arable from the conditions above described. Such minute blood-clots are only to be distinguished upon very careful sectioning of the brain, and INJURIES AND SURGICAL DISEASES OF THE HEAD. 641 are found most often in the region of the medulla and along the floor of the fourth ventricle. They are probably caused by the forcing into the fourth from the lateral ventricles of the fluid contained in the latter. Symptoms of Contusion. — When the ordinary symptoms of shock which follow all severe injuries to the head, especially when the deep lesions are not too severe, fail to disperse in a short time under proper treatment, and when, in particular, new and irregular symptoms are superadded to those of shock alone, we have every reason to think that the intracranial condition is one of contusion rather than of shock. "When, for instance, mental agitation changes into delirium, when the rapid, feeble pulse becomes stronger and slower, the respiration deeper, the limbs moved in inco-ordinate ways, the speech disturbed from muscle inco-ordination, the patient selects wrong words, or when the mental condition becomes more serious and stupor or coma takes the place of delirium, while external irritants have less and less effect, and when the pupils gradually enlarge while failing to respond to light, — we may say that the condition of contusion is making itself apparent. If along with muscle-uncertainty there be also muscle-spasm or rigidity, with fixation of the fingers in the athetoid position, the evidence to this effect is increasing. If with all this the thermometer fails to show that an active inflammatory condition — i. e. meningitis — is prevailing, the diagnosis may be regarded as certain. Error may possibly arise when there are evidences of alcoholism. Coma following head injury ought not to be ascribed to the alcoholic condition except by the strictest pro- cess of exclusion. Temperature alone will be of the greatest service in this direction, since in alcoholism it is usually subnormal. In apoplexy and non-traumatic hemorrhages it is also usually subnormal at the com- mencement of the attack, rising to normal, and remaining there if the patient recover, but continuing to rise in cases where the prognosis is bad. The treatment of brain contusion must be managed largely in response to special symptoms. Physiological rest, attention to scalp wounds, fractures, etc., shaving of the scalp, application of ice to the head, with such stimulation to the heart as may be necessary in extreme cases by subcutaneous administration of strychnia, atropine, etc., by local fomentations over the epigastrium, or by immersion in a hot bath when surroundings permit it, — these in a general way constitute most of the methods of treatment in contusion. When only symptoms of diffuse and minute lacerations can be recognized, the use of the trephine is impracticable, even unjustifiable, save when indicated by some exter- nal marking — /. e. compound fracture or the like. When localizing symptoms are present the trephine is, of course, called for. When the skull injury is recognized as a basal fracture, venesection or the appli- cation of leeches behind the cars will be most serviceable. In every such case there is the greatest necessity for regulating the excretions and preventing auto-intoxication. For this purpose diuretics and laxatives must be used, often in conjunction with intestinal antiseptics. The catheter should be resorted to whenever indicated by the condition of the bladder, which should be carefully watched. As the days go by and patients lie more or less helpless and inert, the greatest care should be exercised for the prevention of bed-sores. When, still later, patience is tried to the utmost because mental inertness, muscle-rigidity, etc. fail to 41 642 SPECIAL OR REGIONAL SURGERY. disappear, I would advise the use of potassium iodide internally, having seen great benefit from its use in many eases, although acknowledging that it is given on purely empirical grounds. Brain-pressure or Compression. That the cranial contents — brain, blood, lymph, and cerebro-spinal fluid — completely fill the cranial cavity has been already amply shown, as well as that there is no room for anything in the shape of a foreign body without seriously affecting the equilibrium between the brain and the contents of the spinal canal. When, however, any foreign substance exerts pressure upon the brain, the results are invariably the same, be this substance what it may, and compression signs are always the same, no matter what the compressing cause. Reduction in size of the cranial cavity — i. e. compression — may be produced — 1. By altering the circulation of its surroundings (e. g. depressed fractures or by direct pressure) ; 2. By increase in the quantity of cerebro-spinal fluid or of the vol- ume of the brain, which latter may be produced by oedema, by serous exudate, or by actual hypertrophy ; 3. By foreign bodies, which may enter the skull from without ; 4. By pathological conditions — collections of blood or pus, tumors, etc., which may be produced either from the brain-substance, its con- taining bone or membranes, or its vessels. In every one of these conditions the size and tension of the brain are affected. The cerebro-spinal fluid is mainly involved in acute, not in chronic, conditions. A very slow reduction of the diameters of the skull produces such slow alterations of pressure as to cause a minimum of disturbance. So far as compression from traumatic influences is con- cerned, we distinguish mainly between — 1 . Compression by extravasation of blood ; 2. By fractures of the skull with depression, or by foreign bodies penetrating from without ; 3. By products of acute infectious inflammation due to septic infec- tion from without. The residt common to all of these is increase of intracranial tension, and its consequence is a less rapid flow of blood and an altered blood- supply to the brain and its membranes. Experiment has completely established that in compression of the brain cere- bro-spinal fluid is forced by pressure into the spinal canal, whose membranes are more elastic, and which thus help to accommodate it; but it has been clearly established that compression of the brain by one-sixth of its volume of any mate- rial is essentially fatal, and that much less is at least serious. That fractures with depression produce sometimes serious, at other times trifling, symptoms is due largely to the varying accommodation of the spinal canal. Both experiment and observation alike seem to confirm the view that consciousness pertains to the cortex as a whole, and that unconsciousness is an inhibitory or paralytic condition which is produced in compression. Temperature is a matter of great importance in studying compression and foretelling its consequences. Elevation of temperature is an early, continuous, and constant symptom in these cases. If temperature be subnormal and subsequently rise, prognosis is bad. Variations of tern- INJURIES AND SURGICAL DISEASES OF THE HEAD. 643 s perature are more reliable guides than conditions of consciousness. A Phelps has remarked, in no condition except sunstroke is temperature so uniformly high as in cases of serious encephalic lesions. Symptoms. — As indicated above, the symptoms and signs of com- pression are practically identical, no matter what the compressing cause. When this cause acts instantly there is no time afforded for differentia- tion, but when it occurs slowly we note the following symptoms, and about in the order as here presented : Irritability or restlessness ; visceral disturbances ; pain ; intense cephalalgia ; congestion of the face ; narrow pupils ; augmented pulse, often seen in the carotids. If compression occur more rapidly, torpor quickly succeeds erethism, after which patients vomit, have convulsions or at least convulsive motions, speech is dis- turbed, and stupor comes on, from which they neither awake nor can be awakened until the compression is relieved. All of these indications refer to involvement of the cortex, which is generally regarded as the seat of consciousness as well as of projection and imagination. During the night of the senses produced by pressure upon the cortex only the automatic basal apparatus and that of the spinal cord continue in more or less disturbed operation. Of all the general functions, consciousness vanishes first and returns among the last. When intracranial pressure has reached a certain point, epileptiform convulsions result, varying in intensity, affecting all the limbs, and terminating perhaps with rigidity. These are an expression of high pressure. Similar convulsions occur in various head wounds, explanation for which is the result of pressure, which, though not extensive, may produce alteration in the circulation with its disastrous consequences. The later and constant evidences of compression, and those ivhich in aggravated cases supervene at once, are reduction of pulse-rate, due to the action of the pneumogastric, which suffers first an irritation and later a paralysis. The pulse becomes not only slackened, but full ; the respiration-rate is correspondingly reduced, so that breathing during coma is deep, slow, and often stertorous. This feature of stertor is an expression of paralysis of the palatal and pharyn- geal muscles, which flap, as it were, in the air-current. Vomiting, which may occur before brain-tension has risen high, is not met with in the most serious cases. Coma is absolute, and nothing can arouse the patient. Along with these signs, the most important other indications are the paralyses, which may consist of monoplegia, hemiplegia, or paralysis of individual muscle-groups according as pressure is made upon a limited area or upon an entire hemisphere. By the division of the cranial cav- ity by the falx and the tentorium it is divided into three chambers, in any one of which pressure may be more manifest than in the others. Nevertheless, a serious compressing cause will affect the tension of the cerebro-spinal fluid and produce general expression of pressure. The pupils often vary, and responsiveness to light is occasionally noted. Nystagmus and ocular rotation may be occasionally seen. Choking of the optic disk is also a frequent phenomenon, to be recognized only upon ophthalmoscopic examination. This is due to pressure in the subdural and subarachnoid prolongations along the optic nerve. In milder cases of chronic compression disturbances of vision are of very great clinical importance. These pertain especially to diagnosis of hydrocephalus and 644 SPECIAL OR REGIONAL SURGERY. of brain tumors. When they occur immediately after injury, and re- main, they depend upon laceration or other severe injury of the optic nerve. Those which quickly disappear depend mainly upon pressure of blood, which is reabsorbed, while those which are later in their appear- ance depend upon later intracranial complications. A unilateral lesion of the optic nerve depends most often upon injuries to it within the optic canal. When the lesion is bilateral the cause lies deep. General paral- ysis may be of the type of hemiplegia, single or double ; /. e. by " double " I mean paralysis of the entire voluntary musculature of the body, which necessarily implies serious, too often fatal, hemorrhage. Prognosis. — This depends in large degree upon the nature of the compressing cause and of the possibility of its removal. While the nature of the same may ordinarily be determined, how much can be accomplished by way of removal may often not be foretold before the operation at which this should be attempted. In every acute case it is desirable to make this attempt early, since high pressure, which may be borne for a few moments, is fatal if continued. Compression to any serious degree, left unattended to, is usually fatal. So soon as paralysis in circulatory and respiratory centres is apparent the beginning of the end is at hand. Another reason for hastening operation, when indicated, is that acute softening of brain-tissue comes on promptly, as well as general cerebral cedema, which has destroyed many a patient from the second to the fourth day after injury. (Plate XXIII.) Treatment. — The treatment of compression is summed up in one phrase — i. e. to remove the cause when possible. The only cases in which this rule may be safely disregarded are those where the attempt to remove the cause means more danger than to leave it unremoved. This is not true, however, in the ordinary cases of bone depression, men- ingeal hemorrhage, etc. Before operation, however, or as a substitute for it in cases of minor severity, it may be well to assist venous outflow by venesection, by which blood-pressure is reduced. In these cases this may well be done from the temporal veins or external jugulars, with the patient in the semi-upright position. Drastic purgatives may also be employed in order to utilize intestinal outpour as a stimulation to resorp- tion of cerebro-spinal fluid. The physiological action of cold (ice-bags) may also be secured for the purpose of contracting the cerebral arteries. But all these measures are only to be resorted to when there is uncer- tainty as to the wisdom of operating, since when operation is clearly indicated it should be done at once, and should take precedence of every- thing else. This operation means ordinarily the procedure to which the now general term trephining- has been applied by common consent, and comprises any measure by which the skull is opened at a suitable place and the dura or the underlying cortex exposed to such extent as to permit removal of the compressing cause. Whether the opening be made with trephine (annular saw) or with the straight or revolving saw, with bone-chisel, with bone-forceps, or with anything else is a matter of choice on the part of the operator. So, too, removal of the compress- ing cause should include the elevation of depressed bone, the removal of dislodged particles as well as of all foreign bodies, the cleaning out of blood- clot, the checking of hemorrhage, and the closure of the wound, with or without drainage or counter-opening at some other part of the skull, as PLATE XXIII. Fig. t. Compound Fracture of Cranium, with Depression ; Fracture of Bones of Face ; Extradural Clot from Rupture of Middle Meningeal Artery. Fig. 2. Horizontal Section of same, showing Depressed Fracture of Bone; C, Extradural Clot; D, Laceration of Brain-substance, with extensive Intracerebral Clot; F, Same condition produced by ConLrecoup. Punctate Hem- orrhages and Mi nute Lacerations at Numerous Points, characteristic of Contusion of the Brain. (Anger.) INJURIES AND SURGICAL DISEASES OF THE HEAD. 645 may seem wise in special cases. This entire procedure comes now under the name of trephining, and must be painstakingly followed in most instances. The operative manoeuvres will be discussed by themselves in another portion of this chapter. Injuries of Intracranial Vessels and Sinuses. Intracranial hemorrhages may occur — a. From external sources through the broken bone or between it and the dura (extradural) ; b. Beneath the dura, between or into the membranes (subdural) ; c. Into the brain-substance proper or the ventricles (subcortical or intraventricular). The vessels whose injuries are most often under consideration are the meningeal arteries, the sinuses, the small vessels of the membranes, and, in very rare cases, the internal carotid. The arteries, like the sinus- walls, may be ruptured either by substances forced in from without or by sheer laceration. The longitudinal sinus is most liable to injury from without. When this sinus is exposed it may be dealt with either by suture if the wound be small, or by ligation, or by tamponing with iodoform gauze. Fig. '259. Compression following hemorrhage from the middle meningeal artery (Helferieh). Hemorrhage from this source is ordinarily not difficult to check. Fatal air-embolism has resulted through an opened sinus not properly plugged. The other sinuses are very rarely injured, as by gunshot wound, fracture of the base, etc. The sinuses have also been injured by compression of 646 SPECIAL OR REGIONAL SVROERY. the skull during parturition. Bleeding from the sinus is usually indis- tinguishable from that from a meningeal artery, save that the former occurs more slowly. Injuries to the middle meningeal artery naturally occur in the immediate neighborhood of this vessel, which is not infrequently rup- tured by contre-coup. The artery runs sometimes in a groove of the bone, sometimes in the dura, and sometimes entirely in the bone. The more it lies within the bone, the more likely it is to be ruptured when this part of the skull is fissured. Basal fractures often follow the groove for this artery. The anterior branch is more often injured than the pos- terior. Extravasations from this source are more common than from all others combined, the amount of blood varying within wide limits. Two hundred and forty grammes of blood-clot have been known to collect, and the dura to be separated down to the very base of the skull. I have repeatedly taken away at least a small teacupful of blood-clot in such cases. The symptoms of this hemorrhage are, of course, those of com- pression, while extravasation may be rapid and quickly fatal, delayed for some time, or may take place in two stages, the first but slight and producing no coma. New clots are always dark and disk-shaped, thick in the middle, with a definite margin. As the clots become older they become more adherent and difficult to remove. The symptoms of meningeal hemorrhage consist of an interval of consciousness or lucidity after injury, followed by epileptic or spastic symptoms, alterations in the pupils and pulse, unconsciousness passing into coma, and stertorous respi- ration. There may or may not be external evidence of head injury. The character of the paralysis (hemiplegia) may indicate that the clot is really upon the side opposite to that of the skull which shows evi- dence of injury. In this case arterial laceration is the result of contre- coup. According to the rapidity of the symptoms is the extent of the primary lesion. Meningeal hemorrhages involve immediately the motor area, which makes diagnosis all the easier. Injuries to the carotid within the cranium are exceedingly rare. Still, it has been injured in basal fractures and penetrating wounds. Development of arterio-venous aneurisms after basal injuries is occasionally noted. They will give rise occasionally to pulsating exoph- thalmos. Pulsating tumors within the orbit which push the eye for- ward not infrequently occur after serious head injury. Of 77 cases col- lected by Bivington, 41 had a traumatic origin. Subdural hemorrhages are not infrequent in the skulls of the new- born, and constitute the so-called apople.ria neonatorum. They may occasion convulsions and paralyses of irregular type, while if the extrav- asations become infected multiple abscess may result. In adults subdural hemorrhages are, for the most part, connected with those brain lesions which have been already spoken of as contusions. They may be the starting-points for pachymeningitis. Their most common results are disturbances of consciousness and mentality. Paralytic dementia follows in some of these cases. Extensive subdural hemorrhage may give a clinical picture corresponding to extra- dural. Disseminated minute ecchymoses constitute minute focal lesions, which are, however, usually so distributed as to confuse and prevent accurate diagnosis. Apoplexy or intraventricular hemorrhages, especially from the lenticulo-striate artery (Charcot's "artery of hemorrhage"), have until very recently never been INJURIES AND SURGICAL DISEASES OF THE HEAD. 647 regarded as warranting surgical interference. Of late, however, especially in the ingravescent or progressive forms, ligature of the common carotid has been of some service, though in order to render this effective ligature must be made very early in the course of the case. Traumatic intraventricular hemorrhage occurs in much the same way as meningeal, by contre-coup. Individuality of symptoms is lost in the general comatose condition of the patient, but when operation is performed, as it is usually best to perform it, if no extradural clot be found and if brain-tension be evidently increased, the dura should be opened ; after which, if no subdural clot be seen, the ventricles should always be tapped with the exploring needle. In this case, if blood be removed by aspiration, a knife should be passed directly into the ven- tricle, after which blood will promptly escape, if present. Dennis was the first to diagnose the presence of intraventricular clot and to deliber- ately incise into it, and I have myself repeatedly imitated this procedure, both with and without success. Lacerations and Injuries to the Brain-substance. These have been already nearly sufficiently alluded to under the term contusion of the brain. They may be divided into those which occur with or without fracture of the cranial bones. The term contusion was first suggested by Dupuytren. The condition comprises all degrees of injury, from the most minute local disturbances to lesions involving the entire hemisphere. The milder forms show a sprinkling of punctate hemorrhages, numerous in the centre of the injured area, the surround- ing tissue taking on a more or less diffused tint, which fades out toward the periphery, discoloration being due to the imbibition of the coloring matter of the blood. In more extensive injuries clots as large as peas or larger are imbedded at various points, each surrounded by its area of discoloration. When foreign bodies have been driven into the brain, the tissue is also discolored, while various foreign materials may be met with. In an instance of great violence there may occur absolute rup- ture of brain-tissue extending from cortex to ventricle. Prognosis. — Prognosis depends in large degree upon escape from or occurrence of infection. In infective cases the principal dangers are from blood-pressure and from later oedema or acute softening. Brain lacerations may heal by cicatricial repair, but usually with some perver- sion, at least trifling, of function. The possibility of cystic degeneration of large or small clots is one of very great importance. (See Cystic Softening, p. 392, Volume I.) A blood-clot now within the cranium which fails to resorb is essentially a hematoma, in whose interior soft- ening and conversion into a cyst may easily occur. These cysts make room for themselves at the expense of surrounding brain-tissue, and when located in the motor area give rise to localizing symptoms as well as to epileptic convulsions. They may be often diagnosed with certainty after an accurate history of the case and the study of the phenomena which it presents. As they grow older their walls become firmer, and it is often possible to dissect them out as one removes any other cyst from its surroundings. That foreign bodies may be encapsulated and remain without producing disturb- ance is now well known. As a rule, however, though encapsulated, they produce symptoms like headache, vertigo, etc. Symptoms. — The general features of brain lacerations are ihose of 648 SPECIAL OR REGIONAL SURGERY. contusion already alluded to, somewhat exaggerated in many cases. So long as the disturbances are minute, even if multiple, or the foreign body small, compression symptoms are not produced, or at least in very incomplete degree. Minute diagnosis is, of course, impossible. The most essential thing is to decide upon the question of operative inter- ference. In the absence of distinctly localizing symptoms or other external markings, which of themselves would indicate operation, it is usually abstained from. Upon the other hand, a lesion which can be distinctly localized is probably due to extravasation large enough to be quite probably reached by opening the skull ; and, unless there be other and sufficient reason to the contrary, this should be done. Fig. 260. Bullet imbedded in anterior fossa (U. S. Army Med. Museum). In many instances, however, contractures or paralyses of muscle- groups occur later, and are followed by spastic conditions which may be permanent. More can be done in these cases by massage, by internal medication, perhaps with external counter-irritation, than by distinctly surgical procedures. Both albuminuria and glycosuria are known to be the result of injuries herein referred to, as well as bulbar paralysis and disturbances of special senses. - More immediate dangers after these head injuries are those of broncho-pneumonia or hemorrhagic or oedem- atous infiltration of the lower lobes of the lungs — conditions often spoken of as hypostatic pneumonia, much resembling those produced experimentally in bilateral division of the pneumogastrics. Some of them are produced by paralysis of the glottis, the result of which is incomplete closure, with aspiration of fluids and solids from the mouth whose decomposition sets up an infection within the lungs which is often spoken of as aspiration pneumonia. Some form of pulmonary disturb- ance follows in perhaps one-third of the cases of the injuries above alluded to, and should be guarded against in every possible way. Prolapsus and Hernia Cerebri. Escape of brain-matter beyond its normal level is not uncommon in connection with compound fractures or their sequelse. It may be pri- mary, escaping with the blood at the time of the accident, or secondary, occurring during the ensuing days. Any lesion of this kind in which INJURIES AND SURGICAL DISEASES OF THE HEAD. 649 the brain appears or can be handled is entitled to the term prolapsus, in contradistinction to hernia, which implies that, though escaping from the proper cavity, it is nevertheless covered by other textures — e. g. dura or scalp. The protrusion may vary in size from a very small tumor to one the size of a fist. It is always the result of increased intracranial tension, and may be produced by hemorrhage, by serous imbibition, or as the result of brain-abscess. When immediate, it is of the first variety ; when later, of the second or third. When abscess is present it usually delays a protrusion, which is produced by degrees. Prolapse occurs for the most part through large openings, such as those made by gunshot wounds, the trephine, etc. Prolapse proper implies laceration of the dura. It pertains obviously to the convexity of the skull, occurring, however, in exceedingly rare cases into the orbit, etc. The prognosis is generally unfavorable. There is always risk of oedema or infection, either of which may prove fatal. Infiltration, gangrene, suppuration, or repair by granulation may so disfigure and disguise the real brain-substance as to lead to error of diagnosis. It by no means follows that every tumor presenting through an opening in the skull is of this character. When gangrene and spontaneous separation occur, spontaneous recovery may follow, the stump being covered by granulations and finally roofed over by connec- tive tissue. Treatment. — Treatment in the primary cases should include the most rigid asepsis with removal of all foreign particles. Localized pressure does some good, especially in those cases where it can be tole- rated. Signs of abscess should always be watched for, and deep explor- ation is often justified or indicated. While excision, cauterization, etc. are often heralded as successful, they are by no means without their dangers. Cases that admit of it should wear a protective shield properly moulded to the part. Skin-transplantation, or even osteoplastic repair of the defect, may give good results in favorable cases. Septic Infections within the Cranium. Under the general term septic infection I mean to include — A. Abscess ; B. Thrombosis; C. Sinus phlebitis ; D. Meningitis ; E. Encephalitis ; these being in effect different manifestations of infection, the clinical picture differing according to the tissues and localities involved. For the production of these infectious conditions no special bacteria other than those already alluded to in Chapter III. are comprehended. Their method of activity is there discussed at sufficient length, and we need here only consider the various paths of infection. These may lie along the blood-vessels, the lymph-vessels, nerve-sheaths, and prolongations of the membranous sacs which extend from the cranial cavity proper. The most common of all the paths of infection is afforded by the middle ear, especially when involved in a chronic suppurative lesion 650 SPECIAL OR REGIONAL SURGERY. which is by no means necessarily connected with the patulous tympanic membrane, and which may consequently be undiscovered, though in more or less constant activity. A. Abscess of the Brain. — This may be traumatic or non-traumatic. The former variety is for the most part due to the direct result of injury, infection displaying its consequences promptly or sometimes not until long periods of time have elapsed. The ordinary form occurs within the first two weeks, usually as an acute cortical abscess beneath a more or less compromised membrane, surrounded by a zone of red softening, and this by another of brain oedema. The chronic traumatic abscesses are less often cortical, but usually are deeper. They are usually marked by prolonged suppuration of the external wound, but sometimes occur through some mechanism not yet well understood. Only the chronic abscesses show encapsulation, the capsule partaking of the character of the pyophy lactic membrane (see Chapter IX.) elsewhere described. It may cover a long period of time — to my personal knowledge at least nine years, while others have mentioned twenty and more. The non-traumatic abscesses are for the most part due to middle-ear dis- ease. When the roof of the tympanum breaks down, it is the middle fossa of the skull which is infected ; when the posterior wall, naturally the posterior fossa. The most common results of perforation of the tympanic roof is involvement of the mastoid antrum or the sigmoid groove and sinus. In the former case we get temporo-sphenoidal abscess ; in the latter, cerebellar, if any. Previous to actual perforation there is thinning of bone with thrombosis along the minute veins con- nected with the sinuses. When the dura is exposed by the carious process, granulation-tissue often protects it against further inroads, while masses of the same projecting into the tympanum have been mistaken for prolapse. If the sigmoid groove be the site of the first disturbance, extradural abscess may form between the sinus and the remaining bone, the granulating process then involving the whole bony groove. Its later consequence is sinus phlebitis, sinus thrombosis, or intradural infection. If there be adhesion between the dura and the cortex, we get actual brain ulceration without formation of a true abscess ; but if once the perivascular sheaths have carried infection to the substance of the brain, there is a rapid purulent disintegration of the same, and formation of a true subpial or deep abscess, which latter is in effect a purulent en- cephalitis. Macewen has shown how important it is not merely to evacuate such abscesses, but to eradicate the path of infection from the point of origin, which is rarely easy. Extradural pus may escape into the mastoid cells by erosion of their inner walls. Such pus may escape suddenly, and serious symptoms thus be mitigated. Even abscess of the bone may thus empty itself by the process of adhesion and pointing toward the surface, but such a thing is most rare. Pus from the mastoid cells may perforate the temporo- maxillary joint or escape along the digastric groove and form deep cer- vical abscesses. Once the arachnoidal tissue be involved, both subdural and sub- arachnoidal spaces participate in the infection, and the brain floats upon a pus-bed rather than a water-bed. Leptomeningitis under these circum- stances becomes quickly diffused and fatal. Serous fluid may accumulate INJURIES AND SURGICAL DISEASES OF THE HEAD. 651 so quickly as to produce death by mere obstruction to the cerebral blood-vessels, while distention of the ventricles and an acute infectious internal hydrocephalus is possible. Leptomeningitis may be propagated wherever anatomical paths may carry it, even to the cauda equina and along the spinal nerve-sheaths. The pus within cerebral abscesses is often discolored, sometimes offensive. A greenish color is usually imparted by the bacillus pyocy- aneus, while the offensive odor comes mostly from the bacillus coli. Around every such abscess is a zone of actively inflamed cerebral tissue. If within this zone a pyophylactic membrane may be produced by con- densation, the abscess may become encapsulated and life be prolonged. When a capsule fails to form, the process being too acute or rapid, death is the speedy termination of such a case. These abscesses are for the most part single, but may be multiple. There is also a metastatic expression of abscess-formation, seen in typical cases of pyaemia where numerous miliary abscesses are found within the brain. Pressure- symptoms are less likely from abscess than from a tumor of the same bulk, while there is much greater liability to oedema and sudden infec- tion. Gradually extending paralysis implies pathological activity around the abscess. Large collections of pus are often met with in the least vital parts of the brain, as in the frontal or temporo-sphenoidal lobes. Symptoms of Brain-abscess. — Aside from causal indications (• ■>> : ' '-A *W S 3 Crushing fracture of vertebral body (Park). ■■Jjft~»- ■■&,**' '- Fracture of spine with displacement: section of vertebrce (Warren Museum). transverse lesions of the cord are partial, the muscular paralysis and anesthesia will be incomplete. The visceral reflexes, especially those of the bladder and rectum, are affected in the same way. Differential Diagnosis of Diseases and Injuries of the Spine and Spinal Cord. (is of hemiplegic type when com- pression is unilat- eral, paraplegic when bilateral, and local when n e r v e-roots are involved). Deformity. Temperature. Dislocation. Hasmalomyelia. Hsematorrhachis. poUmmeUMs Fracture. Immediate. Immediate. Immediate Hemi- or paraple- gia. Hemiplegia. In partial disloca- tion may be absent. Present. Usually present. Rises after Same, second or third day. Paraplegia. Absent. Same. Bowels and bladder. Paralyzed. Paralysis Same. usual. Progressive. Incomplete. Hemi- or para- plegia. Absent. Same. Slow. Absent. Paraplegia. Absent. Precedes the paralysis of degenera- tion. Affected late No paralysis, if at all. INJURIES AND SURGICAL DISEASES OF THE SPINE. 679 Hemorrhage- In the diagnosis of injuries to the spine and its contents it should be remembered that sudden paralysis may be caused by — / hsematomyelia, \ hsematorrhachis. 2. Embolism. 3. Fracture. 4. Dislocation. Rapid paralysis may be caused by — 1. Hypercemic exudate in process of repair. 2. Inflammatory exudate. 3. Pus. 4. Hemorrhage. 5. Acute poliomyelitis. The subjoined table, inserted by the kindness of Dr. Dennis, will assist in locating the lesion : Paralyses and Reflexes due to Spinal Injury. Spinal Nerve. 1. 2-3. 4. 1. 2-12. Motor Paralysis. Death from pressure of odontoid. Death from paralysis of diaphragm. Deltoid muscles of up- per arm. Supinators of hand. Biceps, triceps, exten- sors of wrist. Pronators of wrist, la- tissimus dorsi. Flexors of wrist, hand, muscles. Thumb. Muscles to back and abdomen. ATUzsthesia. Upper shoulder, outer arm. Outside of arm and forearm. Outer half of hand. Inner side of arm and forearm. Inner side of hand. Ulnar supply to hand. Skin over back and abdomen in areas corresponding to distribution of spi- nal nerves. Reflexes. Pupil. Pupil, scapular, supina- tor, triceps. Pupil, scapular, triceps, post, wrist. Pupil, scapular, post, wrist, ant. wrist, pal- mar. Scapular, post, wrist, ant. wrist, palmar. Scapular, palmar. Epigastric, 4-7 ; abdom- inal, 7-11. £ hi 3 1 3- l 2. 3-5. Psoas and sartorius. Quadriceps ext. femo- ris. Abductors and inner rotators of thigh. Adductors of thigh, tibialis anticus. Outward rotators of thigh, flexors of knee and ankle. Muscles of foot, pero- nei. Perineal muscles. Groin. Outside of thigh. Outside of leg. Perineum, anus, sac- rum, genitals. Cremasteric. Cremasteric, patellar. Front and inside of Cremasteric. thigh. Inside of leg, ankle, Gluteal. and foot. Back of thigh and leg ; Gluteal. outside of foot. Plantar. Ankle-clonus. The bladder and rectal centres are in the lower lumbar segments and traumatism in this region causes incontinence of urine and feces! Injuries higher up cause retention. 680 SPECIAL OR REGIONAL SURGERY. Fig. 275. Reflexes are elicited as follows : Pupillary : Dilatation produced by pinching side of neck. Scapular : Scratching skin over scapula causes muscles to contract. Supinator : Tapping tendon at wrist causes flexion of arm. Triceps : Tapping tendon at elbow causes extension of arm. Posterior wrist : Tapping tendons causes extension of hand. Anterior wrist : Tapping tendons causes flexion of wrist. Palmar : Scratching palm causes flexion of fingers. Epigastric : Stroking mammae causes retraction of epigastrium. Abdominal : Stroking abdomen causes retraction. Cremasteric : Stroking inner thigh causes retraction of scrotum. Patellar : Striking patellar tendon causes extension of leg. Gluteal : Stroking buttock causes dimpling in gluteal fold. Plantar : Stroking sole of foot causes flexion and retraction of leg. Ankle-clonus : Forcible extension causes rhythmical flexion. 1 The prognosis of fracture of the spine is very grave. Gurlt reports 217 deaths in 270 fractures, but statistics are not of absolute value unless they are still further classified according to the nature of the accident and site of the fracture. Treatment. — The treatment is either non-operative or operative. Operative treatment consists of laminectomy for the purpose of re- moving from the cord the pressure of extravasated blood or loose spic- ulse of bone. Chipault advocates early interference if an operation is to be done, owing to the fact that degenerative alterations of the cord take place within twenty-four hours, as has been shown by experiments on ani- mals and autopsies. Lauenstein believes that even if there is incontinence of urine and faeces, with cystitis and bed-sores, an operation is justifiable, as recovery cannot be expected without operation. Horsley is definitely in favor of an operation in all cases where there are symptoms which would show pressure upon the cord. Bur- rell analyzed 168 cases, and advocates ope- ration in the first twenty-four hours in all cases of fracture, even including those in the cervical region. Thorburn has reported 61 cases of operation, with 35 deaths; Chipault has collected 95 cases, with 38 deaths ; Lloyd has found mortality of 57 per cent, after operation. The danger from an operation in- creases with the height of the lesion. Where the fracture is limited to the arches, with displacement, an operation is manifestly indicated. Chipault concluded that in cases of lumbar or sacral fractures surgical interference 1 From Dennis, by permission. k Specimen of consolidated fracture of the spine (Warren Museum). INJURIES AND SURGICAL DISEASES OF THE SPINE. 681 should be undertaken at once if there be prominence — I e. de- formity. An operation is not indicated if it be certain that the cord is de- stroyed. Where it is uncertain, as is usually the case, and where there are symptoms of constant pressure upon the cord from hemorrhage, laminectomy is to be advocated. The procedure, however, is one which in itself involves considerable danger, and should not be undertaken if it be clear that the patient is unable to endure the shock of the operation : this, however, is a question which can only be determined on examina- tion of each case. A description of the operation of laminectomy is given later. Non-operative treatment of fracture of the spine consists in placing the trunk and spinal column in such a position as will promote healing. This can be done in an ordinary fracture bed, steadying the patient by sand-bags if necessary. The fixation of the patient's trunk in plaster- of-Paris bandage .is of assistance where it is possible. Some surgeons have recommended the suspension of the patient, with or without an anaesthetic ; the procedure is, however, not without danger. The method of application of the plaster corset upon the patient lying in a sheeting hammock, such as is used in caries of the spine, as described elsewhere, has much to recommend it. No anaesthetic is required, and a convenient method for an attempt at rectification of the malposition following injury is afforded. Dislocation op the Spine. Ashhurst has collected 394 cases of severe injuries to the spine, of which 124 were pure dislocations, the remainder being dislocations with fractures. It is difficult, however, if not impossible in many instances, to make a certain diagnosis between the two injuries. As a rule, the dislocation is bilateral ; in some instances it is unilateral. Unilateral dislocation of the spine in the cervical region produces a twist of the neck resembling torticollis. The face is turned to the opposite side, and abnormality in the line and position of the spinous and transverse pro- cesses with muscular rigidity is present. If the dislocation be higher, there will be dyspnoea. In some of these instances the torticollis from high cervical caries following an injury is regarded as an old dislocation. The appearance and symptoms are somewhat the same, and there is a noticeable twist, with an alteration in the position of the transverse and spinous processes. A diagnosis can, however, be made by a careful investigation of the history of the case, as the torticollis from disloca- tion appears immediately after the injury, while that from caries is developed more gradually. In bilateral dislocation the head is thrown back, the chin raised. In dislocation of the lower five cervical vertebrae the patient's face is usually drawn away from the side of dislocation. There is a prominence on the dislocated side, the muscles being put upon the stretch upon that side ; those upon the opposite side are relaxed. There is deviation of the spinous processes. There is frequently deformity inside the pharynx. Dislocation without fracture in the dorsal and lumbar region is extremely rare. 682 SPECIAL OR REGIONAL SURGERY. Forcible reduction of dislocation of the spine is necessarily a pro- cedure of gravity. In the cervical region it has been done with success. Fig. 276. '?"&' i Fracture dislocation with great displacement— patient almost completely recovered (Park). Great care is needed in the administration of the anaesthetic. An assist- ant steadies the trunk, while the surgeon, standing at the head of the operating table, holds the patient's head (in cervical dislocation) firmly between his hands, the fingers grasping the back of the neck, the palm pressing upon the lower jaw, and with the thumb reaching under the chin : the necessary amount of traction and manipulation is thus possible. After the correction of the deformity the patient should be placed upon a bed-frame and the head steadied by means of sand- bags. Wounds of the Spine. The penetrating wounds of the spine result either from violence, the use of knives or missiles in war, or from accidents, splinters with penetration of wood, cutting instruments, or falling. They either injure the bone alone or, entering the canal, divide the cord partially or com- pletely. The larger vessels near the column may be injured, causing death by hemorrhage. If the bone alone be injured, the case involves no great danger. The wound should be thoroughly cleansed and recover}' can be expected. AVhere a large artery is divided an exploratory incis- ion is necessary, with control of the hemorrhage by haemostatic forceps. Gunshot "Wounds of the Spine. — These injuries may vary from the perforation of small portions of the spinal column to the most extensive destruction. The nature of the wound depends somewhat upon the size and range of the missile. There is always considerable shock following the injury, and the lesion is necessarily grave. The lower in the column the wound, the less the mortality ; in the cervical region the mortality, according to the Medical and Surgical History of the Civil War, is 70 INJURIES AND SURGICAL DISEASES OF THE SriNE. 683 per cent. — 63 per cent, in the dorsal and 45 per cent, in the lumbar region. The symptoms vary with the extent of the injury and the part injured. A\ r here the missile gives rise to contusion of the spine, there is a temporary disturbance of the function of the cord. Wounds of the muscles or injuries to the ligaments give rise to stiffness of the back. In some instances suppuration and necrosis follow. Where the spinal canal is opened there may be escape of cerebro-spinal fluid, though this symp- tom is not constant. Where the cord is injured there is partial or complete paralysis, with resulting anaesthesia and hyperesthesia. The transverse and spinous processes are more frequently injured than the bodies, but when the latter are wounded the lesion is necessarily more grave. Park has operated on one case of gunshot wound of the spine and cord, the ball entering the chest, passing through the lung, and lodging in the vertebral column, where, after opening the spinal canal, air jntered the chest through the bullet-track, the patient thus breathing partially through his back. Sprain op the Spinal Column. The spinal column is firmly held by strong ligaments and protected by muscles : it is not, therefore, as liable to receive the slighter injuries as the less protected articulations. In severer injuries, however, it may sustain the same lesions as other articulations, and a sprain of the spine will give rise to distressing symptoms analogous to the sprain of the large joints. Even when there is no injury to the bony structure or to the cord patients will suffer pain, distress on motion, and disability from the rupture of the ligamentous fibres connected with the spinal support. Many of these cases, combined with the nervous disorganization accom- panying invalidism and following an injury, present functional symp- toms not dissimilar to those seen in the traumatic neuroses. Patients of this class need careful treatment. Sufficient amount of rest should be enforced to permit healing of torn ligamentous fibres, followed by such measures as will improve the circu- lation and diminish the congestion and local swelling following sprains. Massage, electricity, and gymnastic exercises (carefully graded) will gradually effect a cure. Contusions and sprains of the trunk following raihvay accidents pre- sent certain features. From the medico-legal complications to which railroad injuries often give rise, the symptoms vary greatly according to the condition of the patient, and are often complicated with studied exaggeration and malingering. The symptoms are at first those of a contusion or sprain, followed by those which result from the confinement after an injury, and resembling those seen in neurasthenia and general invalidism. These are recognized by their varied and ill-defined character, unlike those of a true organic lesion. It is often necessary that the injury should be treated at first as if a severe contusion were present : after the lapse of sufficient time for recovery from any traumatism, if symptoms still are present, they should be treated as neurasthenic cases are treated, by muscular development and stimulants to the circulation, muscle-building, and nerve-training. 684 SPECIAL OR REGIONAL SURGERY. These cases are not to be confounded with those of true malingerers, where recovery takes place immediately after the verdict. Concussion and Contusion of the Spinal Cord. The existence of contusion of the spinal cord has been questioned, but there is apparently no doubt that a severe lesion may take place in the cord without any external evidence of injury. The importance of these few cases lies in the fact that they appear to support the theory that although the spinal cord is carefully protected in the canal, both by the solidity of the structures which surround it and by the strength of the attach- ments which support it, yet in some instances of comparatively slight violence without external injury lesions in its structure may take place. It is difficult to explain the physical law by which such injuries are inflicted, but the facts cited seem beyond question. Spinal Hemorrhage. Hemorrhage may take place in the cord or within its membranes — i. e. they may be extradural or subdural. It may also occur in the structure of the cord itself, a lesion termed hcematomyelia. Gowers claims that this is a rare lesion, whereas Thorburn considers it not infre- quent, and in examining 21 cases of injury to the spine found it in 6. It is more common in the cervical region. Where the hemorrhage is sufficient in extent to destroy the tissues paralysis and atrophic changes result. If, however, the lesion simply give rise to compression, the symptoms subside as the blood absorbs, leaving spastic symptoms in the lower limbs if degenerative changes have taken place. The attack is sudden, a distinct interval of time usually elapsing after injury, with paralysis and anaesthesia below the point of lesion and retention of urine and faeces. Where the hemorrhage is in connection with the membranes the lesions is termed hcematorrhaehix. It may be under the arachnoid, within the dura, or outside of the dura. (Vide Plate XXV.) Laminectomy has been performed for spinal hemorrhage, and, although the results up to the present time are not encouraging, yet the procedure is indicated in every instance where the patient's condition warrants any surgical intervention. Pott's Disease ; Spondylitis ; Vertebral Caries. Pott's disease, or caries of vertebral bodies, was first described by Percival Pott in 1779. It consists of a destructive ostitis affecting the spongy tissue of one or more of the bodies of the vertebrae. The ostitis is tuberculous, and is similar in character to tubercular ostitis seen in the epiphyses of the long bones. The changes in tubercular ostitis are described elsewhere in this work (Chapter XXXIV.). Owing to the superincumbent weight of the head and shoulders pressing upon the carious vertebral bodies, the spine and trunk become peculiarly and characteristically distorted. The morbid process is lim- ited, as a rule, to the bodies ; the transverse, articular, and spinous processes are rarely primarily affected. The caries is aggravated by the pressure thrown upon the affected PLATE XXV. 4th C Ji rf/S c 6th C 7th C 8th C nt D <■ sd D intraspinal Hemorrhage, mostly Subdural, with Minute Subpial Ecehymoses. (Park.) INJURIES AND SURGICAL DISEASES OF THE SPINE. 685 vertebral body ; portions of the diseased bone become absorbed ; the vertebral body becomes excavated or yields ; the spine bends forward above the seat of the disease, and backward angular deformity at the point of disease results. This extends as more vertebra are involved : the knuckle or projection is seen in the back ; this enlarges and the so- called "humpback" results. This projection is to a certain extent modified by compensating curves in the healthy portions of the spine and alteration in growth in the shapes of the healthy bodies, and peculiar characteristic distortions result. The process may be arrested, the development of healthy bone take place, and a natural cure with deformity results ; or the process may extend beyond the curative efforts of the cicatrizing ostitis, and necrosis with caseous foci and abscesses may result; which latter, extending to the adjacent tissues, discharge, forming sinuses, followed by prolonged suppuration with accompanying sepsis. Deformity inevitably results, with death in the severest cases, though ultimate recovery may take place even in cases regarded as hopeless. The ostitis extends to the adjacent tissue, involving the spinal canal and attacking the spinal cord and its membranes, giving rise to a pressure paralysis. This is not due to the narrowing or dis- torted shape of the spinal canal, except in rare instances, but comes as the result of an external pachymeningitis. Inflammatory thickening of the dura results ; myelitis follows in certain instances, with ascending and descending secondary degeneration. The process may arrest itself, leaving no permanent change or a slight sclerosis, or the whole cord may be reduced to a fraction of its normal size. Paralysis may also be caused by the pressure of an abscess, and in rare instances by loose frag- ments of bone. In severe cases of angular deformity the chest becomes disturbed, with secondary pathological changes in the shape of various viscera. The shape and capacity of the chest are very much altered, and the ribs sometimes sink into the pelvis or rest upon the crests of the ilium. Hypertrophy of the heart may follow. Narrowing of the cavity of the aorta has also been noticed by Lannelongue. A cure, however, is possible even if the deformity be very pronounced, but the correction of a pronounced deformity cannot be effected. Symptoms. — The symptoms of caries of the spine vary to a certain extent according to the portion of the spine affected. They may be classified as follows : First, those symptoms which are due to irritation of the nerves proceeding from the spine ; second, those due to a stiffness of the muscles of the back and of the spinal column ; third, to peculiar- ity in attitudes from the inability of the spine to bear superimposed weight. Typical cases of Pott's disease are so characteristic that the diag- nosis is evident at a glance from the singular deformity of the back ; but in the early stages some experience is necessary in recognizing the affection. Peculiarity of attitude due to muscular stiffness, referred pain, or nervous disturbances are then prominent early symptoms, and may be present before a projection has been noticed. The peculiarity of attitude is due either to reflex muscular spasm similar to that seen in joint dis- ease, or to an unconscious effort on the part of the patient to prevent jar or any increased pressure upon the affected vertebral bodies. This attitude necessarily varies according to the point of the spine attacked. 686 SPECIAL OR REGIONAL SURGERY. In the upper cervical region it resembles that of wry neck ; in the lower cervical or upper dorsal region the chin is held somewhat raised and the spinal column below the point of disease is straighter than normal ; in the middle dorsal region the attitude noticed most frequently is an ele- vation of the shoulders, sometimes with one held higher than the other, and some lateral deviation of the spine ; in the lower dorsal or lumbar region the patient, in the early stage, will be frequently noticed to lean backward. The patient walks upon the toes, with the knees bent so as diminish the jar of the spine. These peculiarities of attitude vary according to the severity of the disease. They may be at one time more noticeable than at another. A certain amount of muscular rigidity of the muscles of the back will be found on palpation, and it will be noticed that children become more easily tired, and after playing for a while will desire to lie down, rest their arms upon a chair, or support the head with their hands. The amount of muscular stiffness and rigidity is, in a measure, an index of the degree of activity of the dis- ease. In addition to the spasm of the muscles of the back, the attitude is affected by contraction of the psoas muscles and in such cases as pre- sent psoas contraction : abscess, beginning or developed, is to be sus- pected. In the early stages this contraction is slight, but as the disease progresses it may be present to such an extent that locomotion on the leg is difficult. Double psoas contraction sometimes occurs, crippling the patient. Pain may be present in Pott's disease to a very severe degree, but, as a rule, this stage is only temporary, and in some cases pain is entirely absent. The pain complained of is not in the back, but is referred to the peripheral ends of the nerves in the cardiac, abdominal, or epigastric region, or frequently in the thighs and legs. In caries of the cervical region it may be referred to the back or to the top of the head. The pain is ordinarily slight, aggravated by jar, and may be only occasional, but severe attacks accompanied by hyperesthesia are sometimes noted. Analogous to these attacks of pain are disturbances of other nerves, manifesting themselves in dyspnoea with cyanosis, digestive disturbances, nausea, vomiting, and troubles of the bladder. These attacks may sub- side, and recur at intervals without apparent cause. Tenderness on pres- sure over the spinous processes is rarely present. When tenderness of the back is observed, it is more an evidence of functional neurosis than of caries. Tenderness of the spine may occasionally be observed in Pott's disease from a general hyperesthesia. This, however, is diffuse and not sharply localized. Paralysis in caries of the spine may be present at any stage of the disease. It is sometimes partial, but may become complete paraplegia. Out of 295 patients with caries of the spine, Gibney noted paralysis in 62. In 189 cases of caries of the upper dorsal or cervical region, paral- ysis occurred in 59. In 106 cases of lower dorsal and lumbar caries, paralysis occurred in only 3. Deformity in Pott's disease is characterized by the backward projec- tion of one or more spinous processes. This is due to the carious dis- ease of the vertebral bodies forming the anterior support of the spine. The spinal column above the disease falls forward, throwing certain of the spinous processes into prominence, and thus causing a projection of one IS JURIES AND SURGICAL DISEASES OF THE SPINE. 687 or more of them. The adjacent vertebrae become more or less involved in the disease or altered in shape from the altered pressure, it being found, as a rule, that as the projection is sharper the disease is more acute. The deformity tends to increase until either a spontaneous cure results or until the carious bone has solidified by cicatrization. The deformity may involve the whole of the dorsal region, and cause also an unsightly dis- tortion of the chest. This consists of a thrusting forward of the sternum, with a projection of the lower portion of the sternum and abdomen, giving a contour caricatured in the well-known traditional figure of Punchinello. Abscess is a frequent complication of Pott's disease. Caseous foci extending from the diseased bone may cause sufficient irritation to form an abscess, which, projecting from the vertebral bodies into the thorax or abdomen, extends down under the fasciae and comes to the surface in various regions. In the cervical region, abscess may point in the throat (retropharyngeal) or in the neck. Dorsal caries may develop thoracic abscess, evacuating itself in the lung or passing through the muscles and pointing in the back or sides. The most common place, however, for abscess in Pott's disease is in the inguinal region or in the groin, passing under Poupart's ligament and developing in Scarpa's triangle — the classi- cal psoas abscess. Before passing through Poupart's ligament, abscesses may accumulate in the inguinal region, dissecting up the peritoneum and presenting a large subperitoneal abscess. The contents of such abscesses are pyoid or sero-purulent fluid containing caseous masses. Frequently calcified or bony spiculse are present, and in some instances the contents are cheesy, with but little fluid. Abscesses may be absorbed and disappear. In a majority of instances, however, abscesses press to the surface and ulcerate through the skin, and thus evacuate their contents. If they open spontaneously in such a way as to be completely evacuated, they may eventually heal, but in many instances the contents are only par- tially discharged. Some caseous matter remains, and, although the external opening of the sinus is closed, a later reappearance of the abscess may take place. In other instances the discharging sinuses per- sist with pent-up pus, and eventually exhaust the patient by the accom- panying septic processes. In examining the patient at an early stage the child should be entirely undressed, made to stand upon a table or to walk across the room ; the position in which the child holds itself, the gait in walking, the attitude in stooping to pick something from the floor are to be carefully noted. The patient should then be laid upon its face on a table or hard bed, and the flexibility of the spinal column tested by lifting the child's feet and legs with the face downward. The child should also be turned upon the back.' The backward extension of each thigh should be examined to determine whether any projection of psoas muscle on either side is pres- ent. The abdomen should also be palpated in the inguinal region. Where cervical caries is suspected the attitude and movements of the head should be carefully noted. The patient should be seated upon a lounge or the floor and directed to bend forward so as to touch the toes with the hands if possible, and at the same time bowing the head for- ward so that the chin should touch the chest. The normal flexibility of the spine varies in individuals, and in children it is much greater than 688 SPECIAL OR REGIONAL SURGERY. in adults. The forward and backward flexibility is greatly diminished where caries of the spine is present, even at an early stage of the disease. Stiffness in rotation of the spine should also be examined by causing the patient to turn while the pelvis is firmly held. Where caries of the spine in the dorsal region is present stooping forward to pick anything from the floor is difficult, and only done by holding the spine in a stiff posi- tion quite characteristic of the disease. This is not true, however, in Fig. 277 Test for stiffness of the spine : normal flexibility. caries in the cervical region except in the more acute stages, at which time disease is unmistakable from the presence of other symptoms. The peculiarity of attitude in early stages of Pott's disease may be noted as a torticollis, a lateral deviation of the spine, an unusual attitude with raised chin and elevated shoulders, bent knees, or an exaggerated back- ward bending at the lumbar region, varying with the portion of the back affected. The seat and localization of the pain and nervous symptoms are cha- racteristic, more in connection with other symptoms than from anything noticeable in the pain itself. They are ordinarily classed by the parents and attending physicians as rheumatic or neuralgic attacks. A grunting respiration and frequent belly-ache, continuing at intervals for a long period, are both significant. INJURIES AND SURGICAL DISEASES OF THE SPINE. 689 The recognition of paralysis is not difficult after it is developed ; begin- ning paralysis is sometimes overlooked. It is characterized by exaggera- tion of reflexes, knee-jerks, and ankle-clonus. Abscesses are recognized in the early stage by palpation and the recognition of psoas contraction. Pott's disease may be confounded with traumatic neuritis of the spine (railroad spine), hysterical spine, rheumatoid arthritis, and sacro-iliac dis- ease. Other mistakes in diagnosis have occurred, but are due more to an ignorance of the ordinary symptoms of Pott's disease than to any inherent difficulty in the diagnosis itself. Mistakes in diagnosis between low caries and acetabular hip disease have been made, but can be avoided if it is borne in mind that in hip disease flexion in abduction of the lame thigh is interfered with, while in caries of the spine motion in abduction is as free on the lame as on the other side ; and this is usually true of flexion. A distinguishing characteristic of traumatic neuritis of the spine or the neurasthenic or hysterical spine, as compared to Pott's disease, is that in the so-called functional affections local tenderness in the back is usually present, but is almost invariably absent in Pott's disease. In rheumatic arthritis the stiffness of the spine is not sharply localized, but involves nearly the whole column; there is usually little muscular spasm, no unusual projection of the spinous processes ; the ribs are ankylosed to the spine, and a full expansion of the chest is interfered with or the amount of expansion is noticeably limited. Prognosis. — Caries of the spine is necessarily a disease of long dura- tion. It involves a severe deformity unless checked, and is attended by severe complications, paralysis, and abscess, and at times alarming symptoms. Facts, however, show that the disease has a tendency to recovery in many cases, but with the development of deformity. Under thorough treatment deformity can be prevented, the symptoms relieved, and patients entirely cured. Pathological specimens, however, show complete bony union and an entire cessation of the carious process, and clinical evidence in abundance can be cited to prove complete recovery in a large number of instances. In the autopsies at the Munich Pathological Institute on patients with Pott's disease 24 out of 31 were found to have hypertrophy of the right side of the heart; 4 had muscular degeneration of the heart-walls; 2 had stenosis of the mitral valve ; 1 showed acute miliary tuberculosis ; 8 died of phthisis, 4 of pneu- monia, and 1 of carbuncle. In one of Lannelongue's specimens of stenosis of the aorta following Pott's disease the aorta only measured 16 mm. at the origin of the brachiocephalic trunk, 12 mm. after the carotid had been given off, and only 8 mm. in the region of the second lumbar vertebra. In another specimen the lumen of the aorta was reduced to a mere slit. Paralysis in Pott's disease shows an unusual tendency to recovery. Taylor and Lovett found that of 59 cases analyzed, 39 recovered entirely, 3 recovered in part, 5 died of an intercurrent affection, and in 12 the termination was not known. Where the bladder and rectum were paralyzed the percentage of recoveries was much smaller. The average duration of paralysis was somewhat less than one year. The disappearance of paralysis was gradual, recovery of sensation appearing first, then that of motion. The recurrence of paralysis was noted in a few cases. Marked paralysis of sensation indicates an extensive myeli- tis, but some impairment of sensation is found in a majority of cases. Paralysis of sensation may be marked, and yet recovery result. 44 690 SPECIAL OR REGIONAL SURGERY. Treatment. — As the course of Pott's disease is a long one, treat- ment through many years is necessary. The measures used, however, varv with the pathological conditions and the activity of the process. The principles of treatment of caries of the spine are simple, though their practical application is attended with difficulty. The diseased vertebral bodv should be protected from jar and pressure until a cure is accomplished." As in ostitis elsewhere, there is an effort toward repair, and everything should be avoided which would hinder this reparative process. The jars which come upon the spinal column are chiefly those received in bending the column forward, and pressure upon vertebral bodies comes from the superincumbent weight of the head and trunk. In treating a diseased vertebra the superincumbent weight should be removed from the part affected as far as is practicable, and all bending forward avoided. To prevent deformity the spinal column should be made as straight as possible and secured in a straightened position. A relapse will occur unless it be supported while the bone is not sufficiently solidified to endure a jar without reawakening an ostitis but partially healed. If the proper conditions are granted, it is possible to effect a cure without a deformity. Although it is sometimes difficult to secure the requisite conditions "for a sufficiently long time, yet prevention of the increase of the deformity in all cases, and even diminution of slight deformity in some instances, can be gained by thorough treatment. The methods of treatment may be grouped as — first, recumbency ; second, the use of appliances or corsets. Recumbency. — If the patient lie upon the back or upon the face on a hard surface, there is no superincumbent weight pressing upon any portion of the spine. If the patient lies upon his back upon a sagging bed, the spine is bent and some pressure upon the vertebrae results, though the superimposed weight is removed. For this reason it is not sufficient in treating caries of the spine by recumbency that the patient be placed in bed : the spine should be held in such a position that the forward concavity of the column should be as slight as possible or ob- literated entirely. The method of treatment by recumbency has certain manifest disad- vantages. It is irksome to the patient and the attendant. It removes, however, superincumbent weight entirely, and it is therefore of use in the acute stage for the purpose of preventing an increase of the inflam- matory process, and of diminishing it by lessening the irritation from jar and superimposed pressure. It will be found in practice that patients who have suffered from attacks of neuralgic pain during the painful stage of Pott's disease, will after a short period of thorough fixation become less restless and irritable, will gain in general condition, and be free from pain. It is difficult to secure sufficient fixation in the recumbent treatment without the use of some form of fixation frame. The gouttiire of Bonnet, though admirable in its efficiency, is cumbersome and expen- sive. Its advantages can be secured by a light bed-frame, made as follows : Four strips of steel bar or four strips of ordinary gas-pipe half an inch in diameter are fastened together, making an oblong frame of the patient's height and width. The steel bars can be riveted at the ends or the gas-pipes can be secured in the ordi- nary gas-fitter's rectangular joint. This frame is covered tightly with stout cotton sheeting, wound about the frame, made tense, and secured at the sides. If this is placed upon a bed, the patient can lie upon it as comfortably as upon the ordinary mattress. The patient cau be secured to this frame by straps about the shoulders INJURIES AND SURGICAL DISEASES OF THE SPINE. 691 and hips and, if necessary, about the knees. The child can be lifted on the frame and carried about easily. The sheeting can be changed when soiled ; an opening should be cut in the region of the buttock, so that the bed-pan can be used. A Fig. 278. Bed-frame. traction adjustment can be added at the ends of the frame. The great advantage of this apparatus is that the patient, while thoroughly protected from jar, can be Fig. 279. Child in bed-frame. moved in an appliance that is neither cumbersome nor expensive. In the severest cases, in addition to the frame, fixation of the trunk by the employment of a plas- Fig. 280. Child in bed-frame, with head traction. ter jacket or corset is sometimes advisable to secure the patient from any twisting in sleep. In ordinary cases, however, the frame alone is sufficient, but the use of pads placed under the back, pressing the spine forward, is of advantage. These 692 SPECIAL OR REGIONAL SURGERY. Fig. 281. pads can be made of saddler's felting, and should be of sufficient thickness to raise the projecting portion of the spine. They should be placed at each side of the spinous process, and can be secured to the sheeting to prevent slipping. In cervical or high dorsal caries a light traction upon the head is of advantage. This can be made by a head-string fastened to the patient's head and secured to the top of the frame or to a weight-and-pulley attachment at the head of the bed ; counter-pull is furnished by a belt secured to the lower part of the frame, or, if a weight and pulley is used, by raising the head of the bed. Treatment by Plaster Jacket. — The most ready method of treatment of caries of the spine is by the plaster jacket introduced by Dr. Sayre. The advan- tages of this method are its ready applic- ability, its cheapness, and the fact that it places in the hand of every practitioner an efficient means of treatment. It can- not be said, however, that a plaster jacket is applicable to all cases of caries of the spine. It is a method which can be used with benefit in suitable cases. Some skill is required in application. A poor jacket does harm rather than good, and deceives the patient and the physician. In applying a plaster jacket the patient should be placed in the recumbent posi- tion or else in as straight a position as possible, with the curve corrected as much as practicable by suspension. Plaster bandages prepared in the usual way are wound around the patient's trunk, with the patient kept in a cor- rected position until the plaster has become hard. When the disease is situ- ated in the mid-dorsal region the patient is firmly supported by this means. In the cervical or high dorsal region a plaster jacket is of use simply as a base for the support of some form of head-retention. The simplest Jury-mast for high dorsal and cervical caries. Fig. 282. Frame for application of plaster jackets in recumbent position. of these is what has been termed a jury-mast, which consists of a bent steel rod serving as a support for a head-sling. Instead of the jury- INJURIES AND SURGICAL DISEASES OF THE SPINE. 693 mast, which is unsightly, an arrangement can be used supporting the head beneath the chin and occiput which is less of a disfigurement. In lower lumbar caries, where much lordosis is present, a plaster jacket Fig. 283. Application of a plaster jacket in the recumbent position. should be applied, with the patient's back hollowed slightly in a position of lordosis and with but slight suspension to diminish to a minimum the intervertebral pressure. During the application of the plaster bandage the patient should either be sus- pended by the head or arms, or both, or a plaster jacket can be applied with the patient recumbent, lying face downward upon a tight sheeting support, like a flat hammock. The hammock, made of stout sheeting, can be made tense by means of pulleys, and if slit, as is recommended by Brackett, along the patient's sides, the surgeon can apply plaster bandages snugly. When these are hard, the sheeting hammock is cut and can be pulled out from beneath the jacket. The details of the application of the plaster are of importance. Projecting spinous processes or bony portions of the pelvis are to be protected by saddler's felt placed at both sides of the bony projection. The plaster should be well rubbed into crinoline free from glue or sizing, which will delay the setting of the plaster. The bandages should be well rubbed in as they are applied, and should be applied after having been thoroughly wet. If the details are properly attended to, the bandages become hard in a few minutes. Proper material should be used for the bandages. Cloth with too close a mesh cannot retain a sufficient amount of plaster, and holds moisture too long to admit of rapid hardening. Too coarse- meshed cloth, while allowing rapid setting, makes a jacket which is liable to crumble. As a substitute for split plaster jackets, and their superior in durability, a cor- set of leather or paper can be made. This is shaped upon a cast taken from a plas- ter jacket used as a mould. Sole leather is wet, stretched, and hammered upon this cast, and thoroughly dried ; if necessary, it can be strengthened by steel strips and fastened with the requisite lacings. Paper jackets are made by pasting upon the cast with white paste strips of thick matrix-paper thoroughly wet. Four to six layers of this paper are used ; between each two layers strips of crinoline or linen are added, with a layer of crinoline inside and outside : the whole should be dried thoroughly, and the resulting corset split and removed from the cast. It can then be painted and varnished, and forms a stiff light jacket. Another form of jacket is made by the use of thin strips of wood fastened by glue. Corsets have been made of strips of steel woven wire and of aluminum. The latter are expensive, and hardly more serviceable than those of paper or leather. Treatment by Means of Braces. — The treatment by means of braces has fallen into discredit from the fact that the application of spinal supports has been left too often to mechanicians whose object is more to sell their appliances than to cure the patient. Furthermore, the proper application of braces requires some experience and skill and attention to detail. 694 SPECIAL OR REGIONAL SURGERY. Selection of Method of Treatment. — It should be clearly borne in mind that no one form of treatment is applicable to all stages of a dis- ease nor to all cases. In the selection of the method of treatment the pathological condition should be carefully considered. In the acute stages absolute and complete recumbency should be enforced, and in such a position as will not only relieve the weight from the affected vertebral bodies, but diminish the pressure as far as possible. In the subacute and convalescent stage the erect position, which is essential for health, and therefore for the establishment of a reparative process, should be allowed, but only allowed when the back is firmly fixed in such a position as will as nearly as possible prevent any additional jar on the unsound verte- bral bodies. Whether that should be done by some form of corset or of brace depends upon the amount of nursing facilities at the disposal Fig. 284. Fig. 285. Anteroposterior support : back view. Antero-posterior support with head-ring for high dorsal caries : side view. of the patient. Braces require more attention and more care. They are more precise, and therefore better, than a corset. In the mid-dorsal region, however, a carefully applied plaster jacket gives a support which is both firm and convenient, and requires no especial nursing. In the cervical and upper dorsal region braces are more effective than the cor- set and jury-mast, but. require some skill in proper adjustment. Treatment of Complications.-^- Lumbar and iliac abscesses constitute a INJURIES AND SURGICAL DISEASES OF THE SPINE. 695 formidable complication. Authorities differ as to the relative advan- tages of expectant treatment over that of early operation. The facts are, that a certain number of cold abscesses in the spine become absorbed if the carious process be arrested. In a certain number the contents tend to evacuation, and, if they can be thoroughly reached with the knife and suitably drained, this should be done. If, however, they are in a region where drainage by spontaneous opening is more thorough than that given by early operation, the expectant treatment should for a time be employed. Where abscesses become large they need to be opened, and this should be done by a free incision under aseptic precautions. In lumbar abscesses the opening should be made in front and back by an incision in front, above Poupart's ligament, near the anterior superior spine, and behind in the region between the ribs and iliac crest. The Treatment of Psoas Contraction. — This deformity should be treated by correction under an ancesthetic or by traction by means of weight and pulley. In resistant cases osteotomy may be necessary. Paralysis. — The natural course of paralysis is toward recovery, and the use of medication is therefore of uncertain value. The same is true of the actual cautery, recommended by the earlier writers. In some instances laminectomy is of advantage, but exact value of this procedure in Pott's disease is not as yet determined. In view of the fact that the percent- age of recovery of cases properly treated is nearly 100 per cent., the advantages of laminectomy can only be urged where thorough treatment has been tried and failed, where care cannot be furnished for a sufficiently long period to establish a cure, or where the patient is becoming worse after a long period of careful treatment. Within the past few years has come into notice a method of forcible reposition of spinal deformities due to spondylitis, which bears Calot's name, and has about it all the gravities of a major operation. It is made, with anaesthesia, by combining forced traction upon the spine with direct pressure over the projecting portion ; indeed a high degree of force must be used, with several assistants, etc. Good has often followed its use, and yet it is not without serious dangers, while death has repeatedly followed. As an operation it is still being tested on its merits, while its adoption should — for the present — rest in the hands of a very limited number of specialists. Curvatures op the Spine not Due to Primary Bone Disease. In addition to what is termed angular curvature or Pott's disease, already described, there is common a lateral curvature or scoliosis, in which the spinal column is distorted by curves due to faulty habits in attitude, paralysis, or weakness of muscles. These curves are termed kyphosis (the curvature with a convexity backward) and Iwdosis (curve with a convexity forward). Lordosis. — The forward bending of the spine (convexity forward) occurs as a deformity often secondary to other conditions, such as con- genital dislocation of the hip. It may result, however, from simple weakness of the erector spina; muscles. The patient assumes this posi- tion in order to balance the trunk in such a way that the weakened muscles are not called upon to act. This is also seen in pseudo-mus- 696 SPECIAL OR REGIONAL SURGERY. cular hypertrophy. It is seen also in early symptoms in Pott's disease and in children with large abdomens. Patients with ascites or abdomi- nal tumors, as well as pregnant women, assume naturally this position. When the deformity exists in a mild form, due to a muscular weakness from overgrowth or from any non-organic cause, it is^benefited by gym- nastic exercises for the purpose of developing the lumbar muscles. In some instances a back-brace or a removable corset is of advantage to relieve the patient from the strain of the erect position, but it should onlv be used in exceptional cases and for a short time. Massage and electricity are useful as adjuvants. Spondylolisthesis. — This term is applied to a rare affection which consists of the dislocation forward of the last lumbar spine where it articulates with the sacrum. A few cases of this has been reported. They were the result of the relaxation of ligaments after confinement. The use of a stiff corset and the employment of crutches constitute the treatment. Spondylitis Deformans. This name is given to chronic rheumatoid arthritis of the vertebral articulations. It is characterized by stiffness of the spine and a curva- ture with the convexity backward. In many instances it is accompanied by ankylosis of the articulations between the ribs and the spinal column, and in many, but not all, instances by rheumatoid arthritis in other joints. The affection is more common in old age, but is occasionally seen in children. It is to be distinguished from Pott's disease by the fact that the stiffness is not narrowly localized, and from a characteristic rounding in the curve, which is entirely different from the angular or sharp curve in Pott's disease. Operations upon the Spinal Column. The operations which have been performed and recommended on the spinal column may be grouped as follows : A. Laminectomy : 1. To enter the canal, open the dura, and examine the injured cord and relieve the pressure of hemorrhage in case of hemorrhage ; 2. For the reduction of dislocation of the vertebrae or removal of spicula? ; 3. For the removal of any tumor of the dura or any foreign body pressing upon the cord ; 4. As a means of examination and exploration of the vertebral bodies in Pott's disease. B. Operation upon the sacrum and coccyx. C Vertebral puncture for the relief of excess of cerebro-spinal fluid. Laminectomy. — The object of this operation is to relieve the spinal cord of any pressure which may be exerted upon it, with the least pos- sible mutilation of the tissues involved in its structure. The indications for this operation have already been spoken of under the headings of Fracture of the Spine, Pott's Disease, and Spinal Tumors. The tech- nical details, however, need special attention. PLATE XXVI. Osteoplastic Resection of Posterior Vertebral Arches (Urban.) INJURIES AND SURGICAL DISEASES OF THE SPINE. 697 The dangers of laminectomy are chiefly those to be encountered from the depth and importance of the tissues and structures attacked. Horsley has called atten- tion to the dangers of hemorrhage, and Keen lays special stress upon the shock following the operation. Especial care should be taken in administering the anaes- thetic. The patient should be brought to the edge of the table, so that the face should project, and placed upon the belly or nearly so, with the face turned to the side, giving the ansesthetizer an opportunity to thoroughly inspect the face. Incisions of different shapes have been recommended. A long, straight, median incision is,however.sufficient inallcases,unlessan osteoplastic resectionis attempted, when an inverted U-shaped incision is advisable. ( Vide Plate XXVI.) The skin, muscles, and fasciae are to be divided, the spinous processes and arches laid bare: the muscles are to be separated from the arches by a knife rather than by raspatory. Time is not to be lost by the use of haemostatic forceps unless large vessels are divided, which is ordinarily not the case. Hemorrhage is to be controlled by packing the wound, by pads, or by hot water. Osteoplastic resection, although advocated by some, is not to be recommended ; the subperiosteal division, being shorter, is preferable. After the spinous processes and the arches are cleared attempts should be made to remove the bony tissue. For this purpose the saw, forceps, mallet and chisel, and the trephine have been used, but the simpler the Fig. 286. Specimen of laminectomy of spine (Warren Museum). method the better. The periosteum is to be pushed back from the spinous pro- cesses and arches as far as possible, and by the use of a pair of strong bone-forceps, 693 SPECIAL OR REGIONAL SURGERY. made for the purpose with a flat plate on the under side, the arches are to be di- vided on each side, care being taken to avoid wounding the dura or the nerves as they emerge from the spinal column. It is necessary to remove several laminae, the size of the opening into the canal depending upon the amount of the cord it is necessary to expose. Fatty tissue will be found lying in the canal. It can be separated by blunt dissection ; the dura is freed from the canal by means of a director, and the cord felt through the dura. In case of extradural lesions, these can be inspected, and the condition of the dura and the contents of the spinal canal determined. It is advisable, if possible, to avoid opening the dural cavity. When it is necessary the incision of the dura should be a straight, median incision. After the operation, in case any is needed, the dura should be closed by sutures, the muscular flaps brought together, and the skin sutured. It is advisable to drain the wound for a few days by means of a gauze wick, as considerable oozing follows the operation. No drain, however, should be inserted within the canal. In some instances it is desirable to suture the muscles and ligaments. A bed-frame after the operation, or a fracture-bed, will be found of assistance. Patients lie most comfortably upon the back after the operation : lying upon the face facilitates attention to the wound and obviates the necessity of turning the patient for that purpose, but does not permit of as complete drainage of the wound as a position upon the back. Attempts have been made to reduce the deformity following fractures or dislo- cations by cutting down upon the spinal column and forcing the displaced frag- ments into position ; but such a procedure is of doubtful efficacy. Spicules of bone can be removed — the condition of the bone examined. Correction of the malposition is to be effected when possible with much circumspection to prevent further injury of the cord or nerves. Laminectomy in Pott's Disease. — The spinal canal is opened in caries of the spine to relieve the cord from pressure, and laminectomy for that purpose does not differ from the ordinary procedure. It has also been recommended as a means of examining the condition of the vertebral bodies. This can be done by separating the dura from its bony attach- ment in the canal, using a curved director for the purpose, and explor- ing the posterior surfaces of the vertebral bodies by means of a probe or director, pushing the dura and cord gently to one side. It is not always necessary that a complete laminectomy should be done for this purpose : opening the canal by removal of the arches on one side will be sufficient unless more room is required. Measures have been recommended for the examination of the vertebral bodies without entering the vertebral canal. This is of value in wounds of the spinal column without injury to the cord for the examination of the bodies in tubercular ostitis, as well as in osteomyelitis. The tech- nique varies in different parts of the spinal column — viz. in the lumbar region, in the dorsal, and in the cervical region. Wiring of the Spine. — Wiring of the spinous processes has been recommended and performed by Hadra. Ligature of the transverse processes, tying together of the laminae, suture of the spinous processes, have also all been recommended after laminectomy and in cases of frac- ture, but have none of them found general acceptance. Operations upon the Sacrum. — Operations for the opening of the spinal canal have been all recommended in the sacro-coccygeal region, but in this region a gouge, chisel, and mallet are to be used instead of the bone-forceps. Removal of the Coccyx. — This operation is performed in obstinate cases of eoccygodynia — -i. e. painful or irritable coccyx. A median incis- ion is made, the bone exposed, and the articulation of the coccyx with the sacrum cut through. The plexus of veins immediately beneath > X X w < ls !frixr "ti T3 s- o o •c c CO a w C o t. CO in INJURIES AND SURGICAL DISEASES OF THE SPINE. 699 the coccyx is to be avoided as well as the rectum. The bone can be removed subperiosteally. Vertebral Puncture. — This has been recommended by Quincke for the relief of pressure from an excess of cerebro-spinal fluid. A small trocar is thrust into the subdural space in the lumbo-sacral region, between the transverse arches or between the spinous processes of the adjacent vertebra. In children the space between these parts of the adjacent vertebrae is comparatively large. The point of election is the third, fourth, or especially, the fifth, space in the lumbar region. ^ The needle is directed toward the median line, entering outside of it — in children at the level of the space, and in adults at the tip of the spinous process. The first few drops of the fluid are slightly tinged with blood, but the remainder is clear. From 20 to 100 c. c. should be drawn off in an adult, and from 2 to 50 in a child. Rigid antiseptic precautions are necessary. The wound should be closed by iodoform collodion. Tumors of the Spine. The spinal column may be attacked by malignant growths in the same way as are other tissues. These tumors are those which originate either in the bone-tissue of the spine or in the adjacent tissues (Plate XXVII.). Congenital Tumors of the Sacrum. In addition to the tumors classed as spinse bifidse, or congenital cysts, there is a rare class which consists of vestiges of an attached foetus. This varies greatly, from an ill-defined mass of tissue to a more or less completely developed structure like a dwarfed or deformed leg project- ing from the sacrum. This can be amputated unless so firmly united with the pelvis that such an undertaking would be fatal. ( Vide Chapter XXV., Dermoids.) Sacro-coccygeal Tumors at the Junction of the Coccyx with the Sacrum. The most common form of these are varieties of spina bifida, already mentioned. They present themselves, however, in some instances slightly to the side of the median line. They are not always fluctuating, and may be dense, though it is characteristic of them that they vary in size from time to time. They are usually mistaken for fatty tumors, as in many instances they are covered by a thick layer of fat. Operative interference with these cysts is too often fatal, owing to the difficulty of securing complete asepsis, from the constant escape of the cerebro-spinal fluid. Dermoid tumors originating in the embryonic remains of the post-anal gut have been already considered in Chapter XXV. Tumors of the Spinal Cord. Of the various malignant growths which develop in the cord proper or its membranes, gliomata are the most commonly met, though fibrom- ata, sarcomata, glio-sarcomata, and angeio-sarcomata are all reported, but 700 SPECIAL OR REGIONAL SURGERY. very rarely. Multiple fibromata have been observed simultaneously in the cord and the peripheral nerves. Fibromata are usually round, and give rise to more or less degeneration of the substance of the cord in their immediate vicinity. Gliomata constitute tumors of oblong shape. They are usually situated around the central canal. Their substance is sometimes firm, though usually delicate, and they frequently contain cavities. They are sometimes rich in vessels. Tumors growing in the cord present a gradual development of symptoms. There is first motor paralysis, later sensory paralysis preceded by pain. The pain is at first neuralgic and lancinating; anaesthesia and pain in the lower limbs ascend gradually from the feet toward the trunk, and there is a dull ache in a distinct portion of the spinal column, accompanied by weakness at that point, which is increased on fatigue. The reflexes, deep and superficial, are exagger- ated, and eventually lost, with symptoms of descending degeneration and wast- ing as the cord becomes diseased. The reflexes, as well as the pain and anaesthesia, begin in the plantar region and pass upward. The symptoms are not symmetrical, but are unilateral. Spasms and rigidity are present ; the pupils are not affected. It should be borne in mind that there is a gradual loss of sensation or motion with intramedullary growths, while in the extramedullary growths the symptoms of pain and spasm indicative of irritation may precede the paralysis. If the paraly- sis be of gradual development, preceded by long-continued symptoms of nerve- irritation, beginning on one side and gradually transferred to the opposite side, a probable diagnosis of compression of the cord by a pressure outside the cord can be made. The successful removal of tumors of the spinal cord belongs to the rarer feats of surgery, the difficulty lying not so much in the removal of the tumor as in the recognition of the affection at so early a stage that relief is possible. Chipault has collected 22 cases of operation on spinal tumors ; Keen reports 3 more. The result of these operations was 11 deaths, 11 recoveries, and the result in 3 is uncertain. The operation is essentially a laminectomy, already described, plus the enu- cleation of the growth. CoCCYGODYNIA. This name is applied to a painful affection of the coccyx, which in some instances arises spontaneously, but frequently dates from an injury, such as a fall or a blow, or comes on after childbirth. It is almost entirely confined to women, and usually appears in persons of a neurotic tem- perament. In many instances an irregularity in the coccyx can be found on palpation. The treatment should be at first that which is found efficacious in neurasthenic patients — massage, electricity, and stimulants to the circu- lation, such as an application of heat and cold, besides general tonics ; in more obstinate cases removal of the coccyx is necessary. ( Vide Ope- rations upon the Spine.) SURGERY OF THE PERIPHERAL NERVOUS SYSTEM. Surgery op the Nerves. Most of the affections of the nervous system belong strictly to the domain of internal medicine. There are, however, certain diseases INJURIES AND SURGICAL DISEASES OF THE SPINE. 701 which should be considered, in part, in a surgical treatise, from the fact that they are relieved by surgical interference. These are divided as follows : I. "Wounds and injuries to the nerves. . II. Diseased conditions calling for surgical interference, mainly — (1) Neuralgia; (2) Muscular spasm. Wounds and Injuries to the Nerves. Contusions of the nerves are not uncommon, either in dislocation or fracture or from direct violence crushing the tissues. Constant pressure, as in the use of crutches (" crutch paralysis "), or lying in a peculiar position with the arms under the head for a long period, as occasionally happens in intoxicated persons, sometimes produces changes which may be classed as injuries.- An injury of the nerves is recognized from the resulting impairment in the function of the nerve — i. e. motor or sensory paralysis. Neuralgia. The subject of neuralgia belongs properly to a medical rather than a surgical treatise, and this is also true in regard to the medical treat- ment. In some instances, however, neuralgia is due to peripheral irritation, compression, or degeneration, rather than central or con- stitutional causes, and surgical interference is justifiable for the pur- pose. Neurotomy, neurectomy, nerve-stretching, have all been employed for obstinate neuralgia, especially for the violent form of trifacial neuralgia. Division of the nerve (neurotomy) for neuralgia, as well as nerve- stretching, does not give as satisfactory results as excision of a portion of the trunk — neurectomy. In some instances of trifacial neuralgia a permanent cure results, and temporary relief follows this procedure in all suitable cases. Recurrence of pain is not infrequent, however, in the most obstinate cases, and recourse has repeatedly been had to removal of the Gasserian and other ganglia for relief. Muscular Spasm. Operations upon the peripheral nerves are sometimes necessary for the relief of muscular spasm. The particular affection for which neur- otomy, nerve-stretching, or, better, neurectomy, has been most often attempted is that spasm of the muscles of the neck known as spasmodic torticollis. Successful cases have been reported by Gairdner, Keen, Richardson, and others, but in some instances the operation affords little or no relief. Keen has recommended a division of the posterior cervical nerves on the opposite side, in addition to resection of the spinal acces- sory on one side. This has been done by the operators mentioned, and with success in some instances. 702 SPECIAL OR REGIONAL SURGERY. Operations upon Nerves. The operations upon nerves are nerve-suture, nerve-grafting, nerve- stretching, division of nerves, and excision of parts of nerve-trunks. Nerve-suture. — Nerves should be sutured as soon as they are divided, if that be feasible (primary suture), even if the nerve be only partially divided. Two or three sutures are passed, not only through the sheath of the nerve, but also, if necessary, through the nerve itself, avoiding twisting the nerve-fibres. Fine catgut or silk should be used and a round needle. Fixation of the limb on a splint is advisable after nerve-suture in order that the sewn nerve should not be torn apart on motion. If there be separation of the ends of the nerves, they can be approximated by stretching, with fixation of the limb in such position as best to relax them. Suture can be also attempted weeks or months after the injury (secondary suture) ; the proximate end is ordinarily easily found from its bulbous termination, but the distal end is not so easily discovered. Recovery with restoration of function takes place in two-thirds of the cases operated upon. In 84 cases of primary suture reported by Howell and Huber, 42 per cent, were successful. In secondary suture the same writers report, in 80 cases, 38 per cent, of successes, 12 per cent, of failures, 50 per cent, with improvement. Nerve-grafting. — Experiments have been tried in grafting nerves where the gap between the ends from a loss of the nerve-substance is so extensive that the ends cannot be approximated even by stretching. Reported cases of success by this method have been reported when the sciatic nerve of a dog has been used. Nerve-stretching 1 or Elongation. — A nerve can be stretched one- twentieth of its length. The amount of resistance to stretching is greater than would be imagined. The sciatic does not break under a strain of less than 80 pounds ; 6 pounds' pull is necessary to break the supraorbital nerve, according to Marshall. The amount of force required is greater in living than in dead subjects. The facial nerve will bear a strain of from 5 to 7 pounds, so that the head can almost be lifted from the table without a rupture of the nerve-trunk. The theory as to the benefit of nerve-stretching is that changes in nutrition follow, while adhesions to the neighboring parts or to the sheath are destroyed. Nerve-stretching is done by exposing the nerve and loosening it from the surrounding tissues : it is then stretched bv hook- ing it under the thumb, or in some nerves, as the seventh, by a button- hook. Nerve-stretching by what has been called the bloodless method has been employed on the sciatic nerve. This consists in flexing the thigh forcibly upon the trunk, the leg being kept straight at the knee while the patient is under an anesthetic. The method lacks surgical pre- cision, although some cases have been reported where benefit has fol- lowed. Nerve-stretching has been used in certain cases of spasm of the facial muscles and in wry neck, but the benefit of this procedure is usu- ally only temporary. Neuroplastic Surgery. — This has been advocated as a substitute for nerve-grafting. A portion of the severed nerve at each of the cut ends is split and freed nearly to the termination ; these strips of nerve are folded over and their unattached ends stitched together. This method is as yet in an experimental stage. INJURIES AND SURGICAL DISEASES OF THE SPINE. 703 Operative Details. The operative details for the finding and resection of the different nerves require especial attention in each individual case. The few fol- lowing facts are to be borne in mind by the surgeon in considering ope- rations upon the nerves and nerve-structures most commonly attacked : The Supraorbital Nerve. — A curved incision, an inch in length, is made across the orbital notch, which can usually be felt. The incision can be made in the eyebrow and the scar will be hidden by the hair. The Division of the Fifth Nerve at the Superior Maxilla. — The infra- orbital nerve comes to the surface at the infraorbital foramen. This is found at the intersection of a line drawn from the superior orbital notch downward between the two lower bicuspid teeth. A curved incision one and a half inches long is made just below the lower border of the eye : where this incision meets the line already mentioned the nerve will be found. It lies under the levator labii supe- rioris. The nerve can be lifted from its bed by a hook and dissected as far back as the orbit. A pull upon the nerve will remove nearly the whole of it. The Removal of Meckel's Ganglion. — This ganglion can be reached by Chavasse's modification of Carnochan's method. This consists of an incision below the eye, T-shaped, the cross portion reaching from one corner of the eye to the other, and the upright nearly to the mouth. The infraorbital nerve is found and tied with a piece of silk. The antrum is opened by means of a trephine or chisel : a trephine is applied to the posterior wall of the antrum ; the nerve is then drawn down after being divided from the cheek, and will serve as a guide to the ganglion, being pulled into the spheno-maxillary fossa of the foramen rotun- dum. Horsley does not trephine the antrum, but lifts the floor of the orbit, including the periosteum, and opens the canal by means of a sharp-pointed bone-forceps, and follows the nerve to the foramen rotundum. Luecke resects the zj'goma, turns the temporal muscles up, and makes an opening for the ganglion. Inferior Dental. — This nerve can be reached in several ways. An incision two inches long is made along the lower border of the jaw; the flap is pushed upward, the masseter muscle being separated from the jaw, and a trephine is applied one and a quarter inches above the angle of the jaw. The nerve is then exposed. Removal of the Gasserian Ganglion. — The removal of this ganglion has been done in cases where the ordinary neurectomy has not given relief. This ganglion is removed in the following manner : The eyelids are sewn together for three days in order to protect the eyeball ; a curved incision is made half an inch below the external angular process of the orbit, along the zygoma, to its posterior end, then downward to the angle of the jaw, and finally along the lower border of the jaw as far as the facial artery. This flap is brought forward ; the zygoma is first divided and turned downward with the attachments of the masseter muscles; the coronoid process is divided and brought upward with the attachment of the temporal muscle. The internal maxillary artery may be ligated and the external pterygoid separated from the sphenoid and the external pterygoid plate. A half- inch trephine is applied in front and slightly to the outside of the foramen ovale, with the edge of the trephine just touching the foramen ovale. There is usually considerable hemorrhage. A strong light is advisable. In the first instance the eye was destroyed, and had to be removed. In later cases, however, this has not been the result. Mr. Horsley, instead of attempting to remove the entire ganglion, which he says cannot be done without opening the cavernous sinus, trephines and removes the squamous portion of the temporal bone, opens the dura, ligates the middle meningeal, lifts up the brain, and exposes the roots of the nerve as they pass to the Gasserian ganglion. These lie in a canal a quarter of an inch in diam- eter beneath the tentorium, which should be opened. The nerve-roots are cut and drawn away from the pons. This operation has never been done but once, and then with a fatal result. Mixter has resected the second and third divisions at both the foramen rotundum and ovale, and has done the operation successfully several times. He makes an incision similar to that for removal of the Gasserian ganglion. The temporal and pterygoid muscles are separated and turned down, using an incision which has been described by Salzer. 704 SPECIAL OR REGIONAL SURGERY. Park has advised a preliminary ligation of the common carotid as a great help, no matter which method of attack be selected. Lingual Nerve. — This has been operated on to diminish pain in cancer of the tongue. The nerve lies on the floor of the mouth beneath the mucous mem- brane, and can be felt if the tongue be forcibly stretched. The mucous membrane is incised and a hook is passed under the nerve. The nerve can also be found as it lies in the tongue close to the first molar of the lower jaw. Fig. 287. Exposure of Meckel's or the Gasserian ganglion (Krause). Fragment removed from the fifth nerve. The Seventh Nerve. — This nerve is reached by a vertical incision two and a half inches long made behind the ear : the parotid is found at its posterior limit and is turned forward; the sterno-cleido insertion is then found, and in the space between these two landmarks the prevertical muscles will be found. The inferior branch lies in front of the fasciae covering these muscles, and crosses both the mastoid and the vertical ramus of the jaw. This nerve can also be found by an incision in front of the ear : one of the main branches is found in the parotid gland, and is followed back until the main trunk is reached. Spinal Accessory Nerve. — This nerve is divided and excised for spasmodic INJURIES AND SURGICAL DISEASES OF THE SPINE. 705 wry neck. It may be reached anterior to the sterno-cleido-mastoid, an incision being made along the anterior body of the muscle, passing two inches downward from the lobe of the ear. The muscle is turned to the outside, and the nerve can be found a little above the level of the hyoid bone. If it be desired to reach the nerve, as it is possible, from the sterno-cleido-mastoid, the incision is made along the outer border of the muscle, the centre of the incision being the centre of the muscle. The nerve will be found a little above this point. Division of the Nerves in the Deep Posterior Cervical Plexus. — Keen divides the posterior branches of the first, second, and third cervical nerves in spasmodic torticollis which has been unrelieved by the incision of the spinal accessory. A transverse incision is made half an inch below the level of the lobule of the ear. The trapezius muscle is divided in the same line. The muscle is then dissected up and the great occipital nerve is found. The complexus is then divided, and the great occipital nerve is followed until its origin from the posterior division is reached. The suboccipital or first cervical nerve is excised. It lies in the tri- angle close to the occiput formed by the two oblique muscles and the posterior straight muscle. The exterior branch of the posterior division of the cervical nerve is found lower down, and should be divided close to the bifurcation of the main nerve. The anterior branches of the cervical plexus may be reached by means of an incision along the posterior border of the sterno-cleido-mastoid muscle. The Brachial Plexus. — An incision is made above the clavicle similar to that which is used for the ligation of the subclavian artery. The deep fascia is opened and the nerves will be found. Median Nerve. — The same incision is used as for the ligature of the brachial artery. The nerve lies in front of the artery and passes from within outward. The median nerve can be reached in the forearm or the wrist. An incision two inches long is made on the inner side of the tendon of the palmaris longus. The nerve lies underneath the deep fasciae. The branches of the median nerve to the thumb and fingers can be reached by an incision along the lower inferior border of the thenar eminence underneath the palmar fascia. Ulnar Nerve. — An incision is made similar to that for the finding of the median nerve. The nerve lies farther back. It can be exposed behind the elbow, using an incision between the internal condyle and the olecranon. At the wrist an incision on the radial side of the tendon of the carpi ulnaris exposes the nerve, which lies under the deep fascias. The Musculo-spiral Nerve. — An incision is made between the biceps and the triceps muscles. The deep fascia is opened, and the nerve is found in a groove in the interspace between the two heads of the triceps. The Radial Nerve. — A longitudinal incision is made on the outer border of the forearm three inches above the wrist-joint. The Great Sciatic Nerve. — An incision is made, four inches long, in the middle line of the thigh, beginning below the gluteo-femoral crease. The deep fascia is cut, the biceps is found, and the sciatic nerve will be seen at the outer border of the muscle. Tibial Nerves. — The anterior and posterior tibial nerves are found through the same incisions that are required for ligation of the arteries. Intraspinal Division of the Posterior Nerve-roots. — This ope- ration has been done by Abbe in a case of inveterate neuralgia. Half of the arch of the fourth and the whole of the fifth, sixth, and seventh cervical arches were removed by Abbe in his first case. The dura was exposed, and the sixth and seventh cervical nerves were divided between the dura and the bone. Temporary relief followed. The operation has also been done by Horsley and others. It is more serious than opera- tions on the peripheral nerves, and the results do not seem to be any more favorable. Tumors of the Nerves. Nerve-tissue may be involved in malignant growths developed in the surrounding tissues, but primary malignant tumors of the nerves 45 706 SPECIAL OR REGIONAL SURGERY. are rare: they are sarcomata or gliomata. ( Vide Chapter XXV.) The term neuromata, a general one applied to enlargements observed in nerves, is unfortunate. The most common form of the neuroma is seen, after amputation, in the bulbous enlargements of nerve-ends which are involved in the surrounding tissue, though this can be more or less readily differentiated. A tumor may occasionally appear in the course of a nerve without apparent external irritation. This is due to an increase of the connective tissue which arises from the endoneurium, though sometimes from the perineurium, the axis-cylinder being there surrounded or its fibres pressed upon by the growth. These, are in fact, fibromata of the nerves. They are usually multiple and limited to cer- tain nerve-tracts. Sometimes these tumors are sessile, and sometimes they have a pedicle. They may be found in the nerves of the skin, and are sometimes called fibromata of the skin. In very rare instances they may attain considerable size, even being reported as large as the fist. Plexiform wuromata consist of a thickened mass of nerve-fibres resem- bling somewhat a plexus of veins. The nerve-fibres are elongated and tortuous and increased in numbers. These form true neuromata, and may be found in the head or in any part of the body. Dislocation op the Nerves. Dislocation of nerves has been reported in a few instances. This is easily recognized by a movable cord which is felt under the skin, and by a sensation which the patient notices when this is pressed upon. Where no other means affords relief it is possible to cut down upon the the nerve and excise a portion, if it be not possible by section and suture to restore it to its place. Dislocation is most common in connection with the ulnar nerve at its passage back of the inner condyle. CHAP TEE XXXIX. SURGICAL DISEASES AND INJURIES OP THE HEART AND PERICARDIUM, WITH SURGERY OP THE LARGE BLOOD- VESSELS ; LIGATIONS. By Duncan Eve, M. D. Wounds and injuries of the heart and pericardium have been, and are likely to be, of only too frequent occurrence. The well-known site of the heart has made it only too accessible to the death-dealing instrument of the suicide or assassin ; its feebly protective surroundings, especially in front, leave it only too approachable to sword-thrust, bayonet, or bullet on the battle-field, or missiles and fragments projected by inten- tional or unavoidable and accidental force. Most generally, the excep- tions being few and far between, lesions of any magnitude — and some quite slight ones, indeed— have and will prove fatal. Yet the history of the past has shown quite a number of slight and some severe wounds that have not been immediately lethal, and yet a few where life was pro- longed indefinitely or determined by some altogether different cause. The number of favorable results in such lesions have been largely added to in the last thirty years, and it is to be hoped will yet be still more largely increased. There are now, moreover, eight cases on record of suture of the heart, after thoracotomy, with three recoveries. Wounds and injuries of the heart produce death by — 1, hemor- rhage ; 2, shock; 3, arrest of the heart's action by the accumulation of blood in the pericardium or around the heart in the thoracic cavity ; 4, by inflammation, suppuration, or sequela; due to the subsequent progress of the wound, lesions set up thereby, or induced by the character of the injury and the instrument producing it. The danger is greater and more imminent by reason of the character of instrument producing the wound, and stands in the following order : (a) contused and lacerated wounds, such as gunshot wounds, those produced by blunt and irregular instru- ments, etc., and punctured wounds if the instrument is of large size ; (b) incised wounds ; (c) punctured wounds made by small instruments. In most instances the hemorrhage in contused and lacerated wounds will be so severe as to cause death almost immediately ; and shock, exces- sive inflammatory, suppurative, and other sequela? are more certain to supervene. Incised wounds are not always attended by immediate alarm- ing or serious hemorrhage, and shock may be at first slight. A thin, narrow blade transfixing the muscular walls makes a valve-like opening by means of the interlacing muscular fibres ; severing some, it passes between others ; while shock is also apt to be slight. A greater danger is from the accumulation of the blood around the heart, impeding or 707 708 SPECIAL OR REGIONAL SURGERY. arresting its action. Punctured wounds are likely to be attended with shock, hemorrhage, and subsequent developments in proportion to the size of the agents by which they are produced. The evidence of wounds of the heart may be summarized as follows : character, site, course, and nature of instrument producing the wound, together with certain phenomena referred to the heart itself, as a systolic bellows-sound, a peculiar tremor about the heart, with small, intermit- tent pulse, an undulating crepitation and bruit, and such phenomena as can be obtained by careful auscultation and percussion. Dulness upon percussion over an increased and increasing area, syncope, rjrecordial anxiety and dyspnoea, diminished impulse of the heart, and pain may be suggestive when present. Treatment. — The patient should at once be placed in the recumbent position and kept there, with head low and every possible movement prevented. If he has to be moved, it must be done with the greatest care and caution to prevent any undue movement of the body, and should be preceded by a full dose of morphia hypodermically. Nar- cosis as deep as may be considered safe should be maintained for some days — at least until all danger from shock and hemorrhage is considered past. Thirst should be prevented so far as possible, and nutrition maintained rather by copious enemata of fluids and semi-fluids than by the mouth, the act of deglutition, even of fluids, having the effect of increasing the heart's action, which is to be avoided as adding to the danger from hemorrhage. Digitalis should not be given, nor stimulants; far better will be found veratrum and other cardiac sedatives : to dimin- ish as much as possible the heart's action is of the greatest importance. So long as the heart's action seems to be maintained to a reasonable degree, only the simplest antiseptic dressings to the external wound are called for. A flannel bandage applied as tightly as consistent with comfortable respiratory movement should be early applied and main- tained in position. Over this an ice-bag or cold applications, rapidly evaporating lotions if the ice-bag seems to disturb the patient by its weight, or cold cloths frequently reapplied. The strictest quiet of sur- roundings and of the patient's mental condition is imperative. If life be maintained for twelve to twenty hours or more, and a care- ful examination, which should be made at frequent intervals without disturbing the patient, shows that the heart's action is becoming impeded by the pressure of extravasated blood around it, manifested by more feeble pulse and heart-sounds, cyanosis, dyspnoea, etc., then comes the propriety of opening the chest and pericardium, removing clots and blood by washing out with warm water thoroughly sterilized or other means. This may be done by simple incision between the fourth and fifth ribs on the left side, if other location is not indicated by the cha- racter of the wound, or by excising the cartilages of one or more ribs. An incision a few lines within the border of the sternum parallel with the lower border of the fifth rib or lower, extending outwardly about one and a half or two inches or more, is made ; then a similar one parallel with the upper border of the fourth or third rib, or higher if deemed necessary, connecting the two by a transverse incision about the centre and turning the flaps well back. The costal cartilages, having been separated from the sternum, may be elevated, and the ribs or their car- SURGICAL DISEASES AND INJURIES OF THE HEART. 709 tilages severed at a point distant enough from the sternum to give sufficient room. The internal mammary artery may have to be secured, as well as the intercostals. Pushing the pleura to one side (if this has not been done by the distended pericardium), the pericardium can be opened to such an extent transversely or longitudinally as may be deemed advisable. Gussenbauer performed this operation satisfactorily for purulent pericarditis after the above method. The site chosen is the one of election. Thirteen years ago Dr. Block of Strasburg pointed out that death in cases of heart-wounds resulted, as a rule, from hemorrhage, not shock, and that sufficient time was often given for suture, which his experi- ments on dogs showed was possible. De Vecchio made a similar report at the last International Medical Congress at Rome, 1895. These are the general outlines suggested ; it may be necessary to vary them in any particular case : First, regard the most imminent danger and ward it off — by passive measures if possible, and, if they seem to be ineffectual, resort to active ones, always keeping within the lines of reason and a correct knowledge of the situation. Should it become necessary, as now generally accepted, to suture a wound in the heart-walls, interrupted sutures closely applied, made of thoroughly aseptic animal tissue, should be used ; so also in closing the wound in the pericardium. While aseptic silk will be encysted, here we want absorption of the suture, which will not be necessary to remain very long : forty-eight hours will amply suffice for adhesion in so vascular an area. Park has shown the success of this measure in dogs. Paracentesis of the heart, or cardicentesis, may be neces- sary in cases of engorgement of the right cavities from pulmonary disease where death from dyspnoea is imminent from the overtaxed con- dition of the heart. While it should never be resorted to so long as other measures hold out any hope, death should at least be held at bay as long as possible by resort to this operation, and a successful issue may result. It is a well-attested fact that the introduction of a small, aseptic aspirator or other needle into and through the heart-walls has produced no material injury of this organ. Of the two cavities of the right heart, I would prefer the ventricle, by reason of its thicker walls. Introducing the needle into the space just above the fourth rib, about one inch to the right of the sternum, and pushing it backward, inward, and slightly downward, or going in just above the fifth rib and pushing it directly backward and inward, the right ventricle may be reached — the only precautions being that the aspirator be in good working order and the needle thoroughly aseptic, as should be the site of puncture as well as the operator's hands. From three to six or more ounces of blood may be withdrawn as the exigen- cies of the case may require. Paracentesis of the pericardium is now a well-known pro- cedure, though not so frequently resorted to as it should be, notwith- standing the valuable addition to its literature made by Prof. John B. Roberts, M. D., of Philadelphia, in his most excellent monograph. Paracentesis should unhesitatingly be resorted to whenever life is in danger from distention of the sac by an effusion of any extent, no 710 SPECIAL OR REGIONAL SURGERY. matter what the amount of the effusion or the cause of the disease may be. Roberts says : " Whenever the effusion, whether it be serum, pus, or blood, accumulates so rapidly or in such quantity that it threat- ens to destroy life and refuses to undergo absorption by ordinary treat- ment, it is the duty of the attendant to tap the distended sac." Given an excess of fluid in the pericardium, great or small, and a manifesta- tion of failure of the vital powers not due to other well-defined causes, indicated by feeble cardiac action, ill-defined and weak heart-sounds, thready and flickering pulse, cyanosis, dyspnoea, orthopncea, etc., then we do not hesitate to use the aspirator any longer than to take timely and necessary precautions that have already been suggested in tapping the heart — viz. a good working instrument, small needle, and strict asepsis. The point to be selected is preferably in the fourth or fifth left inter- costal space, about two to two and a quarter inches to the left of the median line of the sternum, entering rather nearer to the upper edge of the lower rib bounding the space, pressing the needle backward and slightly inward until the sense of resistance is no longer felt by reason of the needle entering the sac or the .fluid appears in the outflow tube. The patient should be as nearly recumbent as possible, to allow the heart to fall back from the anterior wall of the sac. Should the sac refill, it can be again emptied, and in the event that pus, and not serum, in a first or subsequent aspiration appears in the outflow, there is nothing to be done when the sac fills again, as it surely will, but open incision 1 and thorough drainage, as in a case of empyema of the pleura. Care should be taken in the introduction of the needle, and a just estimate made as to the depth at which the heart will be found : this reached and no evi- dence of having gained access to the sac existing, the needle had better be withdrawn slightly and pushed forward in a little different direction again, or another site tried. Rotch of Harvard University advises the fifth right interspace as being the most accessible, and with less danger of puncturing the over- lying pleura than the left side. His observations possibly having been made on children, the heart is more likely to be found nearer the central line than in adults. In purulent pericarditis, which cannot be definitely diagnosed until the character of the fluid is open to ocular inspection, there is only one course of procedure. It has been thought that a purulent effusion would be indicated by a greater degree of severity in the clinical phenomena, greater depression, a lower state of health, more feeble cardiac and pulse movement, etc. But there is no satisfactory and reliable evidence other than the fluid itself : this may be obtained by a long needle attached to an ordinary hypodermic syringe. When we are satisfied that there is pus within the pericardium, it should be thoroughly evacuated by a free incision, a drainage-tube inserted, and, if thought necessary, the cavity washed out with a warm (100° to 105° F.) mild antiseptic solution. Or it may be well enough, in order to secure thorough drainage, to remove a section of one or more ribs, which will be advisable in some cases. In cases of hydropericardium due to renal disease or other cause than pericarditis I would prefer an open incision and drainage rather than repeated tapping. 1 First practised by Komero in 1801, afterward by Rosenstein and others. SURGICAL DISEASES AND INJURIES OF THE HEART. 711 Ligation op Arteries. The ligation of arteries is resorted to for the control of hemorrhage, the cure of aneurisms, the arrest of the growth of inoperable tumors, and the relief of hospital gangrene. While the necessities of the case may require any point to be selected, the operations here given are at the site of election, and may have to be materially modified to meet the exigencies of the occasion. The essentials are a correct knowledge of the anatomy of the part and the principles of modern or aseptic surgery. It is not essential in all cases, as was taught by Celsus and others in his day, to use two ligatures, dividing the vessel between them, one ligature usually sufficing, leaving the artery undivided, as in the event of secondary hemorrhage at the site of the operation the vessel will again be more readily found. Nor is it necessary in using the aseptic ligature to tie the artery so tight as to divide the internal and middle coats, but only to press the opposing surfaces together temporarily to secure obliteration of its canal. The intima becomes covered with granulations, developed from it and the clot that forms at the point of arrest of the circulation, which, uniting, form a firm union ; also plastic matter forms around the ligature, absorbing it if of animal tissue or encysting it if of aseptic silk, the exudate strengthening the vessel at the point of ligation. If an artery be divided and its extremity is to be secured, the knot should be sufficiently tight to prevent its slip- ping off. The ligature should be of perfectly aseptic silk, proportionate in size to the vessel to be secured, which I prefer to silkworm gut, catgut, or other animal membrane. Silk can be thoroughly sterilized by boiling, and is much safer and more reliable. The artery when reached will be apparent to the sense of touch. When held between the finger and thumb it can be compressed and its pulsations will be apparent; it is less easily compressed than a vein, which swells out below on pressure, and scarcely feels like a tube, while the nerve cannot be flattened by pressure, and is firm, resisting, round, and cord-like. If an aneurism exists beyond the site of operation, pul- sation in it will cease on compressing the artery. It next remains to open the sheath and clear a part of the vessel for the passage of the aneurism-needle. The sheath is picked up with a pair of rat^toothed forceps, grasping it in a transverse position or at right angles to the course of the vessel, held firmly and well up from the artery, and a clean incision from one-quarter to one-half an inch made in it parallel with the direction of the artery ; the blade of the scalpel should be inclined obliquely, with the flat of the knife toward the artery. Eetaining hold on the sheath by means of the forceps in the left hand, the, scalpel is exchanged for the aneurism-needle, which should be gently insinuated halfway around the artery within the sheath, enter- ing on the side of the incision held by the forceps, which are now detached, and the sheath on the other side of the incision is grasped and held up ; moving the point of the needle slightly from side to side, it is gently insinuated entirely around the vessel until the eye emerges from the opening in the sheath. The ligature is then inserted in the eye of 712 SPECIAL OR REGIONAL SURGERY. the needle, which is withdrawn, bringing the ligature with it. Care must be taken not to include a vein in the ligature, and more especially the trunk of a nerve, which can be ascertained by making careful trac- tion on both ends, slightly lifting the artery. The needle should be kept throughout at right angles to the artery, and should never be threaded until it has passed around the vessel. The ligature should be passed and tied also at right angles to the artery with a " reef-knot," unless there are special indications for the use of the " surgeon's knot." The points of the two fore fingers, with the ends of the ligature in the hand passing over them, should meet upon the artery as the knot is being tightened, and care should be taken that the artery is not dragged out of its place. The knot should be tied gently, slowly, and firmly, avoiding anything like a jerk. The wound is closed by superficial and deep sutures if the latter are considered necessary, well dusted with iodoform, and the limb bandaged. If the main artery of a limb is ligated, it should be slightly elevated, kept sufficiently warm by artificial heat, bottles of hot water, etc. if necessary, and absolute rest maintained for two or three weeks longer — in case of the subclavian, iliac, or common femoral absolute rest is imperative for at least three weeks. Ligature of the Innominate Artery. — The patient lies upon the back close to the edge of the table, chest raised, and head extended and turned to the left, with the arm pulled down and securely fixed. The surgeon stands on the right side and in front of the shoulder. A good light is essential, and means should be at hand for getting it well down into the depths of the wound. Along the upper border of the inner third of the clavicle the first incision is made about three inches in length, which is joined by one of the same length along the anterior edge of the sterno-mastoid muscle, the two joining at an acute angle. The skin and superficial fascia having been divided, the flap is dissected up. The sterno-hyoid and sterno- thyroid muscles, with a few fibres of the sterno-mastoid, are separated from the sternum, care being taken of the anterior jugular vein as it passes behind the last-named muscle at its origin, which may have to be divided ; if so, it should be secured by two small ligatures and divided between them. The deep cervical fascia is now exposed and divided in the line of the external wound, and the common carotid artery sought for, its sheath opened as low down as possible, and this artery followed until its junction with the subclavian is reached. According to Jacobson, the engorgement of the venous circulation, increased by the ansesthetic, will cause the internal jugular and the innominate veins to protrude through the wound. The artery may be flattened out by an aneurism, making it difficult of recognition ; and the cellular tissue around the vessel and between it and the sternum may be so matted with adhesions as to make it difficult to define the artery and its important surroundings — viz. the par vagum, pleura, and innominate vein. The artery must be cleared with the utmost caution, especially on the outer side ; the par vagum and innominate vein may be drawn to the outside. The aneurism-needle should be passed from without in, and a little from below upward, so as to avoid the pleura as much as pos- SURGICAL DISEASES AND INJURIES OF THE HEART. 713 sible. Several aneurism-needles with different curves should be at hand, and a laryngeal mirror will be a valuable aid. Ligature of the Common Carotid below the Omo-hyoid Muscle. — The patient is placed as in the former operation, the head turned slightly to the opposite side, and the hand of the affected side placed behind the back. An incision is made about three inches in length over the course of the artery, commencing a little below the cricoid cartilage and extending to just above the sterno-clavicular articulation, following the inner border of the sterno-mastoid muscle, which is exposed and drawn outward ; the sterno-hyoid and sterno-thyroid are drawn to the inner side ; the omo-hyoid, if brought into view, is pushed upward. The communicating vein from the facial to the anterior jugular and the latter vein must be avoided, and the inferior thyroid veins may give some trouble. Retractors are needed and a good light is essential. The sheath is opened on the inner side, and care must be taken to avoid the descendens noni nerve. The needle is passed from within outward. On the left side the interna] jugular vein may complicate the operation. Ligature above the Omo-hyoid Muscle. — Position of the patient same as in the preceding operation. Incision, about three inches in length, with its centre level with the cricoid cartilage, is made over the course of the artery. The skin and platysma having been cut through (together with branches of the superior cervical nerve), the deep fascia along the anterior border of the sterno-mastoid is cut through. The edge of this muscle having been made out, it must be followed down until the omo-hyoid is reached. The communicating vein from the facial and the anterior jugular must be avoided. The sterno-mastoid may be drawn a little outward and the omo-hyoid downward, and the angle between the two muscles well cleared. The pulsations of the artery should now be sought, and the vessel can be readily detected as it crosses the "carotid tubercle." The carotid tubercle is "the anterior projection of the transverse process of the sixth cervical vertebra, and is about two inches above the clavicle. The sterno-mastoid artery and the superior and middle thyroid veins must be avoided, and care taken of the descendens noni nerve. The needle is passed from without inward. Ligature of the External Carotid. — Position of the patient same as in the preceding operations. An incision from near the angle of the jaw, along the line of the artery, is made, terminating about even with the middle of the thyroid cartilage. The greater cornu of the hyoid bone will be about the centre of the incision. The integument and pla- tysma having been divided and superficial veins secured, the fascia is next divided, and the anterior border of the sterno-mastoid exposed at the lower part of the incision, which must be drawn outward. The pos- terior belly of the digastric is next cleared at the upper angle of the wound, and the hypoglossal nerve below it exposed, being careful not to injure it. With the finger the great cornu of the hyoid must now be sought, and the artery will be found and can be readily exposed opposite its tip, and can be ligated between the superior thyroid and lingual arteries, or below the latter if necessary. The facial and superior thyroid veins m ust be avoided and lymphatic nodes may lie in front of the artery. The artery having been cleared, the needle is passed from within outward, taking care not to include the superior laryngeal nerve, which passes down behind the artery. 714 SPECIAL OR REGIONAL SURGERY. Ligature of the Lingual Artery at its First Part. — Position of patient same as in operation on the common carotid ; incision similar, though shorter, with its centre opposite the body of the hyojd bone. The external carotid is sought for, and carefully followed until the lingual is reached. The wound will be deep, and the first portion of the vessel more or less obscured by numerous veins (Figs. 288 and 289). Fig. 2! Fig. 289. Surgical anatomy of the neck ; ligation of the carotid, lingual, and facial arteries (Bernard and Huette). Ligature of the facial artery may be placed by an incision similar to that exposing the external carotid or the first part of the lingual. It is more conveniently secured as it crosses the margin of the lower jaw. A horizontal incision is made over the course of the artery, along and just under the inferior margin of the jaw, one inch in length, where we SURGICAL DISEASES AND INJURIES OF THE HEART. 715 find the artery crossing the bone at the anterior border of the masseter muscle. It is only necessary to divide the skin, platysma, and fascia. The facial vein is behind the artery and very close to it. The needle should be passed from behind forward (Figs. 288 and 289). Ligature of the temporal artery is applied by an incision, one inch long vertically, over the course of the artery, between the tragus and condyle of the lower jaw. It is only covered by skin and dense fascia, a single large vein lying behind and overlapping it. Temporo-facial branches of the facial nerve cross the artery, which lies behind the auriculo-temporal nerve. The ligature should be passed from behind forward. Ligature of the occipital artery may be applied close to its origin and also back of the mastoid process. In the first position an incision similar to that exposing the external carotid at its upper part will suffice. In the second position an incision nearly horizontal, two inches long, is made, commencing at the tip of the mastoid process and carried back- ward and a little upward. The skin and fascia having been divided, the posterior fibres of the sterno-mastoid are cut ; next the splenius is divided, and so much of the trachelo-mastoid as many be necessary. The artery is then felt and exposed in the interval between the mastoid pro- cess and the transverse process of the atlas, which can be felt with the finger. The needle can be passed either from above or below. Ligature of the Internal Carotid. — Position of the patient and ope- rator same as in operation on the external carotid at its lower point, and the incision is also almost similar, being a little more to the outside. The anterior edge of the sterno-mastoid is exposed and drawn outward. The external carotid is found and followed down to its junction with the internal, and drawn gently inward with a blunt hook. The digas- tric muscle is drawn upward. The sheath of the vessels is opened with care, and the needle passed from without inward, observing the same care as in ligating the common trunk. The internal jugular vein, the par vagum, the sympathetic ganglion, and the ascending pharyngeal artery, all lying close to the artery at this point, must be avoided. The internal differs from the external in giving off no branches in this part of its course (Figs. 288 and 289). Ligature of the Vertebral Artery. — Position of the patient same as in ligation of the external carotid. An incision commencing at the clavicle is carried up along the outer edge of the sterno-mastoid muscle for three inches, dividing the skin and superficial fascia ; a few fibres of the attachment of the sterno-mastoid must be severed close to the clavicle. The deep fascia having been severed, the sterno-mastoid muscle and anterior jugular veins are drawn inward. The scalenus anticus muscle is next found, and the interval between it and the longus colli muscle entered with the finger, the position of the common carotid and internal jugular vein made out, and the transverse processes of the sixth and seventh cervical vertebrae located ; below that of the former the artery should be felt. The various structures must be pushed to one or the other side. The vertebral vein lies in front. Care must be taken not to damage the inferior vessels, the pleura, or the thoracic duct on the left side. The needle is passed from without inward. Ligature of the Inferior Thyroid Artery.. — An incision three inches 716 SPECIAL OR REGION AL SURGERY. in length along the inner edge of the sterno-mastoid muscle, as in liga- tion of the common carotid, low down, the wound reaching down to the clavicle. The sterno-mastoid is drawn outward, and the carotid artery and its vein are also drawn gently outward. The transverse process of the sixth cervical vertebra is now carefully sought, a little below which the artery may be found, passing inward behind the carotid, close to which vessel the ligature is applied, thus avoiding the recurrent laryngeal nerve. Ligature of the Subclavian Artery. — While the ligature has been applied to the first and second portions of the subclavian, it is now Fig. 290. Fig. 291. Surgical anatomy and ligation of the axillary and subclavian arteries (Bernard and Huette). almost exclusively limited to the third part, which comprises that seg- ment of the vessel crossing the posterior triangle of the neck and where SURGICAL DISEASES AND INJURIES OF THE HEART. 717 it is most superficial. The base of this triangle is formed by the outer edge of the scalenus anticus muscle and the sides by the omo-hyoid muscle and the clavicle, the latter muscle being about one inch above the bone (Figs. 290 and 291). The suprascapular artery lies behind, covered with the clavicle, and the transverse cervical artery crosses beneath the omo-hyoid muscle at some distance above the main vessel. Normally, there is no branch given off from the subclavian at this part. In ligating the subclavian in the third part of its course the patient lies on the back, near the edge of the table, with thorax raised and head extended and turned to the opposite side, the arm pulled well down, passed behind the back, and securely fixed. The operator stands in front of the shoulder, a good light being essential. Drawing the skin over the posterior triangle well down with the left hand, an incision is made through it, reaching the clavicle. The incision, parallel with the clavicle, should be about three inches in length, and when the downward traction of the skin is withdrawn should be about one inch above the clavicle, extending across the base of the posterior triangle from the trapezius to the sterno-mastoid, with the centre of the wound even with a point about one inch to the inner side of the centre of the clavicle. The integument, the platysma, and supraclavicular nerves, with, possibly, a vein passing over the clavicle connecting the cephalic vein with the internal jugular, are divided by the incision. The amount of the trapezius and sterno-mastoid exposed will depend upon the extent to which they are attached to the clavicle (Figs. 290 and 291). The deep cervical fascia is next divided the extent of the primary incision, carefully and without the aid of a grooved director. If the external jugular vein cannot be drawn to one side with a blunt hook, it should be divided between two ligatures and all bleeding vessels secured. The outer margin of the scalenus anticus should next be made clear, and the position of the omo-hyoid developed, and if at all in the way it must be drawn upward. The finger should be passed along the edge of the scalene muscle until the tubercle of the first rib is reached, when it will be in contact with the artery and its pulsations felt, the vessel rest- ing on the rib. A little careful dissection will clear the artery and bring into view the lowest cord of the brachial plexus, which should be systematically exposed by a slight but careful dissection. The sub- clavian vein will be seen and felt, but it does not encroach upon the field of operation. The needle may now be carefully passed from above downward and from behind forward, its course guided by the fore finger of the left hand, protecting and holding the vein out of the way. In some cases portions of the trapezius and sterno-mastoid may have to be cut. The transverse cervical or suprascapular arteries may be in the way, and must be drawn aside, and in no instance cut, as they per- form an important part in the collateral circulation. If the patient is stout with short neck, the difficulties will be en- hanced. A plexiform arrangement of the veins, their engorgement, matting together and oedematous condition of the tissues greatly increase 718 SPECIAL OR REGIONAL SURGERY. the difficulties. The pleura must be carefully avoided in passing the needle, as well as the lower cord of the brachial plexus. Ligature of the axillary artery is practically limited to its third part. The course of the artery will be covered by a line from the cen- tre of the clavicle to the humerus, close to the border of the coraco- Fig. 292. / Tg^ZZ Pig. 293. Surgical anatomy of the axilla and ligation of the axillary artery (Bernard and Huette). brachialis muscle, when the arm is so abducted as to be at right angles to the body (Figs. 290-293). The patient is placed upon the back, close to the edge of the table, with the shoulders raised, the arm at right angles to the body and held horizontally, the surgeon placing himself between the arm and the thorax. SURGICAL DISEASES AND INJURIES OF THE HEART. 719 The axilla having been shaved, an incision about three inches in length is made along the course of the artery, commencing at the middle of the outlet of the axilla, at the junction of the anterior and middle thirds, and continued downward along the inner margin of the coraco- brachialis muscle. The knife should be held with the blade horizontal, and the coraco-brachialis thoroughly exposed after skin and fascia have been divided. This muscle, with the musculo-cutaneous nerve, is gently drawn outward, when the position of the artery may be deter- mined with the finger. In clearing the artery the median nerve is exposed, and should be drawn outward with a blunt hook, and the inter- nal cutaneous nerve pushed to the inner side. The vense comites having been well demonstrated, the needle is passed from within outward. Ligature of the Brachial Artery at the Middle of the Arm.— The limb should be extended and abducted, with the hand supine and held away from the body, the arm itself unsupported, but the limb held securely by an assistant grasping the forearm. The surgeon stands on the outside of the limb on the right side and between the body and the limb on the left, making his incision from above downward. The incision, about two and a half inches in length, should be made along the inner edge of the biceps muscle in the line of the artery. The fascia, which is here thin, is exposed and divided, and, the muscular layer reached, the inner edge of the biceps clearly exposed and defined. The muscle is displaced slightly outward, and the pulsation of the ves- sel sought. If the median nerve is not brought into view, a little dis- section will clear it : in the middle of the arm it usually lies in front of the artery, and should be displaced gently to the outside : below the middle of the arm it is more conveniently displaced inward. While the artery is being exposed the elbow may be slightly and moderately flexed (Figs. 294 and 295). The sheath of the vessel having been opened, the vense comites sepa- rated as well as possible, the inner one usually being the larger, the needle is passed from the median nerve. In the upper part of its course the inner margin of the coraco-bra- chialis is exposed instead of the biceps, and the ulnar nerve will be found lying to the inner side of the vessel. Ligature of the radial artery may be applied at the upper, middle, and lower third of its course. The radial continues the line of the brachial, and a line extending from the middle of the bend of the elbow to the gap between the scaphoid bone and the extensor ossis pollicis and extensor internodii pollicis will give its position reasonably definitely. In the upper third of the forearm an incision two and a half inches in length is made in the line of the artery. The radial or other surface vein may be encountered. After the deep fascia is divided the interval between the supinator longus and pronator teres is opened up, the fibres of the supinator being vertical and those of the pronator oblique. Beneath the supinator the vessel will be found unaccompanied by the nerve. The needle can be passed from either side. The limb is supin- ated, and firmly held by an assistant grasping the hand and arm. The surgeon stands on the side to be operated on (Figs. 296 and 297). In the middle third, the limb placed as above, an incision two inches in length is made along the course of the artery, any superficial veins 720 SPECIAL OR REGIONAL SURGERY. from the median or radial being avoided. The anterior division of the musculo-cutaneous nerve lies usually in the line of the artery between the superficial and deep fascia, and must be held aside. The fibres of the superficial fascia run longitudinally, and those of the deep fascia transverse. The deep fascia, being made clear, is divided the length of the superficial incision, and the supinator longus is exposed about the point where it becomes tendinous. The ulnar border of this muscle is Fig. 294. Fig. 295. Surgical anatomy and ligation of the brachial artery (Bernard and Huette). defined and drawn outward ; the elbow being slightly flexed will allow this to be done more easily, and the vessel will be found lying upon the insertion of the pronator radii teres, with which it is connected by con- siderable connective tissue. The nerve may or may not be seen. The vena? comites being separated as well as possible, the needle is passed from either side. In the lower third, with position as before, an incision one and a SURGICAL DISEASES AND INJURIES OF THE HEART. 721 quarter inches long is made over the line of the artery at the point where the pulse is usually felt, parallel with and between the supinator longus and flexor carpi radialis muscles, but must not extend below the tuberosity of the scaphoid (Figs. 296 and 297). Fig. 296. Fig. 297. Surgical anatomy and ligation of the radial and ulnar vessels (Bernard and Huette). The commencement of the radial vein lies over the artery and must be avoided. The fascia, which is here quite thin, is divided in the course of the superficial incision, and the gap between the two tendons made out. The terminal part of the anterior division of the external cutane- ous nerve is over the artery and in close relation. If it is found impos- sible to separate the vense comites sufficiently to let the needle pass, they may be included in the ligature. Ligature of the Ulnar Artery. — This vessel, larger than the radial, 46 722 SPECIAL OR REGIONAL SURGERY. follows a curved course in the upper third of the limb, and perfectly straight the remaining two-thirds. It lies too deeply for ligature in the upper third, except for arrest of hemorrhage when cut or divided, and the operation of election is left for the middle and lower third. It may lie ligated, however, close to the origin of the brachial, if needed, by slightly extending downward the incision for ligating this vessel at the end of the elbow (Figs. 296 and 297. The artery in the lower two-thirds of its course will be found beneath a line drawn from the tip of the internal condyle of the humerus to the radial side of the pisiform bone. Ligation of the palmar arch and branches of it and the radial or ulnar arteries is only required for traumatisms, the nature of which will determine the method of application. Ligation of the Abdominal Aorta. — The eleven cases of ligation of the abdominal aorta having all terminated fatally, it is, in my opinion, an unjustifiable operation, affording neither hope to the patient nor eclat to the surgeon ; consequently it is only mentioned to be condemned. Ligation of the common iliac artery can be performed by an ante- rior or lateral incision or by the intraperitoneal method : the latter is con- sidered by Treves as the best, though it has not yet been satisfactorily tested. It can be carried out by the intraperitoneal method of reaching the internal iliac, to be subsequently considered. In the anterior incision the bowels should be thoroughly evacuated, any gaseous distention relieved if possible, and the pubes well shaved. The patient lies on the back, with thighs well extended and close together, with the head and shoulders slightly raised to relax the abdominal parietes. The surgeon stands on the side to be operated on, facing the patient, cutting from above downward on the right and in an opposite method on the left. An assistant, to whom is entrusted the care of the broad retractor to be used, stands on the opposite side. An incision five inches in length is made, commencing one and one- fourth inches to the outer side of the spine of the pubes, a little above Poupart's ligament, the first inch and a half being made parallel with the ligament, when the incision is curved slowly upward, perpendicular to the ligament, terminating about one and a quarter inches to the out- side of the umbilicus. The three abdominal muscles and the trans- versalis fascia are divided carefully ; the peritoneum is carefully and gently stripped from the iliac fossa with the fingers, pushed inward, and held out of the way with a broad retractor : the patient may be turned to the opposite side to aid in keeping the intestines out of the way. A strong needle, of good length, with lateral curve, will be found most available, which should be passed from within outward. The vein lies directly behind on the right, and to the inner side and slightly behind oh the left. Great care must be taken to avoid injury to the perito- neum. Ligature of the internal iliac artery is accomplished by the extra- or intraperitoneal method. The extraperitoneal method is identical with the anterior operation on the common iliac previously described. The peritoneum having been pushed aside until the external iliac is reached, this vessel is followed down to its junction with the internal. The wound is deep, and several varieties of needles with different curves SURGICAL DISEASES AND INJURIES OF THE HEART. 723 should be at hand, and on either artery the needle should be passed from within out. By the intraperitoneal method the abdomen is opened in the median line by an incision extending from symphysis to umbilicus, or a little above in fleshy subjects. The intestines having been pushed up and Fig. 298. Fig. 299. Fig. 300. Surgical anatomy and ligation of the femoral, external iliac, and epigastric arteries (Bernard and Huette). drawn aside, the area of the deep wound is surrounded by aseptic gauze mats, preferable to flat sponges, and so cut off from the peritoneal cavity. The wound being held well open by broad retractors or spatulse, the peritoneum over the artery is divided to the extent of an inch and a half, and the common artery followed down to its bifurcation. The vein is much larger than the artery, and the separation will require care. 724 SPECIAL OR REGIONAL SURGERY. The ureter must not be injured or included in the ligature, and sympa- thetic nerve-fibres must be avoided. Ligature of the External Iliac Artery. — The modified form of Sir Astley Cooper's operation is as follows : The patient lying on the back, head and shoulders slightly raised, an incision is made three and a half inches long above Poupart's ligament. The incision, slightly curved, beginning one and a quarter inches outside the pubic spine, runs for two-thirds of its course about three-eighths of an inch above the ligament and parallel with it, the outer third curving slightly away from the ligament. The skin and superficial tissues having been cut through and the divided superficial epigastric artery secured by ligature, torsion, or pressure-forceps, the white, glistening aponeurosis of the external oblique now brought into view is divided in the line of the primary incision, following very nearly the direction of its fibres. The parts being retracted, the outer border of the conjoined tendon is made out at the inner angle of the wound. The lower fibres of the internal oblique are divided close to their attachment to Poupart's ligament as far as necessary. The transversalis muscle is attached only to the outer third of the ligament (Figs. 298-300). The transversalis fascia, being exposed, is divided transversely over the artery and as far on either side as necessary. The deep epigastric artery lying between this fascia and the peritoneum must be avoided. The external iliac artery now being made out, the subperitoneal tis- sue about the vessels should be carefully loosened, and the peritoneum pulled from the artery and vein with the utmost care and pushed upward toward the umbilicus, and held out of the way with a broad retractor. The loose subperitoneal tissue, which forms a kind of sheath for the artery, should be cautiously cleared away and the needle passed from within outward. In closing the wound the divided fibres of the internal oblique may be attached to Poupart's ligament, and the aponeu- rosis of the external oblique united by a few catgut sutures. Ligation of the femoral artery is usually performed at the base of Scarpa's triangle, at its apex, and in Hunter's canal. With the hip a little flexed and the thigh abducted and rotated outward, a line drawn from midway between the anterior superior spine of the ilium and the sym- physis pubis to the tuberosity of the internal condyle will indicate its course. The centre of Poupart's ligament is to the outer side of the line of the vessels. Ligation of the common femoral is best done at the base of Scarpa's triangle. The patient lies upon the back, with the hips a little flexed, the thigh abducted and rotated outward, the knee bent, and the leg rest- ing on its external surface. The surgeon stands on the outer side of the limb, and cuts from above downward on the right, and vice versd on the left. An assistant stands on the opposite side (Figs. 298-302). An incision two inches in length, commencing just above the centre of Poupart's ligament, is made downward directly over the course of the artery. The fatty tissue covering the fascia lata having been reached, is divided, care being taken not to injure any of the lymphatic nodes and the superficial epigastric and superficial circumflex iliac veins. The cribriform fascia is divided in the line of the original wound, especial care being taken to avoid the superior external pubic, the superficial SURGICAL DISEASES AND INJURIES OF THE HEART. 725 epigastric, or other arterial branches. The crural branch of the genito- crural nerve lies on the sheath of the artery, on the outer side. The sheath being carefully opened, the needle is passed from the inner side. Ligation of the Superficial Femoral at the Apex of Scarpa's Tri- angle. — Position same as in preceding operation. An incision over the line of the vessel, with its centre at the apex of the triangle, is made. Pres- sure, having previously been made over the saphenous vein where it joins the deep femoral, will outline the course of the superficial veins. The saphena will generally be to the inner side of the incision. The integu- Fig. 301. Fig. 302. ..::■ Surgical anatomy and ligation of the femoral artery (Bernard and Huette). ment and superficial fascia having been divided, the deep fascia is divided and the inner border of the sartorius muscle is sought for it being the guide to the artery, and is recognizable by the course of its fibres downward and inward, underneath which the sheath of the vessels will be found. The muscle, having been detached with the finger is held outward with a retractor, exposing the sheath, the artery in front and the vein behind, the long saphenous nerve generally, and' sometimes a nerve to the vastus internus lying on the vessel. The sheath having 726 SPECIAL OR REGIONAL SURGERY. been carefully opened, the needle is passed from within outward, caution being used to avoid injury to the vein. If the vein is wounded by the needle, it should be closed by a small ligature and the ligature applied to the artery higher up. A needle curved laterally will be more readily passed under the vessel. Ligature of the Superficial Femoral in Hunter's Canal. — Position same as in preceding operation. An incision three and a quarter inches long is made over the course of the vessels in the middle third of the thigh. In the subcutaneous tissue will be found the anterior division of the internal cutaneous nerve, and to its inner side the long saphenous vein, which must be drawn to the inner side. The fascia lata is now divided in the line of the primary incision, the sartorius muscle exposed, and its anterior outer edge drawn inward. The leg being now well abducted, making prominent the fibres of the adductor magnus and the lower border of the adductor longus, the site of Hunter's canal, lying between the adductor magnus and the vastus internus, will be well defined. Clearing away any fatty tissue that may obscure, the part of the fascia forming the roof of Hunter's canal, with its fibres running transversely, will be made distinct. At this point, at the outer side of the wound, the nerve to the vastus internus must be looked for. Opening the canal in the line of the wound, the artery is exposed, and the needle may be passed from either side. In front and to the inner side will be found the internal saphenous nerve, which must be avoided and care taken not to injure the vein (Figs. 301 and 302). Ligature of the Posterior Tibial Artery. — A line drawn from the centre of the popliteal space to a point midway between the inner malle- olus and the heel will correspond to the lower half of the artery. The upper half curves slightly inward from this line. In operations on this artery the patient lies on the back, the knee flexed, the leg lying on the outer side, the feet on the table, secured in this position by an assistant. The surgeon stands on the outer side of limb (Figs. 303 and 304). In the middle of the calf an incision, four inches in length, in the middle third of the leg is made, parallel to the inner margin of the tibia and three-quarters of an inch behind its crest. After dividing the skin care must be taken not to injure the internal saphenous vein, which should be drawn aside. The fibres of the deep fascia, all of which are transverse, are divided and the margin of the gastrocnemius brought into view. The soleus is next exposed and divided the length of the incision, the aponeurosis with its fleshy fibres being cut through. Here the knife should be held perpendicular to the muscle, its edge directed toward the tibia and the blade nearly horizontal. The fascia covering the vessels and the deep muscles of the leg is now exposed, and the artery can be felt lying near the outer border of the tibia. The nerve lies to the outer side of the artery. The veins are very conspicuous, and may hide the vessel, and in all probability will have to be included in the ligature. The needle must be passed from the nerve. Ligature in the lower third of the leg is applied by an incision two inches in length along the line of the artery midway between the margin of the tendo Achillis and the inner edge of the tibia. The superficial and deep fascia are divided, as well as the annular ligament at its upper SURGICAL DISEASES AND INJURIES OF THE HEART. 727 part. The artery will be found lying on the flexor longus digitorum muscle, with the nerve to the outer side. The needle is passed from the nerve, and the venae comites may have to be included. Ligature behind the Malleolus. — A curved incision, two inches long, is made about one-half an inch behind and parallel with the margin of the inner malleolus, the knife being directed toward the tibia. The internal annular ligament is divided over the artery. The vessels and nerve lie in a gap between the tendons, and can be readily made out by the touch. Separating the artery from the vein, the needle is passed from within outward (Figs. 303 and 304). Fig. 303. Fig. 304. Surgical anatomy and ligation oi the posterior tibial artery (Bernard and Huette). Ligature of the Anterior Tibial Artery.— The course of this artery will be found under a line from midway between the head of the fibula and the outer tuberosity of the tibia, extending down to the centre of 728 SPECIAL OR REGIONAL SURGERY. the ankle-joint in front. The patient lies upon the back, the limb straight upon the table, fully rotated inward, with the foot projecting beyond the table and forcibly extended. In the upper third of the leg an incision, three and a half inches long, is made along the line of the artery, its upper end about one inch below the head of the tibia. The deep fascia is divided along the same Fig. 305. Fig. 306. Surgical anatomy and ligation of the anterior tibial and peroneal arteries (Bernard and Huette). line, and the interval between the tibialis anticus and the extensor com- munis digitorum made out. The foot is now flexed to relax these mus- cles, and the space between them opened up by finger or handle of scalpel, the external border of the tibia being distinctly made clear to the touch before the artery is sought for, the extenser communis being held down by the fingers of the left hand, while an assistant holds the tibialis anticus toward the tibia with a retractor (Figs. 305 and 306). SURGICAL DISEASES AND INJURIES OF THE HEART. 729 The artery will be found lying on the interosseous membrane to the outer side of the border of the tibia, covered and held down by a mode- rately dense connective tissue. A second retractor now holds back the extensor communis, and the artery is exposed. The vense comites may have to be included in the ligature. The nerve lies to the outer side of the artery, and, as it sometimes does not join the artery until the middle third of the leg is reached, may not be seen. The needle is passed from without inward. In the middle third of the leg make an incision three inches long over the line of the artery. The deep fascia, being exposed, is divided in the interval between the tibialis anticus and the extensor communis digitorum, the latter being tendinous at this point. The foot is flexed and the muscles separated with the handle of the scalpel, keeping in the direction of the tibia. The artery will be found on the interosseous membrane, the extensor pollicis to the outer side. The nerve will be exposed before the artery is reached, as it lies in front of the vessels. The needle may be passed from either side. The vense comites may be included in the ligature, but the nerve must be carefully protected from injury (Figs. 305 and 306). Ligature in the lower third of the leg is applied by an incision two to two and a half inches in length over the line of the artery, and just to the outer side of the tendon of the tibialis anticus, identifying with certainty the tendon. The foot need not be quite so much rotated as in the preceding operation. The deep fascia, or upper band of the annular ligament, is divided in the same line, and the tendons of the tibialis anticus and extensor pollicis exposed and defined. The artery will be found between them on the front of the tibia, imbedded in fatty con- nective tissue. The foot being slightly flexed, the tendon of the exten- sor pollicis is drawn to the outer side with a blunt hook, exposing the artery. The nerve lies to the outer side, and the needle should be passed from it. The vense comites can be readily separated (Figs. 305 and 306). CHAPTER XL. SURGICAL DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. By D. Beyson Delavan, M. D. (Edematous laryngitis is a serous, seropurulent, or purulent infil- tration of the submucous cellular tissue of the larynx, and is, practically speaking, an acute cellulitis. The frequency of its association with erysipelas has often been observed. The oedema may be situated above, at, or under the glottic aperture. It is generally above and in the aryteno-epiglottic folds and the ventricular bands, which, with the epiglottis, may become enormously swollen and entirely occlude the larynx. The swelling is usually bilateral. Unless resolution takes place the infiltration may become sero-purulent, and later purulent, resulting in abscess. OEdema of the larynx may be inflammatory or non-inflammatory, acute or chronic. The non-inflammatory form may occur from certain non-surgical causes. Inflammatory oedema may develop from an attack of acute catarrhal laryngitis or complicate erysipelas of the pharynx. Symptoms. — The chief local symptoms are dyspnoea, aphonia, dys- phagia, with, occasionally, cough, and a sensation of marked irritation in the throat. The laryngoscope reveals intense congestion of the larynx and often of the adjacent parts, with the characteristic swelling of the arytenoids and the epiglottis. The latter may attain such size as to entirely occlude the larynx, and thus produce asphyxia. The false vocal bands are sometimes implicated. The disease may be unilateral, but is more often symmetrical. Treatment must be prompt. In early stages applications of cold in and outside of the larynx, or, if better borne, steaming inhalations (tr. benzoin, co., acid, carbolic, or tr. opii, of either, 3j-0ij). The admin- istration of a slightly purgative dose of calomel is often valuable. Vocal and physical rest. To relieve temporarily, local applications of a 4 per cent, solution of cocaine. Should oedema become severe, scarification, per- formed with the concealed laryngeal knife, aided by laryngoscopic demon- stration of the parts, or with Buck's scarificator. Following scarification, application of cocaine to the larynx, as suggested by the writer, for the purpose of constricting the oedematous tissues and, if possible, emptying them. If necessary, quick tracheotomy, in which the simplest methods are permissible, for want of better, as long as the asphyxia is relieved. The value of the O'Dwyer tube in these cases has often been proved. 730 DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 731 Besides relieving the dyspnoea, its pressure upon the infiltrated parts may actually hasten the disappearance of the oedema. These cases should be watched throughout with the closest vigilance. Injuries to the Larynx. "Wounds of the larynx and trachea generally complicate more extensive injuries of the neck, involving division of the great vessels and speedy death. Sometimes the larynx or trachea may be wounded, the cervical vessels receding before the knife, and thus escaping injury. (Vide p. 790.) Inflammation or septic infection is a more frequent source of danger in the smaller wounds, and in the larger ones necrosis, inhalation of detached fragments, growth of granulations, secondary hemorrhage, tracheo-bronchitis, pleurisy, and broncho-pneumonia. Death in from eleven to fourteen days, and recovery in uncomplicated ones in from thirty to forty. Defective voice, laryngeal stenosis, and tracheal fistula sometimes result. The prognosis is serious, especially in the case of small penetrating wounds. Treatment must be prompt and energetic. Union by first intention is unusual. Provision should therefore be made for drainage. Usually hemorrhage must be checked and asphyxia pre- vented. The air-passages must be cleared of blood, partly detached frag- ments of tissue removed, a tracheal cannula inserted, the strength of the patient sustained, and the indications in special cases actively met. Tracheotomy may be required, on account of asphyxia and to relieve hemorrhage, which the asphyxia increases. Fracture of the Larynx. — Most common in men, and is generally due to direct violence. It may be simple or compound, incomplete or complete. The thyroid is most often implicated, the cricoid next, while fracture of both is unusual, and that of the arytenoids very rare. Frac- ture may be complicated with fractures and wounds of neighboring parts and with injury to the external jugular vein. The symptoms, varying in severity, are functional disturbance, expectoration of frothy blood or of bloody mucus at or shortly after the time of the accident, stridulous respiration, dyspnoea, more or less aphonia, dysphagia, and sharp pain in the larynx, increased on pressure. Inspection will reveal swelling and ecchymosis, and over the larynx itself various irregularities, with unusual flexibility, mobility, or even crepitation of the cartilages. All of the latter signs may be absent. The symptoms are sometimes slight and recovery speedy. Gener- ally, they are either severe from the first or gradually become so. Later, the danger is from abscess, necrosis of fragments, and the forma- tion of deforming cicatrices and consequent stenosis of the larynx. The prognosis is serious, and the rate of mortality verv high, especially in fractures of the cricoid. Eesulting cicatricial stenosis of the larynx may make the permanent wearing of a tracheal cannula necessary- Diagnosis is easy except where there is little displacement and much swelling. Treatment. — Several methods of treatment have been recom- mended : while some cases have recovered without surgical aid, trach- 732 SPECIAL OR REGIONAL SURGERY. eotomy has generally been advised when dyspnoea threatens. In frac- tures with displacement tracheotomy may be followed by attempts at replacement of the fragments and their retention in position by means of a suitable support. Some advise a thyrotomy and the separation of the two halves of the larynx until the fragments have united in good position, or, if some have become detached so as to obstruct the larynx, to either replace or remove them. Wagner performs thyrotomy, asep- ticizes the wound, replaces or removes the fragments of cartilage, and packs the cavity of the larynx with iodoform gauze. Burns of the air-passages may be caused by the inhalation of flame or steam or by the swallowing of hot or caustic liquids. Such accidents are quickly followed by acute inflammation, and sometimes by considerable swelling. Inflammation may extend to the trachea, bronchi, and lungs. The early symptoms are pain, dyspnoea, dysphagia, aphonia, and shock. Respiration is rapid and stridulous, the countenance pale and anxious, and there is marked restlessness. The symptoms may be mild at first, but later severe, especially after the ingestion of caustic liquids. Often oedema of the larynx and fatal dyspnoea soon supervene, or, if these are escaped, pulmonary complications quickly follow. Tkeatment. — The inhalation of flame or of steam is always a grave accident, complicated as it usually is by other injuries or burns, and by physical depression and severe mental shock. Absolute quiet should be secured, the strength supported, the digestion regulated, and the patient carefully watched for the development of serious respiratory symptoms. Many have recommended the administration of calomel. Warm inhala- tions, containing a small proportion of opium (tr. opii J5J, boiling water Oj), are sometimes successful in relieving irritation and quieting glottic spasm and cough. When oedema is imminent, if the case is seen early, cracked ice, held in the mouth, will often subdue the inflammation and quiet the pain. The patient must not be left unwatched for a moment, and if oedema occur prompt aid must be afforded by scarification and the subsequent application of cocaine. Often urgent dyspnoea develops with startling rapidity, requiring instant relief by intubation or tracheotomy. Where caustic fluids have been swallowed neutralizing agents should of course be resorted to if the case be seen in time. Foreign Bodies in the Air-passages. Liquids accidentally drawn into the larynx or trachea are usually expelled by efforts of coughing. When there is laryngeal insensibility it is more serious. The only symptoms may be severe dyspnoea and the existence of moist tracheal rales. Death follows at once or is caused secondarily by pulmonary inflammation. Spasm of the glottis and even death may be caused by the topical application to the larynx of strong medicated solutions. The entrance of blood or pus into the air-passages may cause rapid suffocation. Pus from the pleural cavity, from an abscess of the liver or of the mediastinum, may find its way into the air-passages. Solids. — The entrance of a foreign body into the air-passages must DISEASES AND INJUJtIES OF THE RESPIRATORY ORGANS. 733 always be regarded as one of the most serious of accidents. Introduc- tion through an external wound is unusual. The variety of bodies which may be inhaled is unlimited. Their size is necessarily restricted to the diameter of the glottic aperture. Of course upon the size, shape, nature, and seat of lodgement of the object will depend largely the degree of harm which it may inflict. Foreign bodies may simply lodge in the larynx itself, or may be detained in one of the ventricles or wedged in the rima glottidis. They may become fastened in the trachea, or descend to its bifurcation, or through one of the greater bronchi into one of the more remote bronchial tubes. The right bronchus is more apt to be the seat of lodgement than the left. A foreign body in the trachea may cause severe reflex cough, together with certain changes in the current of inspired air heard upon ausculta- tion. Lodged in one of the bronchi, unless relieved it will almost cer- tainly cause death. Following the exclusion of the air, pneumonia may readily develop, or,- if the foreign body be particularly irritating in its character, abscess or gangrene of the lung may be established. In such a case the diagnosis will often be a matter of extreme difficulty unless a clear history of the inhalation of the body be obtainable. Auscultation will sometimes reveal, at a certain point in the neighborhood of one of the larger bronchial tubes, such changes in the air-currents as will indi- cate partial occlusion. The prognosis, always exceedingly grave, is more serious in the child than in the adult. Caustic substances or foreign bodies, such as beans, which are capable of swelling, are especially dangerous. The long-continued presence of a foreign body in the air-passages may sim- ulate phthisis. Laryngoscopy, aided by local anaesthesia, will often be of great assist- ance in demonstrating the position of the foreign body. Treatment is often extremely difficult. The statistics of operation, although not satisfactory, are slightly in favor of surgical interference. In simple cases it is not good practice to excite cough, sneezing, or vomiting. Even the inverted position, assisted by percussion upon the back, is not recommended, although often effective with children choked from the ingestion of too large morsels of food, the danger being the causing of spasm of the glottis by the impact of the body upon the vocal bands. If the foreign body is impacted in the larynx, it may be removed through the natural passages, in the case of large objects, by means of the finger or a pharyngeal forceps. Smaller bodies should be removed, with the aid of the laryngoscope, by means of suitable endo- laryngeal instruments, the parts having first been thoroughly cocainized. If the object is too large to be removed at once, it may be crushed and taken away piecemeal. If it has fallen into the trachea, one of the special O'Dwyer tubes may be inserted, in the hope that the object may be expelled through it. If it has become impacted in the larynx in such a way that it cannot be extracted otherwise, thyrotomy may be indicated, or, if the object is small, cricothyrotomy. When the body has entered the trachea, tracheotomy is required. The trachea should be opened low down, and, unless the body is easily reached and expelled several rings should be divided and 'the edges of the wound widely 734 SPECIAL OR REGIONAL SURGERY. separated, the patient inverted, and efforts made, by palpating the chest or by exciting cough, to cause its expulsion. If necessary, long, slender forceps may be used for dislodging it. Sometimes the foreign body will remain in situ for several days. It has also been suggested to attack these bodies from behind, by trap-door operations upon the posterior thoracic wall and exposure of the roots of the lungs through the posterior mediastinum. The method is ingenious, but the cases must necessarily be exceedingly rare in which so serious and uncertain a plan can be safely adopted. Perichondritis of the Larynx. Perichondritis of the larynx is an inflammation of the perichondrium and of the cartilages, sometimes followed by caries or necrosis of the latter. It is generally secondary, and rarely primary. Among its most common causes are tubercular, specific, and cancerous ulceration of the larynx. It may also follow typhoid fever, variola, scarlet fever, erysipelas, and pyaemia. It is sometimes occasioned by injury. When the perichondritis is due to deep ulceration, necrosis of the cartilage is apt to follow through impairment of its nutrition. Separation of the fragment sooner or later takes place. In some cases the destructive process is rapid and the seques- trum is quickly detached. Deformities, often leading to stenosis of the larynx, and sometimes to fistulous openings of it, and ankyloses, particularly of the crico-aryte- noid articulations, are some of its results. Stricture op the Larynx, other than that due to inflammatory thickening and to new growths, con- sists of permanent deformity, the result of previous disease or injury, and caused either by displacement of the parts or, as is most commonly the case, by the presence of deforming cicatrices. Fractures, perichon- dritis, chondritis, ankylosis of the arytenoid articulations and " web of the larynx," may occasion it, but it is generally due to injury or ulcera- tion of the soft tissues which line the larynx, commonly from tertiary syphilis, and also to other diseases causing deforming cicatrices, and to destruction of the soft parts due to burns. Stenosis of the trachea may occur at various parts of this canal from the formation of bands of fibrous tissue which distort the tracheal rings. Sometimes the stric- tures are multiple. Between them are occasionally seen dilatations of the tube. The symptoms may be divided into three stages — that of active dis- ease, that of stenosis, and, finally, that of suffocation. Again, they may at first be mild and progressive, beginning with slight laryngeal stridor. This increases, being especially marked on inspiration, and is later accompanied by dyspnoea, and often by change in the quality of the voice, which becomes hoarse in stenosis of the larynx or simply weak in stenosis of the trachea. Later, dyspmea increases. Respiration is feeble and slow. The attacks of urgent dyspnoea are apt to take place at night, and are due to spasm of the glottis. Death may be caused by sudden asphyxia or by pulmonary congestion, pneumonia, and oedema. Sudden death from syncope will sometimes occur, due to an inhibitory action upon the bulbar centres. In stenosis of the trachea the point of greatest constriction may sometimes be determined by auscultation, as well as by laryngoscopic examination. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 735 In diagnosing this condition the existence, position, and character of the stricture must be established. It has been said that if hoarseness has preceded dyspnoea the stenosis is in the larynx ; if dyspnoea pre- ceded, it is tracheal. A mediastinal tumor, possibly compressing the trachea or bronchi, may be revealed by examination of the chest ; tumor of the neck may be recognized by palpation of this region, and a laryngoscopic examination will establish the differ- ential diagnosis between paralyses, tumors of the larynx, and actual stenosis. The prognosis is serious, especially in stenosis of the lower part of the trachea, which is almost necessarily fatal. The treatment consists especially in dilatation of the stenosed parts. Should this fail, the permanent use of a tracheal cannula is always possible. For the actual relief of the stenosis the application of intubation has accomplished much. Tracheotomy. Tracheotomy is a general name for several operations employed for the admission of air to the trachea where the latter, or the approaches to it, have become obstructed. These operations are crico-thyroid laryngotomy, made through the crico-thyroid membrane ; laryngo- tracheotomy, through the cricoid cartilage and the first ring of the trachea ; and the two operations most commonly resorted to, high and low tracheotomy, respectively above and below the isthmus of the thyroid. Before attempting any of these operations it is imperatively neces- sary that the anatomical relations of the trachea in connection with them should be thoroughly well understood. Tracheotomy is easier performed high in the neck than low, for the anterior jugular veins are smaller above and transverse branches are rare ; the muscles are somewhat separated above, while below they are in contact; the great vessels and the inferior thyroid veins are avoided. Here, too, the trachea is nearer the surface and more readily held in position. The lower the incision in the trachea, the greater the danger of sepsis and of broncho-pneumonia. On the other hand, par- ticularly in the adult, the necessities of the case will sometimes demand a low operation. The Tube. — The tube should be selected with careful reference to the case in hand. The one now in common use goes under the name of Trousseau. The thickness of the tissues covering the trachea varies greatly in different individuals. Durham has therefore devised a can- nula the length of which from the neck-plate can be regulated by means of a screw-collar. The cannula itself is straight until within a short distance of its distal end. Certain defects of the Durham cannula have been avoided in the tube devised by Keen. Konig's tube, designed for the relief of stenosis occurring low down in the trachea, is about four and a half inches long. Abbe suggests an improvised cannula for deep tracheal obstruction, made by inserting a piece of soft-rubber tubing into the trachea and transfixing its proximal end with a safety-pin. 736 SPECIAL OR REGIONAL SURGERY. Many different devices have been made for the performance of rapid tracheotomy. They are practically never used. Tracheal tubes are composed of silver, aluminum, hard rubber, soft rubber, and celluloid. As a rule, metal tubes are preferred. The hard rubber-cannula, how- ever, is very useful when the tube is to be worn but for short time, and is more comfortable, for several reasons, than metal. The indication for tracheotomy is the presence of an occlusion of the normal opening of the larynx from acute or chronic causes, which causes dyspnoea sufficient to endanger life, which cannot be overcome by other means. The operation in itself is usually not dangerous, nor is it likely to cause serious complications to the disease for which it is employed. Its early performance where indicated, there- fore, should, wherever possible, be advised. When practicable, chloroform anaesthesia should be employed before this ope- ration. Ether causes nausea, vomiting, and embarrassing reflex movements of the larynx. The hypodermic injection of cocaine, although recommended by some, in the experience of the writer has not always succeeded in allaying the pain. In tracheotomizing children, especially in diphtheria, chloroform is apt to be contraindicated. Its administration may cause rapid increase of dyspnoea, and greatly complicate an operation which under the condi- tions of cyanosis present is not likely to create suffering. The operation of tracheotomy is generally performed as follows, under chloroform unless contraindicated by dyspnoea and laryngeal irritation, and with proper antiseptic precautions : The patient is placed upon his back near the right side of the opera ting- table. A suitable firm sup- port is placed under the neck and shoulders, and the head allowed to bend backward in extreme extension. In this position the anterior Fig. 307. Position of patient for tracheotomy. structures of the neck are rendered tense, the trachea steadied, drawn as far upward as possible, and brought somewhat nearer to the surface of the neck, and the superficial veins somewhat emptied. To the assist- ant who administers the anassthetic is also given the duty of holding the patient's head steady and of keeping the chin exactly hi the median line. The latter is very important to the surgeon, the accuracy of whose incisions is likely to be determined by the careful observance of it. At least one other assistant is desirable to attend to the bleeding and super- intend the instruments and the tube. Before making the first incision the operator should clearly define the position of the thyroid and cricoid cartilages and of the median line. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 737 With a sharp scalpel, held between the thumb and finger, an incision should be made through the integument from an inch to an inch and a half long, and precisely in the median line, downward from the level of the upper border of the cricoid, the parts on each side of the cut being steadied meanwhile by the thumb and fingers of the left hand. The movements of the thorax in respiration make it impossible to support the right hand upon the chest during the performance of the operation. Next, in the same way as above, the subcutaneous fat and the anterior cervical fascia are divided. By successive incisions, aided by the director and the handle of the scalpel, the sterno-hyoid and the sterno-thyroid muscles are reached, and the space between them opened, and the fascia covering the trachea demonstrated. Then, keeping strictly in the median line, the deep fascia is divided and the trachea laid bare. For the divis- ion of the fascia the help of a director is valuable. Any veins encoun- tered at this point in the operation should be pushed aside with the handle of the scalpel. The isthmus of the thyroid must be similarly pushed downward, and, if necessary, held out of the Avay with a small blunt retractor. The tracheal rings may now be felt with the finger, the fact that the trachea is actually laid bare assured, the exact situation of the cricoid noted, and the precise position of the intended opening into the trachea located. A silk suture passed through the trachea on either side the opening, and then through the skin, tied, and the ends left long, makes a most serviceable retractor and guide should the tube require replacing. For the next division of the operation the following should be in readiness and at hand — namely : A sharp scalpel or tenotomy knife, the tenaculum, the tracheal dilator, a damp towel, and, finally, the tube, properly oiled, to which a tape of length sufficient to twice surround the neck of the patient should have been passed into one of the eyelets at the side of the neck-guard. Everything being in order and if possible all bleeding controlled, a small sharp tenaculum is passed into the cricoid cartilage in the middle line and held by the assistant, who stands behind the patient's head. His duty is to keep the tenaculum in the median line, and with it to draw the cricoid forward and keep the trachea steady and tense. The up-and-down movement of the larynx in respiration will make it necessary to not hold the hook too rigidly. Having decided which rings to divide, the operator introduces the scalpel into the wound the edge of the knife being directed upward, and, guided by the left fore finger, inserts the knife, exactly in the median line, into the lowest of the two or three selected rings (usually the first three of the trachea) and cuts directly upward toward the tenaculum. The latter is still held in position, and the knife not removed from the tracheal incision, but turned slightly upon its vertical axis, so as to separate the sides o'f the opening and admit the tracheal dilator, which is next inserted, and the opening sufficiently dilated to enable the tracheal tube to be passed. This should be done as easily and expeditiously as possible, and the tube at once secured in position by passing one end of the tape around the patient's neck, through the unoccupied eyelet of the neck-plate of the tube, and back around the neck, to be tied to its fellow. The presence of the tenaculum in the cricoid excites such urgent reflexes of the larynx that until the trachea is opened the patient in 738 SPECIAL OR REGIONAL SURGERY. many instances cannot breathe. The effect of the sudden entrance of the air is to excite such expulsive efforts of cough that the mucus, blood, or membrane which may be in the trachea are projected forth with great violence. For the protection of the operator as the trachea is being dilated, an assistant should hold a damp towel a short distance above the wound. In no case should the tube be introduced without previous separation of the edges of the tracheal incision. Disregard of this rule will defeat the attempt at introduction, and may result in serious injury to the parts, particularly where the rings of the trachea have become partly ossified. Pressure against the incision only forces its edges the more firmly together, while undue force may either frac- ture the cartilages or, from the slipping of the tube, force it downward through the tissues on the side of the trachea, thus inflicting damage. .In such cases, where the tube must be worn habitually, it is better not to rely Upon a simple vortical incision of the trachea, but to actually exsect a circular portion of the anterior wall equal in size to the diameter of the required cannula. The result is more comfortable to the patient, and enables the cannula to be inserted more easily. When the tube is in place the tenaculum may be removed, and the wound below the tube brought together by one, two, or three sutures. A piece of lint properly shaped to cover and protect the wound is smeared with some antiseptic ointment and placed under the shield of the cannula. Subhyoid pharyngotomy has, on rare occasions, been employed in the removal of a foreign body or of a new growth situated in the upper opening of the larynx, and particularly in the neighborhood of, or in connection with, the epiglottis. Infrathyroid laryngectomy has been performed for the removal of subglottic growths. In operating, the laryngotomy should be made sev- eral days before the attempted extirpation of the growths, in order to accustom the parts to the presence of the tube and thus reduce the irrita- tion for the chief operation. In performing the latter the crico-thyroid space is well opened up and the cartilages separated as widely as possible. Laryngotomy. Laryngotomy, performed by opening the larynx through the crico- thyroid membrane, is sometimes employed in place of tracheotomy. The operation is not as difficult as the latter, and may be performed more rapidly. It is not applicable to children, on account of the small size of the crico-thyroid space. While it may answer for emergencies, it is not desirable where the tube must be worn for any length of time. The only important vessels to be encountered are the crico-thyroid arteries, which cross this space and are usually of small size. They may, however, be large enough to give rise to serious hemorrhage. The operation of thyrotomy consists in the complete division of the thyroid cartilage in the median line. It is employed in gaining access to the larynx for the removal of new growths or for other obstructive conditions, such as impacted foreign bodies, irremediable cicatricial bands, or the like. As it is likely to cause impairment of the voice, it should not be undertaken unless clearly indicated through failure of endolaryngeal methods to attain the desired end. On the other hand, in certain serious conditions it affords the best possible opportunity for the thorough accomplishment of the purpose for which it is performed, ^.nd in good hands has been attended with excellent results. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 739 A preliminary laryngotomy or tracheotomy is required, and should be performed a number of days before the main operation. The selec- tion of the point at which the tube is to be inserted should depend upon the situation of the growth and the probable length of time that the tube will have to be worn. Should extensive bleeding be expected, a tampon- cannula must be used. In performing the thyrotomy the incision already made is prolonged upward from the median line and the tissues divided down to the cartilage, the cut extending upward to some point in the thyro-hyoid space. In dividing the thyroid cartilage it is customary to carry a perfectly true incision accurately in the median line, the crico- thyroid membranes being also divided as far as is necessary. The division of the cartilage should be effected from above downward and from without inward, and may be accomplished by means of a small but strong knife in patients in whom the thyroid has not begun to calcify. In case the latter condition is present, brilliant results have been gained by the electric saw, as recommended by Wagner. A strong scissors may also be used for the purpose. The dissection having been accomplished, the wings of the thyroid are drawn apart by means of two small sharp retractors or by means of threads passed through them, and the interior of the larynx is thus exposed. In closing the wound the two halves of the thyroid are united by two or three sutures of fine silver wire and the superficial wound closed. The subsequent treatment, in the main, will be such as is carried out after tracheotomy, special indications being met and the interior of the larynx meanwhile not being neglected. In performing operations of this class it is sometimes necessary to prevent blood from entering the trachea, which may be accomplished either by packing the latter with sponge or gauze, or by means of a device know as the tampon-cannula. This instrument is a tracheotomy- tube around the outside of which is attached a dilatable sac of India- rubber, which, being inflated when the apparatus is in position, effect- ually occludes the trachea above the opening of the tube. Excellent modifications of the original Trendelenberg cannula have been made by Roswell Park, Hahn, Gerster, and others. Fig. 308. O'Dwyer's laryngeal tube and introducer. Intubation of the Larynx. Intubation of the larynx, as perfected and established by Dr. Joseph O'Dwyer, is a most valuable addition to the surgery of this department. 740 SPECIAL OR REGIONAL SURGERY. Intubation Instruments. — A set of instruments for children under the age of puberty consists of six tubes, of different sizes and varying in length from one and a half to two and a half inches ; an introducer, an extractor, a mouth-gag, and scale of years. Each tube is provided with a separate obturator for the purpose of attaching it to the introducer. The numbers of the scale represent years and indicate approximately the ages for which the corresponding tubes are suitable. The female larynx in children as well as in adults is smaller than in the male. In measuring the tubes the heads are of course included. Having selected the tube, a strong thread is passed through the small eyelet at its head, and the ends tied together. Braided silk is the best, and the piece should be sufficiently long to reach the stomach and still leave a portion protruding from the mouth. The obtu- rator is then screwed firmly up on the introducer to prevent the tube from rotating while being inserted, and fixed so that the long diameter of the tube line with the handle of the Fig. 309. Mouth-gag. for when applied and ready introducing instrument. Indications for Intubation use is in a -The indications for intubation in chil- dren are the same as for tracheotomy. There is no reason why one Fig. 310. Extractor. should be performed earlier than the other. The beginning of the suf- focative stage is the proper time to interfere. Marked cyanosis is too late a symptom to wait for, and, besides, fatal obstruction may exist in the glottis with extreme pallor of the surface. The method of intubation applies to any obstruction of the larynx not due to a foreign body. Method of Operating. — The person who holds the child should be seated on a solid chair with a low back, and the patient placed as repre- sented in Fig. 311. Fastening the hands in front of the chest, or thick garments in the same location, render it more difficult to depress the handle of the introducer sufficiently to carry the tube over the dorsum of the tongue. The gag is then inserted well back, behind or between the teeth in DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 741 the left angle of the mouth, and the jaws very carefully separated. In children who have not at least one bicuspid on the left side, the finger Fig. 311. Intubation of the larynx. should be used instead of the gag. An assistant holds the head firmly, at the same time slightly elevating the chin. The operator stands in front of the patient, holding the introducer lightly between the thumb and fingers of the right hand, the thumb resting on the upper surface of the handle just behind the knob that serves to detach the tube, and the index finger in front of the trigger support underneath. Held in this manner, it is impossible to use undesirable force. The index finger of the left hand is carried well down in the pharynx or beginning of the oesophagus, and then brought forward in the median line, raising and fixing the epiglottis, while the tube is guided along beside it into the larynx. If any difficulty is experienced in locating the epiglottis, it is better to search for the cavity of the larynx, into which the tip of the finger readily enters, and which cannot be mistaken for anything else. Once in this cavity, the epiglottis must be in front of the finger. The latter is then raised and pressed toward the patient's right to leave room for the tube to pass beside it. The distal extremity of the tube should be kept in contact with the finger, and even directing it a little obliquely toward the right side of the larynx is necessary to get inside the left aryteno-epiglottic fold, especially in very young children. The handle of the introducer is held close to the patient's chest in the beginning of the operation, and rapidly raised as soon as the lower end of the tube has passed behind the epiglottis, other- wise it will slip over the larynx into the oesophagus. 742 SPECIAL OR REGIONAL SURGERY. When inserted the cannula is detached by pressing forward the button on the upper surface of the handle of the introducer with the thumb, and in removing the obturator the movements required for insertion are reversed. To prevent the tube from being also withdrawn, the finger must be kept in contact with its shoul- der either on the side or posteriorly, and the tube should be carried well down in the larynx before it is detached. The gag is removed as soon as the tube is in place, but the string is allowed to remain long enough to be certain that the dyspnoea is relieved and that no loose membrane exists in the lower portion of the trachea. In withdrawing the tube the child is held as in introducing it, and the extractor is guided along the side of the finger, which is brought in contact with the head of the cannula, and then pressed toward the patient's right, in order to uncover the aperture and allow the instrument to enter in a straight line. No attempt at extraction should be made until the head of the tube is felt. Introduction of the tube must be accomplished quickly, the whole performance not occupying more than ten seconds. To place a tube in the larynx of a struggling, choking child in the brief space of time that is compatible with safety is a difficult thing to do, and should not be attempted, except in case of emergency, without previous practice on the cadaver or on the larynx of an animal removed and placed in a suitable position. The proper time for removing the tube from the larynx will depend on the age of the patient, the character of the disease, whether of slow or rapid develop- ment, and the progress of the case. In diphtheria the younger the patient, as a rule, the longer the tube will be required. In children under two years of age it is better to leave it in seven days. When the above disease has developed slowly, and has therefore run a greater part of its course before calling for operative inter- ference, the tube can be dispensed with earlier — sometimes as soon as the second or third day. If the case cannot be seen within a reasonable time, it is safer, if progressing favorably, to leave the tube in position for seven or eight days, and the exceptions are few in which it will be necessary to reinsert it after this time. The tube should always be removed on the recurrence of severe dyspnoea, because it is sometimes impossible to ascertain with certainty whether it be par- tially obstructed or not. The best evidence to the contrary is a good respiratory murmur or numerous rales over the lower posterior portion of the lungs. Even under these circumstances the lumen of the tube may have been encroached upon. In cases refusing nourishment after intubation it is useless to remove the tube for the purpose of feeding, unless it has been in long enough to give some reasonable hope that its further use will not be necessary, as it is difficult to convince children for some time that they can swallow any better than before. If no dyspnoea recur in half an hour after the extraction of the tube, it is safe to leave the patient, if not at too great a distance to be reached within two or three hours. Accidents and Dangers of Intubation. — The most serious of the accidents incident to this operation is apncea from prolonged attempts in unskilful hands to introduce the tube. Ten seconds is the longest time that should be occupied in each attempt if the child be suffering from urgent dyspnoea at the time. If the finger be then removed from the mouth and the patient be given a chance to get his breath, many attempts to properly place the tube can be made without danger, although the expert seldom requires more than five seconds to complete the opera- tion, except in difficult cases. In these, if necessary, an anaesthetic may be used. If the tube have once passed on the outside of the larynx, and this is recognized before it is detached from the obturator, it is useless to try to rectify the position without first depressing the handle of the introducer, as in the beginning of the operation. The tube may be passed into one of the laryngeal ventricles and a false passage made if care be not taken to pass it in the median line. If the patient's head be thrown too far back, the tube may also be arrested by coming in contact with the anterior wall of the larynx or trachea. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 743 Pushing down membrane before the tube is the most serious of the unavoidable accidents attending this operation. In several such cases removal of the tube has been followed by expulsion of complete casts of the trachea, although in none of these cases was the dyspnoea relieved by the ejection of the membranes, and the immediate reintroduction of the tube was necessary because the obstruction was in the glottis. Where the child is inclined to injure the string with his teeth, the difficulty may be overcome by passing the thread between two of the double teeth. When this plan cannot be adopted, a smaller tube than the one suitable for the age should be used, which seldom fails to be rejected if obstructed. In the event of sudden asphyxia the nurse should hold the child head downward, at the same time shaking it or slapping it vigorously upon the chest. Serious obstruction does not seem to result from loose membrane above the tube, but extreme tumefaction of the epiglottis and aryteno-epiglottic folds does in rare cases give rise to dangerous constriction at this point, necessitating tracheotomy. The tube is more liable to be expelled in the act of vomiting than by coughing. The larynx may be injured in attempting to remove the tube if the extractor be passed down beside instead of into the opening. It is important, therefore, to remember that no force whatever is required to remove the tube, and that any resistance to the withdrawal of the extractor proves that it is caught in the tissues on the outside. In feeding after intubation the entrance of food into the trachea is almost sure to be fatal. Liquid or semi-solid food may be given through an oesophageal tube or by enema. The best method is to allow the child to swallow it while his head is depressed and a little to one side. Tumors of the Larynx and Trachea. New growths of the larynx may affect it primarily or may extend to it from neighboring parts. They may be either benign or malignant. Distinction between the two varieties is sometimes extremely difficult. The so-called tubercular specific tumors which are occasionally seen in the larynx are not properly to be included in this class of affections, and should be considered elsewhere. The etiology of benign growths of the larynx is practically un- known. Although more common between thirty and fifty, they may be observed at any age, and one form of growth, papilloma of the larynx, may be congenital. These tumors are more common in men than in women, and their most frequent location is upon the vocal bands. Subglottic tumors are comparatively rare. Intraglottic growths usually spring from the free border of the anterior part of the vocal bands — those above the glottis from the epiglottis and from the aryteno- epiglottic folds, the subglottic from the inferior surface of the vocal bands. The benign tumors which may occur in the larynx, somewhat in order of frequency, are — 1. Papillomata; 2. Fibromata; 3. Cystic; 4. Angeiomata ; 5. Adenomata ; 6. Myxomata ; 7. Lipomata ; 8. Chon- dromata. Although these growths occur in considerable variety, there are but few that are seen with any degree of frequency. 744 SPECIAL OR REGIONAL SURGERY. The symptoms of intralaryngeal growth will depend upon the loca- tion, the size, and the shape of the tumor, whether it is pedunculated or not, and, to some extent, upon the age and characteristics of the patient. The most commonly observed symptom is the alteration in the quality of the voice. This, at first hardly perceptible, becomes more and more marked, until finally complete aphonia may result/ Especially is this the case with new growths situated upon the vocal bands. The change in position of a pedunculated growth may cause sudden and marked alteration in the symptoms, while a vascular growth, particularly in the early stages of its development, may demonstrate its presence or not in accordance with the state of activity of its circulation. Dyspnoea, gen- erally wanting in the adult unless the growth should have attained con- siderable size, in the infant is commonly present and may be urgent. It is generally more severe at night than during the day, is accompanied by stridor, and is due to obstruction by the growth, the inflammatory conditions excited by it, and sometimes by the attendant spasm of the glottis. It may be so simple as to pass unnoticed, or so severe as to cause death from asphyxia, varying with the location of the growth. Cough in the adult is usually not marked, and is distinctly laryngeal in character. In the child it is a frequent symptom, and often severe. It is spasmodic, and is sometimes accompanied with haemoptysis. There is rarely dysphagia or pain. The prognosis depends upon the nature of the new growth and upon the age and general condition of the patient. It is far more serious in the infant, on account of the difficulty of endolaryngeal operation, and also because in the child the papillomatous variety is the most common. Of all the varieties of growth, so-called diffuse papilloma is by far the most serious, on account of the difficulty in differentiating it from epi- thelioma. Recurrence is frequent in this, contrary to what is true in the case of other benign growths. Treatment. — Laryngeal growths are probably less common now than formerly, by reason of the early and effective treatment of the subacute and chronic affections of the upper air-passages, and especially those of the nose. As to the actual treatment to be pursued in a given case, everything will depend upon the age and condition of the patient, the location, size, and shape of the growth, and, most important of all, upon its histological character. The possibilities of the treatment of papilloma may be considered as follows : In infants, particularly where the growth is interfering with respiration, it should generally be removed as speedily as possible. Thyrotomy in many cases has given excellent results. Danger from the growth of granulations may be avoided by the wearing of a tracheal cannula. Whether a supposed papilloma is in reality a malignant growth or not, it should never be unduly irritated. If the tumor be pedunculated, circumscribed, and located conveniently, there are few objections to its removal by endolaryngeal operation. When, on the other hand, it is sessile, difficult to reach, or multiple, such attempts may give imperfect results or be followed by quick recurrence, and other methods may be indicated. Of these the one attended with the best results in the experi- ence of the writer is the frequent daily application to the interior of the DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 745 larynx of a spray of strong alcohol. Under this, persistently continued, growths of considerable size have entirely disappeared. Local rest is imperative. Complete cure has more than once followed tracheotomy. Malignant Growths op the Larynx. Malignant disease of the larynx may be intrinsic or extrinsic, pri- mary or secondary. It may be sarcomatous or carcinomatous. Epithe- lioma is by far the most common. Laryngeal cancer most frequently attacks men at middle life. It may occur, however, in the young. Local irritations seem to favor its pro- duction. In its earlier stages it is generally unilateral. Sarcoma commonly originates either from the true or from the false vocal bands, although it may spring from almost any part. The tumor is usually rounded, and single or somewhat lobulated. Its surface may be either smooth or somewhat papillary or rugose. The color is gen- erally red ; sometimes, however, it is grayish-yellow, and in other cases of a darker color than the surrounding membrane. Often, especially when ulceration has taken place, it may be difficult to distinguish it from papilloma, and the diagnosis can only be established by microscopical examination. When the disease is making rapid progress and destroy- ing and infiltrating the structures in its neighborhood, it is difficult to dis- tinguish it from carcinoma. It is commonly of the spindle-celled variety. In the later stages diagnosis is less difficult. The surface becomes ulcerated, covered with unhealthy granulations, and bathed in fetid pus ; the surrounding mucous membrane is inflamed, and sometimes there is considerable submucous oedema. The cartilages are attacked, and sometimes those in its neighborhood become ossified, especially the upper tracheal rings in extensive epithelioma of the lower part of the larynx. Deformities of the exterior contour of the larynx appear, and as the disease progresses the neighboring parts outside the larynx be- come involved in a process of general destruction. The TREATMENT OP MALIGNANT TUMORS OP THE LARYNX may be either palliative or curative. The palliative treatment may be either therapeutic or surgical. For the former, various topical applications may be made to the affected parts by means of solutions, sprays, powders, or vapors. Solutions are generally used in the form of atomized sprays, and are employed for purposes of cleansing or disin- fection, to subdue pain, and to retard or overcome the progress of the growth : they may consist of antiseptics (Dobell's solution, listerine, boracic acid, and the like), anodynes (cocaine or morphine), or caustic medicaments. The comfort of the patient may be enhanced and much local and general irritation prevented by keeping the parts strictly cleansed and by great care in the matter of feeding. By the surgical palliative treatment dyspnoea may be relieved by intubation or trache- otomy, and obstructing fragments of the growth may be removed. The curative treatment may be divided into three classes — namely, endolaryngeal operation, laryngo-fissure or thyrotomy, and laryngectomy or extirpation of the larynx. Tumors of the trachea may be benign or malignant. The benign growths, often referred to as polyps, are generally either fibromata or 746 SPECIAL OR REGIONAL SUROERY. papillomata. Submucous cysts, multiple enchondromata, and osteomata have been observed. In addition to these may be mentioned the various kinds of growth composed of granulation-tissue which develop after tracheotomy either during the time the cannula is in position or, as occasionally happens, in the cicatrix of the wound. The dyspnoea which they cause sometimes necessitates reopening the trachea for their removal and the reintroduction of the cannula. The treatment consists in the removal of the growths. This may occasionally be done through the natural passages, as described by Jarvis, or with the Grant forceps in cases where the growth occurs in the vicinity of the glottic aperture ; otherwise, tracheotomy and removal by suitable means. In operating, the head of the patient should be low, in order that the blood may not gravitate into the bronchi. Laryngectomy. In total excision the patient lies on the back with a pillow under the shoulders, the head being somewhat low. A preliminary tracheotomy is often performed and a tampon-cannula inserted. An incision is made in the median line from the hyoid bone to a point a little below the cricoid cartilage, and a transverse incision over the hyoid bone meets this at its upper end. On exposing the larynx the sterno-hyoid muscles are drawn to one side and severed close to their insertion. The soft parts are bluntly dissected from the larynx. Vessels are ligated as encountered. After the sides of the larynx become free the inferior constrictor of the pharynx is cut close to its insertion into the thyroid cartilage. The trachea is next cut across just below the cricoid, and drawn forward, while its lumen is well packed with sponges or iodoform gauze, after the insertion of a trachea tube of proper size and form. Where possible, preservation of the lower half of the cricoid will aid in the adaptation of the artificial larynx. The larynx is dissected from the deeper parts until the upper corners of the thyroid are freed. Finally, the thyro-hyoid membrane is cut across and the larynx removed. The epiglottis is removed or left in place according to its condition. If it is desirable to see the inside of the larynx before removing it, the thyroid can be split down the middle and the sides held apart, while the upper end of the trachea is packed with sponge or gauze. The organ can then be removed piecemeal. The partial operation is usually performed bv splitting the thyroid down the middle, packing the upper end of "the trachea, and ' then removing as much of the larynx as is desirable. After the operation the upper end of the trachea is packed firmly with gauze to prevent blood and saliva from flowing into it, and the rest of the wound stuffed lightly with an antiseptic gauze. Foreign material may be prevented from entering the lungs bv elevating the foot of the bed. Nutritive enemata are given for the first forty-eight hours ; then a stomach-tube may be passed through the wound into the oesophagus and gastric feeding' begun. The packing is removed from the wound as often as necessary, and the parts washed with a weak antiseptic solution. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 747 If suited to the ease, an artificial larynx may ultimately be in- serted. The simplest and best of these is the one devised by Bond of London. In a modification, practised with brilliant success by Cohen, the whole larynx is removed and the free end of the trachea fastened to the outside of the cervical wound. This secures complete removal of the growth, and subjects the patient to the minimum of risk of impair- ment of special function and usefulness of the part, of discomfort, and of outward deformity. The chief danger, aside from unskilful technique and accident occurring during operation, is that of septic infection or of septic pneumonia. Injuries to the Epiglottis. In a wound of the epiglottis the question is whether the injury can be spontaneously repaired or whether the removal of the lacerated or diseased portion may be desirable. Experience has proved it advisable, where necessary, to remove almost any portion of this member, patients who have suffered its entire loss being able to swallow, with the exercise of a little care, without difficulty. In certain conditions of disease— as, for instance, where the epiglottis has been so deformed by contraction as to obstruct the larynx, or where it is the seat of severe tubercular dis- ease — the removal of the offending portion may be undertaken. This is sufficiently easy, and may be effected by the use of the galvanic cau- tery, snare, or by properly-curved cutting forceps. New growths of the epiglottis, when situated upon its anterior face, are often easy of removal, especially where the growth is not of a malignant character. The Uvula and Soft Palate. Amputation of the uvula is now practised with more discretion than formerly. The simplest and best instrument for its performance is a pair of long-handled scissors, one blade slightly hooked at its tip so that the uvula may not slip from its grasp. A holder, made on the principle of the thumb-forceps and about eight inches in length, possesses the advantages over other forceps that it has not the inconvenient scissors- handle, that it may be held firmly and with great steadiness by allowing its proximate end to rest in the hollow between the thumb and fore- finger, the whole hand meanwhile being steadied by resting the fourth and fifth fingers against the patient's chin, and, finally, that in applying the scissors the forceps may be used as a guide. Syphilis of the Velum Palati — The occurrence of the primary lesion of syphilis, although now and then observed upon the tonsil, is, upon the velum, almost unknown. The tertiary form of syphilis may occur in the soft palate at any period of time beyond two years after the primary infection. It is characterized by true ulceration or loss of tissue, and is the result of the degeneration of gummatous deposit. The treatment of this condition consists in the attempt to separate the adherent tissues, and to establish, more or less perfectly, commu- 748 SPECIAL OR REGIONAL SURGERY. nication between the upper and lower pharynx. In operating, by cutting against the point of a sound passed through the nose into the upper pharynx and used as a guide, an entrance may generally be effected. Congenital Malformations of the Pharynx. Congenital malformations of the pharynx are of rare occurrence. Of congenital malformations of the neck, the pharyngeal fistula is by far the most common. This is divided into two varieties, the complete and the incom- plete. They are, as a rule, unilateral, and occur more commonly on the right side. They are usually incomplete. Their external opening is usually found upon the side of the neck, anywhere in the course of a line from the sterno-clavicular articulation to the angle of the jaw. Rarely they may open in the median line over the larynx or trachea. The internal opening is generally found in the lateral wall of the pharynx, behind the cornu of the hyoid bone and near the tonsil, or in the pharyngo-palatine arch. The canal varies in length and in diameter, is usually somewhat tortuous, and sometimes so much so as to be almost impassable to a probe. Its diameter is always greater than that of the external opening, and it can be much increased by retained secretions. Retropharyngeal Abscess. Circumscribed abscesses of the pharynx are generally due to the breaking down of lymph-nodes. Their situation in the neighborhood of the pharynx causes them to manifest peculiar symptoms and to be attended with special dangers. Three varieties may be recognized — the retro-, the lateral, and the anterior pharyngeal. Chronic abscess of the retropharynx is a common disease in the young. It is a serious condition, threatening as it does the life of the patient, but one which is, as a rule, entirely remediable by the prompt application of proper treatment. Although almost invariably found in infants, it has occasionally been observed in adult life. A debilitated condition in general, chronic cachexia, and the influence of certain infectious diseases may all pre- dispose to it. A serious form of retropharyngeal abscess is sometimes found in per- sons suffering from caries of the cervical vertebrae. The early symptoms are like those of ordinary pharyngitis. The pharyngeal inflammation, however, continues, and, instead of subsiding, the swelling continues to increase. The neighboring cervical lymph- nodes may be enlarged. The attack is sometimes sharp and well pro- nounced, and in other cases it is slower in its course • the symptoms are less conspicuous and the development of the condition is insidious, the progress of suppuration being very slow. The first variety is more common. Its onset is characterized by high fever, headache, and vomiting, sometimes by chills and convulsions. The symptoms of the acute sore throat are more or less severe, with considerable pain in swallowing. Another prominent symptom is dysphonia. Pain is especially marked in the back of the throat and is increased by move- ments of the head. The treatment of retropharyngeal abscess in its early stages is similar to that of acute inflammatory conditions of the pharynx. Upon the earliest detection of pus, free incision should be made through the DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 749 posterior wall of the pharynx into the abscess, the most prominent part of the swelling or that at which the fluctuation is most distinct of course being selected. In doing this the pharynx should be clearly demon- strated, full preparation made for the operation, and the instant the knife is withdrawn the patient, if an infant, should be inverted to pre- vent the escaping pus from entering the larynx. In the adult the patient's head may be caused to hang over the edge of a table. Anaes- thesia is contraindicated. Treatment. — Incision is not always possible through the wall of the pharynx, and in many cases it will prove easier to reach it from the outside. External incision has been highly recommended, because it is the best means of thorough evacuation and treatment of the cavity. Where pus has migrated into the mus- cular planes of the neck this treatment will of course be required. Hemorrhage from one of the great blood-vessels from erosion of its walls is almost necessarily fatal. Nevertheless, in such a case the common carotid has been successfully tied. Foreign Bodies in the Pharynx. Small objects are apt to be lodged in the tonsil or entangled in the adenoid tissue at the base of the tongue. Larger substances will be more commonly found either in the glosso-epiglottic or the pyriform sinuses. The sensations and opinions of the patient as to the existence of a foreign body in the pharynx are unreliable, hyperesthesia of the pharynx often simulating the latter condition. Examination should be conducted by the aid of a strong light and cocaine anaesthesia. Irritability may be relieved by the swallowing of ice or very cold water. For direct inspection of the throat it is sometimes useful to assist the action of the tongue-depressor by pressing upward the thyroid cartilage, thus bringing the different parts into view. Failing to discover the object in this way, the laryngeal mirror should be used. The practice of digital examination of the throat, although valuable, should be made a last resort, on account of the reflex irritation which it excites. A small object in the tonsil may easily escape detection. It is always well to sweep a probe gently over the surface of the gland, and to examine with a rhino- scopic mirror behind the palatal folds. The extraction of one object does not preclude the possibility of others remaining. The treatment depends upon the immediate extraction of the offending subject, with means at hand for the proper demonstration of the throat and suitable curved forceps to accomplish removal. Where the body is lodged very low in the pharynx and is of a shape which renders its extraction through the natural passages impossible, entrance to the pharynx from the outside may be demanded. The continued presence of an irritating body in the throat may give rise not only to dangerous local symptoms, but to cough and local irritation of a dis- tressing character, causing the general condition of the patient to rap- idly deteriorate. Lymphoid Hypertrophy at the Vault of the Pharynx. Lymphoid hypertrophy at the vault of the pharynx is a condition of chronic enlargement of the tissue at the vault of the retronasal space, otherwise known as Luschka's tonsil, the pharyngeal, or the third ton- sil. As commonly met with, it is of two varieties. In the first the lymphoid element may be associated with more or less fibrous tissue ; 750 SPECIAL OR REGIONAL SURGERY. in the second the latter is but feebly represented. The size of the growth may be so great as to practically fill the retronasal space, or, on the other hand, it may be so small ■ FlG - 312 - as to make it difficult to determine whether or not its condition is path- ological. It may be confined strictly to the vault, or be diffused over the posterior and lateral walls of the pharynx, or it may exist upon the posterior wall of the pharynx alone, either in a large well-aggregated, tumor-like mass or in more or less thickly scattered elevations. Its symptoms are, first, those due to mouth-breathing — namely, a dull, stupid expression of the face, anaemia, drooping of the eyelids, open mouth, projecting teeth, arched palate, pinched nostrils, and the deformity of the chest known as "pigeon breast." Again, there is mental dulness, loss of hearing, nasal obstruction with all the dis- tressing symptoms of which it is the cause, defective speech, and, generally, almost constant catarrh, the secretions from which are swal- lowed, with the result of producing indigestion. The occurrence of reflex effects is shown in frequent headache, irritative cough, laryngeal spasm, and other neurotic symptoms, including in some exceptional cases such extreme results as chorea and, it is said, epilepsy. Even in the infant it may be suspected through the presence of mouth-breath- ing, snoring, and a marked inability to perform the act of nursing. One effect of the obstruction to nasal respiration is the permanent deformity of the bony framework of the nose and hard palate which generally accompanies it. Considering these things, it becomes important to secure the early recognition of the necessity for treatment in such cases, and to see that it is promptly and efficiently carried out. This must depend in some degree upon the nature of the growth, the size to which it has attained, and upon the age of the patient. In a few instances, where the disease is acute or subacute, where the tissue is soft, and the amount of growth small, the application of resorptives and the administration of alterative and tonic medicines, together with careful attention to hygiene, may possibly accomplish a cure. Almost invariably however, these means will be found unsatis- factory. In the surgical treatment of this condition by far the most effective method is its forcible removal by means of some surgical operation. For removal by operation many instruments have been devised. These may be divided into four classes : a, those made upon the principle of the curette ; b, Position of adenoid enlargement as commonly located in the upper pharynx. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 751 the double curette or forceps ; c, the wire loop ; and, finally, d, the adenomatome. The first class includes the ring-knife of Dr. Meyer and its modifications and the sharpened finger-nail of the operator, a useful adjunct to the more complicated instruments ; the second, the forceps of Loewenberg and its varieties ; the third, a modification of the Jarvis snare; and, finally, the fourth, a double cutting instrument, furnished with 'scissor blades, called the adenomatome. Of these instruments, the most generally useful are a modified Loewenberg forceps and the sharp curette. The other instruments necessary for operating under anaesthesia are a good mouth-gag and a soft-palate retractor. The latter should be made with a shank broad enough to protect the uvula from injury during the process of operation. The position of the patient during operation is of considerable im- portance. Two methods, performed under complete ether or chloroform anaesthesia, are in common practice : In the first, applicable mainly to infants, the child is held upon the lap of an assistant in the sitting pos- ture, with the head upright and turned toward a good light. The head is steadied by a second assistant, who also manages the mouth-gag and administers the anaesthetic. The soft palate may be drawn upward and forward by means of the palate-retractor or White's palate-hook, or it may be secured by tapes passed inward through the nose and outward through the mouth, the ends being tied outside after Wales' method. With the head inclined forward in this position the blood caused by the operation will tend to escape from the mouth, instead of being swallowed. Moreover, the pharynx can be well illuminated and the steps of the ope- ration better directed by the aid of vision. The position upon the back is preferred by many good operators, requiring as it does the services of but one assistant, and being the one to which a large majority of sur- geons are better accustomed. It is not so favorable as regards the admission of light to the pharynx, and therefore it requires a greater degree of skill on the part of the operator, whose tactile sense must be highly educated by way of substitute. The blood, instead of flowing from the mouth, is swallowed into the stomach. This is not a disad- vantage, for it trickles down from the posterior wall of the pharynx and escapes into the oesophagus almost without making its presence felt, unless the flow excited has been considerable. A possible objection to the upright position is the additional risk of fragments of detached tissue falling into the larynx and thus causing asphyxia. Such accidents have been reported, having occurred in the Fig. 313. Gottstein's curette. course of the use of the Gottstein curette. This would not be possible under the use of the forceps. The management of the palate-retractor should be entrusted to a skilled assistant, as upon this the convenience, and to some extent the success, of the operation will depend. 752 SPECIAL OR REGIONAL SUROERY.. Nasopharyngeal Tumor. This variety of growth, fortunately, is of rare occurrence. It origi- nates usually about the time of puberty, tending to subside, after the patient is of age, and is most common in males. Treatment. — While its base is still absolutely limited to the pharynx, operation through the natural passages is clearly and unmis- takably indicated. For this purpose the ecraseur, either in the form of the galvano-caustic loop or the cold snare, has been found decidedly the most practical. In the employment of the electric loop the best method is, if possible, to surround the base of the growth with the galvanic ecraseur, passed either through the nose or through the mouth. The inclusion of the growth within the loop is often difficult. Much easier manipulation is made possible by the use of a separable double cannula, through which the wire may be passed. The curved cannula, carried behind the palate, is inferior to that used through the nose. The loop, aided by the finger in the pharynx, should be fixed to the highest possible point. Excision without preliminary operation is, from the danger of hemor- rhage, unjustifiable. Ligation is sometimes useful. The use of the galvano-cautery, both in the form of the loop and for the destruction of remnants or of points of recurrence, makes it possible to thoroughly eradicate fibromatous growths. The electrolytic method is sometimes of great value. Great aid is afforded the surgeon in these manipulations by the inva- riable enlargement of the pharyngeal space which is present. When the growth has advanced beyond the vault of the pharynx and removal by the natural passages is impossible, the old method of removal after a preliminary operation must be discussed. While such radical procedures have now and then succeeded, the general statement may be made that they are far inferior in safety and success to early operation with the loop. Three varieties of procedure have been employed — namely, operation carried on through the nose, through the mouth, or through an entrance effected by operations more or less for- midable upon the superior maxillary bone. Fibro-mucous Polypi. — These are composed of a mixture of the structural elements of the tissue from which they originate. They vary from a tumor of small size to one sufficient to fill the upper pharynx, and are generally smooth, dark red, and ovoid in form. They are probably more common than true fibromata. The symptoms to which they give rise are principally those of nasal obstruction. They are otherwise harmless to the surrounding structures, and are not prone to bleed. They show little tendency to recur when removed, and may be extirpated by evulsion, or, better still, by the cold- or the hot-wire loop. Bnchondroma. — Enehondroma of the nasopharynx is extremely rare. Malignant Tumors. — Malignant tumors of the nasopharynx, al- though rare, are really less uncommon than has been supposed. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 753 Chronic Hypertrophy of the Tonsils. Chronic enlargement of the tonsils consists in an abnormal increase of the lymphoid tissue of the organ, sometimes accompanied with a pro- liferation of its fibrous stroma. The latter is apt to occur where the disease is of long standing, although not uncommon in the young. The hypertrophic process is most active at the age of puberty, after which time it tends to decline until beyond thirty the disease is more uncom- mon. It may originate, however, at almost any time before adult life. It has been present in old age. The symptoms are usually plain and easily recognized, and are in many particulars similar to those which accompany the local obstruction and irritation found with lymphoid hypertrophy at the vault of the pharynx. In some cases the tonsils are chronically inflamed, without being materially enlarged, the condition giving rise to annoying symp- toms. These cases may be much relieved by the application of astrin- gents to the crypts, or, still better, by the opening up or cauterization of such of the latter as are either dilated or inflamed. Tonsillotomy. — Of the methods for removing the tonsil most com- monly used, may be mentioned cauterization by chemical or electrical escharotics ; ecrasement, by means of the galvano-caustic loop or of the cold wire ; abscission, by means of some modification of the knife or scissors. Both ligation and the injection into its substance of various supposed absorbents only need be mentioned to be condemned. The practice of enucleating the tonsil with the finger has lately been revived in some quarters. Excepting in young children it is of questionable value. During the operation the patient should sit facing a good light, the operator with his back to it. By those familiar with the use of the head-mirror the latter, however, will generally be preferred. The patient, if an adult, should sit upright and well back in the chair, the head fixed against a properly-adjusted head-rest or supported by an assistant. The latter should stand directly behind the chair, and, while holding the head with both hands, should place the fingers of each hand over the tonsillar region of the corresponding side — that is, immediately below the angle of the jaw. Thus the tonsils may be prevented from receding before the pressure of the tonsillotome when it is introduced, and the operation may be performed with greater accuracy and thor- oughness. Having engaged the tonsil in the ring of the instrument, push the blade firmly and steadily through the included tissue, separate the frag- ment of tonsil, and, withdrawing the instrument quickly, remove the excised gland adhering to it, and at once, and before the patient realizes that there is to be a second operation, before bleeding sets in, and with- out giving opportunity to cough or clear the throat, excise the remaining gland. Thus both may be removed at one sitting, so that but one con- valescence is to be endured : few young patients will submit to a repe- tition of the operation. The Physick tonsillotome has been modified, so that the handle may be reversed, enabling it to be used first in one hand and then in the other. Ambidexterity in the use of the one instrument is far better. The operation may generally be done very quickly. 48 754 SPECIAL OR REGIONAL SURGERY. As a rule, anaesthetics are not indicated in tonsillotomy. Cocaine ansesthesia is often effective, although, if the child is highly sensitive, irritable, or feeble, chloro- form or nitrous oxide may be desirable. The introduction of the instrument into the pharynx is often more complained of than the actual separation of the tonsil. Bleeding after operation is usually slight, and soon ceases spontaneously ; if not, it may generally be checked by simple means, such as direct application to the cut surfaces of a mixture of one part gallic and three parts tannic acid, slightly reduced with water and applied upon a pledget of cotton. The sucking of cracked ice is also effective. Sometimes, however, hemorrhage may be severe, and, while fatal results have very rarely occurred, there are several cases on record in which this accident has taken place. With regard to this question, it may be said that moderate hemorrhage requiring direct pressure or astringents to check it is not very unusual: a severe hemorrhage occasionally occurs, and in view of the enor- mous number of tonsillotomies done the proportion of serious results has been exceedingly small. The source of the bleeding may be either arterial, from the division of one or two comparatively large arterial branches, or from the division of a large number of small arterial twigs ; venous, from the division of the small plexus of veins which lie outside and below the tonsil ; and capillary or general, from the presence of the hemorrhagic diathesis. The records show that hemor- rhage has very rarely occurred before the eighteenth year. This may be explained by the presence of the larger amounts of fibrous tissue in the adult tonsil. Park has discovered a new styptic of extraordinary efficiency, easily made by mixing fairly strong (25 per cent.) watery solution of antipyrine and alcoholic solution of tannin. A most tenacious, gummy mass is thrown down, which when applied on cotton or sponge with a little pressure will check all oozing. Foreign Bodies in the Tonsil. Foreign bodies may develop spontaneously in the tonsillar crypts through retention of the secretions of the latter. The presence of such a cheesy mass may give rise to much irritation. The condition should be relieved by removal of the deposit and free opening of the crypt. In rare instances a true calculus of the tonsil has been found. The presence of a tonsillar calculus may be determined by the discharge of fragments of the calculus, by inspection, a part of the mass being visible, or by examination with the finger or probe. Their removal may be accom- plished either by enlarging the mouth of the crypt and extracting them or by excision of the tonsil. Their presence may pass unnoticed, not only by the patient, but by the physician, the symptoms often being obscure. Tumors of the Tonsils. Tumors of the tonsils requiring radical operation are usually malig- nant, and are either epitheliomatous or sarcomatous. The latter are generally of the round-celled variety. The rapidity of their growth, their tendency to recur, the readiness with which the neighboring lym- phatic nodes become infiltrated, and, finally, the important anatomical position of the tonsil, all militate against the success of efforts made to remove them. Operation may prolong life and give a certain measure of relief, however, and in some cases at least it has effected a cure. It should never be attempted without the clearest possible understanding, not only of the normal regional anatomy of the vicinity, but, in partic- ular, of the important arterial trunks near by and their possible anoma- lies. Tumors of the tonsils may be removed through the mouth or through incision in the neck and into the pharynx. The latter method is called pharyngotomv. DISEASES AND iy JURIES OF THE RESPIRATORY ORGANS. 755 Operation through the Mouth. — In cases where the tumor is well defined and projecting, as in the case of some sarcomata, and, now and then, of epitheiiomata which have developed in an already enlarged tonsil, removal may be successfully accomplished by means of the gal- vano-caustic loop or even with the cold-wire teraseur, and such diseased tissue as remains subsequently taken away by any suitable method which may recommend itself. Even in this operation a preliminary trache- otomy is sometimes necessary. This method is less dangerous, and its results are as good as those of the more severe operations. The three principal operations known as pharyngotomy for the removal, from without, of malignant tonsillar disease are Cheever's, Czerny's, and Mikulicz's. Tumors and Polyps op the Nasal Cavities. The form of tumor known as simple mucous polyp, naso-fibroma, or, incorrectly perhaps, nasal myxoma, is by far the most common form of neoplasm found in this region. The etiology of these growths is obscure. Their duration is often difficult to determine. The symptoms are, in general, those of obstruction to breathing, loss of the olfactory sense, local irritation, and persistent catarrh. They are usually referred to a time at which the patient became especially susceptible to acute coryza : the symptoms have grown progressively more annoying, and they finally reach a state where they are incessant. When located comparatively high or confined to one side, the patient may be unaware of their presence. On the other hand, the growths may actually protrude from the vestibule of the nose. As nasal obstruc- tion becomes more pronounced the symptoms and the general discomfort become more severe. Mouth-breathing, snoring, and fatigue upon com- paratively slight exertion are usually present. Reflex symptoms are not uncommon, such as headache, oftentimes severe, neuralgia in different localities and especially through the distribution of the facial nerve, reflex cough, and, finally, marked asthmatic attacks and neuras- thenia. The eye may suffer from irritation of the conjunctiva and lachrymation and from various more or less obscure disturbances of vision. The auditory apparatus may also be seriously affected, owing to the obstructed nasal respiration, the catarrhal inflammation, and the possible reflex irritations which the polyps may excite. Vertigo, impair- ment of memory, mental hebetude, and insomnia are more or less com- monly observed. The symptoms of coryza may vary from a tendency to sneezing and to the appearance of a watery discharge, apparently from slight exposure to cold, to catarrhal symptoms of the most pro- nounced and inveterate character and with excessive secretion. Pro- nunciation is affected, and the tone-quality and carrying power of the voice greatly impaired. The peculiar inability to fix the attention in these cases is called aprosexia. The treatment of nasal polyps should be first, thorough removal, and, second, prevention of recurrence. For the former various means have been employed from an early period, some of which are still in use. External applications to the growth are generally ineffective. 756 SPECIAL OR REGIONAL SURGERY. Rarely, astringents may retard development and add to the comfort of the patient. The means most commonly employed, however, are those by which the growth is removed with forceps, separated by means of a wire snare, or destroyed by the galvanic cautery or ring knife. In order to operate intelligently and successfully the nasal cavity, under cocaine anaesthesia, should first be demonstrated by anterior rhinoscopy, the removal of as many polyps as possible effected, and, when sufficient hemorrhage has occurred to obscure the parts, further operation deferred until another sitting. Variously constructed forceps are used for this operation, and for the removal of certain varieties there is no better method. In general, alligator forceps, the jaws of which should be serrated and not too large, will be found the most convenient. The most generally useful and least painful instrument for the removal of polyps is the Jarvis snare. For the removal of small growths situated Fig. 314. Jarvis snare. high in the nasal cavity a finer quality of piano wire than that com- monly employed is desirable. For the prevention of recurrence the growths must not only be removed, but the localities from which they have originated must be absolutely freed from all trace of their presence. Either at the time of removal or subsequently applications of the galvano-cauterv or other caustic should be made for this purpose. The nasal cavities should be treated locally meanwhile with alkaline and antiseptic sprays and, if necessary, with astringent solutions. Removal of the anterior extremity of the middle turbinated for access to the region which it covers may sometimes be required for the extirpation of polyps, but should be practised with great caution. In the rare event of polyp appearing in the course of an atrophic rhinitis, its presence may act as a stimulus to secretion, and thus prove helpful. Insects and Foreign Bodies in the Nose. The impaction of a foreign body in the nose is a common accident. The entrance of living organisms, on the other hand, is somewhat rare in temperate latitudes, but sufficiently common in tropical and subtropi- cal countries. While the former seldom gives rise to severe symptoms, the latter may readily prove fatal. Foreign bodies are most apt to lodge in the widest part of the canal. Any object sufficiently small and capable of locomotion, such as an in- sect, may find its way into one of the adjacent sinuses. A foreign body may give rise to great irritation, as may also attempts made to ex- tract it. The variety of foreign bodies which have been found in the nose is very great. The list comprises extraneous substances introduced either DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 757 by accident or design by infants or insane adults ; sequestra of diseased bone ; and parasites. The history is usually as follows : A child of about two years of age unobserved thrusts some small rounded object into its nostril. Soon symptoms of unilateral chronic inflammation are established, the irrita- tion often being severe and the discharge extremely fetid. The body, if too firmly impacted to be dislodged by simply blowing the nose, remains fixed until removed by the surgeon. Not infrequently the presence of a foreign body passes unsuspected for many years, and the child is treated indefinitely for simple catarrh. Treatment. — Preparatory to removing a foreign body first cleanse the mucous membrane anterior to it. Then thoroughly anaesthetize the membrane with a 6 per cent, solution of cocaine. The passage thus hav- ing been widened, the body may often be extruded by simply blowing the nose. Should it still be so firmly impacted as to require the use of an instrument, its removal will be greatly facilitated by the anaesthesia of the parts as well as by the additional space provided. A probe or small forceps will often answer the purpose of extraction. If necessary, the body may be first crushed. The copious hemorrhage which com- monly results from the old method of extraction is not likely to follow after the use of cocaine, for the reason that less injury is done to the parts. In all cases of fetid catarrh, particularly when confined to one side and dating back to infancy, careful examination with speculum and probe should be made, the nostril having first been thoroughly cleansed by means of a warm douche and the presence of a foreign body excluded before a positive diagnosis is made. Diagnosis is generally easy. In some cases, especially of long stand- ing, the foreign body may be completely concealed by the secretions of the nose or by a mass of granulations. In the latter case the appear- ances have often been mistaken for syphilis, malignant disease, or lupus. Examination with a probe will at once determine the nature of the trouble. After removal of the object the nostril should be washed several times a day with a weak disinfectant. Cure quickly follows. The so-called rhinoliths, or nasal calculi, are concretions formed of the earthy salts of the nasal secretions. Sequestra of bone, particularly in tertiary syphilis, sometimes remain in the nasal cavity after their .separation, thus acting as foreign bodies. Fungi and Parasites.— Various fungi, as well as ascarides, leeches, centi- pedes, and earwigs, have found their way into the nasal cavities. The symptoms •commonly present after such an accident are epistaxis, sneezing, headache, lachry- mation, nasal discharge, and stenosis. Rhinosclbroma. This rare condition involves both the integument and the mucous membrane of the nose, whence it extends indefinitely. The disease appears in the form of well-defined tubercles, rounded prominences, or flat structures of considerable density, which begin upon the alse and adjacent parts of the lips. The tubercles may be of the color of the skin 758 SPECIAL OR REGIONAL SURGERY. or else of a brownish red, shiny upon the surface, devoid of hair, and traversed by dilated blood-vessels. Rigidity of the affected parts becomes apparent in consequence of the infiltration. Fig. 315. Rhinoscleroma (Dr. Wunde's case). Epistaxis. Epistaxis, or hemorrhage from the nasal cavities proper and their accessory sinuses, may be either active or passive. It may occur from violence, from some remote pathological condition, or as a vicarious phe- nomenon. The former is the most common. The bleeding may come from one nostril alone or from both. It may originate in the deeper part of one nasal cavity, and, owing to some stoppage on that side, be deflected into the nasal cavity of the opposite side, and emerge through that nos- tril or into the pharynx. Hemorrhage occurring during sleep, and the patient in such a position that the blood gravitates into the pharynx, might easily escape detection until serious loss of blood had resulted. Changing the position of the patient and causing him to clear his throat would probably demonstrate the presence of the bleeding. Treatment. — Before attempting to treat epistaxis it is necessary to determine, as far as possible, its precise origin and cause. Vicarious hemorrhages and those occurring at the critical period of certain fevers may be allowed to continue unless excessive. With the plethoric also, and especially where it appears instead of menstruation, it should not be hastily interfered with. To stop the flow simple means will gener- ally prove effective, such as absolute rest, the supine position, avoidance of allowing the head to hang forward, and standing with the head erect and the arms raised above it. The application of cold to the nose and DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 759 the insufflation of cold water are effective, while the injection of water as warm as can be borne is an excellent styptic. Whenever possible direct applications should be made to the bleeding point, the latter hav- ing been carefully dried, with absorbent cotton, of nitrate of silver, of chromic acid, or of the galvanic cautery. Various astringents, such as alum and tannin, may also be used directly upon the bleeding point. The injection of a solution of antipyrine, from ten to twenty grains to the ounce, has been found effective. If necessary, control of the hemorrhage may be gained by plugging the parts in the neighborhood of the bleeding. Anteriorly, this may easily be accomplished by pack- ing against the bleeding surface a tampon of absorbent cotton, or, still better, one composed of a narrow strip of surgical gauze upon which some styptic — as, for instance, tannin — has been sprinkled. Park has Fig. 316. Plugging the nares with Bellocq's cannula (Fergusson). recommended most highly the combination of solutions of tannin and antipyrine (each of 10 per cent,), by whose union a most tenacious and powerfully styptic substance is formed. This may be applied directly. Occurring posteriorly, the bleeding may be checked by inserting a tam- pon in the nasopharynx, and, if necessary, at the same time packing the anterior part of the nasal canal. For this a flexible catheter or Bellocq's cannula is used. The latter consists of a cannula curved at one end, through which is passed a curved steel spring, the end of which is protected by means of a perforated ball. In order to use the Bellocq cannula a loop of silk should be threaded through the eyein the end of the cannula. The steel should be drawn backward into the cavity of the can- nula before the introduction of the latter into the nasal canal. To introduce the cannula pass the extremity with the silk loop through the nostril and backward along the floor of the nose to the posterior wall of the pharynx. Having reached the latter, thrust the steel spring forward, so that it shall emerge from the cannula and appear beneath the soft palate. A tampon of cotton, lint, or sponge saturated with vaseline, should have previously been prepared and attached to the'middleof a stout piece of soft woven silk, the latter about eighteen inches long One end of this silk should now be securely tied to the loop of silk in the eyelet of the cannula, and with the aid of the latter, assisted by the finger placed in the phar 760 SPECIAL OR REGIONAL SURGERY. ynx, the string should be drawn forward through the nasal cavity until the tam- pon arrives in the lower pharynx. Here, by means of gentle traction made upon the string, combined with careful pressure upward from the finger, the tampon should be forced into the upper pharynx as desired. The tampon having been duly placed, it is well to make a firm block of absorbent cotton, around which the anterior nasal end of the string may be wound and held in the vestibule of the nose. The pharyngeal end of the string should be conducted out of the mouth and loosely attached to the patient's ear. In removing the tampon there is con- siderable danger that the parts may be irritated and thus the bleeding again pro- voked. It should never be drawn forcibly from the pharynx. The best plan, as a rule, is to first cleanse the parts as thoroughly as possible, and then apply a weak solution of cocaine in order to cause as much contraction of them as possible. While it may be considered in some cases necessary to do so, it is not desirable to allow the tampon to remain in the pharynx for more than twenty-four hours. Severe bleeding may require the use of revulsives intended to cause reflex con- traction of the nasal blood-vessels, the administration of remedies intended to quiet the action of the heart, the application of pressure internally as well as ex- ternally, and, in extreme cases, transfusion or some kindred measure. The Accessory Sinuses. The sinuses adjacent to the nasal cavities, and communicating with them, are four in number — namely, the frontal, the ethmoidal, the maxillary or antrum of Highmore, and the sphenoidal. It may be said of them all that they are located in regions of great anatomical importance, that the diseases to which they are sub- ject are of an unusually serious character, and that the treatment which the latter may require for their relief is such as to demand the highest degree of special skill. The accessory sinuses may be the seat of hypercemic and of infective processes. The first condition generally complicates an attack of acute rhinitis, and may be difficult to distinguish from the latter except for the localized pain which it may occasion. Suppurative disease of these parts is an affection of much greater importance, the symptoms being more severe and the results more serious. The most important of the latter is the development of various abnormal conditions of the soft tissues lining the cavities, and of caries or necrosis of the bony struc- tures underlying them. These diseases may develop from simple acute catarrh, from chronic rhinitis, or, in exceptional instances, from trau- matic causes. In the maxillary sinus disease is often due to dental irritation. Local destructive processes accompanying syphilis or tuber- culosis may possibly give rise to them. The symptoms of sinus disease are often obscure, and diagnosis difficult. When pain is present, it may be of two kinds : the first is deep-seated, dull, and throbbing, and located in the neighborhood of the affected sinus. In addition to this, neuralgic pains of the most intense character may appear, sometimes distinctly radiating from the affected centre and sometimes difficult to trace. In the more chronic cases pain may be more or less wanting. External swelling over the frontal and maxillary sinuses may be present in extreme cases. The location of the pus exuded into the nasal cavity, although apt to be misleading, is sometimes a guide as to its source, that issuing from the ethmoidal cells or the maxillary sinus pouring downward from beneath the middle or the anterior border, respectively, of the middle turbinated body. By the method of transillumination pus may be demonstrated in unilateral disease 'of the maxillary and frontal sinuses, although this test is not always to be relied upon. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 761 The principles of the treatment of these diseases may be summed up under three heads — namely, free drainage, systematic cleansing of the cavities, and removal from them of diseased tissues and bone. The special application of these principles to the different sinuses requires separate consideration. In general, however, it may be said that in case of acute inflammation occur- ring in any sinus active measures should be taken to subdue it, both by general measures and by such local means as shall subdue the swelling and congestion in and around the sinus-canal. Dilatation of the parts by sprays of cocaine, fol- lowed by the use of cleansing sprays, the use of steaming inhalations, and, finally, the absolute avoidance of all irritating applications, will often greatly hasten recovery. Cure may sometimes be effected in the less severe chronic conditions by removal from the points of exit of the sinus-canals of any hypertrophic tissue, polypoid growth, or other obstructive condition which may interfere with the drainage of the part. In cases not amenable to the above treatment more severe surgical measures involving forcible entrance into the sinus may be required. The interior of the frontal sinus may be approached from one of three points — namely, through its floor from just above the inner can- thus of the eye ; from in front, by an incision parallel with the upper margin of the eyebrow ; and from in front, by a vertical incision away from the median line. The bony wall of the sinus maybe so thinned as to be penetrated with ease. Should this not be the case, entrance may be effected by the use of the chisel or trephine. If necessary, the walls of the sinus are scraped and diseased tissue, polyps, and diseased bone removed. In all cases drainage should be established from the sinus through the natural canal into the nasal cavity. Where suppurative disease of the ethmoid cells is present ob- structive thickenings must be removed, polyps destroyed, malpositions of the anterior end of the middle turbinated body relieved, or the walls of the cells entered. Preliminary to the latter operation, it may be necessary to expose the region by the actual removal of the anterior end of the middle turbinated body. This having been done by means of the Jarvis snare or a suitable cutting forceps, the anterior wall of the ethmoid cells is penetrated, and, if required, the bony septa which divide the various compartments are broken up sufficiently to allow of the free irrigation of the whole cavity. Disease of the sphenoidal sinus, the most difficult of all to reach, has sometimes been relieved by puncture of, the anterior wall of the sinus and subsequent irrigation. (For diseases of the Maxillary Antrum, see chapter on Diseases of the Mouth and Jaws.) Deformities op the Nose. Congenital deviations from the normal condition of the nose are sometimes found, consisting in absence or reduplication of the whole organ or of any of its constituent parts, in complete or partial closure of its canals, or in abnormalities of size and shape of certain of its parts. With the exception of the last-named conditions, which are common these deformities are rare. Of the acquired deformities of the nose, deviations of the nasal sep- tum are so common as to be the rule. Practically, they are the most 762 SPECIAL OR REGIONAL SURGERY. important abnormalities of the nose with which the surgeon has to deal. Undoubtedly the most common cause of septal deflection is trauma- tism. Some of the worst cases, however, occur in those who have been mouth-breathers from pharyngeal obstruction, and in whom the disuse of the nose on the one hand, and its altered nutrition on the other, have been active causative agents in the production of the trouble. Fracture of the Nasal Septum. The nasal septum is composed of three separate parts — the cartilag- inous portion, the perpendicular plate of the ethmoid, and the vomer. Any of these three parts may be fractured alone or any part of them may partake of the injury. Fracture of the septum, therefore, may be divided into three parts : first, that of the perpendicular plate of the ethmoid ; second, fracture of the vomer ; and third, that of the septal cartilage. The treatment is a matter always requiring a considerable amount of care, skill, and judgment. In all cases great advantage is gained from an examination of the nose before swelling has taken place. Dislocation of the cartilage in children is, as a rule, impossible to remedy by any known efficient means. Complete luxation having once taken place, the base of the cartilage is so loosened that it is impossible to retain it in its normal position, and even when it is retained from the earliest period after the accident it generally happens that the displacement will recur in spite of treatment having been carried on for a long period of time. With older subjects the case is some- what easier, and even in children where complete healing of the parts has taken place considerable may be done at a period subsequent to the accident by surgical means. For the relief of these deformities Asch has attained success by incising the cartilage in the lines necessary to relieve the deformity, fracturing it at the points necessary to overcome its resiliency, replacing it in the median line, and causing the patient to wear for a number of weeks a perforated tube of hard rubber made to fit the parts. This tube may be manipulated by the patient after a little instruction, and its presence need not be irritating. This operation may be used with advantage in cases of deflection extending beyond the cartilage. Operations upon the nasal septum are commonly called for and extensively practised. They may be divided in general into two classes : 1. Those for the removal of projections in cases where the normal thickness of the septum has been increased ; 2. The straightening of deflected septa whose transverse diameter has not been materially altered. These two varieties of deformity may require widely different treat- ment. Projections from the nasal septum may be removed by the use of caustics, the cautery, or electrolysis. They may require the use of some cutting instrument, such as the saw, the knife, the chisel, or the forceps. The use of caustics is mainly applicable to hypertrophy of the soft tissues of the septum, and particularly those which occur on the anterior and inferior part, The galvanic cautery is of somewhat more extensive application on account of its greater destructive power. It may be used for the destruction of cartilage and even for bone. Elec- trolysis has been used with some success for the removal of small ante- rior projections of soft tissue. DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 763 For cartilaginous and osseous spurs other means will generally be required, although the electro-cautery is sometimes useful in these. Kemoval of these is best accomplished by some cutting instrument, the most popular of which is the simple nasal saw. The latter should be specially constructed for the purpose and of the best workmanship. The electric trephine, merely a variety of the saw, is often a valuable substitute for the latter. Variously constructed knives, scissors, and gouges are used either to separate the ridge or to reduce remaining pro- jections after the use of other instruments. The removal of septal spurs may be accomplished either with local or general anaesthesia. Where the operation promises to be severe the latter may be required. In nearly all cases cocaine will suffice. In operating strict aseptic precautions should be attempted, notwithstanding the evident difficulty of actually securing them in the nasal passages. The patient should be seated and his head firmly sup- ported. The nasal cavity, having been cleansed and anaesthetized, should be care- fully inspected, and the exact nature, extent, and direction of the proposed incis- ion determined upon. In using the saw it is generally more convenient to cut from below upward. Everything being ready, the saw should be introduced, the line of direction carefully noted, and as little time as possible consumed in cutting through the fragment, the operation being guided by means of anterior rhinoscopy, and every precaution taken to avoid injuring the neighboring parts. The distal end of the saw should always be probe-pointed, to avoid unnecessary injury to the membrane of the posterior part of the septum and of the wall of the pharynx, which latter, however, the saw should not be allowed to touch. The bony structures hav- ing been separated, the detached fragment should be finally separated by a smooth incision through the remaining mucous membrane, made either with the knife or scissors. In using the trephine the instrument is attached to an electric motor, and is applied by the aid of rhinoscopy to the anterior end of the projection. Revolv- ing rapidly, it is caused to cut its way through the long diameter of the ridge. Where the base of the spur is narrow, its removal may be accomplished with one introduction of the trephine. If it is somewhat broad, several such attempts may be required. In cases of unusual difficulty, and where the thickness of the septum will permit, a large core may be pierced through the longitudinal centre of the projection and its final removal accomplished with the nasal saw. Irregularities remaining after the use of the trephine should be removed with the aid of some suitable instrument. Bleeding after operation is not usually severe, and in any case may be stopped by tamponing the nose with a narrow continuous strip of antiseptic gauze. The use of the tampon is often unnecessary, although, as a rule, air should be excluded from the nostril. The shock of these operations is often severe. The patient should be warned of this, and should be treated with the same consideration, as to rest and general attention, as would apply to any other surgical condition, even slight operations upon the septum being sometimes followed by considerable general disturbance. CHAPTER XLI. SURfilCAL DISEASES AND INJURIES OF THE FACE. By Edmond Souchon, M. D. Congenital Malformations. Absence of face is called aprosopia ; more or less marked imper- fections of the face are called atelo-prosopia. Congenital branchial fistula have been observed on the face on the line extending from the auditory meatus to the labial commissure, and also in the groove between the nose and cheek. Congenital atrophy of the face may affect the whole face or one side only. In unilateral atrophy the skin is shrunken, yellowish, hardened. In sclerema neonatorum the skin is waxy, hard, tense, cold ; the body lies motionless as if the face and limbs were fixed in death ; the child cannot open its mouth to suck ; the disease occasion- ally appears a few days after birth. Albinism is congenital absence of pigment in the skin, hair, and eyes. Congenital hypertrophy of the face may include the whole face or only one side. Double face has been observed on a living subject. Congenital syphilitic hypertrophy of the face in children or in young adults, presenting evidence of congenital syphilis, is characterized by prominence of the frontal eminences, imperfect development and de- pression of the bridge of the nose, opacity of the cornea, pits and scars on the face and forehead, cicatrices and fissures of the cheeks and at the angles of the mouth, malformations of the permanent teeth, especially of the central incisors of the upper jaw (Southam). Long-continued proper specific treatment will improve such appearance. Birth-marks or port-wine stains are more frequent on the face than anywhere else; they may be very small or very large; they may be level with the skin or they niay be raised. They should be treated as they are in other parts — -with more care, if possible, on account of the cicatricial marks. Congenital deviations of the face, or asymmetries, in which the face is thrown to one side, have been observed to a lesser or greater degree. Acquired Deviations of the Face. — Mutilations are on record in which one side of the face is natural, and the other drawn so as to present the expression of perpetual laughter, as depicted in Hugo's " V Homme qui Bit." Injuries of the face would be still more frequent than they are, on account of its exposed position, but for the small size, excessive mobil- ity of the head, and the protection afforded by the arm and forearm instinctively brought up quickly in front of the face. Burns are usually deeper than they seem at first : they are often 764 SURGICAL DISEASES AND INJURIES OF THE FACE. 765 followed, in the mildest forms, by at least coarseness of features, ugly cicatrices, and deviations, whose result is dribbling of the saliva: the cicatrices sometimes interfere with the movements of the lower jaw. It is important to prevent the patient from scratching himself during sleep or delirium, so as to prevent a frequent and potent cause of increasing the deformities. Contused and lacerated wounds often present a lesion of the deep much greater than of the superficial parts, as it is the underlying bone that has done the cutting. Contused wounds produced from without are the most frequent ; sometimes they are very extensive, such as a result of the kick of a horse, terrific falls, etc., and large portions of the facial mask are torn away and hang down. Deep sutures can be placed to advantage to support and approximate the parts. Punctured wounds, when deep, are apt to be followed by subcu- taneous hemorrhage : they may penetrate one of the cavities, where the weapon may be broken, as in the maxillary sinus, orbit, cranium. Incised wounds usually gape much : very often fatty lobules pro- trude between the edges of the wound. Sabre wounds sometimes carry away the whole of projecting parts ; they bleed freely. Great care should be taken to approximate the edges properly, so as to avoid unsightly cicatrices : fine needles should be used, also fine silk ; plaster strips or collodion should be placed over them. These wounds unite generally by first intention, because the skin, subcutaneous tissue, and muscles form but a single matted layer or structure. Gunpowder stains should be removed at once and thoroughly : if they are allowed to remain, they will remain for life. If necessary, cocaine or an anaesthetic must be used ; the parts should be first scrubbed with a hard nail-brush ; then all the grains of powder must be picked out, one by one, employing a cataract needle ; a 1 per cent, solution of mercuric chloride will facilitate the removal of the grains of powder. The immediate complications of the wounds of the face are emphysema, due to fracture of nasal fossae or maxillary sinuses; wounds of Stenson's duct; cerebral contusion : this is not very frequent nor severe ; it is, on the contrary, remarkable how few cerebral symptoms develop after violent injuries of the face; this is due to the fact that the bones are soft and yield readily. Wounds of the deep arteries give rise to hemorrhage through the mouth, without our being able to ascertain positively whence the blood comes. The secondary complications are oedema of tongue and pharynx, interfering with deglutition, cephalic tetanus, persistent neur- algias, cramps, and contractures. Secondary hemorrhages are frequent in lacerated and gunshot wounds of the face ; they usually take place between the fifth and the twenty-fifth day : it is the small deep vessels that are the troublesome factors. No styptics should be used, especially here : it is preferable to use methodical plugging with long narrow strips that are well packed in small segments in all the nooks and corners with as hard a compression bandage as the patient can stand. The bleeding arteries should be ligated in situ if possible, but this is very difficult, and often unsatis- factory on account of the inflamed and sloughing condition of the tissues. Bv applying a provisional loop ligature around the common carotid the hemorrhage may be controlled until a thorough search and a satisfactory ligature of the bleed- ing points be accomplished in situ, when the provisional ligature is removed. In such cases the common carotid should be exposed close to its bifurcation so that if the above procedure should fail, the external carotid is within easy reach. It might be well borne in mind that it is the external carotid that must then be ligated, not the common carotid, on account of possible cerebral complications In extensive or general bleeding it may be necessary to ligate both external 766 SPECIAL OR REGIONAL SURGERY. carotids : in such an emergency the ligations should be applied above the origin of the Unguals. The sequels of injuries of the face are reflex contractions of the muscle of the face from a wound of the face or scalp, constrictions of the jaws, ectropion of the lids or lips, atresia of the mouth. These injuries are sometimes followed by amaurosis, especially if they occur near the orbit or the malar bone; the lesion is often a dislocation of the lens or a detachment of the retina; sometimes there is no detectable lesion. Neuroses of the Pace. — Anaesthesia of the skin of the face is usually due to the paralysis of the trifacial ; it is a symptom of a lesion of the nerve-centres. Double paralysis of the face is called diplegia. Facial paralysis, or Bell's palsy, is usually caused by brain lesions, but may be due to the effects of cold on the nerve, of blows, of wounds or operations injuring the nerve in some point of its course or at its point of emer- gence ; diseases of the temporal bones (fractures or caries), or otorrhcea. Its peculiar symptoms are inability to close the eye, prolapse of the cheek, eversion of the lower lip, the deviation of the face toward the sound side. When the patient laughs, the expression of the whole face is most peculiar and characteristic. The treatment varies with the cause. Facial hyper- cesthesia comprises dermatalgia, or painful skin, or pruritus or itching, especially of the skin of the beard or of the nares ; it is rather rare. Facial neuralgia is called tic douloureux when the pain is accompanied by contraction of the muscles ; its special cause here is often a carious tooth, although the tooth itself may be painless ; the other causes are painful cicatrices, foreign bodies, callus including a nerve, tumors, inflammations, diseases of the petrous bone or intracranial tumors. Its special treatment in obstinate cases is the stretching or the section of the nerves at their points of emergence (neurotomy and neurectomy) or the removal of the Grasserian ganglion. Facial spasm, or convulsive tic with- out pain, is a clonic spasm causing contortions of the side of the face : it ceases during sleep. Cephalic hydrophobic tetanus may result from a bite of a non-rabid animal ; it affects the course of a cranial nerve ; the facial nerve is paralyzed on the side of the wound. The symptoms are those of hydrophobia ; the face is congested and haggard. Furuncles or boils most frequently affect the face and neck. Car- buncles of the face are comparatively rare and nearly always fatal. These lesions are particularly grave about the face, because, of the septic absorption by the facial vein and its direct conveyance to the sinuses of the brain. Carbuncles should be freely incised or curetted at the very outset. Erysipelas is common : it is usually due to some lesion in the interior cavities, buccal, nasal, pharyngeal, Eustachian tube or external auditory canal ; it emerges from the tip of the nose or from the lachrymal points or from the external auditory canal. When it first travels through the Eustachian tube and the middle ear it is preceded for two or three days by most agonizing pains : it is more serious here than anywhere else, because of the propaga- tion to the brain and membranes. It seldom stops until it has gone over the whole face and head, seldom extending beyond the neck to the trunk : it usually leaves the features coarser than before its advent. Ulcers of the face may be due to many causes. Tubercular ulcers are the most frequent outside of syphilis ; they are called lupus, and the face is their favorite site. Lupus erythematosus is not tubercular. SURGICAL DISEASES AND INJURIES OF THE FACE. 767 Lupus non-exedens is characterized by an eruption of pale or reddish tubercles which ulcerate, and become covered with white scales and scabs, which on coming away leave behind a smooth white depressed cicatrix. Lupus exedens destroys by ulceration ; lupus non-exedens destroys by atrophy. Ulcers of the face which resist ordinary treatment should be cocain- ized and curetted ; if necessary they should be extirpated like cancers. The Bishra button or Aleppo boil is a tropical disease beginning by a boil which leaves a foul ulcer : it is due to a micro-organism. Syphilitic ulcers are common in all their forms and varieties — papular, tubercular, rupial, etc. General specific treatment is indispensable. Indurated chancres may occupy any part, but they are more rare than around the mouth ; they are sometimes two or three in number ; they are usually accompanied by a hard and purple oedema, with greater nodular engorgement than in other situations. Chancroids or soft chancres of the face have been observed, but are very rare. Tertiary syphilitic ulcers are tuberculo-ulcers and resemble lupus : they often pre- sent here a rapid evolution, and are rebellious to specific treatment, destroying soft parts and bones alike, followed by destruction of nose, and cicatrices, causing atresia and ectropion of the natural orifices. Yaws, or frambcesia, presents reddish papules, tubercles, or tumors studded with yellow points, which ulcerate : it is a very rare disease. It may appear first on the lip ; sometimes the papules are arranged in rings, especially round the eye, nose, mouth, and the genitals. Tertiary ulcers of yaws are also common about the lips. Cancerous ulcers are limited usually to the skin ; however, cancers on the deeper tissues, and especially the bones, finally ulcerate. Cancers commencing on the skin are the squamous epithelioma and the rodent ulcer. Rodent ulcer is a form of epithelioma : it is remarkable that almost every case of rodent ulcer has its seat within an area bounded by a line drawn from the uppermost point of the pinna to the root of the nose, and another drawn from the lobule of the ear to the columella of the nose. It exceptionally occurs on the hands. It must be thoroughly curetted or destroyed by pastes or extirpated. Epithelioma is the most common of all cancerous affections of the face, which is a favorite site for it. It is important to remember its forms and varieties — superficial or flat epithelioma, presenting scales or a grouping of papules or an inflamed sebaceous outlet ; the indurated or circumscribed ; the papillary ; the infiltrated or diffused, which resembles the condition of chronic inflammation : sometimes it begins by separate spots which coalesce ; there is no elevation of the diseased parts. Epithelioma of the face when small should be curetted or attacked with pastes ; but when of size or deep, extirpation is the best remedy : early interference is most desirable to avoid large scars. Tuberculoderma of the Pace. — Tubercular ulcers, due to primary tuberculosis of the skin, are ulcers with infiltrated, ragged, and undermined edges, and a slightly indurated floor covered with yellowish tubercles moistened with a thin and scanty secretion : they may occur on the face, on the head, and elsewhere. They are sometimes due to breaking down of small tubercular nodes preceding or following pul- monary or intestinal tuberculosis. They are generally situated at the 768 SPECIAL OR REGIONAL SURGERY. junction of the skin and mucous membrane, about the corners of the mouth- and margin of the nares, especially in cases of lung disease. The treatment of these diseases has already been described. Syphiloderma of the Pace. — Syphiloderma includes all the diseases of the skin of syphilitic origin. Primary sores or chancres have already been mentioned above : they may occur on the lips, cheeks, tongue, from smoking infected pipes, from using infected glasses, forks, spoons ; from kissing ; from dentists' instruments ; from unnatural practices. Of the secondary manifestations the eruptions affect usually the face last : they may be papular, tubercular with or without ulcera- tion ; rupia or alopecia of beard, eyebrows, eyelashes. Small papules may form a kind of circlet on the brow round the margin of the hair (corona veneris). The more common position of tertiary syphilitic lesions is the forehead and the margin of the scalp. In congenital syphilis the face sometimes presents a senile aspect. Tertiary ulcers have already been mentioned above. Tumors of the Pace. — Some tumors of the face originate from the spheno-maxillary fossa and become superficial on the cheek. Of the gaseous tumors we will mention here emphysema of the face, due to frac- tures and dislocation of the nasal, lachrymal, and superior maxillary bones or to rupture of the nasal mucous membrane, with penetration of air into the tissues ; it calls for prompt reposition of the bones and pressure to prevent the spreading of the disease to the neck and larynx. To the fluid tumors (blood, serum, pus) the following points of peculiar in- terest apply : Liquid hmmatomata should not be punctured nor incised, but should be aspirated in time if they resist compression. Aneurisms of the face are rare : they are usually traumatic. A lymphatic nodule raised by the facial artery may be mistaken for an aneurism. Ectasis of the facial vein has been observed once near the commissure. Angeioma or erectile tumor or nozvus of all kinds from the birth-mark to the venous and arterial, from the small or limited to the broad and diffused, is rather common on the face. The same means should be employed here as elsewhere, bearing in mind the cicatrix and deformity that will follow. Lymphangioma circumscriptum cutis is characterized by the formation of vesicles, forming patches of greater or lesser extent : they have been found on the face, limbs, neck, and shoulders. The essential features of the condition are overgrowth and dilatation of the lymphatic vessels ; they should be curetted or extirpated. Lymphangeioma of the face is frequent : the face is its site of predilection. It is always congenital : it corresponds to what is called congenital hypertrophy, and may be limited to one region ; when incised the lymph runs out. Macromelia is congenital hypertrophy of the cheek. Cystic lymphangeioma resembles serous multilocular cysts of the neck : the cheek is raised by a tumor of variable size, almost round, limited or diffuse, lobulated, with ill-defined fluctuation ; it may extend under the zyomatic arch. Upon a superficial examination it resembles oedema, but by palpation isolated hard nodules are felt. Oysts of the face are serous and multilocular, branchial, sebaceous, sudoriparous, salivary. Hydatid cysts are very rare, but exist : they are not usually diagnosed unless punctured. Sometimes the puncture cures them : it is well, therefore, to wait before extirpating them. Solid tumors, not elsewhere considered, present the following varieties : Callosities are rare. Horny excrescences have here a site of predilec- tion. Papillomata or warts may be small or large : this affects their SURGICAL DISEASES AND INJURIES OF THE FACE. 769 mode of treatment. They present the following varieties : the vulgar, plane, filiform, digital, acuminated, sessile, pedicuhited. Flat irart* (verruca plana) in young persons are most common in the face, particu- larly the forehead. Verruca seborrheica, or seborrheic wart, consists in multiple patches of warty growths; the face is rarely attacked ; it is most common in old people. Hcematomala containing clotted blood, usually following injuries and resisting' compression and aspiration, should be incised with as small an opening as possible, on account of the cicatrix. They are most commonly seen on the face ; the eye- lids are their favorite situation. Hasmatomata formed of solidified fibrin, result- ing from blows or cured aneurisms, are extremely rare. Sebaceous ci/xfs, or steatomafa, are most commonly seen on the face near the seal]) ; usually their dissection here is more difficult than might be thought at first. Dermoid cysts may occur on the face occasionally ; they are sometimes very numerous and resemble fibromata, but on cut- ting into them a sebaceous-looking material escapes. Adenoma (seba- ceous) occurs chiefly on the face : it consists of small, firm, whitish or yellowish, solid tumors firmly imbedded in the skin at different depths or projecting from it. These are sometimes grouped about the end of the nose ; they vary from the size of a pin's head to that of a pea ; they are sometimes red, owing to the dilatation of the capillary veins on their surface ; the lesions are usually symmetrical, and, though thickly crowded together, they do not run together to form patches. They present no opening : when pinched inspissated sebum can be squeezed out of them. They are usually congenital, though further crops of lesions appear after birth, especially at puberty ; they undergo little change. Telangiectasis, acne rosacea, warts, nsevi, keratosis pilaris, etc. often coexist with adenoma sebaceum ; the patients are usually of a low grade of mental development. Epithelioma adenoidex eysticum is formed by small tumors which become shining and translucent, containing one or more minute white, brightly-refracting milium- like bodies : they are firm, but not hard, and can be felt imbedded in the skin. The most common sites are the space between the eyebrows, the root of the nose, the nostrils, the cheeks, the upper lip, and, to a less extent, the chin : they are so thickly clustered together as to form disfiguring lumpy patches ; they may occur on other parts of the body. Syphilitic gumma, and diffused syphiloma of the face exist and re- semble leprosy ; they usually follow syphilis of the lip. Lipomata are not often met with on the face : they are usually small and numerous, as in all situations where the bones are superficial ; they are sometimes congenital. Branchial fibro-chondromata, also called auricular append- ages, supernumerary auricles, congenital appendices of the face, are not very rare : they are congenital. Their surface is formed of skin -. in the centre is often found a cartilaginous stem ; they are most common in front of the tragus or on it, but they are also seen in all the regions of the branchial arches ; also on the cheek on a line joining the external auditory canal to the labial commissure or below the line — in one case on the lower lip under the mucous membrane. They are excessively rare in the other regions of the face. They may be symmetrical • are about one-third of an inch long; are conical or club-shaped or pediculated ; in the pre-auricular regions they are often multiple, and arranged in pairs along a vertical line, and may be symmetrical. After 49 770 SPECIAL OR REGIONAL SURGERY. birth they seem to increase, and then they remain stationary ; sometimes they are associated with branchial fistulas. Fibroma of the skin, or fibroma molluscum, presents pear-shaped or roundish tumors covered by smooth skin, usually pedioulated, but sometimes sessile : it is commonest on the face next to the trunk. Diffuse fibroma is a molluscum in which the tumors are large and attached by broad bases : they are usually mul- tiple and overlap each other, forming folds of loose skin with dilated sebaceous follicles. Hard fibroma, or neuro-fibroma, is rare on the face, in size varying from a pin's head to large dimensions. Large hard fibroma is rare outside of the maxilla. Keloid is most common after burns. Addison's keloid is not a keloid proper, but a form of morphoea ; the keloid of Adibert develops spontaneously on cicatrices, especially on burns. Do not extirpate a growing keloid. Operations of the Pace as a Whole. One of the points of importance about operations on the face is to endeavor to leave as little disfiguring scar as possible. Operations on the Branches of the Fifth Pair in Cases of Invet- erate Neuralgia. — Neurotomy, or section of the frontal nerves at the point of emergence at the supraorbital foramen, of the superior maxil- lary at the infraorbital foramen, and of the inferior dental at the mental foramen, affords only temporary relief. ( Vide also p. 703.) Neurectomy, or resection of a portion of these nerves as far as they can be traced in the canals and grooves that lodge them, gives more dur- able relief, but many cases recur. The inferior dental nerve is more thoroughly exposed by trephining through the outer table of the lower maxilla along the course of the inferior dental canal. Resection of the branches from the Gasserian ganglion, or of the ganglion itself without the motor root, gives more permanent relief than any other course, but it is a very grave operation. Extirpation of tumors should always be done from the interior of the mouth when possible : although more difficult, the advantage is that there is no external scar ; when the tumors are small and the operation aseptic there scarcely should be a scar left. Ligation of the external carotid on one side or on both sides will often give relief and temporarily arrest the growth of the tumor. If the two arteries are ligated, the ligations should be applied above the Unguals. When the tumor is large and its removal compels that of a portion of the skin, the spot should be grafted or a plastic operation resorted to at once to close the solution of continuity. In making incisions about the face care should be taken to make them in a direction that will spare the vessels, the nerves, and Stenson's duct ; in one that will leave a less noticeable scar by following, when possible, the natural folds, grooves, and wrinkles of the face ; by using thorough asepsis ; a sharp thin-bladed knife ; stopping hemorrhage thoroughly before stitching, so as to secure primary union ; using fine needles, fine silk, collodion dressing, and slight pressure on the parts; using pins if much strain is expected on the sutures or if apprehensive of movement of the parts. SURGICAL DISEASES AND INJURIES OF THE FACE. 771 One of the serious difficulties of operating on the face and its cavities is the neces- sity of often removing the face-piece through which the anaesthetic is being admin- istered, so as to uncover the field of the operation and delay the operator. This drawback and the consequent possible dangers are overcome if, after the patient Fig. 317. Souchon's intranasal inhaler. has been fully anaesthetized by the ordinary method, a tube is passed through the nose into the lower pharynx, and the anaesthesia is maintained uninterruptedly by injecting through the tube the vapor only of the anaesthetic; thus a free field is Fig. 318. Souchon's intranasal inhaler. secured. This is accomplished by an apparatus invented by the writer: it is so constructed that it can be used with chloroform alone or with ether alone, or with a mixture of the two : it is also provided with an attachment to connect it with a bag of oxygen or nitrous-oxide gas if desired/ 1 For detailed description see Medical News, Philadelphia, Nov. 23, 1895. 772 SPECIAL OR REGIONAL SURGERY. Surgical Diseases and Injuries of the Nose, Exterior. Congenital Malformations. — Fissures are more frequent on the ridge of the nose than anywhere about the face, and yet these are very rare. Nasal dermoid flstulse are always ascending, and may reach the dura mater. Congenital absence of the nose has been observed by Maisonneuve : it was in a child nine months old. There existed only a flat surface with two small holes. Langenbeck recommends in these cases the transplan- tation of the periosteum of the frontal bone. Occlusion of the nostrils has been noticed. Congenital clefts and fissures of the nostrils are due to incomplete closure of the branchial fissures of the cheek or of the naso-genial fissures ; they are directed usually toward the external angle of the eye. Plastic operations are necessary to remedy the defect. A bifid nose due to a fissure between the lower lateral cartilages is recorded by Verneuil, Thomas, Borrelli. Congenital hypertrophy has been observed. Double noses exist ; they are more or less well formed. The remedy consists in removing one and closing the gap by a plastic operation. Sometimes the additional nose is a tumor. Congenital deviations are more or less frequent, such as parrot nose, saddle nose, pug nose, excessive deviation to the right. A case is reported of the successful removal of a morbid mass implanted on an abnormal bifurcation of the nasal bone, and in which was recognized the rough appearance of a foetus : at the lower part of this foetal mass, between its thighs, was noticed a penis, cavernous and erectile. Acquired Malformations of the Nose. — Destruction of the nose is frequent enough as a result of injuries by ulcerations. A plastic ope- ration is necessary to remedy the defect, or the wearing of an artificial nose supported by spectacles. Closure of the nostrils follows burns, fractures, and small-pox : the contracted nostrils should be dilated gradually like other strictures ; the dilatation must be kept up so as to prevent recontraction. Depression or flattening of the bridge may be due to fractures or to syphilis. Dislocations of the nose, cartilages, or bones require treatment sim- ilar to fractures. Fractures of the nose are usually due to severe blows or falls ; fractures of the upper part of the nose require very great force. The direction is transverse, with backward displacement, if the blow be from above ; it is lateral if the blow be from the side ; in children it sometimes happens that the bones are fractured only in the middle, and are sunken in. The symptoms are those of fractures in general. The diagnosis may require an anesthetic if there be much swelling, as a correct diagnosis is important before the bones begin to unite, which may occur before the swelling has disappeared. The prognosis is serious, because of the probable and frequent deformity : very often much prominent deformity follows a fracture which at first was thought to be slight. The treatment must be directed toward replacing the bones and preventing SURGICAL DISEASES AND INJURIES OF THE FACE. 773 deformity: the fragments should be replaced by using external and internal man- ipulations ; internal aseptic tampons should be used with caution on account of the possible sepsis. Apply externally strips of plaster and compresses ; in cases where the fragments fall back they should be raised and supported by passing a needle transversely between the fragments and the sound bone. A complication that is not uncommon is emphysema if the lachrymal bones have been broken or if the mucous membrane has been lacerated : very often there is much bleeding, with persistent headache, even with concussion symptoms. The latter complication, if grave, may cause death. The dreaded sequel of frac- ture of the nose is the deformity : sometimes the nose has to be refractured and readjusted; in some cases osteoplastic operations are required. Poisoned wounds, stings, bites, present no special remark here, except, of course, glanders, which shows externally first by an inflamed and ulcerated condition of the nostrils and upper lip. The diseases special to the nose, and not seen anywhere else, are — rhinoscleroma (Fig. 315), erythematous lupus, acne rosacea, acne hyper- trophica (lipoma nasi). The diseases that are most frequently met with on the nose are — naso-genial congenital fissure or fistulse, bifid nose, deviations, strumous hypertrophy, frog-face, seborrhoea oleosa, frost- bite, knock-out blows, glanders, erythema solare, Eeynaud's disease, lupus exedens and non-exedens, epithelioma. Scrofuloderma of the nose is represented by a peculiar hypertrophic nose and the peculiar eczema of the nostrils. Tuberculoderma is represented particularly by lupus. Operations on the Nose. Plastic operations for the repair of partial losses or for the construc- tion of a whole nose are among the most delicate operations in surgery. The operation is called rhinoplasty, and comprises the Italian method and Indian method. The Italian or Tagliacozzian method is named from Tagliacozzi. It consists in making a pattern which is applied to the skin of the arm ; the skin is then incised all around it, but one-third more on every side for shrinkage ; a pedicle is carefully preserved ; the flap is raised, and is allowed to remain so for about fifteen days, when its lower edge is much thicker on the under surface and presents granula- tions. Then the edges of the stump of the nose are pared, as also the edges of the flap, and the arm is brought in such a position as to allow the ready fitting of the flap to the nose, where it is properly stitched. The arm is held in that position by a liquid-glass or a plaster bandage or by some special apparatus until union has taken place, when the pedicle is severed and the arm released. The upper lip is used afterward to make the columna. In the Indian method a pattern is also made, and is applied to the skin of the forehead, which is incised in exactly the same manner, but the flap is at once placed in proper position. Care should be taken not to wound the angular artery. The gap created by the taking of the flap is closed by a sliding autoplasty or by grafting: it is sometimes advisable to raise the periosteum with the flap, or even the outer table of the frontal hone (Kb'nig). For the minute details of these ope- rations the student is referred to special works. Surgical Diseases and Injuries, of the Lips. Congenital Malformations of the Lips. — Absence of the lips, or aeheilia, is very rare. Astomia is absence of the buccal orifice, which is different from the simple atresia due to excess of adhesions of the lips. Atresia of the mouth, when incomplete, is narrowing of the buccal ori- 774 SPECIAL OR REGIONAL SURGERY. fice ; when complete, it is also called imperforation : this differs from astomia in this, that behind the lips there is a buccal cavity. Incom- plete atresia is also called phimosis of the mouth : sometimes the oblite- rated mouth is replaced by a congenital genian fissure. Atresia of the Fig. 319. Complete bilateral fissures (coloboma) of face (Guersant). orifice of the mouth, without loss of substance and without adhesion of the jaws, may be called ankylocheilia ; it is usually due to lupus, syphilis, variola ; in one case the orifice was completely closed. Congenital fissures all start from the lip ; they present the follow- ing varieties : fissure of the lip alone, or prolonged fissures which extend Fig. 320. Fig. 321. Incomplete hare-lip (Bruns). Complete Assure in double hare-lip (Park). toward the face or the neck ; the prolongation is sometimes a mere cica- tricial line looked upon as an intra-uterine cure of hare-lip. The hare- lip is simple when it involves only the lip ; it is complex when it affects also the alveolar process or the hard and soft palates. The other varieties SURGICAL DISEASES AND INJURIES OF THE FACE. '75 are the ordinary or vulgar hare-lip — i. e. a fissure under the nostrils ; the coloboma or bueco-orbital fissure (Fig. 319), external to the wing of the nose ; the median fissure, the genian commissure, and the median fissure of the lower lip. Commissural fissures constitute macrostoma ; they are compound or associated fissures. Congenital fistules of the lower lip are often represented by two small orifices symmetrically situated on each side of the freenum and opening on the free edge of the lip nearer to the mucous surface ; sometimes there exists also a hideous ectropion of the lower lip, and also a transverse groove. Median fissure of the lower lip, varying from an inch in width to a regular Fig. 32 Fig. 323. Double hare-lip with philtrum or snout (Park). Complete Assure, with labial defect and pro- jecting intermaxillary (Brims). groove, which may be prolonged as a continued line as low as the sternum ; the lower maxilla may also be involved; also the tongue may be bifid. Branchial fistula: of the lips have been observed. Atrophy of one lip, causing tightness of the same or of both lips, is not uncommon. Congenital microstoma, or small mouth, is mostly due to arrest of development of the maxilla. Macrostoma, large mouth, or fissure of the cheek, is due to the lack of closure of the branchial fissures; the commissure is extended into the cheeks horizontally or upward or downward, on one side or on both sides. Median fissure of the upper lip is very rare on account of the peculiar development of the middle portion of the upper lip. Hypertrophy of the lips is not infrequent. Macrochilia is thick everted lip; it is a condition of lymphcedema. In the general hypertrophic form all the struc- tures are involved ; the upper lip especially is affected ; it may involve only the mucous membrane and form a sort of chemosis of the lip, or it may involve also the glandular layer and increase the appearance, or the whole lip may be involved ■ the mucous surface of the lip is covered with a rough, wrinkled mucous mem- brane, presenting a separate pouch on each side of the median line. ( Vide Chapter XXIX.) Mucous ectropion, or hypertrophy of the mucous membrane or extrophy of the hps, is usually congenital. Congenital hypertrophy is not uncommon in strumous subjects, especially of the upper lip. Macrocheilia is a special form of congenital hypertrophy of the lips; it is different from the big lip of the scrofu- 776 SPECIAL OR REGIONAL SURGERY. lous, of cretins, of paralytics, of negroes : the cause is unknown ; it is congenital ; it is most common to the upper lip, whereas angeio-elephantiasis selects the lower lip. The alveolar border is also affected ; the lip may be increased as much as 14 centimeters in length, 8 in height, and 3 in thickness. Fig. 324 Illustrating the osseous (palatal) defect in com- plete fissures (Bruns). Projecting intermaxillary bone (Bruns). Acquired Malformations of the Lips. — Acquired microstoma, or union of the lips and closure more or less complete of the mouth, has been observed after burns, injuries, ulcers and removal of tumors. Atresia of orifice of mouth, with loss of substance and adhesions to the jaw, is called syncheilia ; it is the rule after cancrum oris. As a result of all these deformities there is constant dribbling of the saliva and dropping of the food during mastication. Acquired macrostoma, or large mouth, is also the result of similar causes. Cica- trices around the mouth are observed in children affected with congenital syphilis, and they may also present a scarred or a fissured aspect at the angle of the lips and cheeks. Acquired deviations or distortions of the lips may be directed upward, downward, or outward ; may affect one side or both ; most commonly it is ectropion that is observed, due to cicatrices from burns, injuries, gangrene, ulcers, operations ; sometimes the lower lip is thoroughly everted and is attached to the skin of the neck. All these interfere with speech and the proper retention of the saliva. Acquired ectropion, or eversion of the lips, may be paralytic, mucous, and cicatricial. Cicatricial ectropion of the lips is due to the retraction of a cicatrix. Scars of the lips do not grow small with age, but grow with the body ; the con- spicuousness of the scars make them doubly objectionable. Chronic swelling of the lips, or hypertrophy, is usually due to chronic lymphan- gitis ; the cervical adenitis increases the lymphangeiectasic condition by becoming an obstruction to the course of the lymph. Chronic swelling of the lower lip is more rare in scrofulous subjects, but in idiots, cretins, and paralytics the lower lip is always pendulous and moistened by the constant running of the saliva. It constantly exposes to air and cold its ulcerated mucous surface, all of which causes a chronic thickening. In cases of old rebellious indurated lips the excision of a V-piece is necessary. The diseases of the bones of the jaw also affect the shape of the mouth, and must be studied with them. Inflammations. — Furuncles and carbuncles are comparatively fre- quent, especially on the upper lip ; the swelling usually affects the mucous side, and it is followed by protrusion of the lip, ulceration, and ectropion. They are especially dangerous here on account of the com- SURGICAL DISEASES AND INJURIES OF THE FACE. 777 plication of phlebitis of the facial vein, which may extend to the sinuses of the brain. Owing to the peculiar anatomy of the parts, carbuncles present a diffuse swelling, are hard, of a brawny dusky color ; they spread rapidly ; the lips are their site of predilection ; they are often followed by simple strumous adenitis (not tubercular). Gangrene of the Lips. — Cancrum oris is phagedenic gangrene of the corner of the lips and of the corresponding portion of the cheeks ; it involves the whole thickness of the lips ; it is observed in ill-nourished and weak, ill-fed children ; it is often followed by great deformity ; the jaws may be drawn down by firm cicatrices ; in some cases there is also necrosis of the bones. Ulcers of the Lips. — Tuberculosis of the free border of the lips is found in patients with lung tuberculosis ; sometimes it is due to direct inoculation, due itself to a wound from a projecting tooth, contact of a pipe-stem, or puncture with a fork ; it is characterized by an ulcer with a peculiar bottom, granular, edges not prominent, irregular, per- pendicular, somewhat serpiginous ; around it the mucous membrane is purple, strewn with yellow dots ; the surrounding tissues are most usu- ally indurated ; the nodes may be affected. Tubercular lesions are rare, especially on the lower lip ; it is usually due to the extension of the lupus of the face. Lupus of the upper lip has a tendency to invade and destroy the nose ; it is often remarkable for the concomitant swelling. Syphilitic ulcers are comparatively common under the form of chancres, which are more common on the lower lip. Indurated chancre of the lip is the most frequent of the extragenital chancres, especially in women and children. It is due to direct contact with mucous patches of the lips by a kiss or by a bite in a scuffle, or by indirect contact with the fingers, pipes, spoons, glasses, etc. It often occupies the mucous surface. The forms peculiar to the lips are — the fissuric chancre ; the commissural or the median formed by two tubercles growing away from each other : erythematous chancre and dwarf chancres are mere erosions, and are not recognized until the secondary symptoms show themselves. One lip may become inoculated with a chancre from the other lip ; gumma of the lips may become indurated and resemble a chancre, but will present a depressed centre and no nodes. Labial chancres require a longer time to cicatrize than the genital chancre : it is said that syphilis thus contracted is more severe than the genital. Mucous patches are also common. The infection is due to auto-inoculation through bad habits, lack of cleanliness. When the ulcers occupy the corner of the mouth, look for syphilis. Remains of hereditary syphilis, early or tardy, have been observed especially on the upper lip ; the lesions are those of sclerosis, with hypertrophy and ulcerative gummata. The disease resembles lupus very much. Can- cerous ulcers take the form of epithelioma, which is the cancer of the lip, especially of the lower lip ; it will be described separately farther on. Epithelioma of the lower lip is a frequent disease in men, but rare in women. It is said to be often due to the irritation produced by a carious tooth, and most frequently by the contact of a short pipe-stem. Sometimes a chronic fissure resembling an ulcer is the starting-point. We must remember that an ordinary ulcer touched by a solid stick of lunar caustic will usually heal rapidly, whereas it has no effect on epi- thelioma, but sometimes stimulates its growth (Fig. 326). 778 SPECIAL OH REGIONAL SURGERY. Epithelioma presents the following clinical forms and varieties, according to the size and character of the ulcer, to the condition of the adjacent lymph- nodes and the skin : It may be flat or superficial, presenting scales or an inflamed sebaceous outlet : this is the less grave form. It may be indurated or circum- scribed, with a raised edge, beyond which the tissues look and feel sound; because of this limitation this variety is the less objectionable. There is also a papillary form, with well-defined, non-indurated edges — and a diffused form, which resembles the condition of chronic inflammation, sometimes beginning by Fig. 326. Fungating epithelioma of lip (Smith). separate spots which coalesce, with elevation of the diseased part: this is the worst form, because it leaves the surgeon always in doubt as to whether he has thoroughly removed all the diseased tissues beyond the microscopically infiltrated or infected parts. It usually runs a more rapid course than the others. Epithe- lioma with nodes affected on both sides is of no very uncommon occurrence ; with digastric nodes affected it is a very rare form ; even when the whole lip is affected it is rare to find these nodes, which receive only the lymphatics from the middle of the lower lip. Operations on the Lips. Hare-lip should be operated early, but the health and strength of the child are more important than the age ; the operation may be per- SURGICAL DISEASES AND INJURIES OF THE FACE. 779 formed from the sixth week to the third month, but we must bear in mind that very young children do not stand bleeding well. Early operations are indicated especially in double hare-lip when the child Fig. 327. Fig. 328. B B Malgaigne's operation : the incision. Malgaigne's operation : the sutures in position ; the lower sutures tied. cannot suck if strong enough : no operation should be performed if there exists any sickness from dentition or other cause. The operation consists in paring the edges freely and bringing them together, and holding them with deeply buried pins and sutures. The pins should be removed after forty-eight hours. In paring great care should be taken that no notch may remain after the operation. The accompanying plates explain the procedure most satisfactorily. For seventy-two hours after the operation the child should be fed with the spoon and also by enemata ; opiates should be given for the pain. Double hare-lip may be operated on in one sitting if not too extensive. In hare-lip with projection of the intermaxillary bone this bone should be pushed in, if possible ; if not, it should be excised. Hare-lip with Fig. 329. Fig. 330. Nelaton's operation : the incision. Nelaton's operation : the sutures. cleft of the hard palate should be operated early, as it will exert an approximating effect on the bones and will tend to diminish the fissure. In hare-lip with congenital fissure of the cheek the fissure should be closed at the same time. Hare-lip with deficiency or partial atrophy of the sides of the cheek calls for plastic and osteoplastic operations if the condition of the child allows ; sometimes there is free bleeding from the artery of the septum ; the orifice of the wound should be plugged. Hare-lip with general malnutrition is always grave, because the mal- nutrition is often due to the defective condition of the lip, which inter- 780 SPECIAL OR REGIONAL SURGERY. feres with nursing. Nutritive enemata should be used freely, and the operation performed as soon as the child's condition permits. The principal operation upon the lower lip is the removal of an epithelioma. It is most important to operate early, before the nodes become involved ; small or even large epitheliomata without lymphatic involvement may be cocainized and curetted, or excised. Fig. 331. Fig. 332. The operation for double hare-lip. Operation for double hare-lip : the sutures in position. In very extensive disease the flaps must be detached from the bone and, if necessary, dissected as far back as the angle of the jaw and as low down as the thyroid cartilage, in order to be able to bring the sides together: the flaps must consist of the skin and platysma, and the line of dissection should be the layer of connective tissue between the platysma and the cervical fascia. Sometimes regu- lar plastic operations must be performed. In epithelioma with lymphatics adhe- rent to the bones, these must be well scraped and even cut away. Where union has once failed one should wait until the tissues are thoroughly removed, because primary union may fail again. Epithelioma recurring on the lips or in the nodes must be operated on at once ; it is the last and only chance. Cheiloplastie operations — i. e. plastic operations on the lips — are per- formed for restoration of the upper or lower lip or for deviations of the angles. They consist in sliding flaps with a pedicle, or in transplanting Fig. 333. Fig. 334. Estlander's cheiloplastie operation. flaps from the neck and face : these flaps must be muco-cutaneous — that is, formed of skin on one side and mucous membrane on the other. Skin-grafting is often of useful assistance in filling gaps. Surgical Diseases and Injuries of the Chin. Congenital Malformations. — Absenee of chin is a possible malfor- mation due to an arrest in the development of the parts, especially of the bones. SURGICAL DISEASES AND INJURIES OF THE FACE. 781 Congenital atrophy of the chin, as well as double chin, is observed as the result of an incomplete fusion of the two halves of the face ; an accumulation of fat causing thick folds under the chin is also called double chin. Congenital deviations forward, or galoche chin, or laterally, are not uncommon. Hypognathy is a malformation characterized by the implantation of a super- numerary inferior maxilla by its own symphysis on the symphysis of the subject : the implanted maxilla is a real one, having the same shape, more or less, and con- taining dental sacs. Sometimes the implantation is bony (myognathes), or is only soft and loose, or it may be pediculated (dermiognathes). It is a tumor of unequal density, here bony and hard, there soft; cysts may develop in its interior and attain great development. It may grow toward the chest, the mouth, or the neck. Surgical Diseases and Injuries of the Cheeks. Congenital malformations and branchial fissures, resulting from the lack of union of the branchial arches, are not uncommon. They may be horizontal or angular ; they may be vertical when the failure of union is located between the extremities of the branchial lamina and the frontal bud from which the nose and the middle of the upper lip are developed ; they may be unilateral or bilateral. Congenital fistulas have been observed on the cheek exceptionally. Congenital salivary fistula?, due to a similar mode of production, are on record. There is no recorded case of absolute absence of the cheek. Congenital atrophy of the cheek is marked by a considerable sinking of the region ; it may be due to a want of development of the bones, the teeth, or the ball of fat that exists between the masseter and the buccinator. Congenital deviations are sometimes observed at birth as a result of the paralysis of the facial nerve due to the pressure of the forceps or to purely structural changes. Swellings of the cheeks are most com- monly caused by a bad tooth ; the next most common cause is an abscess of the antrum. Injuries of the Cheeks. — Contusions are not rare : when they involve the malar and frontal bones they are said to be followed by amaurosis, due not to reflex action, but to injuries (detachments) of the lens, iris, retina, or choroid, or to extravasation of blood in the cham- bers of the eye. Burns and frost-bite, extending to Stenson's duct and to the facial nerve, are followed by salivary fistulse and paralysis of the face. Punctured wounds present nothing peculiar unless they pierce the facial artery or vein or Stenson's duct. Large perforating wounds may leave a permanent fistulous opening through the cheeks. Wounds of Stenson's duct must be attended with solicitude to prevent a fistula ; they are more rare than those of the gland, being protected by the malar bone and zygoma. The division is usually complete ; they are followed by the escape of saliva ; if union fails, there occurs a fistula or a salivary tumor between the two divided ends, which fills at meals and empties after by pressure ; obliteration of the canal and atrophy of the gland may follow. In recent wounds stitch the duct ends together ; in old wounds introduce catgut in distal end ; then press on the parotid to discover the proximal end, and stitch it to the catgut of the peripheral end. The wound should be enlarged if necessary, and the proximal end curved into the interior of the mouth and retained there by sutures. ( Vide below.) Wounds of the branches of the facial nerve should also be stitched if possible : although the branch may be small, yet if paralysis should follow its injury, the result may be most serious, especially if it be the branch distributed to the orbicularis of the eyelids. Fractures of the 782 SPECIAL OR REGIONAL SURGERY. malar or of the zygmotie arch are rare, because very great force is required to produce them : most commonly the arch is broken and depressed. It should be raised by means of a narrow lever. If the fragment be loose and fall back out of place, it should be raised with Fig. 335. Salivary fistula : treatment by single puncture (Hartmann). two or three silver sutures passed under it and tied over a sterilized small aseptic splint placed over the extremities of the facial bones. Inflammation of Stenson's duet is called sialo-ductilitis : it is more rare than that of Wharton's duct. Bristles, fish-bones, straws, tooth-brush hair are the usual causes ; it is sometimes due to propagation through Fig. 336. Salivary fistula: Eichelot's method by double puncture and insertion of drainage-tube (Hartmann). the mouth ; there is swelling of the gland, abscesses, fistula. Fistulae may be due to carious teeth or bone. Fistula of Stenson's duct is usually situated on the buccinator : the orifice is narrow and in the centre of a granulation or in the midst of cicatricial tissue ; a viscous fluid is discharged, increasing during masti- cation. Lymphatic fistula; of the region are rare ; their outpour does not increase during meals ; the liquid coagulates ; sulphocyanide of SURGICAL DISEASES AND INJURIES OF THE FACE. 783 potassium is absent from it. Fistulse of the parotid gland are recog- nized by exploring with a probe from the mouth. The treatment consists in the cauterization of the orifice, its compression with collodion to produce occlusion, or in operative closure. These measures are good if the peripheral end is pervious ; if not, we must re-establish the course of the saliva toward the mouth by re-establishing the normal canal, which is difficult. Fig. 337. Salivary fistula placed anteriorly to border of masseter; double puncture of mucous membrane and enclosure of portion in a wire loop ; fistula thereby made internal (Hartmann). One operates from within the mouth by passing a threaded needle around the duct back of the fistula, penetrating and coming out as nearly the same point as feasible, having the duct in the loop, but leaving out the skin, then tightening, or by single puncture and drainage when the fistula corresponds to the anterior border or occupies the region of the masseter. When the course of the saliva is re-estab- lished, then the fistula is pared and closed. Other means are — causing atrophy of the parotid by compression or by ligation of Stenson's duct behind the fistulous ori- fice, or by injection of oil or iodine into the duct: this is very successful on the horse; it never cures in man. (For other methods see Figs. 335-337.) Tumors of the Cheeks. — Cysts of Stenson's duct and dermoid cysts have been observed near the parotid region, in the depth of the cheeks, or in the course of the infnndibuliform fissure. Angeiomata of the fatty ball of Bichat are usually well circumscribed, stationary, and may obliterate Stenson's duct and be accompanied by parotidean lithiasis; the superficial veins are dilated. Lipoma of the fatty mass of Bichat usually becomes superficial in the cheek in front of the masseter or malar bone, or submucous when the yellow colora- tion is sometimes seen ; sometimes it ascends under the temporal fascia. Sarcomata of the fatty ball of Bichat have been observed ; they grow back- ward. Angeio-sarcomatous cysts of the cheek have been observed over the masseter. Salivary colic is sometimes observed, due to the passage of a calculus through Stenson's duct. Diseases of an Accessory Parotid. — Tumors of the cheek some- times originate from an accessory parotid gland or from Stenson's duct. Cysts with a glandular epithelial lining are forms of grenouillette of the accessory parotid. CHAPTEE XLII. SURGICAL DISEASES AND INJURIES OF THE NECK. By Edmond Sotjchon, M. D. Congenital Fistula of the Neck. These are due to arrest of development or lack of fusion of the branchial laminae or folds and clefts of the pharyngeal fissure ; they are sometimes hereditary, but are sometimes discovered only a long time after birth. They may be due there to a cyst which has ruptured externally. They are usually very small, seldom admitting more than a case probe, exceptionally the end of the little finger. The external orifice is situated most commonly on the right side of the neck in front, and behind the sterno-mastoid, and between the thyroid cartilage and the sterno-clavicular articulation ; sometimes, but rarely, at the angle of the jaw ; it is sometimes on a projection, at other times in a fold of the skin ; it occasionally presents cartilaginous or osseous particles ; it may be found blocked by the dried secretions. These fistulse resemble congenital tracheal fistulse, but open less commonly on the middle line ; they are rarely found on one side, and still more rarely on both sides. The internal orifice may open into the pharynx or larynx or trachea: it is observed almost always near the tonsil and base of the tongue, and is very small; it may become the starting-point of serious inflammation and abscess. When complete an injection of milk penetrates the pharynx or the larynx. These fistulae may be externally or internally blind : the externally blind are by far the most frequent. The course of the fistula is marked by a cord-like-tract which corre- sponds to the tract of the fistula ; its direction is straight or tortuous, oftenest in the direction of the great horn of the hyoid bone ; it is constituted by an external thick, fibrous coat which forms the cord and is lined by a sort of mucous mem- brane which secretes a thin, viscid fluid containing epithelial cells or puruloid. Internal blind fistulse are very rare, but positively exist. They present the variety called diverticula " by pulsion " of the pharynx and oesophagus, due to the dilata- tion and development of an originally small pouch under the influence of the accumulation of the food ; they sometimes form very large tumors. The diag- nosis of congenital fistulse rests upon the secretion of the fluid, the presence of the cord, the penetration of the probe, and the injection of colored fluid. Con- genital fistulas are almost always stationary; the lesion is more of a deformity than a disease. Treatment is usually unnecessary, and fortunately so, because it usually fails when limited to stimulating injections, dilatation, or curetting, and excision is a laborious operation, not without danger, and scarcely justified by the inconvenience experienced. Both orifices may close and leave an intermediate tract. Congenital atrophy of the whole or of more or less extensive parts of the neck is very rare without participation of the rest of the body. Congenital atrophy of the sterno-rruixtoid has been observed. Wounds of the neck are comparatively rare in civil practice; sometimes they are accidental, and due to a fall on a fragment of glass, a stem of iron or of wood ; they are most commonly due to ;tt- 784 SURGICAL DISEASES AND INJURIES OF THE NECK. 785 tempts at murder or suicide ; the latter are the most common and most instructive. The symptoms of entrance of air into the veins arc a wind-suck- ing or gurgling sound, immediate pallor of the face, dilatation of the pupil, irregular or tumultuous action of the heart, embarrassed breath- ing, and sometimes death. The wound should be plugged at once with the finger, and all the usual means of resuscitation vigorously and persistently applied. The amount of air introduced is a grave factor. If the wound be small, the operation may be continued by keeping it constantly filled with warm sterilized water. In all injuries of the neck causing obstruction to the free circulation of the air, from whatever cause, there are great dyspnoea, cyanosis, anxiety ; the pulse is full, rapid ; there is also aphonia, dysphagia, pain. Tracheotomy should be performed : it is often advisable not to wait for very urgent symptoms, because death may come on rapidly or suddenly before the patient can be reached to have the operation performed. Cellulitis, deep or subaponeurotic, is a very grave affection, because of the compression due to the swelling, and because these symptoms are increased by the unyielding nature of the fascia. It may be primary, the result of cold, or secondary, due to some injury or some lesion of the teeth, especially of the wisdom teeth, bones, lymphatics, thyroid body, scalp, ear, face, mouth, or to low fevers. It may come from neighbor- ing organs : tonsillar abscess sometimes opens under the inferior maxilla, and deep axillary abscess in the supraclavicular region, as may also an anterior mediastinal abscess. Abscesses following injury or scarlet fever sometimes form a hard mass, slow in suppurating, causing great damage ; sometimes they bleed alarmingly when opened or even after they have been opened several days, on account of sloughing of the vessels ; they may be accompanied by thrombi in the large veins or sepsis. When the cellulitis suppurates, the abscess may be circumscribed or diffuse ; the pus may fuse in the chest, in front of the thyroid and sternum (previsceral route), behind the pharynx and oesophagus (retrovisceral route), or along the carotid and jugular vessels in their sheath or in the sheath of the nerves of the brachial plexus behind the sterno-mastoid, reaching the supraclavicular region and the axilla ; it may open into the pharynx, oesophagus, larynx or trachea, pleura, mediastinum. Retropharyngeal abscesses may be limited : then they project on the sides of the neck in the maxillo- pharyngeal space ; when they are median they can be reached through the mouth. In some subacute cases, in the upper cervical region and at the root of the neck, abscesses have a tendency to become encysted, and finally open on the skin; they may be chronic. When an "abscess is near or over the carotid, it pulsates, but there is no expansion. The diagnosis of deep abscesses, especially of the acute abscesses, should be made at once by using the exploring needle and syringe — not a hypodermic needle, which may not give passage to thick* pus, but a needle at least twice as large as an ordinary hypodermic needle. Explo- ration should be repeated every second day if necessary. The treatment is of course evacuation and drainage, but in these dangerous regions fear of wounding important structures often holds 50 786 SPECIAL OR REGIONAL SURGERY. the surgeon's hand when the abscess is one or two inches deep, until it becomes more superficial. By incising in the middle line and going around the trachea the knife can penetrate deeply with safety ; also by incising behind the posterior border of the sterno-mastoid, and along the base of the jaw. It is recommended by some to cut down and ligate the vessels as they are divided, but when these are imbedded in indurated tissue it is almost impossible. Others leave the needle in place and cut down along it, but the divided vessels present the same dangers and difficulties. Hilton's method is to use the knife only to start, and as soon as deep parts are reached to tear with the director and use dressing-forceps to dilate the small entrance gained into the abscess : it presents the same objections. The writer's method he calls guided dilatation. It consists in the following steps : Use a proper needle, as above described, to locate the pus at the depth of one, two, or Fig. 338. *& e- d Guided dilatation in evacuating abscesses. three inches ; unscrew the syringe and leave the needle in place ; introduce through the needle a steel wire seven or eight inches long, until it reaches the bottom of the abscess ; remove the needle, leaving the wire in place ; make a small incision through the skin to overcome the only serious resistance to the introduction of the dilators ; take a trocar (with cannula) of one-eighth of an inch in diameter, per- forated from point to handle, and run it over the wire into the cavity of the abscess. It penetrates by dilating the tissues by the three blunt edges of its prismatic tri- angular point. Then remove this trocar, leaving the wire still in place ; take a trocar and cannula of three-sixteenths of an inch and introduce it likewise along the wire ; withdraw the second trocar, and insert in a like manner one of a quarter of an inch ; then one of five-eighths ; finally withdraw the trocar and the wire and leave the cannula in place ; through the cannula introduce a drainage-tube of a quarter of an inch in diameter ; remove the cannula, leaving the drainage-tube in place. A suitable probe can be introduced through the drainage-tube, and a counter-opening made at the proper place. After forty-eight hours the opening can be safely dilated to a half inch or more if it is found that the quarter-inch drainage-tube is not sufficient. By this method the tissues are not cut, but simply uniformly pushed aside ; there is no cutting at any time, since the edges of the triangular SURGICAL DISEASES AND INJURIES OF THE NECK. 787 point are blunt : a round or conical point sometimes packs the tissues and does not penetrate. If a vessel or a nerve be encountered, it is pushed gently aside : that is one reason why the dilatation should be gradual, and why it is not advisable to pass from a one-eighth to a five-eighths trocar. There is no difficulty experienced, so far as the introduction is concerned, in passing from the smallest trocar to the largest. TUMOKS OF THE NECK. Aeroceles (laryngocdes, tracheoceles) are tumors formed by air filling an adventitious pouch : this excludes pneumatocele. The predisposing causes are weakening of the tract and emphysema. The occasional causes are strains (cough, labor). Some are congenital dilatations of the laryngeal ventricles, abnormal prolongations ; some are traumatic and due to wounds of the trachea, rupture of the intercartilaginous spaces ; others are pathological, due to dilatations of the glands of the mucous Fig. 339. Bilobed multilocular cyst of neck (Lannelongue). membrane, to ulcerations, syphilitic or due to former disease of the cartilages, or to abscesses. The course varies; they are usually per- sistent. The palliative treatment consists in compression. In some cases extirpation is possible. Pneumatocele is due to hernia or great protrusion of the lung into the supraclavicular region : it is recognized by percussion and by its disap- pearance upon pressure and its quick reproduction by forced expiration. Pneumatocele follows the respiratory movements. 788 SPECIAL OR REGIONAL SURGERY. Cysts of the neck are of several kinds, and are known under the following names : mucoid cysts (Lannelongue), branchial cysts, deep dermoids, deep atheromatous tumors, congenital hydroceles of the neck, hygromata, atheromatous cysts of the lymph-nodes. They are almost all rare and congenital ; but they are not all branchial. They are situated along the course of persistent obsolete tracts lined with epithelium, in Fig. 340. Congenital multilocular serous cysts (hydrocele) of neck (Lannelongue). the neighborhood of the pharynx and larynx, and along the large ves- sels ; they often have prolongations adhering to the muscles, the vessels, the thyroid cartilage, and hyoid bone, and even the vertebral column ; they may be single or multiple, resembling a bunch of grapes. They may take a sudden and unexplained rapid course and become very large (Fig. Serous cysts have been confounded with dermoid, mucous, or branchial cysts, although they do not, like those cysts, occupy a definite region corresponding to the branchial fissures : the neck is their seat of predilection, and they serve as a type of their kind. When they are single or unique they are almost always on the median line and on the left side ; they occupy principally the anterolateral surface of the neck (Fig. 340). SURGICAL DISEASES AND INJURIES OF THE NECK. 789 Sanguineous cysts are at times connected with the anterior jugular vein; they contain a reddish fluid, which characterizes them upon exploration ; occasionally they remain in connection with vessels. They Dermoid (ad-hyoid) cyst at base of tongue (Marehant). are emptied by pressure, but they refill rapidly ; they must not be taken for aneurisms when the vessels impart pulsations to them. Hem- orrhagic sanguineous cysts are due to intracystic hemorrhage. Punctures and incisions are sometimes followed by intracystic hemorrhage, which may ultimately end fatally. Dermoid cysts are frequent here : the cyst may be attached to the trachea. These cysts are not bursal cysts : the epithelial lining shows they are congenital. They are all congenital, but they may not become manifest except at a later period, especially at puberty. Lateral branchial cysts usually occupy the region of the sterno-mastoid. Median branchial suprasternal cysts sometimes penetrate into the mediastinum. Median thyro-hyoid cysts often take on a rapid growth at puberty or after a confinement : they are often opened by mistake, and this is followed by a persistent fistula with mucous secretions (Fig. 341). Fibroma is rare ; it rises from the fibrous layers. Congenital branchial fibro-chondroma of the neck is seen in all regions of the branchial arches. It occupies almost always the external orifices of a congenital fistula, a little above the sterno-clavicular articulation. Myxoma and myoma are rare : one case of chondroma is on record following chondroma of the scapula. Those independent of parotid and lymphatic nodes are very rare ; some tumors are very large ; they may adhere to the vessels and to the deep structures. 790 SPECIAL OR REGIONAL SURGERY. Infrahyoid Region. Congenital Malformations. — It is in the lower part of the region that the orifices of the branchial congenital fistulas of the neck are most frequently met, near the head of the clavicle ; they may also be met in the thyro-hyoid region. In hanging the compression very often bears on the base of the tongue, and the larynx, vessels, and nerves are not injured. In strangu- lation the traumatism is applied upon the larynx and the trachea, which may be torn by the fingers or the rope ; all the structures are more or less torn. In some cases lesions of the skin of the neck, of the trachea, and of the larynx may cause inhibition of the heart, of the respiratory organs, and of the brain. It is especially in cases of traumatism of the anterior region of the neck that we observe a complete loss of con- sciousness and a respiratory and cardiac syncope. This is what takes place in cases of death through incomplete hanging, which does not prevent the passage of air through the respiratory passages. In such cases the red blood of the arteries continues red in the veins, whereas in death by true asphyxia the blood becomes rapidly black in the arteries. Suicidal -wounds are the most frequent; they are seldom punctured but are usually incised wounds ; are most frequent at the point of the thyro-hyoid ligament or below it ; they are lacerated, jagged, and deeper on the left side, and are usually directed from left to right and obliquely downward or transversely across the neck ; the large muscles are seldom injured. Usually the suicide, throwing his head back, cuts too high ; the trachea and the rigidity of the sterno-mastoid protect the vessels. If the head is too bent, the larynx, the trachea, and the sterno- mastoid also protect the vessels. There is usually a single gash. These wounds are more commonly fatal than the other wounds, because the victims are usually intoxicated or are laboring under delirium tremens or insanity : these patients should be watched closely, because they often tear away their dressings and die of hemorrhage. These wounds some- times present much hemorrhage, although none of the larger vessels are hurt, except the anterior jugular vein : there are cases on record where air has penetrated into it and to the heart, causing death. The edges of these wounds are often much separated and have a tendency to roll in, on account of the action of the fibres of the plastysma ; coaptation therefore needs more care. Penetrating wounds above the larynx are less dangerous than those of the larynx and of those below it ; the lower the wounds the more dangerous they are. Wounds throuqh the thyro-hyoid membrane pene- trate into the pharynx, injure the epiglottis, the aryteno-epiglottic folds, the cartilages, the vocal cords ; they are less dangerous than below, because they allow feeding ; they are more liable to suppuration. Wounds of the larynx are comparatively frequent, because of its promi- nence : they are usually very dangerous ; they are also easily diag- nosed by the rushing sound of the air passing through. They should be treated like those of the trachea. Wounds of the trachea are commonly followed by great hemorrhage, because of the large vessels around it, which may also have been wounded by the same cause. When the severance is incomplete, there is slight gaping ; when the section is SURGICAL DISEASES AND INJURIES OF THE NECK. 791 complete, the lower end is drawn in deep at each effort of inspiration, and the soft parts cover up the orifice, causing suffocation. In all cases keep the blood and foreign substances out of the respiratory tract until hemorrhage is checked. Rose's position may be of assistance. In incomplete wounds there is slight gaping, and the wound should not be stitched ; the head should be flexed on the chest and fixed in that posi- tion by a liquid-glass bandage. In complete wounds, when longitudinal, there is little gaping. In complete transverse wounds the retracted lower end should be searched for and a strong thread passed deeply through it. An attempt at stitching should be made ; if it fails, a tracheotomy- tube should be placed in it ; the tube should be longer than the ordinary one, because the swelling may lift it out of the trachea ; the head should also be kept flexed ; a moist cloth should be placed over the tube ; the room should be kept warm, at about 70°, and a vessel with boiling water should keep the atmosphere moist — all this to avoid bronchitis and pneumonia. Later Ave should be mindful of the exuberant granulations, which may obliterate the canal. Penetration of the respiratory tract is recognized by cough, bloody expectoration, hissing or boiling sound. The secondary dangers are inflammation of the larynx, oedema of the glottis, bronchitis, pneumonia, abscesses and purulent dissections, emphysema, aphonia more or less complete, dysphagia : secondary hemorrhages are common and serious complications. In all injuries with solution of continuity of the mucous membrane the most frequent source of death may be due to mediastinal emphysema and inhalation pneumonia. Wounds of the neck parallel to the longitudinal fibres of the muscles are more apt to be followed by emphysema. The remote effects and sequels may be exuberant granulations, causing dyspnoea; cicatrization, producing strictures of the larynx, trachea, and oesophagus ; persistent fistula;; paralysis, due to inflammatory thick- ening, which may disappear later, or due to injury of recurrent nerves or the pressure of a bullet. All these complications should be treated here as elsewhere. Fracture or subcutaneous rupture of the trachea without actual wound has been observed after great traumatism ; they are less frequent than the others ; they present the same symptoms and indications as the fracture of the larynx, but the lesion is lower down. The trachea should be opened below the fracture, and a long tracheotomy-tube introduced ; when the fracture is low down, the lower end should be hooked, raised, and sutured to the skin or upper fragment. Spontaneous ruptures of the trachea, due to violent efforts, are accepted by some. All these fractures are more serious if accompanied by displacement which obstruct the air-passages. The symptoms are those of obstruction and shock, plus those of frac- tures in general — crepitation, abnormal mobility, plus also aphonia, dys- phagia, emphysema. The fragments should be replaced by external and internal manipulations ; if necessary the parts should be incised through and the fragments stitched. Tracheotomy in often indicated : it is well to perform the operation before grave symptoms develop, because these sometimes come on so suddenly that the patient may succumb before the surgeon can be had to operate. Laryngo-tracheal abscess causes much dyspnoea, and shows a tend- ency to extend down along the trachea. 792 SPECIAL OR REGIONAL SURGERY. Such lesions are often the starting-points of the peculiar broad or diffuse cel- lulitis of Dupuytren ; they are sometimes secondary to cellulitis of the substerno- mastoid connective tissue ; they are at times produced by cold, by crying loud, so that the public criers and street-venders are most often affected ; usually it is women in bad health that are most commonly affected; men very seldom. These diseases are usually connected with some general diathesis; they may extend from the ear to the clavicle and from the nucha to the larynx; they may involve also the other side. The pus is infiltrated in the muscular interstices and the connective tissue; gangrene is not infrequent. The pressure symptoms are very great. This descrip- tion resembles that of the disease called diffused cellulitis of Gray-Coley and Hannon, which they say is mostly limited to the anterior region of the neck — is due to cold and humidity, and resembles erysipelas : it gives the sensation of hard oedema without fluctuation. The inflammation of the infrahyoid region gives rise to greater risk of oedema of the glottis and extension to the mediastinum. Bursal cysts develop in the serous bursse found in front of the hyoid bone, Adam's apple, the cricoid cartilage ; they are usually called hy- groma or hydrocele of the neck ; they form the group of the thyro-hyoid cysts. All the tumors of this region present these peculiar features : first, they give rise to more grave pressure symptoms than anywhere else ; second, they are usually in the way of tracheotomy, and relief can only be found by operating ; they often penetrate behind the sternum, and in order to follow them it is necessary to remove the upper part of the sternum. These retrosternal tumors should be explored with the syringe first ; when fluid they should be treated by incising and packing; when solid they should be explored by an incision, and, when possible, enu- cleated. Great care should be taken not to excise any of the deeper parts of the walls, because the large veins of the region are often adher- ent to them, and are thus severed, when uncontrollable deadly hemor- rhage supervenes ; the walls should not be incised even between the two forceps or ligatures, because if these large trunks are involved, the inter- ruption to the circulation may be too serious. Most of these cases are operated for palliative purposes of a temporary nature. In cases of injuries and inflammations about the neck the great dan- ger is from suffocation due to the obstruction of the respiratory tract from swelling or cedema of the glottis, or from displacements in cases of fractures or raptures. These accidents often come on so suddenly that the surgeon has not always time to reach the patient and operate in season to save the life ; therefore precautionary anticipating tracheotomy should be performed at the least evidence of serious suffocation. It can be well done under cocaine ; it will relieve the existing symptoms of dys- pnoea, will prevent their aggravation or the death of the sufferer, and will not add to the risks if properly and regularly done. The tube should be long, because of the existing inflammation, and because the inflammation that will follow may lift the tube out of its proper posi- tion and render the procedure useless, deceptive, and dangerous— because it will lead to the belief that the operation has been done with no benefit. In cases of growing aneurisms at the root of the neck, in view of the distressingly painful condition of these patients and of the fact that they are doomed, the surgeon is justified in reset-tin;/ the upper part of the sternum as an exploratory operation. When it is found that the aneur- ism is one of the origin of the right subclavian, and that the innominate is not dilated beyond an inch and a half, it is advisable and justifiable to SURGICAL DISEASES AND INJURIES OF THE NECK. 793 make the desperate attempt of tying them by applying two or three strong catgut or kangaroo ligatures, with as much of a bloodless space as possible between, and tighten them as much as deemed safe without rupturing the coats. The same remarks apply to the left carotid and subclavian if they are not dilated beyond an inch in diameter. In cases of tumors of the infrahyoid region penetrating down behind the manubrium, the same resection for exploring purposes is recommended, with a view to total removal of the tumor if it is found possible. The Thyroid Body. The location of a disease in the thyroid body is recognized by the fact that the organ ascends and descends with the larynx during deglutition. Another way to determine if the tumor is of the thyroid body is to seat the subject with the head stretched back and resting; then with the thumb communicate a slight but brisk movement from below upward: if the tumor budges, it is because it is not adhe- rent or is little so. Congenital Malformations. — Absence of the thyroid body has been observed occasionally in whole or in part, and congenital atrophy has been occasionally observed. Congenital hypertrophy may affect the whole region or one side only, or even one part. There are also cases of aberrant thyroid, due to the separate development of some of the lobules of the organ ; these may be single, double, or multiple, or unilateral, as low down as the sternum or even behind the manubrium. Acquired atrophic malformations are due to injuries, to diseases, and to surgical operations destroying or removing the body in part or in whole. The total destruction or removal of the thyroid gives rise to a peculiar train of symptoms. The immediate sequels of total destruction of the entire thyroid by thyroidectomy are acute mania, tetany, hysteria, myxoedema, or cachexia strumapriva. Few who have been operated before full growth escape ; the signs begin to show on the third or fourth day ; there are paleness, lassitude, weakness, anaemia; swelling and coldness of the extremities; muscular tremor; swelling of fingers first, then of the rest of the body, mostly apparent in the face and neck; this swell- ing is not oedema ; it is hard and elastic, without pitting; the face presents the characteristics of this swelling in the highest degree ; there are also cephalalgia, vertigo ; the pulse is small. In tetany there sometimes exists such swelling, but it is not infectious. The complication is prevented by not removing the whole mass — /. e. by leaving a portion, especially that which is adherent to the trachea. The best treatment is by thyroid extract or the transplantation of the thy- roid body of the sheep into connective tissue or the abdomen. The changes are relative to the alteration of the mucin and other metabolic waste. Pachydermic cachexia (or myxoedema of English writers) resembles myxoeedma, and results from the destruction of the body by disease. Thyroiditis, sometimes called inflammatory goitre, acute goitre, stru- mitis, is usually unilateral. The external causes are the various trau- matisms, infection of an ordinary wound, the influence of cold, etc. The internal causes are an effort causing a hsematoma, the influence of rheumatism, a pre-existing infectious disease, especially pvsemia, puer- peral fever, malaria. The pre-existence of a congestion or tendency to a goitre is a great predisposing cause ; if it discloses itself in a manifest goitre, small or large, it is not a true thyroiditis, but a strumitis. Suppurating thyroiditis is always of a microbic origin. The pathologi- 794 SPECIAL OR REGIONAL SURGERY. cal peculiarities are that death may take place before suppuration has been established : when formed, the pus may fuse in the mediastinum, along the respiratory tract, and the oesophagus. The peculiar symptoms are great thirst, owing to difficulty in and aversion to drinking on account of the pain in swallowing ; raising at each pulsation of the carotid arteries ; cephalic symptoms, due to the pressure upon the veins ; great congestion of face, and epistaxis due to the same causes ; nausea and vomiting, due to pressure upon the pneu- mogastric. The course is continuous ; the duration about fifteen or twenty days. The terminations are by persistent indurated spots or by sup- puration ; sometimes abscesses are formed ; fistulous openings, single or double, occur ; the abscesses may open into the larynx, trachea, oesophagus, or may fuse in the mediastinum ; gangrene of the thy- roid sometimes takes place. The prognosis of thyroiditis is grave. Tumors of the Thyroid Body. — Cystic tumors are represented especially by hematoma following an injury or due to a hemorrhage in a pre-existing cyst, either from a traumatism or from a puncture with a too large needle, and removal of all the liquid or enough to destroy the equilibrium of the pressure. Pulsation in the thyroidal tumors is not uncommon, owing to the pressure on the great vessels. Congenital mixed cysts are the most common ; they contain thyroid vesicles, pave- ment epithelium, cartilage, muscular fibres. A peculiarity of the thyroid cysts is that, whether small or large, they may from sudden congestion or rupture cause suddenly great dyspnoea, which may be rapidly fatal. Cystic growths of the thyroid should be enucleated, as this avoids any possible injury to the recurrent laryngeal nerve, and also avoids the possibility of cachexia strumapriva by leaving all the thyroidal tissue that is not diseased. Solid tumors are represented mostly and almost entirely by goitres : although they sometimes contain cavities or cysts, yet their walls are usually so thick they are considered as solid tumors, and are described with such. The great majority are simple hypertrophies. GrOITRE. This is an enlargement or hypertrophy of the thyroid body without structural changes ; it may involve the whole region or be unilateral or bilateral ; it is more frequent on the right side. The causes of goitre in general are not yet known. The alterations as regards size and shape are variable. The microscopic alterations consist in cavities, channels, and compartments lined by a pavement or cylindrical epithelium. This form of goitre is the primordial form; it is epithelial or follicular : the other forms of goitre are only modifica- tions of it. The symptoms are those of a hypertrophied organ in general ; the peculiar symptoms are — the shape of a horseshoe ; the movements following the larynx ; the veins developed on the surface ; the peculiar deformity of the region ; the pressure-symptoms on the cerebral and facial circulations. SURGICAL DISEASES AND INJURIES OF THE NECK. 795 The course is usually very slow, and sometimes irregular. The duration is ordinarily very long. The prognosis becomes serious with the degree of pressure-symp- toms and the complications. The true treatment of goitre consists in extirpation, especially if it grows and if the pressure-symptoms are serious. We must bear in mind that an apparently innocent goitre may suddenly enlarge and cause suffocation or even sudden death. The internal treatment consists in long-continued thyroid-feeding, which will diminish the size of a goitre and even bring on a condition of atrophy, so that the danger lies in abolishing the functions of the thyroid. Sodium phosphate has the same effect and consequences. We should be careful in using anaesthesia if there are already signs of pressure ; the use of morphine or cocaine is preferable. Operation with cocaine is often possible ; the pain does not seem to be beyond endurance ; the dangers of the operation are much lessened without anaesthesia; there is much less turgescence of the veins than when an anaesthetic is used — none, of course, from coughing, vomiting — and the dangers of complications? are thus diminished. The incision should extend from one side of the neck to the other in a very sharp and long curve, with the convexity downward toward the sternum. The upper part of the tumor would better be attacked first, and the upper vessels tied, then the middle or the inferior ; the hemorrhage is reduced to a minimum by careful haemostasis by means of forceps and double ligature of the larger vessels before incising between the ligatures. When the inferior thyroid artery is being dissected and tied, by engaging the patient in a conversation for a few minutes the possibility of including the recur- rent laryngeal nerve in the ligation is avoided, as the altered voice immediately warns the surgeon of the danger. At the lower right angle is the portion which often penetrates into the mediastinum behind the sternum ; there exist usually at that point large veins. When possible lift the body from its bed and encircle the pedicle with an elastic tubing before enucleating, as recommended by Rose and Poppert. The dangers are hemorrhage and asphyxia by blood falling into the trachea when it is torn : to avoid these perform preventive tracheotomy when pos- sible. In the hypertrophied thyroid the arteries are larger than in the normal, but are in their usual situations. Be careful again not to tear the trachea : if this happen, introduce at once a long tracheotomy cannula. In exophthalmic goitre Kocher resorts to ligature and ties only three arteries. In one case when four arteries were ligated tetany set in immediately. Intracap- sular enucleation is the safest, but is not always feasible. When the difficulty of tracheotomy is due to pressure, division of the isthmus may afford relief. Aberrant goitres are those found in the supernumerary thyroid bodies — i. e. those in the lobules developed independently and which failed to unite with the rest of the body : they are sometimes called ganglionic goitres, because they resemble hypertrophied lymph-nodes. Peri- and retrovascular goitre* are those which send processes around and behind the large vessels of the neck. Colloid goitre is one that attains the largest proportions. Exophthalmic goitre, or Basedow's or Graves' disease, is accom- panied by protrusion of the eyeball and tachycardia, with irregular, fre- quent loud sounds ; the heart is dilated ; there is also alteration of the normal sounds ; the arteries of the wrist and head throb. These svmu- toms are due to changes in the middle and lower ganglions of the sym- 796 SPECIAL OR REGIONAL SURQERY. pathetic. Suppuration is very rare. There is a surgical exophthalmic goitre, due to the pressure upon the nerves, purely mechanical and very distinct from Graves' disease. Exophthalmic goitre is now occasionally subjected to operation, either by ligature of its arteries or by complete or partial extirpation. But no case should be put through this ordeal until thorough trial has been made of thyroid extract and of sodium phosphate, given internally and in gradually increasing doses. In goitre with a feeble heart and a weak pulse great care should be exercised in operating. Inflammation of a goitre is called strumitis : it is much more frequent than thyroiditis or inflammation of a normal thyroid ; it is serious because of the enlarged condition of the organ. Tracheotomy may be performed for relief until the pus is located and evacuated by incisions or by dilatation upon a guide. All the other solid tumors of the thyroid body are rare. Sarcoma is more frequent, and has been observed in all its varieties. The difference between hypertrophy and sarcoma is that usually the hypertrophy has the same shape as the gland, whereas the sarcoma has not. Carcinoma is also among the infrequent tumors of the thyroid outside of goitre. It is sometimes connected with the oesophagus or larynx ; it may be metastatic from the cancer of some other part. The primitive cancer is the one here considered : it is rare, and is met especially in goitrous countries. The Suprahyoid or Submental Region. Congenital branchiogenic cysts of the region of the hyoid bone extend sometimes into the mouth and resemble ranula, but they are independent of the submaxillary and sublingual glands. Simple serous or suprahyoid grenouillettes have been studied only recently : they are usually seated underneath the cervical fascia ; they are very often an extension of a sublingual cyst or grenouillette through the muscles of the floor of the mouth. Dermoid cysts sometimes remain dormant for a while, and then become apparent ; if by the history the cyst may be traced to infancy, it is a dermoid cyst. Foreign bodies in salivary passages are most frequent in Wharton's duct ; they may be bristle, fish-bone, straw, hair of a tooth-brush. There are pain, swelling of the gland, abscess, fistula. They may give rise to salivary colic. Inflammation with abscess of the salivary gland itself is extremely rare. Osteoperiostitis from diseased teeth is often confounded with adeno-cel- lulitis ; in the former the swelling corresponds to the body and to the border of the maxilla ; its tendency is toward the face and the masseter portion of the cheek ; the vestibule is painful and sometimes fluctuant. In adeno-cellulitis the swelling exists below the maxilla and has a tend- ency toward the neck. Chassaignac's subangulo-maxillary adeno-cellu- litis is met with beneath the angle of the jaw, and is due to the difficult eruption of the wisdom tooth. Ludwig's acquired or infectious submaxillary angina is characterized by excessive swelling and pain; the tongue is swollen and immovable; the mouth is distended in front; there is difficulty of swallowing; it may terminate in gan- grene ; it often ends in death. SURGICAL DISEASES AND INJURIES OF THE NECK. 797 The treatment of these abscesses consists, of course, in evacuating the pus as soon as possible. Incision should be made under and parallel with the inferior border of the maxilla, so that the cicatrices will not show ; by using the method of dilatation on a guide the evacuation takes place when the exploring needle has located the pus, and there is no cicatrix of any consequence remaining. Retropharyngeal abscesses often point toward this region, although they may fuse down into the mediastinum ; in the former case the large vessels are between the pus and the surgeon's knife. It is best to try and evacuate through the mouth, to avoid the course of the large vessels and nerves. An incision on the middle line of the pharynx, if it will accomplish the object, is preferable, as safer ; it is well then to place the patient in Rose's position to prevent the entrance of the pus into the larynx. Salivary calculi are peculiar to this region ; they give rise to pain and swelling ; sometimes abscesses are followed by fistulous openings, temporary or permanent. The calculi sometimes occupy the centre of gland or the deep surface, and the most important symptoms, as also the fistulous openings, are in the mouth. They are diagnosed by search- ing carefully for the opening of the fistula and probing it, when the pecu- liar click will be felt ; if necessary, a needle thrust deeply through the gland in several directions will strike the calculus if it be present. The Parotid Region. Congenital absence of the parotid and atrophy of the gland are very rare. However, occasionally subjects are seen with a deep hollow between the ramus of the jaw and the mastoid process, showing the partial atrophy at least of the gland. Injuries of the parotid region are rare ; they are grave, on account of cicatricial disfigurement and injuries to the facial nerve and to Sten- son's duct. Incised deep wounds are most serious. Hypersemia of the parotid is here represented by the disease called mumps. It is considered a specific infectious disease ; it is contagious in schools ; it is most serious in spring, in damp and cold weather ; young male children are more commonly liable ; sometimes it follows orchitis, but it is usually the reverse. The pathology is obscure. The most remarkable symptoms are pain and swelling without red- ness or heat, softness of the part ; no induration ; no fluctuation ; the pain is increased by biting, chewing, swallowing ; there is little or no general reaction. The beginning is often sudden, also its termination ; it sometimes moves suddenly to the testicles, ovaries, or breasts. The duration is about ten days. Termination by resolution is the rule ; it is altogether exceptional when it suppurates. The treatment consists of soothing liniments and keeping the parts warm. Acute parotiditis is a comparatively rare disease. Its cause may be mumps (rare), a debilitated state of the system, an infectious disease (typhoid fever, sepsis) ; it may be complicated with ear, eye, tonsil or brain syphilis, but it is very rare. A pathological peculiarity is that the capsule of the gland prevents the pus from coming to the surface quickly. The symptoms are those of deep cellulitis, with the addition of 798 SPECIAL OR REGIONAL SURGERY. the general symptoms due to the lesion which is the cause of the parotiditis. It terminates almost always by suppuration ; the pus may open in the ear, pharynx, vessels, down in the neck and chest, in the space behind the pharynx ; it may terminate by several successive abscesses, it may terminate also by gangrene. The prognosis is most grave. The treatment consists in keeping the mouth disinfected and in an early evacuation. In superficial abscesses be mindful of the course of the facial nerve and of Sten- son's duct; in deep suppurations, of the external carotid: in these cases follow Hilton's method or dilatation upon a guide. Fistulae of the parotid are not very common. The prognosis is bad, because they are often difficult to cure. The treatment consists in local cauterization — if insufficient, in making a large hole in the region and closing the surface opening by a plastic operation ; in persistent cases, in destroying the parotid. Tumors of the Parotid. — The lymphatic nodes, while not situated in the parotid, may present almost all the tumors that develop in the salivary gland ; they are called supraparotid tumors ; they are usually movable, whereas the tumors developed on the parotid gland are not. Solid tumors of the parotid may be of all the varieties elsewhere found. Chondroma forms 30 per cent, of the tumors of the region. Sarcoma, together with fibroma and cystoma, is about equally often present. Carcinoma represents about 45 per cent, of all the tumors of the parotid region. Usually they are mixed tumors, in which the epithelial element has taken a great development; they may be secondary to similar tumors originating in the pharynx or on the face. Primary carcinoma is rare. Encephaloid develops at forty-one, on the average. Pulsating encephaloids are very rare. Melanotic cancer is very rare ; it usually involves the lymphatics. Scirrhus usually de- velops at sixty or seventy. Mixed tumors are commonly those called simply chondromata ; they usually remain limited to the parotid, and do not invade the other regions ; they may become very large, so as to affect the mastication ; some have a rapid course, some a slow one ; they may degenerate into sarcomata ; they return rarely if operated in the first period ; they return often if operated in the second period ; gener- alization is very rare. Tumors special to the parotid region are represented by the sali- vary calculi developed in the parotid ; they are rare in the gland itself; they are said to be more frequent in males and in adults ; also to be due to the inflammation of the duct-radicles which retard the flow of the saliva; also to changes in the chemical composition of the saliva. They usually cause pain, inflammation, and an abscess, which upon opening leaves a salivary fistula : using the probe through the opening or by penetrating the gland deeply with a needle, the calculus is felt; they may cause atrophy of the gland by sclerosis. They should be removed through an incision. SURGICAL DISEASES AND INJURIES OF THE NECK. 799 Operations on the Parotid Region. The possibility of extirpating the whole parotid has been much discussed, but it presents no practical or clinical value. When the gland is diseased, the disease must be removed, whether it affects the whole gland or not. A partial disease of the gland with prolongations is as bad as, if not worse than, a disease affecting the whole gland without such processes. The dissection should proceed from below and behind, upward and forward; the external carotid should be located and ligated or clamped, otherwise it might be cut several times. When the dissection leads into the deep parts, the patient's mouth should be opened, as this increases the size of the parotid cavity and renders the deep dissection easier by affording more room. A previous permanent ligation of the external carotid might be done, or a provisional loop ligature applied to the bifurcation, so that if it should become necessary to ligate the internal carotid, the same incision will answer for all purposes. In penetrating the region the dangerous structures are at the entrance, and in front, to the inner side of the head and neck of the condyle ; more deeply, they are on, the posterior wall. Some tumors of considerable size, and sometimes extending to the pharynx, are removed with little difficulty and little hemorrhage if the adhesions are loose ; whereas adherent tumors, even of small size, are fraught with danger. The safe plan is to proceed as long as the adhesions with the surrounding structures are easily broken, and to stop as soon as they become too resistant and as we approach the deep dangerous structures, which may be adherent to the tumor. Then the cleared part of the tumor should be cut off. It is a remarkable fact that often the stump left will, in growing again, become more superficial, and it is sometimes possible to remove the stump entirely by a second operation. The Lateral Region of the Neck. Congenital malformations are represented in this region by the orifices of the branchial fistulse situated most commonly along the lower part of the anterior border of the sterno-mastoid ; also by the congeni- tal deformity of the sterno-mastoid, called hsematoma of the sterno- mastoid and congenital torticollis ; also by the congenital atrophy of the same muscle. Acquired malformations comprise the various forms and varieties of torticollis and the deformities due to cicatrices. Cica- trices of the neck are most objectionable especially when affecting exposed parts. Penetrating -wounds of the external jugular, of the internal jugular, and the carotid arteries are most serious injuries. They may all give rise to circumscribed or diffused hsematoma. When this' is of some size and stationary, it must be aspirated or incised. When it pul- sates and grows, it is because a traumatic aneurism has formed, and the wounded vessel, vein or artery, must be ligated above and below at the injured point. When the penetration is comparatively small the sac may be incised at once, after making as good pressure above and below as possible. When the puncture is large and there is risk of the patient bleeding much before the proper ligatures are secured, a provisional loop ligature must be applied below the wounded point. When the wound or the swelling is very low down, enough of the sternum must be resected to reach the root of the carotid and the innominate, and apply there the provisional loop ligature. Considering the gravity of a possible terrific hemorrhage, this advice is not too heroic. Wounds of the vertebral artery in this part of the neck are more common in the canal of the transverse processes. At the base of the 800 SPECIAL OR REGIONAL SURGERY. neck the wounds of the vertebral are more grave than those of the carotids. Wounds dividing the sterno-mastoid muscle may lessen power of the muscle from lengthening due to the cicatrization. When the muscle has been completely severed and the head is still, it is some- times brusquely thrown to the severed side by the contraction of the intact sterno-mastoid. In case of division of the muscle from opera- tion this does not take place, because the other muscles have gradually become accustomed by the pressure of the tumor to keep the head prop- erly balanced. The severed ends must be strongly and closely stitched with strong catgut, and the head kept in proper position by a liquid- glass bandage. Incised penetrating wounds of the internal jugular are perhaps more serious than the wounds of the carotid, because of the danger of penetration of air. When the respiration becomes embarrassed the hemorrhage increases, just as in tracheotomy, where as soon as the tube is introduced the hemorrhage ceases. These wounds are oftenest tear- ing wounds during the removal of tumors. Incised penetrating wounds of the carotids give rise to profuse, even terrific, hemorrhage. When the wound is large or when the hemor- rhage is moderate, unless at once attended to on the spot, it may be immediately mortal. A man will thus bleed to death in four minutes from the carotids, it is said. When the larynx or trachea is wounded, the blood penetrating in them causes death also from suffocation. The hemorrhage is sometimes stopped by fainting if the wound is not too large. Upon reaching such a case, the first thing to do is to plug the wound with the fingers or pack it quickly. Packing will stop the hemorrhage only temporarily if the vessel is of any size above one-sixteenth of an inch. It is best and safest to enlarge the wound and attempt to ligate the two ends in the wound ; if this causes too much bleeding, a loop ligature must be applied, as above described. If the bleeding has stopped, it must be borne in mind that it will almost surely return, and that it may do so when proper surgical assistance cannot be procured, and the patient may bleed to death ; therefore, the case should be treated as described above for punctured wounds. Incised -wounds of the nerves of the region (recurrent, phrenic, pneumogastric, sympathetic, spinal accessory, cervical plexus) are fol- lowed by the following symptoms : When the recurrent is wounded there is aphasia more or less complete. The section of the phrenic and pneumogastric on one side only is accompanied by respiratory and cir- culatory irregularities ; they are not necessarily fatal, but it is a most serious complication. Park has shown that only about 50 per cent, of these, cases are fatal. Complete wounds of the sympathetic are followed by atresia of the pupil, slight ptosis, con- gestion of the conjunctiva, headache, congestion of the side of the face (unless only stimulated) ; it produces mydriasis, pallor of the face, protrusion of eyeball. Injury of the superior laryngeal nerve is sometimes very serious. When possible the divided ends must be sutured with fine silk. Rupture of the sterno-mastoid is the most common rupture of all the muscle ruptures ; it has taken place after falls, sudden twists, violent muscular contractions. There are great pains, a depression on the course of the muscle, great hematoma ; the head is often twisted by the action of the other muscles. SURGICAL DISEASES AND INJURIES OF THE NECK. 801 The treatment consists in placing the head in proper position and immobilizing it in a liquid-glass bandage. The rupture is usually partial ; when complete the ends are far apart ; it is well to cut down and stitch ; otherwise a kind of torticollis may result from the lengthening of the muscle. Hsematoma of the sterno-mastoid in the new-born is most re- markable and unique : it usually appears after birth ; it is more fre- quently on the right ; it occupies the body of the sterno-mastoid, par- tially or totally, forming a part of its substance ; it is firm, elastic ; it is oval ; it is stationary. There is no pain except on pressure ; the head is inclined as in torticollis ; there is no tendency to grow nor to suppu- rate ; it usually disappears by resolution in a few weeks or months. It is thought to be due to obstetrical traumatism or to a malformation ; it is common after breech presentation when traction has been made to extract the head ; it may cause a permanent torticollis. It must not be confounded with enlarged nodes. Induration of the sterno-mastoid in adults is syphilitic : it may be a diffused sclero-myositis ; it may occupy the whole muscle, which is transformed into a cord, or it may be localized in one spot. Gummata of the sterno-mastoid are found usually at the inferior inser- tion of the muscle ; they may attain the size of an orange. This mus- cle is a point of election of gummata ; they develop rapidly in four weeks, without traumatism and without trace of pain. One case of hereditary syphilis of the sterno-mastoid is reported. Neuroses are represented by the disease known as torticollis. Inflammations in the sheath of the sterno-mastoid are common : sometimes they begin in one of the small lymph-nodes situated in the sheath itself; when originating from these, it is remarkable that the inflammation and the pus that usually follows it remain very strictly limited to the sheath, and descend toward the lower third of it, near the clavicular attachment, where they become superficial. This inflamma- tion leaves after it a stiffness and a shortening of the muscle. Phlebitis of the internal jugular vein is not very common ; it is usually due to infections from the interior cavities or to metastasis. It is accompanied with great pain and swelling along the course of the vein ; it is often complicated with phlebitis of the lateral sinus and with cerebral symptoms. It is diagnosed with the exploring needle ; it is of the utmost im- portance to diagnose early and to evacuate early by incision or dilatation on a guide. Angeioma of the neck is sometimes called sanguineous cyst. It must not be confounded with a cyst in which hemorrhages have taken place or have opened into a cavity ; it may be superficial, deep, or cavern- ous. Angeioma sometimes presents a single vein opening in the jugular by one or several orifices ; sometimes several angeiomata open into the jugular. The neck is a special seat of ampullar venous dilatations forming cavities in an erectile tissue with narrow spaces. Angeioma is often completely reducible. In operating it is advisable to place a liga- tion on the large vessels as soon as possible before extirpating the tumor thereby diminishing very much the hemorrhage during the removal and 51 802 SPECIAL OR REGIONAL SURGERY. facilitating the same. A sanguineous cyst is sometimes due to a serous cyst with a hemorrhage in its cavity. The aneurisms of the carotids are seldom traumatic ; however, they may be the result of contusions. The common carotid is more frequently affected ; it is comparatively frequent in females, surely more so than the other aneurisms ; it is also more common in young subjects than aneurisms of other arteries. These aneurisms may be confounded with vascular or aneurismal goitres, pulsatile sanguineous cysts of the thyroid when they exist on the course of the carotids ; also with pulsatile encephaloids ; also with other tumors of the neck situated on the course of the carotids. The determination of the affected artery in cervical aneurisms is often most difficult. Clinically and practically, the diagnosis is made by operating. A pro- visional ligature should be applied below the tumor. When this stops the pulsa- tions, another ligature should be placed above : if this be not possible, the ligature below should be tightened, the sac incised, the upper end of the artery secured, and the bleeding points, if any, clamped, and the sac extirpated if not too closely adherent to the important vessels and nerves. When, after placing the loop liga- ture, the pulsations are not affected, it is because the wrong artery is attacked ; the loop should still be kept in place and the vertebral should have a loop ligature placed under it, when the pulsations will stop; another ligature should be placed above, if possible. The Supraclavicular Region. Congenital Atrophic Malformations. — A form of atrophy of the region is presented in subjects, young and old, in whom the supraclav- icular fossa is unusually deep, causing the deformity called " salt-cellar neck." Orifices of congenital branchial fistula? are sometimes met with in this region. Punctured wounds of the subclavian vein and artery may also give rise to serious hsematomata. When persistent they should be aspi- rated or incised. We should bear in mind that hsematoma may be due to a wound of the vein, and that the connection may still exist. This will surely be the case if after aspiration it fills up again. In case of incision the deeper clots should not be disturbed, so as not to open the wound in the vein in case that lesion has occurred. Injury to the subclavian artery is recognized by the pulsations of the hsematoma ; it is then a traumatic aneurism. The artery should be ligated. When the swelling is moderate, the ligation should be made in the supraclavicular region, using, if necessary, an aneurismal needle with a detachable point. In the majority of cases this simple ligation will suffice to cure the aneurism ; if not, compression of the axillary or its ligation should also be done ; then the sac incised and the injured points ligated above and below. When on the right side, the artery can only be reached and encircled in its second portion after dividing the anterior scalene ; no permanent ligature should be applied there; a provisional loop ligature should be placed, the sac incised, and the injured point of the third portion ligated permanently above and below. On the left side the ligation of the second portion can be made permanent at once, as it is as safe on this side as a permanent ligature is unsafe on the second portion of the right side. When the swelling is so great as to cause the failure of the above procedure, or so as to discourage even the attempt, but only then, a provisional ligature should be applied upon the first portion of the subclavian ; the axillary SURGICAL DISEASES AND INJURIES OF THE NECK. 803 should be compressed or treated in the same way : then the sac is incised and the two ends ligated. In some cases these ends cannot be found. Packing with bits of aseptic sponge should then be resorted to, with compression over it. Should the hemorrhage return, the clavicle should be sawn through and the two ends secured. Incised wounds of the subclavian vein are most serious, because of the amount of bleeding often causing rapid death, and also because of the quick penetration of air into the vein. The vein should be at once plugged with the finger, or, better, an aseptic packing; then an attempt should be made to enlarge the wound and to clamp it, and then ligate the two ends. When this is impossible a provisional loop liga- ture should be applied on the first portion of the vein ; also compression should be made on the axilla and the two ends ligated ; the ligation of the proximal end is to secure against hemorrhage and also entrance of air, but the ligature also of the distal end is of course indispensable. "Wounds of the lymphatic duct on the right side and of the tho- racic duct on the left are diagnosed by the oozing of the peculiar fluid they contain. If possible, the distal end should be ligated, and this usually stops the flow, since there is a valve on the provisional end. There is seldom if ever any discharge from it. When ligation is impos- sible, compression will often suffice. It is very seldom that any further trouble is noticed, because there exists usually two or three branches of that duct, and the uninjured ones carry on the circulation. When this fails and a chyle fistula is established, then the patient gradually loses flesh and succumbs. "Wounds of the brachial plexus are followed by paralysis of the affected area ; they should be sutured at once. The lesions, from what- ever cause, may affect only one branch. These neuroses never affect the internal, anterior, and posterior surfaces of the arm, because these are supplied by the anastomoses of the intercostal filaments with the inter- nal cutaneous. They must not be confounded with the anaesthesia and paralysis resulting from contusions of the shoulder in hysterical subjects (hystero-traumatism). The treatment is by electricity. If a callus includes a nerve, it must be resected. Incised wounds of the phrenic nerve are most serious. However, when the nerve has been pressed upon by a tumor for some time, the wounding of it is not so dangerous. Incised wounds of the apex of the lungs are not so apt to be fol- lowed by emphysema as the punctured wounds. Neuroses. — Sometimes the callus of a fracture of the clavicle includes a nerve branch ; hence neuralgia or paralysis requiring resec- tion of the callus. A simple contusion, without fracture, may produce a paralysis of the plexus. Repeated slight contusions may produce paral- ysis, as in the case of the strap of the carriers, especially water-carriers. The Posterior Region op the Neck. "Wounds of the spinal canal through the interlaminar spaces when the head is flexed forcibly, or through a fracture of the lamina?, are serious only if becoming infected. Incised wounds reaching the spinal cord itself are followed by paralysis of the parts below. If the wound be and remain uninfected 804 SPECIAL OR REGIONAL SURGERY. then cicatrization by primary union may take place and the paralysis disappear ; if not, it will be permanent. If between the occipital and the atlas or axis the oblong medulla is severed, death is instantaneous. Infanticide is often produced by a long needle or pin driven between the occiput and the vertebra. If the lesion is above the origin of the phrenic, death follows quickly by paralysis of the diaphragm. Wounds of the posterior region are said to be followed by sexual impotency when the membranes of the cord are involved ; also by paresis and wasting of the lower extremities, also of the testicle. Larrey contends that this may take place even when the cord is not affected. Ruptures of the muscles of the nucha are reported in those who carry heavy loads on the head. The symptoms are those of other muscular ruptures. Ruptures of the attachments of the rhomboid and of the elevator of the angle of the scapula have been seen in farm-laborers. Neuroses are represented by acute torticollis (posterior) of the trapezius. This is said to be even more frequent than the torticollis of the sterno-mastoid. When in the trapezius and complexus, the head is inclined on the affected side, but the chin is toward the opposite side ; the head is slightly thrown backward. There is no cord, no diffuse indu- ration, no atrophy of the face : the pain is near the atlas, and is increased by pressure. Under anaesthesia the head can be straightened. This torticollis may be confounded with occipital arthritis with inclination of the head. The treatment consists in applying a soluble-glass bandage or a plaster apparatus ; it should be worn one year. When both the trapezius muscles are affected the head is thrown back. In cases of torticollis of the trapezius the sterno-mastoid is often also contracted, but it is a contraction of immobilization ; the pain is along the trapezius, and not along the sterno-mastoid. Very often the torticollis affects also simultaneously the deeper muscles, the splenius, the elevator muscles of the scapula, the rhomboid. The scalenes and the platysma are sometimes the site of torticollis. Aneurisms of the vertebral artery are not rare in this region ; they are usually traumatic, and are often high up. The artery should be ligated above and below if possible, or above or below whenever pos- sible, and the sac incised and immediately plugged with aseptic sponges. If possible, the distal bleeding end should be ligated. In case a second- ary hemorrhage should occur through the distal end, and be uncon- trollable by plugging, the ligation of the vertebral on the other side must be considered and weighed. CHAPTER XLIII. SURGERY OF THE CHEST. By Frederic S. Dennis, M. D. Fig. 342. Malformations . A congenital malformation of the thorax frequently occurs. This may follow a difficult parturition. The accompanying figure shows a congenital malformation in which the up- per ribs were separated from the lower ribs and the lung protruded in the in- terspace. This condition remained as a permanent malformation. There waa a distinct sulcus into which- the side of the hand could be thrust. Subse- quently marked contraction took place, and the side of the thorax became permanently distorted. Malformations of the chest may also occur as a result of the non-closure of the foramen ovale. The left side of the chest bulges outward and forward, and the hypertrophied right auricle is situated at a point far distant from its normal place. The apex-beat is situated below the mar- gin of the cartilages of the eighth, ninth, and tenth ribs. The opposite side of the chest is compressed, so that there is a marked difference in the symmetry of the thorax. Malformations of the chest may arise in consequence of a chronic pneumonia. Respi- ration in these cases is carried on with great difficulty ; the pulse is rapid ; cyanosis of the face is present ; a dry cough harasses the pa- tient ; the alee nasi are dilated ; and the ribs have a limited movement, and are forced inward instead of outward by the act of inspiration. This peculiar respiration causes the transverse diameter of the chest to become diminished instead of increased. Malformations of the chest occur as a result of rickets. The chief distinguishing feature is an alteration in the shape of the thorax, since there is usually a marked antero-posterior curvature, and the thorax is narrowed and flattened from before backward. These changes begin in early infancy or about the sixth to the eighth month, and may continue 805 Congenital malformation of chest (Sayre). 806 SPECIAL OR REGIONAL SURGERY. Fig. 343. until the third year or even beyond that time. The epiphyses of the ribs and cartilages become beaded and enlarged notably upon the pleural surface. To this condition the term rickety rosary has been given. This condition is the result of the eifects of atmospheric pressure during the inspiratory act, combined with the lateral pressure induced by the weight of the upper extremities, and partly also by the fact that the ribs have lost their normal power of resistance. The angles of the ribs are less obtuse than in the normal chest, and the ribs are also somewhat shorter than usual. The sternum in the rachitic condi- tion of the thorax may project forward or in rare instances may be depressed. The forward projectiou causes lateral compression of the cavity. The spine is subject to certain alterations in its normal curves, since the great dorsal curve is exaggerated, giving rise to the condition of kyphosis. This deviation is eventually compensated for by a cor- responding exaggeration of the cervi- cal curve and a marked diminution in the lumbar convexity. As the child grows, lateral curvature may also be caused, with the concavity to the right side, owing to the position which the child assumes while carried on the nurse's left arm. As the child grows up scoliosis is likely to follow in con- sequence of the vertical position which the patient assumes, together with the loss of resistance on account of the softened bones and ligaments. Rachitic kyjohosis must not be mis- taken for Pott's disease. In the former case extension of the body while the child is in the recumbent position obliterates in a large measure the cha- racteristic curve, whereas in tubercu- losis of the vertebrae the extension does not affect the angular curvature. In rachitic deformity the kyphosis is in the form of a curve, and not an angle, as in Pott's disease. In the relief of kyphosis of the spine due to rickets some form of spinal brace can be employed when the child is up and about. In conjunction with rest in the recumbent position, good nutritious food, sea-bathing, and out-of-door exercise are to be employed as adjuvants, together with the use of the syrup of the iodide of iron and cod-liver oil. Deformity of the chest also occurs in consequence of lateral curvature inde- pendent of any disease. Malformations of the chest occur as a result of empyema. Under Deformity of the thorax , the result of rickets (Gibney). SURGERY OF THE CHEST. 807 these conditions the thorax may be barrel-shaped, and move up and down during respiration as if the cavity were formed of a single cylinder. The lateral expansion may be absent, and occasionally a marked bulg- ing may occur in unilateral empyema. Malformations of the chest may occur as a result of traumatism sustained in early life. The injury is independent of a fracture, and as the child grows the distortion becomes well marked. Pott's disease usually results from this traumatism in a patient with tuberculous ten- dencies. Malformation of the chest may occur in the form of lateral cur- vature due to empyema. Malformations of the chest also occur as a result of pleurisy. The pleura becomes adherent to the internal surface of the chest-wall, and in consequence the affected side is altered in shape and gives signs of arrest of development. The Fig. 344. Fig. 345. Malformation of chest following empyema (Sayre). intercostal spaces are obliterated, while those of the opposite side become exagge- rated. The spinal column also is affected, as distinct lateral curvature follows. The form of the thorax is also altered in consequence of a paralysis of the serratus, rhomboideus, and latissimus dorsi muscles. The angle of the scapula projects from the latero-dorsal aspect of the chest like a wing. Malformation of the breast occurs to which the term cams pectinatum has been assigned. The deformity is difficult to overcome, but the treatment is considered in the chapter on Orthopaedic Surgery. Another deformity of the thorax is sometimes observed in a deep depression at the lower extremity of the sternum. The term bird's- nest deformity has been applied to this malformation, on account of 808 SPECIAL OR REGIONAL SURGERY. a fancied resemblance. There is no treatment which will effect a cure. We may have another deformity of the chest in consequence of poliomyelitis. Malformation of the chest may occur as a result of long-continued Fig. 346. Fig. 347. Malformation of the chest due to tight lacing (Goodwillie). and tight lacing. The chest shows marked thoracic with slight abdom- inal respiration. The diaphragm has been arrested in its growth and the respirations are peculiar in character (Fig. 346). Malformations of the chest may arise in consequence of certain occu- pations, also as a result of certain forms of exercise. The bicycle-rider comes to have a peculiar chest when the exercise is long continued in the stooping posture. The writer has seen a well-pronounced deform- ity of the chest in which the patient presented apparent atrophy of the muscles of the left side of the thorax and marked hypertrophy of the right side. For many years the patient has constantly exercised the right side of the chest in the practice of his profession as a musical conductor. The muscles upon the right side were so largely developed that the condition gave rise to the appearance of a lipoma. The scapular muscles bulged out on the right side in consequence of the unremitting and long-continued exercise of the arm in the constant swing of the baton. Deformity of the chest may follow in consequence of spastic paraly- sis. The chest loses its normal shape, and other muscles besides those of the thorax are involved. SURGERY OF THE CHEST. 809 Malformation of the chest has been observed where an arrest of de- velopment in the vertebrae has occurred, and the sternum was either entirely absent or else imperfectly developed. The bone sometimes pos- sesses a cleft in the centre. The ribs have been observed free or else attached to the sternum by fibrous tissue. The ribs have also been noticed as attached to each other in a manner similar to the lateral union Fig. 348. Congenital absence of the pectoralis major muscle of right side (Richardson). of two ribs after the opening in the chest and the introduction of a drainage-tube for the relief of empyema. In these cases of congenital defect some protection should be worn in the form of a shield, in order to protect the important thoracic organs from injury likely to occur on account of their great exposure. Tattooing of the chest is of frequent occurrence. It is shown by Ellis that there is no class of people among whom tattooing is as com- mon as among criminals. Alborghetti reports that the proportion is 15 per cent., and Lombroso 32 per cent., among prison inmates. Tattooing is almost exclusively confined to the male sex. In addition to the crimi- nal classes, the insane often indulge in this habit. Children are seldom 810 SPECIAL OR REGIONAL SURGERY. found tattooed. Lacassagne has shown that among the non-criminal classes only about 1 per cent, of the cases of tattooing are found. Among sailors the thorax is a favorite seat for tattooing, and the ship under full sail is most frequently the emblem. Lombroso tells us that tattooing upon the back of the thorax or upon the sexual organs is found only among the residents of the -Pacific islands, except in cases where this has been done during prison-life. Lacassagne regards tat- tooing "as the uninterrupted and successive transformation of an instinct." Malformation of the chest, finally, has occurred in consequence of a congenital absence of the pectoralis major muscle (Fig. 348). Stintzing has collected from surgical literature thirteen cases of this nature. Injuries. Injuries of the thorax not proceeding from fractures are not serious, since in 225 cases of injuries of the chest due to kicks of horses, rail- road disasters, falls, and other accidents, there were only 5 fatal cases, as recorded in the Surgeon General's reports of the late Civil War. The injuries of the thorax, excluding fractures, which are considered elsewhere, consist of contusions and wounds of every variety. Inflam- matory affections may also result from injuries, the peculiar features of which will be discussed later in this chapter. In addition to the ordinary contusion of the chest-wall, an injury has heen described under the name of commotio thoracica, which resembles contusion or laceration of brain. Sudden death may follow severe commotio thoracica and the autopsy fail to reveal any tangible lesion. In these cases the sudden death is due to shock. In commotio thoracica the pain is very severe, abdominal respiration is present, and a peculiar decubitus is observed, in which the patient, while lying upon the back, inclines at the same time toward the injured side. The fact must not be lost sight of that in apparently slight contusions of the chest-wall serious visceral lesions may occur. The pleura may be injured, the lung crushed, the pul- monary air-vessels ruptured, and interstitial cervical emphysema follow. The pericardium and its contents may also be injured. In addition, secondary inflam- matory complications may ensue. The treatment of contusions of the chest-wall consists in the administration of opium, provided there be no contraindication to its use. This drug relieves the pain, has a controlling influence over inflammation, and diminishes the number of respirations. Hot fomen- tations are often applied with benefit during the first few days, after which a broad strip of adhesive plaster is placed around the thorax after the manner of dressing a fracture of the rib. In commotio thoracica the cardiac stimulents are indicated, such as strychnia, digitalis, strophanthus, and nitro-glycerin, as well as alcohol in the form of hypodermic injections. In case dyspnoea is serious, artificial respiration should be employed, and if profound cyanosis is present, the inhalation of oxygen is indicated. The head should be lowered and artificial warmth applied to the sur- face of the body. The management of contusions of the thoracic viscera in connection with external injuries of the chest-wall requires no special treatment aside from that to be presently considered under Wounds of the Viscera. SURGERY OF THE CHEST. 811 Wounds of the chest may be the result of a gunshot injury or a stab, either of which may be penetrating or non-penetrating. If the wound is non-penetrating, it is not usually serious ; but occasionally a hemorrhage may occur from one of the large vessels upon the thorax, or the muscles be cut across so as to cause a hematoma and gaping in the wound. In consequence, a large hsematoma develops under the skin, and the clot, if infected, may give rise to dangerous cellulitis. In the non-penetrating injuries of the chest-wall phlegmonous inflamma- tion may occasionally occur. The phlegmon takes its origin in the loose con- nective tissue which abounds in the muscles over the scapula and beneath the pectorals and in the axillary region. The progress of the inflammation is very rapid, and produces great prostration from septic intoxication. The anatomical arrangement of the axilla with its various compartments produces a honeycomb condition, so that the pus is contained in many small cavities. The treatment of phlegmonous inflammation in this region requires prompt action on the part of the surgeon and demands the most rigid antiseptic precau- tions. The numerous pockets must be opened, the contents allowed to escape, and the cavities thoroughly curetted and drained. Care must be exercised lest the important vessels in the axilla be injured and give rise to alarming secondary hemorrhage. Before dismissing the topic of wounds of the chest-wall the non- penetrating gunshot wound should be considered. Gunshot -wounds of the thorax form about 50 per cent, of those which terminate fatally in battles, and about 10 per cent, of the gunshot wounds treated in hospitals. In the non-penetrating injury a fracture of the rib may occur or a wound of an important vessel or nerve. The non-pene- trating wound, uncomplicated by any injury of the bones or vessels, gives rise to no special disturbance beyond that of any wound of the chest-wall, and the mortality is only about 1 per cent. The respirator)' movements of the thoracic parietes often retard the healing process, and occasionally it becomes necessary to restrain the chest movements by broad strips of rubber plaster after the manner of treating a fracture of the ribs. In the old bullets the ball often took a circuitous course around the chest. The writer once removed a bullet from the angle of the scapula that entered the body in front near the edge of the sternum. In the modern rifle or pistol bullet this deflection is never observed. The chest-wall may receive a contusion from a shell, in which dyspnoea, pain, and col- lapse are present, at least as a temporary condition. In addition to the injury of the chest-wall the lung may receive a contusion or be com- pressed so as to give rise to severe symptoms of shock. Still further fractures of the bones forming the thoracic parietes, including the verte- brae, may increase the gravity of the case. in these complicated wounds the prognosis is nearly always fatal. The pleura may also be torn or lacerated, and this also adds to the seri- ous character of the injury. If the axillary or scapular vessels are wounded, the danger of a fatal hemorrhage is immediate. The signs and symptoms of a perforating wound of the chest are severe pain, violent paroxysms of coughing, and expectoration of blood. If the pleural sac be filled with blood, there are the additional physical signs of compression of the lung, with diminution of the respiratory movements and dulness over the pleural cavity. If, instead of blood in the pleural cavity, air gains admittance, the resonance is tympanitic 812 SPECIAL OR REGIONAL SURGERY. and the physical signs of pneumothorax are present. A perforating wound of the chest is often associated with other injuries, notably wounds of the important vessels, lodgement of foreign bodies in the chest, haemo- thorax, pneumothorax, pyothorax, injury of the spinal cord and dia- phragm, and even an associated abdominal injury. Hemorrhage may proceed from the intercostals, the mammary or axillary vessels, or from the large vessels situated in the thoracic cavity. The treatment of penetrating or perforating gunshot wounds of the thorax consists in the arrest of hemorrhage, the removal of foreign bodies, the disinfection of the wound, the withdrawal of the fluid from the pleural cavity, the management of the fractures involving the vertebrae, ribs, or sternum, attention to the injured diaphragm, and the alleviation of the symptoms arising from associated abdominal lesions. The arrest of primary hemorrhage is effected by a double ligature placed upon the proximal and distal ends of the artery. This method is applicable in the event of a wound of the branches of any of the large vessels upon the surface of the thorax. If the internal mammary or intercostals are torn, it may be necessary to cut away quickly a piece of the rib in order to reach the bleeding point. If the hemorrhage is not alarming, and there is an opening between the ribs sufficient to admit the finger, a small tampon attached to a string can be pushed into the thorax, and then drawn out so as to make pressure upon the vessel against the inner surface of the rib. A hemorrhage from the lung-tissue itself can be controlled with a tampon, absolute rest, and large doses of opium. The differential diagnosis between an arterial and a pulmonary hemorrhage is that in the former the blood comes in spurts synchronous with the action of the heart and is bright red in color, while in the latter the blood wells up from the bottom of the wound and is dark blue or nearly black. A very ingenious method of differential diagnosis between hemorrhage from an intercostal artery and the lung-tissue was devised by Richter, who suggested introducing into the wound a visiting card rendered aseptic and rolled up in the form of a circular tube and bent at an angle, and if the blood flows out along the groove, it shows the origin of the hemorrhage is from the intercostal artery, but if the blood flows out of the wound under the card, the source of the bleeding is from the pulmonary tissue. The removal of a foreign body should be attempted if it is within reach of the surgeon. A bullet or a part of the clothing or a piece of loose rib should be extracted in order to make the wound aseptic. The surgeon should not attempt any deep exploration, and should use his finger, rendered thoroughly aseptic, in preference to a probe. The dis- infection of the wound is accomplished by free irrigation of a solution made of sterilized water impregnated with bichloride of mercury of about 1 : 2000 in strength. The withdrawal of fluid from the pleural cavity is indicated. Blood left in the pleural cavity under such circumstances is not likely to absorb, but to give rise to an empyema. The removal of the fluid prevents a purulent collection. If after a few days serum collects, it should be dealt with in the same manner. In case fractures of the bones forming the thorax are found as an associated injury, they should be treated as compound fractures occurring independent of a gunshot wound. Injury to the diaphragm is attended with a peculiar respiration, severe pain, and irregular pulse. The question of abdominal section SUJRGERY of the chest. 813 must be considered, as rents in the diaphragm have been stitched and recovery followed. The associated injuries of the abdomen must be treated according to the rules which govern the surgeon in the management of these wounds independent of any chest complication. Gunshot wounds of the mediastinum may occur so that scarcely any visceral injury is inflicted. Fig. 349. Gunshot wound of the chest (Medical and Surgical History of the War). Injuries of the thoracic viscera include wounds of the pleura, lung, diaphragm, thoracic duct, the vessels, pericardium, and heart. "Wounds of the heart and pericardium are discussed in another chapter. Wounds of the pleura occur in consequence of fracture of the bones forming the thoracic parietes ; also in cases of severe contusion, in gun- shot and stab wounds. The injuries of the pleura complicating fracture of the ribs is discussed in another chapter. The pleura may be ruptured in violent contusions of the chest. Rapture of the pleura occurs in consequence of a severe blow upon the chest-wall or by a crush. This accident may occur without any visible external wound. If the visceral layer is torn, percussion reveals the pres- ence of localized dulness, and auscultation gives evidence of crepitation. Dyspnoea and cough occur, which in some rare cases are accompanied by bloody expectoration. Blood may escape into the pleural cavity and give rise to hemothorax ; or air, in which case, pneumothorax develops. 814 SPECIAL OR REGIONAL SURGERY. The air may be drawn in from the outside if an external wound exists, but the air escapes again at the same opening, and does not cause expec- toration of bloody and frothy mucus, as is always the case when the lung is injured. To this condition the term traumapncea has been given. In some cases both conditions may exist simultaneously. A small local- ized rent reappears without much disturbance, but a large tear may be followed by a superficial gangrene of the lung, by abscess, or by a uni- lateral pleurisy. Hemothorax and pneumocele are likely to develop in conse- quence of the injury of the pleura. The former occurs from rupture of the lung itself or of the internal mammary or the intercostal arteries, and the latter from hernia of the lung through the tear in the pleura. When this latter condition arises, the term pneumocele or hernia of the lung or prolapse of the lung is used. The pneumocele may occur at the time of the injury, or subsequently by pressure of the lung against a weakened cicatrix. Pneumocele is rather a rare sequela in penetrating wounds of the chest, since in 20,000 cases of chest wounds only 5 were followed by pneumocele. The most frequent seat of pneumocele in punctured and stab wounds is upon the anterior part of the chest. Occasionally the wound is situated low down, so as to be com- plicated with hernia of some of the abdominal viscera. If the pneumocele be primary, the parietes are injured, and the lung is forced out by a violent act of expiration with the glottis closed. The section of lung thus protruded may be returned if seen soon after the occurrence of the accident; if not, the hernia cannot be returned, owing to the enlargement of the mass due to congestion and inflammation. In very exceptional cases the pedicle may become more or less strangulated. The mass can now be left to slough, or it can be amputated by Paquelin's cautery and the wound left to heal by granulation. Instead of the peritoneal sac, as in abdominal hernia, the pneumocele may be surrounded by the pleura, which thus forms a serous covering. If the pneumocele occurs secondary to an injury, the hernia does not present for some time. The tumor has a peculiar crackling feeling under the skin, which in this variety is usually intact, and auscultation reveals the presence of air in the pulmonary vessels. The tumor increases in size on expiration, and diminishes during the act of inspiration. The percussion-note is resonant and the respiratory murmur is intensified. The escape of the hernia may be due besides to a weakened cicatrix, to a rupture of the intercostal muscles, or to some degenerative changes in the muscular wall. The writer has under observation a case of pneumocele the result of a stab wound. The hernia gives rise to no unpleasant symptoms, the patient wearing over the tumor a small compress which prevents it from enlarging and protects it from injury. Rupture of the lung- has occurred without any external injury of the chest- wall. The injury is serious, and is accompanied by emphysema, by pneumothorax, by hemothorax, by haemoptysis, and sometimes by empyema. Pleuritis and pneumonitis have also followed rupture of the lung. Gosselin believes that at the time of the accident the lung is fully distended with the glottis closed, so that the lung is incapable of yielding and rupture of the organ occurs. "Wounds of the intercostal artery are by no means trivial, since, according to the Surgeon General's report of the Civil War, 11 out of 15 cases, or 73.4 per cent, had a fatal termination. This high rate of mortality is not to be wondered at, since the intercostal artery can pour out four pounds of blood into the pleural cavity. The vessel can be ligatured near the vertebral column before the artery bifurcates, or one of its branches can be secured after the bifurcation along the SURGERY OF THE SPINE. 815 inner surface of the rib. The vessel is usually injured by a gunshot wound complicated by compound fracture of the rib. The ligation of both ends is necessary, and the compound fracture of the ribs dressed aseptically, and aspiration of the pleural cavity if that sac is filled with blood. Many devices were employed to arrest hemorrhage from this vessel, but these have at the present time only historical interest. Girard suggested enlarging the wound sufficiently to pass a curved needle around the rib and to the thread attach a compress, and draw it against the inner surface so as to compress the vessel. Eeybard suggested a curved blunt-pointed needle which also made compression. Henermann employed a staphylorrhaphy needle. Lotteri used a steel button, and Quessnay utilized an ivory plate for the same purpose. All of. these methods are objectionable, because they are likely to produce suppuration in the wound and injure the pleura, and be followed by secondary hemorrhage. If any means are employed besides the ligature, an antiseptic compress is the only safe measure. The compress can be introduced through the wound into the chest, and the tam- pon drawn outward against the rib. The gauze can be used like the finger of a glove, and then the pocket packed and drawn against the rib. The internal mammary artery has been injured as a result of gun- shot and stab wounds. The wound of this vessel derives its chief importance not only from hemorrhage, but especially from associated injury to the pleura. This complication gives rise to hemothorax. The artery has been injured by a sabre in which the point glided off from the sternum and perforated the intercostal space. Langenbeck mentioned to the writer that he had seen 5 cases of injury of this artery as a result of duels among the students in the University of Gottingen. Of this number, 2 died and 3 recovered : Langenbeck also stated that up to 1876 there never had been a successful ligation of the internal mammary artery. The surgical anatomy of this artery is important in relation to its ligation. The internal mammary artery comes off from the subclavian artery at a place cor- responding to a point between the two heads of the sterno-cleido-mastoid muscle and directly opposite to the thyroid axis. The vessel rises parallel with the ster- num one centimetre from its edge, and has the vein on its inner side between the artery and the edge of the sternum. In the upper two intercostal spaces the artery lies on the pleural sac, and if injured in this part of its course the pleural cavity is in all probability opened. In the intercostal spaces below the second the pleural cavity need not be necessarily opened, and, as a matter of fact, is not in wounds of the internal mammary, since the triangularis sterni muscle is between the pleura and the artery. It thus follows that if the artery is wounded above the third intercostal space, the pleural cavity is opened ; if below the third interspace, it probably escapes injury. Tamponing the wound above the third interspace is therefore impossible, while this procedure can be carried out below the third inter- costal space on account of the triangularis sterni muscle. The prognosis in wounds of the internal mammary artery has been most unfavorable, since Voss collected the cases and showed that the mortality is as high as 68 per cent. The diagnosis of injury of this artery is attended with no difficulty if the blood flows out toward the surface, but it is often extremely diffi- cult to determine this injury if the hemorrhage be internal. Under these circumstances rapid anaemia, the situation of the wound, and the signs of lung compression from blood are the points which the surgeon con- siders as aids to diagnosis. The treatment of injury of the internal mammary artery consists of ligation of the wounded vessel. If the hemorrhage be primary, the wound in the vessel should be found, and the artery completely divided 816 SPECIAL OR REGIONAL SURGERY. and both ends ligated. If the hemorrhage be secondary, the artery should be exposed in the next intercostal space above the wounded point, and the vessel tied in its continuity. It has been necessary to resect a portion of the rib in order to reach a wounded vessel. The technique of ligation of the internal mammary consists of making an incision parallel with the ribs and in the centre of the intercostal space at right angles to the outer side of the edge of the sternum. The skin, fascia, pectoral muscle, and intercostal muscle are all divided and the vessel exposed. The artery runs one centimetre to the outer side of the sternum, and has the vein between it and the border of the sternum. Langenbeck suggested another incision parallel with the artery, and at the point of election of ligature made a horizontal incision at the upper termination of the vertical incision. This T-incision affords more room to the operator. The pleura must not be injured when the resected portion of the rib is lifted from beneath by an elevator. The edge of the rib must be made smooth, so that no ill consequences may follow from the sharp edges of the divided rib. The hemo- thorax must be relieved by incision below, and a drainage-tube can be introduced above through the original wound, now enlarged by a partial resection, and carried into the pleural cavity and out of the chest at the point below where the wound was made, to afford drainage for the blood contained in the pleural cavity. The pleural cavity can be irrigated through the tube, if necessary, by an antiseptic solution. Injury of the thoracic duct occurs in consequence of stab and gun- shot wounds, and also as a result of contusion of the thorax and fracture of the vertebrae and ribs. The duct has been ruptured by dilatation as a result of pressure of an abdominal neoplasm ; also from stenosis of the duct the result of inflammation. If the wound has an external opening, a whitish fluid escapes, which upon analysis proves to be chyle. The fluid has been known to escape into the pleural cavity, and that cavity tapped upon the supposition that an empyema existed. An important clinical sign as to the character of the fluid is its coagulability upon exposure to the external air and its milky appearance if removed during the process of digestion. In traumatism of the upper part of the vertebral column or in diseases or tumors of the segments of the cord itself there are pres- ent certain nervous manifestations which affect the thorax. These phe- nomena should be studied, because upon an accurate interpretation of them a diagnosis of the lesion and its situation can be established. They appear immediately in case of fracture or dislocation or foreign body, a short time after the injury in case of hemorrhage, and a long time after the beginning of the cause in case of disease or tumor. (Vide page 679.) In the case of disease or tumor the onset is therefore slow and grad- ual, while in hemorrhage it is shortly after the injury, and in fracture and dislocation immediately upon receipt of the traumatism. Emphysema. This condition arises in consequence of the escape of air from the pul- monary organs into the subjacent subcutaneous tissues. The emphysema may occur as a result of a wound of the lung produced by mechanical violence or by a stab or gunshot wound. Emphysema may occur also without an injury to the lung, in which case the air is sucked in through a valvular skin-wound from without into a wound in the pleura during SURGERY OF THE CHEST. 817 the respiratory acts. This condition gives rise to a pneumothorax, the physical signs of which are the same as are ordinarily found. On the other hand, an emphysema may arise in consequence of a rupture of some air-vesicles in the lung and the pleura be uninjured. This variety of emphysema usually affects the mediastinum, and then the cervical region, and is the result of a sudden violent compression of the chest- wall. The condition may be so extensive that the patient's features are obliterated and the act of respiration seriously impaired. The writer has observed the emphy- sematous crackling in the scrotum from an injury to the lung. The air seldom if ever extravasates in the subcutaneous tissue of the scalp or in the palms of the hand or the soles of the feet. The air is forced along between the planes of con- nective tissue by the action of the muscles. Associated with emphysema is usually haemoptysis. The treatment consists in combating the sepsis by the application of the principles of antiseptic surgery. In intestinal emphysema the prognosis is most unfavorable, and the only treat- ment is an immediate laparotomy. The wounded gut should be sutured and the peritoneal cavity washed out under the most strict antiseptic precautions. Intercostal Neuralgia. This has been treated by surgical interference. Von Nussbaum sug- gested and carried into practice the operation of stretching the nerves. In one case he exposed by incision the eighth, ninth, and tenth intercostal nerves. The incision began 6 cm. from the vertebral column, and was carried 6 cm. through the integument, fascia, and the intercostal muscles. The nerve was then isolated, as it accompanies the artery and vein. In another case this same operator cut down upon the eighth, ninth, and tenth intercostal nerves upon both sides in front between the xiphoid cartilage and the umbilicus, and upon the outer edge of the rectus abdominis. In performing the operation he wounded the peritoneum upon the right side, but the case terminated favorably. The Thoracic Walls. The diseases of the bones and cartilages of the thoracic parietes include caries and necrosis, 'periostitis, osteomyelitis, also chondritis and perichondritis. These processes may arise in consequence of syphilis, tuberculosis, scurvy, and the infective fevers, notably typhoid. Any of these conditions may give rise to sinuses which become tortuous. The treatment consists of opening up the sinus down to the bone, and, if the latter is diseased, scraping the bone as well as curetting the sinus itself. The track of the sinus should be packed with iodo- form gauze, so as to permit the wound to heal by granulation from the bottom. In addition to acute abscesses and phlegmonous inflammation, cold abscess is often found upon the thoracic parietes. As this variety of abscess is associated with tuberculosis, there is danger of a general infec- tion. The abscesses should be opened, irrigated, curetted, and drained. Injections of a solution of iodoform and glycerin are found useful, as well as a solution of the bichloride of mercury, after which iodoform powder should be dusted over the abscess and into the cavity. These abscesses may occur independent of any bone lesion. 52 818 SPECIAL OR REGIONAL SURGERY. It must be borne in mind that abscesses upon the thoracic wall have been known to perforate an intercostal space and burrow their way into Fig. 350. Erosion of sternum, the result of pressure of an aneurism (Wood Museum). Fig. 351. Erosion of vertebrae, the result of pressure of an aneurism (Wood Museum). the lung itself. Under these circumstances the pus is expectorated. In these cases there is no purulent collection in the pleural cavity, and SURGERY OF THE CHEST. 819 the external abscess disappears by absorption from the surface of the thorax. Caries of the ribs or cartilages, or even periostitis, has been known to give rise to a pleurisy or abscess of the lung by propagation. The pleuritic eifusion is caused by the conveyance of germs from the seat of disease through the lymph-channels direct to the pleura. The same may be said of inflammatory affections of the diaphragm as well as of dis- eases of the liver. The bodies of the vertebrae, as well as the sternum itself, are often eroded in consequence of the pressure of an aneurism. In case of perforation of the sternum the sac protrudes, and some of the signs are identical with those of abscess of the thoracic parietes. This mistake must not be made, as an incision into the sac upon the supposition that the tumor is an abscess would terminate in instant death. Subphrenic Abscess. Subphrenic abscess was first described by Barlow in 1845. Hilton Fagge collected several cases, and, following his article, Leyden and Beck have pub- lished classical monographs upon the subject. Von Volkmann in 1879 demon- strated that purulent collections beneath the diaphragm could be treated by sur- gical interference. Fig. 352. hep. fi. Relations of the thoracic and abdominal viscera (Beck). The causes of subphrenic abscess are connected with traumatisms of the diaphragm, also with lesions of the stomach, notably ulcer ; also with disturbance of the kidney, especially the left, since this organ is higher upon that side. 820 SPECIAL OR REGIONAL SURGERY. Cos. pi PL cav. Absc. opening' The signs and symptoms of subphrenic abscess vary according to the origin and special variety. The history of the illness leading up to the development of the abscess must always be considered. If the abscess be due to a gastric ulcer, disturbances indicative of that lesion have preceded its development ; if to echinococcus, the his- tory of that disease precedes the formation of the abscess beneath the diaphragm ; if to abscess of the kidney, examination of the urine may throw some light upon the diagnosis. Usually the abscess if situated upon the anterior surface of the kidney gives rise to swelling, pain, tenderness, and collateral (edema in the abdominal wall. If the abscess be the result of a perforation from the pleural cavity downward, the signs of pleuritic effusion and empyema precede the signs of presence of pus beneath the diaphragm (Fig. 353). The explor- ing needle will afford valuable infor- mation as to the character of the fluid. If it be subjected to micro- scopical examination, the presence of special germs like the pneumococ- cus, echinococcus, or bacillus tuber- culosis throws some light upon the etiology and diagnosis. Fiirbringer has called attention to the motions which are communicated to the exploring needle when intro- duced into the abscess-cavity as pathognomonic of this disease. Weir has called attention to the clinical fact that inspiration increases the outflow of the pus through the cannula in subphrenic abscess, while the same respiratory movement diminishes the outflow if the purulent collection is in the pleural cavity alone. Maydl has recently called atten- tion to the fact that the manometric pressure may be absent if paralysis of the diaphragm is present. The physical signs are most important. The abscess may be situated upon the right side, as is often the case, owing to the fact that subphrenic abscesses frequently develop from some disturbance con- nected with the intestinal canal, notably the ilio-csecal valve and the costal and other veins in this vicinity. Deep percussion elicits pulmonary resonance instead of liver dul- ness, and absence of the respiratory murmur from the third or fourth rib above downward. The line of flatness beneath the diaphragm changes according to the attitude of the patient. Succussion can be obtained by placing the ear over the seat of the abscess, then shaking the patient, and the succussion note will be found to be limited to the subdiaphragmatic region. The absence of cough in connection with purulent collections in the region points to the subdiaphragmatic origin and seat of the fluid as opposed to a pleuritic origin. In some cases perforation of the lung has followed and the pus expectorated. In all cases of purulent collections in this vicinity the expectoration should be microscopically examined. Thoracic opening in subphrenic abscess (Beck). SURGERY OF THE CHEST. 821 Litten has called attention to a new diagnostic sign to which he has given the name of "diaphragm phenomenon." This sign consists of a "shadow-like line moving across the chest down and up with each inspiration and expiration." The treatment of subphrenic abscess consists of evacuation of the pus, followed by free drainage. When the diagnosis is made certain, free incision should be made, with resection of a portion of the ribif necessary. Beck suggests the space between the eighth and tenth ribs in the mid-axillary line. If the entrance of air into the pleural sac causes dangerous symptoms, the final incision can be postponed for two or three days. Bull in one case stitched the pleural surfaces to avoid infection of the pleura. General anaesthesia may be indicated, but if the pus be near to the surface, the abscess can be opened by the use of the chloride of ethyl and cocaine and the ether spray, combined with free alcoholic stimulation by the mouth. In regard to the irrigation of the abscess after incision, the same rules hold good which have been given in connection with Empyema. The Mediastinum. The injuries of the mediastinum consist of contusions, wounds, fractures, and dislocations of the sternum. Contusions of the mediastinum may arise from blows and falls upon the chest and from crushing of the thorax. The contusion may be accompanied by a hematoma which gives rise to serious cardiac dis- turbance. If blood collects in the space, aspiration of the cavity is indicated. The treatment for simple contusion is absolute rest by fixation of the thorax by means of adhesive plaster and by the administration of opium to allay pain and to control the movements of the chest. Wounds of the mediastinum follow gunshot and stab wounds, and are serious in proportion to the associated injuries of the viscera con- tained within the space. Hemorrhage is to be treated as described above in connection with Contusion, and the special injury of each viscus is to be dealt with according to rules laid down in connection with injury of each organ. The foreign body should be removed in all cases if possible, and the parts dressed antiseptically and the chest immobilized. Fractures and dislocations of the ribs and sternum are discussed in another chapter especially devoted to this subject. The great danger besides shock in all mediastinal injuries is that of abscess-formation — a condition soon to be discussed. Mediastinitis may be either acute or chronic. Acute mediastinitis takes its origin from infection, from cervical abscesses, from caries and necrosis of the ribs, sternum, and vertebra?, from injury such as gunshot and stab wounds, and also in consequence of a fracture of the bones forming the anterior wall of the mediastinum. Inflammation of the mediastinum has been observed in connection with typhoid fever, erysipelas, and measles, and other infectious and contagious diseases. The signs and symptoms consist of substernal pain, which is in- creased upon coughing or deep inspiration, dyspnoea, cyanosis, localized oedema, difficulty of deglutition, and palpitation of the heart. Flue- 822 SPECIAL OR REGIONAL SURGERY. tuation may exist, and a bulging at the episternal notch and in the cor- responding intercostal spaces. Percussion over the mediastinal area elicits dulness, changing according to the position which the patient assumes. Auscultation reveals the loss of respiratory murmur over the area of the abscess. Chills, rigors, elevation of temperature, rapid and irregular pulse are among the constitutional disturbances. The general constitution of the patient, the character of the suppu- ration, and the tendency of the pus to burrow influence the prognosis. The treatment of acute mediastinitis consists in affording an escape for the pus and in irrigation and drainage of the cavity. An incision is made over the most prominent point of bulging through the skin down to the abscess-wall. A trocar and cannula can now be inserted, and a small quantity of pus allowed to escape, the amount of which depends upon the condition of the pulse. Sudden withdrawal of all the pus at once may cause fatal syncope. The drainage-tube can be inserted through the cannula, and the latter withdrawn after the drain- age-tube is in place. If the surgeon is unable to reach the pus by incision, trephining of the sternum has been suggested, but it is an operation fraught with great danger, and is only to be resorted to in cases of great gravity. If by pressure of the pus necrosis of the ster- num has taken place, a still more serious operation is called for — viz. excision of the sternum. This operation, while called for to save the patient's life, is nevertheless a most serious undertaking. Before cut- ting down upon the abscess or trephining the sternum or exsecting it the surgeon must be certain that he is not dealing with an an- eurism. Quenu and Delorme have devised a method of attacking the posterior mediastinum by a trap-door operation on the posterior aspect of the thorax. It is applicable— in rare instances — to evacuation of abscesses, removal of foreign bodies, and possibly of tumors. Those interested in further knowledge of it are referred to the Jour. Am. Med. Assoc, Aug. 26, 1893, p. 296. Chronic mediastinitis may be caused by pulmonary tuberculosis or from scrofulosis, or be the result of primary mediastinal disease. The signs and symptoms are very similar to those mentioned in connection with the acute variety. The pain may radiate to the shoulder or be transmitted around the chest-wall by the intercostal nerves. This is likely to occur when the pus is found in the posterior mediastinum. The pain may be situated in front of the chest at the termination of the intercostal nerves, from pressure of pus on the roots of these nerves at their origin. The treatment of chronic mediastinitis consists of aspirating the mediastinum just as soon as the presence of pus is evident. If the pus is found in sufficient quantities to cause bulging of the chest-wall, incision can be made, using the same precautions as have been men- tioned in connection with acute mediastinitis. Great care should be exercised if the aspirator is employed, lest any air enter the mediasti- num, since this would rapidly convert a chronic into an acute abscess. The withdrawal of only a small quantity of pus at a time must be practised, so as to avoid a fatal collapse. The continuous drainage extending over a short time is the safer method. SUBGERY OF THE CHEST. 823 The Lungs. Before describing the surgical diseases of the lungs it is necessary to preface the subject by a few anatomical facts. The lung itself never completely fills the pleural sac, which explains the absence of dyspnoea in small effusions. This anatomical fact serves to explain the escape of pulmonary lesions in a restricted number of penetrating stab wounds of the chest. The lung itself also fails to suffer collapse in external injuries if the opposite lung carries on respiration and the accessory muscles are not paralyzed. Williams has pointed out that a sound lung soon expands when pressure of the external atmosphere is interrupted. The lung may be the seat of abscess and of gangrene, to relieve both of which conditions surgical operations have been performed with success. Abscess of the lung may result from a pneumonia, from a suppura- tive inflammation, from the presence of a foreign body, or from a septic embolus derived from a bed-sore or a wound, or an ulcerative endocar- ditis ; from the uterine sinuses ; from an otitis media ; from tuberculosis ; or from a fractured rib or sternum. Abscess of the lung may be also caused by an osteomyelitis of the bones forming the thorax, by a pene- trating gunshot wound, by an empyema, or by ulcerating mediastinal nodes ; likewise by traumatism and by pyaemia. It may also be caused by syphilis, by bronchiectasis, by extension of an hepatic abscess, by an inhalation or deglutition pneumonia, by puerperal fever, and finally by necrosis of rib, sternum, or vertebras. The signs and symptoms of abscess of the lung consist of a limited unnatural area of dulness, changes in the respiratory murmur, increase in the fremitus, and vocal resonance and bronchial whisper. The sputum is most offensive, and the pus is greenish or brown in color. Shreds of lining tissue are found under the microscope ; also crystals of fat and hsematoidin and elastic fibres. Septic micrococci are found in the discharge, and the absence of the bacilli tuberculosis excludes the probability, though not the possibility, of tuberculosis. The presence of pus in the lung gives rise to constitutional disturb- ance, such as is found in connection with the formation of pus in other parts of the body. The treatment of abscess of the lung consists in the evacuation of the pus, to which operation the term pneumotomy has been given. Having rendered the field of operation thoroughly sterile, an incision is made down to the intercostal space, and then an aspirating needle is introduced into the abscess-cavity. If adhesions of the pleura to the chest-wall are present, the operation can be completed at one time. The needle acts as a guide to the surgeon as he cuts into the cavity of the abscess. The incision into the lung can best be made by the actual cautery knife, but very great care must be exercised in the use of Paquelin's cautery if ether is employed. A serious explosion has followed the use of the actual cautery in thoracic surgery; and this fact must be borne in mind. If the cavity is reached, the pus will flow out through the cannula or through the open wound. The abscess-cavity cannot be irrigated except with very great gentleness, lest the limiting abscess-membrane 824 SPECIAL OR REGIONAL SURGERY. wall will be ruptured and the fluid be let free to set up a purulent bron- chitis. A drainage-tube should be inserted and left in situ as long as pus is discharged. If the cavity is situated unfavorably for drainage, a counter-opening should be made, provided pleuritic adhesions are present. If after cutting down through the intercostal space no adhesions of the pleura are found, it is best to terminate the operation at this stage and defer its completion until adhesions have formed. With a view to assisting nature in forming adhesions, Godlee has suggested stitching the lung to the chest-wall, and after waiting a few days finish the opera- tion by cutting into the abscess-cavity. Stitching the lung to the chest-wall is attended with some difficulty, owing to the friability of the pulmonary tissue and the constant movement of the lung on account of respiration, and also owing to the small opening through which the surgeon is obliged to work. Even when this step in the operation is successfully accomplished, the stitches often tear after a few hours in spite of every precaution which has been taken. The opening of the abscess-cavity is made in the manner already described. The adhesion of the pleura to the chest-wall is necessary before the abscess is opened, and if nature has not already accomplished this, the surgeon must wait a few days in order to pre- vent the escape of even a few drops of pus into the pleural cavity and thus set up an empyema. The results of pneumotomy for abscess of the lung are most encour- aging, since there have been 15 cases of complete recovery which the writer collected in two years, and to this number it is safe to say that several have been added. This is a most remarkable showing for a new operation designed to relieve a class of cases which hitherto were almost uniformly fatal. Tuberculous abscesses of the lung have also been subjected to pneumotomy. These abscesses can be curetted and drained if there is a fistulous opening leading to the cavity or, if the pain is very severe, in those cases in which pleuritic adhesions have formed. It is impossible to cut away enough adjacent pulmonary tissue to remove all the tissue containing bacilli tuberculosis ; but fortunately it does not seem always necessary, since the same principle holds good here as in joint tubercu- losis. In the latter cases statistics have shown that in resection of a tuberculous joint, even if some infected tissue is left behind, nature will arrest the disease if aided by surgical interference. Gangrene of the lung may be due to traumatism such as a gunshot or stab wound ; from contusion of the chest-wall ; from the presence of a foreign body in the bronchus ; from an infective embolus ; from a tuberculous abscess ; from bronchiectasis ; from a pneumonia ; and in rare cases from diabetes and bulbar paralysis. This condition may also fol- low acute interstitial nephritis consecutive to scarlet fever. Gangrene of the lung may also be caused by extension of suppurative processes in the lung, pleura, or diaphragm, or from Pott's disease or infection from bronchial nodes, and, finally, from pertussis. It is seldom if ever a primary disease, but generally secondary to some inflammatory lesion of the lung. Gangrene of the lung may be diffuse, in which case it is usually embolic, or it may be circumscribed. The diffuse variety does not con- cern the surgeon, but in the circumscribed form operative interference can be undertaken. The localized gangrene may vary in size from a bean to that of an infant's fist, and it is usually situated upon the periph- SURGERY OF THE CHEST. 825 ery of the lung, and generally in the lower lobe. In the mass the bac- teria of suppuration are always found. The signs and symptoms of gangrene of the lung consist of cough, pain, rapid respiration, with expectoration of a sputum containing pus and necrotic shreds of lung-tissue. The odor from the breath is most offensive. If the sputum is allowed to stand in a glass vessel, three dis- tinct strata are formed. The upper is opaque and frothy and yellow in color, the middle layer is serous, and the lower stratum is green or brown in color. This latter contains necrotic pulmonary tissue with bacteria, crystals of triple phosphates and fatty acids, fat-globules, and pus-cor- puscles. Traube has demonstrated that the presence of elastic fibres is characteristic of lung-abscess, together with chills, elevation of tempe- rature, and frequent pulse. The physical signs reveal the presence of a gangrenous area : in some cases the signs are those indicating a cavity. Fetid bronchitis may be mistaken for gangrene of the lung, but the microscopical examination fails to show the presence of lung-tissue. The treatment of gangrene of the lung is by pneumotomy, the technique of which is to be carried out practically in the same manner as has already been described in connection with abscess of the lung. Hydatid cysts may be found in the lung. In 2137 cases of echino- coccus which have been collected from various reports, 212, or 10 per cent., of the cases affected the lungs. The surgical treatment of hydatid cyst involving the lung is called for, since 75 per cent, of the cases terminate fatally. The cyst can be tapped with a trocar and cannula and a few cases of cure have been reported from this simple operation. On the other hand, sudden withdrawal of the fluid has been followed by fatal collapse. If a simple tapping fails to relieve the condition and the fluid becomes purulent, pneumotomy is indicated. Hydrothorax, Hemothorax, and Pyothorax. These are conditions which often call for surgical interference. As the technique of the operations for relief is practically the same for all these conditions, one description will suffice. The surgical treatment of these affections varies according to the peculiar character of the fluid, and consists of thoracentesis, thora- cotomy, and thoracoplasty. Thoracentesis is an operation by which fluid is withdrawn from the pleural cavity by the introduction of an aspirating needle, a trocar, and a cannula, or by a special instrument known as an aspirator attached to the needle. This operation is to be preferred when the fluid is not purulent, and when the object to be obtained is simply the relief of mechanical pressure upon the lungs. This operation may also be indicated as a diagnostic test, as the cha- racter of the fluid can be quickly determined after its withdrawal. The signs and symptoms of effusion into the pleural cavity must necessarily depend upon the character of the fluid. Acute hydrothorax is attended by a serous exudation, and is due to an acute pleurisy with effusion, or it may be secondary to changes in the 826 SPECIAL OR REGIONAL SURGERY. circulation in consequence of heart or kidney disease. In the latter case it is a simple exudation, and occurs usually as a bilateral affection. Thoracentesis is indicated when the fluid in the pleural cavity is sufficient in quantity to produce marked dyspnoea, or when a large quantity still remains, even though medical treatment has been carried out for a long period of time. A most important point to be considered in performing thoracentesis is the danger of converting a simple serous effusion into a purulent one, thus producing an empyema. To avoid this danger the most rigid asepsis must be employed in the performance of the simple operation. Thoracentesis should be employed as soon as possible after the fluid is sufficient in bulk to cause dyspnoea, since the lung is more likely to expand and the chest- wall to contract, and the relations between the lung, pleura, and chest-wall be- come normal, under the circumstances of an early tapping. Permanent adhesions of the pleura are also prevented by an early operation. In children this is espe- cially important, and often will effect a permanent cure, because iu this class of cases the fluid is due to the presence of the pneumococcus, while in adults the fluid usually contains, besides the pneumococcus, several other varieties of pyogenic organisms. In children no irrigation is necessary, but in adults, if the bacilli tuberculosis are present, with no bacteria or mixed infection, thoracen- tesis alone is indicated. A small amount of the fluid can be withdrawn by a hypodermic needle and examined, and if found to contain pneu- mococci only in children, or the bacilli tuberculosis only in adults, thora- centesis alone is indicated. If irrigation of the chest is to be performed, the solution should be warm, as cold irrigation chills the pleura and severe shock is apt to fol- low. In a few cases hemiplegia has followed irrigation by cold solutions. This accident has been ascribed to an embolus detached from a venous thrombus — a theory which has been proved incorrect, since in the autop- sies no embolus has been found. Another theory is that the hemiplegia is reflex in character, and is caused by some inhibitory action of one- half of the cerebrum. This theory has not been accepted, since the pleural surfaces are insensitive, because they are transformed into the walls of an abscess-cavity. Still another theory has been advanced, that the hemiplegia is epileptiform or uraemia or toxic in character or caused by the absorption of the antiseptic solution. All of these theories have been abandoned, and in their place the theory substituted that shock itself, in the majority of cases, is the cause of the hemiplegia. There are evidently other factors to be considered before we can explain every case of hemiplegia after irrigation with cold solutions. Broadbent refers to a case in which aspiration was followed by death from cardiac syncope in three or four hours after the tapping. The writer has seen the same accident occur in a case of aspiration in which the fluid was caused by cancer of the pleura. Gayley reports a case of convulsions followed by sudden death after washing out the chest with a warm solution of iodine and water. Death has followed simple aspiration in the Buffalo clinic. Vallin met with the same acci- dent, and Eaynaud lost a patient as the result of irrigation of the chest, death being preceded by convulsions and hemiplegia. These cases clearly demonstrate the danger of deferring paracentesis until the chest is full of fluid, which causes the formation of thrombi in the pulmonary veins. They also reveal the danger of washing out the chest after aspiration. Early tapping before the lung is compressed and the heart is displaced, and the SURGERY OF THE CHEST. 827 thoracic circulation is interfered with, offers to the patient the best prospects of cure. It is a noteworthy clinical fact that the dangerous symptoms have always occurred during the injection of the fluid, and not during its removal. Before performing thoracentesis the field of operation and the instru- ments should be made thoroughly aseptic. This is of the greatest importance, in order to avoid the danger of converting a simple serous effusion into a purulent one. The skin over the chest and the axilla should be shaved, washed and scrubbed, and disinfected with a solution of bichloride of mercury or carbolic acid. The instruments, including the needle and tubing, should be boiled and then immersed in an anti- septic solution. The aspirator should also be disinfected. A sterilized rubber cloth should be placed over the chest-wall, and over the rubber, dry sterilized or wet bichloride towels placed. Wet towels should never be placed in direct contact with the chest-wall, since an acute pleurisy is often aggravated by this proceeding, and in cases where operations are performed upon the chest for other reasons a pleurisy might be developed. The surgeon and assistants should thoroughly disinfect their hands in order to ensure a typical aseptic operation. The place where the needle is to be introduced should be sprayed with ether or preferably with the chloride of ethyl, for thus the introduction of the needle is rendered painless. Cardiac syncope should be anticipated and prevented by the use of stimulants before and during the operation. The patient can sit in the half-upright position and be supported by pillows, and these can be removed and the patient lowered as the fluid is withdrawn. The recumbent position can be assumed at once if there is any tendency toward syncope. The entrance of air must be prevented, and care must be exercised lest the viscera be injured. The fluid should be withdrawn slowly and only in part, as a sudden withdrawal of the fluid or of the entire amount at one time might be attended by dangerous symptoms and even by death itself. The too precipitate withdrawal of the fluid affects the heart, and the sudden expansion of the compressed lung causes great pain and distress. Coughing or a sudden change in the character of the pulse is an indication to arrest the flow of the fluid, since either of these signs points to a too rapid expansion of the lung and a too violent tearing up of adhesions. The parts should be allowed to gradually accommodate themselves to the vacuum caused by the removal of the fluid. It must be borne in mind that the fluid is not forced out of the chest-cavity as pus is from an abscess-cavity, but by re-expansion of the lung and by the ascent of the diaphragm. The point of election for the introduction of the aspirating needle or the trocar and cannula is either the eighth intercostal space near the angle of the scapula, or the sixth intercostal space in the mid-axillary line just in front of the border of the latissimus dorsi muscle, or else at a point where the bulging is the most prominent or the dulness most marked. A small incision can be made in the skin before introducing the needle. In cases of pleuritic effusion associated with tuberculosis of the lung the theory has been advanced recently that the fluid should not be with- drawn, for the reason that the pressure of the fluid compresses the lung 828 SPECIAL OR REGIONAL SURGERY. and prevents it from moving. This action of the fluid is compared to the action of a splint on a tuberculous joint. Le Fevre reports four cases in which thoracentesis was followed by general tuberculosis. This careful observer believes that an intercurrent attack of pleurisy may be non-tubercular, although tuberculosis of the lung is present, and that an attack of acute pleurisy may be the first intimation of pulmonary tuberculosis. The writer has recently seen a case of tubercular empyema in which early tapping and irrigation were not performed. The autopsy, a year later, showed solitary tubercle in the right auricle of the heart, also a tubercle the size of a walnut in the left hemisphere, which caused Jacksonian epilepsy and occasionally attacks of aphasia ; also a tubercular osteitis of the spine and a pachymeningitis with a caseous deposit which caused girdle pains. Early operation might have prevented general infection in this case, and, judging from a surgical point of view in a number of cases, the writer recommends tapping and irrigation and drainage in tubercular empyema. Bloody fluid in the pleural cavity points to tuberculosis, but if that condition can be eliminated primary carcinoma of the pleura or lung is in all probability present. It must be borne in mind, however, that a clear serous fluid does not absolutely preclude the presence of a tumor. The rapid recurrence of bloody fluid after aspiration is a strong argu- ment in favor of cancer of the lung or pleura, or both. Prune-juice expectoration is a sign of cancer or sarcoma of the lung or pleura or lobar pneumonia. The color is due to a decomposition of the blood and its mixture with frothy mucus. It may also be occasion- ally observed in tuberculous hemorrhages. It is thus evident that while this peculiar sputum may occur in tumor of the lung, it also is present in other diseases of the lung. It is therefore not pathognomonic of tumor, but only one sign that is often present. The expectoration in tumor may be purulent or hemorrhagic, or even gangrenous, in character. Some writers have called attention to metastatic deposits in the lymph-nodes as a diagnostic aid. Behier believed that involvement of supraclavicular nodes is associated with tumor of the lung or pleura, whereas involvement of the submaxillary nodes pointed to tuberculosis of the lungs. Dyspnoea is a sign oi tumor of the lung or pleura, and when these attacks came on very frequently and there are no physical signs present to explain the condition, tumor should be suspected. In these cases aspiration of the chest is not followed by relief as in other conditions, since the neoplasm itself causes the dyspnoea and not the fluid alone, and it is but slightly and only temporarily relieved by the withdrawal of fluid from the pleural cavity. Thoracotomy. Thoracotomy consists in making a free incision into the chest-wall in order to allow fluid to escape, and afterward to irrigate the pleural cavity if necessary. It often happens that nature anticipates the sur- geon and a spontaneous opening occurs, generally in the third intercostal space a few inches distant from the bone of the sternum. If an exami- nation of the fluid withdrawn by a hypodermic needle shows the pres- SURGERY OF THE CHEST. 829 ence of the bacteria of suppuration, a thoracotomy is indicated. Every antiseptic precaution should be taken, as described under the preparation for thoracentesis. Local anaesthesia is usually sufficient to ensure a painless incision ; the use of the ether atomizer or the chloride of ethyl or cocaine will render the operation painless. Stimulants should be also given according to the directions detailed under Thoracentesis. In exceptional cases general anaesthesia is necessary if a portion of a rib is to be exsected, but great care must be exercised in the administration of the anaesthetic. The place of election for the incision is in the sixth or eighth inter- costal space upon the side of the chest, just anterior to the border of the latissimus dorsi muscle. A point corresponding to the ninth rib and a little external to the angle of the scapula has been suggested by Godlee, while the intercostal space a little posterior to the scapular line, in order to avoid wounding the diaphragm, has been recommended by Hewson. Stokes believes that even the eighth intercostal space is too low. It is not necessary to select the lowest part of the cavity, since the diaphragm ascends during the escape of the fluid from the chest. The technique of the operation is as follows : The skin should be drawn upward, and an incision two inches in length should be made along the space between the ribs. Retraction of the skin thus affords a valve-like opening. Before the pleura is incised the exploring needle can be introduced if it has not been done before the operation. If pus is found, the pleura can be incised to correspond with the external incision. If the pus is fetid and contains many clots, the pleural cavity can be irrigated with a warm bichloride solution, 1 : 10,000, and followed immediately by irrigation with warm distilled or sterilized salt solution. Washing out the chest must be undertaken with caution, since cases of sudden death have occurred during the irrigation, to which reference has already been made. While washing out the chest the position of the patient should be changed so as to permit the antiseptic fluid to come in contact with all the pleural surface. A rubber drainage-tube with no lateral openings can be introduced, or a silver cannula with a broad flange, either of which must be held in place by some mechanical device. The chest can be irrigated daily according to the temperature. The lung is not apt to expand too rapidly in cases where free incision is made, because atmospheric pressure exists upon both sides. Beck recommends a resection of a portion of the rib in order to permit the surgeon to introduce his finger with a view to exploration of the pleural cavity and to remove any fibrinous exudation, and also to determine the size of the cavity. After the thoracotomy is completed and the irrigation finished, antiseptic gauze should be applied to the chest-wall and to the mouth of the tube, and over all absorbent cotton. A bandage can now be applied and the dressing chano-ed according to the amount of discharge. The tube should remain until the pus ceases to flow and the discharge becomes serous in character. The wound must not be closed too soon, as this procedure might call for a repetition of the tho- racotomy. If the empyema is tubercular, thoracotomy is to be preferred to simple thoracentesis, since the latter permits too rapid expansion of the lung, which act causes tearing up of adhesions and at the same time produces paroxysms of cough- ing. A pneumothorax or a haemothorax might thus be engrafted upon a tubercular empyema. Thoracentesis, on the other hand, is recommended in children and in adults when the empyema is not tuberculous. Cauterization of the pleural cavity with a 50 per cent, solution of chloride of zinc has been recommended bv Eoswell Park. 830 'SPECIAL OR REGIONAL SURGERY. In tubercular empyema thoracotomy permits the entrance of a cer- tain amount of air from outside, which prevents too rapid expansion of the lung. If the effusion is large, the heart is displaced, and its return to its normal position must not be too sudden, as this might seriously embarrass its action. In children after thoracentesis or thoracotomy pulmonary gymnastics should be practised during convalescence. This can be accomplished by two large Woulff's bottles, one of which is filled with water, while the other is empty. Children are expected to blow the fluid from one bottle into the other, and by this act cause a slow and steady re-expansion of the lung. In adults, occasionally, these pulmonary gymnastics may be of service. Empyema may occasionally involve both pleural cavities. Garee" reports a case of this kind in which he resected a portion of the rib and drained the cavity on one side for four days, then made the same opera- tion upon the other side. In studying the literature of the subject the writer has collected 10 cases of double empyema, with recovery in every case but ] . Aspiration was performed in 4 out of the 10 cases, and drainage with resection of the rib in the remaining 6. The operation of thoracotomy, with resection of a small portion of the ribs and drainage, seems to be preferable to paracentesis if the lungs are compressed, since the admission of air from without prevents a too sudden expansion of the compressed lung. Gould has wisely suggested that in cases of double empyema, in which delay between the two operations seems dangerous, " the two empyemata should be care- fully aspirated a few hours before the operation. By this means the shock pro- duced by the sudden removal of pressure from the lungs is obviated, and the simultaneous drainage of the two pleurae is robbed of its chief danger." Cantley suggests aspiration on both sides as a preparatory procedure in order to diminish the amount of the fluid and relieve the heart, and upon the following day to perform thoracotomy on the left side, and in a few days to a week later to operate on the right side. He also prefers local anaesthesia to general. Thoracoplasty. Thoracoplasty, or resection of the ribs, was first suggested by Dr. Warren Stone of New Orleans, La. To Esflander is due the credit of establishing the operation as a recognized procedure. The operation is a serious one, and is only undertaken to save life. The mortality depends upon the character of the empyema and the general condition of the patient. This operation is indicated when thoracentesis and thoracotomy have failed in their object, or when a new sacculated empyema has developed, or a rupture in the chest-wall has occurred and an incurable fistula exists. The operation is also indicated when general tuberculosis is threatened, or when the remote effects of the empyema upon the brain, kidney, or lung are serious. All of these conditions preclude the possibility of recovery, because the lung is fixed, which prevents its expansion. The pleura is adherent and inelastic ; the chest- wall is rigid, leaving an unnatural cavity. Thoracoplasty aims to relieve these morbid conditions. Anaesthesia is necessary, and the administra- tion must be conducted with great care. The patient must not be placed too much on the sound side, since the narcosis might cause too much shock or the pus might get into the bronchi of the sound lung and cause SURGERY OF THE CHEST. 831 a limited suppurative pneumonia. The number of the ribs to be exsected depends upon the size of the cavity, which can be explored by the finger before the ribs are removed. The dimensions of the cavity influence the size of the flap and the direction of the incision and the amount of bone to be sac- rificed. The second to the seventh ribs are usually selected, since they generally corre- spond to the anatomical situation of the cavity. The first rib is never selected, owing to its anatomical relations with the subclavian vessels. As much bone must be removed as covers the size of the abscess- cavity, and this may vary from one inch to an area extending over the entire osseous structure covering the cavity. A flap shaped like the letter U can be made, with its pedicle upward, as suggested by Godlee ; or transverse cuts along the centre of each intercostal space, with removal of the upper and lower ribs in the wound, as recom- mended by Estlander; or several small flaps, as advised by Jacobson ; or a vertical incision, as practised by Gould. Whatever incision or variety of flap is adopted, the periosteum and ribs are removed as soon as the parts are exposed. The thickened pleura must be cut away and the hemorrhage at once arrested by ■ Ji ; ^ * forceps and ligature. Result of Estlander's operation for chronic empyema (Richardson). Sehede has suggested the resection of all the tissues of the wall except the skin and superficial fascia of the pleura, which are then sewed to the Dleura. Tumors of the Thorax. Tumors of the thorax may be situated upon the thoracic wall or involve the bony parietes, the viscera, or the mediastinal nodes. Gurlt collected 14,630 tumors from several hospitals, and of this number 104 grew from the thorax. The neoplasmata affecting the external surface of the thorax may be benign or malignant. The former class includes lipoma, fibroma, chon- droma, osteoma, neuroma, and the latter sarcoma and carcinoma. The benign growths may take their origin from the soft parts. It is of the greatest importance to distinguish between those which grow from the external parts and those which take their origin from within and present externally by forcing their way through the chest-wall. The question should be carefully considered before undertaking any surgical opera- tion. The tumors that most likely arise from the external soft parts are the lipomata, which grow from the subcutaneous fatty tissue which abounds so plentifully upon the back and sides of the thorax. The lipoma in 832 SPECIAL OR REGIONAL SURGERY. this situation is generally pedunculated, attains only a moderate size, and is freely movable under the skin, which can be usually gathered up in wrinkles over it. The tumor is painless unless it embraces a nerve-fila- ment or becomes inflamed. Fig. 355. Sarcoma of rib and pleura, result of injury by a base-ball. Lipoma is the most frequent benign growth which is found upon the thorax. It is usually situated upon the' back of the chest, notably between the scapulae, and takes its origin from the fatty tissue which appears in such abundance in this situation. Billroth reported the removal of one from this situation which was equal in weight to about one-third of the body. PLATE XXVIII. Neuro-fibroma of Skin. SURGERY OF THE CHEST. 833 Fibromata are also found upon the chest-wall. They are of two vari- eties, one of which is hard and slow-growing and less movable than the lipoma, and springs frequently from the axilla, and also beneath the pee- toralis major muscle. The other variety is soft, multiple, and usually congenital, and termed fibroma molluscum. There are no metastases from this growth, although regional recurrence sometimes is found (Plate XXVIII.). These fibromata may be pedunculated or sessile, and in either case raised well above the surface of the skin. Keloids are sometimes observed upon the sternum, and occasionally assume the characteristics of the recurrent fibroid tumor of Paget. Chondroma of the chest takes its origin from the sternum, ribs, and cartilages. The tumor is hard, solitary, painless, and slow-growing unless it partakes of cystic degeneration, and usually occurs during adult life. The chondroma, if pure, is benign, but, unfortunately, the growth is found to be associated with sarcoma, in which case it is highly malignant. It must not be forgotten that in exceptional cases the chondroma may grow inward and involve the pleura or the diaphragm. Traumatism seems to explain the origin of chondroma of the ribs, since the tumor has been observed to start from the seat of a fractured rib. Neuroma may be found on the chest-wall, and it grows from one of the intercostal nerves. Echinococcus of the sternum has been observed in a few cases, and also dermoid cysts. They are, however, so rare that they are mere surgical curiosities. Osteomata grow from the bony structure of the thorax. They are hard as bone itself and do not form secondary deposits. Sarcoma is found upon the thorax, but usually it has an intra- thoracic origin, having made its way through the parietes. The tumor grows rapidly, soon forms a fungous mass, and causes metastases. In the early stage the growth appears hard and nodulated, and admits of little movement under the skin, which very soon becomes discolored and ulcerates. The growth may appear upon the front or in the axil- lary region. Sarcoma may grow also from the sternum. The writer has seen several of these cases, but in each case the tumor was situated upon the manubrium and had perforated the bone. It is a question whether these sarcomata grew from the connective tissue behind the sternum and perforated the bone or from the periosteum upon the front of the sternum. In either case the prognosis is not favorable. Gummata are found on the chest-wall : they appear as indurated swellings just beneath the skin. These tumors appear in the tertiary stage of syphilis. The skin over the swelling soon becomes cyanotic denoting a disturbance in the nutrition of the skin. This condition soon leads to the formation of an ulcer. Tuberculosis of the chest-wall is occasionally observed. The dis- ease may be present in the form of an ulcer or a cold abscess. If the former is the case, caseation of the mass usually follows. Some parts of the tuberculous mass may undergo calcification. This break- 53 834 SPECIAL OR REGIONAL SURGERY. ing down of the tuberculous nodule may be followed by an abscess to which reference has just been made. The condition calls for radical surgical treatment, since general tuberculosis may follow from this focus. The disease may also produce caries of the ribs or sternum, just as gummatawill cause these changes in bones. The tuberculous nodule is situated in the subcutaneous tissue, and from the mass long sinuses lead outward which are lined by unhealthy granulations. The sinuses may be very tortuous and extend for a long distance beneath the skin. Occasion- ally the tuberculous nodule may take its origin in the subperiosteal instead of the subcutaneous tissue, in which case there is danger of visceral infection. The treatment of tuberculous ulcers upon the chest call for practi- cally the same local measures as are indicated in gummatous ulcers. Tonics should be employed, but not the potash and mercury as in syph- ilis. Out-of-door life, physical exercise, and sea-bathing are among the means suggested to improve the general health. Actinomycosis affects the chest -wall. The disease begins upon the thorax and extends inward until the lung becomes involved. The con- dition gives rise to a fistula which has been mistaken for tuberculosis. The signs and symptoms of actinomycosis of the chest-wall con- sist of the presence of a hard lump over which the skin has become cyanotic. The integument soon sloughs and a peculiar discharge con- taining yellow granules escapes. Into the mass numerous tortuous sinuses are seen, and from these sinuses the characteristic yellow dis- charge flows. The presence of much liquefaction indicates the activity of the fungus, while granulations springing up point to the death of the fungus. The treatment of actinomycosis of the chest-wall consists of ex- cising the indurated and sloughing mass and scraping with a curette the sinuses, and then applying the actual cautery. The use of bichloride of mercury as an antiseptic irrigation is highly extolled. Gautier injected a solution of iodide of potash into the indurated mass, and then passed a galvanic current through it. This liberated the nascent iodine into the tumor and destroyed the actinomycoses. Carcinoma may be situated anywhere upon the front of the chest and also in the axilla. The disease begins upon the skin and ulcerates its way into the deeper tissues. The mode of origin is different from that of sarcoma, which usually begins under the skin and grows exter- nally. The axillary carcinoma is usually secondary to breast carci- noma, although in two instances the writer has seen primary carcinoma in the axillary nodes. The tumor grows rapidly, is attended by pain and cachexia, and soon gives rise to metastatic deposits. The ulcer bleeds, has an irregular edge, and is covered with a discharge. The tumor is usually situated over the sternum, and is immovably connected with the subjacent structures. The treatment of tumors involving the external surface is early excision, with removal of the nodes if the growth be malignant. The treatment of tumors of the breast is not here considered, for a full description of which the reader is referred to the chapter on Diseases of the Mammary Gland. In concluding the subject of tumors of the outer surface of the thorax the SURGERY OF THE CHEST. 835 possibility of an aneurism must be considered. The writer has seen two cases of aneurism of the innominate artery which have bored their way through the upper part of the sternum and presented themselves in the form of a tumor having the size of a child's fist. The characteristic signs of aneurism serve to distinguish this tumor from neoplasmata, and the withdrawal of pure blood by an aseptic hypo- dermic needle will establish with accuracy the diagnosis. Tumors of the mediastinum are frequently observed. Like tumors of the extrathoracic variety, they may be divided into benign and malignant. Among the former are lipoma, fibroma, enlargements of the mediastinal nodes, together with the dermoid and hydatid cysts, which are not, strictly speaking, tumors, and also the growths connected with the thymus. Among the malignant tumors may be mentioned sarcoma, carcinoma, and lymphoma. Sarcoma of the mediastinal nodes may be primary, although it often occurs as a metastatic deposit from the pleura or from the breast or from the abdominal organs. In the latter case the deposits are carried by the blood-vessels or by lymph-channels through the oesophageal opening in the diaphragm. Sarcoma may also affect the mediastinal nodes by sec- ondary deposit from sarcoma of the humerus, while sarcoma of the thigh affects but the lumbar, pelvic, and abdominal nodes. Sarcoma, unlike carcinoma, may affect simultaneously different organs and struc- tures in the body — a clinical fact to be borne in mind as a distinguishing feature from carcinoma. The signs of sarcoma of the mediastinal nodes are lancinating pain, cough, aphonia, cyanosis, dyspnoea, epistaxis, tin- nitus aurium, dysphagia, palpitation of the heart with angina pains, oedema of the cervical region due to obstruction in the venous return, dropsy of the serous cavities. Displacement of the heart also occurs, with some- times oedema of the lower extremities. If the tumor irritates the pneu- mogastric or phrenic nerves, the usual functional disturbance is present. The physical signs show a marked difference as contrasted with simple and purulent effusions in the serous cavities or with a chronic non-resolving tuberculous pneumonia. The differential diagnosis between mediastinal tumors and aneurism is often most difficult, and at times in the early stages of the respective diseases almost impossible, inasmuch as either of the two affections is capable of duplicating any of the physical signs produced by the other. Carcinoma of the mediastinal nodes presents many signs identical with those just given in connection with sarcoma. This variety of malignant disease stands first in point of frequency. The situation of the tumor is generally in the anterior mediastinum. The disease occurs in adult life, and may be primary or secondary to mammary carcinoma. The disease may originate primarily in the tracheal or bronchial nodes or in the remains of the thymus gland, from the periosteum of the posterior surface of the sternum, or in the abundant connective tissue in the anterior mediastinum. The tumor has been observed to take its origin even from the pulmonary tissue itself. The medullary variety is most frequently seen, and next the scirrhous or col- loid ; the two latter kinds, however, form only a very small percentage of the cases. The treatment of malignant tumors involving the mediastinum con- sists of removal of the neoplasmata if they are situated in accessible areas. The tumor can be excised if it presents externally by the use of the knife and Paquelin's cautery. 836 SPECIAL OR REGIONAL SURGERY. If the tumor be situated posteriorly, it can be removed by a method described by Bryant, for a full description of which the reader is re- ferred to the Transactions of the American Surgical Association for 1895. Sarcoma and carcinoma of the lung are the malignant tumors affect- ing this organ. The accompanying figure shows a typical carcinoma of the lung. The disease in this case is secondary to carcinoma of the pelvis. The diagnosis of malignant neoplasm of the lung is almost impossible in the incipient stage of the growth, since many other con- ditions at the beginning give rise to similar physical signs. The only positive means of diagnosis is by an examination of particles of the tumor which have been obtained by expectoration, as in abscess of the lung. This occurrence is extremely rare, since only four well-authenticated cases have been published. Particles of lung-tumor may be obtained for microscopical examina- tion by means of the harpoon. There are two such cases recorded. The examina- tion of the fluid in the pleural cavity has also been employed as a diagnostic test in tumor of the lung. Quincke has demonstrated that the presence of such a pleuritic effusion as hydrops adiposus points to the presence of cancer, since fatty cells seldom, if ever, are found in pure inflammatory exudations, unless occasion- ally in tuberculous effusions. Pneumotomy has been employed to remove these neoplasms. It is only when the growth is situated upon the periphery of the lung and the diagnosis is certain that operative interference is justifiable. Andrews of Chicago in 1892 exhibited to the Chicago Medical Society several pulmonary concretions which were removed by pneumotomy. Tumors affecting the pleura consist chiefly of carcinoma and endothelioma. The writer has seen one case in which the withdrawal of bloody serum twenty-four hours before death was the first evidence pointing to the malignant character of the disease. The condition was thought to be tuberculosis from the physical signs that were present, especially as the mediastinal and cervical nodes were involved. The pleura may undergo calcification, so that the membrane is rigid, and the process is similar to that involved in calcification of an artery as it is seen in plaques. Dermoid cyst of the right pleura has been observed, in which the cyst set up an empyema and had a communication with the bronchus, from which the patient coughed up hair. Lipoma has also been observed growing from the parietal layer. Tumors of the lung are seldom primary. They are usually secondary to malignant disease of the breast. Under the circumstances no operative interfe- rence is indicated. Tumors of the lung consist of carcinoma and sarcoma. The former is generally secondary to carcinoma of the breast or the mediastinal nodes. Sarcoma is also usually secondary to the disease in some other part of the body. Tumors of the thoracic, duct have been observed. These neoplasmata were secondary deposits from malignant disease of the testicle, uterus, and also the lumbar nodes. In one case of carcinoma of the duct the disease was secondary to an undescended testicle. Adenoma has been described by Chiari. Lipoma, chondroma, adenoma, and osteoma are occasionally observed. But these benign neoplasms are chiefly of pathological interest and seldom call for surgical interference. It is often verv SURGERY OF THE CHEST. 837 difficult to decide whether a primary tumor had its origin in the lung and sec- ondarily invaded the pleura, or vice versa. Gummata are found in the lung in the form of multiple globular nodules. They may exist for a long time, and if small give rise to no special disturbance. The writer recently examined lungs in which several gummata were imbedded. In a few of the nodules the caseous material in the centre had become softened and broken down, and a distinct fibrous capsule formed of plastic exudation seemed to surround the mass — a condition not usually found in gummata. The capsule was formed of fibrous tissue similar to that surrounding a blood- clot. In these nodules the three characteristic zones were visible — the outer consisting of cells, the middle formed of fibrous tissue, and an inner zone made up of caseous material. The Diaphragm. The surgery of the diaphragm can be classified according to the plan pursued in the discussion of the other viscera. The consideration of the subject embraces the congenital defects, the injuries, the disease, and, finally, the tumors. The diaphragm is a muscle which separates the thoracic from the abdominal cavities. Posteriorly the muscle is attached to the vertebral column, and laterally and anteriorly to the. thoracic walls. Upon the right side the muscle rises to a level with the third cartilage during a forced expiration, and descends to the level of the fifth intercostal space during a forced inspiration. Upon the left side the diaphragm descends to a point a little lower down. The diaphragm has been observed to ascend as high as the second rib in cases of extreme distention from intestinal tympanitis, and it has been found to descend even below the false ribs in pleuritic effusions. The muscle has a serous lining upon both its thoracic and abdominal surfaces. In the former case the pleura affords a lining, and in the latter the peritoneum. This anatomical fact serves to explain the peculiar character of the inflammatory affections of the diaphragm. The congenital defects of the diaphragm consist of fissures which permit the escape of the abdominal viscera into the thoracic cavity. The condition is rapidly fatal, since strangulation soon occurs. The accompanying figure shows a case of congenital diaphragmatic hernia in which the viscera have ascended through a fissure in the diaphragm into the thoracic cavity. Treatment by laparotomy is indicated, provided the diagnosis can be established, but as the infant dies very soon after birth, no operative treatment can be undertaken. Injuries of the diaphragm consist of gunshot wounds, stab wounds, and rupture. Gunshot wounds of the diaphragm, as well as stab wounds, present nothing of the interest which attaches to these wounds in other parts. The injury is serious, because the associated abdominal or thoracic lesions render the prognosis exceedingly fatal. Laparotomy is indicated if the diagnosis can be made approximate]} - certain. Rupture of the diaphragm is caused usually by some, form of trau- matism, by muscular action, or by the bursting of a liver-abscess. This lesion may occur with or without any corresponding injury to the integ- ument. The rupture occurs, as a rule, through the fleshy part of the muscle, and also, as. a rule, upon the left side, because the liver affords protection upon the right side. 838 SPECIAL OR REGIONAL SURGERY. The signs of rupture of the diaphragm are a rapid, irregular pulse, which is due to a disturbance of the pneumogastric nerve ; a character- istic manner of respiration, which follows an exaggerated action of the accessory thoracic muscles ; quiescence of the diaphragm during respira- tion ; a depression of the epigastric and hypochondriac regions ; severe pain and persistent vomiting, both of which are increased by hiccough or coughing. If the stomach or intestine ascends through the torn part, there is an abnormal tympanitic resonance, with a loss of the normal Fig. 356. Congenital diaphragmatic hernia {Wood Museum). respiratory murmur. If fluid is taken into the stomach, a succussion- sound is heard by auscultation. The facies denote severe internal injury. If the rupture has occurred as a result of the bursting of a liver- abscess, there have been as premonitory symptoms temperature and jaundice. Following quickly upon rupture signs of pleurisy appear. SURGERY OF THE CHEST. 839 Tympanitic resonance is heard over this area if the stomach or a coil of intes- tine have forced its way upward through the rent. The respiratory murmur is altered in consequence of the transposition of the above-named viscera. Auscultation reveals the presence of a succussion-sound after imbibition of fluid. This sign is very similar to the metallic tinkle pathognomonic of air and fluid in the pleural cavity. Shaking the patient causes the splashing of fluid in the stomach, which can be heard if the ear of the surgeon is placed at this point. Facial expression is pathognomonic, since it denotes great physical suffering. Following very soon upon these signs, those indicating the onset of pleurisy and peritonitis are observed. In only 10 per cent, of the cases is there absence of a visceral hernia. The treatment consists in an immediate laparotomy, the performance of which has been successful in at least 8 reported cases. Postempski operated in 1 case in which an omental hernia was present, the reduction of which, together with the suturing of the rent, terminated successfully. The laparotomy should be performed early, in order to avoid the dangers of the shock of a delayed operation, and also to avert an im- pending pleurisy and peritonitis. The diseases of the diaphragm are very few. The chief one is paralysis of the muscle, due to the peripheral lesion of the phrenic nerve. The diaphragm may also be affected in consequence of a dia- phragmatic pleurisy or peritonitis, or from toxic influences, such as diphtheria and lead-poisoning, or even from suppuration in the form of a subphrenic abscess, a discussion of which has already been considered. Hysteria may also cause paralysis of the diaphragm. The symptoms of paralysis of the diaphragm are loss of movement of the muscle during the respiratory act, an increase in the number of the respirations, a depression in the epigastric and hypochondriac regions, and dyspnoea. Paresis of other muscles is present if the lesion is central, and if this muscle alone is affected, the cause is due to a lesion of the phrenic nerve. The treatment of paralysis of the diaphragm consists in the administration of iron and strychnia, in galvanism, and in the use of any antidotes to a poison such as lead, or antitoxin in case of diphtheria. Tumors of the diaphragm are exceedingly rare as a primary affec- tion, although tumors affecting the viscera may cause disturbance which may even lead to rupture of the muscle. In these cases the signs indicative of rupture are present, but the onset of the symptoms are not sudden, as in rupture due to traumatism. As the symptoms develop slowly, the patient becomes more or less accustomed to the altered conditions, and the phenomena are not so well pronounced. Diaphragmatic hernia may occur in consequence of a congenital fissure or from a tear in the muscle due to traumatism. The injury may be caused by a broken rib or by muscular action. The seat of the lace- ration is nearer the posterior than the anterior part, and usually upon the left side on account of the presence of the liver upon the right side. The stomach and transverse colon are the parts usually found in the hernial sac. In addition to the traumatic variety of hernia, a spontaneous variety may occur in which the viscera enter the thoracic cavity through one of the natural openings of the diaphragm. The left side is the usual seat 840 SPECIAL OR REGIONAL SURGERY. since the liver occupies by its convex surface the vaulted part of the diaphragm. The opening is generally between the xiphoid cartilage and the costal interspaces. The symptoms of strangulated diaphragmatic hernia are those already observed in this condition, together with the presence of a tumor in the thoracic region, accompanied by the signs of dyspnoea. The treatment of diaphragmatic hernia due to injury is laparotomy, as has already been mentioned. If the hernia is due to congenital defects, no operative interference is of avail. If due to the spontaneous variety, in which the viscera ascend through one of the natural but now dilated openings, laparotomy is indicated, provided the diagnosis can be established. The (Esophagus. Malformations of the oesophagus occasionally are observed, and are due to incomplete closure of the branchial clefts. There have been about seventy-five cases reported in surgical literature. The oesophagus may be entirely absent. MacKenzie has reported 14 cases of this kind. The upper and lower part of the canal were present, and the two parts were connected with each other by a cord. In some cases a communication is observed between the trachea and the oesopha- gus to which the term tracheo-oesophageal fistula has been given. Dila- tation of the canal is observed in cases where fatty degeneration of the muscular fibres has taken place. Dilatation of the oesophagus may be localized, in which case a diver- ticulum is formed, or it may be general and involve the whole length of the canal. If the condition is not congenital, the cul-de-sac is caused by nature endeavoring to force downward food through a stricture. The pouch is thus formed by a stretching of the oesophageal walls just above the point of obstruction. Operations have been performed successfully from the neck with a view to obliterate the pouch. The cul-de-sac has been dissected away, and the wound in the oesophageal wall closed with sutures. The pouch is called a pharyngocele. The presence of the pouch is most annoying to the patient, since food often collects in it and gives rise to paroxysms of coughing, and often induces the disagreeable sensation of choking. In some rare cases death has occurred in consequence of choking. Diverticula of the oesophagus may occur by distention from within or by traction from without. The diverticulum formed from distention is usually found in the extreme upper part, and has been considered a hernial protrusion of the mucous membrane through the separated fibres of the inferior constrictor muscle. This condition presupposes some pathological changes in the walls of the oesophagus. There are between fifty and sixty cases of this kind scattered throughout sur- gical literature. In this variety of diverticulum the symptoms are not pronounced until the pouch is distended with food, which enables the patient to swallow with some degree of comfort. Vomiting, regurgitation of food, and dysphagia are com- mon symptoms. The distended diverticulum can be emptied by external manipu- lation. If this is not done, the food undergoes fermentation and the breath becomes extremely offensive. The passage of an oesophageal bougie will make clear the nature of the trouble. The sound passes into a pouch or sac in the upper part of the oesophagus and becomes arrested, while in case a stricture is present SURGERY OF THE CHEST. 841 the bougie will pass with difficulty into the stomach and the operation followed by regurgitation of bloody mucus. The obstruction is usually situated lower down, and has present many other signs characteristic of malignant disease. The traction ditvrtieuhi are seen in adhesions of tumors to the walls of the oesophagus. The development of the growth causes the canal to be pulled aside, and subsequently the walls of the canal and the neoplasm become blended in one mass. Aneurism may also pull the oesophagus to the side, and by dragging upon the walls cause a divertic- ulum to be formed. This variety of diverticulum is also observed in connection with cicatricial contraction in tuberculosis of bronchial and mediastinal nodes ; also from ulceration due to the presence of a for- eign body. In the treatment of these cases little has been accomplished by sounds, special alimentation, and gastrostomy. Recently operations have been performed with a view to excision of the diverticulum, and either closing the wound in the oesophagus with sutures or packing it and allowing it to heal by granulation. Some surgeons suture the oesophageal wound and pack the cervical wound until the danger of extravasations has passed. The treatment is substantially the same in the second variety of diverticulum, except when ulceration is present, in which case the oesophageal wound cannot be sutured. Wounds of the oesophagus occur externally in consequence of injuries, and internally by the action of sharp-pointed foreign bodies. The wounds by external injuries are caused by stab, bayonet, and pistol-shot wounds ; also in cut-throats. The wounds by internal inj uries are caused by the passage of sharp instruments and by foreign bodies. Pins, needles, and dental plates cause ulceration of the mucous membrane. In one case, the specimen of which is in the Wood Museum, a small plate of false teeth was swal- lowed by accident, and became lodged in the oesophagus and ulcerated through into the pericardium. (Esophageal probangs have injured the walls to such an extent as to cause fatal results. The treatment of the external mound of the oesophagus consists in either leaving the wound open, packing it with gauze and feeding by an oesophageal tube ; or else suturing the tear in the walls and pro- viding for drainage in the cervical wound by iodoform gauze for a few days. In the internal wounds of the oesophagus rest and nutrient enemata are indicated ; but if perforation have occurred, the conversion of the internal wound into a complete external wound and disinfection are the proper methods of treatment. In rare cases gastrostomy is called for, and the patient thus nourished a sufficient period to allow the wound in the oesophagus to heal. Rupture of the oesophagus has occurred in consequence of severe vomiting. There are about twenty-five cases reported in surgical liter- ature. It is generally believed that in these cases of rupture the mus- cular walls of the canal were rendered weak from fatty degeneration. The rent in the canal is usually a linear one and involves chiefly the mucous membrane. 842 SPECIAL OR REGIONAL SURGERY. Von Ziemssen and Zenker believe that the walls of the oesophagus are softened by excessive use of alcohol, and that the presence of softening is a necessary con- dition to rupture. Rupture of the oesophagus is attended by violent pain, following upon an attack of vomiting, usually to dislodge a foreign body. Collapse at once occurs and vomiting of blood is present. Cervical emphysema appears, and the patient dies in a few hours. If the diagnosis can be made, external cesophagotomy is the proper plan of treatment, but as yet no case has recovered. Perforation of the oesophagus from other causes than traumatism occurs as a result of peptic or other ulcers, malignant disease, foreign bodies, and from diseases connected with the mediastinum and pleura ; also from pressure of aortic aneurisms. Fig. 357. .Tack-stone lodged in oesophagus (Phelps). The treatment must necessarily vary according to the nature of the cause of perforation. An cesophagotomy is indicated for the removal of foreign bodies, and a gastrostomy for malignant disease. In case of ulcer, rest, the use of the stomach-tube or rectal feeding, are among the means to be employed. Foreign bodies may be lodged in the lower part of the pharynx near the oesophagus. At this place pieces of meat, potatoes, apples, sausage, etc. are arrested on account of their size and volume. In the tonsils and the glosso-epiglottidean fold such foreign bodies as needles, pins, small fish-bones, etc. are often lodged. In every case the pharynx should be carefully examined, since the sensations of the patients are often misleading, as they are under the impression that they have swal- lowed the foreign body, when it is still caught in the fold of mucous membrane. The opposite condition sometimes prevails, and the patient thinks the foreign body is still in the throat, when in reality it has passed into the stomach. The bruising and laceration of the mucous SURGERY OF THE CHEST. 843 membrane cause the same peculiar sensation as occurs when the body is actually impacted in the folds of mucous membrane. For these reasons it is always advisable to examine the throat carefully when- ever the accident has occurred, irrespective of the sensations of the patient. Foreign bodies are also arrested opposite the fifth cervical vertebra and thyroid cartilage, and they may even descend lower in the oesopha- gus and become lodged in the walls of the oesophagus itself or at the cardiac extremity. The signs and symptoms of foreign bodies in the oesophagus vary according to the place of lodgement. If the body is of good size and is lodged in the upper part of the tube, choking and suffocation are the prominent signs. If in the lower part, the same symptoms are present, and pain is a constant symptom. Erosion of the mucous membrane soon supervenes, and sometimes a slight hsematemesis follows. The removal of foreign bodies lodged in the oesophagus is often attended with the greatest difficulty. The nature and character of the Fig. 358. Oesophageal forceps. foreign body, its exact lodgement in the gullet, and its shape and con- sistency are points to be considered in all attempts at extraction. Richardson has demonstrated that a foreign body which is found to be 14j inches from the incisors is lodged at the cardiac end of the oesophagus ; if 9 inches below, it is behind the arch of the aorta. Any foreign body lodged 9 inches from the incisors is in a dangerous position, as Richardson has pointed out, since ulcer- ation into the vessel is imminent. Foreign bodies may be removed by instrumental means through the mouth, by external incision or ossophagotomy, and, finally, by gastrotomy. Before describing the operative measures a brief mention should be made of the employment of emetics for the purpose of dislodging any foreign body impacted in the oesophagus. As a rule, emetics for this purpose are to be con- demned, since perforation and even rupture of the oesophagus have occurred. If the foreign body have no sharp facets upon it and is small, the imbibition of food in the form of a large alimentary bolus has been recommended. This should not be done when the foreign body has sharp edges or is too large to pass through the pylorus or the ileo-csecal valve. The size of the foreign body is not so important as its shape, and also the fact whether it can be digested by the gastric juice. 844 SPECIAL OR REGIONAL SURGERY. Instrumental means through the mouth con.sist in the use of the oesoph- ageal forceps, Von Grate's coin-catcher, and Sayre's bristle or umbrella probang. Any and all of these instruments should be employed with great care, on account of the danger of perforation and rupture of the oesophagus itself, and also on account of laceration of the mucous membrane. Attention has been called by Richardson to impac- tion of the instrument itself, in which case no violence should be employed, but the removal should take place by a gastrostomy, for a description of which the student is referred to the chapter on Surgery of the Stomach. External cesophagotomy was first performed by Goursault in 1773. The mortality of the operation formerly was very small, and the results since the introduction of antiseptic surgery are most brilliant. The incision is made upon the left side of the neck and along the anterior and inner edge of the sterno-cleido-mastoid muscle just below the thyroid cartilage. The larynx and trachea are upon the inner side and vessels upon the outer side. The skin, superficial and deep layer of the fascia superficialis colli, with the platysma myoides between them, are first divided. The fascia media colli and the fascia profunda colli are next divided. The sterno-cleido-mastoid muscle should be pulled aside and the omo-hyoid muscle divided. The descendens noni nerve must be protected from injury, as well as the recurrent laryngeal, which lies in a groove between the trachea and the oesophagus. The superior and inferior thyroid arteries must also be protected from injury. A male sound can be introduced through the mouth and the wall of the oesophagus divided upon the beak. Two curved needles armed with silk can be introduced through the oesophageal wall, and the incised wound held apart by an assistant in a manner similar to that employed in the urethra during external perineal urethrotomy. The wound in the neck thus held apart by retractors and the incision in the (esophageal walls by the silk, the interior of the oesophagus is open to free inspection and instrumental manipulation. The after-treatment of the wound may be conducted by two methods. The first consists of immediate suture with catgut for the purpose of obtaining primary union. The second is by granulation, which necessitates packing the wound with iodoform gauze. Whichever method is adopted, the patient must be fed for a few days by rectal enemata, or, if by the mouth, through a soft-rubber catheter. In some cases external cesophagotomy is employed in connection with gastrostomy, and foreign bodies are dislodged by the combined method, as suggested by Richardson. Internal cesophagotomy consists of the introduction of instru- ments into the canal for the purpose of dividing strictures. The instruments employed are made after the manner of urethral instru- ments and are used in much the same way. The operation is fraught with considerable danger, and nearly 25 per cent, of the cases have died. (Esophagismus, or spasm of the oesophagus, is observed in hysteria. This condition may also arise in connection with some reflex irritation, such as oesophagitis, or ulceration of the mucous membrane of the canal. The condition has also been observed in connection with hemorrhoidal disease or associated with some functional disturbance of the liver. It has also been observed by Zenker and Ewald in brain and spinal-cord SURGERY OF THE CHEST. 845 and kidney disease ; also in neuralgia and pregnancy ; and finally in cases of inflammation of the oesophagus or stomach and in gastric ulcer. CEsophagismus differs from any organic stricture in its intermittent character. If a bougie is introduced into the oesophagus, it meets with but little resistance as compared with that arising from an organic stenosis. If food is imbibed, regurgitation j? IG . 359. occurs immediately, and, in cases of organic stricture, after an appreciable interval. The patient often complains of globus hystericus. The treatment consists of the in- troduction of the oesophageal bougie at regular intervals. In hysterical patients this operation often relieves the condition. Strychnine and iron and atropine are indicated as tonics, and food which is simple and thoroughly masticated only is to be swallowed. Sea-bathing has also been highly ex- tolled. Faradization has been em- ployed with great benefit. Stricture of the oesophagus may be due to the presence of benign or malignant tumors, to chronic oesopha- gitis, to neuroses, to congenital defects, to ulcers, to cicatrices, and to pressure from without upon the tube. Stricture of the oesophagus due to malignant disease will be considered in connection with cancer and sarcoma of the oesoph- agus. When the stricture is caused by oesophagitis or by ulcer, rest and rectal feeding are the means to be employed ; if due to hysteria, the occasional use of the oesophageal probang, with the internal administration of drugs suit- able for the cure of that disease. As to congenital defects, little can be done, as the cases usually die from inanition in a few days. If due to cicatrices, division or divulsion of the stricture is indicated, and finally if to pressure by a neoplasm or an aneurism, nothing can be done if the aneurism or neoplasm cannot be treated. The cica- tricial stricture may occur in children in consequence of the imbibition of hot soups, or in adults by swallowing caustic alkalies or acids. The dangers of oedema glottidis must be remembered in acute inflam- mation. Stricture of the oesophagus. 846 SPECIAL OR REGIONAL SURGERY. In introducing the oesophageal probang or sound the surgeon must exercise great care and gentleness, lest irreparable damage may follow. The patient should be placed upon a low, firm stool with the head thrown well back. The surgeon should stand directly in front of the patient, and with his left fore and middle fingers introduced into the patient's mouth depress the tongue, and guide the catheter or probang with the right hand along the index finger. As the instrument passes down the pharynx it should be carried a little to the right of the median line at this point, so as to avoid bringing the point against the epiglottis. When the instrument has cleared the pharynx it occa- Fig. 360. sionally impinges upon the prominence of the fifth cer- vical vertebra near the level of the thyroid cartilage. If the slightest obstruction is met with, the patient's head should now be inclined forward, and the probang will enter the stomach without any difficulty. If any stricture exists as a result of malignant disease, the caution cannot be too often repeated that the danger of perfora- tion is very great. In tubercular ulceration of the oesophagus the same warning is pertinent, since the walls are often very thin and a false and fatal passage can be made. The probang is used to detect foreign bodies and to examine for stricture. It may also be employed to relieve oesophagismus. The catheter is likewise employed for the purpose of feeding the patient in case of insanity or trismus. The soft-rubber catheter has also been used, and in some cases introduced into the stomach through the nostril. The treatment of oesophageal stenosis consists in the introduction of sounds made expressly for this pur- pose. The instruments employed for this object are pro- bangs with olive-pointed tips (Fig. 360) ; also steel bulhs, rubber bougies, and flexible hollow sounds, Whalebone guides are also used, and probangs with ivory or sponge tips. The olive-tipped probangs of various sizes are first employed in order to locate the density, the calibre, the length, and general extent of the stricture. The sur- geon should begin with a moderate-sized probang, and, finding the stricture, should change to a smaller or larger one according to the amount of resistance. Great care should be exercised lest a perforation is made, as the writer has known this accident to occur and with a fatal termination. If any shreds of tissue adhere to the instrument, which is especially the case with a sponge probang, they should be care- fully preserved and submitted to a microscopical examination. The passage of well-oiled olive-tipped probangs at regular oesophageal intervals of every few days will dilate a cicatricial stricture or bougies. even cure the spasmodic variety, coupled with internal medica- tion consisting of tonics and antispasmodics. A malignant stenosis is in no way benefited by the constant use of sounds. The use of the probang in the latter condition is limited to diagnosis. Ewald has recommended the hypodermic injection of atropia and morphia before using the sounds, with a view to relaxing the muscles and to diminishing the quantity of saliva and mucus. SURGERY OF THE CHEST. 847 The use of dilators like laminaria tents, etc., is open to serious objections, and is mentioned only to call attention to the damage which they inflict. Retrograde dilatation of strictures of the oesophagus has been performed by Richardson, Abbe, Murray, Lange, Franks, Loreta, and Schede, to the latter of whom is due the credit of suggesting this method by performing first a gastrotomy. Paralysis of the oesophagus occurs in consequence of lead-poisoning, alcoholism, and after certain infective diseases like diphtheria. The condition may also result from hysteria. Oesophageal hemorrhage occurs in connection with cirrhosis of the liver. Garland has recently reported a case in which the patient had repeated hemorrhages during a period of several years until a fatal one occurred. The source of the hemorrhage was from ruptured oesophageal veins surrounding the cardiac end of the canal. The rupture was the result of obstruction to the portal circulation. The writer has recently observed hemorrhage from the oesophagus in a case of obstructive jaun- dice with enlarged liver. The mouth and pharynx appeared perfectly normal, but the hemorrhage occurred at intervals, and finally disap- peared : but the patient quickly succumbed. McKenzie reports a fatal oesophageal hemorrhage in a boy suffering from varicose veins. Malignant disease of the oesophagus consists of sarcoma and carcinoma. These conditions are often diagnosticated by means of the cesopha- goscope, an instrument which is introduced into the pharynx and oesoph- agus for the purpose of examining the parts. The instrument can also be utilized for the purpose of detecting foreign bodies, as well as various changes in the mucous membrane which eventually give rise to stricture of the oesophagus. The oesophagoscope is used in connection with an electric light. The manipulation necessary to make a satisfactory exam- ination requires the services of one who has had considerable experience in the use of the instrument. Sarcoma of the oesophagus seldom occurs, since only about half a dozen cases have been reported. Carcinoma of the oesophagus is the malignant disease of this organ in over 90 per cent, of the cases. The variety most frequently met with is squamous epithelioma. The cardiac end of the oesophagus is the most common seat, although the disease has been found throughout the entire leDgth of the canal. The epithelioma may be secondary to carcinoma of the stomach or of the larynx or of the pharynx, or even of the tonsils. From these secondary deposits the bronchial and mediastinal nodes often become involved, also those of the trachea and liver. Epithelioma of the oesophagus is also primary, and takes its origin from the mucous membrane, which has become the seat of ulceration in con- sequence of impaction of foreign bodies, the irritation due to swallowing corrosive poisons, etc. The oesophageal canal may become perforated by ulceration, and an opening established between it and the trachea, or even into the large blood- vessels. The surrounding tissue often becomes infiltrated. Pain is a constant manifestation of malignant disease of the oesopha- gus, and its intensity increases as the disease progresses. Regurgitation of bloody mucus often follows attempts at deglutition. The shreds of tissue regurgitated should always be subjected to a microscopical exam- ination, as often a positive and early diagnosis can thus be established. Stricture of the oesophagus soon becomes a serious symptom, and in 848 SPECIAL OR REGIONAL SURGERY. some cases prevents the passage of all instruments, even though small quantities of fluids are imbibed and pass through the narrow opening. With these local .signs certain con- stitutional symptoms soon super- vene, and the patient rapidly be- comes emaciated in consequence of loss of food and the constant pres- ence of pain. Inanition is only relieved by a gastrostomy. The treatment of malignant disease of the oesophagus admits only of oesophagectomy as a radi- cal operation, the mortality of which is very great. Gastrostomy is indicated as a palliative measure in those cases in which an oesopha- gectomy is impossible. The special technique in connection with oesoph- agectomy is as follows : (Esophagectomy consists of excision of a small segment of the oesophagus for the removal of ma- lignant disease. Czerny, Park, and others have per- formed the operation on several occa- sions, but with only partial success, since patients have died a few months follow- ing the operation on account of the return of the disease. Epithelioma of oesophagus (Wood Museum). , _ . Ihe steps ot the operation are similar to those already described for external ossophagotomy, and after the segment is removed the lower open end is stitched to the cervical wound. The operation is not considered justifiable except where the segment to be removed can be reached by external cesophagotomy and no metastatic growths are present. The wound should be treated precisely as the wound following cesophagotomy, unless the segment excised is very small, in which case approximation of the ends can be accomplished. In union of the divided ends the edges must be united like the intestinal canal, and some mechanical device can be employed to help the surgeon. CHAPTER XLIV. SURGICAL DISEASES AND INJURIES OF THE MOUTH, TONGUE, TEETH, AND JAWS. By Arthur D. Bevan, M. D. Mouth. The study of the bacteriology of the mouth is of great interest to the surgeon. The relationship between mouth bacteria and local lesions of teeth and jaws and mucous membrane, of secondary gastric disturbances, and the study of the mouth as a point of infection for both local and general diseases, is a wide subject, and cannot be freely discussed in this practical text-book. Suffice it to say that normally the mouth contains scores of varieties of bacteria — more than one hundred have been iso- lated ; that these bacteria are for the most part saprophytic, but include also some common pathogenic forms, such as staphylococcus aureus and albus, pneumococcus, streptococcus pyogenes ; that many of these bac- teria have the power of producing lactic acid and decomposition of dead organic substances ; that dental caries is produced by such bacteria ; that pathogenic germs may be normal inhabitants of the mouth without injury to the individual ; that when the resisting powers of the indi- vidual or of the local tissues are lowered to a sufficient degree these pathogenic bacteria may find a favorable breeding-ground for the pro- duction of disease. The mouth furnishes a point of infection for many pathogenic germs, such as those of diphtheria, erysipelas, actinomycosis, the oi'dium albicans of thrush, tubercle bacilli, and the virus of syphilis. It is probable that some of these germs, such as that of diphtheria, may be temporary guests in the mouth-cavity without producing disease, probably finding either the local or general resisting power of individuals such as not to favor their development, and remain innocuous. Injuries of the Mouth. — The injuries of the mouth may be mechan- ical, chemical, or thermic. Mechanical injuries include incised, lacerated, and perforating wounds. They should be treated as such wounds are in any portion of the body. They demand no special discussion beyond the reminder that the mouth-cavity contains at all times saprophytic and pathogenic bacteria capable of producing infection and decomposi- tion ; because of this fact wounds about the mouth cannot be placed in an absolutely aseptic condition ; mildly antiseptic mouth-washes of boracic acid or bichloride of mercury should be frequently employed to render the cavity as nearly aseptic as possible. Burnx and xcahh of the mouth are not uncommon ; they are, as a rule, of mild degree, and demand nothing in the way of treatment except mild antiseptic mouth- washes. Extensive burns of the lips and the tissues of the face and neck result sometimes in great deformity of the mouth from cicatricial 54 849 850 SPECIAL OR REGIONAL SURGERY. contraction, and require extensive operations for its correction. Chem- ical injuries result usually from the drinking of strong acids or alkalies. If the case is seen soon after the accident, a neutralizing agent, such as soda or vinegar, should be at once applied. The further treatment will be the use of a borax mouth- wash. Chemical injuries of the mouth due to chronic poisoning by mercury, lead, and phosphorus will be discussed under the subject of Injuries and Diseases of the Jaws. Congenital Defects. The subject of hare-lip is discussed in the chapter on the Surgery of the Face. Cleft palate is a congenital condition, as already explained, due to a failure of closure of the maxillary processes. Defects of palate struc- ture may result from trauma or disease, and demand the same surgical interference. Congenital eleft palate may involve both the hard and the Fro. 362. Whitehead's mouth-gag (Dennis). soft palate, or but one of these structures ; as a rule, both the hard and the soft palate are involved, and hare-lip also exists. The cleft in the soft palate is in the median line ; that of the hard palate, when single, is a little to one side, and when double presents itself as a wide central cleft. The malformation seriously affects the function of speech, giving a peculiar nasal character to the speech characteristic of the difficulty. The alteration of the normal speech may be so great as to make the speech almost unintelligible except to those accustomed to the individual. This deformity has in some cases a marked effect on the life of its unhappy possessors, sometimes driving them to seclusion. In addition to the interference with speech, the cleft permits of the passage of food from the mouth to the nasal cavity, causing irritation and odor from the decomposition of the retained food-masses. Thrush often occurs in children with cleft palate. The problem presented by these cleft-palate cases is the closure of the defect so as to correct the speech and prevent the passage of food and drink from the mouth to the nasal cavity. This can be done in two ways — by a plastic operation with the purpose of closing the opening, or by an artificial obturator. Both of these SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 851 methods have their advocates, some surgeons advocating the one method to the exclusion of the other. The author believes that both have their use, and should be employed according to the individual case : the arti- ficial obturator finds its special field of usefulness in acquired palate defects, the plastic operation in congenital cleft palate. Operations for closure of cleft palate are divided into uranoplasty, the closure of the hard palate, and daphylorntphy, the closure of the soft palate. The question as to how long after birth should the defects be closed is an open one. Many surgeons take the ground that hare-lip should be operated upon some time between the third and fifth months, and cleft palate left to the seventh or eighth year. There is a growing tendency to operate very early in these cases, within the first year of life, and there are many arguments to support this view Fig. 363. — the fact that the defect in such a case is corrected before the child begins to talk, and the fact that in children who have learned to talk the closure of the defect does not, as a rule, improve the speech. The argument against operating in very early life is the difficulty of ma- nipulation in very small mouths, the greater danger to the patient, and the fact that at seven or eight the after-treatment can be easier carried out than in an infant. The operation for cleft of the soft palate is done in the following way : The child is anaesthetized, placed in the hanging-head position — i. e, with the body on the table and the head hanging over the edge : this position is the best for the purpose of preventing the passage of blood into the trachea ; the teeth are held apart by a Whitehead gag ; the corners of the mouth held apart with elastic retractors. The edges of the cleft are freshened by a narrow-bladed knife in such a way as to Retractors for lipe or mouth, with elastic hand (Konig). Fig. 364. Staphylorrhaphy, sutures placed (Konig). make a broad surface, more tissue being removed from the mouth side than from the nasal or pharynx side. The edges of the cleft are brought together by means of silver wire, silk, or silkworm-gut sutures, placed 852 SPECIAL OR REGIONAL SURGERY. accurately and closely together, and lastly a myotomy of the tensor palati, and if need be of the palato-glossns and pharyngeus, is made with a teno- tome — if there be much tension ; dividing the tissue of the soft palate from the centre of each horizontal plate of the palate bone downward and outward to almost the free edge of the soft palate. In case no tension exists, this myotomy can be omitted ; the stitches are allowed to remain eight or ten days. In many cases the entire line of aj3proxima- tion will be found to have united ; in others, however, failure at one or more points may occur, necessitating a second operation, or, when the defect is slight, it may heal by granulation or be assisted by touching with silver-nitrate stick or fine platinum cautery. The operation for closure of the hard palate — uranoplasty — requires anassthesia, hanging-head posi- tion, Whitehead's mouth-gag, and retractors, the same as staphylorrhaphy. The margins of the cleft are freshened as in closure of soft-palate defect. An incision is then made through the mucous membrane and periosteum close to the alveolar processes and parallel with the cleft; the periosteum is ele- vated from the bone ; and the flap, consisting of mucous membrane and periosteum, is widely freed, so that the edges of the cleft can be ap- proximated without tension. The approxi- mation should be accurate, and the sutures employed should be silver wire or silkworm gut. Silk, however, can be employed, or even catgut, the latter, of course, having the ad- vantage of not requiring removal, but it is not thoroughly reliable. The sutures can be placed by means of a fine full-curved needle and needle-holder. The defect on the bone is uranopiasty-showing incisions covered by granulation, and the periosteum in (Tillmanns). in -n 1 i i the flap usually produces bone, closing the cleft eventually with bone-tissue. ( Vide also Appendix to this chapter.) The after-treatment requires considerable attention ; a liquid diet is imperative. In some cases it is advisable to introduce a soft-rubber tube into the (esophagus and feed the patient in this way. The mouth should be kept as clean as possible by mild antiseptic mouth-washes of borax. The patient, if old enough, is cau- tioned not to speak or attempt to speak. The late after-treatment consists of a prolonged and diligent effort on the part of the patient, assisted by instruction, to correct the cleft-palate speech. Much can be accomplished by intelligent and per- sistent training in this direction, but still the peculiarity of speech is seldom fully overcome. The use of artificial obturators instead of operative procedures has much to recommend it. Work of this kind is largely in the hands of dental surgeons, who are more competent than the general surgeon to make and apply the rubber plates required. Acquired defects of either the hard or the soft palate can be corrected in the same way as con- genital ones. The time to undertake such operations is of course after the pathological processes producing such defects have ceased to be active. Syphilis is a common cause of palatal defects : in such cases operation should be delayed until some months after the disappearance of the last SURGICAL DISEASES AXD INJURIES OF THE MOUTH, ETC. 853 symptom of such disease, and after an active and prolonged course of iodides and mixed treatment. Traumatism is a rare cause of acquired palate defects, and in those cases the operative repair should be either immediate or after the complete wound healing, and all disappearance of wound infection has taken place. When acquired defects are too large to be closed by plastic operation, the artificial obturator should be employed. ( Vide also Appendix to this chapter.) Fig. 366. Acute Inflammatory Processes in the Mouth. Stomatitis catarrhalis is a simple catarrhal condition resulting from irritation of the mucous membrane from mechanical, chemical, or my- cotic causes. It presents the symp- toms of a desquamating catarrhal condition. Its treatment should be the removal of the cause wherever pos- sible, as, when the condition depends on decayed and neglected teeth, the removal or filling and cleansing of the teeth and the use of some simplo and non-irritating antiseptic wash, such as boric acid. Stomatitis ulcerosa may fol- low simple catarrhal stomatitis or thrush, or may follow a severe and protracted illness or the lowering of the vitality of the tissues of the mouth from poisoning by mercury, phosphorus, lead, and copper. The character of stomatitis ulcerosa will differ with its cause. Its treatment will be the removal of the cause wherever possible ; general and local treatment for the condition are at times required, the general being directed to the improvement of the resisting powers of the individual, and the local consisting of application of silver nitrate in stick or in strong solution to the ulcers, and the use of mild antiseptic mouth-washes. Noma is a peculiar mycotic gangrene of the tissue of the cheek and jaws occurring in illy-nourished children, living, as a rule, under bad hygienic conditions, and usually during or after an attack of one of the infectious fevers. The probable pathology of the condition is that it is not a disease produced by a specific microbe, but that a greatly lowered vitality, such as follows the infectious fevers in children living under extremely bad hygienic conditions, may enable the normal microbe inhabitants of the mouth to invade the tissues of the cheek and jaws, and produce a rapidly-spreading gangrene, and later general septic infection. The disease is rare in America. The DIAGNOSIS does not present difficulties when the disease is well established : an early diagnosis is desirable, and should be followed by energetic local treatment, the destruction of the invaded tissue with Destruction of cheek, the result of cancrum oris (A. McL. Tiffany, Amer. Syat. of Dent., vol. iii.). 854 SPECIAL OR REGIONAL SURGERY. nitric acid or actual cautery, and the use of continuous mild antiseptic dressings and washes; general treatment should be directed to the support and stimulation of the little patient by properly selected food and alcoholic stimulants. The prog- nosis is grave ; the great majority of the patients die. Those who survive present the disfigurations due to loss of tissue and the resulting cicatricial contractions. Extensive plastic operations are required for correcting deformities resulting from noma — flaps being taken from the face or neck and turned into the defect in the cheek, the raw surface from which the flap is taken being closed by sutures or covered by skin-grafts. ( Vide Chapter V.) Epithelioma of the lower lip is a very common surgical lesion ; the upper is seldom involved. It occurs with much greater frequency in men than in women. This difference is attributed largely to the use of tobacco. A good deal of evidence seems to support this theory, as tobacco is one of the chronic irritants, like soot and paraffin, that seem to play some part in the production or localization of carcinoma. The picture of epithelioma of the lower lip is so typical that when the stu- dent has seen several cases the condition is readily recognized. The age of the patient is of value ; the presence of induration, scab-forma- tion, ulceration, the length of time the lesion has existed, all aid in the diagnosis. Primary syphilis might be mistaken for carcinoma. Wherever a question exists as to diagnosis, resort to the microscope should be made. The treatment is that of carcinoma elsewhere — removal of neo- plasm and adjacent tissue widely, and where there is evidence of lymphatic-node involvement these structures should be as widely as possible removed. In epithelioma of the lower lip the submaxillary and sublingual salivary glands are often involved, and when involved should be removed. The prognosis of carcinoma of the lip is that of carcinoma else- where. When the lesion is limited to the tissues first involved, and Fig. 367. Cheiloplastic operation on lower lip (Tillmanns). there is no regional or general infection, it is possible to obtain a per- manent cure by complete removal of the diseased tissue ; but whenever the nearest group of lymphatic nodes are involved, even microscopically, recurrence after removal, or rather a continuation of growth of the car- cinoma cells remaining, goes on unchecked by the operation. There has been a persistent effort made within the last few years by surgeons in various specialties to improve the prognosis in carcinoma, and this has led to the publication of conflicting statistics, some surgeons claiming as high as 25 or 30 per cent, of permanent cures, or rather cases which have had no recurrence for SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 855 three years after the operation. Most of these very favorable statistics are the result of juggling, the reporters being dishonest, at least with themselves. Perma- nent cure after operation for carcinoma is not common ; and such cures, at present at least, form but a small percentage of cases, probably 10 per cent., and are to be looked for, not in the extensive operations demanding wide removal and removal of adjoining lymphatics, but in the early simple cases, where a V-shaped incision of the lower lip will remove all the carcinomatous tissue (Fig. 367). The Tongue. Congenital malformations of the tongue present themselves most commonly as a very much shortened frcenum, tongue-tie, or a growing together of the floor of the mouth and under surface of the tongue. The condition of tongue-tie seldom needs surgical interference, al- though the frsenum is often divided unnecessarily by physicians in children who are backward in learning to talk. Sometimes, however, the frsenum is so short as to interfere with the functions of the tongue and demands division. The operation is a simple one, and consists of division of the frsenum with curved scissors, care being taken to avoid injury to the ranine arteries, which run parallel to the frsenum on either side, covered simply by the mucous membrane. Another malfor- mation is a very long frsenum, permitting the tongue to fall backward against the epiglottis. Cases of suffocation in children have been reported from this cause. A rare malformation is that of bifid tongue. An abnormally large or long tongue or abnormally small tongue, or even total absence of the tongue, occurs as a congenital defect. Injuries of the tongue may result from mechanical, chemical, or thermic causes. The mechanical injuries present themselves as incised, lacerated, and penetrating wounds. Lacerated wounds occur often from biting the tongue in epileptic attacks — from falls upon the face with some foreign body, as a pipe, in the mouth. Wounds of the tongue may be serious from division of some large arterial branch, and may require ligation of the vessels at the site of injury, or ligation of the lingual artery at the point of election immediately above the hyoid bone. Extensive wounds of the tongue should be handled as wounds elsewhere : the hemorrhage should be controlled, the tissue made as aseptic as possible, and the edges accurately united with catgut stitches. The after-treatment should consist of mild antiseptic mouth-washes. The fact that local infection may extend to the tissue of the floor of the mouth, and even to the pharynx and larynx, the latter sometimes resulting in oedema of the larynx and demanding tracheotomy, should be borne in mind. Chemical injuries of the tongue may result from the drinking of acids and alkalies. The treatment required has been outlined in similar injuries of the mucous membrane of the mouth. Burns result from the accidental drinking of very hot liquids ; as a rule, they are not severe and require as treatment a mild antiseptic mouth-wash. Acute inflammatory lesions include acute inflammation of the mucous membrane and acute inflammation of the deeper tissues of the tongue and the floor of the mouth. Acute inflammations of the mucous membrane are usually coexistent with stomatitis, and due to the same causes and require the same treatment. 856 SPECIAL OR REGIONAL SURGERY. Acute inflammation of the deeper tissues of the tongue, acute paren- chymatous glossitis, may result from injury or be secondary to some lesion of the mucous membrane, or it may appear without the occurrence of a recognized injury. It may be limited to one side of the tongue. Usually, however, it involves both lateral halves. The symptoms are those of swelling, sometimes extensive ; pain and dryness of the surface ; and constitutional symptoms varying in degree, but often marked; the inflammation may extend to the floor of the mouth and to the epiglottis and larynx ; suppuration may result ; when pus forms it should be early recognized and evacuated by free incision. In making the incision care should be taken to avoid the large vessels, and if the pus-accumulation is deep, the best plan to pursue is that adopted by Hilton in deep cervical abscess — i. e. the division of the mucous membrane with the scalpel, and then bore into the deeper tissues with a closed artery-forceps until the pus-cavity is reached. The blades of the forceps are then opened and with- drawn in this position, making in this way free drainage with the least possible danger to the vessels and nerves of the part. When the inflammatory process has extended to the floor of the mouth it may result in the condition described by Ludwig, and known as Ludwig's angina. This condition may result from an acute glossitis, but is more commonly the result of infection extending from the teeth or jaw, or may make its appearance as a primary condition without any other known injury or pathological condition. It is an acute inflamma- tory affection of the tissues of the floor of the mouth, involving especi- ally the fibrous tissue. It may or may not go on to suppuration ; the dangers are general infection and oedema of larynx. Early in these cases the treatment should be hot aseptic poultices externally and antiseptic mouth-washes. If the infiltration is extreme, free incision, both externally and internally, is required, after the Hilton method, and if pus-formation occurs free drainage in the same way. The danger of cedema of the larynx may usually in this way be avoided, but if urgent dyspnoea presents itself, a tracheotomy should be prepared for and not too long delayed. The oedema of the larynx may come on rapidly. The author has seen one case in which this condition came on and resulted fatally within a few hours after the first symptoms presented themselves. Granulomata of the tongue include tuberculosis, syphilis, and actinomycosis. Tuberculosis of the tongue as a primary affection is rare. It occurs usually in cases of general tuberculosis. When primary the diagnosis is difficult, and the case may be mistaken for carcinoma or syphilis. Sometimes the bacilli of tuberculosis can be found in the scrapings of the ulcer, but this is not the rule. Syphilis can be eliminated by the use of large doses of iodide. The lesion appears, as a rule, as a chronic ulcer with mouse-gnawed edges and covered with a gray membrane. The question of diagnosis between carcinoma and tuberculosis is often difficult. The peculiar mouse- gnawed edges of the ulcer, the fact that the margins are not as indurated as in carcinoma, the presence of small tubercles in the immediate vicinity of the lesion, and the removal of a small section and its histo- logical examination will, as a rule, determine the diagnosis. In cases of advanced general tuberculosis, tongue-tuberculosis should receive palliative treatment, the occasional application of silver nitrate, the use of an antiseptic mouth-wash. In cases of primary tongue-tuberculosis SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 857 very radical treatment should be employed — the removal of the entire lesion and the healthy tissues some distance beyond, either with knife or cautery. The prognosis in such cases, not only for the cure of the local lesion, but the prevention of general infection, is good. Caseating tubercular foci may appear in the tongue as in the mam- mary gland — may be single or multiple. Their treatment, when simply an evidence of general tuberculosis, should be palliative or incision and removal of tubercular granulation- tissue with sharp spoon ; when primary, wide and radical removal. Syphilis of the tongue is common. It may present itself in several forms, either the primary lesion of syphilis or the mucous patches of secondary syphilis or gumma, which may break down and form a deep syphilitic ulcer ; or, lastly, syphilitic warts of the tongue. The primary lesion of syphilis is not common ; it is not often diagnosed early because of its occurrence in such an unusual locality. It presents the character- istics of hard chancre, usually single, indurated base, sloping edges, slight dis- charge, resulting adenitis. In questionable cases treatment should be delayed until the diagnosis is made certain by the appearance of secondary symptoms. The other forms of syphilis are, as a rule, readily recognized, and should be sub- mitted to antisyphilitic treatment of iodide of potash and mercury, and local treatment of silver nitrate and antiseptics ; best, boric-acid mouth-washes. Syph- ilitic condylomata can be removed, but the general and local treatment as outlined above should be instituted. Actinomycosis of the tongue is a rare lesion. The condition may present itself as a hard mass of granulation tissue, or later, after soften- ing, as an ulcer or cold abscess. The benign tumors of the tongue include ncevi, which are common, dermoid, lipoma, papilloma, fibroma, and enchondroma. In this connec- tion we may well discuss the matter of retention-cysts of the small mucous glands about the tongue and the rather confused subject of ranula. Ncevi of the tongue may be divided into arterial, venous, or capillary, accord- ing to the preponderance of one or the other systems of blood-vessels involved. Yiq. 368. They are, as a rule, congenital, and often present themselves as very small tumors at birth, which may grow rapidly and involve a large portion of the tongue, and even extend beyond the limits of that organ. They are to be treated as neevi elsewhere — when possible by clean excision ; when not, by ligation or the use of galvano-eautery needles. A lesion somewhat resembling nsevi is the condition of macroglossia, which is due to an hypertrophy of the lymph-vessels. Cases of macroglossia Maorogio'sHI (Tiiimanns). grow sometimes to great size. (See Chapter XXIX.) They demand operative relief, excision of the redundant portion, and accurate flap-formation and suture to manu- facture a tongue of the tissue allowed to remain. The other forms of 858 SPECIAL OR REGIONAL SURGERY. benign tumor — dermoid cyst, lipoma, enchondroma, fibroma, etc. — are to be treated by removal. Retention-cysts of the tongue are common, those occurring in the floor of the mouth being grouped under the name ranula. The most common is a cyst formed by retention in the gland of Nuhn on the side of the frsenum. Similar clinical pictures are presented by retention- cysts of the ducts of Wharton or of Rivinus. The diagnosis is, as a rule, not difficult, but may be mistaken for a dermoid in the floor of the mouth. Usually the cyst-wall is thin, trans- parent, and the cyst filled with clear fluid. The best treatment is to dissect out the entire cyst-wall, which can, as a rule, be done. When this is not possible, a large section of the cyst-wall should be snipped out with scissors and the cavity packed with gauze, and a permanent opening obtained, or the cyst-wall remain- ing can be destroyed by the cautery. Dermoid cysts in the floor of the mouth, when small and superficial, should be dissected out by an intra- oral operation ; when large and deeply seated, an external dissection is to be preferred. The tongue is often the seat of primary epithelioma. The lesion occurs much more frequently in men than in women, and, like carci- noma elsewhere, is a disease of advanced middle life and old age. It is probable that the use of tobacco is an etiological factor in the develop- ment of tongue-carcinoma : cicatricial tissue, the result of chronic lesions and benign growths, such as papilloma, sometimes becomes the seat of carcinoma. The cancerous growth begins, as a rule, on the tip or sides of the tongue, and consists in the majority of cases of flat epithelial cells. It rarely begins in the epithelium of the glands of the tongue. The diagnosis is made from the induration, the chronicity of the lesion, the age of the patient, and by the exclusion of the granulomatous lesions, of syphilis, tuberculosis, and actinomycosis. The disease may appear as a warty growth, an ulcer, or as a fissure. In all forms the characteristic hardness of carcinoma is present. In advanced cases the diagnosis is easily made from the clinical picture. In lesions seen early it may be impossible from the clinical evidence above to make a diagnosis. In such cases syphilis should be excluded by antisyphilitic treatment, and the question of the pathology of the process established before radical ope- ration by a removal of a part of the growth, and a careful histological examina- tion. An early and accurate diagnosis is of the greatest importance. Every warty growth or persistent ulcer or fissure of the tongue, especially in individuals beyond forty, should be regarded with suspicion, and its benignant or malignant character determined by the most careful analysis of the case, resort being made to the removal and microscopical examination of the tissue where a positive diagnosis can- not be arrived at by other means. A primary carcinoma of the tongue is followed later by regional involvement of the submaxillary lymphatic nodes and cervical lymphatics — by the involvement of the surrounding structures, the submaxillary gland, the sublingual gland, the tissues at the floor of the mouth, the fauces, and even the inferior maxilla. In advanced cases the condition of the patient is most pitiable: severe pain, interference with speech, mastication, and deglutition, pro- found carcinomatous cachexia, gradual exhaustion, septic infection, hemorrhage, complete the clinical picture. The prognosis is grave, both from the standpoint of possibility of cure and the life-expectancy of the individual. Cases live from one to two years after the beginning of the disease. Return after even early and radical operations is the rule; probably not 10 per cent, of cases of SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 859 carcinoma of the tongue are alive and free from recurrence three years after radical operation. The treatment of carcinoma of the tongue is simply stated : early and radical removal in operable cases ; the euthanasia of morphine andcleansing mouth-washes are advisable in the inoperable cases, with possibly the added resection of the lingual nerve to relieve the excruci- ating pain which is an almost constant accompaniment; and proximal ligation of the lingual artery to control hemorrhage and to retard the rapidity of the growth. Orthoform used locally will also give great relief. * The operative treatment involves either the partial or complete removal of the tongue and draining lymph-nodes. In small lesions removal of the involved area and the apparently normal tissue wide of the disease should be the treatment. In lesions distinctly limited to one side, all of that side should be removed. In advanced cases and cases involving both sides the operation of complete extirpation of the tongue and adjoining lymphatics should be carried out. Partial excision of the tongue can be, and should be, made as an intraoral operation ; a preliminary ligation of the lingual just above the hyoid bone can be made, but is usually not necessary. The mouth is thoroughly cleansed and made as aseptic as possible. The patient is anesthetized ; a mouth-gag is inserted between the teeth and widely opened ; the tongue is drawn well out of the mouth with a stout silk suture passed through the tips or with volsellum forceps. If the lesion involves the tip, after division of the frsenum a V-shaped segment, in- cluding the carcinoma, is removed, the hemorrhage controlled by catgut ligatures, and the lines of incision approximated by sutures. When the carcinoma is limited to one-half of the tongue, after division of the frsenum the tongue is split into two halves with scissors through the comparatively non-vascular raphe. The diseased half is removed with scissors, the hemorrhage controlled with clamp-forceps, the larger vessels are ligated, and the parenchyma- tous oozing is controlled by the deeply applied sutures employed to approximate the mucous membrane. The same result may be obtained by removal with gal- vano-cautery wire or 6craseur. Clean removal with scissors and careful ligation is to be preferred to either ecraseur or cautery. Complete extirpation of the tongue should be made through the floor of the mouth as an external operation, after the method of Kocher, of Regnoli, or of Billroth. Kocher's Operation. — An incision is made from the symphysis of the jaw downward in the median line to the body of the hyoid, then along the body and great cornu of the hyoid, and then from the tip of the great cornu to the mastoid process. This flap is dissected upward, the facial vein and artery ligated. The submaxillary gland is either turned upward with the flap or removed. All lymphatic nodes are extirpated. The mylo-hyoid muscle is separated from its attachment to the inferior maxilla, the mucous membrane of the mouth divided, and the tongue drawn out through the incision. The entire organ is then under direct control, and can be either completely or partially removed. If the entire tongue is to be removed, the lingual artery of the opposite side is ligated before the division of the lingual mass. A preliminary trache- otomy is desirable in cases of extensive involvement, but is not always necessary. After the introduction of the tracheotomy-tube the pharynx is tamponed with sponge or gauze to which a strong silk ligature is attached to facilitate its removal. The tongue can be removed either 860 SPECIAL OR REGIONAL SURGERY. Fig. 369. by cautery, ecraseur, or scissors. The latter is to be preferred, great care being taken to ligate each bleeding point. The wound is packed with iodoform gauze ; the tracheotomy-tube may be removed at once or allowed to remain a number of days. The patient is fed with a stomach-tube ; the external wound is not closed, but allowed to heal by granulation. The dangers of the operation are hemorrhage, sepsis, and aspiration pneu- monia. The mortality to be looked for in uncomplicated cases of extirpation of tongue is about 5 per cent. Kocher's own cases included a number of complicated cases which resulted in 20 deaths in 104 opera- tions. The operation of Kocher's is to be pre- ferred to the other external operations of Regnoli, Billroth, v. Langenbeck, and Sedillot, which, however, are of sufficient interest and value to warrant a brief description. The Billroth operation consists of a transverse incision below the symphysis, joined by two incisions, one on either side and parallel to the body of the jaw, extending to the great cornu of the hyoid bone. The skin and superficial fascia are first divided ; then the mylo-hyoid, the genio-hyoid, and the genio-hyoglossus muscles are separated from their attachment to the lower jaw ; the mucous mem- brane at the floor of the mouth is divided, and the tongue drawn through the external incision and the extirpation proceeded with. The Regnoli operation, of which Billroth's operation is a modification and improvement, consists of practically the same procedure by a different external incision. An excision is made in the middle line extending from the symphysis to the body of the hyoid bone. This is joined by two lateral incisions extending from the symphysis parallel with the lower jaw to the attachment of the masseter muscle. The operations of Sedillot and v. Langenbeck involve the division of the lower jaw, an undesirable complication. Such a procedure maybe required in extensive operative removal of the tongue and contiguous structures, such as the fauces and tonsil, but, as a rule, the same result can be accomplished by the Kocher operation. Lines of incision for total excision of the tongue (Chalot). Jaws and Teeth. Congenital Malformations of the Jaws and Teeth. — The com- mon malformation of the upper jaw called cleft palate has been dis- cussed in connection with the surgery of the mouth ; other rare malfor- mations are arrest of development of one side of the upper or lower jaw or failure of union of the two halves of the lower jaw. Such conditions are not amenable to surgical treatment. Malformations of the teeth are common. They present themselves as excessive development of a tooth or a part of a tooth, either the enamel or the fang, or lack of develop- ment of a single tooth. An amalgamation of two or more teeth into a single mass ; the development of a tooth in an abnormal position, as in the tissues of the hard palate ; the projection of a tooth in an abnormal direction ; the absence of a number of teeth — this condition may exist as a total absence, edentulous jaws resulting ; the presence of an ex- cessive number of teeth, three sets of teeth having been often reported, SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 861 though few of these cases are credited. The formation of a tooth-tumor, an odontoma, from the embryonic tooth-tissue is to be regarded as a con- genital abnormality. Most of these malformations are treated by dental surgeons ; the general surgeon, however, should be familiar with such conditions, because some of the tooth-malformations present themselves as obscure conditions in patients applying for diagnosis and treatment. A tooth which has failed to erupt may lie as an encapsulated foreign body Fig. 370. Misplaced and imprisoned tooth (Forget). for years, and then become the focus for infection and abscess and result- ing sinus, or, surrounded by granulation-tissue, may be mistaken for malignant growth. Diseases of the teeth and alveolar processes and gums include a discussion of dental caries, resulting pulpitis, infection of nerve-canals, and alveolar abscess. The subject of dental caries has been much discussed, and many theories have been advanced to explain the condition. The following is its explanation : Many bacteria of the mouth have the power of producing lactic acid. Lactic acid dissolves out the inorganic elements of a tooth ; it has little effect upon normal enamel, but acts rapidly upon den- tine. A crack in the enamel as well as congenital defects favor this process. After a decalcification has been brought about, the organic tissue remaining is readily destroyed by the saprophytic bacteria of the mouth. This destruction may extend to the pulp-cavity ; as soon as the pulp-cavity is uncovered it becomes infected and sooner or later is destroyed. The infection may travel down a nerve- canal and infect the tissue of the alveolar process and gums, the periosteum, or the jaw itself. As a rule, the infection is limited, forming a small alveolar abscess or gum-boil, but the infection may be extensive and even result in general septictemia pyaemia, or death. A common result of alveolar abscess is a sinus leading from the root of the tooth through the alveolar process and opening on the mucous membrane. In? TREATMENT of dental caries is the removal of the carious structure and the filling of the cavity with gold, cement, or amalgam. This treatment is very satisfactory, and has been developed by American dentists to a high degree of technical perfection. When infection of the pulp-cavity has occurred the tooth can be saved by a destruction of the pulp with arsenic or other chemical agents the removal of the pulp, the thorough sterilization of the pulp-cavity and nerve- canal, and filling the cavity with gold or amalgam. It is, however, difficult to thoroughly disinfect the pulp-cavitv and nerve-canal, and as a result many of the 862 SPECIAL OR REGIONAL SURGERY. Fig. 371. teeth in which the nerve has been killed have a small suppurating sinus leading from the root to the mucous membrane. Alveolar abscesses, if small and superficial, usually open without assistance from the surgeon. When deeply seated they are exceedingly painful, the pain being produced by the retained inflammatory secretions. The pus burrows through the alveolar process ; as soon as the diagnosis of alveolar abscess is made, the tooth, if worthless, should be extracted. This affords free drainage and immediate relief. If it is not desirable to extract the tooth, an early incision should be made and free drainage for the in- flammatory products obtained. When a large alveolar abscess forms and points toward the integument, even though fluctuation can be clearly made out from external palpation, still the abscess should always be incised within the mouth-cavity in order to avoid the disfiguring and retracted scars which often result where the abscess opens on the face. Gingivitis, or inflammation of the gums, may result from a number of causes, local and constitutional. Pyorrhoea alveolaris, mercu- rial gingivitis, scorbutic gingivitis, lead gingi- vitis, and phosphorus gingivitis are known. When the disease is due to purely local causes, as tartar on the teeth and uncleanliness, the cure can be brought about by the removal of the cause. When mercury is the cause, the treatment would demand a discontinuance of mild antiseptic mouth-washes. In cases of scurvy and lead-poisoning the cause should be removed and proper general treatment and locally mild antiseptic washes should be advo- cated. Extraction of the teeth is to-day not considered a part of general surgery, but a knowledge of a few general principles may prove of value. The operation has been already described. Acute inflammatory processes of the jaws include periostitis and osteomyelitis, and resulting necrosis. The most common cause of such lesions is infection of the alveolar process from a carious tooth or from fracture. Osteomyelitis of the jaws may occur as a primary condition from infection from the circulation, as occurs in osteomyelitis of the tibia, but this form is rare. Osteomyelitis sometimes follows the acute infections diseases, as scarlet fever, small-pox, typhoid fever, measles, etc. (See Chapter XIV.) Other causes are mercurial poisoning and phosphorus-poisoning. The alveolar process is alone involved, as a rule, in pus-infection from a tooth caries ; sometimes, however, the entire thickness of the jaw may become involved. The treatment is free and early incision to afford drainage for the inflammatory products, and later, if necrosis results, sequestrotomy. The periosteum should be preserved when possible, for in the history of Chronic alveolar abscess at the root of a lower incisor: a, abscess-cavity in the bone ; l) t fistula discharging on the gum ; c, lip ; d, tooth (G. V. Black, M. JD., Ama: Syst. of Dent, vol. i.). the drug, and localh SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 863 these cases, even when the entire thickness of the jaw is removed, a serviceable jaw is reproduced from the periosteum remaining. Necrosis from mercurial and phosphorus-poisoning is now, fortunately, rare, because of the smaller doses and less frequent use of mercury as a drug, and because the improved methods of manufacturing matches, at least in America, protects the employes better from the phosphorus fumes, and the weekly examinations of the mouths of match-workers now in vogue in American match-factories reveals the condition in its incipiency, so that the patient is saved from serious phosphorism, either by being compelled to give up his employment or by proper hygiene of his mouth. The PATHOLOGY of phosphorus-necrosis is of interest. Chronic phos- phorus-poisoning produces an ossificating periostitis ; small osteophytes form in the periosteum of the alveolar process. This condition so lowers the vitality of the jaw-tissues, gums, periosteum, and bone that the normal bacteria of the mouth can invade the tissue and produce infection. Empyema of the Antrum. — As a secondary lesion resulting from inflammatory lesions of the teeth and bone structure of the upper jaw we find empyema of the antrum of Highmore. This condition may also be secondary to inflammatory lesions in the nasal cavity. The symptoms of empyema of the antrum are pain and swelling, discharge of pus, either through a fistula in the mouth or into the nasal cavity, where an exit for pus is present. When there is no exit the accumulation may distend the thin wall of the antrum and appear as a prominence in the mouth or on the face, or, by pushing up the floor of the orbit, produce a protrusion of the globe of the eye. When empyema of the antrum is due to diseased teeth or bone structure, these causes should be removed ; free drainage should be obtained, either through the mouth or nasal cavity. Where a diseased upper molar is the cause, after removal of the tooth a free opening may be found leading from the root-socket into the antrum, or, if a free opening does not exist, with a perforator the antrum may be opened and drained with a silver or rubber tube. The drainage may be made in the thin wall of the antrum just above the alveolar process, the thin bone being readily perforated at this point, or we may employ the method of Mikulicz of boring through the external wall of the nasal cavity below the inferior turbinated and making a permanent free opening between the nasal cavity and antrum. Park urges free opening into the antrum through its external thin wall, made from the mouth, so as to permit of digital exploration of its entire cavity. The jaw is a favorite seat of that rare lesion actinomycosis, or at least, if not the bone itself, the soft parts in contact with the bone are involved. Its common occurrence at this point in cattle has given to the disease its popular name of lumpy jaw. (Chapter IX.) The disease maybe mistaken for sarcoma. When pus exists it sometimes contains the small yellow bodies characteristic of actino- mycotic pus. The diagnosis is settled by a histological examination of the tissue. The treatment is removal of the granulation-tissue and the internal use of iodide of potassium. Diseases of the inferior maxillary articulation of surgical interest are especially those conditions followed by partial or complete ankylosis of the joint. These are acute conditions, such as acute arthritis following injury, infectious diseases, as typhoid fever, small-pox, etc., acute rheu- matism, gonorrhoeal rheumatism, etc., or inflammation extending from the teeth or jaws to the joints. The author has seen two cases of pseudo-ankylosis result from the irritation of the eruption of a wisdom tooth. Chronic lesions also, as arthritis deformans and tuberculosis and lastly cicatricial contractions following burns, noma, and injuries, result later in ankylosis. The condition of complete ankylosis is one very difficult to rectify. In cases of pseudo-ankylosis, opening the jaws under anaesthesia, and later the daily use of a mouth-gag to pry 864 SPECIAL OR REGIONAL SURGERY. the jaws apart either by the patient or the surgeon, may bring about a cure. In cases of complete ankylosis a false joint must be made by an excision of the condyloid and, when necessary, coronoid processes. When complete ankylosis is complicated with extensive cicatricial con- traction of the soft tissues, an extensive plastic operation is required. The results after operation for complete ankylosis are not, as a rule, satisfactory. A peculiar condition of relaxation of the teniporo-maxillary ligaments is occasionally met with, which permits of frequent subluxation of the joint. This occurs with a snapping sound usually during eating — is unnoticed by the patient himself, but not by others. It is painless, harmless, and not amenable to treat- ment. Tumors of the jaws include osteoma, odontoma, fibroma, chondroma, sarcoma, carcinoma, mixed tumors, as fibro-myxoma, and cysts. The vague term epulis given to tumors springing from the alveolar pro- cesses, and usually fibroma or sarcoma, has nothing of value to warrant its retention in a scientific classification of jaw tumors, and should be discarded. Resection of the Jaws. Resection of the lower jaw may be demanded for necrosis, for granu- lomata, as tuberculosis and actinomycosis, and for tumors. The excision Fig. 372. Resection of superior maxilla (Farabeuf). may be 'partial or complete — may demand the removal of one lateral half of the jaw or of the horseshoe-shaped body. The technique of remov- ing one half of the lower jaw is as follows : An incision is begun at the symphysis a little below the bone and carried along the lower border of the body to the angle, then upward along the posterior border of the ramus to the condyloid process. The facial artery and vein are ligated SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 865 and divided in front of the masseter muscle. The attachments of the masseter are divided ; the periosteum at the line of the symphysis is divided vertically and the jaw divided in the same line with a saw. The attachments of the mylo-hyoid and genio-hyoid and genio-hyoglossus muscles to the inner surface of the jaw are separated, care being taken to control the hemorrhage as the operation proceeds. The attachment of the mucous membrane of the mouth to the gums is divided. The attachment of the external and internal pterygoid muscles, the division of the inferior dental nerve and vessels, the division of the temporal and buccinator, allow of a free exposure of the temporo-maxillary joints, the division of the ligaments, and the removal of the bone. Great care should be taken in working at the upper angle of the wound not to injure the facial nerve, the internal maxillary artery, and Sten- son's duct. In resection of a portion of the lower jaw for necrosis care should be taken to preserve the periosteum. In resections for neoplasms this is not, as a rule, possible. Resection of the upper jaw is a more formidable operation. The hemorrhage is, as a rule, great, and in cases of complete resection and in extensive resections for tumors it is often advisable to make a pre- liminary tracheotomy, tampon the pharynx, and continue the anaesthetic through the tracheotomy-tube in order to prevent the blood flowing back into the larynx. The operation can be done in the hanging-head position or in the sit- ting position under mixed partial ansesthesia. In extensive operations preliminary tracheotomy and operation under complete ansesthesia is to be preferred. A great number of incisions have been devised for the operation of resection of the upper jaw. The operation know as the Fergusson operation is, as a rule to be preferred. (See Fig. 372.) The upper lip is split in the middle; the excision is then continued along the margin of the anterior nares, the wing of the nose the lateral margin of the nose to beneath the inner angle of the eye, then along' the lower margin of the orbit to its lower and external angle ; this excision extends to the periosteum ; the flap is dissected up from the bone and reflected downward and outward; all hemorrhage is checked. The superior maxilla is then separated from the other bones of the face, a chain saw or keyhole saw or a large pair of bone-forceps or chisel may be employed. The malar, which is composed of com- pact tissue, is best divided with a saw; the palate process can be divided with large bone-forceps; the nasal process of the superior maxilla can be divided with forceps or chisel ; the orbital process with chisel or bone-forceps ; the attachments of the bone behind to the palate bone and the attachment of the palate to the pterygoid process of the sphenoid are best separated by grasping the mass of bone after the separation above referred to has been completed in a large pair of bone- i° i n A force P s and listing out the entire mass. The hemorrhage is free and should be controlled by pressure, forceps, and ligature. Great care should be taken to ligate every bleeding point. The wound is packed with iodoform gauze and external incision closed. The dangers of the operation are sepsis and hemor- rhage and aspiration pneumonia. Many other methods of making the external incision have been employed : such as those of Velpeau and Langenbeck but the operation of Fergusson is to be preferred. Partial resections are more often required than complete resections • removal of the alveolar process can be completed as an intraoral opera- tion by removal of the teeth, exposing the alveolar process with knife and penosteotom, and removal of the alveolar process with chisel or bone-forceps. Temporary resection is sometimes performed as an initial 866 SPECIAL OR REGIONAL SURGERY. step in removing the second division of the fifth nerve or in the removal of a naso-pharyngeal tumor. Fig. 373. Resection of inferior maxilla (Farabeuf ). In making an osteoplastic resection of the upper jaw the opera- tion of Langenbeck is to be preferred. A tongue-shaped flap of the soft parts and the bone between the hard palate and the floor of the orbit is raised and turned inward, the soft parts being allowed to remain attached to the bone after the operation, for which the preliminary osteoplastic operation is made, has been completed, the flap of bone and soft tissues is replaced and held in position by deep and skin sutures. APPENDIX. EARLY OPERATIONS FOR THE CLOSURE OP CLEFT PALATE. By Truman W. Beophy, M. D., D. D. S. Operations for the closure of cleft palate should be performed in early infancy. In making this statement I fully realize that my views are not in accord with those of many distinguished surgeons, but clinical SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 867 experience has demonstrated that what I presented to the profession a few years ago as a theory in regard to palate operations has become a well-established practice. It is well known that many infants which are born with this defect die within a short time after birth when the cleft is of a marked character. Tait says that one-half of the children born with extensive clefts die from starvation within a few days after birth. In this complication of hare-lip with cleft palate the practice has almost invariably been to operate upon the lip, and allow the fissure of the palate to remain unclosed. This, in my opinion, is a mistake. The palate should be first operated upon, for various reasons : 1. The fissure of the lip enables the operator to gain a little more room in which to work. 2. The closure of the palate is an operation attended with great diffi- culties in its performance ; besides, the closure of the cleft through the alveolar process, if it exists, may be more surely accomplished when fully exposed to view through the divided lip than when covered as it would be subsequent to the closure of the lip. It is unnecessary to say that the bones are soft and will easily yield in early infancy. The tissues unite kindly, and the shock following the operation is not so great if performed within the first month as it would be later in childhood. It is a well-known fact that the nervous system of a child is not so well developed in early infancy as it is later ; hence one of the advantages of performing this ope- ration before the nervous system has developed to a point which would subject the child to a more severe shock. The operation, therefore, should be performed as soon as the functions of the organs of the body are well established. This may be within the first week or any time within the first month. 3. After the operation the child will be better nourished. 4. If performed in early infancy the muscles of the palate will be brought into action and will be developed, whereas if the mus- cles are not thus put into use they will atrophy, and later it will be found, as is often the case, that there is insufficient tissue to restore the palate to its normal form. It is scarcely necessary to state that muscu- lar tissue which is not subject to action and use will not develop nor- mally. 5. One of the most important reasons why we should operate in early infancy is, that the parts operated upon early not only develop well, but the child when arriving at the age when articulation in the form of speech is attempted finds that he can speak as other children do, and does not acquire the habit of articulating through the nasal passage, which is characteristic of this deformity, for the nasal accent when once acquired cannot be easily corrected. Fissures or clefts of the palate are almost invariably accompanied with pharyngitis. 6. Before the calcification of the bone is far advanced, and also before eruption of the teeth, the operation on the hard palate can be more easily and successfully accomplished ; if made subsequent to the eruption of the teeth, it is always attended with more difficulty and the Tesults are less satisfactory. The operation is as follows : Introduce the oral speculum and vivify the edges of the fissure ; do it thoroughly. A mere scraping of the mucous membrane will never suffice to bring about union which will be permanent and satisfactory. On the hard palate trim well the opposing surfaces of the bone. If this be well done, it will secure a 868 SPECIAL OR REGIONAL SURGERY. sufficient exudate to make the operation a successful one in this respect. The knife will easily cut through the soft bone of the hard palate and the alveolar process of young patients. Then raise the cheek, and well back toward the posterior extremity of the hard palate, just back of the malar process, and high enough to escape all danger of not being above the palatal plate of the bone, insert a large braided silk suture, carrying it through the substance of the bone, so that it will come out at a cor- responding position upon the opposite side. It is often difficult to pass the suture through to the opposite side, and under such circumstances the needle, with eye in point, may be carried from the buccal surface of the bone to the median line, the stitch taken up with a tenaculum, and then the needle inserted from the opposite side, the thread then to be united and carried through. The silk suture is more easily introduced by the needle, but a wire suture of silver should be substituted for it and drawn through in its place, and this wire may be doubled in case the condition of the parts and the tension upon the tissues necessary to approximate them seem to require it. Nearer the front portion of the palate insert another wire, carrying it through the substance of the bone above the palatal plates, and out through the other side in a position corresponding to the place of entrance. Thus we shall have one wire passing over the palate in front of the malar process of the bone and another behind it. The next step is to take a lead button, moulded to fit the convexity Fig. 374. Manner of placing sutures. No. 2 shows gain in closing defect after cutting malar process. of the part, and long enough to pass beyond the exit of the wire sutures, so that they will pass through it. Have it provided with eye-holes, through which are passed the protruded ends of the wires upon each SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 869 side, and then twisted. These are heavy tension sutures, and once approximated the parts cannot be separated by the patient. If we are unable to close the fissure with these wires, if from lack of tissue or from firm resistance of the parts it cannot be done, there is a further method to be employed which will obviate these difficulties. After the cheek is well raised divide the mucous membrane just over the malar process. Here insert a knife in a horizontal direction, and when well inserted sweep the handle around from one side to the other, as from behind forward. In this way a maximum amount of bone is divided and a minimum amount of the mucous membrane. This done on each side, the bone can very readily be moved toward the middle line. Having thus divided the bones upon either side, the wire sutures pass- ing through the lead buttons may again be twisted, and the cleft of the hard palate will be easily closed by approximation of the two sides. The incision in the mucous membrane in making the separation of the bones should be as small as possible, for the reason that this membrane must serve to retain the bones in proximity or to hold them nearly together. If, after the parts are approximated, they are kept antiseptically clean, the bones will kindly unite and the palate will be restored, so that its full function will be performed. Separation of the bones is attended with little hemorrhage, and the parts do not usually cause more inconvenience to the patient than the ordinary operation of lifting the hard palate according to the practice of Fergusson. The germs of the teeth are sometimes disturbed, as I have found later, when they were erupted, that certain teeth were imperfectly formed. This applies to the molars of the temporary set, but the germs of the permanent teeth may also be disturbed, and the teeth made imperfect by this procedure ; but the dental defects are of little import- ance when offset by the benefits of being relieved of so great a deformity. The palate, too, may be contracted to an abnormal extent ; and yet it is a well-known fact that the alveolar process develops with the erup- tion of the teeth, and my experience has convinced me that in mouths thus treated the upper teeth when they erupt opposed in a normal way those of the lower jaw. If, however, the superior arch should be abnormally contracted, the means well known to the modern dentist may be employed to widen it. After the approximation of the edges in the manner I have described the parts should be thoroughly dried, the edges of the wound carefully examined, and if need be some fine sutures inserted here and there to ensure perfect coaptation of the parts. The after-treatment is very simple, consisting solely in antiseptic clean- liness, nourishing of the patient upon liquid food, the prevention of disturbance of the parts by the child, or of the introduction into the mouth of anything that might interfere with the sutures. Abrasions of the mucous membrane caused by the buttons need not disturb the operator, for they are usually slight. A New Method of Closing the Soft Palate. The difficulties attending the closure of the soft palate may be, to a very great extent, overcome by making use of the method which I here illustrate. Delicacy of the tissues and the tendency of the sutures to cut out suggested to me that a modification of the quill suture, long ago introduced, would aid us materially in retaining the sutures and preventing their cutting out after performing the operation of staph- ylorrhaphy. 870 SPECIAL OR REGIONAL SURGERY. Inasmuch as lead is tolerated so well by the tissues, I have employed it for this purpose. The first drawing (Fig. 375) will show cleft of the soft palate, the fissure extending through the palatal plates of the maxillary bones. After the edges of the cleft are well freshened, a properly formed needle, curved after the fashion of the gynecologist's needle, is em- ployed with which to introduce silk sutures, four of which are carried through the tissues, as shown by the drawing, and these are substituted by rather strong silver sutures ; then the lead plates are perforated with Fig. 375. Staphylorrhaphy : sutures in position. holes corresponding to the number of four sutures, shaped so as to extend from the anterior margin of the fissure back to the distal border of the soft palate, and bent to conform to its shape. The wire sutures are then passed through the holes, as shown by the drawings, and twisted together. Tension is thereby exerted upon the divided portions of the palate and their edges are approximated. Should it become necessary, as is often the case, to divide the bones along the border of the hard palate nearest to the molar teeth, this may be done by the use of a strong scalpel or chisel, and then the lead plates are easily brought toward each other, together with the tissues that they embrace. In certain cases the elevation of the soft parts, together with the perios- teum, may serve our purpose quite as well : this can be accomplished by means of a properly bow-shaped periosteotome. After the edges of the plate have been approximated by twisting the wire sutures to- gether, as shown by the drawing (Fig. 376), fine silk sutures may then SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 871 be employed with which to hold the approximated edges in close contact and secure immediate union. Fig. 376. Staphylorrhaphy : sutures and lead plates in position. The advantages claimed for this method of procedure are — 1. The prevention of the cutting out of the sutures, since the lead plates com- ing in contact with the soft palate exert pressure thereon, and the ten- sion, therefore, is not made by the suture alone, which exerts pressure on so limited a space, but it is upon the entire length of the palate covered by the lead plates. 2. The lead plates serve as a splint, ren- dering the palate inflexible to a very great extent. The movements, which are almost constant, are suspended ; the active muscles are put out of use until union of the cleft may take place. In conclusion, after using this method of closing the soft palate I feel confident that better results in a certain number of cases can be secured than by the employment of sutures alone. This is not to take the place of the operation of dividing the bones at the malar process and carrying the greater portion of the maxillary bones together, but it is adapted to the treatment of patients whose bones are well ossified and whose deciduous teeth are well erupted. It is in such cases that I recommend this operation. CHAPTER XLV. SURGERY OF THE ABDOMEN. By Maueice H. Richardson, M. D., ASSISTED BY FABBAB COBB, M. D. Injuries and Wounds of the Abdomen. Contusions of the abdominal 'wall may cause hernia, hemorrhage, lacerations, and ruptures of muscles and aponeuroses. Ventral hernia from this cause is unusual. The inguinal, the femoral, or the umbilical rings may give way as the result of direct blows, though powerful reflex contractions of the abdominal wall are a more common cause of hernia. (See Hernia.) Circumscribed hcematomata and extravasations of blood between the layers of the abdominal muscles occur most frequently in the flanks, where they may attain great size. Extensive hemorrhage results in circumscribed or diffused haematomata which present characteristic signs. Unaccompanied by sepsis, even the largest haematomata are rapidly absorbed, and require no treatment beyond rest and cooling applications. Increasing in size from persistent bleeding, they may require incision, ligation of vessels, or gauze- packing. When sepsis supervenes thorough drainage is demanded. If the serum of a hsematoma is withdrawn by aspiration, excessive care is necessary to prevent infection. Prom blows ■without penetration the abdominal viscera are fre- quently the seat of more or less serious lesions. The hollow viscera are liable to rupture with extravasation ; the solid, to fracture with hemor- rhage. Lacerations of the omentum or of the mesentery cause, if anything, hemorrhage. After abdominal contusions the earliest pos- sible recognition of extravasation or of hemorrhage is demanded. The exact seat, nature, and extent of the lesion can be determined only by surgical exploration. Rupture of the hollow viscera, with extravasation, is marked, as a rule, by the symptoms of localized or of general peritonitis ; rupture of other viscera, by the signs of hemorrhage. Intestinal extravasation after a blow is attended by pain, tenderness, vomiting, and distention ; the abdominal muscles are rigid, the resonance tympanitic. When gas has escaped freely into the peritoneal cavity, its presence between the upper surface of the liver and the diaphragm usually masks by tympanites the liver dulness. The signs of extensive abdominal hemorrhage are faint- ness, pallor, rapid and feeble pulse, restlessness, sweating, shallow respi- ration, thirst, and cold extremities. Large amounts of blood in the abdominal cavity will cause dulness in the flanks. In slight hemorrhages pain and faintness are transitory, though the shock is generally out of 87S SURGERY OF THE ABDOMEN. 873 proportion to the amount of blood lost. A local tumor may exist, though it may not always be detected. Retroperitoneal hemorrhages may cause a prominence, with ill-defined resistance deep in the abdominal cavity. Rupture of the Stomach. — Ruptures of the stomach, owing to the thickness of its walls and the tendency of the mucous membrane to evert, are not ordinarily followed by so rapid or so extensive a perito- nitis as rupture of the intestine. In perforations of the posterior wall the infection, usually confined to the lesser omental cavity, results in subphrenic abscess. Perforations in the anterior wall, especially when the stomach is full, are more liable to be attended by extensive extrav- asation and general peritonitis. After a blow upon the epigastrium pain in that region, with vomiting, tenderness, and muscular rigidity, indicates rupture of the stomach. Hrematemesis shows that the stomach is at least lacerated. The symptoms of subphrenic abscess following such a history are dependent upon rupture of the posterior wall. The edges of the wound in rupture of the stomach should be carefully inverted and sutured. If the lesion is in the anterior wall, this is comparatively easy ; if in the posterior, difficult, sometimes even impossible. Extensive lacerations may require the infolding of large areas. In case satisfactory closure of wounds in either surface is impossible, gauze should be packed about the gastric opening and brought out of the abdominal incision. This method ensures rapid adhesion- formation and efficient drainage. Hemorrhage should be controlled by means of ligatures or of gauze tamponage. Rupture of the Intestine. — When the intestinal wall is torn, the extravasation is usually so rapid as to produce immediately a general and fatal peritonitis, especially if the intestine is filled with gas and liquid fieces. When the intestinal contents are solid, as is generally the case below the ileo-caecal valve, the extravasation may be slight and limited, and the patient often recovers spontaneously. When the perforation is small, eversion of the mucous membrane may limit the extravasation to a localized infection or even prevent it entirely. Diagnosis. — If the initial pain and tenderness are about or below the umbilicus, and the symptoms are rapidly progressive and gas is free in the abdominal cavity, it is more likely that the intestine rather than the stomach is the seat of rupture ; if in the epigastrium, with moderate peritonitis and early vomiting, especially if the vomitus contains blood, in the stomach i-ather than in the intestine. Extensive and rapid extrav- asations from either stomach or intestines, unaccompanied by ha?matem- esis, can be differentiated only by the seat of the initial pain. At times a clear discrimination is impossible. TREATMENT. — When intestinal rupture is suspected the incision should be made in the median line, either above or below the umbilicus according to the preponderance of symptoms. A region of extreme ten- derness, an area of dulness, or a tumor may at times indicate the precise line of incision. The escape of turbid serum, of gas, or of fecal matter the moment the peritoneum is opened proves the existence of some serious complication. The seat of the lesion can be found at times only by examining the whole intestinal tract. It is important, therefore to have an incision sufficiently long to permit efficient examination. The distention usually present in these cases makes thorough inspection with- out complete evisceration at times impossible. Extensive exposure of 874 SPECIAL OR REGIONAL SURGERY. the intestines, however, adds gravely to the shock. Exploration should therefore be made with as little exposure as possible, and as rapidly as is consistent with thoroughness. Rupture of the healthy gall-bladder in some instances causes no symptoms beyond those of transitory pain and shock ; in others the con- tents of the inflamed and distended gall-bladder are sufficiently septic to cause a rapid general infection. In the former the lesion can be only suspected ; in the latter it may be evident. Peritonitis from this cause is seldom so fulminating as in ruptures of the intestinal canal. The pain is situated at first in the region of the gall-bladder ; later it becomes general. When rupture of the gall-bladder is suspected, surgical exploration is demanded. The rent in the gall-bladder should if possible be sutured ; if this be impracticable, temporary drainage by means of a tube or of gauze may be used as in cholecystot- omy. The extravasated bile should be removed as thoroughly as possible. Rupture of the spleen, the pancreas, or the liver is usually attended by signs of hemorrhage, with pain referred to the seat of lesion. Gen- eral peritonitis rarely complicates this accident : septic processes in these viscera are, as a rule, limited to abscess. For serious hemorrhage inter- ference is demanded ; for slight, rest and palliative measures. The prognosis in ruptures of abdominal viscera is usually serious. Intestinal extravasations are generally rapidly fatal. Rupture of the stomach results more favorably after interference than rupture of the intestines. Simple hemorrhages, extensive enough to produce serious exsanguination, are in themselves grave accidents. Hemorrhages of even moderate extent, complicated by septic extravasations, usually result in a fatal infection. In retroperitoneal hemorrhage the source of the blood is obscured by the infiltration of the connective tissue. It is best not to make pro- longed attempts to find the bleeding point, but to control by means of gauze tamponage. The loss of blood may be so moderate as to cause few if any symptoms, or it may be so extensive as threaten life. In penetrating' wounds of the abdomen, usually caused by gun- shots or by stabs and cuts, the abdominal wall may be the seat of extensive hemorrhagic infiltration or the source of rapid external bleeding. The tendency of a completely divided artery is to contract and to curl up ; when this occurs deep in the abdominal wall the arterial stream may be directed backward into the abdominal cavity, and the latter filled with blood before the truth is even suspected. Such an accident has hap- pened after cutting the deep epigastric artery in the course of operations near the inguinal ring. The epigastric artery may be injured also by the use of cutting needles in sewing up abdominal wounds. Prolapse, more or less complete, of the omentum, the intestines, the stomach, the spleen, the pancreas, the liver, or even the kidney, may take place through incised wounds of the abdominal wall. At times evisceration may be extensive. The omen- tum of all the abdominal viscera is most likely to escape. The accident occurs not infrequently from separation of an abdominal wound, caused by coughing, straining, etc. after or even before the removal of the sutures. In the treatment of wounds of the abdominal wall it is important first to discover and to check a concealed hemorrhage. The presence of an SURGERY OF THE ABDOMEN. 875 external hemorrhage is always conspicuous ; its treatment obvious. The wound itself should be carefully cleansed and sutured if it is evident, on careful examination, that no injury has been done the abdominal vis- cera. Wounds clearly septic should" be drained by means of a strand of gauze. Prolapsed viscera should be carefully cleansed, and if unin- jured replaced. The wound may be sutured immediately unless sepsis is feared. When the abdominal cavity has been penetrated the wound should be enlarged sufficiently to permit satisfactory demonstration of the condition of the intra-abdominal organs. The treatment requires exploration in all cases. Hemorrhage must be treated by ligation, tamponage, or, in extreme cases, excision of the organ (spleen, pancreas, or kidney) if that is possible. Extrava- sations, intestinal, gastric, urinary, biliary, and pancreatic, require repair of the rent, or, if that is impossible, drainage, with general peri- toneal cleansing. Intestinal coils too extensively cut for repair or necrotic from injured blood-supply require excision. Gunshot wounds of the abdominal viscera have an importance far greater than incised or stab wounds. The lesions are more severe, their complications more frequent, their results more disastrous. Gunshot wounds of modern civil life are chiefly produced by revolvers of moderate dimensions, carrying missiles of .22, .32, .38, rarely .44 calibre. Abdominal gunshot wounds are usually homicidal and accidental rather than suicidal. For the study of gunshot wounds of battle the reader is referred to works on military surgery. Treatment. — In gunshot wounds involving the abdominal cavity exploration by laparotomy is always indicated in the first hours ; after an interval of six hours or more without symptoms of either hemor- rhage or peritonitis the treatment may be expectant. In other words, all gunshot wounds in which injury to the abdominal viscera may have occurred demand exploration if seen immediately. Symptoms appear- ing late — localized peritonitis and abscess — should be treated by explo- ration, incision, and drainage. (See Peritonitis.) A gunshot wound of the abdomen, when seen directly after infliction or within an hour or two, demands immediate investigation whatever the symptoms. The wound of entrance must be explored under complete anaesthesia. If it appear that the missile has been deflected from the peritoneum, an antiseptic pad to the wound of entrance will suffice. If penetration of the abdominal cavity has taken place, either the wound must be enlarged or an incision must be made over the viscus most probably involved. In doubtful cases is required a median incision, even if the wound of entrance is remote. When the line of flight is toward or even across the centre of the abdomen, that incision should be selected which permits the most efficient exploration of the whole abdominal cavity. Serious lesions must be treated according to their situation and character — hemorrhage by ligation of vessels or by gauze tamponage ; intestinal, gastric, gall-bladder, and urinary-bladder rents by suture. (See Rupture of Stomach and Intestine, and Hemorrhage.) If the hemorrhage have ceased, the blood in the abdominal cavity should be thoroughly removed. 876 SPECIAL OR REGIONAL SURGERY. Intestinal extravasation requires most thorough investigation and repair. Every wound must be sutured with extreme care ; coils too badly lacerated for suture may require excision with suture, anastomosis, or artificial anus. (See Operations on Intestine.) In extreme cases the injured bowel may be sutured temporarily into the abdominal wound. Inasmuch as the intestinal perforations may be multiple, and some of them hard to find, inflation of the gut through the anus with hydro- gen (Senn), with air, or with fluid may be employed to demonstrate the integrity of the bowel-wall. Gunshot wounds of the abdomen of some hours' standing require exploration if symptoms of persistent hemorrhage or of peritonitis exist. For hemorrhage the usual methods of treatment should be applied ; for peritonitis the treatment of peritonitis (g. v.). Intestinal perforations must be closed and the peritoneal cavity cleansed. Surgery op the Stomach. Congenital Malformations of the Stomach. — The stomach may be transposed ; it may be abnormally small. Atresia of the pylorus has been observed, usually associated with hypertrophy of the muscular Avails of the stomach ; also hour-glass constrictions unaccompanied by signs of previous disease. Surgical interference is demanded but rarely in these conditions. Ulcer of the stomach has recently acquired surgical importance from the encouraging results which have followed prompt intervention in hemorrhage and in perforation, lesions previously regarded, if not necessarily fatal, as beyond relief. Ulcer of the stomach occurs usually in young girls, though it may appear in both sexes at any age. The direct cause of ulcer is ischcemic necrosis of a circum- scribed area of the gastric wall, due to diminished vascular supply, the etiology of which is obscure. The ulcers are usually single and small, and are situated most frequently near the pylorus, along the lesser curvature. They may be exten- sive or multiple, however, and involve other portions of the stomach. The shape is usually that of a truncated cone, the base of which is toward the interior of the stomach. The local necrosis is followed by digestion of the necrotic tissues. In the course of the digestive and gangrenous process an artery of considerable size, such as the gastric, may be eroded and cause alarming hemorrhage. Symptoms and Course. — Gastric ulcer may give rise to no symp- toms whatever until sudden perforation or hemorrhage occurs. In other cases epigastric pain and discomfort suggest the lesion. The usual symptoms are gastric irritation and discomfort, with more or less pain. Vomiting after eating sometimes occurs. The pain is boring in character, and is often referred to the back : hemorrhage causes either vomiting of blood, usually bright in color, or tarry stools. Continual persistent hemorrhage produces a characteristic waxy anaemia. The most important symptoms surgically are those of hemorrhage and of perfora- tion. In perforations guarded by adhesions no symptoms, except those of the ulcer itself or of local peritonitis, are usually present. Perforations into the abdominal cavity cause the symptoms of a general peri- toneal infection. (See General Peritonitis.) Occasionally, as the result of perfo- ration, abdominal abscess, pyothorax, subphrenic abscess, abscess of the pancreas and spleen, with or without perforation of the diaphragm, are observed. (See Subphrenic Abscess. Treatment. — Surgical intervention in gastric ulcer is indicated — (1) SURGERY OF THE ABDOMEN. 877 in the symptoms of rapid and dangerous hemorrhage ; (2) in the anmnia caused by the persistent, slow loss of blood ; (3) in perforations with general extravasation ; and (4) in localized peritonitis with abscess. The exploratory incision made in the median line may be extended transversely in case the stomach is contracted or small. The anterior surface and the lesser curvature, where the lesion is most apt to occur, should be examined first. By separating the layers of the lesser omen- tum most of the posterior wall of the stomach can be examined, dig- itally or visually. Inflammation of the peritoneum frequently shows the seat of the ulcer. In some instances the lesion can be detected by the sense of touch. The seat and extent of the ulcer having been de- termined, the disease may be treated (1) by infolding the whole ulcer- uniting the peritoneum around the ulcer to the abdominal wound ; (4) by walling off the ulcer from the general peritoneal cavity with sterile gauze. The choice of methods depends upon the symptoms which indicate interference — whether from hemorrhage or from perforation. For perforations, infolding, excision, suture to the wound, or gauze packing may be practised, according to the size, shape, and situation of the lesion ; for hemorrhage, all the methods except infolding. (1) Infolding consists in uniting the lax walls of the stomach over the affected area, which is deeply depressed for this purpose by the fingers or by an instrument. The peritoneum is united by means of continuous or interrupted Lembert sutures. (2) Excision and suture are applicable in both hemorrhage and perforation. The tissues should be freely excised beyond the limits of the disease, and the wound closed by inverting the peritoneum with a continuous or an interrupted stitch. The direction of closure must depend upon the size and shape of the resulting wound. (3) Suture to the abdominal wound is to be resorted to when the gap resulting from excision is such that closure of the stomach is impossible or in cases in which excision is for some reason impossible. (4) Packing with gauze remains as the only resort in case neither suture of the stomach nor approximation to the abdominal wound is possible. Ulcers in the posterior wall may require this method of treatment. If hemorrhage into the stomach is alarming, the stomach should be opened so as to give a clear view of the field. The bleeding surface may then be ligated or cauterized. If an artery of considerable size is bleeding, a thread may be passed under it by means of a curved needle and tied. The stomach wound may then be closed or it may be united to the ventral cut. Localized peritonitis with abscess should be treated by incision and drainage. Perforations guarded by adhesions may result in gastric fistulse. (See Gastric Fistulse.) Subphrenic abscess may arise from any cause by which the lesser cavity of the omentum or the under surface of the diaphragm becomes infected. The most common cause is the perforation of a gastric or duodenal ulcer ; more rarely extension of infective perforations of the vermiform appendix or of the gall-bladder. Subphrenic abscess either makes its way to the surface by adhesions or it breaks into the peri- toneal or into the pleural cavity. Adhesions to the diaphragm, especi- ally on the left side, may cause rupture into the pleural cavity or into the pericardium. A pyo-pneumothorax without other cause should suggest the possibility of direct infection through the perforation of gastric ulcer or indirect through the rupture of a subphrenic abscess. 878 SPECIAL OR REGIONAL SURGERY. Gastric fistulse result usually from the perforation of gastric ulcers through the anterior wall of the stomach and of the abdomen. They may be caused, however, by direct injuries to the stomach or by the presence of foreign bodies. Internal fistulse result from perforations into contiguous portions of the alimentary tract. The latter rarely give rise to symptoms. Gastric fistulse, like intestinal, usually heal spontaneously. Such as do not by themselves close under cleanliness and stimulation may be treated by nitrate of silver, the actual cautery, mechanical approxima- tion by means of straps or crepe lisse, or by resection of the sinus, with suture. New Growths of the Stomach. — Though carcinoma is by far the most important neoplasm of the stomach, sarcomata, adenomata, and myo-jibromata have been observed. The last three, from their rarity, have little surgical importance, though one or two large sarcomata and one adenoma have been removed from the stomach-wall. Cancer of the Stomach. — Cancer is more frequently seen in the stomach than in almost any other part of the body. It is usually of the scirrhous variety, and is a disease of adult or advanced years. Cancer is situated usually at the pylorus, less frequently at the cardia, and least frequently in the main body of the stomach. Cancer situated at the pylorus often causes stricture with dilatation of the stomach. The infection of lymph-nodes appears late, if at all. Symptoms. — The first symptoms of cancer of the stomach are dis- turbances of digestion, generally associated with constipation. Pain is next observed, sharp in character and aggravated by food, with vomit- ing after eating, gradual loss of weight, and cachexia. The vomitus often contains digested blood resembling coffee-grounds. Free hydro- chloric acid in the gastric juice may be diminished or wanting in exten- sive gastric cancer. Too much reliance must not be placed upon this symptom, because hydrochloric acid may be diminished or absent in certain other diseases, and because, even if present in normal amounts, gastric cancer may nevertheless exist. The tumor of gastric cancer is often imperceptible, especially in the early stages, when radical operative extirpation is possible. When con- spicuous, the tumor is usually situated at the pylorus or in the anterior wall. Situated in the posterior wall or near the cardia, it cannot, unless very large, be detected by palpation. The tumor of gastric cancer is usually hard and tender ; it may be smooth or nodulated, globular and sharply defined, or a flattened oval and gradually merging into the surrounding structures. It may be superficial and extensively mobile or firmly and deeply fixed. At times the tumor will be found with extensive contig- uous metastases. The relation of the tumor to the stomach can usually be deter- mined by the aid of lavage, inflation, or by the use of the gastro-diaphanoscope. Cancer-cells can sometimes be detected in the vomitus or in the washings. Brr»- tation of the stomach, often to an extensive degree, due to pyloric obstruction, is usually present. The chief points of difference between ulcer and cancer of the stomach are as fol- lows : Cancer occurs usually at or after adult life, ulcer in late youth. Pain, usually present in cancer, is sharp, referred to the shoulder, and increased by food ; that of ulcer, boring through the back, relieved by food. Blood vomited in ulcer is usually fresh and bright ; in cancer it resembles coffee-grounds. In cancer there usually is a tumor; in ulcer, none. The symptoms of ulcer often extend over a long period of time without affecting markedly the weight, general NUIWl'MY OF THE ABDOMEN. 879 appearance, (ir si Ton^t h ; cancer, 11 progressive disease of comparatively short duration, ulloi'ts curly and profoundly flic constitution. In ulcer the cachexia is usually tlmf of loss of blood — a distinct amrmia; in cancer, even with the loss of blood, it is conspicuously the cachexia of malignancy. Free hydrochloric acid is diminished or absent in cancer; It is increased in ulcer. Tlvc surgical TisuATMNNT of (•iiiici'i' of the pylorus is either radical or palliative. Pyloric stenosis requires cither i':i(lii':i.l excision of the disease with suture, or anastomosis between the stoniaeh and (lie jeju- num. Perforations with extravasation may require immediate inter- ference and repair unless the patient's chances of life are, from the advanced condition of the disease, necessarily too small to make sur- gical intervention worth while. Hemorrhage is rarely severe enough to demand operation. Even if extensive, the wisdom of surgical inter- vention may well he questioned. When palliation and medical treat- ment are unsuccessful, the shock of operative measures is not likely to he safely borne by an exsanguinated patient. Stricture of the Pylorus. — The causes of pyloric stricture are — (1) Congenital malformations; ("J) Cicatricial contraction of ulcers; (.'!) Malignant and benign tumors; (I) Twists at or near the pylorus; (;">) External pressure from growths ; ((i) Spastic contractions. Conijcnital atremi, though very rare, has been observed. Cicatrized ulcers situated near the pylorus frequently result in permanent stenosis. The lumen may be considerably diminished without causing symptoms; it may be more or less restored by ulceration after a. temporary nar- rowing. Complete atresia is rarely, if ever, seen. Maliijnaut discaxc. involving the pylorus obliterates it more or less completely. Tirmtn may take place in the pylorus id' a dilated stomach, especially when the abdominal walls are extremely relaxed. Tumors of the liver, the ""ill- bladder, the pancreas, (he omentum, or the retroperitoneal space by pressing upon the pylorus may diminish its lumen. Movable kidney and spleen have been said to cause obstruction by dragging on the stomach. The existence of spastic stricture of the pylorus is doubtful. The symptoms of pylorio stenosis are those of dilatation of the stoniaeh — malnutrition and impaired digestion, with decom posit ion of food. The dilatation maybe extreme; the stoniaeh may extend into the left Hank, into the pelvis, or even into (he right Hank. Sagging with fluid and distended with gas, it gives rise to marked suceussion. The palliative tk ioatm knt of dilated stomach is systematic lavage, massage, and electricity. Dilatations which result from atony may be so much improved by this treatment (hat operative measures are unne- cessary. The radical treatment of pyloric stenosis consists in viec/ianical dilatation (Loreta's operation), pi/lori'ctom//, pi/loroji/axti/, t/axfro-cntcrox- tuni/i, or pjilorrctoinji combined with y method of suturing. or by bougies. Hemorrhage and rupture of the stomach may complicate this operation ; the stricture may recur. Pyloroplasty rather than digital divulsion should be the operation of choice for benign strictures of the pylorus. It consists in taking out SURGERY OF THE ABDOMEN. 883 a double V- or diamond-shaped piece in the longitudinal axis of the pylorus, on the anterior surface, as in Fig. 379. This incision is sutured transversely, as shown in Fig. 380. Fig. 381. Pylorectomy : pylorus excised ; stomach-opening partially closed, ready for suturing to the duodenum. Pylorectomy. — Pylorectomy, or resection of the pylorus, was first successfully performed by Billroth in 1881. The operation is indicated Fig. 382. Pylorus resected : gastro-enterostomy completed. in malignant strictures of the pylorus in which the disease is limited to the stomach, and in benign strictures in which a pyloroplasty will not 884 SPECIAL OR REGIONAL SUROERY. afford relief. Preparation for the operation consists in rectal feeding and gastric lavage. The stomach should be exposed by a median abdominal incision above the umbilicus, long enough to permit free inspection and manipu- lation. The stomach and upper part of the duodenum should be pulled out of the wound, and the abdominal cavity walled off with gauze. Resection of the diseased portion should be thoroughly effected by cut- ting well above and below the lesion through sound tissues. The result- ing openings in the stomach and duodenum must next be fitted together according to their size and shape, as suggested in Figs. 381, 382. If they cannot be satisfactorily united, these openings must be closed and a gastro-enterostomy performed (q. v.). Coaptation of the divided structures should be made by the Lembert stitch. To prevent extravasation, strands of sterile gauze may be placed against the line of suture and led out of the abdominal wound ; these may be removed on the third day. The mortality of pylorectomy has been very high (over 70 per cent.) ; this is due mainly to the unfavorable nature of many of the cases. Combined pylorectomy and gastroenterostomy consists in ex- cision of the pylorus, closure of the divided stomach and duodenum, and the formation of a lateral anastomosis between the stomach and the jejunum. This procedure has had a mortality slightly less than pylorec- tomy, probably due to the greater rapidity with which it may be accom- plished. Gastro-enterostomy is an anastomosis between the stomach and some portion of the intestine, preferably the jejunum. It is indicated in cases of malignant disease of the pylorus in which the process has extended to the walls of the stomach, or in which neighboring structures are involved, or when there is extensive metastasis. It is sometimes indicated in benign stenosis with extensive adhesions, in which pylorec- tomy, pyloroplasty, or dilatation is impossible. Gastro-enterostomy should be performed by joining a loop of intes- tine to the posterior wall of the stomach by sutures or by some mechan- ical aid (Fig. 383). Von Hacker in 1883 showed that anastomosis on the posterior stomach-wall was essential, but this cannot be accomplished when the stomach is bound down by adhesions. To prevent stagnation of food and bile in the unused portion of the duodenum several additional anastomoses between intestinal coils have been suggested by Braun. Gastrorrhaphy is an operation devised to reduce the size of a dilated stomach. It has been performed but rarely, and consists in making a single or double plait in the anterior wall of the stomach, the peritoneal surfaces being sutured together to hold the folds in place. Theoretically it may be successfully applied in cases of simple chronic dilatation which are not relieved by lavage. Operations for Painful Gastric Adhesions. — Adhesions of the stomach to the abdominal wall or to the neighboring viscera, occurring as a remote result of gastric ulcer, may cause severe gastralgia. In numerous cases, after failure of palliative treatment, exploratory la pa- SURGERY OF THE ABDOMEN. 885 rotomy with free division of the adhesions has effected a complete cure. Gastro-anastomosis consists in making an anastomotic communica- tion between the cardiac and the pyloric ends of the stomach in cases of extreme hour-glass contraction of that organ. The operation has been performed but very few times up to the present year (1899). Fig. 383. Pylorectomy : gastroenterostomy. SURGERY OF THE INTESTINES. (Foe wounds and ruptures, see page 873; for non-traumatic perforations, see Typhoid Ulcers, Tuberculosis, Cancer, Appendicitis, and Fecal Fistulse.) The most important anomaly of the intestine is Meckel's diverticulum, which from its possible situation, size, and relations may cause acute obstruction or bowel-necrosis, or both. Congenital atresia may occur at the ileo-csecal valve and in the ileum and the jejunum. Doubling of the small intestine, a rare and unim- portant anomaly, has been observed. Intestinal Obstruction. Intestinal obstruction may result from lesions which contract or obliterate the intestinal lumen, or it may be dependent upon a paresis of 886 SPECIAL OR REGIONAL SURGERY. the muscular wall of the bowel, of septic or of inflammatory origin. The former only are considered as true obstructions. Acute obstructions are caused, as a rule, by mechanical lesions not associated with disease. Simple mechanical closure of the intestinal canal may be congenital ; it may be caused by intussusception, volvulus, internal and external strangulation, kinks and flexures, and the impac- tion of foreign bodies. The passive obstruction dependent upon intes- tinal paresis is seen in general peritonitis, in mesenteric embolism, and thrombosis. Chronic obstructions are caused by disease — by new growths, benign and malignant, involving the intestinal wall, by the pressure of external growths and inflammatory masses by cicatricial strictures after intes- tinal ulceration. Chronic and intermittent obstructions sometimes occur as the result of faulty adhesions and internal incarcerations. Acute Intestinal Obstruction. — Bands, Kinks, and Flexures ; Inter- nal Strangulation. — The commonest form of mechanical obstruction is that due to the various forms of external hernia. (See chapter on Her- nia.) A Meckel's diverticulum may cause acute obstruction with strangu- lation either of itself or of an intestinal coil. Bands occasionally exist without antecedent inflammation and without interfering with the intes- tinal stream ; they may suddenly, however, without apparent cause, pro- duce complete or partial obstruction. A protrusion of the intestine through an opening in the mesentery or in the omentum or under a band resembles greatly the lesion of an ordinary hernia, and has been called internal strangulated hernia. Retroperitoneal hernia — i. e. prolapse of the intestine into an abnormal peritoneal pouch, either at the fossa duodeno-jejunalis or in the region of the caecum or the sigmoid flexure — is a form of internal hernia that may cause acute obstruction. Strangulation of an intestinal coil through the foramen of Winslow is a very rare accident. Foramina in the mesentery or in the omentum cannot be explained except as the result of trauma, of operation, or of congenital influences. Kinks and flexures result from faulty adhesions. Bands dependent upon such adhesions may occur after any form of general or of partial peritonitis, after operations, in the course of ectopic gestations, and without known cause. Adhesions in their effects may vary between extreme limits. A single point of faulty attachment may produce a constricting loop ; on the other hand, a total matting together of intestines, uterus, tubes, and ovaries, no mechanical obstruction whatever. As a rule, the former is more productive of obstruction than the latter. A single band may compress the intestine transversely or it may strangle a whole coil. Kinks and flexures are produced by the adherence between a coil and a contiguous viscus — between the small intestine and a uterine horn, or between the intestine and the scar of a vaginal hysterectomy. Changes in the size of the uterus or in the depth of the contracting vaginal cicatrix may drag the adherent coil into a sharp angle, by which, under ordinary conditions, no obstruction is produced. Distention of the proximal coil by pressure against a solid viscus or against the pelvic brim may suddenly occlude the outlet into the distal lumen, producing a valve which is tightened more and more by the increasing distention. Separation of the adhesion at once relieves the tension, opens the valve, and restores the lumen. The intestinal coils are frequently extensively matted together, at times with more or less obstruction. Single or multiple fistulae occasionally exist between the coils. SURGERY OF THE ABDOMEN. 887 Congenital obstructions, though rarely found except in the rectum and the anus, have been observed in the duodenum, the jejunum, the ileum, and at the ileo-csecal valve. Congenital defects due to Meckel's diver- ticulum are much more important. In this malformation the ileum either communicates directly with the umbilicus or is attached to it by means of a fibrous cord or band. Pressure from this prolongation not infrequently results in strangulation of an intestinal coil or of the diverticulum itself. Fig. 384. ? 5 C8 t » -I S« Meckel's diverticulum causing fatal obstruction (Dr. H. \V. Cushing, Warren Museum) Acute obstructions result occasionally from the impactions of foreign bodies, gall-stones, enteroliths, and intestinal worms. Foreign bodies seldom become impacted in the intestine after leaving the pylorus unless they have sharp edges or angles. Objects small enough to pass the normal intestine may cause pathological changes by which they become permanently arrested; ulceration and even perforation may 888 SPECIAL OR REGIONAL SURGERY. result, with cicatricial stricture as a remote possibility. When stricture is present a body no larger than an orange- or apple-seed may produce the first symptoms of obstruction. Enteroliths are usually formed upon gall-stones, though they may be composed entirely of fecal substances or of phosphates combined with animal matter. Obstructions from gall-stones usually occur in women of advanced age. The calculi make their way by slow ulceration from the gall-bladder into the duodenum. The seat of the impaction is usually in the small intestine. (See Plate XXIX.) Intestinal obstruction by masses of roundworms has occasionally been observed in children. Intussusception. — Of all the cases of acute intestinal obstruction, 30 per cent, are due to intussusception. The majority of cases occur in children. Among adults it is more common in women than in men. The situation of an intussusception is usually at the ileo-csecal valve, the small intestine being invaginated into the large. The process may be confined, however, to the small intestine. In rare instances a double invagination may occur, or even a retrograde telescoping. Pathology. — An intussusception consists of three layers of bowel, that which is received being called the intussuseeptwn, and that which receives, the intussuscipiens (Figs. 385, 386). Most of the cases are at the ileo-csecal valve. Spontaneous recovery by slough- ing and elimination of the intussusceptum occurs in about 40 per cent, of the cases, but spontaneous recovery is not always permanent, for death may take place sub- sequently from perforation of the intestine ; moreover, stricture of the gut is very likely to occur. Recovery after intestinal resection in children with this form of obstruction is almost unknown. The longer operating is delayed the greater the mortality. Operations performed on the first or second day are by far the most successful. The causes of intussusception are generally obscure; occasionally, however, they are obvious, as when an intestinal polyp is found. Predisposing causes are irregular peristalsis, feeble health, diarrhoea, adhesions of the bowel. The symptoms of intussusception are chiefly those of acute intestinal obstruction, and are usually without premonition, though some predis- posing causes may have been observed. The pain, rapidly increasing in severity, is due partly to violent intestiral contractions, and partly to dragging and pressure upon the mesentery, with distention of the intus- suscipiens and beginning necrosis of the intussusceptum. Vomiting, dis- tention, and collapse appear early. The characteristic symptom in the passage of blood and mucus from the rectum. This form of acute obstruction unites with the symptoms of stenosis those of acute gan- grene ; hence the fulminating nature of the disease. In rare instances, however, invagination may be slow, and the intussusceptum may accommodate itself to the altered conditions without necrosis and without violent symptoms. If the abdominal walls are thin and if distention is slight or absent, an ill-defined sausage-shaped tumor can generally be detected ; if the abdominal walls are thick and if distention is excessive, the tumor, unless very large, cannot be felt. If the intussusception is low down, the invaginated bowel may be felt through the rectum. Treatment. — The treatment of intussusception may be palliative or operative. Palliative measures include massage, rectal injections with the patient inverted, and inflations of the colon with air or gas. It is doubtful, however, in a clear case of intussusception whether time ought to be taken for palliation.. The excessive mortality in this disease is PLATE XXIX. Enterolith with Gallstone for a Nucleus; Removed by Enterotomy. (Richardson.) SURGERY OF THE ABDOMEN. 889 largely due to delay in applying radical surgical treatment ; it is best, therefore, if attempts at reduction by non-operative measures be used, that they be as brief as possible if not immediately successful. Reduction of the invagnation by inflation and enemata is not possible after the invaginated portion has become swollen from the constriction of its efferent Fig. 386. Intussusception (Warren Museum). Intussusception at the junction of the small and large intestine. The former has passed outward and the caecum retains its place, the appendix projecting from the neck of the invagination (Warren Museum). vessels and fixed by adhesions. In advanced cases the intussusceptum is presum- ably necrotic. Under such circumstances dilatation sufficient to force back the intussusceptum can hardly fail to burst the intestinal wall. If the abdomen were immediately opened in all cases, the mortality would doubtless be very much diminished. In the hands of general practitioners and operators of no experience the chances of recovery are probably better if the patient be left to purely medical treatment, for a certain number of cases recover spontaneously after sloughing and separation of the intussusceptum. The operative treatment of intussusception consists (1) in the reduction of the invagination, (2) in resection and suture, and (3) in the formation of an artificial anus. The incision should be made preferably in the median line, unless the tumor, far to one side, requires for facile manipulation a cut directly over it. The situation of the lesion can usu- ally be detected by the presence of a tumor and by the tense mesentery dragged upon by the intussusceptum. If the integrity of the bowel is 890 SPECIAL OR REGIONAL SURGERY. not impaired, gentle efforts at reduction should first be made. If these be unsuccessful after prolonged trial, resection of the invaginated por- tion well above and below the constricting and the constricted portions of intestine should be made. The mortality of the procedure, however, is so excessive that the advisability of palliation by the formation of an artificial anus above the constriction should be seriously considered, especially if the strength of the patient does not admit of the prolonged manipulations of resection and suture. Appendicitis, a condition of sufficient importance to receive distinct consideration in another part of this chapter, must nevertheless be enumerated here as a common cause of acute obstruction, which it pro- duces by means of the adhesions resulting from copious exudate of plastic lymph about a compromised appendix. These are the cases often masked by the co-existence of a generalized septic or putrid peritonitis. Volvulus. — In this rare form of acute obstruction the lesion may be produced by the revolution of a single coil about its mesentery or by the twisting together of two separate coils. An intestinal coil heavily loaded with faeces, hanging by a long mesentery, presents the most favorable condition for a twist. The most common seat of the lesion is the sigmoid flexure, where it is not unusual to find an enormously lengthened coil, which when distended stretches out in the form of a huge S from the left sacro-iliac synchondrosis to the liver, thence into the pelvis. Volvulus usually appears after middle life, and is four times as common in men as in women. In a second form the twist usually involves the sigmoid flexure and a loop of small intestine, though it may be confined to two loops of small intestine. A twist once formed is soon so fixed by adhesions as to become completely and perma- nently obstructed. The diagnosis of volvulus cannot be made with certainty. If the symptoms of acute obstruction develop suddenly late in life in a patient habitually constipated, volvulus may be suspected. This suspicion may be strengthened by the detection of the ill-defined tumor of a distended and resistant intestinal coil. These symptoms, however, are present also in an intussusception ; the absence of bloody stools would indicate rather a volvulus. An absolute diagnosis can be made only by exploration. Treatment.— In the treatment of volvulus palliative measures are of no avail. By the time the formidable symptoms of acute obstruc- tion have become manifest the intestine is fixed in its abnormal position. External manipulations accomplish nothing, and enemata do more harm than good. The lesion is a mechanical one, like the twist of an ovarian tumor upon its pedicle, and demands immediate exploration. Unfortu- nately, the unavoidable delay before surgical relief can be applied is in most instances so great, that the mortality after operation is very high. By the time the affected coil can be untwisted the constitutional depres- sion is extreme, especially in old people, and the local condition beyond remedy. Symptoms in General of Acute Intestinal Obstruction. — Symptoms of intestinal obstruction cannot be definitely divided into the acute and the chronic, because many forms of acute obstruction are dependent upon chronic disease. From the clinical point of view, the symptoms of obstruction may be divided into those which come on sud- SURGERY OF THE ABDOMEN. 891 denly without antecedent causes, and those which appear slowly as a gradually increasing obstruction or as intermittent acute attacks of greater and greater severity. The symptoms of acute obstruction due to chronic disease, especially carcinoma, are found on careful questioning to have been preceded, in most instances, by obscure symptoms of the original disease. Incomplete obstructions due to the pressure of bands, to internal incarcera- tions, and to similar mechanical lesions may exist for years without producing absolute stoppage of the intestinal stream. In such cases temporary obstruction causes attacks of transitory colic which disappear spontaneously. Similarly a history of preceding attacks of pain is often elicited when acute symptoms sud- denly develop in the course of chronic obstructions dependent upon organic dis- ease of the intestinal wall. Serious apprehension may not have been aroused in any of these attacks. In most of the lesions causing acute obstruction no pre-existing symptoms dependent upon them could have existed. The symptoms of acute obstruction are pain, vomiting, diarrhoea, and distention, with a primary shock which varies in depth with the causative lesion. Constipation necessarily results. To the above cardinal symptoms of acute obstruction are added in the course of a few hours those dependent upon bowel-necrosis and local or general peritonitis. Diagnosis. — The diagnosis of the variety of the lesion is of great clinical importance; for practical purposes, however, it is necessary to know only that some lesion exists demanding interference. In acute mechanical obstructions constitutional signs are at first absent ; peristalsis is increased; intestinal coils can be seen in contractions under the abdominal walls if they are thin ; no pre-existing cause can be found ; distention is at first local, later general. In general peritonitis constitutional signs are present early; peristalsis is diminished, then absent; no intestinal movements can be seen or heard ; a pre-existing lesion can generally be demonstrated ; distention is general. Common to both conditions are pain, vomiting, distention, shock. The pain of obstruction is paroxysmal ; that of peritonitis, continuous. Vomiting, distention, and shock do not differ materially in the two lesions. In the later stages of those obstructive conditions which cause gangrene differ- entiation must depend upon the history only. Except in the rarest instances an exploratory diagnosis is demanded by the chief symptoms common to both obstruc- tion and peritonitis. The diagnosis between the different forms of obstruction, though of con- siderable importance, does not justify prolonged observation or the employment of time-taking methods. Between the lesions of internal strangulations, bands, kinks, and between acute and chronic lesions in general, the distinction is at times impossible. As a rule, however, one is able to say whether the symp- toms are due to a slowly progressing organic disease or to one of the ;\cute varieties of mechanical obstruction. All acute obstructions come on suddenly, without previous symptoms. If acute obstructions occur in the course of chronic disease, a careful consideration of the history will bring out the fact, or will, at least, suggest it with some probability. Inflation of the rectum by gas or air may be employed as a diag- nostic measure in the course of the palliative treatment of intussus- ception and volvulus. In a general way, the seat of the obstruction if below the ileo-caecal valve can be determined. Forced injections beyond the ileo-csecal valve are hardly justifiable in view of the great danger of rupturing the intestine. In rare instances manual examination by the rectum may be employed for the determination of lesions low down in the sigmoid flexure. Treatment. — Surgical interference is indicated whenever an acute intestinal obstruction is suspected. When the nature of the lesion ■smsim0s«^^ i '^^^ ti ^* : ' v * tJM * m - 892 SPECIAL OR REGIONAL SURGERY. is beyond doubt the favorable period for intervention has usually passed. Surgical treatment, to be successful, must be applied in the earliest hours of the disease. The symptoms which demand exploration do not differ materially in most of the abdominal emergencies, whether the case be one of hemorrhage, of intestinal extravasation, of intestinal obstruction, or of any of the emergencies of pelvic disease. In acute abdominal lesions marked by pain, nausea, vomiting, and shock, with rigidity of the abdominal muscles, exploration is demanded. Though these symptoms may not invariably be caused by a grave lesion, in the majority of cases they are due to some mortal complication. The symp- toms of later stages — distention, obstipation, stercoraceous vomiting, collapse — though they may justify interference, do not encourage it, from the mortality of operations at this stage. It is a question, indeed, whether in those cases in which death is clearly impending the surgeon's duty requires him to interfere. Nevertheless, inasmuch as a rapid ex- ploration, with formation of an artificial anus, sometimes succeeds in these desperate conditions, exploration is probably the best course to pursue unless the patient is actually dying. Palliative treatment in acute intestinal obstruction is justifiable only in excep- tional conditions, for the mechanical causes present in the great majority of cases demand a mechanical remedy. The possible exceptions are intussusception, vol- vulus, and impactions low down in the intestine. By the spontaneous efforts of nature intussusceptions may be thrown off, twisted coils may be untwisted, im- pacted bodies may be detached. Abdominal taxis and massage in these conditions may assist spontaneous efforts at relief. In no other forms of intestinal obstruc- tion, whether acute or chronic, do palliative measures offer reasonable hope of cure. When exploration has been determined upon, the abdomen should be immediately opened — in obscure cases in the median line above or below the umbilicus, or in clear cases over the seat of the lesion. A short incision should be made at first through the peritoneum to deter- mine, by the escape of serum, pus, fecal matter, or blood, whether some serious lesion is present. The operator, in full confidence that he is on the right track, may then enlarge the incision enough to permit manual examination of the whole abdominal cavity. The subsequent manipu- lations will depend upon the lesion found. Acute obstructions should be treated radically if the patient's strength justifies prolonged opera- tion. (See Special Causes of Acute Obstruction.) If haste be essential, an artificial anus (enterostomy or colostomy), a temporary measure, may rapidly be made ; radical intervention may be practised later. Bands must be divided ; strangulations, intussusceptions, and twists reduced ; necrotic bowel either excised or fastened into the wound and opened. The excessive distention usually present in acute obstructions and in general peritonitis seriously embarrasses both exploration and radical operation. To relieve such distention the distended coils may be aspi- rated or incised. The prognosis in all forms of acute obstruction is grave ; it is espe- cially serious in those lesions attended by necrosis of the bowel-wall and general peritonitis. Obstructions due to impactions, bands, and internal strangulations are more favorable than those due to intussusception and volvulus, embolism and thrombosis. All forms of acute intestinal obstruction relieved in the first few hours of the attack have a prog- SURGERY OF THE ABDOMEN. 893 nosis by no means unfavorable. As soon as death of the bowel-wall takes place and general infection develops, the mortality under any method of treatment is excessive. Chronic Intestinal Obstruction. — Chronic obstruction to the intes- tinal flow results from : (1) The growth of tumors which involve the intestinal wall (carci- noma, sarcoma, and fibroma) ; (2) Cicatrized and contracted tubercular, typhoidal, diphtheritic, dysenteric, and syphilitic ulcerations ; (3) The pressure of external growths and inflammatory masses ; (4t) Fecal impactions ; (5) Ileus paralyticus of the insane. Carcinoma, by far the most common cause of organic stenosis, is situated most frequently at the sigmoid flexure ; less frequently at the ileo-cffical valve and at the hepatic and splenic flexures. The disease may be annular and limited to the inner layers of the intestine, or it may penetrate early the peritoneum and involve adjacent coils. Metastasis through the lymph-channels is usually slow. The causes of intestinal cancer are unknown. They probably do not differ from those of cancer elsewhere. The disease has been known to start in the cicatrices of intestinal ulcers and in the inflammatory thickenings about impacted foreign bodies. The cancerous tumor may be a narrow ring or a broad fusiform mass involving the internal layers only of the intestine and constricting its lumen ; it may involve all the layers and contiguous coils as well. Starting from the internal surface, it may project into the lumen and fill it with a fungous and ulcerating mass (Fig. 387). The tumor may be imperceptible by palpation or it may be conspicuous to touch and sight. In some cases the tumor cannot be felt because of its situation ; in others, because of its nature. The tumor may be fusiform, oval, or flat- tened, smooth or irregular ; of varying degrees of density, though usu- ally hard. It may be freely movable or firmly fixed. It may be dull or tympanitic — dull if in the anterior wall ; tympanitic if in the poste- rior and covered by a distended portion of bowel. The internal surface may be ulcerated, friable, and bleeding, or projecting, smooth, and indu- rated. The lumen may gradually become entirely dosed, and later be re-established by ulceration. As soon as the peritoneum is extensively affected serum is exuded ; ascites may be excessive. Diagnosis of Cancer of the Intestine. — Cancer of the intes- tine must be distinguished from benign neoplasms and from benign strictures, from lesions outside the intestine causing obstruction, and from incomplete obstruction by bands and incarcerations. The diagnosis is generally easy. The symptoms are progressive. A gradual impairment of health and loss of weight, preceding obstruc- tive symptoms in patients at or beyond middle life, suggest the pos- sibility of cancer ; a marked cachexia strengthens the diagnosis ; a hard movable tumor, with ascites, confirms it. Yet the lesion may not be cancer. Exploration alone will decide the question. In the absence of a tumor the diagnosis must be in a measure doubtful, though obstruc- tion in an adult preceded by loss of weight alone is sufficient evidence in the majority of cases to warrant the diagnosis. 894 SPECIAL OR REGIONAL SUROERY. In strictures of benign origin the health is unimpaired, cachexia is absent, the symptoms are not, as a rule, progressive. Even in cicatricial strictures and in pressure obstructions the patient lives for months or years in comparative comfort. Fig. 38' Cancer of intestine obstructing the lumen. Above tlie constriction the bowel is enormously dilated and its wall thickened (Warren Museum). The treatment of intestinal cancer is (1) medical and palliative — to keep up the strength (food and tonics) ; to allay obstruction (opiates, liquefaction of faeces) ; (2) operative — excision of the disease ; end-to-end suture with anastomosis ; artificial anus. Obstructive symptoms are best allayed by opiates, which relieve spasm and proximal pressure. Small doses of opium or morphine will often produce evacua- SURGERY OF THE ABDOMEN. 895 tions when cathartics will prevent them. Liquefaction of faeces, always present above chronic obstructions," may be augmented by the avoidance of coarse food, seeds, etc. Whenever possible the tissue involved should be thoroughly excised. Repair must be made according to circumstances — end-to-end suture if possible or closure of the resected ends and lateral anastomosis. Sarcomata of the intestinal wall are rare, though occasionally seen. They occur at all ages, but most frequently in the young. They are usually secondary. More rapid in growth than carcinomata, they pre- sent the same symptoms. A tumor can generally be felt. Palliative and radical treatment does not differ from that of cancer, though radical removal is possible only in primary cases. Stenoses resulting from cicatricial contractions, after intestinal ulcers, tubercular, typhoidal, syphilitic, and diphtheritic, present the symptoms of gradually increasing obstruction. Typhoidal and tubercular ulcers are usually situated in the small intestine ; diphtheritic (dysenteric), in the large ; syphilitic, at the rectum. Cicatricial stenoses, like cancerous, may not be suspected until the lumen is extremely small. Transitory colics result from a narrowing which requires unusual peristaltic effort. The general health is unaf- fected. Complete obstruction may come on suddenly from impaction of a seed or other solid particles. The treatment should be radical in all cases — by excision with suture or anastomosis or by enteroplasty. Artificial anus need never be employed ; anastomosis at one point or another is always possible. External pressure from neoplasms or inflammatory masses should be suspected whenever obstructive symptoms arise in the presence of abdominal tumors and inflammatory exudations, the nature of which is obvious. Chronic obstructions occasionally occur as the result of the impaction of hardened fecal masses in the ascending or the transverse colon. This condition is most frequent in constipated old women. Fecal masses simulating hard, nodulated, and movable tumors can often be felt through the thin abdominal walls. Serious mistakes in diagnosis may occasion- ally be made in this condition. Ileus paralyticus is due to the paralysis of the muscular coats of the intestine. The possible occurrence of this lesion should be borne in mind in the presence of chronic obstructive symptoms in the insane. Fecal Fistula and Artificial Anus. An artificial anus is an abnormal opening in any part of the abdom- inal wall through which all the contents of the bowel escape. The opening in the bowel is made after securing it to the abdominal wall. An intestinal fistula is an opening through which only a part of the intestinal contents escapes. Intestinal fistulse may be external or in- ternal. An external intestinal fistula is a direct opening from any portion of the intestine through the abdominal parietes. An internal intestinal fistula is a communication between the intestinal tract and the the bladder, the stomach, the vagina, the gall-bladder, the pleura, or the lungs, or between contiguous intestinal coils. Etiology. — An artificial anus is practically always intentional made 896 SPECIAL OR REGIONAL SURGERY. for the relief of surgical emergencies or chronic obstructions. Intestinal fistulse are always accidental, and may be caused by (1) Penetrating and lacerated wounds and ruptures of the intestine; (2) Perforation of the intestine by typhoidal, syphilitic, and tuber- cular ulcerations, by the necrosis and gangrene of internal strangulation, by foreign bodies, and by malignant disease ; (3) Intestinal actinomycosis ; (4) Rupture of appendicular or other pelvic or abdominal abscesses ; (5) Injury to the intestine in the course of abdominal operations ; (6) The giving way of ligatures or sutures ; (7) The pressure of drainage-tubes. The ulcerations that most frequently terminate in intestinal fistulas are of the tubercular variety. Foreign bodies, gall-stones, enteroliths, or fragments of bone may make their way out of the abdomen through adhesion-formation, abscess, and external perforation. Malignant disease, complicated with septic infection and suppuration, is a not uncommon cause of intestinal fistulse. Actinomycosis occa- sionally results in abscess, intestinal perforation, and fistulse: it occurs most fre- quently-in the ileo-csecal region. The most common causes of external and in- ternal intestinal fistulse are pelvic and abdominal abscesses. The majority of intestinal fistulse close spontaneously sooner or later. Those that may be reasonably expected to close under palliative treat- ment are the ones in which the opening in the bowel is small, not due to tubercular or malignant disease or actinomycosis, and in which the fistula is not lined with intestinal mucous membrane. Internal intes- tinal fistulas in the majority of cases cause no symptoms. The surgical treatment of intestinal fistulse consists in — (1) Stimulation and cauterization of the fistulous tract and free drainage of the abscess-cavity, with or without curetting; (2) Disinfection and suture of the fistulous tract, without opening the peritoneal cavity ; (3) Complete excision of the fistulous tract and intestinal resection or anastomosis. The risks in the radical operation are considerable. The mortality has been high, because of the difficulty of preventing contamination of the general peri- toneal cavity. When the fistulous opening is so high up in the small intestine that the nutrition of the patient is seriously impaired operation should be per- formed as soon as possible. On the other hand, cases in which the nutrition is not interfered with should be treated for many months by the simpler methods before resorting to intestinal resection or anastomosis. Closure of an artificial anus should be accomplished by complete freeing of the intestine, with resection of the fistulous opening and suture. The adherent coil should be completely separated and drawn out of the wound. The fistulous opening can then be carefully and thoroughly excised ; the freed coil will permit satisfactory approxima- tion of the refreshed edges. After suture the coil may be returned to the abdominal cavity and the external wound closed, a small strand of gauze being left for security against extravasation. Methods op Intestinal Suture. (For the history and development of intestinal suture methods the student is referred to larger works on surgery.) The correct principle SURGERY OF THE ABDOMEN. 897 until 1825, when surfaces to serous. Fig. 388. of uniting intestinal wounds was not determined Lembert taught the necessity of approximating serous Since then a multitude of sutures and mechanical de- vices have been brought forward, only a few of which have stood the test of practical use. Those most used at the present time are — (1) The Lembert suture in its different forms; (2) Czerny-Lembert suture ; (3) Halsted's quilted suture ; (4) Cusbing's right-angled suture ; (5) Senn's bone plates ; (6) The Murphy button. (1) The Lembert suture may be applied either as an interrupted or a continuous stitch. (See Fig. 389.) It has the advantages of simplicity and rapidity. (2) The Czerny-Lembert suture differs from the preceding in that a preliminary set of interrupted stitches is applied to the mucous mem- brane. (3) Halsted's suture applies the Lembert principle to the plain quilted stitch. (4) Gushing' s right-angled suture is a continuous quilted suture. Fig. 389. Diagram of Lembert suture. Application of the interrupted Lembert suture. Senn's bone plates and the Murphy button are the two mechanical aids to intestinal anastomosis and suture most widely known and used. (5) Senn's plates, composed of decalcified bone, have been used for making rapid anastomosis between hollow viscera. In the viscera to be approximated, suitable incisions are made, into which the plates are slipped. They are then fastened into position by transfixing the walls of the bowel with the needles and tying the threads. Additional inter- rupted stitches may be used for greater security. (6) The Murphy button is a recent mechanical device, the construc- tion of which will be seen in the accompanying figure (Fig. 390). It 57 898 SPECIAL OR REGIONAL SURGERY. can be used with rapidity and accuracy in end-to-end union and in lateral anastomosis. The two portions of the button are first secured Fig. 390. The Murphy button. by purse-string sutures in the coils to be united, which are then approxi- Fig. 391. End-to-end union of intestine by means of the Murphy button: the two portions of the Murphy button, held in position by purse-string sutures, are ready to be pressed together. mated as shown in Figs. 391, 392. Union of the peritoneal surfaces Fig. 392. Union— end to end— with the Murphy button. results ; the button is released in from ten to twelve days by sloughing of the included tissues and passed per anum. SURGERY OF THE ABDOMEN. 899 Wounds of the intestine may be closed by either the Lembert, the Halsted, or the dishing suture in a single or a double row. End-to- end union or lateral anastomosis may be performed by the use of sutures alone or by the aid of Senn's bone plates or the Murphy button. If time permits, union by the application of the Lembert or Halsted suture is far preferable to that by mechanical contrivances. When the condi- tion of the patient demands speed, it is best to use either the plates or the button as may seem preferable to the individual operator. Senn's plates are used only in anastomosis ; Murphy's button, in anastomosis and in end-to-end approximation. Operations on the Intestine. The principal operations on the intestine are — resection, anastomosis, enterotomy, enterostomy, and enteroplasty. Intestinal resection is demanded — (1) Whenever the vitality of the bowel is seriously impaired by injuries, internal or external strangulation, mesenteric embolism or thrombosis ; (2) In intussusception and volvulus; (3) For restoration of the lumen in cases of benign stricture and for extirpation of tumors and malignant disease ; (4) For the cure of fecal fistulse. Most of the lesions demanding resection involve the small intestine, although the seat of intussusception and volvulus is usually the large intestine. Previous to resections of the intestine the howel should be empty whenever possible, for manipulations are thus facilitated and the danger of fecal escape and of peritoneal infection are minimized. Excepting in acute emergencies and chronic obstructions, in which the distended bowel above the obstruction cannot be reached, the intestines may be emptied by rectal enemata and by the use of cathartics and liquid food for twenty-four or forty-eight hours before the opera- tion. Preliminary washing out of the stomach may also be employed. The incision through the abdominal wall should be made long enough to permit free delivery of the diseased intestinal coil. Operative manip- ulations should be as far as possible outside of the peritoneal cavity, which should be protected thoroughly by gauze packing. Great distention in the intestinal coil may be relieved by aspiration or by incision. (See Peritonitis.) Compression of the bowel above and below the diseased portion may be effected by the fingers of an assistant or by mechanical aids — rubber bands and clamps. Digital compression is preferable. The seat of the disease should be completely excised, the mesentery being tied in sections. Huture of the divided bowel should begin at the mesenteric border. It is at this point that the greatest care must be taken to make the joint tight. Excision of a V-shaped piece of mesentery may be necessary before the application of the stitches. After the mesenteric border has been thoroughly secured application of the remaining sutures may be made in any order, provided that the inverted edges are brought securely together. Any one of the methods of intestinal suture previously described may be used, according to the preference of the operator. The interrupted Lembert is undoubtedly the best and the one generally employed. The manner of applying the stitches and of securing the mesentery will be seen in the accompanying 900 SPECIAL OR REGIONAL SURGERY. diagram (Fig. 393). If time permit, a second row of interrupted sutures may be used, though in the majority of cases this procedure is not neces- Fig. 393. End-to-end suture after the application of interrupted Lembert stitches. sary for safety ; moreover, by inverting too broad a margin a constrict- ing ring may be produced in the lumen of the gut. Fig. 394. Lateral anastomosis : first stage of the operation. If the condition of the patient is such as to demand extreme rapidity in opera- tive technique, no better method can be employed than the use of the Murphy button, as shown in the diagrams (Figs. 391, 392). Lateral anastomosis, after resec- SURGERY OF THE ABDOMEN. 901 tion and closure of the divided ends, possesses no advantage over end-to-end union by suture. The operation cannot be done any more rapidly ; peristalsis is inter- fered with; the course of the fecal stream is abnormal; and the lateral opening always contracts. When the condition of the patient will not permit end-to-end union by suture or even by the use of the Murphy button, an artificial anus should be made, and secondary suture performed at a subsequent and more favorable time. After intestinal resection and suture a strand of gauze should be left in contact with the line of sutures to provide against the giving way of a stitch with extravasation and peritonitis, the principal cause of death after this operation. The strand of gauze should emerge from the lower angle of the abdominal wound, and the wound itself be almost entirely closed. The gauze should be removed at the end of forty-eight hours. Intestinal Anastomosis. — Portions of the intestinal tract more or less distant from each other may be united by lateral intestinal anasto- mosis, an expedient by which the intestinal stream is diverted around some obstacle to its flow. The procedure is indicated (1) in lesions of the intestine too extensive for free excision and end-to-end suture ; (2) in cases demanding haste. Anastomoses between the stomach and the intestine are indicated in pyloric obstructions too extensive for resection. In the field of gastroenterostomy the principle of lateral anastomosis is most useful ; in many instances it affords the only prospect of relief. Fig. 395. Lateral anastomosis : operation finished. Lateral anastomosis may be performed with sutures alone or by mechanical devices. When performed by means of sutures alone, a longitudinal cut is made two or three inches in length, through the coils to be united. The incision should be made opposite to the mesenteric attachment (Fig. 394). The posterior edges are first brought together by means of a continuous or an interrupted stitch. The margins of the cut may be sewed over and over before uniting them. The anterior edges are next united by another continuous stitch. Finally, for additional security a second line of interrupted or continuous sutures may be applied (Fig. 3951 902 SPECIAL OR REGIONAL SURGERY. The disadvantage in the use of sutures alone is the time required. The objection to the use of mechanical devices in general is the insufficient size of the anastomotic opening and the great danger of secondary contraction ; to the use of the Murphy button, in particular, the danger of extravasation and of the impaction of the button itself. To prevent closure by contraction the intestinal opening should be as large as possible. Intestinal anastomosis is generally made between intestinal coils above and below a constricted portion. Enterostomy is the formation of a permanent opening into the intes- tine ; the term is usually restricted in its use to such operations upon the small intestine. It is an emergency operation, demanded for the tem- porary relief of acute intestinal obstruction ; it is not to be employed if the strength of the patient justifies radical procedures. Enterostomy differs from the formation of an artificial anus only in that it usually involves the small intestine. The operation consists simply in incising the bowel after it has been sutured to the abdominal wound. The objec- tion to the operation is that if the opening be made too high in the small intestine, the nutrition of the patient is seriously impaired. Notwith- standing this, enterostomy, even high up in the small intestine, may be successful in tiding the patient over the immediate dangers of an acute obstruction, so as to permit radical treatment of the disease later. Jejunostomy for purposes of feeding is a form of enterostomy occa- sionally necessary as a substitute for gastrostomy in cases of malignant disease of the pylorus and neighboring structures so extensive that neither resection nor anastomosis is feasible. The operation has been performed but seldom. In the execution of this procedure care must be taken not to interfere with the excretion of the bile and the pancreatic juice. Enteroplasty is an intestinal operation exactly similar in its tech- nique to pyloroplasty. (See Operations on the Stomach.) By this procedure fibrous strictures of the intestinal wall are overcome without resection of the gut. Through the tissues of the stricture a diamond- shaped incision is made which is sutured transversely. Opportunity for such an operation seldom arises, however. DISEASES OF THE VERMIFORM APPENDIX. Excluding possibly pelvic inflammations in the female, appendicitis in its various forms is the most common surgical affection of the abdo- men. In males it is by far the most important. Etiology. — Appendicitis is a very common disease. It occurs much oftener in males than in females. No age is exempt from it ; it has been seen in a child of two and in a man of eighty. It is seen most frequently in the early years of life. Excluding deaths from certain zymotic dis- eases, deaths from appendicitis exceed in number those from any other acute abdominal lesion. It is by far the most common cause of peritonitis in the male, and it is not an uncommon cause in the female. There are no recognized conditions predisposing to appendicitis. Though it not infrequently occurs in the course of diarrhoea, it is seen quite as fre- quently in persons of constipated habit. The etiology is obscure. Pathology. — The inflammatory changes of appendicitis usually begin in ulcerations of the mucous membrane, through which micro- PLATE XXX. Illustrating various degrees of involvement of Appendix Vermiformis. (Richardson. ) A. Chronic, recurring. B. Ditto, much thickened. C. Acute, with necrosis and ruptun D, Showing local necrosis. E, Gangrene and perforation permitting faecal extravasation F, Total gangrene without perforation. SURGERY OF THE ABDOMEN. 903 organisms make their way into the adenoid tissues. A necrosis ensues which may be limited in depth, length, and width ; a small area may be involved or the whole organ may become gangrenous. Invasion of the peritoneum may cause a localized septic peri-appendicitis ; sloughing oi the necrotic area may result in perforation and extravasation. Ulcera- tion of the mucous membrane may be caused by the pressure of fecal concretions or of foreign bodies, though foreign bodies are rarely met with. Smooth, hardened fecal masses, varying in size from that of a white bean to that of an olive, are found in the great majority of cases of gangrenous appendicitis. In some instances, however, no such cause is found. Pathological changes in the mucous membrane of the appen- dix are often associated with similar lesions in the mucous membrane of the cfflcum, and are doubtless often dependent upon them. In a considerable number of perforative inflammations no local cause can be found. In all acute gangrenes of the appendix the afferent artery, a terminal without anastomoses, will be found thrombosed — it will not bleed when cut. In fully-established necroses the gangrenous pro- cess extends from the interior to the surface. The width of the necrotic area is generally larger on the internal than on the external layers. In many instances the process will be found limited to the mucous and adenoid layers ; as a rule, however, all the layers will be found affected. Very frequently the process goes on without symptoms until the peritoneal coat becomes involved; hence in many cases the very first symptom is that caused by an infection of the peritoneum — an infection which varies from that of a minute bacterial invasion to a rapid and extensive fecal extravasation. The necrotic area may be situated anywhere in the appendix. ( Vide Plate XXX). The course and the prognosis of the disease depend largely upon the exact seat and size of the perforation. As a rule, when the perfora- tion is situated at the tip, extravasation is slow and the peritonitis localized ; when at the base, extravasation is rapid and the peritonitis general. The rapidity of the extravasation depends also upon the size of the appen- dicular lumen and upon the amount and liquidity of the csecal contents. In some instances the necrotic process is so near the cfficum that a por- tion of its wall is involved. This complication, though extremely rare, is as a rule rapidly fatal. Sometimes the whole appendix, with its mesentery, is gangrenous. Acute inflammations of the appendix which affect its peritoneum remit almost always in peritonitis, either localized or general. The same bacteri- ological element probably exists in both, the difference being one of degree. When the perforation, from its size or its position or from any other reason, causes a rapid fecal extravasation, the infection is usually gen- eral; when slow, local. In other words, the extent of the infection depends largely upon the power of the peritoneum in a given case to form barriers against spreading inflammation. In many chronic lesions of the appendix the peritoneal layer is unaffected and no adhesions whatever exist. Occasionally a long-continued though mild type of in- flammation results in extensive adhesions — sometimes of cartilaginous firmness. In the so-called obliterative appendicitis the ulceration and gangrenous process result in cicatricial contractions by which the lumen 904 SPECIAL OR REGIONAL SURGERY. is partially or entirely obliterated. Such an appendix may be contracted throughout its extent, or it may be club-shaped — cicatricial contractions separating the distal end from "the caecum. The tip under such circum- stances is often distended by the secretions of a mucous surface which has no outlet— an appendicular cyst, the contents of which are often sterile from long encapsulation. Here, as in so many other instances, a careful examination of the blood will afford most valuable prognostic information. Either the absence of or a very excessive leucocytosis means such lack of reparative power or such terrific infection that the chances of life may be thereby quite accurately measured. This is, to be sure, equally true of all suppurative and acute inflam- matory processes, as also of pneumonia. Symptoms. — The first and most important symptoms of appendicitis are pain and vomiting, which, in the vast majority of cases, are the only symptoms in the first few hours of the attack. The subsequent symp- toms are those of a localized or of a general peritonitis. Pain usually begins in the region of the umbilicus or in the epigastrium. It is soon accompanied by tenderness, and both become localized in the right iliac fossa or wherever the appendix may be situated. The pain is at first paroxysmal — later, constant. The temperature and pulse rise. Chill is rarely observed in the beginning of the attack, or, in fact, at any time during the course of the disease. The objective signs are either negative or they are those of a localized or of a general peritonitis. Sharp inflam- mations, not attended by extravasation, show no further symptoms than those already described. The pain and tenderness gradually subside ; there is neither dulness nor tumor ; the appendix can seldom be felt ; the constitutional symptoms disappear ; and in the course of a few days the patient is able to leave his bed. When by perforation the contents of the appendix or of the ceecum escape, the symptoms of a localized or of a general peritonitis ensue. (See Peritonitis.) Dulness and tumor are present if the inflammation and effusion are localized and near the sur- face. Such inflammations, however deeply situated, give no external signs whatever. When the lesion is deep in the pelvis, tenderness and tumor will sometimes be detected by rectal examination ; when high up above the csecum, tenderness and dulness are noticeable in the right flank ; when at the usual seat of the appendix, at a point halfway between the anterior superior spine of the ilium and the umbilicus. The absence of tenderness in this definite spot by no means precludes the possibility of an appendicitis. The constitutional signs of infection gradually sub- side as the infection becomes limited by adhesion-formation. The physi- cal signs of abscess become more and more pronounced as the collection of pus increases in size. A distinct tumor can be felt early in superficial cases, late in those deeply placed. Diagnosis. — The diagnosis of acute appendicitis is rightly regarded as easy. Chief among the lesions to be differentiated from appendicitis are perforations of other portions of the alimentary canal, internal straiif/u/ations, right-sided renal calculus, strangulation of a Meckel s diverticulum, rupture of an extra-uterine pregnancy. In the female inflammation of the Fallopian tubes must be considered. Treatment. — The treatment of acute appendicitis depends first SURGERY OF THE ABDOMEN. 905 upon the period at which the disease is recognised. Without doubt the best treatment, could it be applied in the first hours of the disease, would be immediate exploration and removal of the appendix. Inas- much as few cases come into the surgeon's hands so early in the dis- ease, however, the question of operation becomes one much more difficult of solution. The rule demanding that every case of appendicitis be ope- rated upon as soon as the diagnosis is made is not approved by the majority of those most experienced in the treatment of the disease. It is extremely desirable to remove the appendix in the interval of health — to ease the patient, if possible, through an acute attack with an intercur- rent operation in view. Certain cases justify medical treatment for this end. Whatever may have been the indications in the early hours of the disease, its probable course can usually be determined with some certainty at the end of the second, third, or fourth day, the period at which the case is usually seen by the surgeon for the first time. The infection at this time is either successfully localized or it has become general. When successfully localized, the case may be watched if the constitutional symptoms are not severe or if they are improving. Yet even in the face of an undoubted amelioration of the constitutional signs delay is not justifiable when the local symptoms are conspicuous. In many cases the temperature and the pulse fall, even in the presence of a marked tumor. Such localized collections of pus must be evacuated immediately. When the local signs are mild, or when, with the con- stitutional ones, they are subsiding, delay is desirable. In all cases the most careful watch should be kept of both. When both local and con- stitutional symptoms are severe, even if there is no evidence of a gen- eral peritoneal infection, exploration is always demanded. Certain specific symptoms, however, in themselves demand exploration ; such, for instance, as continued and intense pain, board-like rigidity of the muscles of the right side of the abdomen, constant vomiting, and high pulse, with or without increased temperature. On the other hand, a high temperature alone is of slight significance as an indication for operation ; a high pulse alone is a much more reliable guide. In cases of doubt it is safer to operate than to delay. Localized abscesses should be opened as soon as they are recognised. The chief objection to operating on the third and fourth day in cases that are doing fairly well — cases in which, presumably, an ad- hesive barrier against the extension of infection has been successfully made — lies in the danger of converting a local into a general inflamma- tion. That this danger is great numerous observations seem to prove. Many a patient that was doing not perfectly, but fairly well, has had the scale turned against him by injudicious interference. Operation. — The guide to the incision should be the tumor ; if none be present, the seat of greatest tenderness. In the absence of definite localizing signs the cut should be made over the usual seat of the appendix — namely, halfway between the umbilicus and the anterior superior spine of the ileum. The incision should be a long one, par- allel with the fibres of the obliquus externus and across the internus and transversalis, so that clear inspection and free manipulation may be pos- sible. In most cases oedema of the cellular tissue between the abdominal muscles will show that the surgeon is on the right track. The peri- 906 SPECIAL OR REGIONAL SURGERY. toneum is often so changed that it cannot be recognized. It must be incised with the greatest care, for many instances have occurred in which the knife has gone directly into the intestine. As soon as the peritoneum is opened, if there be any intra-abdominal lesion present, serum, either clear or turbid, will escape. Turbid serum generally, though not always, contains micro-organisms ; serum containing gas and faeces indicates a general fecal infection. If the peritonitis be limited, and if it must be approached through the general cavity of the abdomen, gauze barriers against general infection should be carefully placed toward the median line on all sides of the tumor. In cases of abscess incized through strong adhesions the operator should be content with simple drainage when the appendix is not easily accessible. The appendix should be removed when- ever it is possible to do so without infecting the abdominal cavity. In those operations in which the peritoneal cavity is necessarily opened no further harm can follow removal of the appendix itself. Separation of the appendix can generally be accomplished easily with the finger. A little experience will enable the surgeon, by the sense of touch, to detect the appendix without question, and to determine the extent and strength of the adhesions. In most cases the appendix can be easily delivered. It should be tied through its base and through its mesentery with cat- gut : silk becomes infected and causes a sinus which persists until it is cast off. After removal of the appendix the parts should be carefully dried with sterile gauze. If the surrounding intestines are extensively infected, irrigation with salt solution or with warm water should be employed. In local infections general irrigation is not advisable, because it may spread the micro-organisms into remote regions of the abdomen. Great attention should be given to cleansing and drying the pelvis. If the pus-cavity be large, tubes and gauze should be used ; if small and dry, gauze alone. In many instances peroxide of hydrogen seems an excellent solution to use for local irrigation. The abdominal wound may be left entirely open or the ends may be closed by one or two stitches. Chronic Appendicitis ; Relapsing- Appendicitis ; Catarrhal Appendicitis. — Whatever may be the pathology of the various lesions included under the term chronic, appendicitis, the symptoms are usually definite enough to permit a determination of the existing cause. The symptoms are referable directly to the appendix and indirectly to the intestinal tract. The chief symptom is pain in the region of the appendix — pain either paroxysmal and intermittent or dull and constant. Local tenderness almost invariably accompanies the pain. In some instances the affection is persistent, in others intermittent ; in some the attack is well defined, in others obscure. Digestive disturbances are usually present, and fre- quently constitute the chief symptoms. The appendicular symptoms are often attributed to indiscretion in diet. The bowels may or may not be affected. In some cases there is diarrhoea ; in others, constipation. The pain is sometimes violent and paroxysmal ; sometimes slight and con- tinuous. In some cases there is fever ; in others, none. In a word, there is a grumbling appendix, which causes sometimes local, sometimes remote, signs, sometimes both. As a rule, chronic appendicitis manifests itself SURGERY OF THE ABDOMEN. 907 by local signs more or less severe, with chronic digestive disarrangement and general invalidism. Treatment of Chronic Appendicitis. — The treatment of thin disease should be invariably surgical — first, because of the disability it causes, and secondly, because of the danger of an acute, fulminating exacerbation. Moreover, the patient can never safely go beyond the reach of a surgeon. The great safety of aseptic methods removes the chief objection to the performance of appendectomy. A minor objec- tion, the liability to hernia, is practically removed by the present methods of operating. Indications for Removing the Vermiform Appendix in the Period of Health. — This question should be seriously considered in at least three classes of cases : (1) After recovery without operation from one severe attack ; (2) After numerous mild attacks ; (3) When local symptoms exist after drainage of appendicular abscesses without removal of the appendix. In this class may be con- sidered the removal of the appendix during the operation for hernia in the scar. Operation for Removal of the Appendix in the Period of Health. — The method of McBurney is by far the best. The incision, an inch or an inch and a half in length, should generally be made over the seat of tenderness, sometimes not more than halfway between the umbili- cus and the anterior superior spine of the ilium. The fibres of the external oblique or its aponeuroses are then separated longitudinally and retracted. The fibres of the internal oblique and transversalis are next separated in a similar manner. The retractors are then so shifted as to separate these muscular bundles. The peritoneum is next opened and retracted. By digital examination the exact situation of the appendix is determined. The caecum is carefully pulled out of the wound between the thumb and fore finger. If it slips, pieces of gauze may be used to aid in delivery. As the caecum is pulled out it should be passed between the fingers along the longitudinal striae toward the appendix. Non-adherent appendices will usually be delivered in this manner without exposing much of the caecum. If the base of the appendix, even in adherent cases, can thus be brought out of the wound, the rest of the organ can usually be separated with the finger. If the adhesions are so strong as not to be easily separable in this manner, the incision should be enlarged enough for free inspection and manipulation. Violent efforts at sepa- rating adhesions should not be made through the small opening already described. In many cases the vermiform appendix may be delivered and removed through an incision not wider than the thumb-nail. Not that it is necessary always to make so short an incision ; it is probably better, as a rule, to make a larger one, for it is often difficult to return the caecum through the opening after the operation has been completed. The meso-appendix must be tied with great care. The appendix itself should be tied close to the caecum, preferably with silk, and separated by means of the actual cautery. If this is not at hand, the stump may be treated with strong carbolic acid or with a strong solution of corro- sive sublimate. When practicable, the stump of the appendix should be buried by infolding it in the csecal wall (Fig. 396). Some surgeons 908 SPECIAL OR REGIONAL SURGERY. make, near the base of the appendix, a cuff of peritoneum, which is inverted and sewed over the stump. Infolding or covering the stump in Fig. 396. Appendectomy: the meso-appendix has heen tied, the appendix removed, and the stitches are in position to bury the stump. the manner just described is probably unnecessary, for cases in which such a technique is impossible seem to progress equally well. In remov- ing the appendix from its mesentery special care must be taken that the ligatures are securely tied. They should be of fine silk. The dangers being hemorrhage and sepsis, great care nlust be taken to avoid both. The abdominal wound is closed by two or three interrupted sutures. In the short incision above described one deep suture is sufficient. The mortality, in the hands of experienced operators, is probably less than 2 per cent. SURGERY OP THE PERITONEUM. In the consideration of surgical diseases of the abdominal viscera the peritoneum is of the utmost importance. Two of its attributes require brief attention. The first is its power of forming adhesions ; the second, its power of rapid, absorption. Upon the former depend the efficient walling-off of septic foci and the success of many abdominal operations ; upon the latter, the absorption of hemorrhagic, serous, and septic exu- dations. Surgery op the Peritoneum. The formation of adhesions requires an irritation, mechanical, chem- ical, or septic, of the opposing peritoneal surfaces. The production of adhesions does not therefore necessarily require the presence of a micro- organism, for aseptic surfaces scratched with a needle and approximated adhere almost immediately. SURGERY OF THE ABDOMEN. 909 The importance of adhesive barriers in the prevention of extravasations is obvious, for example, in the lesions of gastric, duodenal, and intestinal ulcer and in perforations of the vermiform appendix. The vast powers of absorption possessed by the peritoneum exert a powerful influence in widely different directions. It absorbs benign exudations into the gen- eral circulation with extreme rapidity ; it absorbs with equal rapidity the ptomaines of bacterial growth. This attribute explains the early and profound systemic depression of general peritonitis, and upon it rests the theory of the saline treat- ment of peritoneal infection— a treatment by which intestinal drainage is supposed to remove the toxic products of germ-growth as fast as the peritoneum absorbs them. The peritoneum with its great extent of surface and its enormous powers of exudation presents a fertile medium for the growth of germ colonies— colonies which reproduce themselves with deplorable rapidity, luxuriance, and virulence. Peritonitis, by far the most important affection of the abdominal cavity, is a disease which is wholly and absolutely dependent upon micro- organisms. Aseptic peritonitis does not exist under the modern definition of the term, though it may be impossible by any known method of culture- staining always to demonstrate the presence of the causative germ. The extent and virulence of peritonitis are undoubtedly influenced largely by the growth, the reproduction, and the absorption of the micro-organisms present. Though it is as yet impossible to classify the varying forms of peritoneal inflammation at present described under the broad term peri- tonitis, it is not without strong probability that a bacteriological classi- fication will eventually be adopted. The causes of peritonitis through which micro-organisms are introduced into the peritoneal cavity are — (1) Extravasations from the alimentary canal — the stomach, the intestines, and the vermiform appendix ; from other septic hollow viscera — the gall- and urinary bladders, the pelvis of the kidney ; from the genital organs of the female through the uterus and tubes; from the rupture of abscesses. (2) Intra- abdominal necroses, which, though less common than the first group, include many of the gravest possible abdominal emergencies: (a) internal strangulation; (b) intussusception ; (c) volvulus ; (d) embolism and thrombosis of the mesenteric ves- sels; (e) gangrenous pancreatitis, gangrenous splenitis ; (/) fat-necrosis; (g) ova- rian and other tumors with twisted pedicle ; (A) movable kidney and wandering spleen with twisted pedicle. (3) Contamination by septic materials, missiles, instru- ments, and fingers. (4) Infections conveyed to the peritoneum, through the circula- tion, from remote foci : (a) rheumatic, gonorrhoea^ and syphilitic peritonitis, in which the direct communication between the original disease and the infection has not as yet been clearly demonstrated, and in which septic peritonitis is favored by the low state of the system in these diseases. (5) The so-called chemical peri- tonitis, dependent upon the irritation of chemical solutions, should not be included under the term peritonitis unless it is associated with the presence of a micro- organism. The pathological condition may be described as an intense local inflam- mation, with constitutional absorption. In the first hours of the infection, during which the lesion is now so often demonstrated, the gross appearances of the peritoneum are little if at all changed. Dilatation of the blood-vessels produces general deepening of the color. A clear serous exudation results from the initial congestion. The enormous reproduction of germ colonies in the peritoneum itself produces here and there broad flakes of lymph intimately connected with the intestinal wall. The serous exudate, hold- ing suspended germs in vast numbers, becomes turbid. When the infection is at its height the peritoneum is everywhere intensely congested, especially over the small intestine; the color is deepened, the muscular contractions enfeebled, and the intestine finally paralyzed and distended. Easily-separated adhesions form between contiguous surfaces. Upon the distended coils, here and there, dark 910 SPECIAL OR REGIONAL SURGERY. blotches appear ; the intestinal wall is thickened ; its peritoneum opaque. As the infection progresses the number and extent of the lymph-flakes increase, becoming occasionally detached and floating in the dependent serum. The disten- tion of the intestinal wall from gas-formation becomes excessive. The serum from being turbid may become opaque, green, greenish yellow, yellow, hemorrhagic; from being thin and watery it may become thick, creamy, or grumous. In extrava- sations from the alimentary canal the exudate is always foul-smelling and gen- erally contains gas. The bacteriology of peritonitis is of the utmost interest and importance. No case should be recorded as one of peritonitis in which the diagnosis does not rest upon an expert bacteriological examination. The bacterial forms which exert the most frequent and powerful influences, according to our present knowledge, are the bacillus coli communis and the streptococcus. Less rapid and virulent, though unfortunately fatal, micro-organisms are the various staphylococci, the pneumococcus, etc. The influence of the gonococcus is as yet undetermined. In the peritonitis of intestinal extravasations the bacillus coli communis, usually found in pure cultures, is doubt- less associated with many other forms of intestinal bacteria, which are masked by the luxuriance and rapidity of growth characteristic of the colon bacillus. In fecal extravasations gas-forming bacteria are almost invariably present. ( Vide Chapter III.) Symptoms. — From what has been said above, it is obvious that the symptoms of general peritoneal infections must vary between extreme limits. Yet certain cardinal symptoms are almost invariably present. They are pain, tenderness, vomiting, shock; rigidity of the abdomen, followed by distention; constipation, fever, systemic depression, collapse. Pain is usually the earliest symptom of peritonitis, though it may be absent ; it is at first local, later general. In local peritonitis, as exempli- fied in apjiendicitis, it is often first general ; later, local. It may be sharp (extravasation), paroxysmal (colic), or dull. In the later stages the pain may subside or disappear. Tenderness is almost always present. It varies in degree and in extent ; is often local, becoming general, or general, becoming local ; it may be exquisite or it may be noticeable only on deep pressure. It is a better guide to the causative lesion than pain, being more definitely referred. Rigidity from reflex spasm of the abdominal muscles, a symptom of the greatest importance, is always present in rapid extravasations. Rigidity points more definitely to a serious internal lesion than any other one symptom. Nothing less grave than a lesion threatening life itself can account for this symptom when it is associated with pain, tenderness, and shock. Distention follows rigidity as soon as the infection, through intestinal paresis, causes stasis of the intestinal stream. The intestines are often distended to an excessive degree. Obstipation and cessation of internal sounds are coincident with distention from the same causes. Vomiting is an early symptom in peritonitis ; at times the very first. The vomitus consists in the beginning of the contents of the stomach ; later it becomes green, then dark or fecal. In some instances it is the only conspicuous symptom throughout the disease, the patient dying of exhaustion, without pain, tenderness, fever, or distention. The signs of constitutional infec- tion are also perplexingly various. At times the temperature rises rapidly to 104° or 105° or more ; stays there or rapidly falls ; at times it is prac- tically normal, at times moderately elevated. The pulse is more constantly affected than the temperature, rising rapidly or slowly, but continuously. In the rarest instances it may remain normal or but slightly elevated until the infection is fully SURGERY OF THE ABDOMEN. 911 developed and hopeless. . The pulse, better than the temperature, indi- cates the patient's true condition. A temperature falling to normal or subnormal, with a rising pulse, is a combination of the gravest import. The fades of peritonitis is characteristic. The eyes are hollow and the cheeks dark red. The systemic depression of peritonitis is always grave. In some instances the initial shock is profound. With the progress of the disease depression becomes extreme and the patient dies in collapse. The usual symptoms are present in the shock and collapse of peritonitis. The enfeebled state of the circulation shows itself not only in a rapid and weak pulse, but in cold extremities and in lividity of the skin of the abdominal wall ; the latter symptom, however, may be present when the patient's general condition is fairly good. Combined with rigidity, abdominal lividity, as shown by the slow disappearance of finger-marks, is a grave symptom. In the early stages, when operative interference is advisable and not without hope, the symptoms may he grouped as follows: (1) Pain general, becoming local; or local, becoming general, according to cause ; (2) Tenderness, general, becoming local; or local, becoming general; (3) Rigidity of the abdominal muscles; (4) Vomiting, green ; (5) Rise of pulse and temperature; (6) Shock, varying in depth ; (7) Diminished peristalsis. In fully-developed peritonitis, in which the wisdom of interference is question- able, the symptoms are — (1) Pain lessened or absent; (2) Tenderness general ; (3) Distention excessive, replacing rigidity; (4) "Vomiting excessive, dark or fecal ; (5) Obstipation; peristaltic movements not heard ; (6) Rapid and feeble pulse ; (7) High or low temperature ; (8) Lividity of abdominal skin ; cold extremities; (9) Peritoneal facies ; (10) Mind clear. In hopeless cases the above symptoms are increased with collapse ; the patient is moribund. Acute abdominal symptoms demanding exploration are always con- spicuous, whatever the cause may be that produces them. In cases of doubt it is the part of wisdom to explore. The treatment of peritonitis may be medical — i. e. opium to prevent peristalsis or cathartics to increase it ; or surgical — irrigation and drain- age. In the vast majority of cases, however, all methods fail. Medical treatment should not be dismissed with a word, for it is better adapted to many cases than surgical. Cathartics, salines or others, are indicated at the beginning of the invasion, when the disease is feared rather than recognized, and before vomiting is frequent or excessive. On theoretical grounds intestinal drain- age by means of excessive liquid stools may remove so effectually the peritoneal exudate as to absorb the infection. If the truth were known, however, it would doubtless appear that in many cases no real infection was present or even impend- ing. The absolute futility of cathartics in advanced cases of demonstrated peri- 912 SPECIAL OR REGIONAL SURGERY. tonitis lends confirmation to this statement. Nevertheless, free watery evacuations undoubtedly encourage the elimination of ptomaines. Saline cathartics should be used only in the early stages when vomiting is not excessive. Calomel in small, divided doses, one-fifth of a grain every hour, will at times produce satisfactory discharges. Cathartics should never be used when intestinal perforations are suspected, for fear of increasing the extravasation. Opium should not be used unless absolutely necessary. It is indispensable in those cases in which the pain cannot be borne, and in which the harm it may do is more than offset by the relief it affords the patient. The surgical treatment of peritonitis consists (1) in the removal of the cause, and (2) in the removal of its effects. (The treatment of the various causes is described elsewhere.) The second indication requires incision, irrigation, or cleansing and drainage. The incision must be in the median line. Its extent and situation will depend upon the cause of the infection. The median incision should be made below the umbilicus. As soon as the peritoneum is nicked serum will escape. The appearance of the serum may indicate in a general way the nature of the infection. If clear, turbid, or purulent, without odor, the infection does not depend upon the alimentary canal ; if foul-smelling and fecal, it comes from the intestinal tract, or, rarely, the tubes ; if urinous, from the genito-urinary tract ; if hemorrhagic, without sepsis, there is mistaken diagnosis. The escape of fluid of one kind or another justifies the exploration and indi- cates its further prosecution. The incision should be enlarged and the fluid in the dependent portions of the abdominal cavity removed as thoroughly as possible by means of gauze or sponges. The exploration should then proceed according to the circumstances of the case. (See Special Causes of Peritonitis.) The manipulations described above are seriously interfered with when distention is excessive or even moderate ; the intestines escape from the wound the moment pressure upon them is relaxed. Under excessive intra-abdominal pressure it is practically impossible to bring the irrigat- ing fluid thoroughly in contact with the diseased coils unless evisceration is complete — a procedure which adds greatly to the shock and which is not infrequently the immediate cause of death. To empty the distended coils and to relieve distention aspiration and free incision have been prac- tised. The latter is of doubtful utility, because a single incision will empty but a single coil. The multiple incisions necessary — all requir- ing suture — accomplish too little in the relief of distention to make them of 'much practical value. A single coil when opened may be fastened to the external wound for a temporary anus. As a rule, no considerable nor lasting effect follows either enterotomy or artificial anus. Acute general peritonitis, when fully developed, presents almost insuperable obstacles to effective drainage. The colonies of micro- organisms make their way into the remotest recesses of the abdominal cavity, which, shut off by immediate adhesions, cannot be efficiently drained. General peritoneal infections, for this reason alone, must be fatal in the vast majority of cases under any method of treatment at present known. SURGERY OF THE ABDOMEN. 913 Tubercular Peritonitis. Tubercle bacilli may reach the peritoneum from the genito-urinary or intestinal tract, from the mesenteric nodes or by way of the circula- tion, from any tubercular focus, or in the course of a general acute mili- ary tuberculosis. In males the usual source of infection is the intestinal tract — more rarely the genito-urinary ; in females, the reproductive organs. In children the mesenteric nodes are primarily affected by direct inoculation through the intestinal mucous membrane. The disease manifests itself in three forms : (a) The ascitic form — tubercular ascites ; (6) the dry flbrino-plastic form — adhesive tuber- cular peritonitis ; and (c) the ulcerative or suppurative form. Symptoms. — The symptoms of tubercular peritonitis are usually vague. There is generally malaise and emaciation, variable hectic fever, gastro-intestinal disorders, diarrhoea, and occasionally pain and tenderness in the abdomen. In the ascitic form abdominal distention develops rapidly and calls attention to the disease. In the adhesive variety the symptoms are obscure. From the matting together of the omentum and intestinal coils the abdominal condition may simulate on palpation any form of intra-abdominal tumor. In the encysted form tubercular peritonitis may be mistaken for hydronephrosis, dilated gall-bladder, cysts of the omentum, mesentery, or spleen. The adhesive variety may closely simu- late malignant disease. • In the ulcerative form the constitutional symptoms are more extreme, the fever more constant and severe, and the abdominal tender- ness more marked. Cases of emaciation and malaise attended by vague gastro-intestinal symptoms and variable fever should be investigated closely, for these symptoms always suggest the presence of tubercular peritonitis. Cases of the general ascitic form have not infrequently been mistaken for ovarian cysts. Treatment may be palliative or operative. Operative measures are demanded in all cases in which the presence of advanced tubercular disease in other organs does not offer contraindication. Palliative meas- ures do not differ from the medical treatment of all tubercular processes. Ascitic distention may be relieved by occasional aspiration. Surgical treatment consists in incision and free evacuation of the fluid, with or without prolonged drainage. The fluid should be removed as thoroughly as possible by median incision below the umbilicus. Additional drainage may be established by incision through the flanks. A single incision, with thorough evacuation of the serous exudate and immediate closure, is followed by quite as good results as prolonged drainage by means of gauze and tubes. Moreover, prolonged drainage by those means may be followed by a persistent sinus or a fecal fistula. Care must be taken not to open adherent bowel in making the incision through the abdominal wall. The ascitic form is the one most favorable for operation, the ulcer- ative form the least. Statistics show 35 per cent, of cures after opera- tion in the ascitic form of the disease. Operation is most successful in children and young adults. The clinical resemblance between simple fibrous peritonitis (peritonitis nodosa), 58 914 SPECIAL OR REGIONAL SURGERY. cancerous peritonitis, and tubercular ascites is so close that a positive diagnosis of tubercular peritonitis with ascites requires an expert microscopic examination of one or more tubercles or nodes. Perforations of Typhoid Ulcers. Surgical treatment in typhoid ulcers is applicable to between 6 and 7 per cent, of the cases which result in perforation. From the nature Fig. 397. Extensive perforation from ulceration of Peyer's patch in typhoid fever in the third week (Warren Museum). of the constitutional disease, from the extreme rapidity with which the peritoneum becomes infected by intestinal extravasation, from the dangers incident to the operation itself, the chances of saving any con- siderable number of cases are extremely small ; yet in 23 reported ope- rations there were 7 recoveries — a record which is better than could reasonably have been expected. The surgery in general of typhoidal ulcers is that of general peri- toneal infection or of localized abscesses. The symptoms of perforation of typhoidal ulcers are those of intes- tinal perforations from other causes — an aggravated general peritonitis with the symptoms of the already existing constitutional disease. When in the course of a typhoid fever, mild or severe, the patient is seized with intense pain, followed by tenderness, abdominal rigidity, distention, and shock, the perforation of a typhoidal ulcer is almost beyond ques- tion. Most cases go on to a fatal termination in the course of a few hours. Unless the collapse is extreme, the treatment demanded is imme- diate exploration. The incision should be made in the median line, and SURGERY OF THE ABDOMEN. 915 the exact seat of the lesion determined. If but one perforation exists, the bowel may be infolded and sutured, as in the operative treatment of stomach ulcers. If the disease be too extensive to permit this method, the coil may be resected or it may be fastened temporarily into the wound. In case these methods are impracticable, gauze may be packed about the seat of perforation and brought out of the abdominal wound. The coexistent peritonitis should be treated like peritonitis from other causes. Abscesses require irrigation and drainage. Duodenal ulcers also perforate occasionally, and there are now on record at least sixteen operations. These ulcers are not alone those which are due to burns, but those which occur just as do similar lesions in the stomach, and largely from similar causes. They may be met at any age, and in the apparently strong and healthy. Consequently, when perforation and the ensuing grave symptoms appear, the latter may be almost inexplicable. There is but one thing to do in such cases — i. e., to operate, commencing by exploration and orientation, and finishing only when the indications have been met. Surgery op the Omentum. Abscess of the omentum is a form of localized peritonitis. It may be due to septic infection after wounds or ruptures, or to extension from neighboring viscera, most frequently from the perforated appendix. The extraordinary capacity of the omentum for forming adhesive barriers against septic processes — extravasations and abscesses — not infrequently results in infection of the omentum itself with single or multiple abscesses. The diagnosis and treatment of omental abscesses are those of any local peritonitis with abscess-formation. New Growths of the Omentum. — Cysts of the omentum may be serous, hemorrhagic, hydatid, or lymphatic. Serous cysts of the omentum are generally of inflammatory origin. Blood-cysts have occasionally resulted from wounds or ruptures. Large multilocular lymph-cysts of the omentum are probably of congenital origin and due to dilatation of the lymph-channels. Hydatid cysts of the omentum are never primary. The so-called dermoid omental cysts have generally been found to be ovarian in origin. A cavernous angeioma of the omentum has recently been removed by Homans. Solid tumors of the omentum may be sarcomata, carcinomata, fibromata, or lipomata. Carcinoma, is never primary in the omentum. Infiltrations of the omentum secondary to cancer of other abdominal structures, and of the breast, are not uncommon. Sarcoma has been observed as a primary omental growth. In the fibro-cystic form it has been mistaken for a simple cyst. Fibroid and fatty tumors of the omentum are very rare. The omentum is involved in general peritoneal tuberculosis and in acute miliary tuberculosis. Diagnosis. — Omental tumors are seldom correctly diagnosticated before operations. Theoretically, a small, non-adherent omental tumor may be moved upward and laterally, but not downward, and will not move with respiration. It will appear superficial to inflated intestines or 916 SPECIAL OR REGIONAL SURGERY. stomach. Large and extensively adherent tumors can only with diffi- culty be differentiated from other abdominal growths. Tumors con- fined to the omentum are not associated with functional disturbances, and are usually undiscovered until large enough to cause pressure- symptoms. Cysts of the omentum are often confused with ovarian cysts. Aspiration may he the only means of determining the cystic nature of an omental growth. Extensive adhesions and matting together of the omentum and intestines may simulate almost any form of intra-abdominal tumor. Treatment of omental tumors should invariably consist in ex- ploratory laparotomy with extirpation of the growth. Cysts which cannot be completely removed should be treated by incision and drainage. Diseases op the Mesentery. The mesentery is the seat of lesions, acute and chronic, which are at times of the greatest surgical importance. Prominent among them is tuberculosis of the lymph-nodes of the mesentery. This disease is asso- ciated with tubercular peritonitis, and is often a part of the disease. Occasionally, however, the lymph-nodes of the mesentery are alone infected ; indeed, the infection may be limited to the mesentery of a single coil. A tuberculosis thus limited is of the deepest surgical inter- est, for free dissection may remove a focus of infection so close to the general lymph-reservoirs as to threaten life. Early and thorough removal of lymph-nodes thus affected may render tabes mesenterica a less formidable disease. The symptoms of mesenteric tuberculosis are those of peritoneal tuberculosis. A limited infection with enlargement of the lymph-nodes may cause a definite localized tumor, the nature of which can only be suspected. The treatment is that of tubercular peritonitis when the infection is extensive ; when localized as a distinct tumor thorough extirpation is demanded. Mesenteric Embolism and Thrombosis. — Plugging of the mesen- teric vessels is probably more common than is usually supposed. Many cases of intestinal necrosis doubtless are dependent upon this lesion. The causes of embolism and thrombosis are similar to the causes of these lesions in vessels elsewhere. The results are most disastrous, for with the stasis of circulation necrotic changes in the intestine immediately appear. Death is sure to follow unless the affected coil is resected at once, or at least isolated by gauze barriers and opened in the abdominal wound. The symptoms are at first indefinite. Pain is an early and promi- nent symptom ; later appear the signs first of intestinal obstruction, and then of gangrene. Excision of the gangrenous coil before a gen- eral infection takes place offers a chance of permanent cure, as in Elliot's case. Cysts of the mesentery are similar in origin, causes, symptoms, and treatment to cysts of the omentum (Fig. 398). Chyle-cysts are found rarely in the mesentery, and still less often in other portions of the SURGERY OF THE ABDOMEN. 917 abdominal cavity. They are due for the most part to obstruction of chyle-conveying vessels, and may attain considerable size. They are not to be diagnosed before opening the abdomen save by examination of fluid withdrawn by exploratory puncture. This fluid will be found to possess the same milky appearances noted in cases of chylous ascites and chylous hydrocele. Such cysts are to be treated on general operative principles by extirpation. Fig. 398. Cyst of the mesentery, containing clear fluid. The hour-glass constriction passes through the layers of the mesentery (from a case occurring in the author's practice). Pancreas. Pancreatitis may be either acute or chronic. The acute varieties are — Acute hemorrhagic pancreatitis ; Acute suppurative pancreatitis ; Acute gangrenous pancreatitis. Acute hemorrhagic pancreatitis is of surgical interest, because often mistaken for acute perforative peritonitis or acute intestinal obstruction. Operations worse than useless have been performed under such erroneous diagnoses. Its onset is sudden, its course rapid and severe, its end almost universally fatal. Those cases that survive the first day or two of the disease and result in pus-formation may possibly recover after drainage. Acute suppurative pancreatitis, or abscess of the pancreas, is the result of invasion of any part of the gland by micro-organisms. Calculi, intestinal round-worms in the pancreatic duct, wounds, injuries and cysts of the pancreas are predisposing causes. The septic pro- 918 SPECIAL OR REGIONAL SURGERY. cess may extend to the pancreas from neighboring organs, especially from ulcers of the stomach or the duodenum. Suppuration may be manifested as a. peripancreatitis, as a retroperitoneal abscess, or as multiple collections of pus disseminated throughout the pancreas. Multiple abscesses may degenerate into one large abscess-cavity, which may communicate with the duodenum or rupture into the general peritoneal cavity. The majority of cases of multiple abscess occur in adults under forty. Symptoms. — The symptoms in nearly every case point at first to the stomach or the liver. Fever is not constant ; jaundice may exist ; the urine may contain sugar. Ascites and oedema have been present in many cases. Diagnosis. — In most of the cases of suppurative pancreatitis the diagnosis has not been made before death. Emaciation, general malaise, and gastric disturbances, with variable symptoms of constitutional sep- sis, suggest the possibility of the disease. A tumor in the region of the pancreas confirms the diagnosis. To determine the situation of the tumor with reference to the stomach the latter may be inflated. The tumor may be in the epigastriutn or in the right or left hypochondrium ; it may be observed in the first few days of the disease, or not for sev- eral weeks after the first symptom. The prognosis is grave. Death is caused by acute sepsis or by pro- gressive exhaustion. In most cases it occurs within a few days of the onset of the disease. Sudden death may be caused by rupture of abscess into the general peritoneal cavity. In rare cases rupture into the intes- tinal tract has resulted in spontaneous cure. Treatment. — Surgical intervention in suppurative inflammations of the pancreas is indicated when the signs of pus are clear. Incision and drainage are demanded. Interference in the acute stage is contraindi- cated. The chief care in the operation should be to prevent contamina- tion of the general peritoneal cavity. Incision should be made in the median line, between the umbilicus and the ensiform cartilage, over the most prominent portion of the tumor. The stomach and transverse colon usually overlie the abscess and must be avoided. The layers of the omentum must be incised or torn to gain access to the pancreatic space. The general peritoneal cavity must be protected thoroughly by gauze. To establish the diagnosis the tumor may be explored with an aspirating needle before incision. If pus is found, the greater part of it should be drawn off" through the needle, as in this way subsequent manipulations are facilitated and the danger of general peritoneal infec- tion is lessened. A free incision into the abscess should then be made and the cavity should be thoroughly irrigated. Drainage by means of gauze and drainage-tubes will be necessary, and must be continued as long as there is any discharge. Closure of the wound after too early a removal of the tubes will result in reaccumulation of the pus. Hemor- rhage from the abscess-cavity may be checked by gauze-packing. In some cases pus, starting from the pancreas and burrowing behind the peritoneum, will make its appearance as a fluctuating tumor in the flank. Such cases should be incised and drained from behind. Gangrene of the pancreas is the result of acute septic infection of the gland. The infection is usually of such virulence that surgical SURGERY OF THE ABDOMEN. 919 measures, to be of any use, must be applied at the earliest moment. Theoretically, there is no reason why a gangrenous pancreas should not be drained or the gangrenous portion removed. In rare cases spontan- eous cure has taken place by the sloughing of the necrosed gland into the intestine. Chronic pancreatitis or sclerosis of the pancreas is a form of chronic inflammation resulting in an increase of the connective tissue of the gland. The process may affect the whole organ. The indications for operative treatment are the symptoms of stricture of the common duct, with retention of bile or of pancreatic fluid. Per- sistent jaundice and emaciation, with little or no pain, suggest obstruc- tion of pancreatic origin. Surgical Treatment. — The only surgical treatment consists in chole- cyst-enterostomy, an operation for the relief of the biliary obstruction. Pancreatic calculi are usually small, multiple, and white. In rare in- stances a single large stone is found. The calculi consist of phosphate or carbonate of lime. Pancreatic calculi have no surgical interest except that they may be the cause of pancreatic cysts and of chronic pancreatitis. Cysts of the pancreas are usually retention-cysts due to the impac- tion of calculi in the pancreatic duct. Cysts of the pancreas may result from — (a) Obstruction of the pancreatic duct by calculi, with attendant changes in the parenchyma of the gland ; (6) Obstruction from cicatricial contractions of the duct ; (c) Obstruction of the duct from displacement of the pancreas ; (d) Obstruction of the duct from trauma. Cysts of the pancreas are globular in shape and may be as large as a man's head. In cysts of rapid formation the wall is thin from disten- tion ; in those of slower growth it is thick ; it may be cartilaginous or ossified. An accessory pancreas may be the starting-point of the cyst. The symptoms of pancreatic cyst are chiefly local — indefinite pain or discomfort in the epigastrium, disturbances of intestinal digestion, varying in severity according to the amount of pancreatic fluid shut off from the duodenum. In some cases diabetes is present. The tumor itself is characteristic : it fills the space occupied by the pancreas and causes a symmetrical swelling in the epigastrium. It is often so tense as to seem solid. The diagnosis must be made from the presence and physical attri- butes of the tumor. To determine the latter aspiration may be em- ployed. Cysts of the pancreas must be distinguished from cysts of the peritoneum and mesentery and from malignant disease of the pancreas. The operative treatment of pancreatic ct/st* should, in the vast majority of cases, be incision and drainage. A few cases have been reported in which complete extirpation of the cyst has been accomplished. The technical difficulties of extirpation practically exclude this operation though enucleation of the cyst, if it can be effected without removing the entire gland, may be attempted. The dangers of enucleation are chiefly those of hemorrhage and shock. Drainage of pancreatic cysts should be made through a median incision between the umbilicus and the ensiform cartilage. Pancreatic fluid may be septic ; therefore great care must be taken not to infect the general peritoneal cavity. The 920 SPECIAL OR REGIONAL SURGERY. incision into the cyst should be large enough to permit thorough explor- ation for stone. Drainage must be used until the discharge cease. New growths of the pancreas may be sarcomata or carcinomata. Sarcoma is very rare. Cancer of the pancreas may be jjrimary or secondary. It is usually of the scirrhous form, and situated in the head of the gland. New growths limited to the pancreas are seldom suspected, excepting when a persistent cholannia suggests their presence. Symptoms of Cancer of the Pancreas. — Epigastric pain with progressive emaciation and cachexia, jaundice, diabetes, and fatty diar- rhoea suggest malignant disease at the head of the pancreas. The symp- toms, however, are variable. A deep-seated, movable tumor in the region of the pancreas may confirm the diagnosis. Cancer of the pancreas must be differentiated from cancer of the pylorus, cancer of the liver and gall-bladder, cancer of the intestines, and impacted gall-stones. It is often impossible to make a differential diagnosis between a gall-stone impacted in the common duct and cancer of the head of the pancreas. Treatment. — Radical excision of malignant disease of the pancreas offers great technical difficulties and slight chance of permanent cure. It should be attempted only in cases in which the disease is limited to the tail of the gland. Palliative treatment should be directed to the relief of the persistent jaundice. The operation demanded in these cases is chole-cyst-enterostomy. The anastomosis should be made, if possible, between the gall-bladder and the duodenum. The Spleen. Suppurative Splenitis ; Abscess and Gangrene of the Spleen. — The chief causes of suppuration of the spleen are septic embolism or infarcts, septic infection from without or within after injuries, and the extension of sepsis from neighboring organs. Diffuse abscesses of the spleen are uncommon. The process is usually circumscribed. In several pyeemic conditions hemorrhagic infarcts of the spleen are not uncommon. Single or multiple abscesses, small in size, may enlarge and coalesce into a single large abscess sac involving the whole organ. Perisplenitis may result with adhesions to surrounding parts, which may guide the pus into the abdominal or thoracic cavity, the stomach, or intestines. Primary suppurative splenitis occurring in malarial or typhoidal conditions is caused by septic infection of an organ the vitality of which has been weakened by constitutional disease — an organ made still more susceptible by vascular engorgement. The symptoms of splenic abscess are vague. Unless the capsule is involved, pain will not be present. Though hectic fever may result, it is of little value as a symptom, because splenitis is usually secondary to a general febrile disease. The vomiting of pus or blood or its passage in the stools may occur, though rarely. Gangrene of the spleen is the result of intense septic infection of the spleen. Its course is so rapid and fatal that surgical treatment is rarely if ever indicated. Displacement of the Spleen. — Stretching of the ligaments of the spleen allows change in the normal position of the organ. Extreme changes in position other than traumatic prolapse and dislocation are SURGERY OF THE ABDOMEN. 921 found whenever chronic enlargement of the spleen has caused abnormal stretching of the ligaments. In rare cases the elongation of the liga- ments may be congenital, but usually the condition is gradually acquired. Ultimately the spleen may be found in the hypogastric or umbilical region, the iliac fossae, or the pelvis. The chief cause of wandering spleen is hypertrophy. The symptoms of wandering spleen are those of dragging of the enlarged organ upon the stomach and the pancreas, the circulation of which, as well as of the spleen itself, may be impaired. The splenic ligament in extreme cases becomes stretched into a long pedicle, the twist- ing of which has been known to cause gangrene of the spleen. Pain may be constant ; it is produced by dragging on the stomach or pancreas or by dragging on adhesions to other organs. The diagnosis is to be made from the characteristic shape of the splenic tumor, with the recognition of the hilum. The normal area of splenic dulness is replaced by an area of tympany. In most cases of wandering spleen the size of the tumor far exceeds the normal size of the gland. The treatment of this affection may be palliative or operative. A trial of palliative measures should be made when the mobility is slight and the symptoms are mild. With the patient in the dorsal decubitus the sjjleen should be held in normal position by means of compresses and ice-bags. If the hypertrophy of the displaced spleen be due to malaria, an attempt to reduce the size of the organ by medical treatment may be made. Except in one or two instances, splenectomy has been the only means of radical cure. The mortality of splenectomies for this cause has been slight. (For the operation of splenectomy see page 922). Hypertrophies and Tumors of the Spleen. — Hypertrophies of the spleen, aside from the acute enlargement occurring in the course of infec- tious diseases, are (1) simple or idiopathic; (2) malarial; (3) leuksemic and pseudo-leuksemic. The diagnosis of idiopathic hypertrophy can only be made after eliminating other possible causes of hypertrophy. Chronic malaria is the commonest cause. Leuksemic and pseudo-leuksemic enlargements of the spleen are secondary to morbid changes in the blood- and lymph-systems. Leukaernic conditions absolutely contraindicate surgical interference. Chronic enlargement of the spleen occurs also in cirrhosis and other chronic diseases of the liver, in chronic pulmonary diseases which cause passive congestions, in syphilis and amyloid diseases. Surgically it is unimportant. New Growths of the Spleen. — Cancer and sarcoma of the spleen are very rare, and are usually secondary growths, though cancer has been known to be primary in the spleen. Cysts of the spleen may be simple serous cysts, blood-cysts, or hydatid cysts. Cysts which contain blood or serous fluid are of anatomical rather than of surgical interest, and rarely justify operative interference. Operative Treatment op Splenic Tumors. — Because of the uncertainty of diagnosis in cases of splenic tumor the surgeon can never know before exposing the spleen whether a splenotomy or a splenectomy must be performed. The choice depends upon the appear- ance of the organ after exposure and the results of aspiration. The 922 SPECIAL OR REGIONAL SURGERY. operation of splenotomy should be reserved for cases of cyst and of abscess. Spleno-megaly, or Banti's disease, has of late assumed a sur- gical importance. It is characterized by splenic enlargement, with marked secondary anaemia and hypoleucocytosis without differential alterations, save in a remarkable myelocytosis which in one case reached 14 per cent., such as is seen only in splenic myelogenous leukasmia, though a very mild degree of the same is seen in various anaemic conditions. (Lyon.) At present writing (June, 1899) the spleen has been removed four times for this condition, and in every case with recovery. Splenic tumors may also be differentiated from renal and other tumors of the same region by a careful blood-count, since leucocytosis is absent in Banti's disease, but present in inflammatory or malignant growths in the renal or the splenic (as in other) regions. Laparo-splenotomy formerly meant extirpation of the spleen, but at present its use is restricted to cases in which a cyst or abscess of the spleen is drained through an incision. The incision should be made at the border of the ribs, over the most prominent portion of the tumor. The chief care in the operation is the prevention of a general septic peri- toneal infection. Adequate drainage of the abscess-cavity should be provided by means of tubes and gauze. Splenectomy has been performed for leukasmic hypertrophy, mala- rial hypertrophy, simple hypertrophy and wandering spleen, cysts of the spleen, malignant disease, abscess and inflammatory changes, syphilis and amyloid degeneration, wounds and ruptures. The incision for splenectomy should be made on the left side of the abdomen along the border of the ribs. The situation and extent of the incision should in all cases be such as to facilitate the securing of the splenic artery, for the chief danger in the operation is hemorrhage. The incision should be made large enough to admit the hand, in order that thorough exploration of the tumor and its attachments may be made. The pedicle should be tied with large silk, and if bloodless may be dropped into the abdomen. Venous hemorrhage should be controlled by ligatures and gauze packing. Splenopexis, for securing the wandering spleen in its normal posi- tion by means of sutures, has recently been advocated as a routine treatment by Bydygier. At present no opinion as to the value of the operation can be expressed. Surgery of the Liver. Displacements of the Liver. — Congenital displacements of the liver may be either transposition of the entire organ, as in »i(us transversus, or hernia of the liver into the abdominal cavity through some defect in the abdominal wall, or into the thoracic cavity through a deficiency in the diaphragm. The normal liver, within certain limits, is freely movable, rising or falling with intra-thoracic or intra-abdominal pressure. Stretch- ing of the ligaments of the liver, especially the suspensory liga- ment, occasionally results in abnormal displacement of the liver, or SURGERY OF THE ABDOMEN. 923 what is called floating liver. This lesion is four times as common in women as in men. The chief cause is repeated pregnancies, associated with pendulous abdomens. The only symptoms are those of pressure — dyspnoea, nausea, vomiting, cyanosis, and occasionally jaundice. Hepatic abscesses may rupture into the lungs, the pleurae, the pericardium, the peritoneum, the intestines, the bile-ducts, or the gall- bladder ; or they may perforate externally. Abscess of the liver is due to invasion by septic organisms. Trau- matism — contused, lacerated, or penetrating wounds — is a predisposing cause. Abscesses of the liver may be of the solitary or tropical form, the multiple embolic or pycemic form ; they may result from gall-stones or from suppuration in the bile-duets. Rarely foreign bodies may pass from the stomach, or the intestine into the liver and cause suppuration. Intestinal round-worms are a possible cause of abscesses in the liver, especially in children. Abscess of the liver must be differentiated from intermittent malarial fever, hydatid cyst of the liver, abscess of the abdomined wall, cancer of the liver, gall-stones, dilated gall-bladder, and right-sided pleurisy. Examination of the blood for the organism of malaria is an important means of differentiation. The diagnosis is confirmed by the presence in the stools of the amoebae coli of dysentery. Cholelithiasis, with dilatation of the gall- bladder, is accompanied by a history of gall-stones, by paroxysmal pain, and by jaundice. The constitutional symptoms are much less severe. Hydatids are rare ; their growth is slow. In the majority of cases there is no fever ; pain comes on late and is not severe. The general condi- tion is but slightly changed. The fluid withdrawn by the aspirating needle is clear and may contain the hooklets of the parasite. Suppu- rating hydatid cyst is with great difficulty distinguished from abscess of the liver. Cancer of the liver is generally a secondary growth. Jaundice is usually present and hectic fever absent. The tumor is hard and nodular. When cancer is associated with abscess its presence may not be suspected. Right-sided pleurisy, with effusion, must be diagnosti- cated by physical signs. Abscess in the abdominal wall gives no history of intestinal disturbance and presents less evidence of general sepsis. Treatment. — Cases of solitary abscess or of suppuration following traumatism are the only ones in which surgical interference should be con- sidered. The severe pyasniic condition and the dissemination of the pus- foci in multiple embolic abscesses contraindicate operation. The cases are almost invariably fatal. If from the presence of an external tumor and from constitutional signs abscess of the liver is evident, the sur- gical treatment should be free incision and drainage. Thorough digital exploration should be made in search of possible sacculations and secondary abscess-cavities. Hemorrhage should be checked by gauze packing. The after-treatment is that of any internal abscess-cavity. The results in operated cases have been excellent. Hydatid Cysts of the Liver (Fig. 399). — Hydatid disease is rare in America. The liver is the organ most frequently affected. The parasites reach the liver from the intestinal tract by the way of the portal vein. The growth of hydatid cysts of the liver is very slow, from four to twenty- 924 SPECIAL OR REGIONAL SURGERY. Fig. 399. five years being the duration of their life. In many cases the cyst never attains sufficient size to cause symptoms ; in many the disease is self- limited and the cyst becomes calcified. From pressure in the region of the liver large cysts cause pain and a feeling of weight ; from pressure on the dia- phragm, dyspnoea and cough ; from pressure on the portal vein or bile-duct, ascites, jaundice, and enlargement of the spleen. The cyst may rupture into the pleura or lungs, into the perito- neum, or externally. Spontaneous cure has resulted from perforation into the intestinal tract. The general condition is usually but little affected. When suppuration in the cyst-fluid occurs, the symptoms suddenly become those of hepatic abscess. The diagnosis may be impossible unless the cyst is such as to be easily palpated through the abdominal wall. The cysts, especially when multi- locular, are sometimes of great size (Fig. 399) ; frequently their irregu- larity in shape may suggest the nature of the disease. A painless enlargement in the liver, a fluctuant and tense tumor, and an occasional hydatid fre- mitus are suggestive signs. The disease has been mistaken for can- cer, for hydronephrosis, for dilatation of the gall-bladder, for right- sided pleural effusion, and for abdominal aneurism. The tumor of an enlarged gall-bladder is pear-shaped, and is usually accompanied by a history of gall-stones or of catarrhal or obstructive jaundice. In cysts of the kidney the colon lies in front of the tumor ; in hydatid cysts of the liver it lies behind. A cyst of the liver moves with respiration. When the diaphragm is pushed up by the pressure from hydatid cyst of the liver, the heart will be found more displaced than in cases of pleural effusion. In some instances it may be necessary to resort to the aspirating needle to establish the diagnosis. Treatment. — When hydatid cysts of the liver are large enough to be diagnosticated with a fair degree of certainty, operation should be performed. Aspiration, except as a diagnostic measure in obscure cases, is not to be advised, not only because of the dangers attending it, but because it will not remove the mother cyst. Electrolysis and injec- tions of iodine have been tried without permanent success. In draining a hydatid cyst the incision should be made over the most prominent part of the tumor, the peritoneum cautiously opened, and the tumor exposed. Adhesions of the cyst to the parietal peritoneum are rarely found. After thoroughly walling off the general peritoneal cavity with gauze the ten- sion of the cyst may be cautiously relieved by removing some of the fluid with the aspirating needle. After the cyst-cavity has been thor- Hydatid cysts of a monkey's liver (Warren Museum). SURGERY OF THE ABDOMEN. 925 oughly evacuated through free incision and digital exploration, its wall should be stitched to the parietal peritoneum and the sac packed with gauze around drainage-tubes. The after-treatment consists in thorough antiseptic irrigation. Cholelithiasis and Surgery of the Gall-bladder. Malformations of the Gall-bladder. — Congenital absence of the gall-bladder and variations in the size and situation of the intestinal opening of the gall-duct have occasionally been noted. Gall-stones are a common affection of middle and advanced life. Three-fourths of all the cases are found in women. Gall-stones are usually formed in the gall-bladder, very rarely in the small branches of the hepatic duct in the liver itself. Their formation probably is associated with some slowing of the biliary flow and with catarrhal disease of the mucous membrane. So long as gall-stones remain in the gall-bladder they may cause no symptoms. The pathological effects of gall-stones are — biliary colic, due to the passage of stones through the ducts, obstruction of the ducts, and septic invasion, leading to suppuration in the gall-bladder and ducts, to ulceration, perforation, abscess of the liver, etc. Symptoms. — Paroxysmal attacks of pain, with or without brief jaundice, followed by periods of complete remission, point to the passage of gall-stones through the cystic duct. Persistent pain, with more or less persistent jaundice, indicates the slow passage of a biliary calculus from the gall-bladder through the common duct to the duo- denum. The diagnosis of gall-stone colic is generally easy, but it must be expected that at times cancer in the vicinity of the gall-bladder will be found associated with calculi. A certain percentage of cases, mainly the cases of the passage of stones through the cystic duct, have no jaundice. In these cases the diagnosis is not so evident. Youth in a patient makes the existence of malignant disease improbable. Complete obstruction of the cystic duct from impaction of a stone or from other causes may result in a dilatation of the gall-bladder, which may attain enormous proportions. The tumor may fill the entire right half of the abdomen and even extend into the pelvis. In long-continued obstruction the fluid contents of the gall-bladder may be clear or slightly tinged with bile. Septic infection may take place, and cause empyema of the gall-bladder. A dilatation of this sort must be differentiated from cystic tumors of the kidney, pancreas, ovary, or mesentery. Dilatation of the gall-bladder from the impaction of calculi in the cystic duct is unattended by jaundice. Impaction in the common duct usually causes marked dilatation of the gall-bladder ; it causes dilatation of the branches of the hepatic duct, and may result in pronounced and fatal jaundice. Infection of the mucous membrane of the gall-bladder or of the biliary ducts may occur at anytime through minute injuries to the epithelium. The usual forms of bacteria are the bacillus coli communis, the streptococcus, and various staphylococci. Infection through the cystic duct may cause empyema of a dilated gall-bladder ; it may convert a catarrhal cholangitis, the usual accompaniment of gall-stone impactions in the common duct, into a suppurative cholangitis, from which abscess of the liver may result. 926 SPECIAL OR REGIONAL SURGERY. Acute phlegmonous cystitis may occur as an indirect sequence. The so-called hepatic fever commonly ascribed to chronic catarrhal cholangitis Fig. 400. Gall-bladder contracted upon a gall-stone (Warren Museum). of the common duct is probably due to septic causes. The septic process may cause ulceration and perforation of the gall-bladder or its ducts ; it often extends to the peritoneal coats, causing firm adhesions of the gall-bladder to neighboring structures. It is not uncommon to find the gall-bladder thickened and contracted upon a large stone (Fig. 400), buried in firm adhesions extending to the colon, the duodenum, or the pylorus. Such adhesions greatly increase the difficulties of operations upon the gall-bladder. Perforation of the gall-bladder or ducts from the ulceration of calculi or from rupture may result in external or internal fistulas, or in direct extravasation into the general abdominal cavity, with general or local peritonitis (Fig. 401.) Perforation may take place into the pleura or into the lung. Internal biliary fistula? have been found between the gall-bladder and the intestines ; rarely between the gall- bladder and the stomach, and still more rarely between the gall- and the urinary bladder ; in the majority of cases perforation takes place into the duodenum. Large gall-stones not infrequently ulcerate into the intes- tinal tract and become a cause of acute obstruction. Strictures in the common duct, and also in the cystic, usually originate from -an old gall-stone impaction through the cicatricial con- traction of the injured mucous membrane ; they may be occasionally due to catarrhal or diphtheritic ulceration. The diagnosis of biliary colic must be made from the paroxysmal nature of the attacks, with or without jaundice. The discovery of a gall-stone in the faeces will positively establish the diagnosis. Persistent SURGERY OF THE ABDOMEN. 927 pain and jaundice, following a history of a number of paroxysmal attacks, point to a stone in the common duct, When the chief symp- Fig. 401. Perforating ulcer of the gall-bladder causing death from peritonitis (Warren Museum). torn is jaundice, the diagnosis between a stone impacted in the common duct and malignant disease may be impossible. Indeed, cancer often complicates retained or impacted gall-stones. Exploration often shows that the jaundice is caused by the pressure of a malignant growth upon the common duct. Malignant disease, situated in the head of the pan- creas and obstructing the biliary flow, most closely simulates an impacted stone. Obstruction of the duct by the pressure of non-malignant growths cannot be absolutely diagnosticated. Symptoms of jaundice and emaci- ation may be the result of a complete obstruction of benign origin, of hopeless intra-hepatic disease, or of the pressure of an extra-hepatic malig- nant growth. The completeness of the biliary obstruction is important. In many forms of intra-hepatic disease attended by jaundice there is a slight amount of biliary secretion, which makes its way into the intestine and may be found on examination of the faeces. In mechanical obstruc- tion, on the other hand, the biliary flow is totally shut off by occlusion of the bile- or common ducts and the faeces contain no bile. Moreover, in a mechanical obstruction there may be temporary relaxation of the pres- sure causing it, with sudden appearance of bile in large quantities in the intestinal tract. Cystic tumors of the kidney, pancreas, stomach, ovary, omentum, or mesentery and hydatid cysts of the liver may at times be confounded with dilated gall-bladder unaccompanied by jaundice. The shape, location, and mobility of the tumor, with the evidence gained by aspiration, throw light upon the diagnosis. In some cases the diagnosis can be made only by exploratory operation. Indications for Operation. — Prolonged pain in the region of the gall-bladder, cholfflmia without pain and without positive evidence of organic disease, and paroxysmal pain, with the discovery of gall-stones in the faeces, are conditions demanding operative interference. Distinct evidences of malignant disease, such as nodular masses in the liver, with cachexia, contraindicate operation, except for the relief of pain, and then only when gall-stones are diagnosticated. Marked diminution in the size of the liver, associated with ascites, contraindicates interference. Surgical Treatment. — Cholecystotomy. — This operation con- sists in incision of the gall-bladder. The gall-bladder is first sewed into the abdominal wound ; it may be incised at once, or the opening may be deferred for two or three days. Ideal cholecystotomy for gall-stones consists in opening the gall-bladder immediately, removing the stone, closing the wound in the gall-bladder by interrupted Lembert stitches, replacing it in the abdominal cavity, and closing the abdominal wound. When practicable, this is a better method than that of leaving the gall- bladder open with permanent drainage, because a biliary fistula is thereby avoided. After drainage, the flow of bile may persist for many months and necessitate a second operation to close it. When the gall-bladder is so contracted that it cannot be sutured into the abdominal wound, incision with drainage, or total extirpation may be performed. The method of drainage consists in the use of rubber drainage-tubes surrounded by gauze. Cholecystectomy. — Extirpation of the gall-bladder is desirable when its walls are thickened and friable and contracted upon one or more stones. The stones may be removed and extravasation may be avoided by tying off and removing the gall-bladder, stones and all. This procedure should not be attempted unless the gall-bladder can be sepa- rated easily from adjoining structures. Drainage is a wise precaution after this operation. In malignant disease of the gall-bladder total extirpation is the only operation offering any chance of permanent cure. The operation is justi- fiable only when the disease is limited to the gall-bladder. Operations upon the Cystic, Hepatic, and Common Ducts. — Few conditions of the cystic duct admit of operative manipulation. Removal of calculi in this duct by incision, if possible, is preferable to pro- longed manipulation with the hands or with forceps. Operations upon the hepatic and common ducts are indicated when stones are impacted in either, and cannot be removed by dilatation of the cystic duct or by reasonable efforts at crushing. Care must be taken when making the incision to avoid the hepatic artery and the portal vein. After being incised, the ducts should be carefully closed with sutures. The possibility of performing this operation will depend upon the build of the patient, the thickness of the abdominal wall, the depth of the wound, the number and firmness of adhesions, the reflections of the normal peritoneum, and the con- dition of the duodenum, stomach, and colon. Even when the sutures have been accurately applied provision for leakage of bile must be made. In all operations on the gall-bladder or ducts great care must be taken to avoid contamination of the peritoneum with bile. SURGERY OF THE ABDOMEN. 929 Cholecystenterostomy. — In chronic, organic, non-calculous obstruc- tion between the liver and the duodenum, in order to avoid a chronic and fatal cholsemia provision must be made for the artificial escape of bile, either externally or into the intestine. Anastomosis bdirecn the gall-bladder and the duodenum is to be preferred, but when the local anatomical conditions render this impossible deviation of the bile-flow into the colon may be effected. Anastomosis may be made without the aid of mechanical devices or with the aid of Senn's plates or the Murphy button. Many cases of the successful performance of this operation with the Murphy button have been reported within the last two or three years. If for any reason the gall-bladder cannot be utilized in making the anastomo- sis, in some cases the common duct may be isolated above the obstruction and fastened into the duodenum or the colon. Such a procedure maybe possible when the obstruction is near the duodenum. Operations upon the common duct by way of the internal surface of the duodenum may be practised under exceptional cir- cumstances. Organic obstructions situated in the hepatic duct, above the juncture with the cystic, admit of no relief, except occasionally by the formation of a biliary fistula above the constriction. 59 CHAPTEE XLVI. HERNIA. By Maurice H. Eichardson, M. D. The protrusion of an internal organ through a congenital or an acquired opening in confining structures is called hernia of that organ. The term hernia must be qualified to denote the organ involved, as hernia cerebri, hernia testis, etc. Hernia used alone means, as a surgical term, a protrusion of the intestine, of the omentum, or of both from the cavity of the abdomen through some defect in its parietes. He raise are best classified according to their anatomical situation : (Congenital, Funicular, T J? iM intantile, Acquired. Direct, Acquired. Femoral. {Congenital, Infantile, Acquired. Ventral hernia and hernise in the linea < alba (other than umbilical), ' Epigastric. As the result of laparotomy or other wounds. As the result of congenital failure of development. Diaphraqmatic, < . °. n 'm r a ' (_ Acquired — 1 raumatic. Gluteal or Ischiatio. Obturator. Perineal. Lumbar. Sacro-rectal. Retroperitoneal. Preperitoneal. Hernise are either congenital or acquired. Congenital hernias are caused by developmental defects in the peritoneum or in the abdominal wall. The chief cause of acquired hernia is increased abdominal pres- sure, constant or intermittent. Acquired hernias may be of slow or of sudden development. Increased abdominal pressure may be due to — 1. Occupation (involving sudden and severe exertion, especially in a stooping posture). 2. Pregnancy (pressure upon and weakening of the abdominal wall). 930 HERNIA. 931 3. Disease — (a) Chronic lung affections (cough) ; (6) Stricture of the urethra (straining) ; (c) Prostatic hypertrophy or urinary calculus (straining) ; (d) Phimosis (straining) ; (e) Constipation (straining) ; (/) Ascites (pressure upon and weakening of the abdominal walls) ; (g) Abdominal tumors (pressure upon and weakening of the abdominal walls). Other causes contribute more or less directly to the production of hernia. Among them are simple weakness of the abdominal walls, trauma, and surgical operations. Trauma, except as a cause of strain, rarely causes hernia. It may, however, produce a ventral hernia by direct rupture of the abdominal muscles. Laparotomy wounds are prolific sources of ventral hernia, especially those which cannot be immediately closed because of the necessity for drainage. Even in abdominal incisions which are immediately sutured, and which heal by first intention, a very considerable number of hernise result. The physical evidence of hernia consists in a tumor, more or less marked, at one of the usual seats of hernia. In size hernial tumors vary within extreme limits (Fig. 402). In the inguinal variety a scrotal tumor may reach to the knees without serious symptoms ; a fatal stran- gulation may occur without a perceptible tumor. Umbilical and ventral hernise sometimes attain enormous dimensions, and contain so large a proportion of the abdominal contents that the abdominal cavity in the course of years becomes too small to contain them on attempted reduction. The Diagnosis of Hernia. — Hernia in general is recognized by the presence, at one of the usual seats of the lesion, of a painless tumor, which disappears in the recumbent posture and reappears in the erect ; which even in the erect position can be replaced ; which may be tym- panitic, and which disappears with a gurgle. (For the diagnosis of special hernia? see Special Hernise.) The physical examination of a hernia should be made with the patient in the erect and then in the recumbent posture. The tumor should be palpated, percussed, and auscultated. (See Special HerniEe.) The contents of a hernial sac may be easily returned to the abdominal cavity or they may be permanently fastened in the sac ; they may become distended with impacted fecal masses ; they may, with the sac, become inflamed ; or they may become necrotic from the cutting off of the blood- supply. Hernia clinically considered with reference to these conditions may be — 1. Reducible. 2. Irreducible. 3. Incarcerated or obstructed. 4. Inflamed. 5. Strangulated and gangrenous. (a) A reducible hernia is one in which the contents of the sac can be 932 SPECIAL OR REGIONAL SURGERY. readily returned to the abdominal cavity. Such a hernia appear? as a rounded or pear-shaped tumor, usually soft and inelastic on palpation, tympanitic on percussion. It receives a perceptible impulse when the patient coughs ; it is reduced with a distinct slip and gurgle. A re- ducible omental hernia suggests a superficial lipoma ; it is dull on per- cussion, somewhat lobulated, and resistant on palpation. It gives a moderately marked impulse when the patient coughs ; it is reduced slowly and without gurgle. The recognition of a reducible hernia made up of both omentum and intestine is often difficult. (b) A hernia is irreducible when the contents of the sac cannot be returned into the abdominal cavity. Herniae may become irreducible, first, from their large size ; secondly, from adhesions between the sac and a portion of its contents ; thirdly, from an excessive development of fat in the prolapsed omentum. (e) A hernia is obstructed or incarcerated when the bowel in the sac of an irreducible hernia becomes obstructed by impacted faeces. It is usually seen in the aged, and is most common in the umbilical variety. An incarcerated hernia is dull on percussion, gives impulse on cough- ing, and is associated with obstipation, nausea, and vomiting ; it is with- out the severe symptoms of intestinal obstruction and bowel-necrosis seen in strangulation. (d) An inflamed hernia, is the result of violence, most often from the pressure of a badly-fitting truss. The parts are tender, red, and swollen ; the hernia is irreducible. Nausea, vomiting, and pyrexia are present to a slight degree ; but here, as in incarcerated hernia, the severe constitutional symptoms of acute obstruction and bowel-necrosis are absent. (e) Strangulated and Gangrenous Hernia.— -The strangulation of pro- truded gut or omentum begins whenever from unusual crowding into the hernial sac or from other causes the return of venous blood is impeded. Passive congestion then makes the bowel or omentum oedem- atous, increases the pressure within the sac, and augments each moment the disastrous action of the constricting ring. Venous stasis becomes complete. The arterial supply is next impeded, and finally cut off entirely. This interference with circulation causes necrosix of the constricted portion, which becomes gangrenous through the invasion of intestinal bacteria. Necrotic changes begin in the mucous mem- brane at the point of constriction. If the strangulation is unrelieved, the gangrenous process extends to the serous covering of the intestine, and eventually results in perforation. In the first hours the hernial sac becomes distended by exudation, the intestinal coils shrunken and dark colored. The exudate into the sac, sterile only in the early hours of strangulation, soon becomes contaminated by the passage of bacteria through the altered bowel-wall. Above the ring the distal loop of intes- tine is usually empty and contracted ; the proximal, distended with liquid faeces, becomes congested and cedematous, paretic and dilated. The constitutional symptoms of toxic absorption, aggravated by those of acute obstruction, as a rule, appear early — incessant vomiting, cold extremities, feeble and accelerated pulse, normal or subnormal tempera- ture, cyanosis, and exhaustion. At times the depth of the systemic depression is out of all proportion to the severity of the local lesion. HERNIA. 933 Death sometimes takes place before the pathological changes in the strangulated gut have advanced sufficiently to cause necrosis and perforation of the prolapsed coil. The fatal result often seen in the early hours of a strangulated hernia is probably due partly to shock from acute obstruction and incipient necrosis, and partly to toxsemic absorption from pathogenic bacteria. Symptoms. — The symptoms of strangulated hernia are general, call- ing attention to the abdomen, and local, calling attention to a hernial tumor. The general symptoms are those of acute intestinal obstruction. They may come on suddenly, without premonition, or in gradually increasing peristaltic paroxysms. The general symptoms of simple mechanical obstruction become aggravated by those of septic absorption as soon as necrosis within the sac takes place. Fi«. 402. J A , Scrotal hernia (Massachusetts General Hospital, Dr. H. H. G. Beach). The local signs of a strangulated hernia are at first confined to changes in the hernial tumor. The later local symptoms become merged in those of acute obstruction, with or without general peritonitis. 934 SPECIAL OR REGIONAL SURGERY. The general symptoms of acute obstruction dependent upon a strangu- lated hernia are accompanied usually, though not invariably, by a tumor at one of the ordinary seats of hernia. The exception is seen when a coil, slightly protruding through a ring, is strangulated deep below a thick layer of fat. The tumor of strangulated hernia is tense, elastic, and incom- pressible. It is tender on palpation and dull on percussion. The dul- ness (fluid from passive congestion) may give place to tympanitic resonance if the effused fluid is slight and the intestine distended with gas. As a rule, however, most tumors of strangulated hernia are dull, not only from fluid transuded into the sac, but from fluid poured into the intestine itself. The color of a strangulated hernia varies from dark red to greenish gray. The different shades of red indicate generally a viable gut; Fig. 403. Indirect inguinal hernia (bubonocele) (original). green, a more or less complete gangrene. A dark wine color is the shade most commonly seen. Such a color means a viable intestine, and it is replaced by the bright red of an acute congestion as soon as the strangulation is reduced. (See Treatment of Strangulated Hernia.) Plate XXXI. PLATE XXXI. Strangulated Inguinal Hernia; Intestine Discolored but still Viable. (Richardson.) HERNIA. 935 A coil is hopelessly damaged if in addition to its shade of green it has a fecal odor or if there is a distinct fecal escape. At times the necrosis is limited to a small patch here and there ; at other times the whole affected coil is melted into an offensive sloughing mass. Inguinal hernia (Figs. 403, 404) comprises 80 per cent, of all cases. It occurs usually in males, and most frequently in the early years of life. In inguinal hernia the intestine makes its way out of the external abdominal ring (Fig. 404), either by way of the internal ring and the inguinal canal or directly through the abdominal wall beneath the exter- nal ring. The former is called indirect inguinal hernia, the latter direct. Indirect inguinal hernia is either congenital or acquired ; direct inguinal hernia is always acquired. In the indirect form of inguinal hernia the protruding viscus may be Fig. 404. \ \v. ">>-*-ia^ ^ Scrotal hernia, showing the upper surface of the ring, with omentum entering it; the inner surface of the sac is exposed with its contents— omentum, and the relations of the latter to the testicle. The ring is closed hy the prolapsed omentum, which is adherent so that no intestine can enter the sac (Warren Museum). confined in the inguinal canal above the external ring. Such a form is incomplete, and from its suggestive appearance is called a bubonocele (Fig. 403). Indirect inguinal hernia, appearing in the first few months of life is of three varieties — congenital, funicular, and infantile or encysted. 936 SPECIAL OR REGIONAL SURGERY. The occurrence of these three forms depends upon the extent and man- ner of closure of the vaginal process of the peritoneum, which in the later months of foetal life is carried with the descent of the testis through the inguinal canal into the scrotum. At birth this process is normally obliterated and replaced by a small fibrous cord. 1 . Congenital Inguinal Hernia. — In this form of inguinal hernia the vaginal process of the peritoneum remains open throughout its entire length (Fig. 405). 2. Funicular hernia, or hernia into the funicular process. The vagi- nal process of the peritoneum in this variety of hernia is closed just above the epididymis, as shown in Fig. 407. 3. Infantile Encysted Hernia. — The vaginal process has been closed at the internal inguinal ring ; the protruding intestine presses this septum into the lower portion, forming a sac of three layers of peritoneum, as will be seen in Fig. 406. The congenital forms of hernia may be present at birth ; they may appear soon after birth, or, in rare instances, in adult life. Congenital hernia is not infrequently associated with a retained testis. In young Fig. 405. Fig. 406. Fig. 407. Congenital inguinal hernia. Infantile or encysted hernia. Hernia of the funicular process. girls indirect inguinal hernia along the canal of Nuck is the commonest form. 4. Acquired Indirect Hernia. — In this form of inguinal hernia the sac has been pushed along the inguinal canal in front of the viscera. It rarely appears before adult life, for its development is generally slow. Indirect inguinal hernia may show itself, first, as a tumor above Poupart's ligament outside of the external ring (bubonocele, Fig. 403). In most cases, however, it first appears at the external ring as a small, HERNIA. 937 soft, painless, easily-reducible tumor, hardly perceptible except by digital examination through the invaginated scrotum. In neglected cases the tumor increases in size by pushing aside the elastic structures about it, until it fills and distends the scrotum (scrotal hernia, Figs. 402, 404). Direct inguinal hernia occurs in adult life, is usually of acute origin, and frequently becomes strangulated. The hernia takes place directly through the abdominal wall at the triangular depression formed by the deep epigastric artery on the outer side, the obliterated hypo- gastric artery on the inner side, and Poupart's ligament below — the triangle of Hesselbach — and appears at the external abdominal ring. Diagnosis of Inguinal Hernia. — The close proximity of the ana- tomical seat of femoral hernia to that of inguinal necessitates careful recognition of important anatomical landmarks in making a differential diagnosis. The relation of the neck of the hernial sac to Poupart's ligament, to the spine of the pubes, and to the deep epigastric artery must be determined in every case. Inguinal hernice emerge above Pou- part's ligament, femoral hernice below it. Indirect inguinal hernise, unless very large, present an oblong prominence just above and parallel to Poupart's ligament, starting at the internal ring. Direct inguinal hernise are usually small and nearer the median line. The deep epigas- tric artery lies to the inner side of the indirect variety, to the outer side of the direct. When the hernia is old and the ring large it is impossible to distinguish between the direct and the indirect varieties by the relative position of the rings or by the direction of the neck, because long-continued pressure approximates the two rings, bringing the one almost directly behind the other. If the epigastric artery can be felt, either before or during operation, its relation to the neck of the sac will demonstrate the variety of hernia present. Femoral hernise emerge beneath Poupart's ligament, and are reflected upward upon the abdominal wall by the pubic portion of the fascia lata. Hernise in the inguinal region must be distinguished also from other forms of tumor — varicocele, the different forms of hydrocele, enlarged inguinal or femoral nodes, aneurism, psoas abscess, undescended testis, and malignant disease. Femoral Hernia. — This variety of hernia is next in frequency to the inguinal, occurring in 10 per cent, of all cases. It is found most commonly in women. Femoral hernia is always acquired and. is very liable to strangulation. The protrusion takes place through the femoral ring into the femoral canal, a passage about half an inch in length between the iliac, crural, and pectineal portions of the fascia lata. The hernia usually lies to the inner side of the femoral vein. Umbilical Hernia. — 1, Congenital; 2, Infantile; 3, Acquired. 1. Congenital umbilical hernia is due to defective closure of the omphalo-mesenteric duct. The sac is translucent ; through it the hernial contents can often be seen. The hernia consists usually of some portion of the intestine, but may be made up of the whole or of part of any of the abdominal viscera. (See Fig. 408, case of congenital umbilical hernia of liver.) The treatment of this form of umbilical hernia mav be palliative or operative. Palliative treatment consists in the application of suit- able pads; operative, in removal of the sac, reduction of its contents and closure of the ring. It is generally necessary to operate within a few hours after birth. 938 SPECIAL OR REGIONAL SURGERY. 2. Infantile umbilical hernia is the commonest variety of umbilical hernia. It generally appears between the second and sixth months of Fig. 408. Hernia of liver through congenital opening in the umbilicus (Dr. J. C Warren, Massachu- setts General Hospital). infancy. It is due to the stretching of the fibrous tissues of the umbil- icus in the straining caused by coughing, crying, constipation, phimosis, etc. The tumor is rarely larger than the tip of the finger. Its contents are almost invariably small intestine. The prognosis in this variety is Fig. 409. Umbilical hernia of pendulous form (Park). good ; strangulation never occurs. In the majority of cases spontaneous cure results. The treatment consists in the use of small, hard pads, carefully adjusted, and in the removal of the usual causes of strain. Operation is seldom required. 3. Acquired umbilical hernia occurs most frequently in women advanced in years. Pregnancy, ascites, abdominal tumors, excessive HERNIA. 939 development of adipose tissue — in fact, all conditions of excessive and long-continued distention — are exciting causes. The hernial sac often contains only omentum, although it may contain both omentum and intestine. Strangulation of the intestinal portion of an umbilical hernia is common. An omental umbilical hernia generally becomes incarce- rated, and constantly tends to increase in volume from hypertrophy of fat-tissue. This form of hernia is associated with severe gastro-intestinal symptoms — indigestion, nausea, pain, constipation, etc., caused by trac- tion of the omentum upon the colon and the stomach. (For treatment of umbilical hernia see Treatment of Hernia.) Ventral Hernia. — Epigastric hernia, a lesion of rare occurrence, consists in a protrusion usually of omentum in the linea alba between the ensiform cartilage and the umbilicus. It has the same predisposing causes as other hernia. It occurs, usually, in stout women. Epigastric hernia is generally slow in its development, and in its early stages pre- sents a tumor too small to be easily perceptible. When large enough to be readily felt, it presents the characteristics of an omental umbilical hernia. The omentum, fixed in its abnormal position, drags upon the colon and stomach, causing discomfort and pain. Gastric and intestinal disorders and nervous phenomena often ensue. In the absence of an external tumor this form of hernia can be only suspected. Hernia following Laparotomy and other "Wounds. — Ventral hernia may take place through any portion of the abdominal parietes, though its usual situation is in the linea alba. Hernise through the scar of laparotomy and other abdominal wounds are the commonest forms. Hernia as the Result of Congenital Failure of Development. — Ventral hernia as the result of congenital defects in the abdominal wall may appear in any portion of the parietes, but is especially liable to occur in the line of muscular aponeuroses. Diaphragmatic Hernia : 1. Congenital, through a defect in the diaphragm ; 2. Acquired, through one of the natural openings in the dia- phragm or through wounds or rupture of the diaphragm. The hernial protrusion may vary in size from a small portion of intes- tine to one-half the contents of the abdomen. It is six times more com- mon on the left side than on the right. In the acquired form symptoms of intestinal obstruction, after a wound of the diaphragm, indicate dia- phragmatic hernia. In the congenital variety the heart is displaced to the right, and the lower part of the thorax is usually dull on percus- sion. The condition is frequently confused with pyo-pneumothorax. Trau- matic cases have recovered after operation. Gluteal or Ischiatic Hernia. — This form of hernia is very unusual. The hernia may take place through either the greater or the lesser sacro-sciatic foramen (Fig. 410). Obturator hernia, usually occurring in stout women advanced in years, consists of a hernial protrusion along the vessels through the obturator foramen. The contents of the hernial sac may be either intestine or omentum. The diagnosis is impossible without the presence of an external tumor. Perineal Hernia. — This rare and obscure form of hernia originates in Douglas's fossa, behind the bladder or uterus, on either side of the 940 SPECIAL OR REGIONAL SURGERY. median line. The protruding viscus forces its way between the fibres of the levator ani muscle, and appears externally somewhere between the labium and the anus. Lumbar Hernia. — This variety is very unusual, and consists in a protrusion of abdominal contents, generally intestine, through the lum- bar fascia, along the outer border of the quadratus lumborum muscle into the triangle of Petit. It is usually of small dimensions and can be Fig. 410. Ischiatic hernia (original). easily reduced. It has been operated upon by mistake for fatty tumor and for cold abscess. Sacro-rectal hernia is of great rarity, and is due to failure in ossifi- cation of the sacral bones. Retroperitoneal Hernia. — This is a form of hernia into an internal peritoneal pouch. It usually occurs in the duodeno-jejunalis fossa. It may also take place in the region of the caecum or the sigmoid flexure. (See Internal Strangulations.) Hernia through the foramen of Winslow may occur, though very rarely. The symptoms, diagnosis, and treatment of strangulated retro- HERNIA. 941 peritoneal hernise do not differ from those of acute intestinal obstruc- tion. When neither incarceration nor strangulation occurs the condi- tion may never be even suspected. Preperitoneal Hernia. — This unusual variety of hernia may be a complication of inguinal, femoral, or umbilical hernia. There must be two sacs with a common opening into the peritoneal cavity, the inner sac lying in the connective-tissue space in front of the peritoneum and behind the muscular layers of the abdominal wall, the outer sac occupying the position of an inguinal, femoral, or umbilical hernia. The usual cause of this condition is a mechanical separation of the peritoneum during attempts to reduce by taxis an existing hernia. A possible cause may be some congenital irregularity in the descent of the testis. Preperitoneal hernia should be suspected when, after appar- ent reduction of inguinal, femoral, or umbilical hernia, there is no relief of symptoms (Fig. 411). Fio. 411. Preperitoneal hernia. This illustrates also incomplete reduction of hernia. Hernial Diverticula from the Bladder. — Portions of the urinary bladder have been found in inguinal and femoral hernise. It is a rarity, and occurs usually in old persons. Urinary symptoms are vague and inconstant, and the condition is seldom diagnosticated before operation. The extraperitoneal portion of the bladder is prolapsed in the great ma- jority of cases. This variety of hernia is sometimes called a cystocele. Hernia of the Vermiform Appendix.— The vermiform appendix not infrequently appears in the sac of an inguinal hernia, either alone or with other parts of the intestine. Under ordinary circumstances its presence cannot be diagnosticated. If incarcerated, an acute appendi- citis may develop, resulting in necrosis, gangrene, and abscess. 942 SPECIAL OR REGIONAL SURGERY. Treatment op Hernia. Palliative Treatment of Hernia. — The palliative treatment of hernia consists in returning the protruded contents of the sac to the abdominal cavity and keeping them there. To restrain the abdominal contents, trusses and supporters are employed. Supporters are useful in large scrotal and umbilical hernia? which have become irreducible or which cannot be retained in the abdominal cavity. The employment of a truss, once begun, must be kept up continuously for a long period of time. Contraindications to the use of trusses are — 1. Irreducible omentum ; 2. Irreducible, inflamed, and strangulated intestine ; 3. A hydrocele on the same side ; 4. Abnormal position of the testicle ; 5. The lack of requisite time and care, due to incompetency, ignorance, poverty, or occupation ; 6. Preperitoneal hernia. Non-operative measures for the treatment of irreducible hernia are posture, long-continued moderate pressure, and taxis, used separately or in combination, aided at times by the application of local heat or cold. By keeping the patient with the hips elevated, by applying the constant pressure of sand-bags over the hernial tumor, with gentle and persistent taxis, hernia of great dimensions can sometimes be successfully reduced. The patient may be kept for days with the foot of the bed raised and with sand-bags, gradually increased in weight, applied directly to the tumor. The treatment should be abandoned the moment it becomes painful. In obstructed hernia the chief efforts should he directed to the relief of consti- pation — by means of high enemata and mild laxatives, with gentle massage of the tumor. Persistent obstruction demands exploration and mechanical relief. Inflamed hernia, should be treated by rest in bed and local applications of heat or cold. Efforts at reduction should be postponed until the subsidence of the local inflammation. Irreducible, obstructed, and inflamed hernia should be closely watched for symp- toms of strangulation. In doubtful cases the sac should be opened and a radical cure attempted. Considering the success which modern methods ensure, both as to immediate safety and permanent cure, palliative treatment, in the absence of distinct contraindications, is justly deemed a greater risk, on the whole, than operation. Operative Treatment of Hernia. — Irreducible hernise, whether or not incarcerated or inflamed, should invariably be treated by open incision and radical cure. When for any reason operation is contrain- dicated or refused, reduction of the hernia by palliative methods should be attempted. Treatment of Strangulated Hernia. — The great mortality in stran- gulated hernia being due to delay (acute intestinal obstruction, shock, gangrene of bowel, general peritonitis) or to violent taxis (rupture of bowel, extravasation, general peritonitis), it is imperative, first, that the treatment, whether by taxis or by operation, be entered upon at the earliest possible moment ; and secondly, that taxis should be employed for a brief period only. Treatment by the use of ice-bags, by posture, or by palliative measures other HERNIA. 943 than taxis promises so little, and, when minutes are precious, adds so materially to the delay, that these methods are mentioned only to be condemned. Treatment by taxis is to be recommended in the very beginning of strangula- tion, for it often succeeds at that time. Moreover, the chief danger, rupture of the intestine, is unlikely to occur, even if the manipulations are forcible. In the later hours of a strangulation, when the bowel, swollen by congestion and oedema, is jammed through a tight ring into the sac, taxis is hopeless and worse than useless. When employed, taxis must be gentle : its good effects, if any, will be the result of persistent and moderate, rather than of brief and forcible, manipulations. By compressing the sac between the thumb and fingers of both hands toward the ring, at the same time manipulating the tumor in various ways, the tension of the sac may, by the reduction of the gaseous or fluid contents of the constricted intestine, be relieved. Such a reduction— small though it may be — promises complete relief. In the case of femoral or of inguinal hernia reduction by taxis is encouraged by flexion of the thighs. The dangers of taxis are as follows : 1. Rupture or bruising of the intestine or sac ; 2. Tearing of adhesions ; 3. Reduction en bloc; 4. Fatal delay. If persistent gentle pressure be unavailing, herniotomy is demanded. In strangulated hernia the emergency to be met by operation is acute intestinal obstruction. This emergency may require merely simple division of the constricting ring ; it may require intestinal resection or artificial anus. Measures for radical cure may be considered in non-septic cases after the satisfactory relief of the obstruction. The first step in herniotomy is exposure of the sac. In the usual forms of hernia — inguinal and femoral — the dissection should be made by layers until the sac is reached. The only layers recognizable, how- ever, are the skin, fat, and possibly the dartos. The sac is recognized usually by its color. To make sure, the sac, with a bit of intestine, may be pinched between the thumb and the fore finger, when the intestine will slip away with a characteristic sensation, leaving the sac alone between the fingers. A little practice will make the sensation so familiar that it cannot be mistaken. The sac is now opened without fear of cutting the enclosed bowel. In cutting down upon the sac in umbilical hernia the greatest care is necessary not to wound the intestine, for at times the gut is directly under the skin, and sepa- rated from it by the peritoneum only. In some instances the skin over the strangu- lated bowel is so thin that it takes the characteristic color of strangulated intestine. The sac is usually distended with fluid which is clear, bloody, purulent, or fecal according to the pathological condition of the affected gut. A cover-slip prepara- tion made at the time may determine the question of sepsis, as well as that of the advisability of drainage, radical cure, artificial anus, or resection. The constricted bowel will be slightly congested, darkly congested here and there necrotic, or totally gangrenous. In the absence of immediate bacteriological examination it may be difficult in doubtful cases to determine the viability of the intestine. As a rule, a congested gut, even if dark red, is viable ; a greenish one, necrotic. Macroscopic perforation, total necrosis, or fecal abscesses are conspicuous. The chief point in doubtful cases is the determination of bowel integrity. Inasmuch as an absolute demonstration is impossible in such cases, safety and con- servatism require that doubtful cases should be treated as if they were septic. 944 SPECIAL OR REGIONAL SURGERY. The next step is division of the constricting ring. In femoral and in inguinal hernia the division of the ring should be made with reference to the position of arteries and veins : in inguinal, to that of the deep epigastric artery ; in femoral, to that of the femoral vein. The operations of the past were described in great detail in reference to these points, because of the desire to make as small a cut as possible, and that blindly upon the finger. Though it is still desirable not to enlarge the rings by free dissection, the parts may be clearly demonstrated in doubtful cases, especially in inguinal hernia, in which by the best of modern radical operations extensive dissections are essential. Simple division may be made, however, upon the finger with a probe- pointed bistoury ; in direct inguinal hernia the cut should be made upward and inward, to avoid the deep epigastric artery; in indirect, upward and outward ; in femoral hernia, upward and inward, to avoid the femoral vein. In the last form of hernia, however, an abnormal obturator (derived from the epigastric) artery may be found impossible of avoidance. After division of the rings the bowel should be drawn out of the wound until sound portions are visible, care being taken in septic cases to protect the peritoneal cavity from infection. The question of sepsis having now been determined by renewed examinations, especially for signs of returning circulation, minute per- forations, etc., there remains for the completion of the operation either (1) replacement of sac-contents in the abdomen, (2) intestinal resection, or (3) the formation of an artificial anus. After return of the gut in aseptic cases the operation for radical cure should be performed. (See Radical Cure of Hernia.) The method selected will vary with the size of the rings, the extent of the incision, etc. Resection of the intestine when its integrity is com- promised should be performed only when the patient's strength permits. When shock is profound and when exhaustion is marked it is better to limit the operation to relief of the constriction and formation of an artificial anus. In performing resection and suture especial care must be taken to pre- vent a general infection, inasmuch as the field of operation is extremely septic. (See Intestinal Resection and Suture.) In favorable cases the prognosis is encouraging, there being probably 50 per cent, of recoveries. The formation of an artificial anus is attended by unusual difficulties in gangrenous hernia, because both proximal and distal openings must be fastened into a septic wound. The bowel ends must be securely united to the skin, and drainage must also be used to prevent a general infection. Moreover, this operation must be followed by secondary resection and suture. The formation of an artificial anus, therefore, is not very much safer or easier than complete resection and suture, though it may be more rapidly performed. In case of extreme need the necrotic loop may be rapidly excised and the bowel ends stitched hastily to the skin ; or the gangrenous loop may be simply incised after division of the ring, the coil being held in its position by adhesions. Resection, on the other hand, demands a careful suturing of the approximated bowel ends, an operation which requires at least half an hour even in the hands of the most skilful. Intestinal obstruction persisting after herniotomy should suggest a reduction en bloc, (Fig. 411) or a twist in the intestinal loop. The HERNIA. 945 former accident, occurring not infrequently after taxis as well as herni- otomy, is caused by a forcible replacement of the gut, constricting ring and all, inside the abdominal cavity. Reduction en bloc is not likely to occur after complete division of the ring : it may take place when the incision is made blindly with the probe-pointed bistoury deep upon the finger. Careful digital exploration will demonstrate whether or not the relief of the constricting ring has been complete. The Radical Cure op Hernia. The present methods for the radical cure of hernia have entirely supplanted the earlier operations, which were clumsy, ineffectual, and dangerous. The principal early methods were — 1. Injection of irritants in the neighborhood of the pillars and rings ; 2. Irritation from the pressure of plugs ; 3. Subcutaneous wiring and suture. The extensive experience of the past few years with the cicatrices resulting from abdominal wounds has shown that scar-tissue under persistent pressure stretches and gives way, and that a large percentage of ventral hernise results. Hence the inefficiency of the granulation method (McBurney's), a method in which it was expected that after excision of the sac high up, and suture of the skin to the muscular layers, healing from the bottom, induced by packing the wound with gauze, would ensure a cicatricial barrier that would not give way. Careful observations after long periods of time have proved that these operations are followed by a large percentage of relapses ; and though perhaps sufficient time has not elapsed to ascertain the ultimate results in the later operations, there seems no doubt that the improvements in the mechanical operative technique of the radical operations of the present day will lead to better results than were attained in the operations of the past. At the present time two methods for the radical cure of inguinal hernia are to be preferred, that of Bassini and that of Halsted. Bassini's Operation. 1 — "1. The external incision begins at a point nearly or quite on a level with the anterior superior spine, continues obliquely down parallel to and about half an inch internal to Poupart's ligament, and ends at the centre of the external ring. 2. The incision is rapidly carried down until the aponeurosis of the external oblique is freely exposed for a distance of two and a half to three inches ; a director is then passed through the external ring just beneath the aponeurosis, and the aponeurosis is divided well above — i. e. a half to one inch above the internal ring. 3. The cut edges of the aponeurosis are held up with forceps and dissected free from the underlying muscles as far as the edge of the rectus, internally and externally, until the shelving portion of Poupart's ligament has been clearly exposed. 4. The sac and cord are then isolated en masse, and this is best accomplished with the fingers and blunt-pointed curved scissors. If the peritoneal layer of the sac is first reached, the dissection is easy, rapid, and bloodless. 5. The cord and its vessels are now separated from the sac, and this, too, is best done with the fingers. The separation is carried high up 1 "TJeber die Behandlung des Leistenbruches," von Ed. Bassini, Archiv f. klin Chir. Bd. 40, 429, 1890, quoted by Bull and Coley in the article on Hernia in System of Sur- gery by F. 8. Dennis, vol. iv. p. 184. 60 946 SPECIAL OR REGIONAL SURGERY. within the internal ring, and the sac is opened and its contents ex- amined. If adhesions are present, they are separated ; omentum, if thickened, is excised, and the contents are reduced into the abdominal cavity. The sac is then ligated or sutured above the internal ring, where it merges into the general peritoneal cavity. 6. The cord is held up and the edges of the aponeurosis rolled back, while from three to five buried sutures are introduced beneath the cord. These are best introduced from within outward, and should include the internal oblique and transversalis muscles, the transversalis fascia (and sometimes the edge of the rectus) on the inner side, and the deep shelv- ing portion of Poupart's ligament on the outer side. The lowermost suture should embrace the conjoined tendon. 7. The cord is now replaced, and the cut aponeurosis is closed over it by means of a continuous suture extending as near the pubis as pos- sible without causing undue constriction of the cord. 8. Closing the skin- wound with interrupted sutures, without drainage, completes the operation (Figs. 412, 413, 414). Fig. 412. Bassini's method of operation for inguinal hernia: A, A, A, subcutaneous fatty tissue ; B, upper portion of the divided aponeurosis dissected from underlying structure ; C, under portion of aponeurosis of external oblique ; E, cord ; F, 1, internal oblique muscle ; 2, transversalis ; 3, fascia of Cooper (Bull and Coley, toe. «(.). Bassini at the time he published his paper (1890) had operated upon 262 cases of inguinal hernia, with but 1 death and but 7 relapses. All but 4 of his cases had been traced (Bull and Coley). Halsted's method consists in the following steps : HERNIA. 947 1. An oblique incision is made by which the external abdominal ring is thoroughly exposed. 2. An incision 3 cm. long is made through the aponeurosis of the external oblique, and through the internal oblique to the internal abdomi- nal ring. The external oblique is incised parallel with its fibres ; the internal oblique is divided at right angles to its fibres (the line of incis- ion deviating from, not parallel to, the previous incisions through skin and aponeurosis of external oblique). The incision in the external oblique should be parallel with its fibres. 3. The prolongation of the fascia transversalis (tunica vaginalis propria funiculi spermatici), which includes the cord, is first split with a knife and then torn. 4. The larger bundle of veins is separated from the vas deferens with as little disturbance to the vas deferens as possible. The larger bundle of veins is excised from the external to the internal ring ; the smaller veins accompanying the vas deferens are left undisturbed. In children the veins should not be excised. It is usually advisable to Fig. 413. Bassini's method of operation for inguinal hernia : fourth step. Suture of the divided apo- neurosis over the cord with a continuous suture (Bull and Coley). excise the veins in adults, unless they contribute but little to the size of the cord. 5. The sac is isolated, opened, transfixed, and tied with one or more sutures, cut off, and the stump dropped into the abdomen. 6. The vas deferens should now be transplanted to the outer angle 948 SPECIAL OR REGIONAL SURGERY. Fig. 414. Bassini's method of operation for inguinal hernia : the end of the third step of the operation. The cord has been transplanted and the musculo-aponeurotic tissues on the inner side have been sutured to Poupart's ligament (D) on the outer side (interrupted sutures are usually em- ployed) (Bull and Coley). of the muscle wound ; the muscle flaps are brought down with forceps so as to enable the operator to include them in all the sutures, except one Fig. 415. Halsted's operation for inguinal hernia : first step (Bull and Coley). or two. The vas deferens should be snugly embraced between, but not constricted by, the two outermost stitches (Figs. 415, 416, 417). HERNIA. 949 The muscular and tendinous layers of the ring and abdominal wall are carefully sutured, layer by layer, with Halsted's quilted suture ; the material used may be silk, animal tissue, or silver wire. The wound is closed without drainage. The stages of the operation are shown by the diagrams. Fig. 416. Halsted's operation for inguinal hernia : second step (Bull and Coley). Recurrence after Operation for Radical Cure of Inguinal Jler- nia. — Under modern methods recurrence after operation for radical cure has become infrequent, though it remains to be seen whether the results will still be as good after the lapse of years. Fig. 417. Halsted's operation for inguinal hernia : third step. Predisposing causes of recurrence are — the giving way of stitches the use of drainage, septic infection and healing by granulation advanced age of the patient, the large size of the hernia, relaxation of scar, fatty abdominal wall, etc. 950 SPECIAL OR REGIONAL SURGERY. Treatment for the Cure of Inguinal Hernia in the Female. — This consists in excision of the round ligament and hernial sac, and obliteration Fig. 418. Femoral hernia, radical cure by Bassini's method : sutures in position. of the canal by the same method of buried suture employed in the cure of inguinal hernia in the male. Recurrence is extremely infrequent. The Radical Cure of Femoral Hernia. — Bassini's method is the Fig. 419. Bassini's method of radial cure of femoral hernia : sutures tied. best. It consists in an incision just below and parallel to Poupart's ligament, with its centre over the hernial tumor. The sac should be exposed, freed as high up as possible, opened, its contents examined and reduced into the abdominal cavity. The obliteration of the pouch should HERNIA. 951 be attempted by high ligation and removal of the sac. The structures of the femoral canal, the falciform, crural, and pectineal fasciae, Pou- part's and Gimbernat's ligaments, must be carefully identified and approximated by buried sutures. The femoral canal may be closed by four or five sutures uniting the falciform edge of the fascia lata to the pectineal fascia. The femoral ring should be closed by three sutures, uniting Poupart's ligament and the pectineal fascia in a line from the pubic spine to the pectineal eminence. The external wound should be closed without drainage. (For stages of operation for Radical Cure of Femoral Hernia, see Figs. 418, 419.) Treatment of Umbilical Hernia. — The treatment of umbilical hernia in adults should be operative in almost all cases, because of the extreme difficulty of retaining the hernia within the abdominal cavity by any form of truss, and because of the danger of inducing inflam- matory changes by any form of mechanical treatment. The operation for radical cure consists in making a long incision around the tumor, including the umbilicus and a large part of the hernial covering. This incision should open the sheath of the rectus on either side. After the hernial sac has been opened its contents should be carefully examined for coils of intestine, which should be reduced into the abdominal cavity. Prolapsed omentum should be ligated and removed. Adherent and necrotic portions of the intestine should be treated as in any form of hernia. After the sac has been emptied of its contents, it should be dissected free from surrounding structures, all redundant portions removed, and the edges carefully sutured together. The muscular bellies of the recti should then be approximated by buried sutures, and the external and superficial structures of the wound closed without drainage. Ventral hsmice may be operated upon for radical cure in the same manner. CHAPTER XLVII. DISEASES OP THE RECTUM AND SIGMOID FLEXURE. By Charles B. Kelsey, M. D. Congenital Defects. Congenital defects consist, for the most part, of forms of more or less complete absence of the rectum or imperforate anus. Thus the rec- tum may terminate in a blind extremity, or may connect with the blad- der, the urethra, or the vagina. They all cause symptoms of obstruction of the bowels unless speedily recognized and relieved. When a new-born infant has failed to soil its diaper within twenty-four, or at most thirty-six, hours, a careful examination with the little finger or with a catheter should be instituted. Should this reveal the condition or should the urine be stained with fecal matter, immediate anaesthesia and operation — depending upon the local condition — are imperative. If after careful exploration with knife, finger-tip, and sound no trace of rectum be discovered, it will be better to do a colostomy (see below) than trust to further search at the pelvic outlet. These conditions are always serious, too often fatal. They are rare, but urgent when present. Hemorrhoids. The most common of all the diseases of the rectum is hemorrhoids, and there is perhaps no better classification of them than the old one of external and internal. By an external hemorrhoid is meant one which arises from the margin of the anus outside the external sphincter muscle. It differs absolutely from the internal variety in the fact that it is always composed either of skin and hypertrophied connective tissue, forming a mere cutaneous tag, or else is composed of a clot of blood extra vasated from a small cutaneous vein. Internal hemorrhoids, on the conti'ary, although composed in great measure of enlarged veins, have a very free arterial supply, and are a mere collection of enlarged blood-vessels bound together by hypertrophied connective tissue and covered by the natural mucous membrane of the rectum. An internal hemorrhoid is, moreover, an affection of the middle hemorrhoidal veins and arteries, which are parts of the visceral system and not of the cutaneous blood-supply. Internal hemorrhoids may also, with advantage, be divided into two classes. In one there is the large prolapsing tumor, generally recog- nized as a pile by the profession and laity alike. In the other we find the flat, strawberry-like surface, raised only slightly above the surround- ing healthy mucous membrane, closely resembling naevus in anatomical structure, and causing no symptoms except those which come from the frequent and often excessive loss of blood. AVithout going at all into the pathology or symptomatology of this 952 DISEASES OF THE BECTUM AND SIGMOID FLEXURE. 953 very common and simple affection, which lack of space forbids, we will at once consider what is of most practical interest — the treatment. The treatment of internal hemorrhoids may be either palliative or radical. For palliative measures we have careful attention to diet to secure regularity in defecation, attention to the general health, and the free use of cold applications to the mass when protruding after stool. For bleeding we have the dry subsnlphate of iron, which may be lightly sprinkled over the tumors when extruded, or used in a suppository, one grain at a time. This is apt to cause considerable smarting pain. Small bleeding tumors may be completely cured by touching them two or three times with strong nitric acid ; and a very severe hemor- rhage may sometimes be stopped for a long time by this simple method, even where there is no hope of a radical cure. But in large, old pro- lapsing tumors the free application of acid to the surface will only cause additional pain. The injection of carbolic acid in some medium, such as glycerin and water, is also a palliative measure which has had great notoriety. It is attended by a chain of accidents which make its use very uncertain, and in many cases unsatisfactory. There are great pain, swelling, the formation of pus, and sloughing. In any large number of trials some of these results are sure to follow, to the disgust of both patient and physician, while the relief obtained by the method, even in the cases which escape these accidents, is but short. The radical or operative treatment of hemorrhoids consists in their removal in any one of many ways, all of which involves the use of an anaesthetic and more or less confinement to bed, as after any surgical operation. Of these only a few will be considered. In small tumors, where there is little to tie or clamp, and perhaps where there is no protrusion at stool, and yet free bleeding and all the other symptoms of hemorrhoids, an exceedingly effective means of cure is punctate cauterization. The sphincters should be well dilated, a Sims rectal speculum introduced, and the tip of the Paquelin cautery at a dull red heat inserted into the substance of the tumor. The writer often does this to the small varicosities which will sometimes remain after an operation with the clamp or ligature. It is often the case that after several very large masses have been tied or clamped off there will still be one or perhaps two small spots which seem hardly big enough to call for another application of the clamp, and yet which the operator does not like to leave. A single touch with the cautery solves the difficulty ; and it is to small tumors of this size that the method is most adapted, although the French have advocated it in all cases, large or small, requiring operation ; and it is effective. Whitehead's operation consists in removing the mucous membrane from the lower inch of the rectum in a cylinder, and with it the hem- orrhoids. There is no essential difference between it and the so-called " American operation," except that in the former the first incision is made in the line of junction of the skin and mucous membrane, and the dissection carried upward, while in the latter the first incision is made inside the rectum above the hemorrhoids, and the dissection carried downward. The objections to it are — the time necessary to perform it ; the fact that no such elaborate operation is ever necessary to cure any case of hemorrhoids; and the liability to two accidents — first, the production of a stricture from failure to 954 SPECIAL OR REGIONAL SURGERY. get union, and, second, the eversion of the mucous membrane caused by pulling it down and attaching it to the skin. Both of these results are now sufficiently fre- quent, and the number of secondary operations necessary to cure patients of the effects of the " American" operation is increasing. Between Allingham's operation by ligature and Smith's operation by clamp and cautery there may not be much to choose. Both are safe and both are radical, and eitlier is quickly performed without profound anaesthesia or loss of blood. And yet for many years the writer has practised the latter in preference to the former, because in his hands it causes less pain, shorter convalescence, and less reflex vesical disturb- ance. This is explained by the fact that a ligature around the pedicle of a pile often includes in its grasp a nerve as well as an artery, and hence causes pain until it comes away. The clamp-and-cautery operation is done as follows : The patient is etherized and placed in the lithotomy position. The sphincter is thoroughly stretched without rupturing the muscle. Time should be given to this, and when the stretching is completed the anus should be patulous and without contractile power. Such paralysis will last two or three days only. After the stretching, the hemorrhoids, if of any size, will protrude, and the largest is seized with volsellum forceps and pulled gently still farther out from the anus. Its attachment is then cut through on the cutaneous margin with scissors. This cutting is done where the skin becomes continuous with the mucous membrane, and is intended simply to avoid including skin in the grasp of the clamp. Where the hemor- rhoid does not rest upon the muco-cutaneous junction, and the clamp can be applied to its base without including any skin, no cutting around the pedicle or base is necessary. In the incision thus made the clamp is applied, care being taken to include all that remains of the stump in its grasp, so that when the pile is cut away none of its blood-vessels shall be outside the grasp of the instrument. The blades of the clamp should lie along the axis of the gut, and the stump when released from the grasp of the clamp should be in the line of the radiating folds of the anus, and not across them. Having grasped lightly the pedicle in the clamp, the pile is cut away at a sufficient distance from the clamp to leave a good thick stump for cau- terizing. This is the important point in the whole operation. If the pile is shaved off close down to the clamp, there will be no room to cau- terize the cut vessels and firmly close their mouths, and the moment the clamp is relaxed they will bleed. There should be stump enough left so that the cautery at a dull red heat can be passed over its cut surface again and again till it is thoroughly charred, and a good thick eschar remains. The clamp is then gently relaxed, and if any vessel spouts, it can be closed and the cautery again used on that point ; but if the eschar remains dry, it is allowed to slip from the grasp of the clamp and is gently pushed up into the rectum. After the operation there will always be some bleeding from the scissor-cuts made in the skin for isolating the pedicles ; this is stopped by pressure of a pad and T-bandage. There should never be any hemorrhage from the eschars or from the cavity of the rectum. After a few hours the pad and bandage may be replaced by a hot poultice. The patient is allowed to stand and pass water ; no restriction is made as to diet; his bowels are moved by a laxative forty-eight hours after ope- DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 955 ration, and kept open every day or second day afterward. Straining and pain in defecation are best relieved by an enema of lukewarm water when the laxative is about to have its natural effect. Patients usually sit up on the second or third day, and leave their rooms by the end of a week, although complete healing can- not be expected in less than three weeks. After years of experience with this operation the writer can only say he has never had an accident, never had to use a catheter, seldom had to give morphine, and confidently expects a rapid and uneventful recovery in every case. But accidents have occurred, though the fault has gen- erally been with the operator and not the method. Only recently has it happened to me to have a distinct case of secondary hemorrhage on the third day after this operation ; but, as this is the only one I have ever seen, and as I happen to know of several after the ligature, my opinion of its value is unchanged. Fig. 420. Rectal Polypi. Polypoid tumors are frequent in the rectum, especially in young children. They are of the myxomatous or adenomatous type or of mixed form, and vary much in size and number. Widespread poly- poid disease is represented in Fig. 420. Some- times they bleed easily. They are occasionally presented for inspection at or after stool, and may require replacement or reduction like cer- tain piles. They cause, for the most part, symp- toms of rectal malaise and tenesmus. Children who are frequently impelled to stool should be carefully examined — if need be under anaes- thesia — to discover polypi if present. These tumors are often pediculated, sometimes by long stems which are elongated by natural efforts at their expulsion. In such a case they may be twisted off. In other cases, when they are more sessile, their careful enucleation or destruction may be required. Aggravated instances are known in which strain- ing efforts, long continued and often repeated, have produced invagination with all its disastrous conse- quences. Peolapsb and Invagination. There are two varieties of prolapsus, to be carefully distinguished from each other in practice. The first is composed of mucous membrane only ; the second, of all the coats of the bowel, and hence, when of sufficient extent, containing peritoneum. The first is a mere eversion of the mucous membrane, rendered possible by the laxity of Multiple polypi of rectum the submucous connective tissue. The second is an exaggeration of the first, in which, after the connective tissue has 956 SPECIAL OR REGIONAL SURGERY. yielded to its utmost, the whole thickness of the rectum begins to pro- trude. It follows, of necessity, that after this protrusion has reached a certain point the peritoneal coat must also protrude through the anus. The first form of prolapse is seen frequently in children as a result of weakness, diarrhoea, or any irritation of the rectum which produces tenesmus. It is also seen in adults, generally as a result of weakening of the sphincters. It is a minor affection, and in all cases easily curable by surgical measures. The importance of distinguishing between it and the second variety at once becomes manifest when it is stated that treatment adapted to it may easily result fatally when applied to the second. A serious and not very rare complication of the second form of pro- lapse arises from the fact that the pouch of peritoneum contained in it may be the sac of a hernia, and may contain coils of small intestine, an ovary, or the bladder. Usually the peritoneal pouch will be found on the front of the prolapse, but it may be both in front and behind, and, when intestine is contained in it, it may be reduced as in any other variety of hernia. It is a mistake to suppose that the second form of prolapse is not met with in children, for it is only an exaggerated form of the first. It is distinguished from it, first, by its size, being from its nature of very considerable dimensions. The first form is not thick to the feel, the folds of mucous membrane radiate from the orifice to the circum- ference, and the opening is circular and patulous. In the second the orifice is slit-like, and is drawn backward by the attachment of the meso-rectum, or, in females, forward by the closer attachment to the vagina. The form of the tumor is conical; its walls are thick and firm ; and when pressed by the fingers the gurgling of gas in a contained loop of intestine may sometimes be felt. Such a tumor may also be resonant on percussion. The treatment of prolapse is both general and surgical. In children a polypus should always be looked for, and removed if found, as this is a very frequent cause of the condition. The same rule applies to calculus, phimosis, constipation, and pin-worms. The general health should be carefully attended to; the tumor when down should be washed with an astringent solution and replaced ; and the child should be made to have its passages in bed, while the buttocks are held together by a nurse. Many cases of prolapse are due to the carelessness of nurses in putting small children upon the chamber and allowing them to remain there and strain. Should these measures fail, Van Buren's operation with the cautery can always be relied upon to cure in prolapse consisting of mucous membrane alone. With the child under ether the pouting mucous membrane is seized with forceps and gently pulled out of the anus. Successive pairs of forceps are used on opposite sides of the anus till the whole amount of the protrusion is in sight. With the cautery at dull-red heat three, four, or even six stripes are drawn on the tumor, commencing at the apex and radiating toward the orifice. The cauterizations should extend only through the mucous layer, should be light at the apex, and DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 957 should gradually increase in depth as they approach the sphincter. After a sufficient number of these linear cauterizations have been made at equal distances from each other on the circumference of the tumor, the whole mass is reduced. The after-treatment is of scarcely less importance than the cauteriza- tion. A firm graduated compress should be applied over the anus and secured by broad strips of adhesive plaster, which also draw the but- tocks firmly together. Opium and chalk or some other astringent should then be given by the mouth to keep the bowels from moving for a week or ten days, if possible. The first passage should be assisted by an enema of water, and should be had with the child in bed and a nurse pressing the buttocks together to prevent protrusion. For at least a fortnight this rule should be carried out. Occasionally it may be necessary to repeat the cauterization a second time, but this treatment will seldom fail in any case of prolapse of mucous membrane alone, where it is thoroughly carried out. In prolapse of the second variety this treatment will also often be found efficacious. It may also be made more radical by burning through the sphincter at two or three points. The idea of the radiating cauterizations through the mucous membrane is simply to bind it and the submucous connective tissue to the muscular coat by linear cicat- rices. In more extensive disease the orifice may also be reduced in size by burning through the sphincters, thus causing a slight degree of con- striction at the anus. But in many of the old and extensive cases of the second variety this plan of treatment will fail, and we are then forced to more radical measures. One of the best of these is amputation of the entire tumor after the method of Mikulicz. The patient is placed in the lithotomy position. Two strong threads are passed through the extremity of the prolapse for fixation. A transverse incision is made through the anterior part of the prolapse till the serosa is exposed. The serosa of the outer layer is then stitched to the serosa of the returning portion, thus closing the peritoneal cavity. Just outside this row of sutures the anterior part of the returning cylinder is also cut across, and the two divided ends of the gut are then sutured with silk through the whole extent of the incision, the threads passing through all the coats and being left long for guides till the completion of the operation. Next the remaining portion of the periphery is cut across in the same way, the mesenteric vessels tied, and the suturing completed as in the anterior lip. All sutures are cut short and the stump of the prolapse reduced. The occurrence of a circular slough as a result of the strangulation of a prolapse is always a very serious complication. The tumor is gen- erally of the second variety ; has become first irreducible, then strangu- lated, and at the apex, around the opening, there will be seen a black ring of dead mucous membrane and connective tissue of greater or less extent. The gravity of this condition consists in the fact that the circular slough may cause a severe stricture after cicatrization has occurred, and the longer the prolapse the higher up the bowel will the stricture be after it has been reduced. 958 SPECIAL OR REGIONAL SURGERY. The treatment of this condition resolves itself into the ablation of the tumor by the method just described. The essential difference between prolapsus and invagination is that the former is a mere everting of the mucous membrane, and perhaps of the other layers, of the rectum, beginning always at the verge of the anus and gradually increasing in size as more and more of the gut protrudes from the body ; while the latter is a telescoping of one part of the gut into the part below, and may begin anywhere in the length of the tube. A prolapse necessarily protrudes from the anus ; the invaginated portion of bowel may or may not do so, depending upon its length and location. Of this condition there are many varieties and degrees. The most common (forming nearly one-half of all the cases) is the ileo-ccecal, or that in which the ileum and the caecum pass into the large intestine, carrying the ileo-csecal valve at the apex. This variety is apt also to be the most extensive, the caecum passing sometimes the whole length of the colon and appearing with its valve and the appendix outside the anus. The next most frequent variety is that involving the small intest- ine ; and after these in frequency come the cases affecting the colon, sig- moid flexure, and rectum. When the large bowel is affected it is most often near its termination, the descending portion passing into the sigmoid flexure, the flexure into the rectum, or the upper part of the rectum into the lower. These latter forms are necessarily limited in length, for when once the invagination has been fairly formed, and after the enter- ing portion has been grasped, the increase in length is always at the expense of the sheath. The obstruction and the strangulation of the contained portion may cause certain changes. The bowel above the implicated part may be simply distended and congested, it may be filled with faeces, or it may be ulcerated and perforated. The serous surfaces in apposition in the two contained portions are apt to become united by adhesions. When pres- ent and extensive these constitute the chief obstacle to reduction, whether spontaneous or the result of treatment. As a result of strangulation of the contained portion its walls may become much SAVollen by transudation of serum, the peritoneum con- gested, the mucous membrane infiltrated ; blood is effused between the mucous surfaces of the outer and middle layers ; and the whole con- tained portion becomes in this way irreducible. Should strangulation be sufficiently severe, gangrene may supervene, and this is Nature's method of cure. It is more apt to take place in acute than chronic cases, and may involve the whole or part of the contained portion. As a result, many feet of bowel may slough off and be passed, either in small por- tions or in large cylinders. The treatment of intussusception consists, first, in gentle efforts at reduction. The mass must be replaced by a process exactly the reverse of the one by which it came down, the most dependent portion being first carried into the body, and the telescope unfolded in this way. This means failing, a reduction may be accomplished by laparotomy, or a gangrenous portion may be exsected, or an anastomosis established around the involved part. The operation of excision with circular ertter- orrhaphy, as described under Prolapsus, may also be curative in old and chronic cases. DISEASES OF THE RECTUM AND SIGMOID FLEXUBE. 959 Chronic invagination of the sigmoid flexure into the rectum, lasting for many years, is a condition quite frequently diagnosticated, but sel- dom seen. The writer has always believed, theoretically, that it might occur and might cause a peculiar train of symptoms, but has never seen an undoubted case till within the past year. Usually the cases turn out to be simple ones of very obstinate constipation attended with great mechanical difficulty in obtaining a movement of the bowels, and possibly with slight prolapsus and obstruction of the anus from crowd- ing down of the normally profuse folds of mucous membrane. A posi- tive diagnosis of invagination can only be made when the condition can actually be felt by digital examination, as the symptoms cannot be dis- tinguished from those of old cases of severe constipation. Abscess and Fistula. Abscesses around the rectum are best divided for clinical study into superficial and deep. By the former are meant those of the sub- cutaneous cellular tissue, which are generally of trifling importance, often break and heal spontaneously without the formation of fistulse, or, when resulting in fistula, leave one of the superficial and trivial variety easily curable by incision. The deep abscesses may be divided with advantage into those of the ischio-rectal fossa and those of the superior pelvi-rectal space, two ana- tomical regions whose relations are important. An abscess of the ischio- rectal fossa is below the levator ani muscle and outside of the pelvic fascia which covers that muscle, and separates the ischio-rectal region from the general pelvic cavity. An abscess of the superior pelvi-rectal space is above the levator muscle, within the true pelvis, and only closed off from the free pelvic and abdominal cavities by the peritoneum. An abscess of the ischio-rectal fossa shows itself with all the usual signs of an acute phlegmon, and can hardly be mistaken for anything else. There should be but one treatment for this form of trouble, and that is an early and free use of the knife. It is a rule that an acute inflammation in this region will end in suppuration, and as soon as the brawny swelling appears it should be freely and deeply incised without waiting for pus. Pus will generally be present, however, before the surgeon is called. The treatment of such a case requires surgical skill. It is about as different from puncturing a superficial abscess and allow- ing the escape of pus through a small puncture as can well be conceived. The patient should be etherized and placed in the lithotomy posi- tion. A long, fine, straight bistoury should be inserted in the centre of the cutaneous hardness, pushed forward, and occasionally turned in the wound, till pus issues by the side of the blade. It may be necessary to carry the point fully four inches upward, and to repeat the puncture more than once before pus is found. In withdrawing the knife an incision two or three inches long should be made through cellular tissue and skin. Into this the index finger should be passed, all sloughing tissue broken down, all pockets opened up, till it is certain that a free communication of all parts of the abscess with the external wound has been established, and that the incision is sufficiently free to prevent any 960 SPECIAL OR REGIONAL SURGERY. further burrowing. The cavity should then be irrigated with bichloride solution 1 : 1000, and freely drained with iodoform gauze. The superior pelvirectal space is bounded by the peritoneum above, the levator ani and its superior aponeurosis below, and the walls of the pelvis on the sides. It is filled up by lax pelvic connective tissue, which communicates in front and laterally with that which fills the iliac fossae and the deeper regions of the abdomen through the interven- tion of the subperitoneal connective tissue of the pelvic walls. Behind it is continuous with the connective tissue of the meso-rectum and the concavity of the sacrum, and it communicates with the gluteal region through the sciatic notch. In women it is also continuous with the con- nective tissue of the broad ligaments. It is easily understood from this why abscesses originating in this location may assume such vast proportions, burrowing laterally into the subperitoneal con- nective issue of the iliac fossa?, or almost anywhere else in the true pelvis; dis- charging into the bladder, vagina, or high up into the rectum ; mounting above the bladder and pointing in the groin or loin ; passing out of the pelvis into the thigh, and causing retention of urine, and even intestinal obstruction, from pressure. In abscess of the pelvi-rectal space the symptoms are often obscured. There is more or less pain in the pelvis and lumbar regions, which is seldom intense. Fever may be entirely absent, is seldom continuous, and chills are only occasionally met with. The patient may soon sink into a typhoid condition, with high temperature and diarrhoea. I think I have more often been able to make an early diagnosis, before the dis- covery of tumor, by the presence of vesical and rectal tenesmus, with deep pelvic pain, than by any other signs. The treatment is, of course, that by incision and drainage, and the incision should be made as soon as pus can be located. It is true that these abscesses tend naturally to discharge themselves into the rec- tum, vagina, or bladder, but to leave them to their own course is attended by great risk. If the pus be approaching the perineum, the incision should be made there ; should it appear in the groin or thigh, free incision may be made there ; and should the tumor appear in the iliac fossa or above the bladder, laparotomy is indicated. There is a form of periproctitis which is not to be confounded with this one. It is distinctly septic in origin, and is the chief cause of death after surgical operations in this region. It is analogous to puerperal septicasmia, and in its general symptoms follows closely the clinical history of pyaemia. In those cases in which the inflammation shows a tendency to become circumscribed, life may be saved by proper surgical treatment, but where it is diffuse and invades the intermuscular planes of connective tissue, there is little hope. I have seen infection start at the rectum, show itself as a brawny infiltration in the right iliac region, and extend up the right side to the axilla, without at any time becoming in the least circumscribed or allowing of surgical interference. Small fistulse of the subcutaneous variety,, like the superficial abscesses from which they result, are generally easily curable by laying open the track and scraping away with the handle of the scalpel the old granulation-tissue which lines it. DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 961 Fistulse resulting from ischiorectal abscesses differ greatly in their extent and gravity. In them the track is much larger, and often double or branching, and the external opening may be far away from the anus. The whole perineal region Avill sometimes be found brawny and indurated, and there may be a dozen or more points at which pus has burrowed to the surface. The fistulae resulting from abscesses in the superior pelvi-rectal space may be of any extent. The track may be very deep, and the probe passed into it may go directly aWay from instead of toward the rectum. Pus starting thus deep in the' pelvis may find its exit in the groin, over the hip-joint, or even in the popliteal space. Fig. 421. Fig. 422. Complicated rectal fistula (Potherat). Complicated rectal fistula, same as Pig. 421, but more complete (Potherat). Tubercular flstulse are generally easy to diagnosticate by their gross appearance without microscopic examination. In them the internal orifice is apt to be large, so that the finger may readily pass into it from the rectum ; the skin over the track is undermined ; the discharge is sanious and unhealthy ; and the general condition of the patient helps the diagnosis. In operating upon such cases the entire track, after being laid open, should be thoroughly destroyed, either with the sharp scoop or the cautery. There seems little doubt that such a fistula may be the starting-point of general tuberculosis, and that a radical operation clone early may prevent general infection. When it has been decided to lay a fistula open into the gut there is but one method to be recommended, and that is the knife. The elastic ligature or ecraseur need not be considered except in cases where the incision is so deep that concealed hemorrhage is to be guarded against • and the silk ligature is unsurgical. Where the fistulous tracks exist in great numbers, two or three ope- rations at intervals may be advisable, rather than an attempt to cure at one sitting. It is easily possible in such cases to do an amount of cut- ting that shall endanger the recuperative power of the patient. Many 962 SPECIAL OR REGIONAL SURGERY. of the tracks will be found to run away from the gut and be merely sub- cutaneous, and it may be possible to divide the different openings into two or three groups, each group having its own independent deep com- munication with the bowel. Although to effect a cure in some cases it may be necessary to divide the sphinc- ters in two or three different places, and in such a greater or less degree of incon- tinence is to be expected, a double division of the sphincters is always to be care- fully avoided if possible. It is wonderful how many different tracks may be laid open and made to drain freely into a single median incision behind, if care and study be devoted to this point. Especially does this apply to the various forms of horseshoe abscess, in which pus has burrowed around the gut in a semicircle either in front or behind, and in which there are often two external and two internal openings. In all of these operations it is well to bear in mind that a large per- centage of all cases are failures, even in hospital practice. This arises from the popular conception that a fistula is a straight track leading from an external opening in the skin to an internal opening in the bowel, and that the operation consists in first passing a director along this track and then dividing it. On the contrary, most fistulse are branching, compli- cated tracks, which need to be dissected up and laid open with great care. The director needs only to be introduced a short distance at a time to do this, and many cases are better operated upon without a director. The after-treatment should be as simple as possible. After the first dressing of gauze has been removed, it is generally only necessary to pass a finger into the deep parts of the cut twice a week to see that it is open well down to the bottom and that no pockets have formed. Ulceration and Stricture. The simplest form of ulcer met with at the anus is what is univer- sally known as a fissure. Although almost invariably due to the trau- matism of a large and hard fecal movement, it probablv may in a few cases be due to an ulceration of one of the sinuses of Morgagni and a thickening and tearing downward of the little valve of mucous mem- brane which forms the pouch. This is the explanation given by Ball of the frequent coexistence of fissure with an inflamed tag of skin at its lower edge, known as a "sentinel pile." Next in frequency to the fissure comes the large class of ulcers due to traumatism, and the traumatism is generally surgical in character. Wounds of the rectum are proverbially hard to heal under the best treatment, and when neglected or badly treated change rapidly from healthy wounds to unhealthy ulcerations. In this way patients who have had slight operations for hemorrhoids or fistula, and have passed out of observation with the wounds healthy and cicatrizing, will return years later with extensive and incurable ulceration and stricture. So fre- quent is this that in every case of doubtful etiology the history in this regard should be carefully inquired into. Allied to these cases are those in which the traumatism is due to chronic constipation and the pressure of scybala; upon the mucous mem- brane. Death has more than once been caused by perforation of the sigmoid flexure due to the pressure of a scybalous mass, and severe ulcer- ation of the rectal pouch may be due to the same cause. DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 963 Tubercular ulceration may occur anywhere in the length of the alimentary canal, and is not very infrequent in the skin at the margin of the anus. It is characterized by its pale-red surface, covered with a small quantity of serum, but devoid of healthy pus, giving it a var- nished appearance ; by the absence, of surrounding inflammation and the granulations which exist in a healthy sore ; by its tendency to spread in depth rather than on the surface ; by the absence of pain ; by the irreg- ular outline ending abruptly in healthy skin ; and, above all, by its chronicity and the utter failure of all ordinary remedies to affect its course. The diagnosis may be confirmed by the microscope. Tubercu- losis of the rectum or anus may be a primary affection, but is generally associated with deposit elsewhere. The ulcers resulting from dysentery vary much in extent and loca- tion, and, although their favorite site is at the rectum and sigmoid flexure, they may occur anywhere in the large intestine. I know of no way in which old dysenteric ulcers can be positively distinguished from chronic ulceration of other varieties except by the history of the disease, but I am convinced that it is by no means an uncommon condition even in our Northern cities. There is still one other form of chronic ulceration of the anus, vulva, rectum, and vagina which has been described under various names, and which until within the past few years was supposed to be a distinct affec- tion. Perhaps the name by which it was best known was esthiomene. It has been attributed to syphilis and scrofula ; has been considered both as lupus and elephantiasis, and as an affection sui generis of unknown etiology. Nobody, I think, before R. W. Taylor grasped the fact, which was evident to him from his large experience in the venereal wards of Charity Hospital in New York, recognized that the greater number of these chronic, deforming vulvar and anal affections " are due to simple hyperplasia of the tissues induced by irritating causes, inflammation and traumatism." In other words, he fails to find any such disease as esthio- mene, but he does find that any lesion around these parts, especially in old syphilitic subjects, may take on a hypertrophic action. A chronic chancroid may do the same, and no venereal lesion is absolutely essential. The condition is recognized by the greed extent of the ulceration, often destroying the rectum and vagina entirely ; by its xloic course, often last- ing many years without affecting the general health ; and by the great hypertrophy of the affected parts. It is most apt to be mistaken for can- ■cer, phagedenic chancroid, or elephantiasis. The treatment should consist in destructive cauterization. In many of these cases antisyphilitic treatment will do good, but by no means in all. There are also several varieties of venereal ulceration. met with in the rectum and at the anus. Gonorrhoea of the rectum may be so severe as to cause distinct ulceration within the pouch, and the irritating discharge from the anus may cause erosions and fissures, or previously exising fissures may become inoculated and spread. Chancroids of the anus may be caused by direct contagion or by auto-inoculation, and, though they may be caused by unnatural vice, their mere presence is no proof of the habit. They are much more 964 SPECIAL OR REGIONAL SURGERY. common in females than males, because of the facility of auto-inocula- tion and the frequency of accidental contact of the male organ. True chancre at the anus is not very uncommon, though it may pass unnoticed. Its presence in the male is proof positive of unnatural viee, as the lesion is not auto-inoculable. Mucous patches are very frequent around the anus, and assume two distinct types, the ulcerative and the vegetating. It is to the latter alone that the so commonly improperly used term " condyloma " should be confined. Of the existence of secondary syphilitic ulceration within the rectal pouch there is no more doubt than of its existence in the fauces and trachea. There is also no doubt in my own mind that this form of ulceration may occasionally result in true syphilitic stricture ; but that it often does so, or that the so-called syphilitic stricture is really syphilitic at all, I do not believe. In thus enumerating the different varieties of ulceration of the rec- tum we have also enumerated most of the causes of stricture, which in the great majority of cases is a simple result of ulceration. Any simple ulceration of the rectum, if left to its own course, and more especially if badly or improperly treated, may result in a stricture from hypersemic overgrowth and contraction, and nearly all strictures not cancerous are of this nature. The only other varieties known are the congenital, the spasmodic, and those due to extensive traumatism or pressure from outside the canal. Congenital stricture of the rectal pouch is not very uncommon, and may not be discovered till the patient reaches adult life. For years the disease will cause little trouble, and the patient may only be aware of the fact that the passages are always very small in calibre ; but as age advances the tissue composing the constriction becomes firmer, the difficulty in defecation increases, and finally a digital exam- ination reveals the nature of the affection. Cancerous stricture is more common in the rectum than any other part of the alimentary canal. As its treatment is now the same as that of non-malignant contraction, no especial space will be devoted to its pathology or symptomatology. The treatment of ulceration of the rectum without stricture has come to be almost entirely operative when the ulceration has reached a point which has involved any great loss of tissue. Only the slighter cases are curable by local applications. Superficial destruction of the mucous membrane, even over a considerable area, may be curable by proper local treatment, and a deep loss of tissue confined to a compara- tively small area may also be induced to cicatrize without very much subsequent contraction ; but, unfortunately, the disease is an insidious one, and rapidly passes the curable stage. The choice often rests between colostomy and extirpation of the rectum. The treatment of stricture, both cancerous and benign, has also come at the present day to be entirely operative, and to consist either in colostomy or extirpation. In only a few of the simplest forms of non- malignant disease is the operation of division with subsequent dilata- tion of any permanent value, as the dilatation can seldom be main- DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 965 tained at a point which will accomplish anything, on account of the irritation it produces. In deciding between colostomy and extirpation in any particular case, whether malignant or benign, the present tendency is to do an extirpa- tion when we can, and a colostomy when we must. Colostomy. In doing colostomy less preparation of the patient is necessary. In cases of prolonged obstruction delay is dangerous and purgation out of the question, and in others there is no occasion for emptying the aliment- ary canal. In fact, the presence of scybalous masses in the sigmoid flexure is one of the best guides to the part of the bowel to be opened. The parts should be prepared as in all laparotomies, and the incis- ion should be about two inches long, crossing an imaginary line from the anterior superior spine to the umbilicus at a point one and a half inches from the spinous process. When the abdomen has been opened by this incision the sigmoid flexure, if in its normal position, will be the first loop of intestine presenting. Before searching for it, however, a silkworm suture with shot and shield on one end should be passed through all the layers of the abdominal wall from without inward at a point about half an inch from the inner lip of the wound, and the needle, still threaded, brought out through the incision and laid to one side. Search may then be made for the sigmoid. If it happen that the small gut present, the best place to search is between the incision and the anterior superior spine, close to the wall of the abdomen. Hook the finger into the wound and draw it along the abdominal wall from the side of the pelvis outward toward the incision, and the sigmoid will often be caught by it. When a proper piece of gut has been drawn through the wound, the needle is again taken up and passed through the mesentery of the loop close to the gut, and then through the whole thickness of the abdominal wall from within outward at a point half an inch from the incision on the side toward the spinous process. When this has been drawn taut and secured by a second shot and shield, the loop of gut will be securely held outside of the abdomen by a suture passing under it through its mesentery and through the whole abdominal wall on each side. The gut is next to be secured more accurately in its place by six or eight silk sutures passed as follows : The needle passes first through the skin at the margin of the incision ; next through the cut edge of the narietal peritoneum ; next through the muscular layer of the gut, but not into its calibre. When such a stitch is tied, it is evident that the gut will be attached to the skin margin of the incision, and that the peritoneal cavity will be closed by the union of the parietal and visceral layers at that point. Enough of these sutures should be used to completely shut off the peritoneal cavity. This part of the operation will be greatly facilitated if, when the peri- toneum is first incised, its cut edges be seized and held at half a dozen different points with forceps, and these be allowed to remain till replaced by the sutures. In this way the stitches can be replaced without wasting time in searching for the edge of the peritoneum. 966 SPECIAL OS, REGIONAL SURGERY. Before any suturing is done except the first suspensory suture of silk- worm gut, the loop of intestine should be drawn well out of the wound, and a longitudinal band selected through which the sutures can be passed for greater strength. One of these is always available, and not infre- quently use may be made of one on each side of the bowel. When the suturing is finished a loop of gut at least two inches and a half in length should be secured in the incision with one-half its calibre at least outside of the body, and the peritoneal cavity completely shut off around it. The gut may now be opened without waiting for adhe- sions. This is done by first snipping into its cavity with a pair of scis- sors, introducing a finger for a guide, and paring away the exposed wall down to within a quarter of an inch of the line of sutures. One or two small vessels may have to be tied. The appearance of the bowel after it is opened should be like that of a double- barrelled gun with a sharp ridge between the two barrels, where the gut is sharply bent over the silkworm suture. The accepted practice for the past few years has been to allow at least forty-eight hours to elapse between stitching the gut to the abdominal wall and opening it. Besides entailing a second slight operation, which is often attended by considerable dread and nervous shock, the practice is troublesome from the fact that the operator if at a distance from home is compelled either to wait two days or return. Five or six hours is amply sufficient to secure the shutting off of the general peritoneal cavity by exudate, but the writer has found even this delay unnecessary where proper care is given to the suturing, and now completes the operation at one sitting. No surprise need be felt if the first movement from the artificial anus is delayed for several days, as the bowel has often lost its tonicity from chronic obstruction before the operation. After healing is complete the patient should always wear a broad abdominal belt and a pad of cotton over the opening, to prevent pro- lapsus. Trusses are seldom well borne. Care must also be exercised to prevent excoriation of the exposed mucosa. In non-malignant disease the prospect of cure and subsequent closure of the artificial anus should always be held out to the patient. It will give great comfort, and it may be done in any one of several ways, but is 1 a more difficult operation than the original one. Extirpation of Rectum. At least four days should be allowed in which to prepare a patient for extirpa- tion of the rectum. On the evening of the first day, three compound cathartic pills should be given, and these should be repeated on the evening of the second. The day before the operation the diet should be exclusively milk and beef tea, preferably the latter, and on the evening before, a dose of bismuth and morphia should be given. This should be repeated on the morning of the operation. The idea of this preparatory treatment is plainly to have the alimentary canal as empty as possible before operating, and to postpone as long as possible the first movement of the bowels after the operation. No preparation of the site of the operation is made before the ether is given, but then great care should be devoted to this point. With the DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 967 patient in the lithotomy position the perineum is first shaved and the rectum thoroughly cleansed. This is done through a speculum with frequent irrigations of bichloride solution (1 : 500), and by carefully wip- ing out the canal as high up as possible with pledgets of iodoform gauze on long forceps. Very often it will be a great help to the operator to introduce his finger into the canal during the operation, and in any case it will be necessary to cut the bowel across above the disease. In doing either of these things the whole wound is apt to become infected, and the object of the preliminary disinfection is to reduce this risk as much as possible. The disinfection may not be chemically or theoretically perfect, but exactly in proportion to its thoroughness will the mor- tality of the operation be decreased. A small tampon of iodoform gauze may be left in the rectum, but too great a mass distends the canal, obscures the limits of the disease while operating, and distorts the normal anatomy. The patient is next turned on the face or practically so, and the whole site of operation scrubbed and disinfected. Soap and brush, if well applied, with a final washing of bichloride, and after that of ether, will be found efficient. The incision should be begun at a point two inches to the left of the middle of the sacrum, slanting it toward the median line, and on reach- ing it extended along the fold between the buttocks to the anus. This incision should be made to reach bone at once, and flaps should be turned to each side by a few strokes of the knife. The right flap should freely expose the lower right half of the sacrum, that on the left the ligaments connecting the sacrum with the rest of the pelvis, and these should be divided. A periosteal elevator is then passed under the sacrum from left to right (the operator stands on the left) at the level of the incision to be made across that bone, and is worked down under sacrum and coccyx till the anterior surface of the bone is freed from soft tissues. In this way very troublesome hemorrhage from the sacra media and its veins may be avoided. When the periosteal elevator has been removed, one blade of a long, strong, straight bone-forceps is passed under the sacrum, and the bone is divided transversely, the lower fragment, with the coccyx, being completely removed. Usually this triangular piece should consist of the last two sacral vertebra and the coccyx. All of this preliminary work should be finished in less time than it takes to describe it, and only slight bleeding will be caused by it. This may generally be disregarded, and will cease spontaneously unless some of the veins of the sacral plexus have been injured. Should there be a persistent loss of blood from just under the stump of the sacrum, it must be controlled either by forceps or pressure with the finger, as it is often exceedingly difficult to get a ligature under this point. A ligature on a needle will sometimes do what cannot be done in any other way but forceps are generally sufficient. Particular attention is called to this minor point, as it is often a troublesome one. The pelvis being now freely opened, the operation may proceed. First, the gut should be isolated on each side by the finger ; no cutting is necessary. In part the gut will roll out of its bed with great ease but it will not come down, and the finger cannot be passed completely under it, for this is its largest part, and it is still firmly held by the peritoneum and connective tissue between it and the sacrum. The key 968 SPECIAL OR REGIONAL SURGERY. to the rest of the operation is the peritoneum, which should be found and opened before any attempt is made to drag down the gut. This may take time, and several small incisions may be made into the cellular tissue covering the peritoneum before its cavity is opened ; but when the finger is once fairly within the free peritoneal cavity the greatest diffi- culties in the operation have been overcome. I usually make the open- ing into the peritoneum on the right side of the gut, introduce the finger, hook it under the gut, and force it out through the peritoneum and cel- lular tissue again till its end appears free on the left side of the rectum. In this way the fold of Douglas is torn open and away from the bowel, and the rectum is prevented from coming down only by the mesorectum and cellular tissue between it and the hollow of the sacrum. While gentle tension is made upon the gut with the finger hooked under it, this last obstacle to its free descent may be cut away. The mesorectum must be cut as little as possible. If it be stripped off from the .gut to too great an extent, the bowel will slough for lack of nourishment. It is generally easy to feel, before the gut is opened, the extent of the disease to be removed, and the rectum should be cut across above it — if for cancer, at least an inch above. No bleeding need be feared from cutting across the gut. Unfortunately, it will often be found only too feebly supplied with vessels after the mesorectum has been cut sufficiently to allow the stump to come down into the wound. Something much more to be feared is soiling the wound with the con- tents of the bowel. This may best be avoided by dividing it between two ligatures made of gauze, or between two intestinal clamps, after the wound has been carefully protected by packing with gauze to be subse- quently thrown away. The upper end after division should be carefully wiped with iodoform gauze, and given to an assistant ; the lower end should be seized firmly by the operator, stripped quickly from its anterior attachments by pulling it downward and outward, and either removed as a whole or amputated below the disease. If it be removed down to the anus, the levator will need to be cut on each side. The operator now has the whole pelvic cavity at his command. In women, tubes, ovaries, and uterus can be plainly seen and easily examined. Several times I have removed tubes and ovaries at this stage of the operation where their removal was imperative, but I prefer not to do it. The shock of an extirpation may be more than a patient can bear, without any additional traumatism. The next point to be decided is what to do with the upper end of the gut — whether to bring it down to the skin and make an anus in the natural place in the perineum, to suture it to any portion of the rectum which may have been preserved near the anus, or to bring it out in the middle of the wound and suture it to the skin just below the stump of the sacrum. This is often a very difficult point to decide, and one upon which not only the subsequent comfort of the patient, but also his life, may depend. If it is determined to bring the stump down to the skin of the perineum, a trial must be made to see if it is sufficiently long and movable, and if not, the mesentery and cellular tissue must be divided a little more freely. After this has been decided the toilette of the peritoneum should be made with hot water or saline solution and sponges, exactly as in a DISEASEC OF THE RECTUM AND SIGMOID FLEXURE. 969 laparotomy. The end of the gut should then be stitched to the point decided upon, all parts of the wound should be closed by deep and super- ficial sutures as carefully as possible, and a tent of gauze should be left in the deep part for drainage. Almost always the suturing will stop all bleeding, and no time need be devoted to special suture of the rent in the peritoneum. Regarding the final disposition of the end of the gut where it has been cut off above the disease, there are many things to be considered. The safest and simplest operation is the old one of stitching it to the skin just below the stump of the sacrum. This does away with much of the danger of sloughing, and hence reduces the mortality, but leaves an anus that is not as satisfactory to either patient or surgeon as one in its natural place. Doubtless the theoretically perfect operation is the one that removes the disease and leaves the patient with as good functional control as he had before ; and this may frequently be accomplished both in cases where the disease has been confined to the lower end of the gut, and where after amputation of two or three inches the stump can be stitched to the skin of the perineum ; and in cases of disease quite high up which allows room after resection for careful apposition of the two ends. But this last operation is attended by many failures, and more risk than either bringing the stump down to the skin of the perineum or turning it sharply backward just below the stump of the sacrum. The upper segment is poorly supplied with nourishment, and the lower has no peritoneal investment. The most careful suturing will fail of its object, and the Murphy button will slough out. In either case the whole wound becomes foul with faeces, and the mortality is greatly increased. This risk is unquestionably greatly reduced by preliminary colostomy. In deciding upon the final disposition of the stump of the bowel, the operator will be chiefly guided by its vitalization and the extent to which the mesentery has been injured in loosening the rectum. In some eases it will evidently be so impoverished that it can only be brought out in the sacral region. Absolute sphincter ic control should never be promised after extirpation. Few patients have it before the operation, and fewer still will have it after. The most that can be hoped for is that the patient will be as comfortable after as before in this regard, which means that he will know when an evacuation is impending and have time to attend to himself. Such in a general way is the operation for extirpation of the rectum, either cancerous or strictured and ulcerated, and the secret of its mor- tality will be found to lie much more in perfect antisepsis than in the amount of shock. CHAPTEE XLVIII. GENITOURINARY SURGERY. By William T. Belfield, M. D. Malformations . Prepuce. — The foreskin exhibits three common abnormalities — undue length, tightness, and adhesion to the glans penis. These three features are commonly combined in congenital phimosis, or inability to retract the prepuce behind the glans. This condition — and the accumulation of smegma under the foreskin which commonly accompanies it — -is responsible for many morbid states : it causes it: childhood local irrita- tion and soreness, straining and pain in urination, and a tendency toward hernia (in every case of acquired hernia in children the prepuce should be examined, and, if phimosis exist, removed as a part of" the treat- ment of the hernia). In certain cases, disorders of the nervous system, such as convulsions, epilepsy, chorea, and paresis, have ceased after the removal of a tight prepuce. In later life phimosis favors balanitis, unnatural excitability of the sexual organs, as shown by frequent emis- sions and nervous phenomena, and it greatly increases the danger of venereal infection. For these reasons phimosis should be promptly relieved by circum- cision whenever brought to the physician's attention. Penis. — Absence of the penis, except as the result of disease or injury, is very rare, and is always associated with arrest of development in adjacent organs. Apparent absence of the penis at birth is less rare, and is due to a misplacement of the organ, which may be detected as a firm cylinder beneath the skin of the scrotum, perineum, or suprapubic space. It can be liberated by suitable incision and restored to its nor- mal position ; a proper covering can be secured by plastic operation. Rudimentary and multiple penis have been occasionally observed. Absence of the urethra, which is replaced by a fibrous cord, occa- sionally occurs. This usually results in the death of the foetus before the completion of intra-uterine life, because the distended bladder presses upon the umbilical arteries and thus impairs the nutrition of the fetus. Yet in a few instances such a child has been born alive ; in some of these it is found that the urachus has reopened and serves as a urethra ; in others the recto-vesical partition is imperfect ; while in a third class the bladder is found enormously distended at birth and needing imme- diate surgical treatment. Occasionally such a bladder has formed an obstacle to delivery until punctured. For practical purposes this con- dition is identical with the following : 970 OENITO-URINARY SURGERY. 971 Congenital Occlusion (Atresia) of the Urethra. — This results from a fusion of the urethral walls over a small area, and is most common in the vicinity of the meatus and often associated with hypospadias. Atten- tion is attracted by the child's failure to urinate and by the distention of the bladder. Examination may show an occluded meatus, which should be incised ; a small button probe is gently passed backward to the bulb, unless the urine flows before that point is reached ; if further separation is needed, the probe is replaced by a small elastic catheter, with which a gentle effort is made to overcome the obstruction. Congenital urethral pouches are rare distentions of the floor of the penile urethra, holding from an ounce to a pint of urine ; though appar- ently resulting from an impediment to the escape of urine, such obstacle has not usually been detected in the cases examined. It is possible that the impediment was a temporary barrier (occlusion) between the penile and glandular urethra, which has been broken through after the forma- tion of the pouch. Treatment consists in excising the redundant skin and mucous membrane, leaving just enough to form a urethra of natural calibre by apposition ef the cut edges. Hypospadias and epispadias are terms designating congenital defects in the urethral walls, as a result of which the urine escapes from the penis at some point posterior to the normal exit, the meatus. These defects are probably due to the conditions already described — congenital occlusion and pouching of the urethra, followed by rupture of its walls prior to birth, and cicatricial contraction of the ruptured edges, often with adhesions to the scrotum, which sometimes cause a turning or " torsion " of the penis on its axis. The commonest locality for congenital occlusion is at the junction of the glans penis with the spongy urethra, for these two portions are sepa- rately developed, the penile urethra growing forward from the pubic bone, the glandular urethra dipping backward from the tip of the glans. These two blind canals normally meet at the posterior surface of the glans, and coalesce through the absorption of the intervening tissue. If, however, this coalescence into a complete canal be prevented by the persistence of a barrier of intervening tissue, various abnormal sequences may occur : (1) simple congenital occlusion ; (2) pouching of the penile urethra behind the barrier ; and (3) rupture of the distended urethra, resulting in hypospadias if the rupture be, as it usually is, on the under surface ; and in epispadias if the rupture occur on the upper surface of the urethra. If the abnormal urethral opening lies behind the scrotum, this sac is split into two, which may be widely separated. In this case the appear- ance of the external genitals — especially when the testicles are unde- scended — simulates more or less perfectly that of the external female organs; hence the individual is often considered an hermaphrodite. Closer examination, however, enables one to recognize in the adult the distorted male organs, and a finger in the rectum detects the prostate, though this may be smaller and thinner than usual. Nearly all the pro- fessed hermaphrodites, including the individuals who exhibit themselves at medical schools under this name, are merely males displaying an extreme degree of perineal hypospadias. 972 SPECIAL OR REGIONAL SURGERY. Epispadias, caused by the rupture of the upper surface of the foetal urethra, is far less common than hypospadias. A few instances of epi- spadias limited to the glans penis or in the anterior portion of the penile urethra, have been recorded ; usually, however, the defect of the upper wall is associated with a similar defect in the bladder and abdominal wall and an imperfect union of the symphysis — the condition known as exstrophy of the bladder. Fia. 423. l. 2. 3. Diagrammatic sections showing different varieties of hypospadias (Kauffmaim) : 1, hypospadias with imperforate glans; 2, hypospadias with blind canal in glans; 3, with barrier placed between penile urethra and balanitic groove ; 4, typical case of hypospadias ; 5, hypospadias with normal meatus ; 6, penile urethra opening below glans ; 7, absence of the whole inferior Eart of the penile urethra; 8, hypospadias with absence of urethra through glans ; 9, case of >' Arnaud ; 10, case of Lacroix ; 11, case of Lippert with normal meatus. Bladder. — Absence of the bladder has been detected post-mortem in a few instances, but has no clinical importance. Division of the bladder by a more or less complete septum is likewise a rare condition, which might, however, puzzle the surgeon in case of calculus-formation in one of the cavities. Hernia of the bladder is a by no means infrequent condition, the pos- sibility of which should not be forgotten in considering tumors at the various pelvic outlets, particularly the inguinal canal. QENITO-URINARY SURGERY. 973 Hernia of the bladder into the inguinal canal or even the scrotum of the male, with or without intestine, omentum, or an undescended testicle, has repeatedly surprised surgeons when operating for a supposed intes- tinal hernia. Skilful operators have opened the bladder in this locality, discovering their mistake only through the escape of urine. The pos- sibility of vesical hernia as the cause of an inguinal swelling is suggested if the tumor be soft and elastic, and if the patient be suffering from cystitis or retention of urine. Pressure and manipulation of the tumor may cause its disappearance, accompanied by a desire to urinate on the part of the patient. Vesical hernia must be especially distinguished from hydrocele of the cord. Inversion of the bladder through the urethra is a form of hernia occa- sionally observed in females as the result of violent straining ; it is easy of recognition if the possibility of this condition be borne in mind. The bladder can be returned to its normal position under anaesthesia, but great care to prevent its recurrence must be observed. Exstrophy of the bladder is a congenital absence of the anterior wall of the bladder, frequently associated with separation of the pubic sym- physis and defect of the upper wall of the urethra ; it is probably due to the same causes as epispadias, already described. The patient's con- dition is deplorable : the constant escape of urine, soon becoming ammo- niacal, the excoriations of the skin as well as of the exposed bladder, contribute to a condition of constant suffering. Treatment consists either in the wearing of a specially constructed urinal or in a plastic operation for the restoration of the defective tissues. Kidney and Ureter. — Absence of one kidney is said to occur once in about four thousand cases : in at least one recorded instance a surgeon has removed the only kidney possessed by the patient, who presently died of suppression. Fortunately, the cystoscope now enables us to deter- mine whether both kidneys are secreting urine. Fusion of the kidneys, partial (horseshoe kidney) or complete, is an anomaly of little surgical importance. A valve-like obstruction of the ureter at its junction with the kidney pelvis is the only congenital malformation of this duct possessing sur- gical importance. This valvular arrangement is apparently due to the insertion of the ureter into the pelvis at an improper angle, and its result is hydronephrosis. A similar obstruction, due to "kinking" of the ureter, is occasionally observed as the result of displacement of the kidney and a consequent sharp bending of the ureter in its upper part. Testicle and Vas Deferens. — Absence and muttijrfi city of these organs possibly occur, but with exceeding rarity. A eunuchoid condition of the testicle is sometimes observed, the organ being of small size and lacking the normal glandular elements. Retained testicles exhibit this condition oftener than do those which have descended into the scrotum. Misplacement of the testicle, due to irregular or incomplete descent, is a frequent and important malformation. The organ may be found in the abdomen (cryptorchidism), the inguinal canal, at the external inguinal ring, in the perineum or crural region. In any of these abnormal loca- tions, except the abdominal cavity, the misplaced testicle constitutes a 974 SPECIAL OS, REGIONAL SVBGERY. swelling which has often been mistaken for hernia, bubo, orabscess (the latter when the testis is inflamed by a gonorrhoea! extension or other cause). Hence the surgeon should make a practice of examining the scrotum in every case of disease of the pelvic organs, that the misplace- ment of one or both testicles may not be overlooked. A misplaced testis can usually be recognized as such not only by its form and size, but also by the peculiar sensation caused by pressure upon it. Misplaced testicles, especially when retained in the inguinal canal, and hence subject to a continuous abnormal pressure, are especially prone to become the seat of malignant disease — an argument in favor of opera- tive interference. If the testicle be retained in the abdomen, no treatment is required ; if it be found in any other abnormal location, it should be transplanted, to the scrotum when possible. If this be prevented by adhesions or shortness of the cord, its removal should be advised, provided the other testicle be found normal. While the patient, when young, will usually object to such removal, yet the frequent annoyance and pain from the misplaced organ will gradually convince him of its advantages. Injuries. Penis and Urethra. — In treating injuries of the penis the great vascularity of that organ must be remembered and care be taken to arrest and prevent hemorrhage. Aside from wounds in general, which need no description, the penis is sometimes the subject of strangulation, dislocation, and fracture (so called). Strangulation occurs in boys or men from tying strings or bands around the organ or introducing it through rings or into bottles : great swelling, even gangrene, has been known to ensue. Occasionally strangulation has been seen to follow paraphimosis. Treatment naturally consists in removing the constricting band and in the liberal application of hot witter to the swollen parts. Fracture of the penis means a subcutaneous laceration of the erectile bodies, usually the corpora cavernosa, and occurs through violence inflicted on the rigid organ. It was often the result of an attempt to " break " a chordee by striking the erect penis, previously laid upon a table, with a book or other object ; and it has been known to result from " missing the mark " in attempts at intercourse, the penis striking vio- lently against the pubic bone of the female. If neither skin nor urethra be lacerated, the hemorrhage from the torn vessels of the corpus cavernosum makes a subcutaneous swelling which should be treated with continuous hot fomentations. If, as more commonly happens, the urethra also is lacerated, profuse, even alarming, bleeding from the meatus ensues : this can be checked either by simple compression of the penis or better by compression against a large metal sound introduced into the urethra. For a day or two follow- ing this accident urination is apt to be difficult or even impossible, and the effort starts the bleeding again. Urinary infiltration is apt to occur, requiring free incision and drainage from without. Laceration of the corpus cavernosum is in any case usually followed by obliter- ation of some of the vascular spaces in that body, and consequent imperfection in erection thereafter, the penis bending when erect toward the injured side. Dislocation of the penis is a rare result of violence to these parts : the GENITO-URINARY SURGERY. 975 Fig. 424. organ has been found displaced under the skin of the perineum, abdomen, or thigh. It should be immediately restored to its normal position and covered with skin, its own or that of surrounding parts (scrotum),when its original covering has been destroyed. Injuries of the urethra may be clinically divided into those that do and those that do not extend through the skin, analogous to the compound and simple fractures of bones. Injuries of the urethra combined with a wound of the overlying tis- sues and skin are usually inflicted by sharp instruments, and, because of the external opening, offer but little danger of urinary infiltration, though they may bleed profusely. Longitudinal wounds of the urethra heal whether sutured or not ; trans- verse wounds should be sutured with catgut whenever possible. This is best done, after enlarging the wound if necessary, over a large catheter in the urethra. Sometimes the wound may have completely severed the urethra, rendering the introduction of a catheter difficult or impossible. In this case, if the patient urinate Traumatic stricture of urethra (by fracture of freely through the wound the surgeon & A %t$£^&S£$& 7 ££&. may wait until the first swelling has sub- phrosis (Turner), sided and then again try to pass the catheter; if, however, there is infiltration of urine, the sound urethra behind the point of injury should be made accessible — either by perineal urethrotomy or suprapubic cystotomy — and a catheter passed from behind forward, on which the urethra can be sutured. The tissues above the urethra may also be united, but a small drain should be left to prevent urinary infiltration. Transverse lacerations of the urethra and all injuries involving the peri-urethral tissues are apt to be followed by stricture. Injuries of the urethra without perforation of the overlying skin are most common and often very serious. They occur in the penile urethra from fracture of the penis already described ; from unskilful handling of metal sounds, catheters, and urethrotomes ; from the introduction by the patient of foreign bodies — needles, pencils, etc. ; and from blows or falls. The less movable urethra posterior to the scrotum is, however the most frequent site of such injuries, which result from the forcible use of urethral instruments, from blows and falls upon the perineum and from fracture of the pelvic bones. Boys who have fallen astride of fences, limbs of trees, bicycle saddles, or other objects furnish a large share of these cases. The chief object of treatment is to prevent urinary infiltration of tissues: the methods for accomplishing this will vary with the locality and extent of the 976 SPECIAL OR REGIONAL SURGERY. laceration of the urethra. In cases of slight wounds of the penile urethra the introduction of a scrupulously clean elastic catheter (without a wire) at necessary intervals, whereby the urine is withdrawn and the urethra irrigated with hot water, may suffice. In some of these lesions of the anterior urethra, and in most cases of urethral laceration posterior to the scrotum, there will soon occur, in spite of this measure, the signs of beginning infiltration of urine — burning pain and boggy swelling at the seat of injury, rise of temperature, and ultimately chills. So soon as the occurrence of symptoms justifies the belief that urine is stagnating outside of the urethra, the surgeon should insist upon making a prompt incision to the seat of rupture and instituting free drainage ; incidentally he should endeavor to suture the wound in the urethra. Early operation not only greatly diminishes the chance of general septic infection and death (which has occurred in about 12 per cent, of such cases), but also, by limiting the local destruction of tissue, reduces the subsequent cicatrix and stricture-formation to a minimum. Physicians are inclined to wait too long before operating in these cases. Surgeons have even operated immediately after the receipt of the injury, without waiting for signs of infiltration. The possible remote results of these injuries are extensive and obsti- nate stricture, urinary fistulse, incontinence of urine from destruction of the membranous urethra, and curvature of the penis during erection from destruction of portion of the corpora cavernosa. Bladder. — Injuries of the bladder may be clinically divided into two classes — those which do and those which do not perforate the wall of this organ. The latter usually proceed from rough instrumentation, and commonly result in nothing more serious than cystitis or possibly sharp hemorrhage. Wounds involving the entire thickness of the bladder- wall are, on the other hand, most serious injuries, generally requiring prompt operative treatment. They are made directly by knives, bullets, fragments of fractured pelvic bones, etc. and indirectly by blows upon the hypogastric region, which compress the bladder when distended — the so-called " rupture of the bladder." The danger from such injuries lies of course in the extravasation and stagnation of urine, either in the peritoneal cavity or in the exten- sive connective tissue of the pelvis which is subjacent to the peritoneum ; in either case rapidly fatal septic infection and peritonitis are imminent. On the other hand, if the wound itself afford free exit to the urine, as when a bullet passes into the bladder or a stick is driven from the rectum or vagina into this organ, a free escape of urine resulting, septic infec- tion often fails to appear. It follows, therefore, that the first and immediate object of treatment in all injuries by which the bladder is opened is to provide free escape for the urine. This may be secured by the insertion of drains through the wound itself; in other cases the wound must be enlarged and explored. Frequently the bladder should be opened by suprapubic incision, through which an attempt to close the wound in its wall can be made as well as perfect drainage secured : the exact measures to be taken must be determined in each case. Rupture of the bladder usually results from violence to the supra- pubic region when the bladder is more or less distended ; in a few instances such rupture has occurred from violent straining and from, distention of the organ by the surgeon as a preparation for suprapubic GENITO-VRINARY SURGERY. 977 cystotomy. The possibility of this accident should be remembered in any case of injury to the lower abdominal region. Ruptures of the bladder- are practically divided into intraperitoneal and extraperitoneal, according as the tear does or does not involve that portion of the bladder covered by peritoneum. Intraperitoneal ruptures have all resulted fatally, usually within three days, unless promptly sutured after laparotomy ; extraperitoneal ruptures are less certainly fatal, though the large majority die in a few days unless operated on. It is evident, therefore, that even a decided probability of bladder rupture justifies an exploratory incision, which is far less dangerous than the delay often necessary before a positive diagnosis of rupture can be made. The surgeon should certainly never hesitate to operate when the first signs of septic infection become apparent. Treatment. — So soon as the diagnosis of bladder rupture becomes probable — even though, as often happens, the surgeon cannot decide between intra- and extraperitoneal rupture — an incision should be made in the median line, extending from an inch below to two inches above the upper border of the symphysis. The peritoneum is not opened, but an opportunity is afforded to search carefully for an extraperitoneal rupture. If none such be found, the incision is prolonged upward sufficiently to enable the surgeon to open the peritoneum and examine the portion of the bladder covered thereby. If an extraperitoneal rupture be found, the surgeon has a choice of three methods of treatment, exactly as in the operation of suprapubic cystotomy : (1) to suture the bladder wound (excluding the mucous membrane) and leave a drain down to the bladder ; (2) to leave the bladder rent open, inserting a drainage-tube therein ; and (3) to suture the torn edges of the bladder to the skin. The choice will be deter- mined partly by the location of the tear, but chiefly by the condition of the urine. If this be aseptic, the first method should be employed ; if, on the other hand, the patient already has a septic cystitis, the second plan will be better. Kidney. — Injuries of the kidney are, for obvious reasons, always grave lesions : the extreme vascularity of the organ itself, its proximity to large blood-vessels and to the peritoneum, its vital importance to the organism, account for the heavy mortality accompanying serious injuries to its substance. Hemorrhage, sepsis, and peritonitis from the escape of urine have each resulted in many deaths. Clinically, we may divide injuries to the kidney into open and subcutaneous lesions, the former made by penetrating objects, the latter by falls, blows, and severe com- pression. The symptoms of the open injuries, aside from the extent of the wound, are shock, nausea, and hemorrhage, the latter from the wound and through the bladder; pain radiating to the testicles is sometimes observed. The escape of blood does not always measure the hemor- rhage, however, as this may occur chiefly into the torn peritoneum or retroperitoneal connective tissue. Blood-clots may plug the ureter and cause colicky pain, as well as retraction of the corresponding testicle ; in the bladder clots cause vesical tenesmus and pain. Permanent block- ing of the ureter causes either urinary fistula or atrophy of the kidney. The escape of urine into the perirenal tissues usually indicates a lacera- 62 978 SPECIAL OR REGIONAL SURGERY. tion of the kidney pelvis ; it may be followed by extensive suppuration and sloughing. The symptoms of subcutaneous rupture and laceration of the kidney are" identical, except that the signs of severe hemorrhage and suppuration are neces- sarily more obscure ; indeed, the admixture of blood with the urine may be first observed several days after the injury. Fluctuating swellings in the kidney region may gradually appear, composed either of blood (hsematoma) or of urine, usually the former. Extensive ecchymoses, extending even to the scrotum, have been observed. The treatment of injuries to the kidney seeks to arrest hemorrhage and to prevent stagnation of escaped urine. The measures required to secure these ends vary with the extent and locality of the injury ; and these, unfortunately, the surgeon is often unable to determine without Fig. 425. Gunshot wound of kidney, necessitating nephrectomy (Richardson). manual examination of the kidney. Hemorrhage constitutes, of course, the more urgent demand for immediate interference ; in cases where this is apparently slight no operative measures may be at first required, though the result may sometimes be death from concealed hemorrhage. If in a few days evidence of urinary infiltration becomes apparent, suit- able incisions and drainage should be made. In many cases severe hemorrhage compels immediate exposure of the kidney through a lumbar incision; and this would probably be the wise course in all cases of undoubted laceration of the organ. Bleeding from the kidney substance can be promptly checked by sutures of the kidney and of its fibrous capsules ; hemorrhage from the large vessels compels ligature of the same, usually with removal of the kidney. Anv lace- rations of the kidney pelvis or ureter should be sutured with silk and GENITO-VBINARY SURGERY. 979 the vicinity thereof drained. Sometimes a septic cystitis is caused by decomposing blood-clots in the bladder, compelling drainage of this organ. Wounds of the kidney substance heal rapidly : even if so extensive as to involve much of the organ, the opposite kidney will hypertrophy to any required extent. Wounds of the kidney pelvis heal more slowly, often requiring months, but the fistula usually closes ultimately without interference. Infections. An infection is a bacterial invasion of a living tissue — a growth of one or more species of bacteria in the tissue, with the local and general disease caused by the diffusion of injurious bacterial products. The genito-urinary tract of the male frequently exhibits a primary infection by the following bacteria : 1. The gonococcus ; 2. The as yet undiscovered agent that produces syphilis ; 3. The tubercle bacillus ; 4. The various bacterial species that cause suppuration — a dozen or more in number — collectively termed the pyogenic bacteria. 1 and 2. Gonorrhoea and. Syphilis. — The gonococcus, with the atten- dant pus-bacteria, producing the mixed infection known as gonorrhoea ; it and the syphilitic infection are discussed in Chapters X. and XL 3. Tuberculosis. — The growth of the tubercle bacillus of Koch in various tissues of the genito-urinary organs is a frequent and most im- portant primary infection of these organs, aside from the numerous cases in which the primary disease occurs in the lungs with secondary infection of the urinary passages. By primary tuberculosis is meant the earliest perceptible tuberculous focus : it is of course always possible that infection of the bronchial nodes or other inac- cessible parts may have preceded the outbreak of the disease in the genito-urinary tract. Sites of Infection. — Primary genito-urinary tuberculosis usually first appears in the epididymis and the ejaculatory duct, less commonly in the kidney, yet it rarely remains long limited to these organs, the prostate and seminal vesicle soon becom- ing infected. In a very few instances tuberculous ulcers of the skin of the penis seem to have been the first manifestation (it is possible that some sores called chancres, and not followed by syphilis, have been tubercular ulcers). Avenues of Infection. — The possibility must be admitted that the fetus at birth may contain tubercle bacilli, yet opportunity for infection after birth is so general that this seems the more plausible explanation. It is probable that infection of the genito-urinary organs is practically always by one route — the blood-current — whereby the bacilli are brought from lungs, intestines, or old foci in the cervical and bronchial nodes. The idea that intercourse with a woman suffering from tuberculosis of the pel- vic organs can cause the ascent of tubercle bacilli along the male urethra to the prostate is fanciful and utterly without proof. That such intercourse may inocu- late the skin of the male genitals, with subsequent lymphatic transfer to the pelvic organs, is demonstrated, and it is probable that the urethra and prostate have been occasionally infected by urethral instruments. Yet since a large percentage of genito-urinary tuberculosis occurs in youths who have never had intercourse nor been subjects of urethral instrumentation, we must consider the blood-current the usual avenue of infection. The symptoms and treatment will be considered under the diseases of the respective organs. 980 SPECIAL OR REGIONAL SURGERY. 4. Sepsis. — The urinary channels are peculiarly exposed to the entrance of bacteria by way of the blood-current, the urethra, and the rectum. Yet it seems that septic infection of the normal urinary tract does not occur — in other words, that suppuration in this tract is always preceded by some impairment of nutrition whereby the natural tissue resistance is depressed. Many examinations have demonstrated that the normal urinary tract from kidney to prostate is absolutely sterile, and, though the normal urethral surface is known to harbor many pus- bacteria, yet they fail to enter its tissues until these have been disturbed by some other agency. Hence cystitis, urethritis, and pyelitis are terms expressing results rather than primary conditions. When the natural vitality of tissues is lowered by any agency, such as the growth of the gonococcus or tubercle bacillus, the stagnation of urine in the bladder caused by a tight stricture or prostatic enlargement, the pus-bacteria — which easily gain access by one of the routes men- tioned — may infect a part or the whole of the urinary tract. Examination of Patients. — The information elicited is subjective, given by the patient, and objective, ascertained by the examiner. The patient should be questioned as to the frequency of urination by night as well as by day ; as to the locality and frequency of pain in urination ; whether micturition is urgent ; whether there is involuntary escape of urine ; and whether this fluid has been observed to contain blood or pus. The age and occupation of the patient, the duration of his ail- ment, antecedent diseases (especially gonorrhoea, syphilis, sexual excesses, and dyspepsia) should be the subject of inquiry. The patient is required to urinate into three small glasses — say a half ounce each into the first and second ; then the examiner introduces the finger into the rectum and gently presses the prostate and seminal tubes, after which the patient passes the remainder of his urine into the third glass. The first of these glasses contains the washings of the urethra, the second a fair specimen of the bladder urine, and the third the products of the prostate and seminal tubes. In many cases — as of tuberculosis, chronic gonorrhoea of the prostate and appendages, malignant disease of the prostate — the diagnosis is established by the measures already mentioned. Yet unless there is some special objection the inter- nal examination of the urinary passages should follow. First, the calibre of the urethra as far as the bulb is examined by means of bulbous sounds or the urethrom- eter, and strictures carefully noted ; then a metallic sound of large size and short beak (15 to 17 of the English scale, unless strictures compel a smaller size) is passed carefully through the deep urethra. To examine the cavity of the bladder this organ should be washed out and then distended with about five ounces of warm sterilized water or very weak anti- septic solution ; a short-beaked sound can then be introduced, the handle depressed below the level of the symphysis, and the instrument rotated on its axis in the search for a stone. If the cystoscope be used, the sound can be dispensed with, as the former instrument is a good stone-searcher. Diseases of the Penis and Urethra. Herpes is a not infrequent disease, the vesicles appearing on the inner surface of the prepuce and in the furrow behiiid the gland. At times it is evidently favored by obvious conditions, such as a tight pre- puce, lack of cleanliness, or a gleetv discharge; in other cases no local GENITO-URWARY SURGERY. 981 cause can be detected, and it is assumed that the disease is due to gouty or neurotic influence ; in these cases it is often recurrent. The vesicles usually follow the same course as herpes elsewhere ; sometimes, however, they ulcerate obstinately. Warts (pointed condylomata) of the prepuce and glans are often developed during or after gonorrhoea, and sometimes without apparent cause. They may be snipped off with scissors and their bases cauterized with nitrate of silver ; a less objectionable but longer method is the daily application of liquor arsenicalis or of acetic acid. Under its use the wart shrivels, dies, and drops off. Cavernitis, acute and chronic inflammation of a corpus cavernosum, may result from gonorrhoea, mechanical injury to the penis or urethra, or syphilis. The chronic cases are not uncommon, attracting the patient's attention by localized tenderness and hardness of the penis and especially by the curvature of the organ when erect. The treatment consists of local inunctions of mercurial ointment, with massage, and of the iodides internally if the patient be syphilitic. Such treatment commonly secures a decided improvement in the symp- toms in the course of a few weeks. Gummata of the penis occur either in the cavernous bodies or in the furrow between them. Distinct nodules in this locality should always arouse the suspicion of syphilis and lead to specific treatment. Epithelioma of the penis usually begins as a warty growth at or near the sulcus, sometimes on the body of the organ. It occasions but little pain until ulceration occurs ; local extension and lymphatic infection are slow. It must be carefully distinguished from ulcerating gumma, which is far more common and has often been erroneously called cancer ; syphilitic treatment will soon decide a doubtful diagnosis. The treatment should consist of amputation of the penis at least a half inch behind the nearest point of infiltration ; less radical meas- ures, such as excision of the growth, usually fail and waste valuable time. Careful examination of the inguinal nodes and thorough removal of all, if any seem infected, should be made at the same time. In amputation through the body of the penis the skin and urethra should be cut a half inch longer than the corpora cavernosa, the urethra split front and back, and its edge stitched to the cut edges of the skin. If the cancer extends close to the symphysis, the entire penis must be removed, the corpora cavernosa being dissected from the pubic bones ; in such cases the scrotum and testicles should also be ablated. Care must be taken to preserve the membranous urethra, which is the chief sphincter of the bladder, and the cut edges of the mucous membrane should be united with those of the skin. Urethra. — The diseases of the urethra not yet described are chiefly ulcers, vegetations (polyps), chancres, and strictures. Cancer of the urethra is exceedingly rare, only about a dozen cases having been as yet demonstrated. Ulcers of the urethra occasionally persist after gonorrhoea, and may be responsible for a slight gleet. They can be seen through the endo- scope, and touched with copper sulphate or other astringent. Thorough stretching of the urethra is usually necessary to cause the absorption of the inflammatory exudate surrounding the ulcer ; indeed, there is no doubt that this alone has often secured healing. Vegetations and polyps are sometimes discovered in connection with a gleet • 982 SPECIAL OR REGIONAL SURGERY. they can be detected and treated only through the endoscope. The larger ones (polyps) have been snared or torn off, the smaller ones withered by careful appli- cation of the liquor arsenicalis or acetic acid. Chancres occur in the first half inch of the urethra, doubtless far more commonly than is generally supposed. They cause a slight puru- lent discharge and some smarting on urination — symptoms which are assumed to indicate a mild gonorrhoea. The surgeon should make a practice of separating the lips of the meatus and inspecting the urethral surfaces in every case of mild urethritis; endoscopic examination is more complete. Strictures of the urethra are portions of the canal whose dilatability is less then normal ; they have usually been classified as spasmodic, inflammatory, and organic. The term spasmodic stricture is applied to a narrowing of the channel due to a supposed spasmodic contraction of the muscular fibres encircling the urethra. The term inflammatory stricture designates the swelling of the tissues during gonorrhoea, and is properly becoming obsolete. Organic stricture — the only persistent and properly styled narrowing of the urethra — means a diminution of the normal distensibility of this canal by an overgrowth of the submucous connective tissue, which may be either congenital or acquired as the result of any inflammatory process, lacerations by instruments or by fragments of calculus, blows and crushing, injuries, and severe urethritis. According to their etiology, organic strictures are usually classified as traumatic and gonorrtweal : this division has been perpetuated because it was formerly supposed that all strictures not traumatic resulted from gonorrhoea. It is now known that many strictures exist in men who have never had gon- orrhoea, but who, having never sought advice for urinary troubles, were formerly not examined for stricture; and it is reasonable to believe that many strictures which are detected only when the patient comes to be treated for gleet were pres- ent prior to that disease. It is certain that strictures of the first half of the ure- thra are often found in men who have never had gonorrhoea ; some of them, at least, are congenital, due to the incomplete removal of the connective-tissue par- tition which in early foetal development separates the penile from the glandular urethra. A more rational — and clinically important — classification of strictures is into traumatic and non-traumatic, the latter class including congenital and gonorrhceal strictures. Organic strictures may be present at any time of life, but are most frequently detected between the ages of twenty and forty-five. In the last decades of life strictures become far less troublesome than in middle life, possibly from the proneness of the fibrous tissue to undergo fatty degeneration. For anatomical reasons women suffer less frequently from urethral strictures than do men. The location of a stricture may be anywhere from the meatus to the membrano-prostatic junction ; strictures of the prostatic urethra are practically unknown. Probably the two most frequent sites of stricture are the bulbo-membranous and the glandular portions. Several stric- tures may coexist in different portions of the same urethra. The calibre of a stricture means the distensibility of the urethra at OENITO-URINARY SURGERY. 983 the strictured point, and is expressed in terms of the French or English catheter scale. Otis proved that the distensibility of the normal urethra was much greater than had formerly been supposed — that in the average man it ranges from 30 to 34 of the French scale; and he was inclined to attach much pathological import- ance to slight narrowings of the canal below this size. For several years his disciples ascribed many disorders of the genito-urinary tract to these alleged " strictures of large calibre," and they attempted to cure such troubles by a rather generous practice of internal urethrotomy. Later experience has shown that the distensibility of the normal urethra varies decidedly in different parts of this canal ; that many of the so-called strictures of large calibre are normal structures ; and that their division fails to cure anything. The term " stricture " should be applied only to an overgrowth of submucous connective tissue which causes an unnatural rigidity of the urethral wall. While in certain individual cases opinions might differ as to the propriety of applying the term " stricture " to a given urethral narrowing, yet there is general agreement that slight narrowings of the urethra may be ignored as pathological entities ; the term " stric- tures of large calibre " may be applied to narrowings of the canal which permit a No. 20 French instrument to pass. Effects on Urethra. — At the strictured point the urethra may present but slight changes from the normal condition ; behind the stricture, however, marked changes ensue, which become more pronounced as the calibre of the strictured part decreases. These changes are largely due to the pressure of the urine, which is arrested by the stricture and dis- tends the urethra behind it ; moreover, a few drops of urine are apt to remain and decompose behind the stricture. The mucous membrane becomes thinned, atrophied, and, though deeply congested, its epithelium becomes eroded ; superficial and then deeper ulceration ensues, and finally the urine escapes into the surrounding tissues, making peri-ure- thral abscesses and fistula?. The course of a stricture is constantly toward contraction, at least until the patient becomes fifty or more years old, when fatty degenera- tion is apt to ensue ; the connective-tissue mass becomes firmer and harder, resembling cicatrix. The body of this cicatricial tissue is apt to be on the floor rather than the roof of the urethra, so that the opening through a stricture is frequently on the upper side of the canal. Traumatic strictures differ anatomically from the non-traumatic only in degree ; the mass of new connective tissue is larger, its contracting tendency greater, and hence the difficulty in maintaining the patency of the urethral canal greater. Traumatic strictures are as a class very obstinate and difficult to treat. Symptoms. — The morbid phenomena produced by urethral strictures vary in details according to the location and extent of the contraction, but two very frequent results require special mention : (a) Effects upon llicturition. — These are especially three — (1) in- creased frequency of the act (by night as well as by day) ; (2) diminu- tion in size and force of the stream ; and (3) dribbling at the end of urination. (6) Prolongation of a Gleet. — One of the frequent causes for the per- sistence of a gleety discharge, in spite of various injections and internal medications, is the morbid condition of the strictured urethral wall. 984 SPECIAL OR REGIONAL SURGERY. Diagnosis. — In every case of gleet or of disordered micturition examination of the distensibility of the urethra should be made ; indeed, such examination should be a routine part of the investigation of almost every case of chronic urinary or genital disorder. Narrowing of the urethral canal may be detected by bulbous sounds (bougies a boutt) when the meatus is sufficiently large to permit their introduction. When the meatus is abnormally small (less than 22 French) the surgeon must either enlarge this opening by incising its lower angle or use a specially constructed dilating bulb, called the urethronieter, which can be intro- duced closed through the narrow meatus and expanded within the canal. For reasons previously mentioned division of the meatus should be in general avoided. (See article Gleet, p. 180.) The bulb, well oiled, is introduced into the freshly irrigated urethra ; if it pass freely, a larger one is used ; and finally a 30 or 32 French is introduced if the smaller instruments have failed to detect any narrow point. These bulbs should not be passed farther than the bulbous urethra; the remainder of the canal is examined by the ordinary conical sounds. If the urethrometer is used, it is intro- duced closed to the bulb of the urethra; the expanding portion of the instrument is then dilated to 30 or 32 French, and gently drawn toward the meatus ; if obstruc- tion is met, the bulb of the instrument is reduced until it passes the obstruction, and then again dilated and further withdrawn. By these instruments the location and extent of urethral contractions can be determined. Treatment. — The restoration of the urethral distensibility is of course the object of treatment ; and it should be understood that by all methods heretofore employed such restoration is usually imperfect and temporary. While by treatment the symptoms produced by stricture can usually be abolished, yet an anatomical cure is probably unknown ; hence it follows that a recurrence of the contraction and of the symptoms produced by it are frequent. A young patient who has a stricture should be informed that even after thorough dilatation the stricture is apt to recur in a few years and need a repetition of the treatment, and that such recur- rences will probably continue until he has passed the age of fifty or fifty- five years. There are two principal methods of treatment of urethral stricture — gradual dilatation and incision (urethrotomy) ; and two subordinate methods of only limited application — electrolysis and massage. Gradual Dilatation. — This is the ideal treatment ; it is successful in most cases of non-traumatic stricture, and should be regularly employed ; in comparatively few cases, to be presently mentioned, it fails. Internal urethrotomy — incisions by an instrument introduced within the urethra — is not without danger, the mortality being at least 2 per cent. ; if the blade perforates the basement membrane, there is a great chance of severe hemorrhage and of urinary infiltration, followed by local abscess and even by general septic infection ; after recovery the penis may exhibit a pronounced curvature when erect, due to local destruction of the cavernous tissue. These unpleasant complications are especially probable if the cut be made on the roof of the urethra. It must be remembered that the entrance of morbid Urine into the tissues may be followed by acute intoxication, severe and even fatal; this may occur within twenty-four hours, before suppuration has developed, and is due either to substances preformed in the urine or to a peculiarly acute bacterial infection. While less common than ordinary septic infection, it does sometimes follow internal urethrot- omy, and constitutes an additional warning against this operation. GENITO-URINARY SURGERY. 985 If an old stricture of the penile urethra should be found undilatable, a combined operation — internal urethrotomy and external perineal ure- throtomy — should be made : the urine is thus prevented from entering the wound in the penile urethra, because drained out through the perineal tube, and the dangers of urinary infection are thus avoided. External Urethrotomy. — In the deep urethra internal urethrotomy should never be made, for extravasation of urine is very probable and very serious, the firm fascia of the triangular ligament confining the septic material. When it becomes necessary to cut a stricture of the deep urethra (many traumatic strictures cannot be dilated without severe laceration) the cut should cdicays be made from the outside — an external urethrotomy or perineal section. After complete division of the stricture, as shown by the passage of a large sound from the meatus, a drainage- tube is carried into the bladder and permitted to remain from six to ten days. Treatment is continued by gradual dilatation with conical instruments, the nar- row point of which is passed through the strictured canal, after which gentle pressure forces the tapering portion into the gradually widened channel The instruments may be elastic (bougies) or metallic (sounds) ; the former are preferable for long or multiple strictures, though their surfaces are rougher than the polished metal. In general, straight sounds with conical tips are best for the penile urethra, and curved sounds for the deeper portion. During the first twelve or twenty-four hours following the passage of the sound there is often sufficient swelling of the strictured tissues to cause a notice- able diminution in the size and force of the stream ; after this the flow of urine is decidedly better than before the use of the instrument. Care should be taken not to use much force, lest three unpleasant results follow : (1) sufficient laceration to cause annoying bleeding; (2) great soreness at the, site of stricture for several days, often with purulent urethritis; and (3) chill and fever, one of the forms of "urinary " or " urethral" fever. It is true that chill and fever may follow the gentlest instrumentation in the urethra, especially in the prostatic portion, but the chances for it are greatly increased by the forcible use of instruments. In two classes of cases special instruments and measures are required for the execution of gradual dilatation : these are cases of very tight and narrow stricture, and cases in which the meatus is undidy contracted. Tight and "Impermeable" Strictures. — In consequence of the patient's neglect to seek assistance, the connective tissue constituting a stricture may have contracted so much as to almost occlude the urethral canal, permitting the passage of urine only in a very fine stream or even by drops. If the subject of such a stricture becomes chilled through exposure or indulges to excess in alcoholic drinking, he may suddenly find himself absolutely unable to void urine. Such strictures are usually amenable to gradual dilatation, provided an instrument can be made to pass the narrow portion ; this attempt must be made by filiform bougies. Formerly, such bougies were made of the same diameter throughout ; the later form, called the " whip," is far more useful : it is filiform for several inches of its length, and then gradually increases in size to 12 or 15 of the French scale. When called upon to treat a tight stricture, impermeable to ordinary bougies, the surgeon should first— especially if there be a history of recent and sudden diminution of the stream due to cedematous swelling of the stricture — apply hot water freely to the penis and perineum, both externally by baths or fomentations, and internally by injections. Then olive or castor oil is injected into the urethra and retained by closing the meatus ; a filiform (or, better, a whip) bougie is gently introduced, the penis being drawn taut so as to obliterate transverse folds of the 986 SPECIAL OR REGIONAL SURGERY. urethra. And now begins what is often a test of patience for both surgeon and patient: the filiform is gently advanced to the stricture, and trials made to make its point find the minute opening in the same. Sometimes success is immediate; more frequently repeated trials, continued for many minutes, are made before the instrument passes. Only gentle force should be employed, since undue violence may result in puncturing the urethra (a false passage) or in doubling the end of the filiform. If the ordinary filiform finally passes freely beyond the stricture, an effort should be made to pass a second along the side of the first, which should on no account be withdrawn, lest the surgeon have to repeat the tedious and painful performance. The filiform should be tied to the pubic hair or to a strip of adhe- sive plaster attached lengthwise to the penis, so that it cannot be forced out, and should be allowed to remain for twenty-four hours. At the end of this period the calibre of the stricture will be much increased, so that a small bougie can probably be passed without trouble and gradual dilatation begun. If the first instrument introduced be the whip bougie, it should be passed in until the expanded portion has been forced into or through the stricture, thus enlarging the contracted part at once to a size which will permit the passage of a small bougie. The patient should be warned that the urinary stream may become very small a few hours later, and instructed to sit in hot water if he should have difficulty in expelling the urine. If all efforts to pass the stricture fail, the surgeon may make a peri- neal urethrotomy, and, passing a small bougie into the urethra through the incision, approach the stricture from behind. If the impermeable part happen to be the membranous urethra, he must either make a peri- neal section without a guide or a suprapubic cystotomy, and catheterize the urethra from the bladder. "When the meatus is unduly small, strictures may be stretched by means of special instruments constructed on the principle of the dilating bulb, called urethral dilators. The barbarous and dangerous method of rupturing the stricture, formerly in vogue under the name of "divulsion," should never be employed under any circumstances. The treatment of stricture may be thus summarized : Gradual dilatation is the preferred and generally successful method ; in tight strictures within half an inch of the meatus, and in tight strictures (especially traumatic) of the bulbo-membranous region, dilatation may fail. In this case internal urethrotomy on the urethral floor should be made in the former, and external perineal urethrotomy in the latter cases. Very tight strictures should be rapidly dilated by the whip bougies to 10 or 12 French, after which gradual dilatation is performed. Ueinaby Fever. Instrumentation in the urethra and bladder is often followed by chills and high fever — phenomena variously termed urethral, catheter, or (best) urinary fever. These unpleasant symptoms most frequently follow lacerations of the mucous membrane, but can undoubtedly occur when no evidence of such laceration can be detected. The clinical course of urinary fever is variable : sometimes all morbid phenomena disappear in twenty-four hours ; sometimes they last for several days ; and in some cases — especially after the sudden evacuation of the chronically distended bladder of the patient with enlarged prostate — the fever assumes a typhoid aspect and continues until the patient's death, a few weeks later. OENITO-URINARY SURGERY. 987 The avoidance of urinary fever should be attempted by — 1. Gentleness of all intra-urethral and intra-vesical manipulations, whereby the chance of lacerating the mucous membrane is diminished ; 2. Careful irrigation through a soft catheter of the anterior urethra, and (when septic infection of the bladder already exists) of the deep urethra and bladder before metal instruments are introduced ; 3. In cases of chronically distended bladders, such as result from prostatic enlargement, the physician should be careful, if called upon to introduce the catheter for acute retention or other cause, never to evacu- ate the bladder completely at the first sitting : a portion only of the urine should be withdrawn, and the bladder gradually emptied by repeated catheterism during several days. Internal Urinary Antiseptics. — It was formerly supposed that the dangers of urinary infection could be much lessened or even abolished by the internal administration of antiseptic substances which are elimi- nated by the kidneys, such as salol and boric acid. This theoretical hope has not been fully realized in practice : though either of these sub- stances may be properly administered in five-grain doses every four hours, yet the surgeon should not place the least dependence upon the avoidance of infection thereby, nor be lulled into omitting any of the far more important local measures to the same end. DISEASES OF THE PROSTATE AND APPENDAGES. The prostate, its utricle, the dilated extremities of the vasa deferentia (called ampulla?), and the seminal vesicles are, like the uterus and tubes of the female, enclosed in a thin fibrous sheath which I have called the broad ligament of the nude. There is one notable difference, however, between male and female, in that the peritoneal covering of this sheath in the female is reflected from its top down its anterior surface before rising again on the posterior surface of the bladder, while in the male the peritoneum crosses directly from the top of the broad ligament to the bladder. There is, therefore, in the male no peritoneal pocket corresponding to Douglas's pouch in the female, the sheath of the seminal tubes being adherent to the bladder; but the essential part of the broad ligament, the fibrous sheath, is found in both sexes alike. Infections. — The most common of these is the gonorrhceal (Chap. XL) ; indeed, this disease and its complications furnish practically all examples of acute infection of these parts. The chronic infections are gonorrheal, septic, and tuberculous, of which the first named has been discussed in Chapter XL The chronic septic infections of the prostate and seminal tubes, when not gonorrhoeal, are caused by urethral instrumentation, caustic urethral injections, by extension from chronic urethritis due to tight stricture of the deep urethra, by extension from a cystitis, and probably some are caused, especially in middle-aged or elderly men, by prostatic calculi. They are favored by the chronic venous congestion of the pelvic organs which is so common in elderly men as the result of constipation, alcohol- drinking, high living, and lack of exercise. The chronic tubercular infection of these organs is usually associated with tuberculosis in the epididymis, and, while often primary in the 988 SPECIAL OR REGIONAL SURGERY. clinical sense, is perhaps usually derived from slumbering infections in cervical or bronchial nodes, etc. Clinically the septic infection is still usually termed chronic prosta- titis, and the tubercular infection, tuberculosis of these organs. Chronic prostatitis — which is really a chronic septic infection of the prostate and appendages — is due to one of the causes just mentioned, which renders the tissues a favorable soil for the growth of the pus- bacteria. It is often the sequel of an acute infection, but very com- monly also a chronic inflammation from the start. Symptoms. — There is dull pain in the perineum, suprapubic region, rectum, and sometimes in the glans penis, aggravated by jolting or sitting on upholstered chairs ; pain in the sacral region (which the patient usually ascribes to his kidneys) is at times the most prominent feature. Urination is apt to be unduly frequent, and is sometimes fol- lowed by the escape of a viscid grayish or watery fluid (from the pros- tatic glands) which the patient commonly considers semen. Sometimes there is a continuous slight discharge of similar fluid from the meatus — the so-called " prostatorrhoea." Sexual desire is often decreased and the normal pleasurable sensation much diminished or even absent; ejaculation is often premature, and erections may be feeble or may sub- side before emission occurs. The patient is often extremely despondent. This is really the condition of incipient impotence, and leads ulti- mately to practical loss of virility. Often the patient complains of the sexual symptoms only, while the others are elicited upon questioning. Examination with the fore finger (best enclosed in a rubber condom) discloses a sensitive and perhaps swollen condition of the prostate or seminal tubes, or of both, with more or less thickening of the connective-tissue envelope of these organs ; in pronounced cases the recto-vesical space is a rather hard and sensitive mass in which the ampulla? and vesicles are not distinctly perceptible. Gentle stroking or milking of these parts toward the anus is soon followed by the appear- ance at the meatus of considerable fluid containing a more or less distinct admix- ture of pus. Treatment. — This will naturally begin with the removal of the cause of the trouble when this is practicable ; thus, a tight stricture must be dilated, a foreign body in the bladder removed, etc. The treat- ment directed especially to the prostate and appendages is the following : avoidance of constipation and of alcoholic and sexual excesses ; the milking of the recto-vesical organ by gentle stroking with the finger- tip in the rectum toward the anus ; this process is continued for three to five minutes and repeated every six or seven days unless vesical irrita- tion is induced, when the intervals are made longer. A large sound should be passed into the bladder once a week, its straight portion entering the prostate ; deep injections of silver-nitrate solution (two ounces of a 1 : 3000 solution) once a week are helpful. The despond- ency of the patient should not be ignored ; a cheerful prognosis and tonic remedies are useful. The local treatment will usually show early results in the removal of the sacral and suprapubic pain, improvement in urination, and the cessation of discharge ; the restoration of the sexual functions generally requires a prolonged treatment. Enlargement (Hypertrophy) of the Prostate. — The familiar con- dition designated by each of these names includes two anatomical GEN1T0-VRINARY SURGERY. 989 states : (1) a diffuse enlargement of the prostate, and (2) localized hyper- trophies of its glandular and muscular tissues, which project into the bladder. The diffuse enlargement is certainly often and probably always the result of the process above described — chronic inflammation of the prostate — and it is always present in cases of so-called hypertrophy ; the local hypertrophies may result from this inflammatory condition or may rank with tumor-formations in general. They are found in a large percentage in the cases of enlarged prostate, though their presence can- not usually be recognized until the bladder is opened, because they grow into the vesical cavity and cause no change in the rectal surface of the gland, which alone is accessible to the examining finger. They may Fig. 426. Intravesical enlargement of the prostate (Forgue). therefore be ignored, except in operative cases ; our diagnosis and treat- ment before operation is that of diffuse enlargement. Prostatic enlargement is a disease of the second half of life, often beginning before the patient becomes fifty years old, but not usually causing him to seek a physician's advice until after that period ; indeed, the advanced cases of urinary derangement due to this cause are usually over sixty years of age. The enlargement of the prostate and the development of urinary symptoms are so gradual that the patient is apt to accustom himself to them as to other phenomena of advancing age, and when some pronounced symptom, such as complete retention of urine, leads him to summon medical aid, an advanced stage of the disease is found. Hence surgeons have been accustomed to meet the more advanced cases, and to think of prostatic hypertrophy as a condition of advanced age, while the disease really often begins in middle life, as above stated. Prostatic enlargement is serious — not directly, but because it inter- feres with the exit of urine by causing (1) distortion of the prostatic urethra, which undergoes elongation, decrease in calibre, sometimes deviation in direction ; (2) elevation at the level at the vesico-nrethral 990 SPECIAL OR REGIONAL SURGERY. orifice; and (3) obstruction to the return of blood to the bladder and chronic congestion of this organ. Following naturally upon the imperfect evacuation of the urine and the chronic congestion of the bladder comes a train of morbid condi- tions which begin with the bladder and ultimately extend throughout the entire urinary tract. These are (1) dilatation of the bladder, with increase of residual urine ; (2) fibroid degeneration of the prostatic sphincter ; (3) hypertrophy and degeneration of the vesical walls and depressions of mucous membrane (diverticula) between the muscular bands; (4) dilatation of ureters and. renal pelvis, with stagnation of urine in them ; (5) congestion and catarrhal inflammation of the entire urinary tract, causing accumulation of its products in the bladder, tending to calculus-formation; (6) ammoniacal fermentation of urine, favored by, but not dependent on, the use of unclean catheters ; (7) septic infection of the congested urinary tract — "cysto-pyelonephritis " and chronic uraemia ; (8) acute and fatal urwrnia, provoked by various agencies, particularly the first use of the catheter. Symptoms. — Among the earliest are difficulty in starting the flow of urine, feebleness of the stream, and undue frequent calls to urinate, especially at night. During this state the patient often complains more of his digestion than of his urinary organs ; he has loss of appetite, dryness of the mouth, and constipation. When catarrh of the bladder-neck begins the urinary symptoms become more prominent : the calls to urinate become more frequent, the normal sense of satisfaction is lacking, the urine becomes cloudy and deposits a white sediment. The incomplete evacuation of the bladder, causing chronic retention of a large quantity — a pint or even a quart — of urine, is apt to be followed by an involuntary escape of this fluid. This dribbling indi- cates not " paralysis of the bladder," but over-distention of the organ. Diagnosis. — A patient over fifty years of age whose history in- cludes these symptoms should be examined per rectum, and undue size of the prostate noticed. The presence of residual urine is then detected by the passage of a clean soft catheter immediately after the patient has urinated ; a flow of urine (which should be stopped at two ounces) shows that the voluntary evacuation of the bladder is incomplete. Treatment is general and local. Personal hygiene is very import- ant, including good digestion, regular and easy defecation, warm cloth- ing, air and exercise, avoidance of cold and wet, of excess in eating or alcohol-drinking. The patient should drink three pints or more of pure water daily. Local treatment endeavors (1) to reduce the congestion and oidema of the prostatic region ; (2) to promote the evacuation of the bladder ; and (3) to prevent or arrest septic infection of the urinary passages. (1) For the first object there are three principal means — the milking of the prostate by the finger in the rectum, previously described ; the passage of a large sound once a week ; and the free use of hot water as baths, rectal enemata, and injections of the bladder. These latter can usually be made without a catheter, because the sphincters in such patients are not firmly contracted ; indeed, with a little perseverance the patient can learn to inject his own bladder from the meatus ; this is most OENITO-URINARY SURGERY. 991 easily done in the semi-recumbent position. The amount of water should not be large enough to distend the bladder, but it should be hot (100° to 110° F.). (2) The contractile power of the bladder is greatly stimulated by these injections of hot water, probably because they reduce the oedema and venous congestion. In some cases, however, the patient must be taught to use the catheter. (3) Septic infection of the bladder, when not arrested by these means, must be combated bv injections of silver nitrate (1 : 2000) or of mercury bichloride (1 : 20,000). Catheters should be Flexible and Clean. — The soft Nelaton catheter (velvet eye preferred) will usually enter the bladder ; if it fail, the stiffer coud6 instrument of Mercier, commonly called prostatic catheter, gen- erally succeeds. Metallic instruments and those armed with a stylet can easily be made to lacerate the urethra, and are rarely needed except in cases of extreme hypertrophy. All instruments used should be aseptic. The soft and metal catheters can be sterilized by boiling ; elastic instruments should be immersed in 5 per cent, carbolic or similar solution. Catheters in frequent use should be kept in such solution. Complications. — These are (1) complete retention; (2) persistent cys- titis of great severity ; (3) such distortion or narrowing of the prostatic urethra as renders catheterism extremely difficult or painful. Complete retention is a most serious event : when called to such a case the physician should observe three rules of great importance : (1) never use force nor lacerate the urethra — in other words, use flexible instruments ; (2) observe strict aseptic precautions as to instruments, etc. ; (3) never empty the bladder completely at one sitting. The patient suffering from complete retention should have the rectum emptied by a hot-water injection, to be followed by a suppository containing a quarter grain of morphine. A hot sitz-bath or hot fomentations should be used for twenty or thirty minutes; the patient is then warmly covered in bed, the hips elevated above the shoulders. The anterior urethra is irrigated with hot water and injected with warm clean oil; a clean soft catheter (No. 10 or 12 English) is filled with the oil and introduced, the penis being drawn firmly forward. Steady pressure is often rewarded by a gush of urine ; if this effort fail, an elastic prostatic catheter is next tried. If no false passage exist, the prostatic catheter will almost invaribly enter the bladder. If, however, the urethra be already lacerated, the difficulties of catheterism are enormously increased. If the softer instrument fail, a metal catheter of long curve and large diameter should next be used; but force must be scrupulously avoided, for no one can know the direction of the distorted and swollen prostatic urethra ; forcible and blind catheterism results in false passages, heinorrha 6 e, and a difficult situation. In rare cases suprapubic aspiration must be made, the needle enter- ing at right angles with the spine about an inch above the upper border of the symphysis. A half of the estimated contents of the bladder is withdrawn, hot fomentations again applied, and the patient left in bed for some hours ; the relief of bladder tension and reduction of prostatic oedema thus secured often result in easy catheterism or even voluntary urination. But should retention persist, aspiration must be superseded by one of the methods of operative relief. Should the physician succeed in introducing the catheter, he must not evacuate the bladder completely at the first sitting ; a third of the 992 SPECIAL OR REGIONAL SURGERY. estimated quantity — say from six to ten ounces — may be withdrawn, and an ounce or two of some antiseptic solution injected. Some hours later a larger quantity may be withdrawn, and thus in the course of three or four days the bladder may be gradually emptied. Even with the greatest care some fever usually follows complete retention requiring the use of the catheter, yet the illness is kept at a minimum by the measures described. Persistent cystitis of high grade and difficult catheterism from pros- tatic distortion must be ultimately relieved by operative treatment. Operative Treatment. — Surgical aid may be furnished in one of four ways : (1) Drainage of the bladder, either by perineal urethrotomy or supra- pubic cystotomy, or a combination of the two. The great improve- ments in suprapubic cystotomy (see section on " Operations ") render it the preferable method. (2) Prostatectomy, by which is meant the removal of projecting por- tions of the prostate through the suprapubic wound and the restoration of a low level channel from bladder to urethra. The prostatic tumors, when pedicled, are removed by scissors, snare, or cautery; when im- bedded in the prostate they are enucleated, the mucous membrane cov- ering them being first freely incised, and an assistant's finger in the rectum pressing the prostate firmly against the operator's finger in the bladder. In this way large masses of hypertrophied prostatic tissue are easily enucleated. The hemorrhage is usually slight, and is controlled by hot water and packing with iodoform gauze. In every case of prostatec- tomy perineal urethrotomy should be made and the prostate thoroughly stretched ; any bar at the vesico-urethral orifice should be freely incised. The prostate may be also almost completely enucleated by a combi- nation of methods, consisting of free exposure from the perineum below, after which by means of a suprapubic incision it is pressed downward toward the perineal opening, while by aid of the finger-nail of the index finger it is gradually shelled out of its capsule and away from the urethra. Alexander, Valentine, and others have been extremely suc- cessful with this method. (3) Cauterization. — This is at present performed almost entirely with an instrument designed by Bottini, by which a concealed glowing cautery-knife is made to pass through the hypertrophied ring of pros- tatic tissue, along the shank of an intra-urethral guide. In the hands of a few experts it has given excellent results, but should be confined to selected cases in the hands of selected operators. (4) Castration. — The work of Eamm and White has led to the attempt to relieve sufferers from prostatic hypertrophy by the removal of both testicles, the plan having been suggested by the frequent atro- phy of uterine fibroids after the removal of both ovaries. As prostatic sufferers are frequently in advanced life, they sometimes consent to this mutilation in the hope of securing relief from the agonies of severe cys- titis and difficult catheterism. In a large percentage of the eases already reported more or less complete relief from cystitis has been secured, and in some the power of voluntary urination is said to have returned ; in a smaller number more or less complete failure to secure any benefit whatever was the result. In some instances double castra- GENITO-URINARY SURGERY. 993 tion has been performed and recommended in cases where an undiscov- ered stone was subsequently found to be the cause of the trouble ; for it is sometimes impossible to detect by the sound a calculus hidden in a pocket of the bladder. It is evident that this operation should be performed only after two premises have been established : first, that the patient's cystitis is not due to vesical calculus, tumor, or any condition other than prostatic enlargement ; and second, that the prospect of relief by simple temporary drainage of the bladder is not good. In other words, double castration should not be made until the bladder has been opened and explored by the finger. Ligature of the vas deferens on each side has been found in the few cases already tried to succeed as well as double castration. Since it is a slight operation, free from the objections — surgical and aesthetic — which may be urged against double castration, it should be substituted for the latter as a purely tentative procedure. To summarize : when surgical interference becomes necessary the best treatment is temporary drainage of the bladder with stretching of the prostatic urethra. If this exploration reveals such great distortion and overgrowth of the prostate as renders the cure by simple drainage doubt- ful, the surgeon must be prepared to make either a prostatectomy, a liga- tion of both vasa deferens, or a double castration , Tuberculosis of the prostate and appendages is a very frequent though often overlooked cause of the symptoms of cystitis ; it is espe- cially common between the ages of fifteen and thirty-five, and may occur in otherwise healthy, robust subjects. The symptoms are those found in cystitis from other causes — fre- quency and pain in urination, as marked by night as by day, with pus and occasionally blood in the urine. Sometimes a slight muco-purulent discharge and swelling of the meatus give rise to a suspicion of gonor- rhoeal infection. The diagnosis can be established by digital examination of the epi- didymis and of the prostate and seminal vesicles, in each of which (at least on one side) nodular thickenings are found. The discovery of tubercle bacilli in the urinary pus makes the diagnosis absolute. There is commonly a slight elevation of temperature. The treatment is medical and surgical. Operative measures should be limited to the evacuation of softened tuberculous foci ; attempts at radical cure are futile both in theory and in practice. Medicinal treat- ment includes hygiene, dry air, sunshine, good food, and guaiacol : the drug should be given internally in doses of five, gradually increased to fifteen drops four times daily, in cream, milk, or wine, and it should be applied locally to the perineum, suprapubic space, and epididymis. To avoid irritation of the skin the guaiacol may be mixed with an equal volume of sweet oil or glycerin. Cancer of the prostate — including carcinoma and sarcoma — is a not infrequent disease, occurring chiefly in patients under ten and over fifty years of age. About seven-eighths of the tumors are found on histological examination to be carcinoma, the remainder, sarcoma ; the clinical distinction is often impossible and usually unim- portant. The diagnosis of cancer of the prostate is sometimes difficult and 63 994 SPECIAL OR REGIONAL SURGERY. often neglected, because of the more frequent occurrence of the ordinary hypertrophy of the organ. Three of the most important and constant diagnostic signs are — (1) progressive emaciation and pallor; (2) hard enlargement of lymph-nodes in the groins, with- in the pelvis, and in Scarpa's triangle ; (3) irregular nodular enlargement of the prostate. The discovery of recognizable cancer-tissue in the urine or the inspec- tion of a malignant ulcer through the cystoscope is conclusive evidence. Prosta- tic cancer may be grafted upon senile hypertrophy, from which it must be care- fully distinguished. In children the fatal termination is reached in a few months ; in elderly men the disease progresses less rapidly, lasting from one to five years. The treatment of prostatic cancer can be only palliative ; for although the cancerous prostate has been extirpated ten times, yet the patients who survived the operation have all died of recurrence within a few months. The pain must be mitigated by morphine ; cystitis and urinary retention require the treatment outlined for prostatic hyper- trophy ; and when other measures fail to relieve the vesical distress, a permanent suprapubic exit for the urine must be made. DISEASES OF THE BLADDER. Cystitis. Cystitis is a bacterial infection of the bladder : the pyogenic bacteria (especially the colon bacillus), the tubercle bacillus, and the gonococcus are the species most frequently concerned. Fig. 427. Internal appearance of bladder in some cases of inveterate cystitis ; mucosa sacculated by columns of hypertrophied tissue (Launois). Pyogenic bacteria arc incapable of infecting a normal bladder: this has been amply proven by experiment, and is illustrated by the fact that unclean catheters and sounds are often introduced without causing cystitis. GENIT0-UR1NARY SURGERY. 995 The important practical fact is, therefore, that cystitis (when neither tuberculous nor gonorrheal) is always a secondary, not a primary, mor- bid condition : we should begin our treatment of a case of cystitis by searching for the pre-existent cause and removing it when possible. The classical symptoms of cystitis are three : frequency of micturition, pain in urination, and pus in the urine. Yet the frequency and pain in urination are really caused by an irritation of the prostatic urethra rather than of the bladder. Hence when these symptoms arc present they indi- cate prostate-cystitis rather than a cystitis proper ; and in practice when we speak of cystitis we mean that the neck of the bladder (prostatic ure- thra), as well as the bladder-cavity, is inflamed — a prostato-cystitis. It is also important to remember that these symptoms may also be caused by an inflammation in the vicinity of the bladder, but outside of its cavity — of the seminal vesicle or of the lower end of the ureter. Infec- tion doubtless usually spreads from these to the bladder, so that a secondary cystitis does really exist. The treatment of prostato-cystitis endeavors first to discover the antecedent morbid condition, and second to recognize the variety of bacterial infection. As already stated, cystitis is secondary to some pre- existing lesion ; the commonest of these are gonorrhoea, a tight stricture of the deep urethra, prostatic enlargement, stone or tumor in the bladder, tuberculosis of the genital organs, and rectal abscess. Since these respec- tive conditions require widely different treatment, it is evident that there is no treatment applicable to cystitis in general : we must treat first the cause, by the removal of which we usually cure the cystitis — stretching a stricture, removing a vesical calculus, etc. For uncomplicated cases treatment consists of rest, overcoming hyperacidity of urine, diluents, the employment of the balsamic remedies and of those antiseptics which are best eliminated by the kid- neys, in order that the urine may be in a measure medicated before it enters the bladder. Relief of urgent frequency of urination is usually effected by drop doses of fluid extract of cannabis indica, given until its physiological effects become too pronounced. The fluid extracts of corn silk and pichi may also be admirably combined and administered frequently. When the urine is at all purulent formaline (40 volume formaldehyde solution) should be used for bladder irrigation, beginning, say, with 1 to 2000, and increasing the strength as the patient can bear it. All bladder-washing should be done with sterilized catheters and every anti- septic precaution. Stone. Calculus is one of the common diseases of the bladder and a fre- quent cause of cystitis. A vesical stone consists chiefly of the normal urinary salts — phosphates, urates, oxalates — deposited upon a nucleus. In many cases this nucleus is a foreign body ; in many others it is an aggregation of crystals imbedded in an albuminous substance. The greatest diversity of objects have been found enclosed in bladder-stones such as a bullet, fragment of bone, piece of a catheter, of lead-pencil, straw, chewing-gum, hair-pin, blood-clot, fragment of necrotic tissue, 996 SPECIAL OR REGIONAL SURGERY. clumps of pus, drops of oil. Some of these objects have been used in irrigating the urethra, and have slipped or been forced into the bladder. Conditions which favor calculus-formation are, possibly, the drink- ing of hard water and eating of albuminous foods in excess ; but certainly a frequent predisposing cause is chronic retention of urine, particularly when accompanied by alkaline fermentation of the retained urine : as these conditions frequently exist as the sequel of prostatic enlargement, calculi are found with great frequency in the subjects of this disease. Symptoms. — The symptoms caused by a vesical calculus vary greatly in severity according to the size, mobility, roughness, and location of the stone. A small stone encysted in a pocket away from the bladder- neck may cause but little distress, while a calculus which is rasped against the sensitive bladder-neck occasions severe pain. The symptoms are in general those of cystitis — unduly frequent and painful urination, with pus, sometimes blood, in the urine : pain felt in the perineum, rectum, and along the urethra, especially the glans penis, is usual. The pain and frequency in urination are commonly increased by active bodily movement, riding in wagons, etc., and diminish during rest in bed. Sometimes reflex pains in other parts of the body — the sole of the foot, instep, chest, or arm — have been known to disappear upon the removal of a vesical calculus. Particles of gravel may be brought away with the urine. In every case in which the symptoms suggest a vesical calculus, even though one of the other conditions (excluding tuberculosis) is present, an examination of the bladder should be made. The means employed are — (1) the stone-searcher or short-beaked sound ; (2) the cystoscope ; and (3) digital exploration through a suprapubic incision. In the majority of cases a stone in the bladder can be detected by the short- beaked sound of small calibre (15 to 20 French). Before using this instrument the bladder should be irrigated with clean water, about five ounces of which are finally allowed to remain in its cavity. The patient lies horizontally with his hips somewhat elevated; the well-lubricated instrument is gently introduced, and the beak made to touch every part of the vesical wall. In a certain number of cases a calculus escapes detection for one of the following reasons: (1) the sound may not enter the bladder, its point remaining in the prostatic urethra; (2) the pain may be so great that the bladder contracts, forcing out the water necessary to dis- tend it; (3) the stone may be so enveloped by a soft covering — the mucous mem- brane (so-called pocketed or encysted stone), pus, or blood — that the sound fails to touch the calculus ; (4) in cases of enlarged prostate, when portions of this gland project into the bladder, a stone may be so situated, above or below these pro- jecting masses, that the beak of the instrument cannot by any manipulation be brought into contact with it. Some of these difficulties are decreased by anaes- thesia, which indeed permits a more, thorough examination ; even then, however, the third and fourth of the above conditions may prevent the detection of the stone. The cystoscope has repeatedly discovered vesical calculi which the sound had failed to reach, even with the aid of anaesthesia. When this instrument is not available it is generally wiser to advise a digital exploration than to assert the absence of a stone when symptoms of severe chronic cystitis cannot be explained by the existence of other causes. Treatment. — The detection of a vesical calculus is a demand for immediate operative treatment : efforts at dissolving the stone are a waste of valuable time. The surgeon has a choice of two operative measures : (1) crushing GENITO-VRINARY SURGERY. 997 of the stone in the bladder and removal of the fragments by irrigation — lithotrity ; and (2) removal of the calculus entire through an incision— lithotomy. The crushing operation is now usually clone at one sitting, and is then termed litholapaxy ; and the incision for the removal of the entire stone may divide the membranous urethra (median lithotomy), the prostate and perineum (lateral lithotomy), or the prevesical tissues (suprapubic lithotomy). The choice among these four operations must be determined by the conditions existing in each case ; their relative advantages are as follows : Litholapaxy has only one point of superiority over the others, though this is sometimes important — namely, its freedom from cutting ; this advantage is appreciated by the patient rather than by the surgeon. The danger of septic infection from the cutting operations is now much less than formerly, and is not entirely absent from litholapaxy. Median lithotomy affords a rapid and safe removal for small stones ; it is not adapted to larger ones nor to cases where the prostate is enlarged. Lateral lithotomy was until 1880 the usual cutting operation, since it permitted the extraction of large stones without regard to the size of the prostate. In the last fifteen years, however, it has fallen into dis- use, having been replaced by Suprapubic lithotomy, which affords perfect access to the bladder and extraction of large stones without any damage to the sensitive bladder- neck. The disadvantages of litholapaxy are three: (1) the length of time, and hence of anaesthesia, required ; (2) the impossibility of grasping and crushing a stone which is encysted or ensconced behind a prostatic enlargement or one which is very hard ; and (3) the chance that a minute fragment may remain in the bladder and thus form a nucleus for a new stone. The disadvantages of the cutting operations, on the other hand, are the patient's natural repugnance to the knife and the greater chance of septic infection. While the latter still exists in cases where the urine is foul, yet the mortality from it has been much reduced by the combi- nation of suprapubic cystotomy with perineal drainage. Surgeons differ in their choice of stone operations according to their estimate of these relative features, as well as according to their experi- ence with the various methods. They are generally agreed upon the following : (1) The suprapubic operation should be made when either the stone or the prostate is very large, the kidneys impaired, or the subject under twelve years of age ; (2) in cases of small calculi, normal prostate, and healthy kidneys the surgeon chooses litholapaxy, median or suprapubic lithotomy, according to his own j udgment of the case. Hence the supra- pubic operation is decidedly the most frequently performed. In boys before puberty the urethra is small and the bladder high in the pelvis, making the suprapubic operation preferable, although some surgeons still advocate litholapaxy or lateral lithotomy for these cases. The cutting operations which are made for purposes other than the extraction of stone are described on page 1018. Litholapaxy is thus performed : If the stone be small, it may be 998 SPECIAL OR REGIONAL SURGERY. removed without great pain and without general anaesthesia : four ounces of cocaine solution, one grain to the ounce, injected into the bladder, may suffice for the mitigation of suffering. Otherwise the patient is thoroughly anaesthetized. The rectum having been emptied, the bladder, which should have been cleansed for several days pre- viously, is again thoroughly irrigated with borax-water, four to six ounces of which are finally permitted to remain ; a rubber tube may be tied lightly around the penis just behind the glans to prevent the escape of water. The urethra is filled with oil or liquid vaseline and the lithotrite introduced. Its shaft is held at an angle of forty-five degrees with the table, its beak then making a depression in the floor of the bladder, into which the stone may roll ; the male blade is then with- drawn an inch or more with the hope of catching the stone in the jaws of the instrument. If the stone be felt, the instrument is locked and the male blade screwed home ; then the opening and closing of the blades are repeated until no large fragment can be detected. The lithotrite is then removed and the large tube of the evacuator inserted. When its point has entered the bladder the communication between tube and bulb filled with water is opened, the water in the bladder driving the air out of the tube into the bulb. The pumping process is then begun and continued until no further clicking of frag- ments against the tube can be detected. After withdrawal of the evacuator the urethra is thoroughly irrigated. Fig. 428. Villous tumor (papilloma) of bladder (Musee Dupuytren). Some cystitis follows so much instrumentation ; it must be treated by irrigation, suppositories, etc., and after its subsidence the bladder should be again washed through the evacuator. Various complications occur during and after litholapaxy, such as hemorrhage, clogging of the blades of the lithotrite with debris, clogging GENITO-URINARY SURGERY. 999 Fig. 429. of the evacuating tube, and breaking of the lithotrite (which should always be tested on a brick before the operation) ; any of which may test the surgeon's judgment and ingenuity. Tumors of the Bladder. — The use of the cystoscope and the prac- tice of digital exploration of the bladder, both of which measures have been employed only since 1881, have shown that bladder-tumors, formerly considered rare, are by no means infrequent. They are found oftener in males than in females, and usually after the age of thirty years. Although many varieties of histological structure have been observed, we may for practical purposes specify three classes : papilloma, fibroma (both benignant), and cancer (malignant). Symptoms. — Bladder-tumors usually give rise to three symptoms — hemorrhage, pain, and cystitis. Hemorrhage occurs from nearly all bladder-tumors at some stage of their growth. It is often distinguished from the hemorrhage due to calculus by three features : (1) its occur- rence independently of exercise, as it often happens during sleep ; (2) its abundance, the bladder perhaps filling with clots ; and (3) its increasing frequency. Pain due to the growth itself is caused more frequently and earlier by malignant than by benignant growths, and by tumors near the bladder-neck than by those more remotely situated ; it is felt in the urethra, glans penis, rectum, and thighs. Such pain is, of course, to be distinguished from that due to the bladder inflammation. Tumor of bladder as seen with cystoscope (Nitze). Fig. 430. Illumination of anterior vesical wall by Nitze's cystoscopy. Cystitis is a common, though often a late, result of a bladder-tumor. There are but two positive proofs of the existence of vesical tumor — the discovery in the wine of fragments of the growth and ocular detection by the cystoscope. 1000 SPECIAL OR REGIONAL SURGERY. Cystoscopic Examination. — In every case of suspected bladder-tumor — indeed in every case of obscure bladder disease — the interior of the organ should be inspected through the cystoscope (Fig. 430). Treatment. — This is palliative and radical. The arrest of hemor- rhage is often accomplished by the internal administration of turpentine oil, three to ten drops on sugar or in emulsion three to five times daily ; clots can be removed from the bladder by washing, through a catheter, with warm water, to which a little pepsin or papain may be profitably added. Pain is of course to be controlled by morphine subcutaneously or by rectal suppository. In cases of inoperable malignant growth pain and cystitis may become so severe as to require the institution of a per- manent suprapubic fistula for the exit of urine. Radical operation means the excision of the tumor, which should always be undertaken through a suprapubic incision. The results of such excision have been very favorable for benignant, but unsatisfactory for malignant, growths, for in the latter class the anatomical relations render the complete removal of the base of the growth difficult, often impossible. Extirpation of a vesical cancer often requires resection of the bladder-wall, and has even then been followed by early recurrence. Tuberculosis. — Primary tuberculosis of the bladder is very rare ; in nearly all cases the infection has spread to this organ from the pros- tate or the kidneys. Its consideration is therefore included in the account of prostatic and renal tuberculosis. The discovery by the cys- toscope of shallow ulcers, and by the microscope of tubercle bacilli in the urinary pus, is the requirement of diagnosis. In one case seen by the writer the most prominent clinical feature was the frequent pas- sage of phosphatic sand ; the cystoscope revealed two ulcers coated with phosphates. Pericystitis ; Pelvic Inflammation and Abscess. The connective tissue of the male pelvis is not infrequently the seat of inflammation and suppuration, the results of extension of a septic infection from the various pelvic organs. This connective tissue con- sists anatomically and clinically of three portions : (1) that which en- closes the rectum ; (2) the broad ligament (enclosing the seminal vesicles, ampullae, and utricle) ; and (3) the perivesical tissue. The infections and inflammations are found clinically to correspond to this anatomical division. Infection of the connective tissue constituting the broad ligament is an extension from septic processes in the seminal tubes and prostate ; its symptoms are therefore those exhibited by inflammation of the prostate and appendages. When suppuration occurs the pus may break through the broad ligament in any direction — the peritoneum, rectum, perineum, or bladder : such disastrous burrowing of pus should be prevented by prompt incision of the abscess either from the perineum or (rarely) from the rectum. Infection of the pelvic connective tissue in front of the broad liga- ment, including the suprapubic space or cavity of Retzius, commonly results from extension of an inflammation from the bladder ; it is espe- cially common in the prevesical space. Less frequently suppuration in Q EN 1T0-U BINARY SURGERY. 1001 this space results from the burrowing of pus from a distant abscess, such as an appendicitis. The usual symptoms of suppuration and cystitis, with a hard swelling above the symphysis, mark this condition and should suggest an incision into the prevesical space. Diseases of the Kidney, Pelvis, and Ureter. Infections. — The upper urinary passages are subject to three bacterial invasions : gonorrhoea! , septic, and tuberculous. Gonorrhoea occasionally extends from the bladder into and through the ureter to the kidney-pelvis and renal tubules, making a gonorrhoeal pyelo-nephritis. Such invasion is marked by the occurrence of chills, fever, pain, and tenderness extending from the kidney along the course of the ureter to the corresponding testicles, and by pyuria. With the cystoscope pus may be seen issuing from the ureteral orifice. Septic Infection : Pyelitis, Pyelo-nephritis, Surgical Kidney. — These various forms of septic infection are frequent sequels of chronic septic infection of the bladder (chronic cystitis), especially in cases where there exists a chronic obstruction to the exit of urine, such as prostatic enlargement, vesical calculus, and tight stricture of the deep urethra : in such cases first the ureter and then the pelves become distended with urine. Septic infection of the upper urinary tract may be provoked by catheterism in the puerperal state, doubtless through infection of the bladder. In all cases of long-standing cystitis, especially in elderly men, the possibility of this condition must be investigated, since treatment and prognosis are determined largely by its presence or absence. When acute, septic invasion of the upper urinary passages is marked by chills, fever, pain over the kidney, along the course of the ureter, down the thigh, and in the corresponding testicle, which may be retracted ; it is, however, more frequently chronic, and is then a gradual and insidi- ous process, whose symptoms are usually masked by the more pronounced signs of the coexistent cystitis. In a few cases an acute septic infection of the kidney and its pelvis occurs from the blood-current, and not by extension from the bladder; it is then a complica- tion of general infections, such as typhoid fever, osteomyelitis, diphtheria, etc. Suppurative pyelitis also follows the formation of a renal calculus. Treatment. — Internal medication, by salol or other antiseptic, is usually fruitless ; the local application of guaiacol, and in the female the irrigation of the renal pelvis, as described in the preceding section, should be tried. In these septic conditions of the kidney there is scarcely any remedv which gives such speedy results as urotropin, alone in 5 grain doses every two to four hours, or combined with equal doses of benzosol. Also in the phosphaturia of chronic cystitis urotropin will be found most beneficial. Rational treatment consists in arresting the cystitis of which the pyelitis is the extension : this may be accomplished by the careful dilatation of the urethral stricture, the removal of the vesical calculus, tumor, etc. In cases of severe cys- titis and pyelitis from prostatic enlargement, simple drainage of the bladder for a few weeks has been followed by a cessation of the inflammation in the upper urin- ary channels. In cases where the septic infection has invaded the kidney struc- 1002 SPECIAL OR REGIONAL SURGERY. ture with the production of multiple abscesses — the so-called " surgical kidney " — cure has not often been obtained, and then only by incision and drainage of the kidney (nephrotomy) or by the removal of the organ. Fig. 431. Double uretero-pyelo-nephritis, with portion of greatly thickened bladder-wall. Ureters dilated and shortened. Kidneys showing changes characteristic of pyelo-nephritis (Musee Guyon). Pyonephrosis. — This term designates an accumulation of pus dis- tending the renal pelvis and sooner or later destroying the kidney sub- stance. It is caused by a combination of septic infection with an obstruc- tion to the escape of urine from the ureter, this duct being occluded by a calculus, stricture, fragment of tissue, tumor in the bladder, or uterine tumor compressing the lower end of the ureter, etc. Pelvis and kidney are converted into a pus-sac ; the occlusion of the ureter may entirely prevent the escape of this pus into the bladder, so that the urine (from the opposite kidney) may be clear and normal. Sometimes the occlusion is intermittent, in which case pus escapes into the bladder and mingles with the urine for some days, and is then shut off for a similar period. The pus-sac may be so large as to be distinctly GEXITO-URIXAEY SURGERY. 1003 perceptible as a tumor in the I'enal region. Spontaneous recovery, though rare, has been known to occur by the escape of the contents through the ureter into the bladder, or by ulceration and discharge into the intestine or the lung. Treatment. — The diagnosis having been established by aspiration of the tumor, a nephrotomy should be made. If a renal calculus be found, its removal will be the only measure necessary ; if no apparent cause for the pyonephrosis be detected or tuberculosis be discovered, the advisability of immediate nephrectomy may be considered. The best practice is, how- ever, simply to drain, not immediately to excise the kidney ; for drainage is often followed by complete recovery, and if a fistula persists, nephrec- tomy can be made later with less danger of a fatal result. In a few cases simple aspiration of a pyonephrosis has been followed by recovery. Fig. 432. Hydro-pyonephrosis (Richardson). Tuberculosis of the kidney may occur at any time of life, though most frequent in youth. It may occasion no symptoms beyond an admixture of pus and a little blood with the urine, some tenderness over the kidney, frequent urination, and a slight but constant increase of body temperature. "When clots of pus or tissue-fragments occlude the ureter, however, then renal colic and pain in the testicle are felt. The infection is apt to spread to the bladder, after which the symptoms of severe cystitis supervene. Treatment. — Many cases of complete recovery after removal of the infected kidney have been recorded ; in many others such removal has been followed by death from uraemia, the autopsy disclosing exten- sive though unsuspected tuberculosis of the opposite kidney and of 1004 SPECIAL OR REGIONAL SURQERY. other organs. The impossibility of proving before operation that the tuberculosis is limited to the suspected kidney has caused a diversity Fig. 433 Tuberculosis of kidney : multiple abscesses and degenerations (Richardson). of opinion among surgeons as to what course is best ; probably a neph- rotomy, thorough curetting of the diseased tissues, followed by the hygienic and medicinal treatment for tuberculosis in general — guaiacol, a dry sunny climate, etc. — are safest and best. Calculus. Stones are found in the kidney at all ages and in both sexes, the majority of cases being in the second half of life and in males. They are usually composed of uric acid, urates, or oxalates ; more rarely of phosphates, cystin, or xanthin. The causes of the calculus-formation are generally constitutional, such as the gouty condition, though a foreign body, such as a clump of pus, of mucus, blood-clot, or fragment of tissue, is commonly found as the nucleus on which the urinary salts have been precipitated. Calculi found in the living subject vary in size from minute aggregations of crystals to stones weighing over two ounces, and in numbers up to hundreds ; the severity of the symptoms bears no relation to the size of the stone, since small sharp concretions may cause the most acute distress. Symptoms. — These vary extremely in degree from distracting suffer- ing to almost nothing. Three symptoms are commonly present — pain, pyuria, and hcematuria ; and several others are frequentr — disorders of micturition, nausea, and vomiting. Pain is felt in the renal region, along the ureter, in the testicle, and down the thigh ; sometimes also in the opposite kidney ; it is commonly intermittent. At intervals the pain is apt to be aggravated into a series OENITO-URINARY SURGERY. 1005 of agonizing paroxysms called renal colic, so severe that nothing but chloroform can mitigate the suffering. Renal colic is due to sfiasmodic contractions of the pelvis and ureter ; sometimes it is provoked by the passage of a small calculus into and down the ureter, and ceases abruptly when the stone enters the bladder ; but it may occur when the ureter is clear, and seems then to be provoked by the irritation of a stone in the pelvis. Pyuria is an almost constant symptom of renal calculus, the pus being derived from the inflamed pelvis and ureter. Hcematuria is not observed in every case, and is generally inter- mittent, being provoked by exercise or jolting in a vehicle. Frequency of urination with some pain is not rare, and should be remembered as a feature of renal irritation, because when associated with pus in the urine the symptoms are often erroneously ascribed to a cystitis. Nausea and vomiting are occasional features in the course of renal calculus ; they are almost constant during renal colic. Diagnosis. — In cases presenting all the symptoms just described the diagnosis is simple ; but since in many cases some of these symptoms — indeed almost all except pyuria — may be absent, the differentiation between renal calculus and pyelitis due to other causes, especially tuber- culosis, is difficult. In every case of pyelitis the surgeon should make a microscopic examination of the urine, noting pus, blood, crystals, and bacteria; the epithelium present is of no particular value in differential diagnosis. Then with the cystoscope it can be seen from which ureter the pus issues, and from the conspectus of symptoms a diagnosis of greater or less certainty is made. It must be said that after most careful and thorough examination competent surgeons have opened the kidney in the full expectation of finding a calculus, but with negative result, though in sev- eral of these cases the drainage has resulted in a cure of the pyelitis. In some cases only minute concretions, as large as pin-heads, have been found, but their removal has effected a cure. Hence a strong probability of renal stone warrants an exploratory incision if the general condition be favorable. Treatment. — In every case of suspected renal calculus medicinal treatment may be tried, not with the hope of dissolving a stone of con- siderable size, but for the purpose of mechanically washing down into the bladder small concretions ; for, as already stated, the small, even minute concretions sometimes cause the severest symptoms, even when no appreciable calculus is present. Medicinal treatment consists of restriction of the albuminous and saccharine articles of diet to a minimum, avoidance of constipation, and the free ingestion of pure water containing alkalies ; whether the solution be natural or artificial is probably immaterial. The popular belief that lithia compounds and spring waters containing them have an especially good effect is hardly warranted by clinical experience ; the same remark applies to the various remedies sold as solvents, such as piperazine. The nitrates and acetates of sodium and potassium — one to two drachms daily, dissolved in two quarts or more of water — may be substituted for the natural alkaline waters, such as Carlsbad or Vichy. In case of persistent nausea, flushing of the kidney can be easily secured by injection of the water into the lower bowel. Much benefit accrues from the use of glycerin in large doses. Espe- cially in the acute stage of renal colic does it seem to have marked 1006 SPECIAL OR REGIONAL SURGERY. analgesic powers. From one to five ounces may be given in divided doses. Such treatment has repeatedly caused the expulsion of small stones and a restoration of the normal condition of the kidney pelvis and ureter. Yet it usually fails, in which case surgical means must be con- sidered. This consists in an incision down to the kidney, a careful digital examination of the organ, its pelvis and the upper part of the ureter ; and if a stone be detected (or even otherwise in the judgment of the surgeon) an incision through its substance. If no calculus be touched by the finger-tip passed into the kidney pelvis, a long probe (uterine or other), bent into the shape of a very short-beaked sound, may be used to explore the calyces of the kidney ; and a flexible probe should be passed down the ureter to the bladder, since a stone lodged in the lower segment of the ureter may give all the symptoms of renal calculus. Some surgeons recommend, after exposing the kidney, the exploration of its tissue and pelvis by repeated punctures with a needle, a negative result causing them to refrain from incising the kidney itself. Such exploration should, however, never prevent the incision and digital exploration of the pelvis. In some cases the kidney tissue is found practically destroyed by the pressure-atrophy and suppuration consequent upon the stone-formation ; yet after drainage complete healing will commonly occur, so that the more dangerous operation of nephrectomy, as practised by some under these circumstances, is to be avoided. Tumors. Enlargements of the kidney and its pelvis are of three kinds: (1) distention with retained urine or pus; (2) cysts; (3) neoplasms. The first class includes pyonephrosis (already described) and Hydronephrosis. — This term designates a chronic distention of the kidney pelvis, calyces, and renal tissue with urine, due to a partial or intermittent obstruction to the exit of urine. Complete and permanent occlusion causes, not hydronephrosis, but arrest of secretion and atrophy of the kidney. The obstacle to the passage of urine from the kidney may be located in the ureter — such as a stone, blood-clot, valvular arrangement of the mucous membrane, a " kinking " due to displacement of the kidney ; or in the bladder, such as a tumor at the ureteral orifice, a calculus, or pros- tatic enlargement ; or, finally, in the urethra, as a tight stricture or a minute meatus. As some of these conditions are congenital, hydrone- phrosis likewise may exist at birth. The effects of such obstruction are gradual dilatation of the pelvis and kidney tissue, and finally atrophy of the latter, the kidney and its pelvis beiug trans- formed into a membrane-like sac. This sac may contain many ounces, even gal- lons of fluid, which, while at first urine, gradually loses its urinary constituents and assumes a cystic character. If infection occur, a suppurating hydronephrosis, and finally pyonephrosis, results. Symptoms. — The gradual development of a hydronephrosis occasions no pronounced symptoms, although the obstructing cause, such as a cal- culus in the ureter, may produce acute signs. Sometimes a dull pain is GENITO-URINARY SURGERY. 1007 observed and undue frequency of urination noted ; commonly, however, the swelling is the first symptom. Sometimes this tumor undergoes Fig. 434. Hydronephrosis from obliteration of ureter by tubercular disease (Turner). rapid decrease in size corresponding to a greater escape of the retained urine, and such cases of intermittent hydronephrosis are apt to have mild renal colic. The diagnosis is made probable- by the history and detection of a fluctuating tumor ; it should be confirmed by careful aseptic aspiration, which alone can furnish positive differentiation from other kidney tumors and from ovarian cysts. Treatment. — Rational treatment would be the removal of the obstruc- tion. To this end medicines are useless : a few cases have been relieved by mechanical means, such as massage of the tumor, inversion of the patient, or aspiration through the loin. Usually, however, operative interference is necessary. Surgical treatment may be either nephrotomy or nephrectomy, made through a lumbar or transperitoneal incision, most surgeons preferring the former. Nephrotomy — or more accurately pyelotomy, since in this case the dis- tended pelvis rather than the kidney is incised — is the operation of choice, the sac being stitched to the skin. Then a careful search is made for ob- structions in the ureter ; a stone or clot is removed, a stricture divided, etc. Often the obstruction cannot be detected nor removed, yet sometimes the result is a cure even when nothing beyond simple incision and drainage is done. If, however, a permanent fistula, discharging large quantities of urine, persists, the advisability of nephrectomy must be considered. Cysts. — Two varieties of renal cysts come to the attention of the surgeon — conglomerate (cystic degeneration) and hydatid. Cystic degeneration of the kidney is often congenital, and sometimes 1008 SPECIAL OR REGIONAL SURGERY. in later life acquired ; usually both kidneys are involved. It causes vague symptoms suggestive of chronic nephritis — light, pale, albuminous, perhaps bloody urine ; cardiac hypertrophy ; occasionally a perceptible renal tumor; oedema of the lower extremities. Medical and surgical treatment are alike useless. Fig. 435. Hydronephrosis in first stage of development (Rayer). Hydatid cysts of the kidney are rare, and cannot be distinguished from other fluid tumors unless the characteristic hooklets or daughter- cysts are discovered in the urine, or by aspiration, or after rupture into adjacent organs. Neoplasms (solid tumors) of the kidney are benignant or malignant ; the former are not common. The malignant tumors — carcinoma, sar- coma — occur as secondary or primary growths ; the latter are most frequent in infancy and in advanced life, often attaining great size in the younger patient — ten to twenty pounds. The cancer remains for a long time enclosed within the kidney capsule, though metastases may early occur. The SYMPTOMS of renal cancer are pain, hematuria, dilatation of superficial veins, tumor, and cachexia ; the latter is the only constant feature. Pressure upon the common iliac vein or vena cava may cause oedema in one or both extremities, as well as enlargement of the veins in the abdominal wall, scrotum, and leg. GENITO-URINARY SURGERY. 1009 Treatment. — There is but one, nephrectomy. Cases in which the tumor and kidney have been extirpated before metastatic deposits existed have furnished a large percentage of cures ; unfortunately, the difficulty of diagnosis has often prevented early operation. Collection op the Urine from each Kidney Separately. There are numerous cases in which it is of the greatest advantage to decide whether both kidneys are furnishing abnormal urine, or whether it may come from one alone. Until recently it has been customary to catheterize the ureters, especially in the female. But this is always difficult, and for most practitioners impossible. Harris of Chicago has recently invented a double catheter, whose halves are introduced together Fig. 436. into the bladder, and then separated so that the beak of each is turned toward its appropriate side. Then, by means of a small lever intro- duced into the rectum, the central portion of the bladder is elevated, and a watershed produced on either side and drained by itself into a collecting flask. This simplifies greatly a hitherto exceedingly com- plicated procedure, and places this means of diagnosis in the hands of all (Fig. 436). Movable and Floating Kidney. Abnormal mobility of the kidney may be congenital or acquired, and the range of movement may be behind the peritoneum, due to laxity of the renal attachment, or within the abdominal cavity, due to the enclosure of the kidney in a distinct envelope of peritoneum — a meso- nephron. The former is called a movable kidney, the latter — far less frequent — a floating kidney ; this anatomical distinction is not clinically practicable until the kidney is exposed. Practically, every abnormally motile kidney is a movable kidney ; the condition is acquired, not congenital ; in at least 90 per cent, of cases it is found in women, especially in those who have borne several children. Symptoms. — Pain varies from almost nothing to a severity that incapacitates the patient for active bodily movement. In the latter 64 1010 SPECIAL OR REGIONAL SURGERY. case a dragging pain in the abdomen, aggravated by movement, stand- ing, constipation, or menstruation, sharp pain, resembling renal colic, general abdominal distress with nausea, are frequently observed. Palpation reveals a tumor which usually corresponds in size and shape with the normal kindey, though sometimes larger ; this may be found even as low as the pelvic brim ; indeed, it has been felt through the vagina : it can generally be pushed back into the normal locality either by the hand or by elevation of the patient's hips. Treatment aims at the retention of the kidney in its normal posi- tion : to this end various trusses and bandages have been devised, and have sometimes in thin patients secured a proper fixation of the kidney. Usually, however, this organ must be exposed, and by means of three or four silk sutures, passed half an inch apart through the kidney sub- stance and the edges of the divided lumbar fascia, sewn firmly to the abdominal wall. This operation is termed nephropexy or nephrorrhaphy : it is almost free from danger and affords a great probability of perma- nent relief. Renal Colic. Spasmodic contractions of the kidney pelvis and ureter are accom- panied with agonizing pain, called renal colic ; painful retraction of the corresponding testicle is a common accompaniment. These contractions are provoked either by the irritation of a calculus in the pelvis or ureter or by any decided obstruction to the passage of urine into the bladder. They therefore occur in several conditions other than renal calculus, being caused by blood- or pus-clots, renal tuberculosis or malignant disease ; kinking of the ureter in cases of movable kidney ; stricture or compression of the ureter by pelvic tumors or inflammatory exu- dates. The treatment should aim ultimately to remove the cause of the obstruction, but the severe pain requires present relief. The patient should be more or less completely inverted, a measure sometimes giving immediate and lasting relief from pain ; if it fail, hot fomentations, sub- cutaneous injections of morphine, or even prolonged inhalations of chloroform, are required. Perinephritis. Inflammation of the fatty and connective tissue surrounding the kidney is a somewhat frequent condition ; it is sometimes secondary to a general septic infection or to inflammation in adjacent organs — appen- dix, liver, colon ; and it is frequently primary. The usual causes of primary perinephritis are wounds and blows in the lumbar region, infections of the kidney substance and pelvis (pyelitis, tuberculosis), and perhaps the so-called gouty diathesis. The course of the perirenal inflammation varies with the cause ; it results sometimes in a chronic thickening of the tissues, more commonly in suppuration. The abscess may long remain limited to the perirenal region, or it may soon burst into the colon, lung, peritoneum, or exter- nally, or it may burrow down into the pelvic connective tissues. GENITOURINARY SURGERY. 1011 Symptoms. — The usual acute form is marked by the regular symp- toms of septic inflammation — chills, fever, pain, and tenderness : there may be fixation and tenderness of the hip, closely simulating tuberculosis of this joint, but a distinct fulness of the lumbar region is apparent. The diagnosis is established by the aspirating needle. Treatment. — In many cases the morbid condition in the kidney itself overshadows the perinephritic inflammation both as to diagnosis and treatment. The perirenal process should be treated as are other septic infections ; that is, before suppuration is evident by the external application of guaiacol, and after pus-formation by incision, and drainage. •Guaiacol, 15 to 30 minims, mixed with a equal volume of olive oil or glycerin, should be rubbed into the skin over the kidney two or three times daily ; absolute rest and saline laxatives are required. If chills and high temperature or the aspirator reveal the presence of pus, incision and drainage should be promptly made ; delay increases the possibility of rupture of the abscess into the peritoneum or of its burrowing into the pelvis. Nephralgia. Pain referred to the kidney is an obvious result of many of the mor- bid conditions already discussed, such as calculus, cancer, and ureteral obstruction. There are, however, cases in which severe and persistent pain in the kidney cannot be accounted for by an obvious lesion. In some of these a gouty condition associated with unduly acid urine has been assumed as the cause, and appropriate medical treatment has followed by diminution of the pain. In others, after the failure of internal remedies, an exploratory incision to or into the kidney has been made ; in some of these cases a small calculus has been discov- ered and removed ; in others, although nothing abnormal was detected, the pain has immediately and permanently ceased. In cases of severe and persistent renal pain, therefore, the failure of internal medication and of the local application of guaiacol justifies the consideration of an exploratory nephrotomy. Renal pain must be carefully distinguished from the frequent pain in the sacral region caused by chronic inflamma- tion of the prostate and appendages. Renal Hematuria. This is another symptom which, while regularly associated with ob- vious kidney disease, such as calculus and cancer, occurs in some cases without apparent cause. In some of these the bleeding seems to be due to malarial infection, because promptly relieved by quinine ; in others the later history or an exploratory incision reveals malignant disease or a calculus ; in at least one case excision of a kidney for prolonged and dangerous hemorrhage has shown a local brittleness of the renal vessel (local hsemophilia). But many cases are on record in which an explora- tory incision, while disclosing no abnormality, has been followed by per- manent arrest of hemorrhage. Oil of turpentine in five- to ten-drop doses on sugar four times daily, and 1012 SPECIAL OR REGIONAL SURGERY. thorough massage of the abdomen and lumbar region, should be tried before ope- rative measures are considered. The fact that these cases of apparently causeless bleeding from the kidney, arrested by simple incision, commonly occur in young women suggests the possibility of an emotional disturbance as a cause. DISEASES OF THE TESTICLE AND EPIDIDYMIS. The acute diseases of these organs are due to gonorrhoea, septic infec- tion, and trauma, all of which have been described in Volume I. ; acute inflammation of the testicle is also seen as a local manifestation of the general infection of mumps, typhoid fever, and other acute bacterial diseases. It requires the same treatment as gonorrhceal orchitis. The chronic diseases are all accompanied by enlargement, general or local, of these parts, and the diagnosis of these .diseases is therefore largely a comparative study of the swellings exhibited by these organs. Tuberculosis is primarily a disease of the epididymis, where the infection appears as irregular, hard, nodular swellings like shot, which may later coalesce into a cord, thus converting the epididymis into a rigid tube as large as the finger ; subsequently the same changes may occur in the adjacent parts of the testicle and in the spermatic cord. The tubercular tissues in the epididymis may become adherent to the skin, soften, and ulcerate, making a small but obstinate sinus. Tuberculosis of the epididymis is soon followed, usually before the patient seeks medical advice, by the infection of the seminal vesicle and prostate ; the remarks as to the age of patients, avenues of infection, and general treatment of " tuberculosis of the prostate and appendages " are therefore applicable here. Surgical treatment was formerly castration, with the idea of remov- ing the tuberculous focus and thus protecting the patient from further infection. Experience has, however, shown the fallacy of this idea, since the infection is usually established within the pelvis before the patient is brought to the surgeon. Conservative local treatment is the wise plan : before softening of the tuberculous foci has occurred guaiacol (twenty drops with an equal quantity of olive oil) should be rubbed into the diseased parts two or three times daily until the skin becomes sore, and then applied to the spermatic cord and groin. After softening has occurred the tissues should be thoroughly curetted and packed with iodo- form gauze : if the infection and softening have already involved most of the testicle, castration should be performed, not with the idea of pre- venting further infection, but simply (like the curetting) to remove broken-down tissue. Trichloride of iodine (1 part to 100 or 300 of pure water) has, in the writer's hands, proved a most valuable agent for appli- cation to tuberculous cavities and tissues in the epididymis and testicle. Syphilis in the secondary and tertiary stages attacks first the testicle, and later the epididymis and cord, thereby offering a sharp contrast to tuberculosis of these parts. It makes a diffuse, smooth, painless enlarge- ment of the testis, which may double or triple the original size of the organ. Cystic Disease. — In middle life the testicle presents a cystic degen- eration distinct from the cystic formation that often accompanies sar- coma. It is a slowly-growing, painless tumor, whose fluid nature may be suspected from its indistinct fluctuation (which is, however, also shown by sarcomata) ; the aspirating-needle can alone establish the diagnosis. GENITO- URINARY SURGERY. 1013 Medical treatment is useless ; castration is usually performed. However, since the cystic degeneration may involve only a part of the testis, it may be well for the surgeon after exposing this organ to incise it, and, if a considerable portion seems normal, to remove only the diseased part. Chronic Epididymitis and Orchitis. — Sometimes as a continuation of an acute infection, oftener as a purely chronic inflammation, the epididymis and the testis, one or both, exhibit a chronic enlargement designated by the above names. This condition seems often to be a continuation of the chronic inflammation so common in the prostate and seminal tubes, and already described in the " Diseases of the Pros- tate and Appendages." Sometimes the epididymis is alone affected, sometimes the testis alone, or both may exhibit the enlargement. This chronic inflammation causes a great and often uniform swelling of the organs ; they are painful and sensitive to pressure. Acute aggravations of the inflammation, resulting in local abscess and sinus, are not rare, and ultimately cysts may develop. The diagnosis is sometimes very difficult ; indeed, this condition is probably often considered tuberculous, cystic, or malignant disease, and castration is performed on this mistaken diagnosis. It must be distinguished from other enlargements by a careful comparison of the symptoms, by examination of the prostate and vesicles, and by the effects of syphilitic treatment. Treatment. — When chronic inflammation of the prostate and appendages is discovered, these should be treated by milking and irri- gation, as already described ; in any case the effects of mercurial oint- ments to the testicle should be tried. Otherwise, the treatment is symptomatic — suspension of the organ, curetting of sinuses and abscess- cavities, etc. Ultimately castration is necessary in a considerable number of cases. Fibroma and enchondroma of the testicle are rare and clinically unimportant. Cancer of the testicle is a term used to designate two varieties of malignant growth, carcinoma and sarcoma, the distinction between "which is often impossible without histological examination. Cancer of the testis is most frequent in the second half of life, though not rare before the completion of puberty. Its origin can often be distinctly traced to a blow, or a previously inactive tumor shows a rapid and malignant growth after such injury. In the early and slow stages there are no sharp diagnostic distinc- tions from the non-malignant enlargements of the testicle already men- tioned : the active stage is, however, marked by rapid enlargement, con- stant pain, dilatation of scrotal veins, induration of the inguinal and pelvic lymph-nodes, and the cachexia and emaciation generally character- istic of malignant growths. The aspirating needle brings only blood. Treatment consists of castration and removal of infected nodes. Yet the records show a discouragingly large percentage of metastases in internal organs even after fairly early castration ; the transfer of cancerous material to the pelvic nodes seems to occur at a startlingly early period. 1014 SPECIAL OR REGIONAL SURGERY. Diseases op the Spermatic Cord. While the vas deferens and its envelope participate in many of the diseases of the testicle and epididymis and of the prostate and seminal vesicle, it exhibits three independent morbid conditions — hydrocele, spermatocele, and varicocele. Hydrocele of the cord is a collection of serous fluid in a portion of the peritoneal process surrounding the cord which has not undergone the usual obliteration after the descent of the testicle. It causes a painless swelling in the position of the spermatic cord and terminating above the testicle ; its upper end may lie within the inguinal canal. It causes no symptoms, unless acute inflammation supervenes, when tenderness and pain are developed. The diagnosis is best made by an aseptic aspiration, which may also be the means for immediate injection of three or four drops of 95 per cent, carbolic acid by way of treatment. Without aspiration it may be possible to recognize a hydrocele by its shape and distinct fluc- tuation, but it is sometimes difficult to distinguish it from omental or even intestinal hernia, with which it may indeed be complicated. When injection of carbolic acid fails, the sac may be incised, stitched to the skin, and packed with iodoform gauze. Spermatocele begins between testicle and epididymis, but extends upward along the spermatic cord, making an oval fluctuating tumor which appears to be inserted at the top of the testis or epididymis. The diagnosis is confirmed by microscopic examination of the fluid removed by aspiration (showing spermatozoa) ; if, after tapping, it again form, the sac may be opened and stitched to the skin. Varicocele — dilatation of the veins of the pampiniform plexus and of the spermatic cord — is a very common affection, found in perhaps 10 per cent, of adult males. Its clinical importance depends quite as much upon the popular belief that it causes sexual derangement as upon its real pathological effects. Varicocele commonly develops soon after puberty, when the sexual instinct is constantly active and imperfectly gratified ; a slight degree of venous dilatation often disappears after marriage. Varicocele is but rarely observed in the right half of the scrotum ; its almost constant restriction to the left side is usually explained by the tendency to venous congestion caused by two factors : first, the opening of the left spermatic vein into the renal vein at a right angle, and, second, the frequent com- pression of this left spermatic vein by a distended sigmoid flexure. Symptoms. — The development of the varicose condition is nearly always gradual ; in rare cases — following violent bodily effort or fatigue — it is acute. This acute form usually subsides under a few days' rest, hot fomentations, and elevation of the testicles. The usual slowly-developing varicoceles are often discovered by accident before they have caused any subjective symptoms, but sooner or later the patient becomes aware of a sense of weight, possibly dull pain, in the testicle and sacral region, aggravated by bodily effort and by sexual excitement. In extreme cases the veins of the scrotum also exhibit the varicose condition. Mental symptoms — anxiety and despondency concerning the integrity of the sexual organs — are frequently pronounced, and the testicle may, in fact, become soft, sensitive, and ultimately atrophied. QENITO-URTNARY SURGERY. 1015 The DIAGNOSIS of uncomplicated varicocele is simple : the wormy feel of the tortuous vein is quite peculiar and unmistakable. If the patient be made to lie down, the dilated veins are emptied and the en- largement disappears ; if he again stand, the surgeon's fingers being meanwhile kept pressed against the external inguinal ring, the veins refill from below (unless the pressure is so great as to obstruct the artery also). The coexistence of hydrocele or hernia can be detected by this test. Treatment. — There are three symptoms requiring treatment : (1) a hypochondriac state ; (2) such pain and distress in the testicle, groin, and back as to seriously annoy and incommode ; (3) wasting of the testicle. If none of these exist, the patient may be dismissed with advice as to sexual hygiene and with a suspensory bandage. If the mental symp- toms are prominent, general tonic treatment and cold douches locally should also be prescribed. If, in spite of support and mental treatment, either of the three symptoms persist, an operation should be advised. This is especially needful if the testicle be flabby, sensitive, or wasted ; for after ligation of the varicose veins the condition of this organ im- proves — often, indeed, to the normal standard. Three operations for varicocele are more or less practised : (1) the amputation of the scrotum, which converts this sac into a natural sus- pensory bandage; (2) subcutaneous ligation of the dilated veins; (3) open ligation and excision of these veins. Amputation of the scrotum may be dismissed as an uncertain and unnecessarily severe operation : the choice really lies between subcutaneous and open ligation of veins. The former is practised and warmly advocated by several skilful sur- geons, notably Keyes, while the open method has the general preference, because by it the surgeon can see what and where to ligate. In ligation of the veins, whether subcutaneous or open, three vital points must be observed: (1) the vas deferens must be excluded from the ligature ; (2) at least three or four venous trunks must remain untied; and (3) the veins must be tied at the bottom as well as at the top of the scrotum — that is, at the globus minor of the epididymis as well as in the spermatic cord. The exclusion of the vas deferens secures the patulenee not only of this important duct, but also of the spermatic artery which accompanies it : ligation of .this artery has been known to cause necrosis or atrophy of the testicle. The obliteration of all venous trunks also renders atrophy of the testis probable ; hence the necessity for leaving some untied. The third injunction — to tie at the bottom as well as at the top of the scrotum — is the result of the frequent experience that ligation of the veins above the tes- ticle only (in the spermatic cord) has often failed to cure the varicocele; for the veins of course fill from below, and such ligation leaves a large mass of dilated veins around the testicle constantly full of blood. The operation is thus performed : The patient's groin and scrotum are thoroughly shaved and cleansed ; a clean rubber band, applied while the patient stands, is made to constrict the scrotum, passing over the root of the penis : this organ is enclosed in aseptic gauze and kept, out of the way against the suprapubic space by a bandage around the hips. Anaesthesia may be general or local (two drachms of a 1 per cent, cocaine solution injected into the skin over the cord and epididymis). A longitudinal incision two inches long divides the scrotum below the rubber band ; the enlarged veins are lifted into the wound ; the vas deferens — distinctly recognizable as a hard cord — is kept carefully away from the wound by the thumb and finger of an assistant ; the bunch of 1016 SPECIAL OR REGIONAL SURGERY. veins, excluding three or four, is very tightly ligated en masse with silk at two points, above the testicle and opposite the globus minor ; some surgeons place a third ligature between these two. The ligatures are cut short; a drain consisting of a few strands of catgut is carried through a puncture in the bottom of the scrotum ; the wound dusted with iodoform and closed ; iodoform gauze dressing and rest in bed for a week follow. After this, as after other operations on the genitals or rectum, temporary retention of urine may occur, requiring the catheter for a day or two. Hydrocele. By hydrocele is meant an accumulation of serous fluid in the tunica vaginalis ; it may be acute or chronic. The acute form is always second- ary to trauma, inflammation of epididymis or testicle, or a general infec- tion such as pyaemia. It usually subsides without other treatment than rest and hot fomentations ; if suppuration occur, incision and drainage are needed. Chronic hydrocele is the condition meant by the term hydrocele unless otherwise specified. Symptoms and Diagnosis. — Chronic hydrocele causes only mechan- ical symptoms — a swelling of the scrotum and a dragging sensation due to the extra weight. The diagnosis is not usually difficult : the tumor is pear-shaped and sharply limited outside of the inguinal canal (unless there be also hydro- cele of the cord) ; there is more or less distinct fluctuation. The classical test of Iranslucence — interposing the tumor between a lighted candle and the surgeon's eye — usually shows the translucence of the greater part of the mass, the contained testicle and epididymis being opaque. This test is less successful when there is much thickening of the connective tissues. The modern test is a clean aspiration, which must always succeed except in cases of advanced periorchitis with absorption of the fluid. Treatment. — There are two recognized modes of treatment : (1) the induction of an adhesive inflammation which shall unite the opposite layers of the tunic and thus obliterate the cavity : this may be attempted by injection of irritating substances (carbolic acid) or by incision and packing (Volkmann's operation) ; and (2) excision of the entire tunica excepting only the part adherent to testis and epididymis. Injection.— The scrotum having been carefully cleansed and the testicle grasped by the surgeon's left hand, a large aspirating needle is passed into the sac away from the testicle, the fluid permitted to escape, and ten to twenty minims of 95 per cent, carbolic acid injected ; the sac should then be so manipulated as to spread the injected acid over its surface — an important item. The patient is kept quiet for a day or two, and then permitted to go about with the testicle properly sup- ported. The scrotum again swells and becomes doughy, as if refilling with fluid, but in a week or so the new swelling subsides permanently. Cautions. — Tincture of iodine, formerly so much used for this injection, should never be employed, because the inflammatory reaction is sometimes extremely severe and followed by sloughing of the scrotum, with perhaps a fatal result. Great care should be taken, before the acid is injected, to see that the point of the needle is still within the cavity of the tunica ; for the collapse of the sac as the fluid escapes may leave the needle outside of the serous cavity, in which case the acid would be injected into the scrotal tissues, causing serious damage. The only objection to this operation is its uncertainty, relapses of the hydro- cele being frequent. GENIT0-UR1NAHY SURGERY. 1017 Free incision and packing of the sac with iodoform gauze, the cut edges of the tunica being sewn with catgut to the edges of the skin, is a simple and safe operation (done aseptically) which can be performed under cocaine anaesthesia. Unfortunately, it is not a certain cure, recur- rence having been occasionally observed. Excision of the sac, which can usually be peeled away from the adhe- rent scrotum before the sac is opened, is the only positive cure : the objec- tions are, first, that it requires general anaesthesia, and, second, that very free oozing of blood may occur from the raw surfaces unless firm pres- sure is maintained for a day or two after operation. Operations. The following operations, needful for the relief of various morbid conditions, have not been described in the text. Circumcision. — The patient, if a child, should be chloroformed ; in an adult local anaesthesia is induced, after constriction of the penis by a rubber band around its root, by the subcutaneous injection into the dor- sum of the organ just in front of this band of a half drachm of a 10 per cent, cocaine solution. The parts are cleansed ; a snap forceps seizes the muco-cutaneous junction of the foreskin on either side : by means of these an assistant draws the prepuce well forward from the glans, which is pressed back by the left hand of the operator. With sharp scissors (with or without the aid of a clamp) the foreskin is amputated just in front of the glans. The skin now retracts, while the cuif of mucous membrane remains over the glans ; this cuff is split with scissors in the middle line (sometimes adhesions to the glans must be broken up by means of a probe), and each segment cut off close to the penis, leaving a fringe only about a quarter of an inch broad. The skin, if excessive, must be again drawn beyond the glans and another section snipped off. The constricting band is removed, any spurting vessels are twisted or ligated, and the cut edges of skin and mucous membrane are united by eight to twelve interrupted catgut sutures, the stitches passing through the inter- vening subcutaneous tissues. The seam is dusted with iodoform or lore- tin, dressed with gauze, and a rubber condom (whose narrow neck is split to avoid constriction) is drawn over the hole. The tip of this con- dom is then cut off and the edges fastened to the surface of the gland with collodion, to prevent leakage of urine into the dressing. External Urethrotomy. — In this operation, also called perineal and membranous urethrotomy, the membranous urethra is opened by an incision through the perineum. It is thus performed : The patient is anaesthetized, the rectum evacuated, the bladder irri- gated, and five or six ounces of an antiseptic fluid injected into it ; the perineum and posterior scrotal wall shaved and cleansed. The legs and thighs are held fully and symmetrically flexed (lithotomy position) ; a grooved staff introduced until its point enters the prostatic urethra and its shaft stands about vertically, is firmly held by an assistant, who keeps the beak well against the under surface of the symphysis. The scrotum is held upward, exposing the perineum ; with a long-bladed, full-bellied scalpel the surgeon makes a vertical incision an inch long through the skin in the median line, its lower end about an inch above the anus. The 1018 SPECIAL OR REGIONAL SURGERY. lubricated fore finger of the left hand is then passed into the rectum and rests against the staff where it enters the prostate. The knife is then turned edge upward and held horizontally ; its point is entered at the lower end of the skin incision, and is thus passed through the perineal tissues till the point enters the groove of the staff; this movement can be guided by the finger in the rectum. The knife, still held horizontally and its point kept in the groove, is then drawn upward until its shaft reaches the upper end of the skin incision ; by this movement the mem- branous urethra is freely opened. The knife is then drawn horizontally toward the operator and away from the staff, cutting its way out. A grooved director or stiff probe is then passed into the incision to the staff, and along the groove of the latter into the bladder. The staff and finger in the rectum are now withdrawn, and the fore finger of the right hand worms its way through the wound, along the director as a guide, into the bladder. A drainage-tube is passed about an inch into the bladder (if of rubber, it should be held in position by a silk suture through the cut edges of the skin) ; the bladder, urethra, and wound are well irrigated ; iodoform gauze is lightly packed around the tube, and a T-bandage applied. Perineal Section. — This differs from the operation just described, external urethrotomy, in that it is made without a guiding staff: the term is applied to the operation in cases of stricture too tight to permit the introduction of a guide through the membranous urethra. A staff is, however, passed as far as possible, since its point aids the surgeon in locating the position of the membranous urethra. Suprapubic Cystotomy. — The patient is anesthetized, the rectum emptied ; pubes, scrotum, and perineum are shaved and cleansed ; the bladder is well irrigated ; five to eight ounces of warm antiseptic fluid are injected and retained by a light rubber band around the penis. The patient is placed in the Trendelenburg position — that is, on an inclined plane which raises the hips twelve to eighteen inches above the shoulders. An incision three inches long, its lower end half an inch below the upper border of the symphysis, is then made in the median line down to the recti muscles ; these are separated by the handle of the scalpel and kept apart by blunt retractors. The operator's finger is then passed down the posterior surface of the symphysis to the bladder and presses the pre- vesical fat upward toward the peritoneal fold. A tenaculum seizes the muscular wall of the bladder near the upper angle of the wound ; a sharp-pointed knife is then plunged through the bladder-wall near the symphysis, making a cut half an inch long, and is quickly followed by the finger before the contained fluid escapes. After the calculus, vesical or prostatic tumor has been removed and the bladder irrigated, a large rubber drain with lateral openings at the end is passed through to the base of the bladder and stitched to the skin : around this iodoform gauze is lightly packed, and the upper end of the wound is closed by sutures passing through skin and recti muscles. The usual dressings are applied around the tube. Nephrotomy. — The kidney may be reached by an incision through the loin or through the abdominal wall : the former is, for obvious reasons, the incision of choice, and the latter is rarely necessary. The lumbar incision should begin at the outer margin of the sacro- GENITO-TJRINARY SURGERY. 1019 Fig. 437. g M .?■ Incisions for exposing the kiflncy : X, longitudinal or vertical incis- ion; A', transverse incision; T, Konig's incision (Stimson) lumbalis muscle (two to four inches from the spinous process) about half an inch below the last rib, and it should be extended parallel with this rib for three or more inches, cutting down to the muscle. The muscular layers are separated down to the strong layer of lumbar fascia under- lying the transversalis muscle : when this is divided in the line of the superficial incision, the perirenal fat is dis- covered, moving up and down synchronously with the respiratory movements of the dia- phragm. The finger and thumb passed into the wound detect the kidney as a solid body which should be drawn into the incision and exposed by dissection of its fatty envelope. The organ being firmly grasped with the left hand, a sharp, narrow knife is passed from the convex border to the pelvis of the kidney and withdrawn, making an incision suffi- ciently large to permit the entrance of the operator's fore finger. A calculus is detected and removed or a flexible probe passed down the ureter : after the manipulations in the pelvis are concluded, the edges of the kidney wound are compressed for a minute or two, whereby hemorrhage is usually completely arrested. A rubber drain is stitched in the lower angle of the wound, which is lightly packed with iodoform gauze, the remainder of the incision being closed by deep and superficial sutures. Nephrectomy. — The combined incision already described affords the space necessary for removal of the kidney unless this organ be greatly enlarged, in which, case nephrectomy xhoidd be clone by laparotomy. When the combined lumbar incision has been made the fingers are gently in- sinuated around the ends and convex borders of the kidney, so as to separate it completely from its fatty capsule, leaving the renal vessels and ureter as a pedicle. ^ r hen possible, the artery should be ligated separately, though sometimes it is necessary to tie all the vessels en •masse : stout silk ligatures are passed around the vessels by means of large aneurism needles. Ligature en masse should be reinforced by a clamp to be left in position for forty-eight hours. During the entire manipulation great care should be taken not to pull strongly upon the renal vessels. The ureter should be ligated separately, and its stump sterilized with carbolic acid. The wound should be closed, drained, and dressed in the usual aseptic manner. Spermato-cystotomy. — The seminal vesicles, when the seat of acute suppuration, can often be emptied into the urethra by gentle pressure with the finger in the rectum ; in some cases acute distention of the vesicles with pus has been treated by incision from the perineum, the knife being guided by a finger in the rectum. Chronic suppuration of the vesicles is likewise usually amenable to treatment by repeated milking or stripping of these organs, as already described. In some cases, however, persistent treatment by this method fails : in two such instances the writer has opened a chronically distended 1020 SPECIAL OR REGIONAL SURGERY. vesicle in the following way : The anaesthetized patient is laid upon the affected side, the rectum emptied, cleansed, and blocked with iodoform gauze about four inches above the anus. The sphincters are then stretched by the thumbs, and the anus kept patent by retractors. A longitudinal incision half an inch long is made through the mucous membrane of the rectum over the lower end of the distended vesicle ; this sac is then gently drawn into the wound by means of an aneurism needle and incised ; its cavity is explored and cleansed with a probe. In one case two small calculi, blocking the ejaculatory duct, were found and removed. Possibly this operation may be often useful in cases of chronic spermato-cystitis which have resisted less radical treatment. DISORDERS OF INSEMINATION. The deposit of motile spermatozoa in the vagina — insemination — is the function of the male in reproduction. Imperfections in this function are known clinically as impotence and sterility : the former means inability to copulate, the latter (when not due to impotence) implies the absence of moving spermatozoa from the semen. Impotence. Inability on the part of the male to copulate, when not the result of malformation, is due to one of two phenomena — premature ejacula- tion or imperfect rigidity of the penis. Both are often exhibited by the same patient, the habit of early ejaculation having existed for some time before erectile power fails. The pathology of this condition is explained by a consideration of the process of normal copulation. The enlargement and hardening of the penis, constituting normal erection, is due to the distention of the cavernous and spongy bodies with blood : this distention is brought about by the dilatation of the penile arteries and the constriction of the venous exits ; the latter effect is produced by the contraction of the perineal and penile muscles innervated by branches of the second sacral nerve proceeding from the genital centre in the lumbar cord. Clinically, the most frequent cause of impotence is chronic inflamma- tion of the prostate and appendages ; a nd this results either from gonor- rhoea! infection of these organs or from sexual excess, whether in venery or in masturbation. The subject of this chronic inflammation often complains of pain in the sacrum (which he thinks indicates kidney disease), less frequently in the suprapubic region, perineum, rectum, testicles, and penis: the last-named organ is often cold and shrunken. Anxiety and despondency are marked ; the patient frequently inspects the external organs, notes and broods upon every trivial deviation from what he considers the normal condition ; he is sure that one testicle hangs down too far, etc. The subject complaining of impotence should be carefully interro- gated as to previous gonorrhoea and sexual excess ; then a digital exam- ination of testicles, prostate, and seminal vesicles should be made, the latter organs being gently pressed or " milked." This milking process often causes a discharge of milky-looking fluid from the meatus, in which GENITO-URINARY SURGERY. 1021 the microscope reveals leucocytes, fatty epithelium, and sometimes motionless spermatozoa. Diagnosis. — Two questions must be answered: (1) Does impotence really exist f and (2) To what is it due f The patient's experience can alone answer the first question ; the physician must estimate how much of the failure is due to emotional disturbance, for in some cases a man fails in intercourse simply because, having as a boy masturbated, he is terrified by the perusal of the quack circulars and pamphlets so widely distributed. If imperfect sexual power seems likely to exist, it must next be decided to which of the recognized causes (above mentioned) this shall be attributed by the methods of examination already described. Treatment. — The treatment of impotence will naturally depend upon the cause : when due to diabetes, etc., the treatment of the sexual deficiency is that of the general condition. When such morbid states have been occluded, the treatment is mental and local. The local treatment is that for chronic inflammation of the prostate and appendages already described — •" milking " of these organs, the passage of larger sounds, deep injections of hydrastin or weak silver- nitrate solution, alternating hot and cold sjDonging of the perineum and external genitals, and pills of camphor monobromide. In cases of exhaustion of the genital centre by sexual excess, rest from all sexual excitement is imperative ; mental and physical diversion is important ; strychnine, phosphorus, and belladonna are sometimes useful. The prognosis varies with two factors — the cause of the impotence and the age of the patient : the most favorable cases are those due to gonorrhoea and in young or middle-aged men ; these usually recover completely in a few months. In cases of impotence due to sexual excess the prognosis is less favorable. Treatment must usually be continued for several months. Sterility. In the majority of unfruitful marriages the cause of sterility is located in the female ; in a minority — perhaps 10 per cent. — in the male. Failure to fertilize the female may be due either to inability to eject the seminal fluid into the vac/ina (impotence) or to the absence of motile spermatozoa from that fluid (sterility proper} : the latter condition may coexist with perfect power to copulate. In some cases no spermatozoa whatever are found in the semen — a condition known as azoospermia, and due either to lack of secreting cells in the testicles or to obstruction in the seminal canals. The fibroid or eunuchoid testicle usually produces no perfect spermatozoa, and testicles retained in the abdomen or groin are apt to be sterile. Obstructions to the passage of spermatozoa may be due to malformations or to inflammatory exudates in epididymis or ejaculatory duct (from gonorrhoea) or urethra (strictui'e). The treatment of sterility is determined by the cause : if examina- tion of the freshly-passed semen (received in a condom) shows no sper- matozoa, treatment is useless unless a chronic double epididymis exist, in which case persistent massage of the indurated tissues with mercurial ointment may be made. If spermatozoa be present, but motionless, the 1022 SPECIAL OR REGIONAL SURGERY. usual treatment for chronic inflammation of prostate and vesicles should be instituted. Involuntary Seminal Discharges. These occur in two ways — as noeturnal emissions, caused by contrac- tions of the genital muscles, and as sper^matorrhoea due to the muscular contractions incident to defecation and micturition. Seminal emissions with the nocturnal orgasm, occurring during sleep and preceded by an erotic dream, are experienced by healthy, continent men at intervals of ten to thirty days : when not followed by languor and fatigue, they may be considered compatible with health. Emissions occurring at short intervals, and followed by lassitude and sacral pain, usually indicate abnormal excitement of the genital tract. They are common in boys and young men who have practised mastur- bation for a long time ; also in those who indulge in sexual excitement without intercourse ; and they often result from the extension of a gon- orrhoeal inflammation to the prostate and seminal vesicles. Frequent emissions cause great anxiety and despondency in youths who have practised masturbation and have been led to believe that nocturnal emissions inevitably cause early loss of virility. Treatment. — The patient should be assured that involuntary emis- sions do not indicate destruction of the genital organs, and that the majority of boys have at some time practised masturbation. He should be instructed to avoid dalliance and ungratified sexual excitement. Con- stipation and alcohol must be carefully avoided. Monobromide of camphor, two grains nighl and morning, will usually diminish the excitability of the genital centre in the cord, and thereby lengthen the inter- vals between nocturnal emissions. Local measures which reduce the congestion of the prostate and seminal vesicles, already mentioned, should be used — large, cold sounds, milking of the parts, deep injections of hydrastin, the hot and cold douche, etc. Spermatorrhoea is the term designating the involuntary escape of seminal fluid, without orgasm or even erotic thoughts : it occurs almost always at the close of defecation or micturition. In the strict sense, which implies that the escaping fluid contains spermatozoa, this is a relatively rare condition, except as the result of straining at stool when the seminal vesicles are full, and this may happen to the healthiest man. The escape from the meatus of a few drops of milky fluid during defecation is, however, common : this fluid is usually ■prostatic secretion containing no spermatozoa, and the condition should be called prostator- rhoea rather than spermatorrhoea. Whether it contain spermatozoa or not, the habitual appearance of this fluid indicates a catarrhal state of the genital organs, which should be treated by the measures prescribed for chronic inflammation of the prostate and vesicles. Pain during ejaculation and an admixture of blood with the semen are sometimes observed as the result of chronic inflammation of the prostate and vesicles. CHAPTER XLIX. CHANCROID OR VENEREAL ULCER. By Roswell Pabk, M. D. Since the day of John Hunter and his pupils, who confused the three totally different and so-called venereal diseases, pathologists have drawn a sharp and distinct line between chancre, which is simply the initial sore of syphilis (vide p. 149 ), and chancroid or venereal ulcer, which is a distinctly local lesion, often destructive, but never followed by con- stitutional disease, save of septicemic or pysemic type. It is found usually upon the genitals, most commonly about the foreskin, glans, and vulva, but may be met with anywhere upon the body where infection may have occurred. It is distinctly auto-inoculable, in which respect it differs from chancre. Although no distinct micro-organism has yet been identified as its active cause, there is good reason to think that there is a specific virus of some kind which causes it. Its course is characterized by local inflammation and tissue-destruction, without changes in the vessel-walls or surrounding induration. Chancroid begins, even in twenty-four hours, as a red point or papule, which is quickly converted into a pustule, and then an ulcer. The borders of this ulcer enlarge, its depth increases, until after a few days it forms a more or less deep, often undermined excavation, irregular in contour, discharging grayish purulent material. In this respect it differs also from chancre, whose natural discharge is more like serum. In other words, chancroid is essentially destructive, chancre constructive, since the latter forms a new growth which ordinarily has little or no discharge. When the necrosis of chancroid becomes exten- sive and tends to spread rapidly, the ulcer is spoken of as phagedenic. This tendency to rapid local gangrene is the combined result, probably, of virulence of virus and lowered local or constitutional tissue- resistance. It is consequently most often seen in alcoholics and prostitutes. In rare instances a surface as large as. the hand may thus be rapidly destroyed, every particle of material thus sloughed being extremely infectious. In chancroids of the mild variety the discharge may dry upon their surfaces and scabs or crusts result, beneath which, when detached, the characteristic ulcer is present. Under proper treatment this foul ulcer is converted into an ordinary granulating surface, which heals by cicatrization, as described on p. 76. Chancroidal Bubo. — Infection — by propagation along the lymphat- ics—of the inguinal nodes is very common, and, since the infection is almost always a mixed one, suppuration is quite frequent. 1023 1024 SPECIAL OR REGIONAL SURGERY. It is necessary to emphasize that the pus of a suppurating chancroidal bubo is often as infectious as the discharge from the original sore; hence it is wise to exercise great caution. Moreover, the edges of the local incision should be promptly cauterized, that they, too, may not become linear chancroids. Phagedena shows itself here as well as about the genitals proper, and differs only in that it makes the case more serious of its kind. Chancroidal bubo may, however, subside without abscess-formation, phagocytic activity being in such event most lively and most kindly. The signs of suppuration are those incident to pus- formation auywhere near the surface. When pus is present its early evacuation is called for. Diagnosis. — Chancroid is most likely to be confounded with chancre and herpes preputialis. Chancroid has no period of incubation. Destruction commences promptly after infection, so that ordinarily within twenty-four hours macroscopic evidence thereof may be observed, and within two or three days the sore has attained distinct size and shape. Chancroid. Local ulcer. A distinctly venereal in- fection. No incubation ; lesion noticed within few Commences as, and re- mains, an ulcer. Usually multiple. Secretion purulent and abundant. May occur again and again. Auto-inoculable. Phagedena frequent. Buboes in about 65 per cent, of cases. Buboes usually suppu- rate. Chancre. First local sign of a con- stitutional disease. Usually a venereal infec- tion. Incubation from ten to seventy days before first lymphatic induration. Commences as a papule, or occasionally an ero- sion. This may ulce- rate later. Usually single. Secretion slight and se- rous or bloody. As a rule, only occurs once in same patient. Not auto-inoculable. Phagedenic action very rare. Bubonic enlargement nearly always. Buboes, as a rule, do not suppurate. Herpes. Local neurosis. May be non - venereal, from friction, irrita- tion, uncleanliness, etc. No incubation. Commences as a crop of vesicles. Multiple and occurring in crops or series. Little or no secretion. Patients who once have it are frequently sub- ject to it. Not inoculable. Never. Lymphatics rarely in- volved. Prognosis. — Except in the most debilitated and dissipated, in whom phagedena may prove fatal, recovery always occurs, but often at the expense of considerable destruction of tissue and disfiguring scars. Treatment. — In mild cases — i. e. those showing but little destruc- tive tendency — absolute cleanliness and the use of hydrogen peroxide, followed by local use of such antiseptics as iodoform, aristol, loretin, etc., or even of calomel, will usually prove sufficient. If the ulcer manifest any tendency to spread, it should be cleansed, cocainized, and then cauterized with nitric acid or the actual cautery, after which it should be treated kindly to encourage granulation. This holds good still more in phagedenic cases, which may call for general anaesthesia, with the use of scissors and sharp spoon, followed by cauterization of every particle of raw or diseased surface. CHANCROID OR VENEREAL ULCER. 1025 Widespread phagedena is much more rare now than formerly. Cases which are extensive do best when submitted to continuous immersion of the hips in a sitz-bath as hot as can be tolerated. All aggravated cases call for invigorating and tonic measures, laxatives, improved nutrition, and sometimes for stimulants. Suppurating buboes should be incised, often curetted, and thoroughly swabbed out with pure carbolic acid, then packed lightly with loretin gauze and allowed to close by granulation. Virulent cases will be accom- panied by sloughing of so much tissue that it is best to remove all sloughs with scissors to save time. Here even stronger caustics will be called for. Phimosis often complicates chancroid, and will necessitate circumcision or incision along the dorsum of the prepuce, with such attention to the parts thus exposed as their condition may require. Mixed chancre, or the combination of the two lesions, has been treated of on p. 151, to which the reader is referred. Extra-genital chancroid may occur upon any portion of the body, but is more rare than extra-genital chancre. It is characterized by the same peculiarities as pertain to the venereal sores already described. 65 CHAPTER L. SUEGICAL DISEASES AND INJURIES OF THE FEMALE REPRODUCTIVE ORGANS. By James H. Etheridge, M. D. The Vulva. Inflammatory processes about the vulva are common, and are due to widely varying causes — gonococci, pus-cocci, irritants from the urine, especially sugar, oxyuris, oidium albicans, and other parasites. The symptoms vary in intensity with the severity of the process. Local pain, sometimes some of the other constitutional disturbances which often accompany local infective processes, discharge, often puru- lent or fetid, inguinal adenitis, are usually present. There may be added the symptoms of vaginitis, endometritis, salpingitis, or even pel- vic peritonitis, which in some cases, especially those due to gonorrhoea, occur by extension. Dysuria may appear, due to the extension to the urethral mucous membrane. In the more chronic cases, especially those due to diabetes, the process is essentially an eczema, and its symptoms are such as occur with eczema elsewhere. (Edema of the vulva occurs sometimes in the course of pregnancy as the result of local circulatory disturbances, and frequently in the course of anasarca from whatever cause. Because of the looseness of the tissue the swelling is often extreme. Treatment must be directed to the cause. Locally, multiple incisions may be made if gangrene of the parts threatens or if the swell- ing be so great as to hinder urination. Very great care is necessary to avoid infection, which is favored both by the local and general condi- tion. The glands of Bartholin, about the size of a bean, situated deeply on the inner side of the labia majora, with ducts opening about the middle of the sides of the vulva, are frequently the seat of inflammatory pro- cess, oftenest gonorrhoea!. It is in these glands that the gonococci fre- quently lodge and lie latent even for a long time. When the infection is severe abscesses are liable to develop in the glands. They cause severe local pain, swelling of the labia and neighboring parts, painful defecation and urination, more or less severe fever, and constitutional disturbances. Fluctuation appears later, first on the inner side of the labium. If untreated, extensive necrosis is liable to result, and severe consequences following on healing, because of the cicatricial contractions. The dangers of septicaemia and pyaemia are present here as with other abscesses (Fig. 438).- 1026 THE FEMALE REPRODUCTIVE ORGANS. 1027 Treatment consists of free incision and antiseptic irrigation, fol- lowed by hot, wet boric- or carbolic-acid dressings. Cysts of the glands of Bartholin result from inflammatory occlu- sion of the excretory ducts. They may be singular or multilocular, vary in size from a nut to an egg, smooth, ovoid, with viscous contents, color- less unless mixed with blood. They cause few symptoms other than dis- comfort while walking or during copulation, unless the cysts suppurate, Fig. 438. Abscess of gland of Bartholin. as they not infrequently do, when the symptoms of an abscess appear. Hernia into the labium must not be mistaken for a cyst. The best treatment is complete removal of the cyst by dissection. Pozzi first removes the contents of the cyst through a trocar, and after irrigation fills the cavity with paraffin of a low melting-point. After hardening the paraffin by cold he dissects out the sac. A variety of tumors occur about the vulva. Varicose veins com- plicate pregnancy rather frequently, and may on rupture cause serious, even fatal, hemorrhage. Subcutaneous rupture of such a varix may occur, and the resulting haematoma be large enough to be an obstacle to delivery. The varicose veins should be treated by compression combined with an abdominal supporter. If an hematoma develop, it should be left alone if small, but if large, because of the great danger of its becoming infected, it should be incised and the bleeding vessel found and tied if possible. If this cannot be clone, the hemorrhage should be controlled by a tampon of iodoform gauze. The most careful asepsis is necessary. Condylomata due to gonorrhcea are common. They are cauliflower- like excrescences on the skin and mucous membrane, pale red or wine 1028 SPECIAL OR REGIONAL SURGERY. color, and often very large. There is an abundant foul discharge, often hemorrhagic (Fig. 439). Pain may be severe. Treatment consists of removal, under cocaine, with the scissors, followed by cauterization of the base. After-treatment is frequent hot antiseptic sitz-baths. Fig. 439. ' ■ 4^m i- ■■■ 1 -■ , Jl Condylomata of the vulva. The Perineum. Laceration of the perineum occurs most frequently during labor. Sometimes it is due to the removal per vagi nam, either by operation or the process of nature, of large uterine tumors, especially submucous myo-fibromata. Rarely the laceration is due to direct trauma. Lacera- tion during parturition is favored by any condition which renders the peri- neum less elastic. These are particularly advanced age — i. e. past thirty years at the time of the first delivery — and chronic vaginal and peri- vaginal inflammation, most commonly gonorrhceal or syphilitic. Lace- ration is favored also by excessive development of the foetal head, its descent in an abnormal position, or its too rapid descent. The symptoms do not usually appear until some time has elapsed, and their severity is not always in direct proportion to the extent of the laceration. A laceration in one woman may cause no especial disturb- THE FEMALE REPRODUCTIVE ORGANS. 1029 ance, while in another a tear of the same size or smaller can cause unen- durable suffering. With the descent of the vagina and uterus there may- be a sensation of gaping of the vulva, the feeling as if the pelvic con- tents were falling out. Later, when the prolapsed parts protrude through the vulva, there is acute pain from the inflammation of mucous mem- brane caused by trauma of some sort. Incontinence of urine or incom- plete evacuation of the bladder lead in time to cystitis. Vesical and rectal tenesmus are common. Although copulation is not obstructed, ste- rility not infrequently results. When the laceration is complete incon- tinence of gas and liquid faeces is added. In addition to these local symptoms there is a great variety of reflex disturbances and general impairment of health. On direct examination the vulvar orifice appears lengthened poste- riorly. The site of the laceration is marked by a glistening white scar, which by its contraction has caused a puckering of the bordering parts. Varying with the case there may be cystocele, rectocele, or prolapse of the uterus. In complete cases the vagina and rectum are no longer separated, and at the lower end of the remains of the recto-vaginal sep- tum one often sees the hypertrophied rectal mucous membrane projecting downward like a polyp. The posterior column of the vagina may be isolated by the laceration passing to either side of it. When a fresh laceration is left to itself, cicatricial bands, irregularly connecting the borders of the tear, are formed. The edges are drawn upward by the levator ani, and the ends of the divided sphincter ani are often marked by slight depressions on either side. All practitioners are now agreed that in all cases, except where the laceration is very superficial, the tear should be sutured at once. Although cases of spontaneous cure occur — and some authors claim that this may happen even in cases of complete laceration — the chances of recovery are too small and the possible results of delay are too serious to warrant leaving a cure to nature, especially as the primary operation adds no danger at the puerperal period. These lacerations should be treated by exactly the same methods which are used in the treatment of lacerated wounds of other parts of the body. Corresponding parts should be united by sutures which are passed deeply enough to secure union of the deeper parts and in sufficient numbers to secure accurate approximation. This procedure is often difficult because of the swollen, oedematous condition of the parts, the abundant hemorrhage, and the exhausted and excited condition of the patient. The less extensive lacerations will require skin sutures only. When more extensive a line of sutures must be carried up to the vagina, and in complete cases rectal sutures are necessary. It must never be for- gotten that the purpose of the operation is the union of the deeper and muscular parts rather than of the skin and mucous membrane. The suture material varies according to the individual preferences of the operator, but probably silkworm gut is more generally used than any other material, and it always proves most satisfactory. The after-treatment consists in the careful protection of the wound surface from urine by the use of the catheter. After a few days voluntary urination may be allowed, and the parts afterward carefully washed with antiseptic solution. The vulva and perineum should be kept covered with moist antiseptic dressing. The bowels should be kept free by laxatives when necessary. The patient should remain in 1030 SPECIAL OR REGIONAL SURGERY. bed for at least two weeks, and throughout the entire time the thighs should be tied together. A large number of operations have been devised for the late treat- ment of lacerations of the perineum, but the purpose of all is the same and the principles underlying them are similar. Although the operations for the complete and the incomplete lacera- tions are essentially the same, it is customary and convenient to describe them separately. Operations for Incomplete Lacerations. Before the operation the patient should be given mild laxatives for several days until the bowels are free from all hard faeces. At the same time care must be taken to avoid hypercatharsis. The vagina should be douched daily for several days. The patient, after being anaesthetized, should be placed in the lithot- omy position before a window or strong light. After the usual anti- septic preparation of the parts, two triangular areas are denuded by Fig. 440. W /v. "i Lacerated perineum : surfaces denuded and stitches in position (Thomas and Munde). the scalpel or scissors, the surface to be denuded being held tense by for- ceps or threads. The base line of the triangles lies in the median line and extends from the cutaneous margin to the highest point of the bulg- ing of the rectum. The third angle of the triangle is on the inner side of the great labium, about midway between the anus and the meatus. After these two triangles are denuded of the cicatricial tissue which covers them, the hemorrhage is checked by ligatures if necessary, though it is rarely that they are demanded. The sutures are then passed from THE FEMALE REPRODUCTIVE ORGANS. 1031 points on one side of the median line to the corresponding points on the other side. The sutures must be passed deeply, and care must be taken to avoid passing the needles into the rectum (Fig. 44u,. The sutures near the rectum are entirely buried, while those uniting the antero-lateral parts of the triangle are exposed in the median line of the vagina. The sutures should be passed with a straight or curved round needle, entered about a quarter of an inch from the border of the denuded surface, and the sutures should be about a third of an inch distant from each other. After the sutures are tied the parts are cleansed and dusted with an antiseptic powder. The after-treatment is the same as with the primary operations. Emmet's Operation. — The area lying between the posterior commis- sure, the lowest caruncle of the hymen, and the crest of the rectocele is denuded on ei ther side. The anterior and the lateral borders Fig. 442. of the denuded area on each side are united by sutures which are passed deeply. The remaining Fig. 441. Emmet's operation for lacerated perineum Emmet'B new operation for lacerated peri- neum. portions of the lateral borders are united to each other. The resulting line of union is Y-shaped, the stem being in the median line, and an arm passing up each side into the vagina (Figs. 441 and 442). 1032 SPECIAL OR REGIONAL SURGERY. Tait's (or the Flap-splitting) Operation. — The posterior wall of the vagina is stretched forward by a rectal tampon and by the fingers in the rectum. The labia are drawn tense by the assistants and sharp-pointed scissors are inserted in the median line, midway between the posterior commissure and the anus. The recto-vaginal septum is split to the depth of one-half or three-quarters of an inch, and for the same dis- tance on either side of the median line. From the ends of this incision another, about one-half an inch deep, is carried up on each side to the anterior border of the cicatrix. The anterior flap is drawn forward by Fig. 444. Fig. 443. '1 Flap-splitting operation for incomplete Flap-splitting operation for lacerated perineum : appear- laceration of the perineum. ance of wound and introduction of sutures for both varieties (Thomas and Mundfi). tenacula, and the resulting rectangular surface is closed by sutures passed from one side to corresponding points on the other (Figs. 443 and 444). Doleris' operation for incomplete laceration of the perineum varies a little from the flap-splitting operations so commonly in vogue in one important particular. The upper stitches traverse the under surface of the flap, thus drawing the latter completely into the wound and making it constitute a portion of the body of the perineum. Fig. 445 represents the line of initial incision made with the knife or scissors. Fig. 446 shows the dissection of the mucous-membrane surface from the posterior vaginal wall by means of the fingers. Fig. 447 indicates the line of introduction of the sutures, a portion of which are carried through the flap. Fig. 448 presents the lower half of the wound closed. THE FEMALE REPRODUCTIVE ORGANS. 1033 Fig. 449 shows the resection of the redundant vaginal mucous membrane. Fig. 450 represents the completed operation. Fig. 446. Fig. 445. Doleris' perineorrhaphy, a. Doleris' perineorrhaphy, 5. Duke's Method of Perineorrhaphy. — The most recent operation for closing an incomplete laceration of the perineum is that offered by Fig. 447. 4lMth Doleris' perineorrhaphy, c Alexander Duke of Dublin, who sent the following description and illustration to the writer in 1892 : " I wish," he said, " to bring before the notice of my gynecological brethren an operation I have designed for the restoration of a lacerated 1034 SPECIAL OR REGIONAL SURGERY. perineum, easy of performance, and which will, when properly executed, form a good perineal floor and, I might almost say, practically a perineal body. The patient, having been prepared by the usual pre- Doleris' perineorrhaphy, d. liminary steps required for the old operation, when under the influence of an anaesthetic is placed in the lithotomy position ; the left index finger being introduced almost its entire length into the rectum, a long straight double-edged bistoury is made to pierce the tissues in front of the anus Pig. 449. Fig. 450. Doleris' perineorrhaphy, e. Doleris' perineorrhaphy,/. at right angles to the vulva, and, guided by the finger in the rectum, is made to penetrate the septum for two and a half inches upward, the incision being enlarged laterally to two inches as the knife is withdrawn. THE FEMALE REPRODUCTIVE ORGANS. 1035 Fig. 451. "The patient is then turned on her side,. and on the points of the incision being pressed together a lozenge-shaped opening will be seen ; and when all sutures required have been introduced and are properly adjusted and approximated the two cut surfaces are brought into direct apposition. The sutures are introduced by a strong cycle-shaped needle, with eye near the point, mounted on a handle, strong silver wire being the suture preferred. " The needle is introduced at the edge of the incision, and, guided by a finger in the rectum, is made to travel under the cut surface to its full depth above, describing the arc of a circle ; and on the point of the needle appearing directly opposite it is threaded with suture and drawn through. On the ends of this being drawn together with the fingers a good idea can be formed of how many additional stitches may be required. When all considered necessary have been in- serted and approximated, being first passed through a perforation in leaden plate (see illus- tration), a finger of each hand passed into the rectum and vagina will at once recognize the gain in thickness of septum, the external tissue being pushed fully an inch forward from the anus and forming a thick and solid perineal body. " The incision being a deep one, on union taking place between the raw surfaces a con- siderable amount of support must be afforded in cases where a pessary is required or where there is much tendency to prolapse of uterus or vaginal walls. My experience of the operation has satisfied me with the results, and, there being no Loss of tissue whatever, should the ope- ration fail it cannot add any difficulty to a sub- sequent one. " Even should the perineum be lacerated to the verge of the anus, what I describe can be done. I find that leaving the sutures for ten days is generally sufficient ; but if I am in doubt as to the union being strong, I cut the wire, but leave it in situ for a day or two longer, thus affording some support and relieving the strain on the edges of the suture-holes ; and I also support the parts by long strips of adhesive plaster carried from hip to hip over new peri- neum. The wire should be stout and not too tightly twisted. " The advantages of my plan of operation Duke's opejatfon^ showing vari- are briefly these: "1. The simplest of performances as yet proposed; no danger of hemorrhage, the surfaces when dry being brought together. " 2. No danger of sepsis, as the incision is not open for the admis- sion of any discharge from either vagina or rectum during the healing process. 1036 SPECIAL OR REGIONAL SURGERY. " 3. ~No loss of tissue, and consequently no harm done should the operation fail " (Fig. 451). The outlines of the denudations made in the operations suggested by Bischoff, Hegar, and Fritsch are presented in Fig. 452. The under- lying principle of each is apparent. Operations for Complete Laceration of the Perineum. Operations for complete lacerations are more difficult on account of the often considerable deformity resulting from the contraction of the scar-tissue, and because of the ready hemorrhage from the rectal mucous Fig. 452. Scheme of the outline of operations proposed by Emmet, Simon, Bischoff, Hegar, and Fritsch (Kelly). membrane. Moreover, unless the preparation of the patient has been most careful, an escape of faeces is apt to occur during the operation. Emmet's Operation. — The area of denudation is similar to Simon's. The peculiarity of the operation is the method of passing the sutures. Using a handled needle, the first suture is entered about one-third of an inch external and posterior to the posterior margin of the denudation, and carried through the lower part of the remains of the recto-vaginai septum to a point exactly opposite. The purpose of this suture is to bring together the ends of the divided sphincter ani muscle. When tied it acts as a purse-string suture, and by thus closing the defect in the septum converts the complete into an incomplete laceration. The other sutures are passed as in the operation for incomplete laceration. Tait's operation for complete laceration differs but little from that for the incomplete. The recto-vaginal septum is split to the depth of about half an inch. At each end of this incision others are made for- THE FEMALE REPRODUCTIVE ORGANS. 1037 ward to the anterior border of the cicatrix, and backward just beyond the ends of the divided sphincter ani muscle. These three incisions Fig. 453. Tait's operation for complete laceration of the perineum. resemble somewhat a capital H. The vaginal flap is turned forward by tenacula, the rectal flap backward, exposing in this way a quadrangular bleeding surface. Sutures are passed from side to side ; the one nearest the rectum is passed first, taking care to pass it deeply enough to include the ends of the sphincter muscle (Figs. 453-456). The after-treatment of the patient is of great importance. The field of the operation should be carefully cleansed, dried thoroughly, dusted with boric acid, and covered with a dry dressing. The wound must be protected from the urine by catheterization. Should the patient pass urine voluntarily, it should be passed under a stream of warm sterilized water. The bowels must be kept con- fined for three or four days, and then moved by a gentle laxative, aided, if need be, by a warm enema, which must be given with care by the physician or nurse, who thoroughly understands the reasons for and necessity of great care. A movement of the bowels once in three days is desirable, and if they tend to move more fre- quently a little opium should be given. If the patient is troubled with gas in the intestines, a soft rectal tube may be passed carefully several times daily. The diet should be nourishing, and for the first week, at least, fluid. Another method of managing the bowels is to give a daily saline laxative. This line of treatment is 1038 SPECIAL OR REGIONAL SURGERY. especially commendable, for obvious reasons, in cases of complete laceration of the perineum. All foods which contain much waste or which readily ferment must be forbidden. The use of an intestinal antiseptic, such as salol, is to be recommended. If the temperature rise, the wound has probably become infected. This can easily happen, because of the difficulty of accurate approximation and the exposure of the wound to the bacteria-loaded faeces. The edges of the wound become red, cedematous, painful, and tender, and, unless the infection can be controlled, union to a greater or less extent will fail. Sometimes the trouble will end on the removal of one or two of the sutures. If union fail along the cutaneous surface, no serious Fig. 454. Tait's operation for complete laceration of the perineum. results follow, but if the failure is in the recto-vaginal septum, a more or less exten- sive fistula results and a secondary operation is necessary to close it. Simple cauterization is sufficient if the fistula is small, but if large the edges must be freshened and closed by sutures. A secondary operation should not be undertaken sooner than four weeks after the first one. The sutures may be removed on the tenth or twelfth day. The patient should not begin to walk sooner than eight or ten weeks after operation, and copulation must be forbidden for at least six months. The Uterus. Prolapse of the uterus and vagina is usually the result of injuries to the pelvic floor occurring during labor, laceration of the perineum, THE FEMALE REPRODUCTIVE ORGANS. 1039 and stripping of the vagina from its relation to the surrounding parts ; but in many cases it seems that this factor does not occur for years after Fig. 455. Tait's operation for complete laceration of the perineum. Fig. 456. Flap-splitting operation for complete laceration of the perineum. delivery. Such accessory factors are— too early return to work after delivery, severe manual labor, malnutrition from whatever cause, and 1040 SPECIAL OR REGIONAL SURGERY. senility. Rarely cases of prolapse occur in young virgins after some violent effort. Some congenital weakness of the supports of the vagina and uterus is supposed to exist in these cases, and this supposition seems to be more probable because the families of such patients often show a large number of hernias. Occasionally senility causes prolapse in women who have never borne children. Retroflexion, retroversion, and hyper- trophy of the uterus predispose to prolapse. The symptoms vary in kind and intensity. The patients complain of bearing-down sensations and of the feeling as if the viscera were fall- ing out. They easily tire on walking, and their gait is often peculiar. The symptoms of endometritis are often present. Function of the bladder and rectum is altered. If the cystocele is marked, cystitis from incom- plete evacuation of the bladder is frequent. Pain from erosions and inflammation of the prolapsed mucous membrane may be severe. The result of local examination varies with the case. In the lesser degrees the vaginal mucous membrane appears only when the patient bears down, the anterior wall usually appearing first. In the complete cases the hypertrophied cervix lies behind the prolapsed anterior vaginal wall. The mucous membrane is variously altered. There may be Fig. 457. Alexander's operation (a) (after Cleveland). inflammation or ulceration, or the character of the mucous membrane can gradually change until it resembles skin. Treatment consists in general tonic with rest and massage. These, combined with a proper pessary or tampon, with astringent douches, will be sufficient in many cases. The operations for cure for this condition are of three sorts — those which improve the supports of the uterus lying below it, those which shorten the uterine ligaments or add other supports to them, and those which remove the uterus. The first class of operations includes perineor- rhaphy and colporrhaphy , many variations of which have been described. The perineorrhaphy is described in the section treating of lacerations of THE FEMALE REPRODUCTIVE ORGANS. 1041 the perineum. The eolporrhaphy has for its purpose the narrowing of the vaginal canal. It may be made separately or in connection with a perineorrhaphy. The different operations vary in details only. An area is denuded on the posterior wall varying in shape from tri- angular to oval, and in size with the degree of the prolapse. Sym- metrical points on each side of the median line are sutured. Care must be taken to secure accurate approximation, using one or more layers of sutures as may be necessary. Martin denudes two long areas on each side of the median line, and closes each denudation by a continuous suture in layers. Neugebauer denudes two areas similar in shape and size, one on the anterior and one on the posterior wall, and unites them to each other, making a band across the vagina. Operations of the second class include the Alexander operation — i. e. shortening the round ligaments and ventro-fixation. These operations are rarely sufficient in themselves, but do well in combination with plastic operations on the vagina and perineum. Alexander's operation is briefly as follows : Incisions are made on either side, exposing the external inguinal ring. The round ligament is next isolated. After replacing the uterus by the sound or by bimanual manipulation the ligaments are drawn outward about three inches. A suture is passed through the upper end of the external pil- Fig. 458. Alexander's operation (6) (after Cleveland). lar of the ring, then through the ligament, and then through the inter- nal pillar and tied. The lower portion of the ligament is treated by Clement Cleveland of New York in a way original with him. It offers the best results known to the writer, and he thus describes it. "At this point I practise a modification of my own, which saves an inch or more of the ligament and, as it seems to me, secures a better prospect of success. A ligature-carrier (Fig. 458), made sharp and delicate for the purpose, is passed at the lower end of the incision under the fascia and out on the mons, at a point an inch or more below the pubic spine (Fig. 457). The carrier is then opened a little in order to make the canal sufficiently large for the passage of the ligament 66 1042 SPECIAL OR REGIONAL SURGERY. and to stretch the fascia slightly. A loop of silkworm gut or other material is then placed in the grasp of the carrier, and the instrument is drawn back with this loop into the incision (Fig. 458). A loop of the end of the ligament is then placed in the loop of silkworm gut (Fig. 458), and the latter drawn back with the ligature through the small opening in the mons (Fig. 459). While an assistant holds the Alexander's operation (c) (after Cleveland). ends of the ligament quite taut the sutures in the incision are then tied, and, lastly, the suture is passed through the integument and ligament at the point of exit of the latter on the mons, then tied, and the excess of ligament is cut away (Fig. 460). The same process is repeated on the other side. If the operation have Fig. 460. Alexander's operation (d) (after Cleveland). taken a good deal of time or there have been rough handling of the tissues and liga- ment, a few strands of silkworm gut are placed under the ligaments in the canal as drainage. A dressing of gauze wet with a solution of 1 : 3000 bichloride is placed over the wounds, with pads of sterilized gauze and cotton above it, all being secured by a double spica bandage firmly applied. The patient is kept in bed for three weeks, Liquid food is given for the first few days, and after that, if no unpleasant symptoms have appeared, as generous a diet as is allowable to a patient kept in bed. The bowels are moved every other day." Ventro-fixation consists in the median incision of the abdominal wall close to the pubes. The uterus is freed from adhesions and PLATE XXXI I. Granular Erosion of Cervix. Cystic Degeneration after Laceration. Deep Stellate Laceration. Stellate Laceration with Eetropium and Cystic Disease. Creseentic Laceration with Erosion of one Lip. Deep Destructive Laceration up to Inner Os. LACERATIONS OF CERVIX. THE FEMALE REPRODUCTIVE ORGANS. 1043 brought forward and upward. Sutures are then passed, either through the entire thickness of the abdominal wall, and through the serous and outer muscular coat of the uterus, or they may be passed in such a way that they are buried after closure of the skin incision. Before tying the sutures the parts of the uterine and parietal peritoneum which will come in contact should be scraped, in order to hasten the formation of adhesions. After leaving her bed the patient should wear a Hodge pessary for some time. Another method of surgical treatment, found satisfactory in most cases, is a combination of amputation of the cervix and an extensive anterior colporrhaphy. These operations are usually followed by a speedy uterine involution with its diminished weight, and by a substitution of anteversion of the uterus for retrover- sion. Laceration of the Cervix. Laceration of the cervix is almost always due to the passage through the cervix of a fully-developed foetus, though it has been known to occur with abortions at the third or fourth month. According to statistics by Mund6, it occurs once in about every four deliveries, and usually with the first child, but in more than half of the cases the laceration never causes any symptoms. The tear is usually bilateral, often unilateral, a-nd then more frequently left than right. Sometimes it is multiple or stellate. (Plate XXXII.) The symptoms vary greatly in intensity, and may be entirely lacking even with deep lacerations. The local symptoms are dull pain in the back, bearing-down sensation, pain in the ovarian regions, reflex pains in the thighs and back, leucorrhcea, menorrhagia and the consequences, sterility and habitual miscarriages. The general symptoms increase the longer the laceration exists, and take the form of a simple ansemia and various neurotic disturbances. The relation of cause and effect between the laceration of the cervix and the general symptoms described by Emmet is by no means clear. The diagnosis of laceration of the cervix is made by digital exam- ination of the cervix and by inspection through the speculum. Occa- sionally there will be a question as to whether a given case is simply an excessive development of the glands and papillse of the mucous membrane or an epithelioma. The question can be settled only by the microscope. Operation. — The patient, under anaesthesia — or without it if there is any contraindication, for this operation is not especially painful — is put in Sims' or the lithotomy position. The cervix is drawn downward by bullet forceps or by sutures passed through the lips. The lower lip is denuded first from its tip to the angle, taking care to remove all of the scar-tissue. A narrow strip of mucous membrane about a quarter of an inch wide must be left in the median line to form the lining mem- brane of the future cervical canal. The anterior lip is treated in the same way, taking care to make the denudation on the anterior and pos- terior lips exactly alike in shape and size. If the hemorrhage be trou- blesome, it may be checked by hot water or by a suture passed through the cervix above the angle of the tear. The sutures are passed through the entire thickness of both lips, the one nearest the angle being passed first. From two to four sutures on each side are usually required. 1044 SPECIAL OR REGIONAL SURGERY. After tying the suture a douche is given and the patient is put to bed, where she is kept for at least one week. If any discharge appear, an antiseptic douche should be given once or twice daily. The sutures are left in place two or three weeks. Myo-fibromata of the Uterus. The most common of the tumors of the uterus is the so-called fibroid, or, more properly, myo-fibroma. It consists of bundles of non-striated muscles arranged in various directions, together with a varying amount of fibrous tissue, which is arranged mostly about the larger vessels, but also between the muscle-bundles. The tumors are, in a way, circum- scribed hypertrophy of the uterine wall. The fibro-myomata developing from the body of the uterus are classi- fied according to their point of origin into three classes — the interstitial, developing in the thickness of the wall, 65 per cent. ; the submucous, 10 per cent. ; and the subserous, 25 per cent. The interstitial tumors, because they can receive vessels from all sides, grow more rapidly and to greater size than the other forms. Their connection with the sur- rounding parts is so loose that they can usually be shelled out of their capsule very easily. The surface is smooth or lobulated according as they develop from one or several centres. The submucous forms occur oftenest at the fundus, and project to a greater or less extent into the cavity of the uterus. They may be sessile or pedunculated. The latter may be entirely detached from the wall and be expelled spontaneously. They are usually small, but they may reach the size of a child's head. They are never lobulated, but their form may be much altered by pressure. The subserous forms are sessile or pedunculated. The length and thickness of the pedicle vary, and, like the pedicle of the submucous fibroid, may be divided and the tumor be detached from its point of origin. In exceptional cases, where there have been no adhesions formed previous to division of the pedicle, the tumor becomes a free body in the abdominal cavity. Usually, however, there are numer- ous adhesions, so that the tumor is attached to some other abdominal organ — a condition which may cause curious diagnostic difficulties. These adhesions are also important because of the complications which they may cause, such as inter- nal strangulation of the intestines, and because by increasing the blood-supply to the tumor they hasten its growth. Fibro-myomata are liable to a variety of secondary changes. Fatty degeneration, either localized or diffuse, is common, and can bring about a softening of the entire tumor into a puriform mass or lead to the formation of irregular cavities filled with a similar fluid. Calcification occurs most frequently in the subserous tumors of small size, though it may occur in tumors as large as an adult's head. The calci- fication may be diffuse, but it is usually in the form of irregular coral-like deposits, Sometimes only the peripheral parts are changed. Suppuration and gangrene occur, the latter especially in the polypoid form. QZdema is frequent, and affects espe- cially the connective tissue, converting it into a transparent, jelly-like mass. Important, but fortunately rare, is the change in the character of the tumor from benignant myo-fibroma to malignant, rapidly-growing sarcoma. The majority of the so-called fibro-cystomata of the uterus are the ordinary fibro-myomata altered by circulatory disturbances. Clear serous fluid can collect in interstices of the tissue or in lymph-vessels, forming even large cysts. These two forms may be distin- guished from each other by the fact that the distended lymph-vessels still show their endothelial lining. Very rarely cysts lined with cylindrical epithelium are formed in combination with fibroma. They are either detached portions of the glands of the mucous membrane of the uterus or are congenital epithelial dystopia?. Very little can be said in regard to the etiology of these tumors. THE FEMALE REPRODUCTIVE ORGANS. 1045 They are never formed before puberty. They are most common between thirty and forty years ; more frequent in negroes than in whites. Nullip- arous women are more subject to them than others. Chronic endo- metritis and menstrual disorders favor their development. The symptoms are more influenced by the position of the tumor than by its size and numbers. Even large tumors may develop from the fundus without causing any symptoms, while small tumors situated low down on the anterior or posterior wall of the body of the uterus or in the cervix, especially when they develop into the broad ligaments, may cause serious symptoms because of the pressure which they exert upon the bladder, rectum, and the large vessels and nerves of the pelvis. Leucorrhoea, menorrhagia, and dysrnenorrhoea are common. The uter- ine hemorrhages are often severe, and frequent enough to greatly debil- itate the patient, and may be so abundant as to cause death by exsan- guination. Pain is frequent and varies in location and intensity. There may be nothing more than a sensation of weight in the pelvis and bear- ing down, or it may amount to a severe sciatica. Uterine colic, expul- sion-pains similar to labor-pains, are common, when the tumor projects greatly into the uterine cavity. Disturbances in urination are common — dysuria, retention, and gradual dilatation of the bladder. In time cystitis develops, and later may lead to an ascending pyelo-nephritis. Pressure may be directly on the ureters leading to hydro-nephrosis on one or both sides. It is probable that many of the deaths which follow operations on uterine fibro-myomata are due to these secondary affections of the urinary tract. Pressure on the rectum causes rectal tenesmus, hemorrhoids, and constipation. The general health of the patient suffers from the loss of the fluids of the body by hemorrhage and the often profuse discharge ; also from the toxaemia resulting from absorption from the urinary and intestinal tracts and from the pain and mental depression. The diagnosis of fibro-myomata of the uterus must be made by the physical examination, by vaginal, abdominal, and bimanual palpation. The tumor, unless small or in a very fat woman, is readily palpated, and its connection with the uterus usually readily demonstrated. The uterine sound, which must be carefully passed on account of the danger •of its setting up a hemorrhage, shows that the uterine cavity is length- ened often to a very considerable degree. Differential diagnosis of myo-fibroma from pregnancy can usually be made by the common signs of pregnancy — amenorrhcea, the breast changes, etc. — but occasion- ally these signs fail to give a positive conclusion, and the patient must be watched for the positive signs of pregnancy. Differentiation from extra-uterine pregnancy is still more difficult and often impossible. In such a case the rule must be that if there are any reasonable grounds for suspecting extra-uterine pregnancy, lapa- rotomy must be done at once. Tumors due to pelvic cellulitis and hematocele are accompanied by signs of acute inflammation or by a history of such symptoms, and are usually readily distinguished from fibroma, but the differential diagnosis becomes impossible in "cases of fibroma in uteri which are adherent and the adhe- sions the seat of acute inflammatory processes. Examination under ether may clear up the diagnosis in such cases. Submucous fibroids are easily confused with incomplete abortions and endometritis. The history may aid in the cases. If not, microscopical examination of bits removed by the curette must decide. Prognosis as regards life is generally favorable, although the gen- 1046 SPECIAL OR REGIONAL SURGERY. eral health is often so impaired by the frequent loss of blood that slight ailments, such as bronchial or intestinal catarrh, may prove fatal. The danger of pyelo-nephritis must not be forgotten, and we must remember that cases of large abdominal tumor show signs of cardiac insufficiency due to fatty or interstitial changes in the myocardium. The tumor may become gangrenous along the course of its pedicle or it may suppurate. On the other hand, the tumors often atrophy on cessation of the uterine and ovarian functions. Palliative treatment is resorted to in the majority of cases, and especially in those where the symptoms are slight or the patient near the menopause. Many of the symptoms, such as pain, sciatica, consti- pation, vesical irritation, which result either from displacement of the uterus or its enlargement, are relieved by reposition of the uterus to its normal position and its permanent retention by the use of whatever pessary most completely fulfils the requirements. The hemorrhages are treated in various ways — by ergot, hydrastis canadensis, cannabis indica, gallic acid internally, and locally by styptics and tampons. If these means fail, the curette should be used. An intra-uterine electrode with the galvanic current is also used for this purpose. The curative treatment is medical, electrical, or surgical. Ergot given hypodermically or by mouth for many months cures infrequently the monolobular variety only. Of all the internal remedies none has proven as beneficial as thyroid extract, given in five grain doses two or three times daily, and watched lest it depress the heart. It is about the only drug worth temporizing with. Treatment by electrolysis requires currents of 80 to 250 milliamperes strength. A large electrode is applied to the abdomen, and the other pole is introduced into the uterine cavity or by puncture through the vagina or abdominal walls directly into the tumor. Each sitting lasts for from three to six minutes, and the sittings must be continued over several months. A certain number of cures are effected in this way. The surgical means used in the cure of fibroids vary greatly with the cases, but the operations may be divided into two classes — the vcu/inal 'and the abdominal. The majority of cases are treated by the former class. Fibroma of the cervix can usually be removed by simple incision of the capsule and enucleation with the finger or dissector. The hemorrhage is usually insignificant, but if severe can be controlled by pressure with a tampon or by the use of hot water. Operations for pedunculated fibroma of the body of the uterus must often be preceded by dilatation of the cervix in order to reach the tumor more easily. This may be done rapidly by Hegar's dilators, with or without bilateral division of the vaginal portion of the cervix with the scissors and of the fibres of the internal os with a bistoury. After dilatation of the cervix the removal of the tumor is usually easy. The tumor is first twisted a few turns about the long axis of the pedicle. After making certain, by examination through the abdominal walls, that the uterus has not been inverted, the pedicle is divided by scissors curved on the flat. The hemorrhage is usually slight, but if severe can be controlled by a tampon or by heat. The uterine cavity is douched with an anti- septic solution, and the cervix, if divided, is sutured as in operation? for lacerations of the cervix. The use of the chain and wire ecraseur has been largely abandoned, because the danger for which they were TEE FEMALE REPRODUCTIVE ORGANS. 1047 introduced — namely, hemorrhage — has been found to be minimal, and they brought with them dangers greater than the one they sought to avoid. It is quite impossible to perfectly control the amount of tissue included in the loop, and perforation of the uterus has happened several times, even in the hands of experienced operators. Submucous fibroid*, including the interstitial tumors which are close to the mucosa, are treated as follows : The cervix, if not already dilated, must be dilated as described above. The tumor is seized with volsellum forceps; the mucous membrane is incised freely along the line where it is reflected from the uterine wall on the tumor. The tumor is now separated by the fingers, scalpel, or scissors from its capsule, and, with or without previous fragmentation, removed. The after-treatment is the same as already described. The dangers of the operation are hemorrhage ; perforation of the uterine wall, which is not a very serious accident if the operation is done with proper asep- tic care ; inversion of the uterus — a favorable rather than an unpardon- able occurrence if it is recognized, as it facilitates the enucleation ; and, lastly, septicaemia, which is to be avoided by the ordinary rules of aseptic surgery. In some cases where the tumor is large the cap- sule is incised, and without effort at enucleation the tumor is re- moved in pieces by morcellation, controlling the hemorrhage by forceps. Vaginal hysterectomy is employed in cases where the tumor does not exceed the size of the fist, when the hemorrhage threatens to be rapidly fatal, and when serious compression symptoms develop. In all other cases, where the tumor cannot be removed by any of the opera- tions already described, the patient is put in the lithotomy position and the vagina douched and scrubbed with antiseptics. The cervix is drawn forward so as to put the posterior wall of the vagina on the stretch, and a transverse incision made down to the peritoneum. Sutures are then passed in such a way as to unite the peritoneum to the posterior wall of the vagina and, at the same time, compress any vessels lying in the cellular tissue. If the Douglas cul-de-sac has been obliterated by adhesions, a second row of sutures may be necessary. The index finger is now inserted into the wound and the broad liga- ment passed forward. A curved needle with a heavy suture is entered in the lateral fornix about one inch from the angle of the wound, and carried deeply enough to pass above the lower branch of the uterine artery, and then brought out about one and a half inches from the point of insertion. The suture is then firmly tied, and the same thing done on the other side. The anterior fornix is now opened, and lateral incisions are made connecting this with the posterior incision. The bladder is carefully dissected from the uterus up to the peritoneum. The uterus is now turned backward and ligatures are passed through the broad ligament and tied. Usually the ligament is tied in three sections. After ligatures are tied in both broad ligaments, the ligaments are divided between the body of the uterus and the line of ligatures and the tumor removed. The parts are now sponged and freed from blood. The wound in the peritoneum may be closed, but it is not necessary. A gauze drain is inserted and the patient put to bed. The patient should be catheterized for a few days. The bowels, after being confined 1048 SPECIAL OR REGIONAL SURGERY. for a few days, should be moved by a mild laxative aided by a warm enema. Vaginal irrigation must be forbidden for a week or ten days (Fig. 461). The details of the operation vary with different operators, but the method above described in brief is satisfactory. Some operators use forceps to prevent Fig. .461. Vaginal hysterectomy : forceps on left broad ligament. hemorrhage from the broad ligaments, leaving them in situ for forty-eight or seventy-two hours. The dangers of the operation are those common to all severe operations — shock, primary or secondary hemorrhage, and sepsis, plus the danger of injury to the ureters at the point where they lie close to the uterus. There is also some danger of opening the bladder. These dangers can be avoided by operating care- fully. Abdominal Myomectomy. — The following operations are done through the abdominal wall : After the customary antiseptic precau- tions the abdomen is opened in the median line and the tumor exposed. The capsule is freely incised and the tumor shelled out. The resulting cavity may be closed by deep sutures or, if thought necessary, can be drained into the vagina. The tumors suitable for this method of operat- ing are the non-pedunculated subserous ones and those which have developed into the broad ligament, Pedunculated tumors are removed after separating any adhesions, dividing them between ligatures if necessary, and then division of the pedicle after ligating it. Abdominal hysterectomy may be complete or may stop at supra- vaginal amputation of the cervix uteri. Each method has its advocates. Results seem to be equally satisfactory in both methods. In the former less detail of technique is necessary. After both operations atrophic changes follow in the vaginal walls, making it difficult sometimes to state which operation was performed. It will thus be seen that the alleged advantage of the incomplete over the complete operation — viz. that the stump of the remaining cervix serves as a keystone to the vaginal arch — is not a good argument. Increased chances of infection through the cervical canal THE FEMALE REPRODUCTIVE ORGANS. 1049 are imputed to the more complete operation by its opponents. It is found, however, that at times infection follows both operations. It is found also that both operations are performed at other times without any infection following. Hence, when infec- tion follows at all, it may fairly be attributed to some fault in operative technique. Dr. Eastman of Indianapolis advocated the best compromise between the two operations yet offered. He neither stops with the supravaginal amputation nor does he incise the vaginal vault. He enucleates the body of the remaining cervical stump from its investing membrane, and does not incise the vaginal tract at all. The abdomen being sufficiently opened to eventrate the tumor after severing adhesions requiring it, the first point to be settled is the method of securing the vascular supply to the tumor. The steps necessary to secure this end vary vastly. In some cases, where the broad ligaments are not split up by the growth projecting into them, the procedure is simplicity itself. In other cases, where masses project from the sides of the tumor into the broad ligaments, the difficulty of securing hsemostasis is rarely excelled in the whole range of surgery. The one point never to be lost sight of is the fact that the broad ligaments contain the ves- sels supplying the neoplasm. When the growth rides high and free in the abdomen and its pedicle is the cervix uteri, not increased in its dimensions, and the broad ligaments are comparatively flabby and relaxed, the simplest and speediest method of operating is to place a large snap-forceps at an angle of about forty-five degrees from the tumor, diagonally across the broad ligament down to the cervix, avoid- ing the ureter. The forceps will thus be made to pass from the upper part of the cervix upward and outward. It is better to place them thus than to place them parallel with, or transversely to, the axis of the tumor. To render the operation as nearly bloodless as possible it is necessary to adjust the forceps most carefully ; which means that they must be made to include the uterine artery. If the uterine artery be secured in the forceps, the ovarian artery will also be caught. It is necessary in adjust- ing the forceps to make the points of the jaws go clear down to the cer- vix. This is best done by making the tips of the jaws at first grasp the cervix a little, and then by a slight retraction of the handles let the jaws pass over the rounded contour of the cervix as they are closed. The bladder as well as the ureter must be avoided by the forceps. With both forceps adjusted the broad ligaments are cut from the tumor, with a knife or a heavy scissors, down to the junction of the cervix and for- ceps. By following down the cut closely with a folded towel, the out- flow of the residual blood from the tumor into the pelvis can be prevented, thus saving a certain amount of sponging. After both ligaments are severed the bladder is dissected from the cervix as speedily as possible. Then a flap of peritoneum is removed from the posterior surface of the tumor. The two dissections thus made, anteriorly and posteriorly, can have a crescentic or a straight border above as the operator desires. All that is necessary is to dissect off enough of the peritoneal membrane to supply an abundance of covering for the stump of the cervix. Then it will be found that naught but the cervix remains to be amputated. This being done, the uterus and the tumor are removed. The next step consists of dealing with the stump. Due caution against contaminating the peritoneum with the cervical secretions must be observed. After forcible dilatation of the canal with a large snap- 1050 SPECIAL OR REGIONAL SURGERY. forceps its entire surface should be rendered satisfactorily aseptic by some approved means. There seems to be none superior to the free use of the Paquelin cautery. After its use the canal should be traversed by a piece of aseptic gauze crowded well down into the vagina with a sound, leav- ing the upper end of it flush with the top of the amputated cervix. This serves perfectly as a means of promptly draining away all wound- secretion through the vagina. It can be removed at the end of two or three day?. Attention should now be paid to the hsemostasis. Along the border of the amputated broad ligament, just outside the jaws of the large snap- forceps, the arteries can be picked up and secured. Silk or catgut can be used on a needle. The arteries can thus be secured singly with the use of a minimum amount of ligature without going outside of the folds of the broad ligament. This is a method better than to gather up the entire end of the broad ligament into a large bunch, which necessitates a longer and larger-sized piece of ligature, as is commonly done. This method of tying the arteries singly, as is done in a leg amputation, is surgically more correct. After securing the vessels in each broad ligament, all that remains to be done is to close the folds of peritoneum over the stump. To facil- itate this step, an Eastman staff" can be introduced through the vagina into the Douglas cul-de-sac, and the seat of the operation can be thrust upward almost into the abdominal incision. This is a great improve- ment over the attempt to cover the stump as it lies at the bottom of the pelvic cavity. The edges of the peritoneal flap are now brought over the cervical stump and turned in, and the surfaces are closed by a con- tinuous Lembert suture of silk or catgut from one side to the other. At each angle of the wound the broad-ligament stump may be gathered in and covered comjaletely out of sight. After completing the suturing there is naught but peritoneum to be seen, the field of the operation being completely extra-peritoneal. Nothing now remains but to close the abdominal incision. In these cases the bladder is sometimes greatly distorted, and a correspondingly greater amount of care is required to avoid injuring it. When it is opened it must be closed perfectly, care being taken to cover the wound with peritoneum. Another procedure now much in vogue is to make the cuff operation. After enucleating the tumor, its peritoneal covering is sewed into the lower angle of the abdominal incision, permitting drainage to be discharged externally. After filling the cavity of the peritoneal covering of the tumor with gauze and bringing it out- side, the abdominal wound is closed. Free drainage is thus secured, and as the cavity closes the amount of gauze is progressively decreased with successive dress- ings till the cavity is obliterated. Castration. — The idea of this operation is to bring about the meno- pause prematurely, for it has been observed that with the menopause mvo-fibromata decrease in size and their symptoms become less, to nil. This operation is indicated when the hemorrhages are severe and the condition of the patient is such as to eontraindicate the more hazardous operations. The operation is contraindieated in cases of large tumors, which are liable to suffer from circulatory disturbances secondary to the operation, and in cases where the pressure-symptoms are marked. A median incision is made at the level at which the ovaries are thought to lie, varying in eases with the size of the tumor. The ovaries are sought out and drawn to the incision. The pedicle is tied with a single ligature or in parts according to THE FEMALE REPRODUCTIVE ORGANS. 1051 its thickness. The ovary is now removed, care being taken to get it all. If neces- sary, separate ligatures are now applied to the vessels in the stump. The stump is now cauterized with the thermo-cautery and dropped back. The other ovary is treated in the same way. In many cases this operation checks the hemorrhages at once or in a varying period of time. It checks the growth of the tumor and often causes marked diminution in its size. Cancer of the Uterus. Carcinoma of the uterus may commence in the body or in the cer- vix, but the latter is the usual point of origin. Some cancers begin in the cervical mucous membrane, either deeply in the form of nodules or merely in inflamed mucous membrane or from the surface. They are usually adeno-carcinomata or the ordinary medullary forms. Less fre- quently they produce papillary excrescences. The external os may escape for a considerable time, but sooner or later it and the entire vaginal portion are destroyed. The parametrium is involved early. A large number of carcinomata start from the vaginal surface of the vaginal portion. They are usually flat carcinomata, but when glands are present adeno-carcinoma may develop from them. These cancers early involve the vagina and perivaginal tissues, also the cervix and parametrium. The cervical cancers often lead to the formation of large ulcers, causing great destruction. An exact anatomical diagnosis in these cases may be difficult, even when post-mortem, but usually examination of the lymph-nodules in- volved will remove every doubt. Carcinoma of the cervix also takes the form of cauliflower-like masses which may be so large as to completely fill the vagina. Symptoms. — Many patients suffer from pain, hemorrhage, and vaginal discharge even early in the course of the disease, while others remain free from any symptoms even with well-advanced carcinoma. The pain varies in character and intensity — pain in the back, colic-like pains, and peritoneal pains. The hemorrhage is at first merely an increase in the amount of the menstrual flow, or, if the patient be past the menopause, she usually thinks that the menstruations have returned. Later it becomes more frequent and abundant, and is readily excited by any trauma, cohabitation, defecation, or exertion. When necrosis of the superficial parts of the tumor occurs there is a most foul odor accom- panying the discharge. Anaemia, emaciation, and cachexia rapidly develop. The patients suffer from sleeplessness and anorexia. When the bladder and rectum become involved, symptoms of their disturbed functions are added. Ill well-advanced cases the diagnosis presents no difficulties, but in early cases, where the diagnosis is so very important, it can often be made only by the microscopical examination of a bit of tissue removed. The palliative treatment is, unfortunately, the one which must be most often employed, because most cases are not seen until too late for radical removal of the disease. If the uterus is fixed and immovable or if the pelvic lvmph-nodes can be palpated, effort at radical removal is useless. If the pain, hemorrhage, or discharge demand treatment, the curette and cautei-i/ are Our best means. All of the neoplasm which can be reached should be removed and the raw surface cauterized with the thermo-cautery or some chemical caustic, such as chloride of zinc, bromine, chromic acid, or perchloride of iron. The vagina is then tamponed with iodoform gauze. The curetting often relieves the pain 1052 SPECIAL OR REGIONAL SURGERY. as well as the hemorrhage and discharge. If it does not, morphine must, sooner or later, be resorted to. Tonics and nourishing diet are necessary, and any symptom which arises must be treated as seems best. [The lamented death of the author of this chapter has prevented reference in this edition to his own introduction of calcium carbide in inoperable carcinoma uteri, which has occurred since this work first appeared. Dr. Etberidge first resorted to this method, for which he deserves the credit. He advised to scrape away thoroughly all fungous and easily bleeding tissue from the cervix and uterine cavity, and after checking hemorrhage then to introduce within the body of the uterus a piece of calcium carbide of the diameter of an ordinary chalk crayon and perhaps 2 cm. in length. This is held in place by a gauze-tampon, after which the vagina is packed loosely. This is repeated every few days. The carbide acts as a mild caustic, while the acetylene gas which it gives off may have some local parasiticidal effect. After its employ- ment great benefit, temporary perhaps, but unmistakable, has ensued. The method is still on trial. — Editor.] The Only Operation for Radical Cure is Hysterectomy. — Ampu- tation of the cervix, in view of the recent pathological investigations, should not be attempted, even in the most favorable cases ; for, although permanent cures do result from this operation, the dangers of recurrence are too great. The best method of performing hysterectomy for carci- noma uteri is still a matter of dispute. Some operators prefer the vaginal and some the abdominal method, but probably the combination of the two is the best. Because of the danger of implantation of the carcinoma, all parts of the cancer which can be removed by the curette are removed, the base cauterized, and the mouth of the uterus closed by sutures or the cavity packed with gauze before any incision is made in the vagina. The vaginal wall is then divided by a circular incision far enough away from the cervix to be in healthy tissue. The dissection is then carried upward as far away from the uterus as possible, taking care not to injure the rectum or bladder. The next step in the opera- tion is opening the abdomen. The broad ligaments are then ligated as far away from the uterus as possible, and then divided. The reason for ligating the broad ligaments through the abdomen rather than through the vagina is because any extension of the carcinoma into the parametrium can be given a wider berth when operating through the abdomen than when operating through the vagina. The after-treatment is the same as after laparotomy for other purposes. The Ovary. Ovarian cysts are the most common neoplasms found in the ovaries, but before describing them brief mention should be made of cystic changes in the Graafian follicles. They occur especially in cases of chronic oophoritis or perioophoritis. The cysts commonly reach the size of a cherry or walnut, and are often multiple, while the larger ones — and they may be as large as the uterus at term — are usually single. The wall is thick, but with the smaller cysts it is often thin. There are no septa or remains of septa, no papillary excrescences, and the epithelial lining of the cysts is the cylindrical follicular epithelium, THE FEMALE REPRODUCTIVE ORGANS. 1053 normal in shape or in the larger cysts flattened by pressure. The cyst- content is thin and serous and never stringy. It contains but few- formed elements, but sometimes it is mixed with blood. A satisfactory explanation of the development of these cysts cannot as yet be given. ( Vide, Chap. XXV.) Somewhat similar cysts occur in the corpus luteum. The cysts usually develop toward the abdominal cavity (Fig. 462), making a pedicle of the ovarian ligament, the broad ligament, and often the tube also. This pedicle may be long and slender or short and thick. Fig. 462. Enormous ovarian cystoma (Rodenstein). Sometimes the cysts develop between the layers of the broad ligaments — intraligamentous cysts. There are numerous secondary changes to which these cysts are liable. Torsion of the pedicle is not rare, and hap- pens the more easily the longer the pedicle and the freer the surface of the cyst is from adhesions. When torsion occurs the veins of the pedi- cle are compressed : hypersemia, stasis, and necrosis result unless the blood-supply through the adhesions is sufficient to prevent it. If necro- sis occur, suppuration or gangrene develops from infection with micro- organisms. Fatty degeneration both of the epithelial lining and the cyst-wall is frequent. Calcification, either diffuse or localized, is com- mon, especially in the papillary form. Hemorrhage into the cyst is also common. Rupture of the cyst into the abdominal cavity occurs, leading to symptoms of acute peritonitis. If the cyst-contents are thin, they are completely absorbed, but the thicker they are the less complete is the absorption. Rarely the cysts rupture into the bladder or intestines. Sometimes sarcoma, and more frequently carcinoma, develop from cyst- walls. Entirely different from the form of cyst just described is the der- moid cyst which occurs with relative frequency in the ovaries. Usually one, but sometimes both, ovaries are involved in the process. The dermoid tumors vary in size up to an adult head, rarely larger — are hard and generally globular. They contain masses of fat and hair, 1054 SPECIAL OR REGIONAL SURGERY. usually skin showing sebaceous follicles and sweat-glands, and often teeth, bones, and cartilage. They are not likely to grow rapidly or reach any considerable size, but the danger of infection and suppu- ration in the cyst and of torsion of its pedicle is sufficient to warrant removal whenever they are found. The onset of symptoms is gradual. At first there are only indefinite reflex disturbances, due to congestion and stretching of the appendages. Sometimes, even very early, severe radiating pains on the diseased side appear with tenderness on pressure. In other cases the first symptoms may be due to pressure on the pelvic viscera, vesical and rectal tenes- mus, incontinence or retention of urine, constipation, hemorrhoids, and also pains in the legs and oedema from pressure on the pelvic nerves and vessels. All of these symptoms may disappear on the sudden escape of the tumor from the small pelvis into the abdominal cavity. The menstruations are often profuse and usually painless. There is often profuse leucorrhoea. Sterility is a frequent, but not inevitable result, so that pregnancy can occur even when both ovaries show cystic degenera- tion, and, if the cyst or cysts are small and not fixed in the pelvis by adhesions, the pregnancy can go to term without serious complications. When the tumor has reached a considerable size disturbances of the gastrointestinal tract are common. Breast-changes similar to those of pregnancy may appear. The urinary secretion may be scanty from pressure of the tumor on the kidneys. The upward displacement of the diaphragm causes the ordinary symptoms of cardiac and pulmonary insufficiency. Adhesions between the tumor and the surrounding parts are often the cause of serious symptoms, such as intestinal colic, vomit- ing, etc. These symptoms may be altered by change in the position of the patient. Sooner or later malnutrition, anaemia, and cachexia appear. These patients often have a peculiar facial expression, the fades ovariana, but this must be seen to be recognized. In many cases there are absolutely no subjective symptoms, and the patient's attention is first attracted by the increasing size of the abdomen. When complications arise, such as torsion of the pedicle, rupture of the cyst, or hemorrhage into the cyst, the symptoms are sudden and severe. Shock, acute anaemia, and the like are followed often by symp- toms of peritonitis. Examination of the patient should be preceded by free catharsis, aided by copi- ous enemata, until one is certain that the colon is free from fecal masses. The bladder should be emptied with the catheter if there is any reason for suspecting that the voluntary evacuation is incomplete. If the resistance of the abdominal walls be too great or the pain too severe, the examination should be made under anaesthesia. The patient should be placed on the back with abdomen fully ex- posed. The size of the abdomen varies with the size of the tumor, but the enlarge- ment is usually asymmetrical, the side on which the tumor lies being the fuller. Percussion over the tumor gives dulness, but unless the tumor is closely adherent to the abdominal wall the area of absolute dulness is less than the size of the tumor as shown by palpation. If dulness be present in the flank, it is not altered with position of the patient, as it is in cases of ascites. Fluctuation of the cyst- contents is the plainer the more nearly the cyst is unilocular. Palpation of the tumor is done both through the abdominal wall and by bimanual manipulation. It should be done gently, for fear of rupturing the cyst or tearing some adhesions. Xo general rule can be given as to the position of the uterus, for it is dependent on a variety of factors — the size of the cyst, its point of origin, the presence or absence THE FEMALE REPRODUCTIVE ORGANS. 1055 of adhesions. The uterus may be pulled up out of the pelvis or pushed down to the vulva. It may be forward or back or to one side. The length of the cavity is not usually increased, but it may be. The differential diagnosis of ovarian cysts is a very broad matter, so that there is no abdominal organ which does not under some circum- stances enter into consideration. Muncle gives the following list of possibilities : Obesity, oedema, tonic spasm of the abdominal wall, tympa- nitis, fecal tumor, dilatation of the stomach, distended bladder, ha'inato- metra, physometra, hydatiform mole, hydrosalpinx, ascites, encysted dropsy, hematocele, cyst of the broad ligament, renal cyst, splenic cyst, hepatic cyst, parasitic cyst, omental and pancreatic cyst, uterine cysto-fibroma, uterine fibroma, enlarged spleen, enlarged liver, sarcoma of the abdominal nodes, malignant disease, omental tumor, displaced kidney, displaced liver, preg- nancy both normal and extra-uterine, pregnancy with amniotic dropsy, with ovarian cyst, and with a dead child. The only treat ment of ovarian cysts is removal. The patient is prepared as for other coeliotomies. The abdomen is opened in the median line just above the pubes. Any adhesions are separated, the smaller torn with the fingers, the larger divided between ligatures. In some cases the adhesions are so abundant that the operation must be aban- doned. After freeing the cyst from adhesions the contents are drawn off through a trocar, taking care that none of the fluid escapes into the abdominal cavity. The sac is now drawn out through the abdominal incision. The pedicle is tied with a heavy ligature, usually in two or more parts. The cyst is cut away, and after tying with separate liga- tures any large vessels found in the stump, the stump is dropped back into the abdomen and the incision closed. The after-treatment is the same as in other laparotomies. The Parametrium. Acute inflammatory processes in the para-uterine cellular tissue are most commonly the results of infection during labor or abortion. They may also follow operation on the genitalia or be due to extension from an infective inflammatory process existing in some of the pelvic organs — the tubes, ovaries, uterus, or rectum. There is serous and cellular infiltration of the cellular tissue, vary- ing in extent and location, but more often found in the broad ligaments, where it may remain or extend to all the uterine ligaments, the abdom- inal wall, the post-peritoneal and post-rectal cellular tissues. It may take the form of a diffuse phlegmon, as thrombo-phlebitis or thrombo- lymphangitis. The exudate may undergo complete resorption and the parts be restored to their normal condition, or the exudate may become purulent, forming an abscess. The abscess may be single or there may be many communicating with each other by tortuous passages. If untreated, the pus may undergo partial absorption, caseation, and cal- cification, but, as a rule, such abscesses increase in size and extend along lines determined by the fascial planes and the influence of gravity. They often rupture through the abdominal wall, the vagina, the rectum, or the bladder. They may also rupture into the peritoneal cavity. Another possible outcome of a cellular infiltration is its organization 1056 SPECIAL OR REGIONAL SURGERY. with the formation of new fibrous tissue. A similar formation of new tissue occurs about abscess-cavities unless the abscesses are promptly and thoroughly drained. Cases of parametritis are almost invariably associated with more or less extensive perimetritis. The symptoms are the general symptoms of all acute septic pro- cesses combined with the symptoms of the local trouble. Usually a chill, often very severe, is the first sign ; the pulse and respiration are rapid. The temperature is high and interrupted at varying intervals by chills. Pain from tension of the ligaments and abdominal walls and from pressure on the pelvic nerve-trunks, added to that of the usually accompanying pelvic peritonitis, is severe. Vesical tenesmus is often troublesome. Vomiting and tympany of the intestines are common. The general strength is rapidly undermined. The emaciation becomes extreme. The symptoms of rupture of an abscess into the general peritoneal cavity are those of a severe generalized peritonitis. In the more favorable cases the symptoms are less severe and of shorter dura- tion. Vaginal examination shows local heat, swelling, and tenderness, with a generally boggy feeling. Later the swelling increases, causing displacement of the uterus. If pus form, fluctuation can usually be discovered. Treatment. — In the very early stages the patient should be kept in bed under the influence of opiates, with the local application of the ice-bag. The general health of the patient should be maintained by the use of alcoholics, quinine, and strychnia. If suppuration seems to be inevitable, cold should give place to hot applications and douches. As soon as a focus of pus can be discovered it should be opened and drained. It is usually best to locate the pus with an exploring syringe, and open along the needle with the thermo-cautery or sharp-pointed scissors, taking care to avoid any pulsating vessels and withdrawing the scissors open. The abscess-cavity should be explored to see whether it communicates with any other cavities. If it does, the opening between them should be enlarged sufficiently to secure free drainage. The abscess-cavity should be irrigated frequently with antiseptic solutions, and free drainage be maintained until the cavity closes throughout. If there is much new tissue formed after the abscess is closed, pelvic massage, combined with hot douches, iodine locally, should be used to limit the deformity resulting from the contractions of the new tissue, and as far as possible to cause the absorption of such tissue. The Perimetrium. Perimetritis, or pelvic peritonitis, is most often secondary to disease of the pelvic organs, though it occurs also as a part of a general peri- tonitis. The most common cause is infection following labor or abor- tion. Other causes are acute and chronic endometritis and metritis, gonorrhoea, inflammation of the tubes and ovaries, malposition and tumors of the ovaries, and exposure, especially during menstruation. The inflammation may lead to the formation of abundant fibrinous or purulent exudate, filling up the cul-de-sac of Douglas, and matting together the pelvic organs and such of the intestines as happen to lie in the pelvis. After a varying THE FEMALE REPRODUCTIVE ORGANS. 1057 period of time the exudate maybe absorbed ; more frequently abscesses form which sooner or later perforate in some direction. These cases most frequently follow puerperal infection. Much more important, because much more frequent, are those cases in which the exudate is less abundant and fibrinous, and by its organ- ization leads to the formation of adhesions between any two peritoneal surfaces which happen to be in contact. The symptoms van 7 as greatly as do the symptoms of generalized peritonitis. Even most severe purulent pelvic peritonitis may exist some time without causing marked symptoms. The acute form usually begins with a more or less marked chill, followed by high temperature and frequent pulse, constipation, followed shortly by tympanitic disten- tion of the intestines, vomiting, and collapse. There are localized pains and tenderness with vesical irritation. In less acute cases the general symptoms are less marked, and the local symptoms, especially the pain, come to the foreground. The pain is severe, and is increased by motion, menstruation, and examination. The patients lose strength rapidly, suffer from insomnia, and often very much from vesical tenesmus. The chronic cases often develop without causing any subjective symptoms whatever, and the earlier existence of a pelvic inflammation is shown only by the resulting adhesions. The symptoms in these cases come on later from the disturbance of the uterus, bladder, and rectum — profuse menstruation, leucorrhcea, vesical tenesmus, constipation, pain in the back, sterility, or repeated abortions. The treatment of the acute cases consists in ice locally and rest in bed. The pain must be controlled by opium. The bowels must be kept open by laxatives. The strength should be maintained by alco- holics and tonics. After the more acute symptoms have disappeared hot local applications are used. If pus form, the abscess must be drained freely, as already described. The chronic cases should pass several hours in bed and the bowels be kept open. All repeated or pro- longed examinations, the use of the uterine sound or pessary, are contra- indicated, because of the danger of setting up an acute exacerbation of the chronic peritonitis. Hot or cold applications should be used for the pain. In some cases the extirpation of the tubes, ovaries, and the adhesions about them is warranted. The Fallopian Tubes. Inflammation of the Fallopian tubes may be acute or chronic. Although salpingitis was not recognized until a few years ago, the con- dition is far from being uncommon. The disease is rarely limited to the tubes. The uterus is diseased in about two-thirds of the cases, show- ing either acute or chronic endometritis, flexion, or version. Many cases show distinct traces of perimetritis, which, however, may be sec- ondary rather than primary to the salpingitis. It is probable that the tubes are rarely the seat of primary inflammation, except for the not infrequent cases of tubal tuberculosis. Many cases are due to puerperal infection. Many cases are due also to acute gonorrhoea. Both tubes are diseased in about half of the cases, and when only one tube is involved the left is involved more frequently than the right. The symptoms of salpingitis are not well marked, because they are 1058 SPECIAL OR REGIONAL SURGERY. almost invariably added to a preceding or coincident inflammation of some other part of the genital tract. A dull pain of varying intensity on one or both sides, and increased by exertion, menstruation, or copula- tion, is usually the first sign. To this may be added at irregular inter- vals signs of acute localized peritonitis- The menstruations are irregu- lar, profuse, and painful. Occasionally the tube will empty itself into the uterus and a large amount of fluid escape into the vagina. At such times the pain is much relieved and the local findings are altered. The presence of pus in the tubes — i. e. pyosalpinx — causes the general symptoms common to all suppurating foci. When suddenly developed there is the chill and the irregular temperature curve, rapid pulse, and rapid loss of strength and flesh. Pus-tubes rarely rupture into the free peritoneal cavity. The usually firm adhesions prevent this. A positive diagnosis of salpingitis can be made only when the dilated tube can be differentiated by palpation from the exudate, and its connection to the uterus by the uterine end of the tube definitely deter- mined. Palpation, in these cases, must be most careful, because of the danger of rupturing the tube, causing severe local or general peritonitis, or tearing an adhesion and setting up a hemorrhage which may be so severe as to necessitate a laparotomy to find and control the bleeding point. Treatment for the acute cases is the same as for peri- and para- metritis. Later, hot douches, iodine preparations locally, rest, proper diet, and regulation of the bowels often accomplish a great deal toward the absorption of the exudate. If, after this plan have been faithfully tried, the symptoms persist, the tube or tubes should be removed. Ectopic Pregnancy. Extra-uterine pregnancy is the development of an ovum outside of the normal uterine cavity. Formerly this was thought to be a rare occurrence, but increasing experience shows that it is far from being so. Anatomically, the cases are classified according to the site of the devel- opment of the foetus into tubal, tubo-uterine or interstitial, tubo-abdom- inal, abdominal, subperitoneal, and others. This classification is of but little clinical value. It is known that impregnation of the ovum often occurs near the ovary. Any cause which will prevent the passage of the impregnated ovum to the uterus may cause an extra-uterine pregnancy. The more common of these causes are inflammation of the Fallopian tubes, pelvic peritonitis about the tubes leading to constriction, tumor, or polypi in the tube. Tubal pregnancy is the most common form, and may occur at any part of the tube, but most often in the middle third. The tubal mucous membrane undergoes changes similar to those of the uterine membrane in the formation of the decidua. During the earlier months of preg- nancy the tumor resembles a hematosalpinx, and can be distinguished only by finding foetal parts or remains of chorionic villi. Rupture of the tube occurs early in the majority of cases. It ruptures most fre- quently into the peritoneal cavity, causing an intraperitoneal hematocele which may be so large as to exsanguinate the patient. Rupture between THE FEMALE REPRODUCTIVE ORGANS. 1059 the folds of the broad ligaments is more favorable, as the ligaments tend to limit the hemorrhage. Sometimes the foetus dies early and the tumor stops enlarging. In these eases, after a few months, it may be difficult to recognize the true nature of the tumor, the fetus having entirely dis- appeared. In other cases the foetus may live to term, developing in the fold of the broad ligament, making the so-called subperitoneal extra- uterine pregnancy, or free in the abdominal cavity as a secondary abdominal pregnancy. In the tubo-uterine or interstitial form the foetus develops in that part of the tube which lies in the uterine wall. The pregnancy usually continues longer than in the tubal form. It may rupture into the uterine cavity, with escape of foetus and placenta through the natural passage, or it may rupture into the peritoneal cavity r . Sometimes the pregnancy goes to term. In the tubo-abdominal cases the ovum develops in the abdominal end of the tube. The sac is made up in part by the tube and in part by false membrane. The sac is adherent to those organs with which it comes in contact. The placenta is usually located in the pelvis. It may go on to term, but as a rule ruptures. Abdominal pregnancy may be primary — i. e. the ovum is impreg- nated and remains in the abdominal cavity — but it is usually secondary to rupture of some other of the forms. The sac is usually made up of thick false membranes, but it may be thin and transparent. The pla- centa is large and irregular both in site and shape. When the ovum is not strangulated, it usually develops to term, uninterrupted by hemor- rhage or rupture. The uterus is, as a rule, enlarged, and its mucous membrane shows changes similar to those which occur with intra-uterine pregnancy. Its location varies with the site of the ovum, but it is more often displaced forward or to the side opposite the ovum. The patient presents all or many of the early signs of pregnancy, but usually there is some irregularity in the course to attract attention. The development of the breasts may not occur, or the menstruation, after disappearing, reappears, often as a continuous flow. There may be expulsion of decidual membranes without any change in the signs of pregnancy. When rupture occurs the symptoms are those of internal hemor- rhage, varying in intensity with the amount of blood lost. If pregnancy goes on to term, we find symptoms due to compression of the rectum and bladder, intestinal colic, and recurring peritonitis. If infection of a hematocele or retained ovum occur, we have the symptoms of septicemia and peritonitis, either generalized or local. If the suppuration is local- ized, it ends as other pelvic abscesses end. It also happens that after the death of the foetus no symptoms result, the foetus being retained as a non-infected foreign body. It may undergo calcification, forming a lithopaedion. In such cases the condition may persist for many years without causing any trouble, but it is a constant source of danger, as it may at any time cause serious complications, such as intestinal ob- structions. It must be remembered in treating these cases that the danger of hemorrhage and sepsis is so great, and the chances of the spontaneous 1060 SPECIAL OR REGIONAL SURGERY. expulsion of the foetus or the safe retention of a dead fetus are so small, that to-day the only rational treatment of extra-uterine pregnancy is operation. The earlier treatments, such as starvation, bleeding, puncture of the cyst, strychnia to toxic symptoms, are abandoned. The use of morphine injections into the tumor previous to the fifth month is still sometimes practised with success, but it is more dangerous than laparotomy. The same thing can be said of the use of electricity. If before the fifth month extra-uterine pregnancy be suspected with any degree of probability, exploratory laparotomy should be performed, and, if the diagnosis be confirmed, the cyst and its contents should be removed. Whenever rupture of the sac occurs a celiotomy should be made at once, without waiting for signs of serious hemorrhage. After .the fifth month, if the fetus be living, operation should be deferred until term or until signs of false labor appear, unless some indication for immediate operation develops. After the fifth month with a dead fcetus the opera- tion should be made as soon as possible, even though the fetus has been retained for years without causing any trouble. Operations for extra-uterine pregnancy are of two classes — laparot- omy and elytrotomy — i. e. operation per vaginam. The special features of each case must decide which of these operations shall be performed. Hemorrhage, which is the greatest danger of the operation, is best con- trolled by the iodoform-gauze tampon. Whenever possible the entire sac and its contents should be removed. When the sac cannot be removed because of adhesions or for some other reason, it should be stitched to the abdominal incision, then opened and its contents removed, and then packed with iodoform gauze and allowed to close from the bottom. When operation through the vagina is done, the vault of the vagina is incised at a point near the tumor, and the opening enlarged sufficiently to allow the extraction of the fetus. The cord is tied and the placenta removed when possible. When impossible, the cavity is irrigated and packed with iodoform gauze. CHAPTER LI. SURGICAL DISEASES AND INJURIES OF THE BREAST. By Charles B. Parker, M. D. Anomalies of the Breast. Complete absence of one breast (Amazon thorax, Hyrtl) or of both breasts is most rare. In those cases in which the breast has been absent the condition was observed to be associated with marked devel- opmental defects in other organs, such as the uterus, ovaries, pectoral muscles, and ribs. Supernumerary breasts (polymastia) or multiple nipples (polythelia) are not so uncommon. The mother of the Roman emperor, Alexander Severus, bore the name of Julia Mammea, from the fact that she possessed a third breast. The discovery by King Henry of a supernumerary breast on the person of the beautiful Anne Boleyn is said to have been the cause of her downfall and death. The supernumerary breasts are usually located internally to, and below, the principal gland. The axillary border, and even Scarpa's space, have been the seat of functionating mammary glands. There seems to be no relation between these anomalies and diseases of the breast. Billroth says that in all his experience he has seen but one case — a car- cinoma — occurring in a breast with two nipples. This observation is not altogether confirmed by other authorities, but we may safely say it is never necessary to remove these supernumerary organs simply because they are present. Skin Diseases occurring on the Breast. The skin and areola of the breast are liable to the various skin affections, especially eczema, which frequently occurs upon the nipple and areola. Eczema in this position, as well as other skin affections when they occur, do not differ in any essential character or in treat- ment from the same disease occurring on other parts of the skin. A peculiar affection of the nipple and areola very closely resembling eczema, and known as Pag-et's disease of the nipple, is occasionally met with. This disease receives its greatest importance from the fact that it is frequently followed by carcinoma in the breast. (For a detailed account of this subject see Chapter XXV.) Hemorrhage ; Vicarious Menstruation. Hemorrhages have been occasionally observed occurring in the breasts of voting women and girls suffering from dysmenorrhea, amen- orrhea, and other uterine disorders where there has been no external 1061 1062 SPECIAL OR REGIONAL SURGERY. injury. Such an extravasation of blood is called vicarious menstruation. The extruded blood produces no pain and, at most, only a sense of ful- ness in the breasts. The treatment consists in supporting the breasts with a handker- chief bandage tied over the opposite shoulder and the application of dilute lead lotion. Diseases op the Nipple and Areola. Inflammation is especially liable to occur during the early days of the first lactation, and in subjects in whom the nipple is ill developed. The nipple receives a slight injury while the child is at the breast. The moisture incident to the act of nursing macerates and loosens the injured epidermis, which, separating, leaves a superficial excoriation. This deepens into a fissure and may extend to a considerable ulcer. The pain increases with every attempt made to place the child at the breast. The dread of this pain leads the mother to extend the intervals of nursing, and the breast becomes distended with milk ; but the real danger in these fissures and ulcers lies in the fact that through them an avenue is opened for the introduction of bacteria, especially the streptococci and staphy- lococci. The result is inflammation of the substance of the gland. The prevention and treatment of this condition become of the first importance. Should a fissure of the nipple form as a result of this abrasion, it should be treated upon antiseptic principles. The greatest care is to be exercised in cleansing the nipple and fissure with boiled water after nursing, and the application of moist antiseptic dressings. Boracic-acid solution, gr. x to 3j, or creolin, or even bichloride, 1 : 6000 or 10,000, may be applied to the breast during the intervals of nursing. Some impervious covering, such as oil silk or paraffin paper, should be applied over the moist dressing. All ointments should be avoided : not only are they of doubtful utility, but they chiefly serve as an impervious coating over the fissure, keeping in the secretions and bacteria and favor- ing their absorption. When the child is about to be put to the breast again, the dressings are removed and the surface thoroughly washed with sterilized water and dried. If the fissure persists and shows no tendency to heal, touching it with a sharp stick of silver nitrate will often start the healing process. Should these means fail after a reasonable trial, and the patient's health begin to suffer from the pain, and possibly both breasts become similarly affected, with the danger of infection from pyo- genic microbes thus doubled, it is the evident duty of the physician to arrest the secretion of milk at once and in both breasts, whether they are both diseased or not. It is not sufficient to arrest secretion in the affected breast alone : the sympathetic relationship between the two is so intimate that nursing on a healthy mamma stimulates the diseased breast to renewed secretion. Such half measures have often protracted this painful affection for many weeks. The local application of belladonna ointment and the administration of potassium iodide in full doses have the approval of accepted practice ; but the equable continuous pressure secured by strapping both breasts is far more effective and affords more prompt and permanent relief. SURGICAL DISEASES AND INJURIES OF THE BREAST. 1063 Acute Mastitis. Acute inflammation of the breast may occur — first, at birth; second, at puberty; third, during pregnancy and lactation. At Birth. — Not infrequently the breasts of the new-born infant of both sexes secrete a milk-like fluid ("witch's milk") for several days. The breasts are turgid, red, and tender. The practice of the untrained nurse of " rub- bing away " the milk only aggravates the condition and leads to sup- puration and abscess-formation. "With intelligent, trained care suppura- tion will be rare, and for the inflammation that may occur it will be necessary, at most, to apply a compress wet with dilute lead lotion, and the process entirely subsides in from a week to ten days. At puberty a similar turgescence and inflammation of the breasts may occur. It is less liable to proceed to suppuration, and requires no treatment beyond careful protection of the parts. During pregnancy and lactation acute inflammation is particularly liable to occur. Of 56 cases observed by Billroth, 50 occurred during this period — 6 in non-pregnant women. Statistics seem further to prove that puerperal mastitis is more frequent upon the right than the left side, and rarely bilateral ; also, that usually only a portion of the gland is afl'ected, and that the lower external part. Billroth insisted that there must be a special irritation to produce the process of inflammation ; and we now know that it is the infection of the breasts by bacteria that induces the inflammation. There are apparently two avenues by which the microbes enter — the one through the fissures and ulcers, however small, upon the nipple ; the other through the milk-ducts by organisms which find their way in through the ducts or have their normal habitat in the deeper layers of the skin (Welch). Infected wounds in the genital passages may also produce metastases in the mammary glands. In most cases the inflammation remains limited to the points of original infection. The inflammatory process may reach a certain degree of intensity and then gradually sub- side, but more commonly it increases in severity and ends in suppura- tion and abscess-formation. Such an abscess is known as a supra-, intra-, or retro-mammary abscess, according as it is located upon the gland, within the gland, or behind it. The superficial mammary abscess is located usually near the nipple. Fluctuation occurs early ; the pus is just beneath the skin, which is red and already thinned by inflammatory softening. The abscess should be opened by an incision radiating from the nipple, to inflict the least possible damage to the secreting structure of the breast. Intramammary abscess is a much more serious condition, and may, in severe cases, lead to a total destruction of the function of the gland by the formation of numerous multiple abscesses and their attendant sinuses. Fluctuation is not always easily made out, the elastic, pil- lowy feel of the breast itself adding to the difficulty of the examina- tion. The signs of inflammation are the temperature, local tenderness, and the hardness which has existed for some days. Within a day or two softening of the area of hardness will be noticed, and within the next two or three days redness of the skin. Retro- or submammary abscess is fortunately rare. It may result 1064 SPECIAL OR REGIONAL SURGERY. from extension of an intramammary suppuration or it may occur by metastasis. The onset may be most insidious ; or it may be severe, with marked evidence of general septic infection. The gland itself may be only slightly involved, and is protruded outward, resting upon a cushion of pus. Usually the pus presents itself on the lower border of the gland in a direction determined by gravity. It may, however, point along the upper border of the gland or in the axilla, and has been known to make extensive dissections of the chest-wall, and even to break into the thorax. As soon as discovered an opening along the lower or axillary border of the gland should be made to secure the very best possible drainage. After opening any of these varieties of abscess no pressure should be made upon their walls to force out their contents, nor should they be irrigated with any watery sterilized solutions. The flow of pus may be favored by the position of the patient, and the cavity should be gently, and not too tightly, packed with iodoform gauze and a volumin- ous antiseptic dressing applied. This dressing usually requires renewal upon the third or the fifth day, or sooner if the temperature rises to 103° F. During all this time the breast must be efficiently supported, and no bandage equals in efficiency adhesive straps applied in the manner already described. The circular strips may be omitted in these cases, and only the long straps passing under the breast need be applied. Ohbonic Mastitis. The chronic lobar induration of some authors is a chronic inflam- matory process involving one or more lobules and ducts of one or both breasts. The cellular infiltration between the acini and the lobules becomes organized into dense connective tissue. This contracts, destroy- ing the acini or closing them off into retention-cysts containing a small quantity of brownish or colorless fluid. The lobule becomes nodular, irregular, and adherent to the structures adjacent. If the larger ducts are involved, retraction of the nipple may also occur. This form of chronic inflammation occurs in women who have not borne children as well as in those who have. Quite frequently it occurs in both breasts, and to some slight degree is present in women between the ages of forty and fifty. The pain is often severe and of a neuralgic character, and is frequently the first symptom that attracts the patient's attention to the breast. The fear of malignant disease and the frequent handling exaggerate the pain and suffering. The differentiation from carcinoma is often most difficult. The two conditions occur at the same age — they each form irregular hard nodules, and the nipple may be retracted in each condition. The following points are of service in making out the differential diagnosis between — Chronic Induration. Carcinoma. Leathery hard. Stony hard. Increased size during menstruation. Hize usually not affected by menstruation. Both breasts frequently affected. Confined to one breast. Growth very slow. Growth rapid. Lymphatics usually not enlarged. Lymphatics always enlarged (late). No cachexia. Always cachexia (late). Improves or remains stationary. Grows worse. SUEGFC'AL DISEASES AND INJURIES OF THE BREAST. 1065 Finalf;/ the examination with the flat of the hand should he made: the clothing should be removed so that the breasts are entirely accessible. Before anv examination is made with the fingers the palmar surface of the hand is placed flat upon the breast over the suspected spot, and with gentle pressure the lobules rolled over each other. If it be merely chronic induration, nothing can be felt ; if a tumor be present, it comes out more distinctly. If the patient is very thin, it is possible to mis- take a costal cartilage or an unusually curved rib for a new growth. This valuable aid to diagnosis dues not serve to distinguish the various forms of new growth, but only to differentiate them from cases of chronic lobar inflammation. And it must be admitted that in the very beginnings of malignant disease, especially carcinoma, this method may fail. In any case of doubt, where all means of diagnosis fail, it is the dutv of the surgeon to insist upon an exploratory incision, the inspection of the mass, and a microscopic examination of a specimen removed. The treatment of this condition by the administration of potassium iodide in full doses or by liquor potassse and arsenic is highly recom- mended. The most useful local treatment is strapping with adhesive straps, as has been elsewhere described. This procedure makes equable pressure over the entire breast, and thus favors the absorption of the new-formed connective tissue ; at the same time the patient is prevented from handling the breasts and thus further aggravating the condition. Tuberculosis. Tuberculosis pursues the same course in the breast that marks its progress in other soft structures of the body. The histological lesions are identical with those characterizing this form of granuloma, and the gross lesions deviate in no way from the usual types. Miliary tuberculosis can scarcely be defined from actual observation, for when encountered clinically the tubercles have usually passed into more or less caseous masses, which may be spread diffusely throughout the glands or become confluent as one or several large cir- cumscribed nodes. The nodules of diffuse tuberculosis vary in size and number. They are usually accompanied by a low grade of inflamma- tory action in the tissues surrounding them, so that the portion of the organ affected bv the disease becomes both nodular and indurated. Cheesy degeneration of the tubercular nodules occurs in due time. Sooner or later the retrograde changes in the tubercular lesion lead to liquefaction of the caseous contents of the nodules, and the softened material thus formed burrows throughout the gland and eventually finds its way to the surface. In this way a series of discharging sinuses may be produced which riddle the breast in various directions. This fate is shared alike bv the diffused and circumscribed tubercular lesions. Spontaneous healing has been noted in mammary tuberculosis in which the foci were small in number and of moderate size. Encapsulation by a protective connective-tissue barrier and absorption or calcification of the inner tubercular material affect the healing process. This method of termination is the exception, and the tubercular breast becomes an ever-present source of danger of general tubercular infection. Of the surrounding structures, the contiguous lymphatic nodes are usually 1066 SPECIAL OR REGIONAL SURGERY. infected from tuberculosis of the breast. Tuberculosis, like most other diseases of the mamma, attacks the gland by preference during the period of functional activity, and it thus happens that puberty, preg- nancy, and the puerperium are the occasions most commonly chosen. Treatment. — Thus far, we have no specific treatment for tubercu- losis, and this disease resists all of our therapeutic measures in much the same way as cancer does. A focus of tubercular disease, like a tuberculous breast, constantly threatens the life of its possessor, since secondary disease in remote parts may spring from it at any time : there seems, therefore, to be but one rational method of treatment at present indicated in all accessible tubercular foci — viz. complete removal of the diseased tissues. In the breast this means the amputation of the dis- eased organ and the removal of infected lymph-nodes and other dis- eased tissue by substantially the same method as will be recommended for the removal of a carcinomatous breast. Syphilis of the Breast. Syphilis is not necessarily a venereal disease. The breasts, next to the lips and mouth, are perhaps most frequently the seat of the initial lesion in non-venereal chancre. In one mode of infection the virus is carried from the syphilitic infant through fissures and abrasions of the nipple to the mother or wet-nurse. Various unique and unusual sources are given in the literature. The chancre, however acquired, takes on the characteristic indurated, circular, punched-out appearance of the specific venereal sore. " It is a bold surgeon," says Mr. Hutch- inson, " who makes the diagnosis of hard chancre before the secondary symptoms appear." If this be true of the diagnosis of venereal sores, how much more of those which occur in unusual localities ! The indurated, circular, non-healing ulcer, together with the enlarged, superficial axil- lary and clavicular nodes, will arouse a strong suspicion of its true cha- racter, and the appearance of the specific secondary eruption will dispel all further doubt. In syphilis the superficial lymphatics of the axilla and the clavicle become enlarged at the same time. In carcinoma it is the deeper lymphatics in the axilla which first become enlarged, and those in the clavicular region much later. Secondary syphilis occurs upon the breast in the form of skin eruptions and mucous patches. The diagnosis is usually readily made in these specific skin eruptions, as they are present in similar forms upon other parts of the body at the same time. Syphilitic mucous patches sometimes form upon the inferior surfaces of the pen- dulous breasts of fleshy women. The anaesthesia and analgesia occasionally observed in the breast are regarded by Fournier as manifestations of later second- ary syphilis. The tertiary syphilitic diseases include rupia, ecthyma, mucous patches, and gummata. Gumma is located either subcutaneously or within the breast, and may be either diffused or circumscribed. The circumscribed gumma, far more frequently than the diffuse, develops without much or any pain, and is often discovered by accident. Treatment. — Syphilis is the most amenable to treatment of all the chronic diseases. Mercury by inunction, or gray powder in grain doses, is recommended by Mr. Hutchinson. Iron and arsenic with the mer- SURGICAL DISEASES ASJD INJURIES OF THE BREAST. 1067 cury, in the anaemic and feeble, is the treatment to be followed in the secondary stage. In the tertiary stage mercurial inunctions and iodide of potassium in increasing doses, combined with essence of pepsin or bitter tonics, continued for a length of time, give the best result. Neuralgia of the Mammje; Mastodynia. A painful affection of the breast occurring, according to Gross, most frequently in young unmarried women from puberty to twenty, though it may occur at any time after puberty. The pain is often most violent and out of all proportion to the local condition which may be found present. Indeed, some of the most severe cases have occurred in women in whom no tumor or other cause for the pain could be discovered, even when the breast was explored by incision. The affection usually occurs in women who have had some pelvic disturbance and are of a hysterical type. In certain cases, however, small tumors may be felt, and Velpeau makes a classification of painful breast, as follows : (1) Neurotic tumors and nodosities ; (2) Neuralgic pains without tumors ; (3) Imaginary tumors. In cases where painful nodosities occur the pain is out of all proportion to the size of the tumor, nor is the pain constant in this or any of the varieties of masto- dynia, but periodical, occurring either at certain periods of the day or, as often happens, just before and during menstruation. The cases in which there are severe neuralgic pains without any tumor are the most numerous. The pain often radi- ates into the arm and down along the sides of the thorax. According to Billroth, Eulenberg, and others, this affection is an intercostal neuralgia with radiation toward the anterior part of the thorax. The treatment of mastodynia, especially those cases in which no tumor is present, is most unsatisfactory. So far, it can only be said that the pain in some cases diminishes greatly and disappears with the cessa- tion of the menses. Any disturbance or disease of the pelvic organs should be looked to and corrected if possible. Local application of lotions, salves, and the like are not to be recommended. A very useful practice, in severe cases, is strapping of the breasts with adhesive plaster. Not only does this produce equable pressure upon the breasts, and thus relieve the pain, but prevents the patient from applying dirty salves and from handling the breast, and thus aggravating the condition. Hypertrophy. Hypertrophy of the breast is a very rare form of enlargement of this gland. In nearly all the cases observed it has affected both breasts, and has occurred in young women, one case at the age of fourteen years. There seems no well-defined cause for the enlargement. The hyper- trophy begins with menstruation ; the growth is very rapid during the first few months, and after that is very slow. The increase in volume takes place in all parts of the breast, and is a diffuse hypertrophy of the normal glandular and fibrous connective tissues of the breast. The weight becomes a burden, incapacitating the patient from work, and by the excessive nutritive activity taking place in the gland the general nutrition is bad. Pregnancy seems, in one case at least, to have had a favorable action upon the groAvth, arresting it, and a decided diminution 1068 SPECIAL OR REGIONAL SURGERY. in the volume of the breast was noted. No known remedy nor method of treatment has any appreciable effect to arrest or prevent the process, although a multitude of remedies, reasonable and ridiculous, have been suggested and tried in this condition. Tumors of the Breast. Nearly all varieties of tumor occur in the breast, not only in simple structural types, but also as mixed tumors; thus, a glandular tumor may be composed very largely of fibrous tissue as well as glandular elements, and is then known as a iibro-adenoma. In this tumor may develop cysts in the course of cystic degeneration, and it is then desig- nated as a fibro-cysto-adenoma. Degenerations are much more com- mon in malignant tumors, particularly the sarcomata; thus Ave have cysto-sarcoma as the result of cystic degeneration or melano-sarcoma as the result of pigmentary degeneration. Williams finds that nearly one- fifth of all tumors, both innocent and malignant, occur in the breasts, and that one-fourth of all carcinomatous tumors have their initial seat in these glands, and still further it may be stated that 92 per cent, of all breast-tumors are cancers. The word cancer is here used as elsewhere in this article in its clinical significance, as equivalent to malignancy, without reference to the particular variety of malignant tumor. Cysts number less than 2 per cent, of all tumors found in the breast. They occur as both single and multiple tumors, and quite frequently are found in both breasts. They contain serous, mucous, often brownish fluid, often milk more or less changed. Others contain a clear lymph fluid, and a rare form of cysts are the hydatids. Cysts vary in size, from those containing but a few drops of fluid to those containing a pint or more. As a rule, however, the cysts of the breast only exceptionally reach such dimensions. True cysts of the breast may be divided into — first, retention or glandular; second, lymphatic; third, hydatid cysts. The greater number belong to the first class, the retention-cysts. The lymph- cysts are very rare — only some 16 or 20 cases were lately collected — while hydatid cysts are even more rare. I'ctention-eyst* are due to obstruction to the ducts or secreting acini, caused by imperfect development of the ducts, injury and disease of the nipple, or inflammation about the ducts and their subsequent contraction. The obstruction is not always complete, as often a quantity of cystic fluid can be squeezed out of the nipple. Retention-cysts are often classified, according to their contents, into (a) serous, mucous, sanguino- lent cysts ; (b) lacteal or galacteal, occurring during lactation or after- ward, containing milk more or less changed, resembling butter and oily substances. Adenoma or glandular tumor (the "chronic mammary tumor" of Sir Astley Cooper) develops in the breast usually after puberty. This neoplasm differs from hypertrophy mainly in the fact that it affects sin- gle lobules or portion of lobules, and not the entire breast (Fig. 463). Adenoma is rarely observed before puberty or after the menopause. These tumors seem, therefore, to develop during the functional activities of the organs. The growth is usually slow and painless. The tumor SURGICAL DISEASES AND INJURIES OF THE BREAST. 1069 has a hard, bossy feel, often nodulated. Owing to its great tendency to cystic degeneration it often has an elastic, semi-fluctuating feel. The tumor has a capsule, and is thus freely movable. Fib. 4G3. «*£&&; :■-«/. \ Transection of an adenoma of the breast removed from a woman twenty-two years old, showing the well-defined capsule, the fibrous stroma, and the foci of proliferated glandular tissue, varying in size, and surrounded by distinct walls of stroma which form compartments (from the gross specimen preserved in formalin solution, natural size). The chief diagnostic signs of adenoma are its hard, nodular feel, slow growth, mobility within the breast, not adherent to the skin, no retraction of the nipple or enlarged lymph-nodes, a slight discharge at nipple upon squeezing the breast, and the patient about thirty. Sarcomata are rare as compared with carcinoma, forming but 7 per cent., and carcinomata 85 per cent, of the malignant tumors of the breast. The round, the spindle, and even the giant-celled sarcomata have been observed as occurring in this gland. More frequently the sarcoma-cells invade a fibroma or adenoma and form a fibro-sarcoma or adeno-sar- coma, or, infiltrated with pigment-cells, a melano-sarcoma. These mixed- celled sarcomata frequently undergo cystic degeneration, and are then known as fibro-cysto-sarcomata. Sarcoma rarely occurs before puberty or after thirty. The tumor becomes voluminous, though the growth at first may be slow. The skin is stretched and shiny, of a dark reddish- brown color with blue veins showing through. The entire gland may be involved in the growth, the so-called sarcoma en masse, or the tumor may develop in certain parts of the gland at about the same time. In the former case the tumor is uniform and the skin stretched smoothly over it ; in the other the numerous points of growth give a nodular cha- racter to the breast. Sarcomata have been mistaken for abscess, owing to the redness, rapid growth, sense of fluctuation, and pain attendant upon the growth, and have been punctured under the supposition that they were abscesses. The history of a recent pregnancy or lactation, the rise of temperature, and distinct fluctuation point to abscess- formation. In making the examination it is well to remember Colles' law, that the wider the area over which fluctuation can be felt the more certain is the pres- ence of fluid. But in case of doubt an exploratory puncture will reveal the true character of the mass. From carcinoma the distinction is still more difficult, and the microscope must in many cases determine the exact character. 1070 SPECIAL OR REGIONAL SURGERY. Age. — Sarcomata occur usually before thirty ; carcinomata are rare before thirty. The skin is stretched, shiny, and reddened, and not early adherent to the sarcoma. In carcinoma the skin is early infiltrated and adherent, pale, blanched, and puckered. Axillary nodes are not enlarged in sarcoma : there is always an early enlargement in carcinoma. In the cut section of a sarcoma there is an absence of adipose tissue, this having been transformed into sarcomatous tissue. In carcinoma there is always considerable fatty tissue present (Cornil and Eanvier). Carcinoma of the breast occurs under two histological forms — acinous and tubular, according as the primary growth develops in the acini or tubules. (Vide Carcinoma, Chapter XXV.) In the acinous variety the carcinoma cells are closely packed in the alveolar spaces and sur- rounded by a connective-tissue stroma. The cells are large, irregular, spheroidal, and multinuclear, showing a large amount of granular matter within the cell-body and frequent mytoses in the nuclei of the cells. Tubular carcinoma occurs much less frequently than the acinous variety, and develops from the tubules or excretory milk-ducts. Injury or inflammation of the ducts or the degeneration of a cyst- wall is frequently the origin of a tubular carcinoma. Fig. 464. l " ! %i A section showing the large amount of dense connective-tissue stroma surrounding the irregular islets of epithelial (carcinomatous) cells. An actual necrotic destruction of the epithelial cells is taking place. The protective and inhibitory influence of the connective-tissue over- growth occasionally seen in scirrhous carcinomata was shown in this case by the slow growth of the tumor and by the absence of metastases in the axillary lymph-nodes of the affected side. (Tissue fixed in formalin solution ; section stained with formalin-safranin. Leitz, obj. 7, ocular 4.) Symptoms of Carcinoma. — The " scirrhous " variety is by far the most frequent, and usually begins in a hard nodule located in the periph- ery of the breast. Statistics seem to prove that the largest proportion develop in the upper outer quadrant of the breast. The next most usual position is about and below the nipple and areola. Apparently the left breast is more often affected than the right ; but what is of much more SURGICAL DISEASES AND INJURIES OF THE BREAST. 1071 importance is the fact that in only 2 cases out of 869 were both breasts simultaneously affected with beginning carcinoma. When any neoplasm, therefore, develops in both breasts at the same time, there is very strong evidence that it is not carcinoma. The primary nodule of carcinoma is often discovered accidentally by the patient in the bath or while she is dressing. Pain, which sooner or later becomes a distressing symptom of all forms of carcinoma, is often entirely absent in its earlier stages. When the nodule is once discovered, the patient, overcome with a dread of cancer, often complains of pain in the seat of the tumor where just previously none had existed. By this infiltration of the tissue with young cells the tumor becomes fixed and immovable. This fixation is an early and important sign of Fig. 465. mi A small portion of a section of a rapidly-growing soft carcinoma of the breast of a woman forty- seven years of age— the so-called " acinous carcinoma " of Billroth— showing the great abun- dance of polymorphous epithelial (carcinomatous) cells, with the very sparing amount of con- nective-tissue stroma. In three of the carcinomatous cells karyokinetic nuclear figures are prominent as dark masses. (Tissue fixed in Flemming's chromic-acetic-osmic-acid mixture ; section stained with Pfltzner's safranin solution. Leitz, objective 7, ocular 4.) carcinoma. It is a fixation of the tumor itself, and any mobility made out by manipulation of the tumor is a motion of the whole breast, and not of the tumor moving within the breast. Coincident with the cellu- lar growth of the carcinoma a degeneration of the cells within the alveoli occurs, with the retraction of the connective-tissue stroma. This tendency to contraction occurs very early in carcinoma, and when the initial lesion is seated in the superficial portion of the breast there is a marked retraction and dimpling of the skin (pig-skin appearance). This is not due primarily to the infiltration of the skin by carcinoma-cells, but rather to the contracting tendency of the tumor, drawing in the ligamenta, suspensoria. In nearly 50 per cent, of all carcinomata the nipple is retracted and drawn in by the contraction of the connective- tissue stroma about the milk-ducts. Thus, carcinomata developing in 1072 SPECIAL OR REGIONAL SURGERY. and about the nipple arc much more liable to produce this symptom than those placed remotely at the periphery of the gland. As retraction of the nipple rarely occurs in non-carcinomatous conditions (5 per cent., according to Gross), this symptom becomes of importance in determin- ing the malignancy of the growth when it is present. But as it is not the earliest symptom, and may be absent altogether, and does occur in conditions other than cancer, it is not as important a sign of carcinoma as is generally supposed. Somewhat later the skin becomes adherent to and infiltrated with the carcinomatous elements. This adherent, retracted, pale, and dimpled skin is a very important symptom of cancer. Fig. 466. Advanced scirrhous carcinoma of eleven years' duration in a woman of sixty years. A superficial ulcerating process has begun in the skin overlying the tumor, and a considerable bulk of the protruding tumor is composed of a fluctuating mass of puruloid material ready to break through the surface. The axillary nodes are extensively involved. Carcinoma often disseminates itself most rapidly through the lym- phatic vessels of the skin. The points of secondary deposits appear as small hard, shot-like nodules in the skin. These nodules rapidly develop — so rapidly, indeed, that the skin assumes a dusky red, inflamed appear- ance, and coalesces into a flat plate-like mass, the squirrhe en masse of Velpeau. Not only does the carcinoma involve the skin, but it becomes adherent to all the adjacent tissues. In certain cases the entire chest- wall is so infiltrated with the carcinoma-cells that it is hard and board- like, and the ribs so fixed that the respiratory movements on that side are interfered with. Velpeau gave to this particular form the name of cancer en cuirasne. It is not to be regarded as a separate variety of car- cinoma, as has been done by some writers (Fig. 466). The atrophic cancer of Billroth is not a distinct variety. A degen- SURGICAL DISEASES AND INJURIES OF THE BREAST. 1073 eration of the alveolar cells takes place early in all carcinomata. In scirrhous or chronic carcinomata, in which the growth of the tumor is relatively slow, there is ample time for an amount of absorption of this material as well as connective-tissue organization, and the alveolar spaces become filled with whorls of connective tissue. Usually the tumor is advancing at some other point while these atrophic changes are taking place, so that it is not by any means true that carcinoma is a self- limited disease and effects a spontaneous cure in this manner. Fig. 467. Recurrent carcinoma eight months after incomplete operation in a woman seventy -five years of age, showing the extensive nodular, ulcerating surface surrounded by cancerous masses under the skin. The oedema of the right arm from the circulatory obstruction occasioned by metastatic growths about the axillary vessels is well shown. The writer saw at the London Hospital a woman in whom such atrophic changes had been taking place for eighteen years. All outline of the breast had long since disappeared, together with the nipple and areola, and only a hard, brown, leathery mass, firmly adherent to the ribs, remained. Successive visiting surgeons from the time of Mr. Curling and the elder Adams had proposed opera- tion, which had been resolutely declined, and she was when seen earning her living as a laundress. The Lymphatics. — The lymph-nodes are very early involved : those of the axilla are usually the first to be affected in carcinoma of the breast. The axillary nodes have been found enlarged and containing secondary carcinomatous deposits in every case where the axilla has been thoroughly explored in the operations upon the breast. They may be so small that it is impossible to detect them before the operation, but their presence will be revealed during the dissection. The lymphatics may be enlarged from simple irritation or inflammation, but in such 1074 SPECIAL OR REGIONAL SURGERY. cases may be felt as sejaarate, distinct nodules. Lymph-nodes contain- ing secondary carcinomatous deposits are very hard, matted together, and indistinguishable from each other. In carcinomata located on the sternal side of the breast the secondary deposits would first appear in the mediastinal nodes, a condition which can only be surmised. When the tumor is placed near the nipple not only the axillary nodes, but the infraclavicular, are early involved. Dr. Halsted finds that in nearly all cases where he has removed the supraclavicular fat and lymphatics a microscopic examination has shown the presence of carcinomatous cells. On making with a knife a section of suspected tissues which have been pre- served in alcohol or 2 per cent, formalin solution, the cancer-tissue, if present, appears blanched and white, in marked contrast to the surrounding tissues. Diagnosis. — The first question to which an answer must be given in a case of tumor of the breast is, Is it innocent or malignant ? The fol- lowing are among the most important points to be considered in arriving at a differential diagnosis : Age. — Innocent tumors appear at any age, as do the malignant neoplasms, but innocent tumors are more apt to occur at puberty and during pregnancy and lactation. Of the malignant tumors, sarcoma occurs before thirty; carcinoma, which is the most common tumor of the breast, is very rare before twenty-five, not com- mon before thirty-five, and most common from forty to fifty. This is known as the caneer period. Skin. — Innocent tumors do not become adherent to the skin (unless the tumor undergoes some degeneration or inflammation, which is most unusual). Malignant tumors involve the skin early. Either the skin becomes stretched, shiny, red, and brawny, with large veins showing upon its surface, as in sarcoma, or it is retracted, pale, and pitted, as in carcinoma. Growth. — The growth of an innocent tumor is always slow, pushing aside the normal tissues, from which it is separated by its capsule. The growth of a malignant tumor is rapid, infiltrating the tissues without any cap- sule or limiting membrane. Mobility. — Innocent tumors are usually freely mova- able, owing to their capsule and method of growth. Malignant tumors early be- come fixed and immovable (there is often an apparent mobility in carcinoma which is not real), and tumors which seemed movable on examination are often at the operation found firmly adherent to the subjacent tissues. Pain. — Innocent tumors are not usually painful ; pain becomes, sooner or later, a prominent symptom in all cases of cancer. The pain, being a subjective symptom, must be taken with great caution. The patient upon discovering a lump in the breast usually experiences some pain from that moment, although there has been no pain before, even with every evidence that the mass had been there for some time. There may Fig. 468. Cancer of male breast (Park). SURGICAL DISEASES AND INJURIES OF THE BREAST. 1075 be no pain in the earlier stages of a malignant tumor, but to wait for the appearance of pain as an essential sign of cancer would be to permit the period in which the patient could be saved by operation to slip away. Secondary affections do not occur in the growth of innocent tumors, while they always occur, and usually very early, in all malignant tumors. When lymphatic enlargement does occur in connection with the growth of innocent tumors, it is in the nature of an hypertrophy of the normal cellular elements, and not a heterologous new growth, as takes place in malignant growth. The hypertrophied nodes may be felt separate and movable, while those containing cancerous deposits are matted together and feel hard and nodular. Metastasis. — Innocent tumors never form secondary deposits in other organs. Malignant growths do form such deposits very frequently ; most important, however, is the fact that these metastases in other organs may occur very early in the development of the tumor, and are not infrequently cause of death, even after the most careful and complete local removal of the growth. Cachexia. — Innocent tumors do not affect the general health, except mechanically. With the growth of malignant tumors cachexia is always developed. Operations upon the Breast. As in every surgical operation, the patient, the operator, his assists ants, instruments, and dressings should be prepared in accordance with the principles of the most rigid asepsis. These details, having been Fig. 469. Diagram showing skin-incisions : triangular flap of skin, ABC, and triangular flap of fat (Halsted). repeatedly given in other portions of this work, are omitted here. As the hair of the patient's head is often the source of wound-infection, the head should be enveloped in a moist bichloride towel-turban, and a sterilized sheet thrown over the face and neck and fastened to the apron 1076 SPECIAL OR REGIONAL SURGERY. of the anaesthetizer, and the anaesthetic administered beneath this. The arm on the affected side is drawn well outward and upward, enveloped in sterilized towels, and given over to an assistant. The thorax and portions of the body not in the field of operation are to be protected by a mackintosh covered with sterilized towels. As the anaesthetic has to be given under a sheet and maintained for a long time, ether, when not contraindicated by organic disease of the kidneys or lungs, should be administered. Some experiments in the use of chloroform combined with pure oxygen have proved it to be a very satisfactory combina- tion. The patients are brought under the anaesthetic in from six to ten minutes; the anaesthesia is easily maintained — no vomiting, no Fig. 470. Breast and pectoral muscle completely separated from thorax ; axilla exposed (Halsted). dangerous interruptions to respiration or heart or pulse, no cyanosis, diminished shock, and patient recovers from the anaesthetic state without delirium. The Operation on Innocent Tumors. — The character of the opera- tion will depend somewhat upon the position and number of innocent tumors present. If the tumor is single and situated within the gland, the incision should be made along the groove at the lower border of the breast. The gland is raised and the capsule of the tumor opened, and the tumor enucleated, the breast replaced, and the wound closed with fine marginal silk suture. In some cases a narrow gauze drain for a few days may be necessary. If the tumor is located in the upper, outer quadrant of the breast, the incision may be made along the pectoral muscle and the breast raised and the tumor removed. By this method of Thomas there is the least injury inflicted upon the secreting structures and the avoidance of a prominent scar on the breast. If the tumor is very superficial, as lipoma, or so placed that it cannot be reached with- out too extensive disturbance of its anatomical attachment, a straight or curved incision may be made directly down upon the tumor and its removal effected. SURGICAL DISEASES AND INJURIES OF THE BREAST. 1077 Operations on Malignant Tumors. No operation upon the breast can be too extensive if infected material remains to be removed, and as the operation described by Dr. Halsted is the most complete and extensive, Ave shall give, in substance, an out- line of the steps of the operation as he performs it : The external incision (see Fig. 469) extends in a wide curve from the middle of the upper portion of the arm out over the chest and edge of the sternum well beneath the nipple, and upward, following the curve of the breast to meet the first incision. This incision should be carried at once through the skin and superficial fat. The triangular flap, a b v, of skin, free from all fat, is dissected down to the inferior border of the pecto- ralis major muscle. The separation of the pectoralis major muscle from its costal origin is now begun and carried upward, the costal portion being separated from the clavicular out to the apex of the axillary cavity. At this point an incision is carried up to the clavicle through the muscle and skin, exposing thus the apex of the axilla. Any fascia made accessible upon the under surface of the pectoralis major is now carefully dissected away. The pectoralis major is next severed from its humeral attachment and reflected with the breast-mass. The fascia over the pectoralis minor is dissected away, and this muscle divided in its middle and reflected back and held by a broad blunt retractor. The axillary vessels are exposed and carefully separated from the mass of fat and nodes occupying the space, com- mencing at the very apex and working downward, and continuing the dissection to the subscapular vessels. Every particle of fat and fascia is to be removed. The next step in the operation is to remove the supraclavicular fat and lymphatics. This may not be absolutely necessary in those cases which are operated very early, before the axillary lymphatics are in- volved. But most cases do not come to the surgeon until a much later period, and it will be, with suitable exceptions, a safe rule to follow. The incision is continued upward from the clavicle over the supra- clavicular triangle to the border of the middle of the sterno-cleido- mastoid muscle. The internal jugular vein is exposed at the inner side of the triangle, and all the fat and lymphatics removed from within outward, down to the clavicle and outward to the outer border of the triangle. The edges of the incision are brought together by a purse-string silk suture, including only the base, however, of the triangular flap. This flap is attached so as to furnish a lining for the axilla. Drainage is ordinarily unnecessary. Healing is usually by first intention. The central portion of the wound, which cannot be brought together, often heals under the blood-clot ; and if regular granulation forms, this sur- face can be quickly covered by skin-grafts after the method of Thiersch. The impairment of movement in the arm is very much less than would be imagined from so extensive removal of muscle. Many operators do not consider it necessary to make so extensive a dissection in removing the breast, and think the removal of the supraclavicular node is only necessary in exceptional cases. Dr. Halsted states that in 7 favorable cases, where the tumor was recent and small and the nodes only slightly enlarged, after 1078 SPECIAL OR REGIONAL SURGERY. the removal of considerably less tissue than in the above-described operation, he had 3 local recurrences, whereas in a series of 50 oomplete operations, many of them much less favorable from the extent of local infection, there were also but 3 local recurrences. This statement alone is sufficient encouragement to the opera- tor to master the technique of the operation by practice upon the cadaver, and to carry it out completely in every case of malignant disease of the breast. In order that these favorable results may be secured the operation must be done early, if possible before the skin has become involved or the lymphatics extensively implicated, and the operation carried out thoroughly as described. Many different drugs have been suggested in the treatment of sar- coma and carcinoma, but not a single one has stood the test of time. The local application of the various caustic pastes and solutions so fre- quently used by irregular practitioners is not to be recommended. The pain inflicted is much greater than that caused by the cutting opera- tion, while the destructive activities of the caustic cannot be entirely controlled. Furthermore, it does not reach the infected nodes, and is therefore always an incomplete operation. CHAPTER LII. AMPUTATIONS. By Rudolph Matas, M. D. Classification. — Into typical, when an amputation is performed according to established rules or methods ; atypical, when the procedure adopted is irregular and without regard to fixed precedent, with the view of meeting anomalous or accidental conditions. When a limb is removed at a joint it is an amputation in contiguity or disarticulation ; when the section of the limb is made elsewhere than at a joint it is an amputation in continuity. Amputations have been classified according to the time or period when the operation is performed, thus : (1) Imme- diate, before reaction from shock, usually within the first twelve hours ; (2) primary, after reaction, but before inflammation ; (3) intermediate, after inflammation, but before suppuration ; (4) secondary, after suppura- tion has been fully established. For all practical purposes these four periods can be reduced to the primary and secondary — i. e. (a) after reaction, before infection ; and (6) after infection. i General Indications. In general terms an amputation is indicated when a part of a limb can be saved, or when life can be preserved or prolonged or made bear- able, by no other means. The conditions that call for amputation have been enormously restricted since the advent of antisepsis. The most frequent and urgent indications for amputation are furnished by — (1) the violent traumatisms which result from railroad, machinery, and other accidents, which cause extensive and irreparable damage to the soft parts and bones ; (2) when the physical condition of the patient is such that a long post-operative treatment and long confinement in bed consequent upon conservatism, even if immediately successful, would leave a useless limb ; (3) amputations are called for in certain patho- logical conditions (non-traumatic) which render an extremity totally incapable of performing its functions, or which permanently interfere with the patient's comfort and usefulness, or which threaten his life. In this category may be classed the chronic diseases of bones and joints (tubercular osteoarthritis, osteomyelitis, tenosynovitis, etc.) which have resisted conservative treatment; the benign and malignant neoplasms that cannot be removed without the sacrifice of essential parts ; large circumferential ulcers which resist grafting or other treat- ment, very rare at present; perforating trophic ulcers of the foot; spreading sepsis ; intermuscular suppuration with threatening general infection ; malignant oedema ; spreading atheromatous or embolic 1079 1080 SPECIAL OR REGIONAL SURGERY. gangrene ; diabetic gangrene ; aneurisms that burst in joints ; and con- genital or acquired deformities that interfere with the comfort of the patient. Local Indications furnished by the Injured Parts. — The avulsion or tear- ing away of a limb admits of no doubt. No doubt will exist when a limb at or below certain points is crushed so that the circulation in the distal part is impos- sible. Compound fractures of both the bones when badly comminuted formerly called for amputation ; now they rarely do, unless too great length of bone is implicated and unless the soft tissues have suffered severe laceration. It is a good rule, other things being favorable, to attempt to save a limb if not more than two inches of the principal bone is comminuted. In attempting to estimate whether or not soft tissues have undergone too great injury for any conservative attempt, the muscular laceration should receive less consideration than the degree of injury to the skin. It is rare to save compound comminuted fractured limbs having slight laceration of the muscles, but extensive injury to the skin. One or two lacera- tions of the skin are not particularly hurtful ; it is the complete death of the skin through immense pressure, as of a weight, produced by crushing of a car-wheel or a heavy beam or a stone. If all the muscles at a given point are pulpefied, ampu- tation is of course indicated. The Vessels. — There is great danger from rupture of the main artery of a limb, a difficulty greatly increased by subcutaneous bleeding, compressing all the tissues through which the collateral supply might be estab- lished, as by a simultaneous injury of the main vein. Serious injury to the femoral or brachial vessels, high up, by a compound fracture, usually requires amputation, but a system of vessels in the forearm or leg (the anterior tibial and its branches, for instance) may be entirely destroyed at a given level and yet the limb be saved. Great contusion and laceration of muscles without fracture of bone and little injury of the skin rarely necessitate amputation — certainly not primary amputa- tion. The important point is to relieve the immense tension of the skin on account of subcutaneous extravasations of blood-serum by immediate multiple incisions or punctures of the skin (after previous sterilization), to drain away the effused fluid. No drainage-tube should be used, not even a strip of gauze ; only cauterization is required, as the least local pressure will usually cause necrosis of the already badly nourished skin, from which infection is apt to occur (Estes). Injury to the skin without serious injury to the deeper parts, with the excep- tion perhaps of the entire sole of the foot, should rarely call for amputation, owing to the great progress accomplished in grafting. In doubtful cases, when the viability of the parts cannot be determined by existing conditions, the surgeon must not be precipitate in his action, since there is very little danger in delaying the amputation as long as asepsis is maintained. The essential point to remember is, that in doubtful cases the delay pend- ing a decision is permissible, but is only made safe by the maintenance of the most rigid asepsis. Eeclus and his followers recognize the fact that crushed tissues are always infected by germs from the skin, the clothing, or earth, and form a peculiarly favorable soil for the growth of such germs. Not only is the crushed limb per- fectly useless, but if left in place it endangers life from profuse suppuration, from traumatic gangrene, and from tetanus, though the last can be warded off by a prophylactic injection of its antitoxin. An amputation wisely arranged does away with all these, dangers. This reasoning, he holds, was absolutely incontrovertible before antisepsis attained its present perfection by the thorough methods that he practises : there is no fear of such complications, provided the patient is seen early enough after the accident for antisepsis to be effective. After infection and putrefaction have set in, it is obvious that the opportunity for antisepsis is over, and the only hope of recovery lies in immediate amputation. In such cases, and in all cases in which profound shock precludes the possi- bility of immediate operation, or when it is not clear that the injured parts have been permanently devitalized, the injured area should be subjected to the most scrupulous antiseptic preparations. When the patient has rallied from shock and the death of the parts is unquestionable, there can be no advantage in waiting for A MP UTA TIONS. 1081 nature to accomplish with very laborious and exhausting efforts what the surgeon can do in a few minutes with the knife, even if one or two inches more of tissue must be sacrificed in cutting through healthy tissue. In fact, the most recent and conclusive experience (Estes) teaches that the sooner an amputation is performed after the indications for the amputation are clearly formulated the better will be the ultimate result. In every case the condition of the patient, his ability to stand the additional shock of an amputation or to cope with the danger of exist- ing or prospective infection, exhausting fever, and suppuration, must decide the operator in his preference for an immediate amputation. Instruments. The instruments required to perform an amputation may be classi- fied into those for (1) the prophylactic and direct control of hemorrhage ; (2) for cutting, dissecting, retracting, elevating the soft parts ; (3) for sawing the bone ; (4) for suturing the flaps. In addition, material will be needed to — (1) ligate the bleeding vessels ; (2) suture the flaps and approximate the soft parts ; (3) to sponge ; (4) to drain ; and (5) to dress the wound and stump. Esmarch's Method. — This consists in the application of an aseptic elastic rubber bandage over the limb after this has been suitably steril- ized and covered with a soft towel, wet with a bichloride (1 : 1000) or carbolated (2J per cent.) solution, which is wrapped around the affected limb. The elastic bandage is applied tightly from below upward in an even spiral (without reverses), and is carried as high up as is desired. The blood is all driven out of the vessels as the bandage is adjusted. Immediately above the upper terminus of this elastic roller a rubber band or hollow elastic tube is wound several times around the limb with sufficient contracting force to entirely arrest all arterial pulsation below it. The constrictor is then held in place by tying it or by a clamp (Wilson's sigmoid clasp is the simplest of the numerous devices that have been introduced for the purpose). After the constricting band is secured the elastic roller is removed, and the limb below the constriction assumes a characteristic pallor which markedly contrasts with the healthy redness of the parts above. The operation can then be performed precisely as upon a cadaver, and is absolutely bloodless. In applying the elastic constrictor or tourniquet at the root of the limb the following precautions should be observed : (1) Never apply the constrictor over the leg or forearm, as the interosseous vessels are protected from pressure by the two bones of these regions, and haemostasis must be imperfect. Always apply the elastic tourniquet over the femoral or humeral shafts, or at such points (the roots of the digits) where no vessel can escape circumferential compression ; thus in the lower third of the femur, just above the condyle, the rigid adductor magnus ten- don may interfere with complete compression of the femoral. (2) In applying the elastic tourniquet begin by compressing the vascular or adductor side so that venous choking of the limb may be obviated. This precaution is especially important when Lister's method is followed. (3) While encircling the limb with the elastic band it is necessary to avoid the repeated constriction of the same circle (linear constriction), as an exaggerated concentric compression may, in thin subjects especially, permanently paralyze the extremity by crushing the under- lying nerve-trunks. Therefore separate each turn of the rubber by an intervening space. (4) Do not allow the constricted member to be decidedly flexed or extended after the constrictor is in place, for fear of tearing subcutaneously the underlying muscles and nerves. (5) Do not keep the constrictor much longer than an hour 1082 SPECIAL OR REGIONAL SURGERY. in place, because sloughing from prolonged arterial fasting and coagulation-necro- sis of the distal edge of the flaps is likely to result. This is especially true of cocaine operations, in which the constrictor is likely to be retained longer for anaesthetic purposes. It greatly favors the absorption of toxic chemical anti- septics, as shown by Wolfler's experiments. Objections to Esmarch's Method. — (1) Excessive capillary oozing, requiring an undue manipulation, an irritation of the injured tissues, and the ligature of many more bleeding points than usual. This is due to vasomotor paresis of the compressed area, and can be corrected by the stimulus of hot water applied to the cut surface and by stroking or superficial massage of the limb. (2) It increases the risk of septic embolism and of cancerous metastasis by forcing particles from the diseased area into the venous and lymphatic circulation. (3) It greatly favors the absorption of toxic chemical antiseptics, as shown by Wolfler's experiments. These objections have led to an application of the rubber tourniquet alone (Esmarch's principle), which secures satisfactory ischsemia without the preliminary elastic compression of the limb. Instead of applying the elastic bandage, the limb is held up in such a manner that the blood is drained out by gravity. While the limb is being held up it is stroked vigorously from the tip of the extremity (fingers or toes) to the trunk ; the process (milking the limb) is followed by the application of the elastic constrictor at the root of the extremity. This method, which is at present known as Lister's method, is very efficient, and, owing to its freedom from the objections urged against elastic compression, bids fair to supplant the typical Esmarch method in most cases. Instruments for Cutting 1 , Dissecting 1 , and Retracting the Soft Parts. — One or two ordinary large scalpels are all-sufficient for the performance of modern amputations. The formidable rapier-like knives of earlier days have been discarded since the abandonment of the trans- fixion methods so popular in the pre-ansesfhetic period, when security was so frequently sacrificed to rapidity. Nevertheless, a strong, medium- sized amputating knife (6-9 inches of cutting edge — Liston's model) is almost a necessity in dividing the thick muscular layers and skin in a circular amputation of a stout subject; a long, narrow, and straight knife to divide the interosseous membrane and to disarticulate the smaller joints is required to operate with rapidity and elegance. A plain or rat-tooth dissecting-forceps, a stout pair of straight scissors, and a periosteotome to clear the bone of periosteum at the point of division, complete the outfit required for the division and retraction of the soft parts. Cloth retractors, made with stout aseptic gauze, will be required to protect the soft parts while the bones are sawn. To Divide the Bone. — The bones are usually divided with a saw. A bow saw (Butcher's model) with adjustable blades, a capital saw with movable back, a metacarpal saw, will usually suffice for all purposes ; Lister's cutting pliers, straight and bent, for division of phalanges and metacarpals ; and gouge or rongeur forceps to nip off irregular project- ing ends. A lion-jawed forceps (Farabeuf's) or osteophor may be needed to steady the movable end of the bone in re-amputating a stump. A Growan-Wyeth's exsector and Macewen's chisels will also be useful in amputating by Neudorfer's methods, and even a chain-saw may be used with advantage in all cases in which it is especially important to avoid injuring the soft parts with the saw. Drainage. — In all amputations through infected areas thorough AMPUTATIONS. 1083 drainage must be provided for. This is best secured by packing the stump with iodoform gauze, which is removed in a few days, when the surfaces may be allowed to come together if healthy. In cutting through sterile tissues no drainage is required if there is absolute cer- tainty that asepsis has been vigorously maintained and no irritant anti- septic irrigation has been produced. If such is the case and the dry sterile method of Landerer has been adopted, the deep surfaces can be approximated and all dead spaces obliterated by catgut or buried sutures. Finally, the skin-flap surfaces must be closed by interrupted silkworm sutures. If there be any doubt as to the asepsis, it is also much safer, even in healthy- looking wounds, to use either a short soft-rubber or a glass drainage-tube at each end of the stump to facilitate drainage. In sutures the greatest care must be exercised not to suture too closely or too tightly, for fear of strangulating the edges of the skin-flaps, especially in the lower extremities, where this risk is proportional, in equality of circumstances, to the distance of the cut edge from the heart. Dressings. — If the stump be septic and a tampon of iodoform gauze be used, adjust another layer of the same gauze over the surface of the stump. Then cover the whole surface with sterile gauze ; then over this, again, a large pad of sterilized absorbent cotton sufficient to protect the stump from all possible mechanical injury. Finally, a bandage must be snugly applied. If the toe has been removed, cover the foot up with dressings to the ankle ; if the foot itself lias been removed, cover the whole leg and put on a splint under the knee and thigh to secure rest. If the leg be amputated, cover it up to the middle of the thigh, and also adjust a comfortable postero-lateral splint like a trough made of perforated tin or binder's board, which can be easily moulded to the surface. The same principles apply to the upper extremity. Or&de's Method. — Crecle discards drainage and sutures and brings the flaps together by means of equable pressure with gauze bandages. In his cases the result was satisfactory, the stumps being in excellent con- dition at the end of ten days. This method can only be utilized in sep- tic conditions or in other states in which the vitality of the flaps would be endangered by suturing. Methods of Amputation. From Hippocrates to the time of Celsus the surgeon simply followed in the wake of nature, never venturing to apply the knife for the removal of a limb except within the limits of the mortified tissues ; and this seems to have prevailed for at least four hundred years. Celsus, the prince of Greek physicians, who lived shortly after the time of Christ, introduced the first innovation by cutting down to the bone between the living and the dead tissues. It is probable, according to the evidence furnished by his writings, that he was aware of the value of the ligature and that he applied it to control bleeding vessels. Archigenes, following closely after Celsus, was the first to attempt prophylactic hsemostasis by applying a cord or baud around the limb to control the hemorrhage during the amputation. With the fall of the Roman Empire and the advent of the long night of the Middle Ages the Celsian method was lost in the general darkness and the old Hippocratic doctrines survived, and were maintained by the all-potent influence of Galen and his Arabian commentators. As late as the middle of the seventeenth century the only haemostatic was the actual cautery and boiling oil, though Guy de Chau- 1084 SPECIAL OR REGIONAL SURGERY. liac had revived the teaching of Archigenes by constricting the limb, on a level with a joint, with a cord which was allowed to remain in situ, to ensure not only haamostasis, but a certain mortification of the stump. In cutting limbs huge chisels and mallets were used. At this period Botalli invented his guillotine, con- sisting of a sharp heavy axe, which, being allowed to fall from a height upon the limb, severed it instantaneously at a single blow. The revived or independent re- discovery of the ligature by Ambrose Pare in 1579, and the discovery of the circu- lation of the blood by Harvey in 1628, led to the invention of Morel's tourniquet (1674), more commonly known as the Spanish windlass, and to the familiar instru- ment, Pettit's tourniquet, which (introduced in 1718) perfected the means of securing prophylactic and direct hsemostasis. From this time onward the treatment of the stump began to receive more systematic attention. Instead of merely chopping off a limb, the soft parts were detached from the bone, so that this could be sawn off at a higher level, in order to avoid the conical projection of the stump which invariably resulted when the primitive methods were adopted. All the methods of amputation that followed — and these were numerous — aimed chiefly at celerity, to reduce the pain of the operation to a minimum, hence the rapid circular section of the soft parts or the rapid transfixion methods which were so much popularized by the brilliant work of Liston, Lisfranc, Desault, Dupuytren, Langenbeck, and others. These finally yielded, in this modern period, to less rapid but more con- servative and perfected methods, which aim chiefly at the preservation of useful tissue and at securing the very best functional prosthetic stump for the patient. Such methods could only be perfected after the advent of anaesthesia and anti- sepsis. Classification. — All methods of amputation may be classified, according to the mode of division of the soft parts, into (1) the circular and its derivatives — the oblique, elliptical, oval, racket, and double-quad- rang idar flap methods ; (2) the flap method; and (3) the mixed, superficial flap of skin and deep circular of the muscles. The" main point to be considered in the selection of a method is the following : the least sacrifice of the healthy tissue of the limb compatible with the saving of life and with the greatest possible use of the stump to the patient. To secure this most important desideratum the following conditions must be complied with: (1) The bone must be amply covered; (2) the skin must not be adherent to the bone nor exert pressure or traction upon the cicatrix; (3) the soft parts, especially the skin, must be subjected to the least traumatism compatible with the proper performance of the operation, with a view to disturbing the blood- supply and nutrition of the flap as little as possible ; (4) the main vessels must be cut transversely ; (5) the nerves must be cut high enough, so that they may not become adherent to the bone or cicatrix, or be affected by pressure upon atmo- spheric changes ; (6) projecting angles or irregularities of the bone must be smoothed and rounded, so that they may not unduly press upon the soft parts ; (7) the section of the soft parts must be made with the view of reducing the exposed scar-tissue to a minimum, and securing for this a position in the stump that shall be away from friction and the chief pressure-points in adjusting an arti- ficial limb or other prosthetic appliance. In connection with the last conditions perhaps it may be well to remember a few general facts of practical interest : The contractility of the skin is subject to great variations : it is practically lost in parts that have been long inflamed and ©edematous. The average contractility of the skin may be represented by one-third of the length of any given portion. To meet the conditions of the present day some of the simplest and oldest methods, modified by the improvements of modern technique, have again been utilized, and are coming more constantly into surgical favor. These are the cir- cular incisions. With Kocher, Wyeth, and others we believe that circular ampu- PLATE XXXIII. Illustrating Lines of Skin Incision in Amputating at Various Levels. A MP VTA TIONS. 1085 tations fulfil the general indications better than any other fundamental type of operation. In circular amputations we include not only transverse incisions, but also those running obliquely to the axis of the limb, provided the line of the in- cision continues in one direction or the incision lies in a single plane. The addi- tion of a single longitudinal incision with rounding of the angles results in the so- called oval incision (an oval with a pointed side is not strictly an oval). The addition of two longitudinal incisions with rounding of the angles results in a true flap operation. The racket (Malgaigne's en raquette) and the quadrangular flaps of Kavaton and Teale are transitions from the circular to the latter method. The tendency is, there- fore, to prefer the circular, modified to suit certain localities. We shall adopt it as a fundamental method of election, and shall refer to other procedures incidentally to the special amputations where they are indicated. ( Vide Plate XXXIII.) The transverse circular method is not only the simplest and the most easily executed, but it secures to the skin the best vascular supply and nutrition. It is contraindicated in favor of the oblique-circular or elliptical method, which is virtually also a single-flap method — (1) when more healthy skin is present on one side of the limb than on the other, otherwise the amputation would necessarily have to be carried higher ; (2) when the cicatrix cannot be placed at the end of the stump, because it is exposed to pressure from below ; (3) when, owing to the excessive elastic retraction of certain regions (as in the adductor and flexor regions of the thigh and the flexor region of the elbow), a transverse circular would leave an insufficient flap (Kocher). There are two modes of performing the circular amputation at the present day : (1) The simple (solid musculo-tegumentary) method, without cutaneous cuffs. Steps. — (1) Division of the Skin. — Both hands of the assistant retract the skin vigorously toward the root of the limb. With a medium-sized amputating knife the skin, subcutaneous adipose tissue, and superficial fascia are cut circularly with the same stroke. (2) At the margin of the fully retracted skin the muscles are divided in successive sections in a plane transverse to the axis of the limb. When the muscles are thick the superficial muscles are first severed and allowed to retract upward, and the deeper layers are divided in a higher plane because the superficial muscles usually retract more vigorously. When the periosteum is reached it is incised circularly in the plane in which the deep muscles have retracted. The periosteum is pushed with an elevator along the bone as far as necessary to cover the sawed surface. The bone is severed at the margin of the detached periosteum. When the periosteum adheres closely, as on the rough lines of the epiphyses and tendinous attachments, it is separated with the knife. In all cases in which the end of the bone is to act as a direct support, and in the lower extremity where the soft parts are likely to rest against sharp projecting angles, these must be rounded off by the saw. This type of circular amputation can be advantageously modified by cutting a short cuff of skin (one- fourth or one-fifth of the full length), after which the muscles are divided squarely to the bone and then elevated with the periosteum as before. (2) The Skin-cuff Circular (a la Manchette). — In this method the flap is made wholly of skin, which is dissected up to the line of bone sec- tion, where the muscles are divided perpendicularly to the bone. In making the dissection care must be taken to include the subcutaneous fat and superficial fascia in solido with the skin. The edge of the knife must never be directed toward the skin, but always against the underlying tissue. In order to facilitate the retraction of the soft parts, especially in well- developed muscular subjects, in cutting through conical regions, as in the upper third of the forearm, lower and middle third of the thigh, middle of the leg, and in disarticulating the shoulder and the hip, a liberating vertical incision, made in 1086 SPECIAL OR REGIONAL SURGERY. the least vascular and less exposed aspect of the limb, usually the outer surface, will aid very materially in facilitating the operation. In some regions two incis- ions may be required at equidistant points, which are cut straight to the bone parallel with the axis of the limb and at right angles to the circular incision, thus transforming the circular into two even equilateral musculocutaneous and well-nourished flaps, which are peeled solidly from the bone with or without the periosteum, as was suggested by Bavaton in the eighteenth century. A further modification of the solid circular which reduces the disturbance of the soft parts to a minimum is the method suggested recently by Neudbrfer of Vienna (1891). In this procedure an incision is made on the outer or least vas- cular part of the limb parallel to the long axis of the bone. The knife is carried down to the point of the proposed osseous section. The bone is then divided with the chisel or a Gowan's exsector, or, better, with a chain saw, and the soft parts are simply lifted up subperiosteally a sufficient length below the saw-line to ensure an ample covering. In certain conditions, such as amputations of the thigh for diabetic and senile gangrene, in which it is extremely necessary to protect the vas- cular supply from injury, this method is certain to remove the'limb with the least exposure of the blood-vessels. The Elliptical method has already been referred to as an oblique cir- cular, and occupies an intermediate position between the circular and single flap. In this amputation the upper and lower ends of the ellipse are best marked by a small incision made by pinching up a fold of the skin and cutting over it. The skin and subcutaneous tis- sues are retracted by gliding or turning a cuff' up to where the highest point of the ellipse is reached ; the muscles are cut squarely to the bone as in the circular incision. Guyon's supramalleolar amputation of the leg, the elliptical disarticulation at the elbow, are examples of this modification of the circular. The Oval or Racket Method. — The incision takes the form of an oval with an end pointed (pedunculated oval) or of an isosceles triangle rounded at its base. The edges of the wound are united in its long axis. The most typical application of this method is seen in amputating the fingers. (See Fig. 471.) The Flap Method. — The flap may be either cutaneous or musculo- cutaneous. In every flap the skin must be cut larger than the muscles. Unless the flap is subperiosteally dissected, a pure muscle-flap is unwieldy and difficult to adjust. A pure skin-flap is very apt to slough. This tendency, as Farabeuf has shown, is least observed in the integument about joints, where the vascular supply of the skin is derived from many channels. Flaps may be single or double. Carden's original transcondyloid of the femur is a typical example of a single-flap method. The limb may be amputated by a long external flap method, but the oblique circular recommended in other places is almost identical in its technique and results. Double flaps may be antero-posterior or lateral. They may be equal in size or unequal. In order to meet the cylindrical form of the limb, the flaps will fit better if made of a U shape than if cut square. This can be done in a circular amputation with lateral incisions which have two even square flaps by rounding the corners (Ravaton, Langenbeck). The flaps may be cut in three ways : (1) By transfixion. This was the favorite method in the pre-anses- thetic period, and in the hands of such masters as Liston, Lisfranc, Fergusson, and others was marvellously rapid in its execution. The great objection to this method lies in the oblique and irregular division AMPUTATIONS. 1087 of the main vessels, which imperils the nutrition of the flaps, and also in the lack of control of the knife in making the section of the soft parts. The method can- not be recommended, and is rapidly becoming only historical. It is still applicable in cutting through tendinous regions, as in the wrist, after the circular section of the skin-cuff from without inward. (2) By cutting a flap from without inward. The outline of the flaps is made by incising the skin with a scalpel. After the skin and fascia have retracted the muscles are cut obliquely to the bone, so as to leave a thinner section at the margin than at the base. Antero-posterior flaps of the thigh and of the arm may be cut artistically in this way by a skilled operator. Each flap should be at least half a diameter, and preferably three-fourths of the longest diameter of the limb. (3) Flap formed by enucleation or dasossement. Subperiosteal excision is exhibited in its purest type in Teale's double, unequal, quadrangular flap amputation, or in Stephen Smith's hooded flap of the leg ; also in lifting up from the radius and ulna the double square flaps resulting from a solid circular with two lateral incisions on the Ravaton plan. 1 SPECIAL AMPUTATIONS. A. Amputations of the Upper Extremity. Amputations of the Fingers. — Rules: (1) Save all parts of a finger, as no prosthetic appliance can replace the tactile or prehensile function of the lost digit. Exception : The proximal phalanges of the middle and fourth fingers, which usually remain stiff, extended, and in the way when the other fingers are present ; save them, however, when all the other fingers are lost. (2) The palmar surface is the most exposed to friction; it is the most sensi- tive and useful ; save and use it as flap material in preference to the dorsal integu- ment, so that the scar in the stump may be placed on the back of the hand, in the least sensitive and most protected locality. (3) The prominence of the knuckles is caused by the proximal bone (nearest the trunk), and the joint is below the knuckle. The line of articulation of the ungual and middle phalanx is one line, or one-twelfth of an inch, below the knuckle of the flexed finger; the joint of the middle and proximal phalanx is two lines, or one-sixth of an inch, below the knuckle ; and the metacarpophalangeal joint is four lines, or one-third of an inch, below first knuckle (LeFort). This is important in disarticulating. (4) The joints are best exposed by flexing the finger. (5) The arteries and nerves exposed are situated on each side (lateral surface) of each finger — important for haemostasis and cocainization. (6) Tli 3 synovial sacs which envelop the tendons of the thumb and little finger are prolongations of the common palmar bursa, which extends below the annular ligament into the forearm. The bursa? of the other digits are independent of the palmar bursa. Hence the greater risk of palmar infection in amputations and injuries of the thumb and little finger. The tendon-canals of all the fingers directly lead to the palm : this is also an easy route for infection to the palm. Methods. — The method of election should be — (1) For disarticula- tion of phalanges : Lisfranc's long palmar flap, made by running a long 1 TeaUs Amputation. — Rule: Measure the circumference of limb on a level with future saw-line, cut a long flap, preferably on the exterior surface of the limb, measuring half a circumference in length and in breadth. Then a short (usually posterior) flap one- fourth the length of the long Hap and one-half of the circumference of the limb in breadth. It is most applicable in the lower leg. 1088 SPECIAL OR REGIONAL SURGERY. Fig. 471 bistoury (finger-knife) into the joint and carrying it out between the distal phalanx and soft parts, until sufficient material is obtained to cover snugly the exposed proximal knuckle. This operation leaves a well-padded stump, without the scar in the dorsal surface. (2) For amputation through a phalanx: (1) A short, dorsal square flap dissected directly from the bone ; (2) a flap two-thirds longer taken from the palmar side is also lifted up from the bone, which is sawn or cut through with pliers. The flap is then turned over on the dorsum to be sutured to the short flap. This leaves an admirably well-padded stump. Amputation of the Entire Finger (inter-phalangeo-metacarpal dis- articulation). — The free edge of the web of the fingers, as measured from the palmar surface, is about three- fourths of an inch from the meta- carpophalangeal joint. The opera- tions of election for these fingers are — (1) for the index, a modified oval or racket flap, with longer flap pro- longation on the radial side, so that the scar will rest as far as possible from the exposed edge of the palm. A longer palmar flap will also ac- complish the same purpose. (2) For little finger (auricularis), the intero- external flap : the greatest length of the flap is on the ulnar side of the digit, so that the scar will be placed away from the ulnar or exposed aspect of the palm. (3) The middle finger is best removed like its fellow, the fourth finger, by either a simple circular cut corresponding to the line of the palmar web and a dorsal slit (Eavaton's method), which allows a free exposure of the joint, or by a Malgaigne racket. (4) The thumb can be disarticulated with greatest advantage by either a single palmar flap or a Malgaigne's racket. By whichever method, the sesamoids attached to the short flexor of the thumb should be resected. Amputation of Two or More Adjoining Fingers Simultaneously. — The best plan is to forego brilliancy and to adopt the incisions in each case which will ensure conservatism and scar protection. Illustrating various finger amputations (Farabeuf). Amputation op Fingers with the Corresponding Metacarpals. General Principles— (1) The amputation of a finger and a part of its metacarpal is a simple, benign, and conservative operation. (2) The amputation of a finger with a total extirpation of its metacarpal bone is a difficult, serious procedure which is rarely called for. (3) The only exceptions or partial exceptions are the first (thumb) and fifth metacarpal bones, the extirpation of which is comparatively easy and safe, owing to the partial isolation of their synovial articular burste from the general carpal joint, with which they usually do not communicate. AMPUTATIONS. 1089 (4) The metacarpal bone should be enucleated without hacking the inter- osseous or palmar tissues and without wounding the deep palmar arch. It is impossible to avoid opening the great synovial sac of the carpus if the complete extirpation of the second and fourth metacarpals be undertaken. Hence the great attention to asepsis to avoid septic synovitis of the wrist. (5) The deep palmar arch crosses the shafts of the second, third, and fourth metacarpal bones close to their bases, and should be avoided. (6) Each digital artery bifurcates a little more than a quarter of an inch (in adults) above the free edge of the web of the finger. (7) The metacarpal bones are most accessible from the dorsal side. (8) The best method of amputating a finger with its corresponding metacarpal is by the racket method, with a long dorsal prolongation, which extends on the dorsal surface from the phalangeo-metacarpal joint to the carpal junction. The palm should always be respected. The bone should be dissected only by enuclea- tion from the base of the finger toward the carpus, the soft parts be cleared by closely hugging the periosteum. By following these rules the only vessels requiring ligation will be the digital arteries at the web. A disregard of this rule will lead to injury of the deep palmar arch and of the interossei, and to troublesome bleeding. (9) In extirpating the index and auricularis (little finger) incline the dorsal incision upward toward the ulnar side over the base of the metacarpal for the index, and toward the radial side for the little finger. The object of this is to place the sensitive scar as far as possible from the exposed margin of the palm. (See Fig. 471.) (10) In disarticulating the thumb from the carpus remember the close prox- imity of the radial artery to the base of the first metacarpal : the artery dips into the palm in the first interosseous space. (11) In dividing the shaft of a metacarpal the best instrument is a scroll-saw passed under the bone so as to cut upward. A Liston's bone-forceps or metacarpal saw may be used with less advantage, and the soft parts must be protected by a metallic spatula or a retractor passed under the bone. Amputation of the Hand — Radio-carpal Disarticulation. (1) The radio-carpal joint is crescentic in outline, the concavity directed toward the fingers. It is most superficial on the extensor surface. (2) The top of the styloid process is the best guide to the joint. (3) The skin on the dorsal surface is scant and lax, and retracts considerably when divided. Three centimetres should be allowed for this retraction (Farabeuf ). (4) Pronation and supination will not be affected by disarticulation of the radio-carpal joint, provided the radio-ulnar triangular cartilage be not injured and the small synovial bursa of the lower radio-ulnar joint be respected. (5) It is easy to mistake the intercarpal joint between the os magnum and semi- lunar for the true wrist-joint. This can be avoided by extreme flexion of the wrist and determining the position of the styloid process of the radius as a landmark. (6) The arteries that require ligation are the radial, the ulnar, and the anterior interosseous. (7) The stump resulting from a wrist amputation should be able to support an artificial hand, and should impart to the apparatus the rotary movements enjoyed by the radius. (8) So long as a stump has no scar upon its anterior or palmar surface, and especially none over the styloid process (the most exposed friction-point), it will allow of the adaptation of any prosthetic apparatus. Methods. — The ideal stump is best obtained by the elliptical or oblique circular, which is also practically a long palmar-flap method, The highest point of the ellipse is on the dorsum of the wrist, a little to the inner (ulnar) side of the middle line and half an inch below the line of the wrist-joint; the lowest point is in the palm on a line with the middle finger, and about the length of the diameter of the wrist from the highest point. In carrying the dorsal incision to the palm on the radial side the line should fall over the carpo-metaearpal joint of 69 1090 SPECIAL OR REGIONAL SURGERY. the thumb, well below the radial styloid. The outline of the ellipse with its palmar prolongation should be first cut with a scalpel from without inward, and the wrist subsequently disarticulated from within outward by cutting the extensor tendons, dorsal and lateral ligaments while the joint is flexed, and severing the deep flexor tendons close to the carpus as the knife leaves the joint. The stump will present the scar on the dorsum. (See Plate XXXIII., C and D.) Amputation of the Forearm. (1) The normal forearm is an elongated cone in shape, the base of the cone corresponding with the elbow ; this makes it difficult to turn up the skin-cuff. (2) The lower third consists almost exclusively of tendinous masses covered with synovial sheaths, which are easily infected and may lead to rapidly ascend- ing purulent fusees of pus far from the line of section. The tendons are useless as flap material. (3) The skin on the flexor side retracts much more than that of the dorsum, in the upper third especially. (4) The arteries are normally the (1) radial, (2) ulnar, (3) anterior and (4) posterior interosseous, (5) comes nervi mediani. (In anomalous arterial conditions as many as eleven arteries have required ligation.) (5) The Esmarch constrictor must be applied above the elbow. Methods. — The best is the circular for the lower or tendinous third, and for the other parts, up to the elbow, two equal (antero-posterior) flaps, made by two lateral incisions, on the Ravaton plan. In the lower third a circular incision of the skin is made around the limb and dis- sected up with the fascia one diameter's length from the cut edge of the skin to the future saw-line. The cuff of skin is retracted and rolled over. (See Plate XXXIII., C and D.) In the middle and upper thirds the circular is the best operation. At these points, where muscles are substituted for tendons, a very short skin-cuff' is dissected upward, and the remainder of the soft parts are cut straight to the bone. Disarticulation of the Elbow. The exact position of the joint is determined by careful attention to the ana- tomical relations of the following osseous prominences : (1) The epicondyle or external condyle of the humerus; (2) the epitrochlea or internal condyle of the humerus, more easily recognized in pathological conditions than the external ; (3) the tip of the olecranon. The external condyle is situated three-fourths of an inch above the articular line; the internal condyle is more than one inch above. The humero-radial joint forms a straight line ; the humero-ulnar, an inverted V, owing to the projection of the coronoid process, thus : /\. When the forearm is extended the line of the joint is separated from the tip of the olecranon by two finger-breadths. The joint is most easily opened on the radial side, and should always be attacked by this route. The skin of the extensor surface is thin, and retracts but little ; that of the flexor side is much more elastic and retracts remarkably, especially on the outer or supinator side. In making circular sections or flaps due allowance must be made for at least one-fourth retraction in the length of the flexor surface, and special provision made to protect the external condyle, which is most liable to exposure by retraction. The stump resulting from a disarticulation at the elbow is exposed to the greatest pressure and friction on the periphery and over the external condyle. The ideal stump should have the line of scar placed behind the humerus or at least within the olecranon fossa. The ideal is impossible to obtain, owing to the AMPUTATIONS. 1091 constant tendency of the flexor muscles to drag the scar forward, thus tending to leave a purely terminal scar, but yet a very useful stump. Methods of Election. — The circular operation, if made with a view- to compensate for flexor retraction, must be obliquely inclined downward anteriorly, and thus virtually becomes an elliptical or single-flap ampu- tation. It is the simplest operation and yields the best stumps. The surest way to secure ample covering for the articular ends of the humerus is by cutting the lowest section of the ellipse the length of one trans- verse (transcondyloid) diameter. In an adult this is usually equal to one handsbreadth from the line of the joint to the point of section. The Arm. (1) The arm is almost perfectly cylindrical in outline, hence most favorable for the circular method. (2) The retraction of the soft parts is notably greater on the flexor side. The important vessels lie on the inner side. Rule : Save all that you can up to the surgical neck of the humerus. Prophylactic haemostasia is secured by elevation of the limb and applying the elastic constrictor over the acromion, and holding it in position by the hand of an assistant when the upper third is involved. For the lower and middle thirds cir- cular constriction on a level with the lower border of the axilla is applicable here as usual. The classical methods of election are, for the lower third, the cir- cular, obliquely inclined downward, on the antero-internal surface, to compensate for flexor retraction ; for the middle, the antero-posterior flap method ; for the upper third, a racket or oval, or the external-flap method of Farabeuf. The circular method, obliquely inclined to compensate for retraction, with an external liberating incision to facilitate the separation of the soft parts, as advocated by Wyeth, is the simplest, and yields perfectly satisfactory results at any level, and is here recommended in preference to all others. Disarticulation of the Shoulder. The scapulo-humeral joint is easily recognized and easily disarticulated. Its weakest and most exposed surfaces are on the anterior and external aspects of the shoulder. Prophylactic hsemostasis is a primary consideration. The important axillary vessels and nerves lie on the inner or axillary aspect of the joint. To control the axillary artery several procedures have been recommended : (1) Digital or mechanical compression of the subclavian in the supraclavicular fossa; (2) pre- liminary ligation of the axillary; (3) primary disarticulation of the humeral head without severing the internal axillary flap (which contains the nerves) until this has been grasped and compressed by the ringers of an assistant. All these are unreliable, and have yielded to two haemostatic procedures which control the bleeding in all cases : Whenever the shaft of the humerus is intact or is pre- served up to the deltoid insertion, the elastic constrictor is applied over the shoulder and vertically across the axilla, and, securely clamped or fastened over the acromial end of the clavicle, will entirely control the axillary vessels, provided these are ligated at the point of humeral section before the disarticulation is effected. Of the thirty-six methods mentioned by Lisfranc and twenty-eight figured in Farabeuf's Atlas, only one will be considered, as it is the simplest, most satisfactory, and generally applicable. This is the circular with a vertical anterior or external incision. In its result this is essen- tially equivalent to Spence's anterior and Larrey's external " racket " 1092 SPECIAL OR REGIONAL SURGERY. methods. The difference lies simply in the fact that the angles of the modified circular are rounded in the racket (Plate XXXIII., F). The Modified Circular. — Steps. — (1) Elevate and milk the limb to drain out the blood, or apply the Esmarch bandage ; (2) apply an elastic constrictor across the axilla, and secure it by tying or by a clamp above the shoulder ; (3) make a horizontal circular incision on a plane a little below the anterior axillary border ; (4) dissect the skin a short distance and allow it to retract ; (5) with the arm held in adduction cut all the soft parts to the bone ; (6) dissect the soft parts in solido from the bone, especially on the axillary aspect ; and (7) find the axillary artery and vein, which must be ligated on a level with the transverse line of section : Fig. 472. Esmarch's strap applied in high amputation of the arm (Smith). this will protect the patient from all dangerous hemorrhage; (8) make a vertical incision extending from the anterior border of the acromion externally to coronoid process and a little external to pectoro-deltoid groove, cutting closely to the bone until a junction with the horizontal circle is effected ; (9) dissect up the solid musculo-cutaneous flaps in each side of the vertical incision, thus completely enucleating the bone and exposing the joint; (10) disarticulate by opening capsular ligament and detaching the scapulo-humeral group of tendons. No vessels of importance, except possibly a circumflex branch, will now require ligation, even if the constrictor should slip when disarticulated. The principle involved in this procedure is essentially that of Fourneaux Jordan's disarticulationof the hip — i. e. to enucleate and disarticulate the humerus after securing the vessels at their peripheral section, while these can be controlled by the constrictor. 1 Wydh's Method. — When after excision of the humeral head an amputation becomes necessary, or when the limb has been torn away so that an insufficient support is given to the elastic constrictor, and this is likely to slip over the stump after disarticulation, it will be safer to introduce a large mattress needle through the anterior axillary fold and another through the posterior fold, on the plan advocated by Wyeth in disarticulating the hip, for the purpose of preventing the elastic band from slipping over the stump before the vessels can be securely ligated. ' The method is identical with that originally suggested by Kavaton for disarticula- ting the hip ; Jordan simply modernized the procedure. As described above, it is the operation practised by Esmarch and others. AMPUTATIONS. 1093 Amputation op the Entire Upper Extremity, including Parts op the Clavicle and the Whole Scapula (Interscapulo- thoracic Amputation). In the typical operation the whole limb is removed with the scapula and outer two-thirds of the clavicle. The external incisions have been materially modified by Chalot, Kocher, and others. Only the Berger- Farabeuf operation will be here considered. Steps. — (1) The clavicle is exposed, and is divided at the juncture of the middle with the inner thirds. The middle third is excised. The subclavian vessels are exposed and secured by a double ligature and divided. (2) An antero-inferior flap is cut, which, beginning at the point of clavicular section, is carried in a curve downward and outward along the outer edge of the delto-pcctoral groove, under the axilla to the edge of the posterior axillary fold. (3) A postero-superior flap is fashioned by continuing the axillary incision previously described down- ward and inward, to stop over the posterior surface of the inferior angle of the scapula. In the last part of its course the knife follows the groove along the vertebral border of the scapula, and cuts through the muscular mass formed by the teres major, latissimus dorsi, etc. (4) After cutting through all the soft parts and securing the suprascapular arteries the extremity is removed by dividing the tissues still connecting the scapula to the trunk. B. Amputations op the Lower Extremity. The Foot. — General Considerations. — The operator must always bear in mind that the foot is essentially — (1) An organ of sustentation or support and of locomotion ; (2) A tactile organ ; (3) And, exceptionally, a prehensile organ. The two last functions are not essential to easy locomotion, and can be dis- pensed with in the ordinary occupations of civilized man. The hand, per contra, is essentially a prehensile and tactile organ capable of the most highly differenti- ated mechanical functions. No artificial appliance can be efficiently substituted for an amputated hand. It is easy to replace an amputated foot only by an efficient artificial substitute, provided a perfectly healthy and painless stump is left after an amputation. No partial or complete amputation of the foot can be made physio- logically useful to the bearer unless it complies with the following conditions: (1) It must be provided with a perfectly sound pressure-bearing plantar sur- face, which can bear the body's weight and resist the constant friction of standing and walking in active life without undergoing pathological changes — viz. ulcera- tion and neuralgia. (2) This result can only be obtained by adopting such a method of amputation as will give (a) an ample covering to the bones bearing the body pressure ; (6) that will solely utilize plantar flaps, which are alone capable of bearing the body weight; (c) that will place all scar-tissue in the most protected locality — ?'. e. the dorsum of the foot. These conditions must be complied with or the foot-stump will be useless as a base of support and will be a source of perpetual distress to the bearer. Hence the extreme conservatism advocated in dealing with the upper extremity can be disregarded in the foot whenever the injury or disease will not permit the surgeon to comply with these essential conditions. Every other condition must subordinate to the one essential requisite — i. e. to leave a useful walking stump. Hence the key to success in all methods of amputation of the foot will be found in the ruling principle — a sufficiency of plantar flap to permit the cicatrix to be placed on the dorsum of the foot. 1094 SPECIAL OR REGIONAL SURGERY. Amputations of the toes are almost always disarticulations, owing to the shortness of the phalanges. Every care must be taken to save as much of the metatarsus, and especially of the first metatarsal and phalanges of the great toe, as possible. The same care need not be taken to pre- serve every possible part of the four outer toes. " A sloughing stump has often resulted from trying to preserve these almost useless digits." (1) Interphalangeal disarticulations are best effected by cutting a long plantar flap (Lisfranc's), which will leave the line of scar on the dorsum. (2) Metatarso-phalangeal disarticulations are made by the oval method. Method of Election for the Big Toe. — By internal plantar or oval flaps prolonged on the mesial side to protect thoroughly the metatarsal head. Leave the cicatrix in the interosseous space (Plate XXXIII., G). Disarticulation of the little toe at the metatarso-phalangeal joint. The same principles apply in this toe, modified to protect the exposed outer side. Disarticulation of all the Toes at the Metatarso-phalangeal Joint. — A continuous dorsal incision and complete musculo-cutaneous flap on a level with the interdigital web. On the inner and outer border the incision is shaped so as to cover efficiently the heads of metacarpals. The cicatrix must lie entirely on the dorsum. Amputation of a Toe -with its Corresponding Metatarsal. — A racket incision, a prolongation that reaches the corresponding tarsal (cuneiform) joint. In each case enucleate the metatarsal subperiosteally through a purely dorsal incision. Remove only the bone ; level all the soft parts behind. In the case of the first and fifth metatarsal bone incline the racket so that the scar will be mesially inclined and removed from the edge of the foot (Plate XXXIII., G). Partial Tarsal Amputation of the Foot. — A great many typical oper- ations have been described by operators for the partial amputation of the foot at the metatarso-tarsal, medio-tarsal, and other joints, all based upon the fundamental idea that the foot is composed of many bones which are held together by numerous complicated joints that must be respected by the surgeon. While this idea is entirely correct from the anatomist's point of view, it should be entirely disregarded by the surgeon whenever the exigencies of conservative surgery demand it. There is no special advantage in following articular lines. It is hard to break through surgical traditions that have been handed down from generation to gen- eration, but it is nevertheless wrong to sacrifice even a quarter inch of foot-tissue for the mere sake of following a classical procedure. As Agnew taught long ago in this country and others elsewhere (Guerin, Mayer, Kocher), the skeleton of the foot must be considered a surgical unity to be treated by the knife and saw, just as the femur or humerus would be, at the exact point which will yield the longest and most use- ful stump to the patient. What is essential in every case is the applica- tion of the principle of plantar flaps — preservation and scar-protection. Some surgeons and artificial-limb manufacturers have lately boldly urged the complete abandonment of all tarsal and tibio-tarsal opera- tions. Truax, whose large experience as a mechanic entitles his views to special consideration, has thus formulated his opinion : " Avoid AMPUTATIONS. 1095 amputation within three inches of the ankle-joint. Do not amputate between the metatarsal bones and the junction of the lower and middle thirds of the tibia. At all other points save all you can, and you will in every case have done the best for your patient." This would exclude all conservative foot operations, from Lisfranc's joint (tarso-metatarsal) up to the point of election in the leg. We would therefore formulate the following rule : Amputate the foot conservatively — save all you can whenever a suf- ficiently long healthy plantar or heel flap can be obtained. If the proper flap material be wanting and scar-tissue must remain on the exposed plantar surface, amputation above the malleoli or at the prosthetic point of election in the leg (junction of lower and middle thirds) of tibia. Medio-tarsal or intramalleolar stumps, if properly made, if painless and healthy, will be equally useful to the poor and the wealthy — to the poor man, because he will be able to walk independently of an expensive artificial limb ; to the rich man, because he will be able to adopt a com- pensating appliance that will disguise his deformity. In all of the partial amputations of the foot a long plantar and a short dorsal flap — cut from without inward — should be made before sawing or disarticulating the soft parts. Through the Metatarsus. — By sawing transversely at any level up to the tarso-metatarsal or Lisfranc's joint (Plate XXXIII., H). Typical Tarso-metatarsal Disarticulation — (Lisfranc's, 1818). — The anterior part of the foot is removed ; the seven tarsal bones are left in the stump. The plantar flap extends to the middle of the balls of the toes. The joint line is indicated laterally by the tuberosity of the fifth metatarsal, in front of which lies the line of the joint. On the inner side a small eminence, the base of the first metatarsal, is dis- Fig. 473. Fig. 474. Tarso-metatarsal disarticulation (Farabeuf). Stump after same. tinctly palpable. The line of the joint is convex downward and out- ward, and has a depression above, due to the recession of the second' cuneiform bone, which lies back of the general articular line 2 to 3 cm. The strongest ligament is between the first cuneiform and base of the 1096 SPECIAL OR REGIONAL SURGERY. second metatarsal (Lisfranc's ligament), and until this is severed (the master-stroke) the joint cannot be made to gape. As in all operations of the foot, the vessels are preserved in the plantar flap, great care being taken not to injure them, on a level with the divided bone. Lisfranc's operation is an admirable exercise on the cadaver, but it is rapidly becoming historical in practice, an even and simple saw- section being substituted with advantage for the more difficult disar- ticulation. Medio-tarsal Disarticulation. — (Chopart's Operation, 1787). — In the typical operation the astragalus is disarticulated from the scaphoid, and the calcaneum from the cuboid. The astragalus and calcaneum are the only two bones left in the stump (Plate XXXIII., H). The line of the joint is indicated on the inner side by the marked projection of the tuberosity of the scaphoid bone, behind which it lies, and on the outer side by a tubercle on the body of the calcaneum, which lies just behind the calcaneo-cuboid joint. An oblique circular or elliptical incision strikes the line of the joint on the dorsal aspect, and passes behind the balls of the toes on the plantar surface. Two short dorso-lateral incisions facilitate the exarticulation (Kocher). The main connection between the bones is the Y-shaped ligament from the body of the calcaneum to the scaphoid and cuboid. The operation has often resulted in a bad stump, owing to equinus position of the foot and chafing at the anterior and inferior angle of stump, especially when the scar is left too low anteriorly. The best preventive measure for this is to attach the dorsal extensor tendons firmly to the stump, prophylactic tenotomy of the Achilles tendon, and primary union to reduce to a minimum the amount of scar-tissue. As in Lisfranc's operation, the saw can be carried through the line of the joint without regard to the articular lines, any loose or thin shavings of bone or carti- lage that may remain being removed after the section. The astragalus may be cut through with saw 1 cm. behind Chopart's astragalo-scaphoid joint, without impli- cating the ankle, thus ensuring still a movable stump. Subastragaloid disarticulation consists in disarticulating the astrag- alus from the calcaneum. It leaves only one bone of the foot in the stump. The original operations proposed by Lignerolles (1839) and Textor (1841), subsequently popularized by Malgaigne, and the numerous modifications that have followed, can be resolved into two methods of cutting the soft parts: (a) The oval or racket ; and (b) the heel-flap method. The oval incision begins horizontally under the tip of the external malleolus, extending toward dorsum to Chopart's line (which is distinctly marked, as above, by the tuberosity of the scaphoid), along which it descends vertically to the sole on the internal side, back to the point of beginning on the outer side. Chopart's joint is opened from above between the head of the astragalus and the scaphoid. Then, without penetrating deeper into this joint, the narrow knife is turned immediately upward and back- ward under the head of the astragalus, so as to sever the strong interosseous astragalo-calcanean ligament in the sinus tarsi, and the calcaneum is enucleated close to the periosteum in the upper, outer, and lower surface, then inward, and lastly posteriorly. On the inner side the most difficult step is the separation of the sustentaculum tali, which extends high up. When the skin-covering is insuf- ficient the head of the astragalus is sawed off (Kocher). Tibio-tarsal Amputation. — Total amputation of the foot (Syme's operation). In the original operation the whole skeleton of the foot is removed, including the ankle-joint with the malleoli. The cutaneous A MPUTA TIONS. 1097 hood of the heel, which contains the calcaneum, alone remains as a flap with which to cover the sawn surfaces of the tibia and fibula. This is still a very useful operation (Plate XXXIII., H). (1) The foot is held flexed at right angles with the leg. A deep incision is made, penetrating to the bone throughout its course from the apex of one malleolus to the other, crossing the sole of the foot trans- versely. (2) The foot is lowered, pressed strongly downward, and a second incision made transversely across the anterior surface of the ankle-joint from the apex of one malleolus to the other, joining the ver- tical with the horizontal incision. (3) Open the ankle anteriorly ; cir- cumscribe the malleoli ; divide the lateral ligaments ; dislocate the astragalus forward. (4) The os calcis is now exposed by traction, and the heel-cap is carefully peeled away with the knife from the calcaneum, being extremely careful not to buttonhole it. The heel-cap can be dis- sected or peeled off first before opening the ankle. (5) Retract the heel and all soft parts away from the tibia and malleoli, and run a saw transversely just above the articular line of the tibia, thus removing the malleoli. The cartilaginous surface may be left behind, and the malleoli alone removed. (6) The hood of the flap is now raised and sutured over the divided tibia to the anterior skin of the leg. If drainage be required, tap the heel-cap on the outer side of the tendo- Achilles attachment ; never perforate the plantar or active surface of the stump. Special Recommendation. — Never cut obliquely backward on the inner border of the heel-flap, or encroach upon this beyond the vertical line indicated, for fear of mortification through injury to the posterior tibial and plantar vessels (Wyeth). Pirogoff's Modification. — The leg-bones are sawed off by a Syme's operation just above the articular line, and to the sawed surface is attached a posterior section of the tuberosity of the calcaneum. The preservation of this part of the os calcis has the great advantage that the skin of the heel remains well nourished and the so-called heel-cap remains filled. With Kocher, Wyeth believes it preferable to Syme's disarticulation as a walking stump. Other atypical conservative operations on the foot have also been devised to meet certain unusual pathological or traumatic con- ditions (Plate XXXIIL, I). Amputation of the Leg. In olden times, when the injury or disease was below the knee it was custom- ary to amputate at the upper third of the leg, with the view to flexing the knee- joint and resting the body on the knee on the generally used peg leg. If the injury were at or near the knee," then, when possible, at the lower third of the femur, as giving the best stump or one most easily fitted to a conical socket, and which would support the necessary pressure on the sides of the stump in walking. In these days, however, the peg leg is rarely seen except among the extremely poor class (the indigent negro population of the South most often), and the mutilation is not so palpably advertised. With the great advances accomplished in the last few years in the manufacture of artificial limbs, and the great reduction in their cost which has made them attainable by almost all classes, the old points of elec- tion have radically changed and the technique of amputations, especially of the lower extremity, has been more than ever subordinated to the exigencies of the prosthetic art. 1098 SPECIAL OR REGIONAL SURGERY. It should be remembered that in amputations through the continuity of the leg the weight of the body is borne by cone-shaped sockets which hold the stump very much as if we attempted to lift a person from the floor by grasping the leg below the calf with both hands. The pressure is therefore circumferential, and in the leg the greatest friction- and pressure-point is in the antero-inferior surface of the stump, which is chiefly used in lifting the artificial leg in walking. Diametrically opposed to the old teaching, we now understand that we cannot have too much natural leg. It is the lever that controls the artificial part, and the longer the lever the better the walking results. While the majority of skilled mechanics agree that it is possible to fit an artifi- cial limb to any length of leg, it is admitted there are some bone-sections that are much more desirable than others from the purely prosthetic or mechanical point of view. Thus, instead of considering the point of election to be a handsbreadth below the knee-joint, as it used to be, the ideal point of election is now placed at the junction of the middle and lower thirds of the tibia — the point of election, be it under- stood, only referring to the bone, and not the soft parts. This leaves space enough underneath the end of the stump for the placing of an artificial joint of the most approved pattern, giving a stump of ample length to provide sufficient leverage to enable the patient to easily swing a substitute, besides leaving the calf in a cone shape, that it may be made to assist the head of the tibia in supporting and carry- ing the weight of the body. The tibia of an adult should not be amputated at a point less than two and a half or three inches from its upper articular surface, as it will flex under the influence of the stronger flexors. The knee will be useless as an articulation, but it will make an excellent stump, as it gives the best possible support. Bearing in mind that the most active surface of the stump left after a leg amputation is its antero-inferior angle, the greatest care should be observed in securing a stump that will exclude most rigorously all sensi- tive and weak scar-tissues at this point. Hence all operations must be rejected which systematically throw the cicatrix in front of the shin. The methods which are best calculated to meet the essential condition — the line of scar posteriorly placed — are : (1) The modified circular (also called bilateral) flap of Stephen Smith ; (2) Bruns' circular (oblique), with lateral liberating incisions which convert the stump into an equal (quadrangular) antero-posterior flap operation ; (3) the long anterior and short posterior flaps, curved or quadrangular (Teale's) ; (4) the long antero- external ; (5) the simple long anterior flap (Bell). Any of these methods will yield admirable stumps, provided the following con- ditions are complied with : (1) That there shall be an ample sufficiency of well- nourished flaps ; (2) that the projecting antero-inferior angle of the tibial crest be rounded off; (3) that the fibula be cut at a higher level than the tibia, so as to favor a conical formation of the stump ; (4) that the scar-tissue be kept away from the antero-inferior angle or surface ; (5) that the end of the stump be mobile and not adherent to the bone (which is best obtained by retaining solid musculocuta- neous flaps and periosteal cuff's) ; (6) that the nerve-trunks be cut high up above the peripheral line of pressure. At the Supramalleolar Point — Guyon's Amputation (see Fig. 475). — Make an elliptical cutaneous incision which crosses the heel below the tendo- Achilles attachment, and reaches a point one inch above the lower articular edge of the tibia anteriorly. Dissect up a solid flap pos- teriorly from the heel, cutting through the tendo-Achilles at its inser- AMPUTATIONS. 1099 tion, hugging the bone all the way. Divide the anterior extensor ten- dons transversely — by transfixion preferably — and saw the bones above Fig. 475. Guyon's supramalleolar amputation (Farabeuf). the malleoli, so that the lower or heel end of the ellipse may be brought distinctly forward. Be careful to cut the post-tibial nerves high up, so that they shall not be exposed to pressure. At the Point of Election (junction of middle and lower thirds of tibia) (Plate XXXIII., I). — Commence an incision with a large scalpel in the centre of the anterior surface, and carry it downward along the side of the leg, so as to make a slightly curved flap with its convexity below : when the incision passes over the prominent part of the leg toward the posterior surface, incline it upward until the middle of the limb is reached, where it should be continued directly up (on the racket plan) to the point at which the bone is to be divided ; make a similar incision on the opposite side. Dissec£ the skin up to the extent of one inch in the adult leg (two inches in the thigh). Now make a circular division of the muscles to the bone with a long knife. Saw the bone at this point, and direct an assistant to seize and hold the extremity firmly with strong bone-forceps. With the elevator raise the periosteum from the tibia to the point where the latter is to be cut ; divide the bone again at the base of the periosteal flap (half a transverse diameter of leg from edge of retracted flap to the last saw-line). The fibula must be cut at a higher point. The Gowan-Wyeth exsector is advantageously used here : a narrow metacarpal saw, or even a chain-saw, will effect the division of the fibula with little injury to the soft parts. The stump left by this amputation is covered by the integument internally, the periosteum externally (in young children the periosteal cuff is not desirable, as the bone is reproduced too rapidly and a pathological conicity of stump will result), while the intervening tissues — muscles, vessels, and nerves — have not been disturbed in the dissection. The periosteal flap falls like a hood over the end of the bone ; the skin-flaps lie in contact without tension ; the drainage is direct from the angle behind. When cicatrization is complete the cicatrix lies posteriorly to the end of the stump; the terminal cushion is freely movable, and the bone does not undergo the usual amount of atrophy. 1100 SPECIAL OR REGIONAL SURGERY. This method is described in detail, owing to the importance of the correct prin- ciples of flap-formation that it illustrates in this most important region. This method of amputating is much more tedious than the old rapid circular with cuff or flaps, and is therefore not very popular with the rapid amphitheatre teachers of the old school, but the admirable stump that results from it amply compensates for the time taken in its execution. In this, as in other solid flap or periosteal operations, the metallic retractor shields of McCurdy will be found to be of some service in protecting and retract- ing the soft parts. Bruns' Method. — Draw the skin up strongly and make an oblique circular incision down to the bone at a distance below the future saw- line equal to two-thirds of the diameter of the leg at the saw-line. Liberating incisions, about two inches for adults, are carried upward from the circular incision, dividing all the soft parts over the inner border of the tibia and the outer aspect of the fibula. Without dis- turbing the attachments of the skin and underlying soft parts, the Fig. 476. Fig. 477. Keetley's dermatoplastic amputation of foot, necessitated by extensive ulcer (Chalot). periosteum is carefully raised from the tibia and fibula as high as the lateral liberating incisions extend, and first the fibula and then the tibia are sawn through. The tibia, as in other operations, is cut obliquely to prevent angular projection of the crest. This amounts to a subperiosteal excision of the bones of the leg, and leaves an exceedingly serviceable and well-protected stump. The angles of the flaps can be rounded off if preferred. When finished this leaves a double antero-posterior flap stump. The Knee. When disarticulation has been decided upon, it is best, if possible, to follow Brinton's suggestion (1872) to preserve the semilunar cartilages. By this means the ligamentous covering of the knee is preserved, and all the fascial relations are preserved intact, which eventually prevents retraction and guards against the pro- AMPUTATIONS. 1101 jection of the condyles. This is totally contrary to the opinions of prosthetic writers of authority, who advocate a total abandonment of disarticulation at the knee, and who, judging purely from the standpoint of mechanical convenience Fig. 478. Gritti's osteoplastic supracondyloid knee amputation : patella utilized (Farabeuf ). and economy, universally claim that the ideal knee operation and point of selection should be three inches above the joint, and that Gritti's supracon- dyloid operation affords much better stumps than a simple disarticulation (Fig. 478). All prosthetic mechanics do not deny, however, that a simple knee dis- articulation offers any insurmountable obstacles to successful prosthesis, and, as this operation is unquestionably superior from the anatomical and sur- gical (conservative) points of view, we shall give it due consideration (Plate XXXIII., I and K). The advantage of disarticulation over the simpler and more brilliant- looking amputation through or above the femoral condyles are many and striking : (1) There is. less shock, less hemorrhage, less loss of limb, and less liability to infect the connective-tissue planes or marrow-canal ; (2) Important muscular attachments are left undisturbed, and there is little muscular retraction ; (3) The stump is an excellent one, capable of great mobility and of bearing direct pressure. The conditions for a successful disarticulation are — (1) That the joint must be absolutely healthy, free from injury, disease, or infection ; (2) that the necessary ample flap can be secured from the anterior surface of the leg to thoroughly cover the large condyloid surface with- out tension ; (3) that the patella and semilunar cartilages should be retained (this is not absolutely necessary, but desirable) ; (4) that the anterior surface of the stump shall be free from all scar-tissue. The length of the anterior flap-covering can be readily estimated by cutting a flap from the anterior surface of the leg, which shall measure the length of the transcondyloid diameter of the femur, from the line bounding the patella to the point of anterior section in a semiflexed position of the limb. This will correspond, as a rule, to a point one inch below the tubercle of the tibia and will furnish ample covering for the condyles. Methods of Election. — Stephen Smith's Bilateral (or " hooded flap ") Method. — With a large scalpel commence an incision about one 1102 SPECIAL OR REGIONAL SURGERY. inch below the tubercle- of the tibia, and cut to the bone ; carry it down- ward and forward beyond the curve of the Fig. 479. s ide of the leg, thence inward and backward to the middle of the leg, thence upward to the middle of the popliteal space. Repeat this incision upon the opposite side ; raise the flap, consisting of all the tissues down to the bone, until the articulation is reached, divide the lateral ligaments, and enter the joint and sever its connections internally Stump after Stephen Smith's ampu- „ j „„j.„ „11„ tation at knee. and externally. Be especially careful with the internal flap, which should be prolonged downward a little more than the external to provide sufficient covering for the internal condyle, which is longer and larger than the external. By this method a well-rounded stump is obtained with a cicatrix sunk in the intercondyloid fossa. Amputation of the Thigh. Through the Condyles. — The osseous section of the femur is made at the base of the condyles, about the level of the tubercle for the inser- tion of the abductor magnus tendon, or a little above this spot. At this level the medullary canal is not opened, as it begins one or two inches higher in the narrower part of the shaft. The saw-line corresponds to the epiphyseal line, which in children must be removed, for fear of secondary growth of bone and conical overgrowth of stump. If the patella is removed as in Carden's amputation, great retraction must be expected in making the muscular section, and due allowance must be made for this in cutting the anterior flap. Methods of Election. — Carden's transcondyloid (1846) consists in reflecting a rounded and semioval flap of skin and fat from the front of the joint (one diameter's length from the point of osseous section), divid- ing everything else straight down to the bone, and sawing the bone slightly above the plane of the muscles, thus forming a flat-faced stump with a bonnet of skin to fall over it. The patella is divided immediately above its upper border, and is thus excluded from the stump. Lister modified this operation by cutting a short posterior flap. Gritti'* osteoplastic operation (1857) consists not only in removing the condyles, but also of sawing the articular surface of the patella and placing its cut surface upon the sawn condyles for the purpose of secur- ing union of the bones (Fig. 478). Stokes's supraeondi/loid modification, which has been generally substi- tuted for the original Gritti, consists in dividing the femur higher up, at a point from one-half to three-quarters of an inch above the con- dyles. The section of the femur at this level is more nearly equal in size to that of the divided patella. The patella at this point is not pulled up by the quadriceps as easily as in the lower or transcondyloid section of Gritti. Through the Shaft and Upper Portion. — Conservatism should rule here. Save every inch of the femur up to the trochanteric line, AMPUTATIONS. 1103 and above this line disarticulate at the hip. Every method of amputa- tion has been applied here with greater or less success. Anatomical Points. — (1) The skin on the inner adductor and flexor surfaces has a great tendency to retraction; hence circular incisions through the lower third should be made obliquely downward to compensate for the unequal retrac- tion of the skin. An oblique section will become a circular after the skin has retracted. (2) The thigh muscles retract very unequally when divided, this retraction being most conspicuous in the hamstring muscles posteriorly and on the inner side of the adductors, owing to their separate attachment to the pelvis. Hence the suggestion of Dawbarn, Brown, and others to tenotomize the hamstrings before amputation, so that full retraction may take place before the amputation is made. There are over twenty recognized methods of amputating the thigh, and there is considerable division of opinion among leading authorities as to which should be preferred, the circular or the flap method (Plate XXXIIL, L). For the reasons given elsewhere we would unhesitatingly recommend the following section of the thigh, from the supracondyloid line of Gritti to the trochanters : The circular, modified by giving it sufficient obliquity downward to compensate for the cutaneous and muscular retraction, and by adding an external liberating incision on the outer aspect of the limb (Wyeth), or by making liberating incisions on each side from the circular line to the level of the osseous section (Ravaton). Whenever the circu- lar is made, the subperiosteal or paraperiosteal solid-flap section is referred to with very short skin-cuff. The preferred circular method is identical with that described in the section on methods of amputation. The bilateral solid flap (or hooded flap) method of Stephen Smith. The procedure is the same here as in the leg, and much simplified by the presence of one bone. Neudbrfer's Method. — This is virtually a circular with lateral lib- erating incisions — only differing in the fact that the osseous section is made first and the flaps cut afterward. It is especially indicated when the disturbance of the soft parts and skin must be reduced to a mini- mum (amputation for senile and diabetic gangrene, etc.). By any of these three methods perfect, movable, well-protected, and well-padded stumps are obtained. The scar-tissue is all thrown back- ward, away from the terminus of the stump, owing to the secondary contraction of the flexors and adductors. The Hip-joint. Disarticulation at the Ilio-femoral Articulation. — The indications for disarticulation are furnished by all injuries or diseases which impli- cate the femur up to the trochanteric lines. The notable exception to this rule of conservatism is in malignant disease of bone, especially medullary growths connected with the middle and upper third of the femur. Here the tendency to recurrence will be diminished by disar- ticulating through the joint. Anatomical Landmarks. — The hip-joint is most accessible and easily opened from the front. The pubic spine is on a level with the great trochanter. The summit of the great trochanter is on a level with the hip-joint. The important vessels are the femoral and its branches, which lie on the antero-internal aspect of the joint. The femoral is separated from the capsule of the hip by the 1104 SPECIAL OR REGIONAL SURGERY. muscle, upon which it lies. The sciatic and its branches are the most important arteries. Special precautions must be taken against— (1) shock; (2) hemorrhage. Thorough haemostasis is the surest way of preventing shock. Prophylactic intra- venous injection of hot normal saline solution (about 40 gr. chloride of sodium to 1 pint) is the most efficient mode of preparing a patient who needs stimulation. In every case in which shock exists, or there is traumatic anaemia from antecedent hemorrhage, inject the saline solution. In every case in which serious shock is apprehended expose the median basilic in the arm, and have it ready to receive the cannula and hot saline solution. Prophylactic haemostasis, with the view of controlling the femoral circulation, has been attempted with more or less success by several methods : Compression of the abdominal aorta mechanically with tourniquets, Lister's, Esmarch's, etc., or by the hand, of which Mac- ewen's recently proposed method is the best ; compression of the common iliac through the rectum, mechanically with Davy's lever ; with the hand (Woodbury's plan) ; by direct compression of the iliac trunks intra- peritoneally, or extra-peritoneally by compressing the common femoral over Poupart's ligament with the finger ; by preliminary ligation of the iliac or femoral arteries and veins ; by elastic circular constriction, as adapted from Esmarch by Jordan ; by Wyeth's method, transfixing the limb with skewers which are passed transversely through the root of the limb between the joint-capsule and the artery, and compressing the soft parts above with an elastic cord tied in a figure of 8 ; or by using two skewers, one in front and one behind the femur (Tredelenburg and Newman) ; or by transfixing the thigh antero-posteriorly (Myles) and applying the figure of 8 laterally ; or by a preliminary dissection of the vessels and their compression with a special compressor (Dillon Brown, 1895) ; or by excising the femoral head by external incision and com- pressing the anterior and posterior halves of the limb separately with elastic bands (Senn). Fig. 480. Wyeth's bloodless method : pins inserted and tube applied. All of these methods have been used with greater or less success by their inventors, and may have some advantages in special cases, but none can compare in their general application, thoroughness, simplicity, and wide range of usefulness with Wyeth's method, which must be consid- ered the method of election. AMPUTATIONS. 1105 Wyeth's Bloodless Method. — Steps, — (1) Expose the median basilic or cephalic in the arm in readiness for saline infusion. Place the patient with the trunk on the edge of the table. Lower the trunk. Elevate the limb and milk it to empty it of blood, or apply Esmarch's bandage from toes to trochanters according to general rules. (2) While the limb is still elevated or the Esmarch bandage is in posi- tion a large mattress needle or skewer, about three-sixteenths of an inch in diameter and ten inches long, is introduced one inch below the ante- rior superior spine of the ilium and slightly to the inner side of this prominence. It is made to traverse superficially the muscles and fascia in the outer side of the hip, emerging on a level with, and about three inches from, the point of entrance. Another needle is now made to enter one inch below the level of the crotch internally to the saphenous opening, and, passing squarely through the adductors, comes out an inch below the tuber ischii. The points are at once shielded by bits of cork to prevent injury to the hands of the operator. No important structures are endangered by these skewers. A piece of strong white rubber tube, half an inch in diameter and long enough when tightened in position to go five or six times around the thigh, is now wound very tightly around and above the fixative needles and tied. If the Esmarch bandage has been employed, it is now removed. By using the skewers and con- strictor high up in this way the absolute occlusion of every vessel at the level of the hip-joint safely above the field of operation is secured, per- mitting the disarticulation to be completed and the vessels secured before the tourniquet is removed. (3) Division of the soft parts. In the formation of the flaps the surgeon must be guided by the condition of the parts within the field of operation. When permissible the following method seems ideal : About six inches below the tourniquet a circular incision is made, and this is joined by a longitudinal incision commencing at the tourniquet aud passing over the trochanter major. A cuff that includes the sub- cutaneous tissues down to the deep fascia is dissected off to near the level of the trochanter minor. At about the level of the trochanter minor the remaining soft parts, together with the vessels, are divided down to the bone by a circular cut, and, in order to facilitate the search for the vessels, the soft parts are rapidly removed from the femur for several inches below the line of the divided muscles. At this stage of the operation the large vessels, veins as well as arteries, should be tied with good-sized catgut. Now leave the entire extremity intact, and use the full length of the limb as a lever in divid- ing the head of the bone. When the large and easily recognized vessels have been secured, the muscular attachments to the extremity of the bone are lifted off with scissors or knife, keeping along very close to the bone. After dividing the capsule of the joint forcible elevation, abduc- tion, and adduction of the thigh permit the entrance of air about the socket, and at the same time rupture the ligamentum teres. The dis- articulation is thus readily effected. Try to sever all known anatomical arteries before loosening the elastic constriction. In this, as in other amputations through thick muscular areas where small retracted arterial branches are likely to give trouble in finding them, after securing the main branches, such as the two femoral, circumflexes, and sciatics, it will 70 1106 SPECIAL OR REGIONAL SURGERY. be an expeditious plan to pass deep catgut sutures through the great masses of muscle all the way up across the cut surface, and to tie these firmly. In this way dead spaces are obliterated, the muscles are brought together, and compression exercised, which prevents bleeding. The Stump. After the saving of life and the removal of the offending part, the object of every amputation is to provide a healthy stump that will render the greatest possible service to the bearer in after life. A good stump is characterized by its regular outline, its firmness, solidity, mobility, painlessness, and capacity for resisting friction and pressure at exposed parts. The bone should be amply covered, and the skin covering it should not be adherent to its surface ; the scar should be linear if possible, and completely hidden in a narrow groove in the most inactive surface. In shape, especially in the lower extremity, it should be like a gradually decreasing cone with a well-rounded outline and free from uneven surfaces. For prosthetic purposes it must be of sufficient length to provide leverage with which to swing an artificial limb, and possess the firmness to bear the contact with the - socket, that both the natural and artificial socket may now move and be operated as one (Truax). The bad stump is characterized by a deficiency in the preceding qualities, and is usually associated with either one of the following con- ditions : viz. conicity (pathological or physiological), ulceration of the Fig. 481. Fig. 482. Ideal stump. Bad stump, because posterior flap was cut too short, and there has been great retraction of all soft tissues (Farabeuf). skin and other soft parts, necrosis of the bone, neuralgia. A bad stump may owe its evil properties to many conditions which are not necessarily associated with the method adopted during the amputation. An ampu- tation wound is liable to all the ills and misfortunes which may attend the course of any other traumatism. Thus sloughing of the skin, with excessive retraction of the soft parts, may be caused by defective nutri- tion of the extremity from constitutional conditions or pre-existing visceral lesions which interfere with the venous return or diminish the arterial supply (senile atheroma) ; from defective innervation, peripheral or central trophic lesions of the nervous system ; certain infections — viz. erysipelas, malignant cedema, also diabetes. After the stump heals a large weak scar-surface remains, which usually becomes painful and AMPUTATIONS. 1107 eczematous with the least provocation. Corns may also develop over exposed friction-points, or adventitous burste may form which inflame easily and help to make the artificial limb intolerable. If the flap- covering is insufficient, the soft parts may retract to such an extent that the bone will project naked at the end or be merely covered with scar- tissue : this is the typical pathological conical stump. If the bone become infected, osteomyelitis and necrosis will follow. The rough or too rapid use of the saw during the amputation is not a rare cause of necrosis of the bone, which frequently necessitates reamputation. A secondary conicity of stumps is not rarely observed after amputations in children, due to the physiological growth of bone during development. This is also a not infrequent cause of,reamputation, and must be borne in mind in pedi- atric practice. The stump may present a healthy appearance in every respect, and yet it may be very painful (the neuralgic stump), and thus be more than useless to its possessor. This neuralgic condition may be due to adhesion of nerves to the scar or pressure on these parts at friction-points, and is usually associated with bulbous enlargement or neuromatous tumors of the divided nerve-trunks. This is also largely due to the neglect of the precaution previously urged — i. e. to cut the nerves high above the original lines of amputation, so that they may be pro- tected and prevented from contracting adhesion to the scar. The Care of the Stump after Healing, Preparatory to the Use of an Artificial Limb. — The tendency of stumps, especially those of the lower extremities, is to remain a long time enlarged and flaccid. When- ever the amputated extremity is allowed to hang in a dependent posi- tion it becomes oedematous and cyanotic from vasomotor paresis. In time, if not treated actively, it also develops a tendency to accumulate fat, which makes it so unwieldy and thick at its terminus that it inter- feres with the proper adjustment of the conical socket of the artificial limb. In amputations of the leg below the knee the stump will have a tendency to become flexed and the knee stiffened and ankylosed in consequence of the unbalanced traction of the powerful flexor muscles. The adjustment of an appropriate splint during the healing process, the frequent bathing of the limb with hot water and alcohol, daily move- ments of the joint, systematic massage, and, finally, the application of a firm roller bandage from the extremity to the root of the limb, will correct these difficulties and will rapidly prepare the stump for the pros- thetic appliance. How Soon after Amputation should an Artificial Limb be Applied ? — The time is variable and depends upon a multitude of con- ditions. The average period is three months (Agnew), but the safest rule is to allow just as long a time to elapse as is necessary for the thorough healing of the stump, and no loncjer (Cook). If too much time be allowed to elapse after the healing of the stump, the muscles become atrophied and inert, the joints stiffen, and a much longer prac- tice is required of the patient to acquire the necessary mastery of the artificial substitute for the lost part. CHAPTER LIU. ORTHOPAEDIC SURGERY. By Robert W. Lovett, M. D. Torticollis. Torticollis is the name applied to a condition characterized by a deformed position of the head, which is held to one side by a unilateral contraction of the sterno-mastoid and other muscles. This condition is also spoken of as wry-neck and caput obstipum. The affection is either congenital or acquired. Of the congenital form, (1) a class of cases occur where the condition is undoubtedly due to that obscure cause, call it what we may, which results in club-foot and similar deformities. In these cases the wry- neck is accompanied by other malformations. (2) Abnormal pressure in the uterus is undoubtedly the cause of some cases, and is manifested not only by the twisted position of the head, but in an asymmetry of the cranium and face, the side on which the muscles are contracted being the smaller. (3) Inflammation of the muscle undoubtedly occurs, as manifested by the pathological data about to be spoken of. (4) Affections of the nerve-centres and of the nerves themselves have been alluded to, but the theory rests upon no scientific foundation. (5) Rup- ture of the sterno-mastoid muscle, occurring perhaps at birth, is an undoubted cause of torticollis. Of late attempts have been made to deny the existence of hematoma as a cause. A case, however, has been reported by the writer where a child was seen shortly after birth with a tumor in the sterno-mastoid muscle, evidently the result of a tearing of it. This case two years later showed a typical torticollis. Acquired torticollis results from muscular contraction — (1) due to exposure to cold, when it is probably rheumatic in origin ; (2) it results from unequal sight in the two eyes, which makes it necessary to hold the head to one side in reading, and which may result in a permanent contraction ; (3) contraction of the muscles, and consequently wry-neck, may occur from burns, injuries, or tumors; (4) it may be the result of a tonic or clonic muscular spasm due to some central or peripheral cause affecting the nervous system. It may also result from paralysis. Both congenital and acquired torticollis occur most often in children. Pathology. — The pathology of the affection has been determined by autopsy and by pieces of affected tissue removed during operation. In some instances the muscle appears normal. More often, however, the contractile tissue is replaced by fibrous tissue. This may be in small patches, in which case Volkmann 1 and Vallert 2 have assumed 1 Cent. f. Ohir., 1885, No. 14. 2 Ibid., 1890, No. 38. 1108 ORTHOPEDIC SURGERY. 1109 the existence of a "fibrous myositis," or the whole muscle may be trans- formed into a tendinous band (Biindell, 1 Hensinger 2 ). Shortening of the muscle on the affected side may be several centimetres (Bouvier, 3 Guyon 4 ). In a case of congenital torticollis measured by Shaffer 5 when the patient was six years old, and again when sixteen, the length of the muscle was found to be the same at both times. In old cases where the muscular substance has been replaced by fibrous tissue the muscle is adherent to the sh ath by many bands, and in some severe cases the two structures bee me fu:;ed and cannot be identified (Duval, 6 Bouvier). The sternal fascia is more often contracted than the clavicular. Asym- metry of the head and lower jaw exists in many cases (Nelaton, Broca, Eulenberg, Witzel 7 ). After rectificatijn this becomes more prominent than before. It is said that atrophy of the cerebral hemisphere of the contracted side may accompany the facial and cranial asymmetry (Diffenbach, Greffie, 8 Broc; 9 ) Lateral curvature of the spine is apt to result from the abnormal posi- tion of the head in long-continued cases. In many cases, in addition to the contraction of the sterno-mastoid muscle, the posterior muscles at the side of the neck, and even the small vertebral muscles, may be affected. In some cases the contraction of these muscles predominates so much Fig- 483. that the affection is spoken of as " pos- terior torticollis." Secondary bony changes may occur as the result of long continuance of the abnormal position. The clavicles have been found of unequal length and the carotid arteries of dif- ferent size. Many theories have been advanced to account for the asymmetry of the head and face. 10 Symptoms. — The one symptom of torticollis is the abnormal position of the head accompanied by the usual muscular contraction. The ear of the affected side is brought nearer to the sternum, the face is rotated to the un- affected side, and the chin is somewhat elevated (Fig. 483). The whole head is generally tilted toward the affected side, but this varies with the degree to which the trapezius muscle is affected. The position of the head will vary in many respects according to the involve- ment of the different muscles. This position may be spasmodic or con- stant. If constant, reposition is not possible, and an attempt to rectify the position of the head results in bringing out as tense bands the sterno- 1 Vogel's Neue Med, Bibl, 1762, v. 189. 2 Berieht von. d. Anthrop. Austatt. m Wurzburg, 1826, p. 26. 3 Lep din. sur Us Mai. de Vapp. loc, Paris, 1 895, pp. 77 and 85. 4 Diet. ency. des Sc. med., 4me Sdrie, xvii. 670. 5 Trans. Am. Orth. Ass'n., vol. iv. p. 305. 6 Revue des Speeialistes, 1843. ' Deutseh. Z. fur Chir., xviii. 534. 8 Montpel. med., Nov. 16, 1890. 9 Quoted by Bedard. 10 Young, Orth. Surgery, p. 256. 1110 SPECIAL OR REGIONAL SURGERY. mastoid and other affected muscles on one side. Attempts to correct the deformity in the congenital form will not be painful, but in the vio- lent spasmodic form of the affection are generally accompanied by much pain. Diagnosis. — Although the diagnosis of torticollis is ordinarily an easy matter, it is sometimes difficult to differentiate it from cervical Pott's disease, where a similar wry-neck is not uncommon. In Pott's disease all the muscles of both sides resist passive movement and attempts at reposition of the head. Pain is almost sure to be present, very little movement in any direction is allowed, the temperature is probably ele- vated, and the other symptoms of tuberculous bone disease are present. In torticollis, on the other hand, asymmetry of the face is common, motion is allowed in any direction except where the muscles are con- tracted, and the contraction of the muscles is always unilateral. Again, true wry-neck may be simulated by sprains of the neck resulting from falls, which cause the head to be held stiffly to one side. Rheumatism of the neck, enlarged and inflamed cervical lymph-nodes, inflammation of the middle ear, and deep cervical abscess in the same way may cause a position of the head which simulates that of true torticollis. Prognosis. — The prognosis in congenital torticollis is not good so far as spontaneous recovery is concerned. The deformity progressively increases up to a certain point, when lateral deviation of the spine is apt to occur. Spasmodic torticollis, on the other hand, may recover spon- taneously. It may yield to medical treatment, but may persist for years unaffected even by operative measures. Treatment. — The treatment of congenital torticollis has been mechanical and operative. The treatment by apparatus is unsatisfac- tory, and for the most part abandoned in modern orthopaedic surgery. Why this is the case is easily understood if one considers the patholog- ical condition. The older books on orthopaedic surgery contain pictures of an indefinite number of appliances used for this deformity, to which the interested reader is referred. The writer wishes to advocate only operative treatment except in the slightest cases, where a tentative effort at correction may be made by means of massage, head suspension, and vigorous manipulation. If it is desired to try mechanical treatment, the apparatus described in connection with the operative treatment is probably the best to be used. Division of the contracted sterno-mastoid muscle and other resistant structures is the modern treatment of torticollis. It may be done sub- cutaneously or by an open incision. The sternal part of the muscle is often the only part contracted, but operation almost always shows the presence of a much deeper contraction than is generally apparent, involv- ing the clavicular part also. Subcutaneous tenotomy is widely practised, especially in Europe, but when one considers the position of the internal jugular vein, which lies so closely under the clavicular portion of the muscle, most careful surgeons will prefer an open incision as being more thorough and less dangerous. This vessel has been divided in both methods of operation. Open incision exposes the muscle, either by a cut parallel to the clavicle and one inch above it, or by an incision along the anterior border of the muscle, which leaves a less noticeable scar. The internal jugular vein is likely to be exposed in thorough operations. In intermittent torticollis division of the muscle is of little use, and ORTHOPAEDIC SURGERY. 1111 stretching, division, or resection of the spinal accessory nerve must be resorted to if electricity and mechanical treatment have failed. After division of the nerve relief is generally not immediate, but spasms per- sist for some time. Division of the posterior cervical nerves has been advocated under these circumstances. After operation the head should be maintained in an over-corrected position for two weeks at least. This is accomplished by confining the patient to bed and by applying to the head three strips of adhesive plaster to which weights are attached. By pulling in three different directions these roll the Fig. 484. Fig. 485. - Hik Apparatus for torticollis (by permission of the managers of the Children's Hospital, Boston). head in the opposite position from that of the deformity. Maintenance of the head in a slightly over-corrected position is necessary for some months after operation in severe cases. This is most easily accomplished by the use of the apparatus devised by Dr. Buckminster Brown (Figs. 484 and 485), which is simple and efficient. It is shown in the figures. A Taylor back-brace with a head-support connected by ball-and-socket joint to the brace is the best of the appliances to be obtained of the instrument-makers, or a plaster-of-Paris bandage may be applied to the head and neck. Lateral Curvature of the Spine (Scoliosis). Lateral curvature of the spine, or scoliosis, is a deformity cha- racterized by a lateral deviation of part of the spinal column.* This causes a change and inequality in the contour of the body. In all but the mildest cases the lateral deviation of the spine is accompanied bv a rotation of the vertebral column on a vertical axis. Under these cir- cumstances the name rotary lateral curvature is applied to the condition. Although scoliosis may rarely exist as a congenital affection, it is then a de- formity due to intra-uterine rickets or to imperfect development of one half of the body. It was formerly thought that lateral curvature developed at the time of 1112 SPECIAL OR REGIONAL SURGERY. puberty, but later researches have shown that it occurs earlier in most cases. In 1000 cases collected by Eulenberg, 85.8 per cent, showed the development of the deformity before the tenth year. Girls are, for some unexplained reason, aifected much more frequently than boys. In 2509 cases collected from various authors by Young, 2123 were girls and only 386 were boys. The deformity is much less fre- quent in America than in Europe as a rule, and, although some slight degree of lateral inequality is exceedingly common in our streets, severe cases are not often seen. The etiology of scoliosis may be formulated simply as follows : In general, the muscular development of these patients is below the aver- age and the circulation is less vigorous than it should be. The digestion is often poor and the children are most often poorly nourished. Ocular defects may be present. These conditions may be spoken of as predis- posing causes. In considering the immediate causes of the deformity in certain cases it is plainly evident what the causation was, but in the majority of cases this immediate cause lies hidden in the deepest obscur- ity, and, although many fanciful theories have been adduced to account for it, it certainly seems more scientific to admit that in the majority of cases of scoliosis we cannot speak definitely as to the immediate cause. Among the cases where the causation is plain may be mentioned those resulting from (a) empyema, (6) infantile paralysis, (c) cerebral paralysis, (d) hereditary locomotor ataxia and pseudo-hypertrophic paralysis, (e) rickets, (/) marked inequality in the length of the legs, (g) certain occu- pations necessitating the use of one arm, (A) the loss of one arm and similar changes, (i) torticollis. The remainder of the cases cannot be accounted for in any such obvious way, and certain theories have been advanced to account for their origin. These are as follows : (1) that unequal muscular action or that a unilateral muscular contraction causes the deformity : evidence is wanting to show primary weakness of the muscles ; (2) that the affection is due to unequal bony growth of the two sides ; (3) that the superincumbent weight of the body comes upon the spinal column held in a faulty position. In some experiments on the cadaver undertaken by Bradford it was demon- strated that when downward pressure was exerted upon the spinal column held in an oblique position a lateral bending took place when a certain point was reached, which reproduced the features of a true scoliosis. The more obliquely the weight came upon the column, the more marked was the scoliosis. It is in this way that faulty attitudes may cause lateral curvature. Each one of these theories accounts, of course, for certain cases, but it must be evident that no one is worthy of general application. The pathology throws no light upon the causation of the affection, and only serves to accentuate the importance of early and vigorous treatment. In the early stages of the affection no pathological changes are noticed, and in the later stages the pathological changes are such as result from the prolonged maintenance of a vicious position. The effects of pressure are noticed in the atrophy of the parts of the vertebra in the concavity of the curve, resulting sometimes in a change from the nor- mal shape of the vertebrae to that of a wedge. The vertebras are rotated on a vertical axis, and the atrophy from pressure results in locking the column in its twisted and distorted position. The muscles and ligaments are contracted on the concave side and stretched on the convex side. The intervertebral disks atrophy from pressure on the •concavity, and the ribs are separated on the convex side and crowded ORTHOPAEDIC SURGERY. 1113 Fig. 486. together on the concave side. They may be so depressed as to reach or even lie inside of the crest of the ilium. The chest is distorted and compressed on the convex side, and the abdominal organs may be dis- placed downward. Symptoms. — Much obscurity has been added to that naturally sur- rounding the study of lateral curvature by the introduction of various terms and subdivisions into varieties and into single and double curves, etc. The condition in question is really this: A persistent lateral deviation of the spine may occur in any part of the dorsal or lumbar region. The I convexity of this curve may be to the right or to the left, and it may involve only a few or it may involve many vertebrae. When once a curve in the spine j has occurred, it is easy to see that either the person must lean over to one side or that the vertebrae above or below the curve must make a compensatory bend in the opposite direction, by which the general up- right position of the body may be maintained. This happens instinctively, and with the dorsal curve to the right one finds a lumbar curve to the left, and probably a cervical curve also. The original curve I is at the root of the mischief, and is spoken of as the primary curve. The others, which are only incidental, although necessary for equilibrium, are called secondary or compensatory curves. For some unknown mechanical reason, when the I lateral curve has reached a certain degree, which varies in different individuals, the vertebral column begins to rotate on a vertical axis, carrying with it, of course, the ribs. The thorax no longer lies in the same lateral plane as the pelvis. So much has been written to account for this rotation, all of j which is unsatisfactory, that the references only are given. The rotation of the vertebral bodies is toward the con- vexity of the curve ; that is, in a right dorsal curve — the angles of the ribs are carried backward on the right side, while the left side of the chest becomes more prominent I in front. The most common form of lateral curvature is I where the dorsal spine curves to the right (Fig. 486). The lateral deviation of the spine itself is rarely Eight dorsal curvature as- noticed by the parents, but rather some of the s e ° q C ufuus ofMt foot. Upes changes are seen which it occasions in the contour of the body. Round shoulders are in many instances, especially where weakness of the muscles is present, the first indication of beginning trouble. The flexion of the spine, however, is rarely appreciated in its true significance, and many a case of serious scoliosis might be prevented if every case of round shoulders were investigated as to the presence of beginning lateral deformity. Most often scoliosis is discovered by one of the following signs : The prominence of one hip ; the elevation of one shoulder ; the backward projection of one shoulder-blade ; the greater 1114 SPECIAL OR REGIONAL SURGERY. prominence of one clavicle ; the fact that the skirt of the dress hangs unequally on the two sides ; the difficulty in fitting the waist of a tight dress on account of the greater distance from the armhole to the waist on one side. It is these trifling and apparently irrelevant signs that most often lead to an examination of the child. The dressmaker is in very many cases the first person to call attention to the condition. Diagnosis. — From what has been said, it will be seen that the diagnosis of scoliosis in slight cases is more likely to be made from the effects of the curvature than from the curvature itself. The existence of round shoulders is always suspicious. For examination the patient, if a child, should be stripped to the hips and examined from in front and behind. Older girls should be covered in front by a common apron tied by strings around the neck and allowed to fall over the chest and abdomen. Examined from in front, especially at a little distance, it will be seen, even in slight cases, that one arm hangs farther out from the side of the body than the other ; that the side of the body is more hollow above one ilium than above the other, which gives the appearance of the greater prominence of one hip ; that the shoulders are not on the same level ; and that in certain cases a lateral deviation of the whole trunk is noticed. The nipples may be noticed to be not in the same horizontal plane. In severe cases these signs will be more promi- nent, and one side of the chest will be seen to stand farther forward than the other ; often it will be seen to be only a one-sided pigeon breast ; again, one half of the thorax will be decidedly prominent. In severe cases the unequal prominence of the clavicles will be well marked. In slight cases lateral deviation of the spine is more readily detected from the front than from the back. When examined from behind, the spine can be made red by drawing two fingers along the spinous processes, when a red streak will show plainly the lateral deviation. In slight cases one notices the unequal outline of the two sides of the body, but less distinctly than from in front. The angles of the scapulae are seen to be on different levels, and the inclination of the whole trunk may again be evident here. In severe cases rotation is noticed by the greater prominence of one scapula, or, if the curve is a lumbar one, by the prominence of the lumbar transverse processes on the convex side of the curve (Fig. 488). The presence of rotation should be searched for by directing the patient to bend forward as if making a bow while the knees are kept stiff and the arms allowed to hang. When the verte- bral column becomes horizontal in this position, if one glances from behind the slightest rotation of the vertebrae can be detected by a prom- inence of one side of the spine in the dorsal or lumbar region. Where the rotation has occurred in a right dorsal curve, in this position an elevation on the right side of the vertebral column can be noticed if any backward rotation is present (Fig. 488). By following in detail the methods described above no case of lat- eral curvature need escape detection. The flexibility of the spine is tested by allowing the patient to hang from a bar or by manual attempts at reposition. Eecumbency on the face will obliterate the curve at an early stage. The length of the legs should be measured to see that the curve is not the result of some inequality. The prognosis in scoliosis is one of the most unsatisfactory parts of ORTHOPEDIC SURGERY. 1115 the study of the condition. In a given case it is exceedingly difficult for even the most experienced to predict whether or not further deform- Fro. 487. Fig. 488. Photograph of case of left dorsal scoliosis. Characteristic appearance of scoliosis in the stooping posture. ity will occur. Spontaneous recovery seems to occur at any stage in every variety of case. The spontaneous cure of the deformity, when once it has become enough, for example, to be plainly evident through the clothes, is extremely unlikely to occur. For mechanical reasons it is obvious that it is likely to grow worse. Treatment. — There is little agreement among surgeons as to the best treatment of lateral curvature. At best it is slow and uninterest- ing, and if the attendance be irregular or if the methods be incomplete, progress is unsatisfactory. The conditions to be met are these : The spinal column is curved to one side ; the superincumbent weight tends to increase this curvature ; rotation on a vertical axis may be present, and stiffness is sure to inter- vene in time if the vicious position is maintained. The problem of treat- ment is to straighten this column and to hold it in the correct position. If stiffness be present, flexibility must be restored — (a) by braces, (6) by manipulation and apparatus. After flexibility lias been restored so far as possible, or if stiffness be not present, the column must be held in the cor- rect position (2a) bv braces and (26) by the muscles. It is hoped that 1116 SPECIAL OR REGIONAL SURGERY. this statement of an almost self-evident problem may relieve the subject of much needless obscurity. (a) Attempts to straighten a stiff curvature by means of braces are for the most part at present con- fined to the instrument-shops. Enor- mously clumsy and heavy appliances with screws and pads and springs have been much used, and can be found figured in any orthopaedic treatise. They need not be dis- cussed here, for they are mechani- cally inefficient. It is plain that a curved spinal column where rigidity is present cannot be straightened by an apparatus which obtains so little hold as these, or which works at such a great disadvantage in the matter of pressure. The plaster jacket, or Lorenz's modi- fication of it as a plaster girdle, may be applied with benefit for a few days at a time to severe cases. The curve is cor- rected as much as possible by bending to one side or by suspension with lateral traction to pull the column as straight as possible. In the. corrected- position a plaster jacket or girdle is applied and allowed to harden. Repetition of this process for several times, with intervals of three to six days, will often produce much improvement in a bad curve for the time being; but the improvement must be held by other means, and the process is most uncomfortable. Left lumbar curvature (by permission of tbe managers of the Children's Hospital, Boston). (J) Attempts to Straighten a Stiff Column by Manipulation and Apparatus. — The object of these attempts is by pressure against the convexity of the curve, either intermittent or continuous, to stretch contracted ligaments, fasciae, and muscles. It does not matter whether the force applied is manual or instrumental. Where stiffness is slight, self-suspension by a Sayre head-piece should be practised, perhaps daily, or the patient might hang from a bar by both arms, and in all but the slightest cases some one should press from the side against the convex side of the curve. The gymnastic exercises to be described later will restore flexibility in the milder cases. These are, in general, such exercises as tend to throw the body into a. position which diminishes the curve. Severe cases need more forcible measures. In a right dorsal curve, for example, a manipulation much used by Dr. Shaffer is very useful. The patient sits on a stool in front of the surgeon between his knees, with her back toward him. The surgeon, sitting on a similar stool, leans his right elbow on his right knee and places his right hand, opened flat, opposite the convexity of the patient's curve. He raises his left arm and places his left hand on the root of the patient's neck at the left side. With a slight rotary and shifting motion of the left arm he throws the patient over to the right, so that her ORTHOPEDIC SURGERY. 1117 weight comes upon his right arm and knee. This should be repeated several times with as much force as the surgeon thinks best. Fig. 490. Self-correction apparatus for lateral curvature (Bradford). Fig. 491. Self-correction apparatus for lateral curvature (Bradford). Perhaps the simplest form of mechanical apparatus for restoring flexibility is the one described by Bradford (Figs. 490, 491), where 1118 SPECIAL OR REGIONAL SURGERY. self-suspension is combined with lateral pressure by means of traction bands. A more forcible machine for applying pressure by screws is shown in Fig. 492. These are used as often as necessary, and if possi- ble the curve is over-corrected. The application of such force is not painful. It may be said, again, that the object of such manipulation is to overcome any stiffness of the spinal column, so that whatever treat- ment is applied may be to a flexible column. (2a) Attempts to hold a Flexible Column Straight by Braces. — Where stiffness has not begun or where it has been overcome the prob- lem of holding the column straight is the one upon which the cure or improvement of the case depends. Fig. 492. In former years the whole treat- ment of lateral curvature has re- volved around the question of, What brace does this most effi- ciently? It is more pertinent to ask (and this question is being asked), Is it better to use a brace or to educate the muscles on one side of the column to serve as a support ? Fig. 493. m k'- k' ;> *£«Bi 9 - 1 -' 4fla '*■■ 9 ^LJ Patient in position in correcting apparatus (Bradford and Brackett). Supporting jacket cut and laced for removal (by permission of the managers of the Chil- dren's Hospital, Boston). Any appliance which takes the place of the muscles anvwhere in the body, and prevents their use, unquestionably weakens those muscles. This is the chief objection to the routine use of braces in lateral curva- ture. Again, any appliance which attempts to hold straight a spinal column by a hold upon the pelvis and the movable thorax, while the force of gravity works all the while against it, is necessarily at a great mechanical disadvantage. Other things being equal, it is plain that the ORTHOPEDIC SUROERY. 1119 best results would come from the education of faulty muscles rather than by supplementing them by apparatus. Whether or not this can be done is largely a matter of individual opinion. The writer believes that the rational method of obtaining improvement, and cure where possible, in lateral curvature lies in the education of those muscles which tend to overcome the spinal curve. It is obvious that these muscles cannot be developed immediately to their full capacity — indeed, that their development is a very slow matter — and the question arises whether it is better in the early stages of treatment, after having restored as much flexibility as possible to the column, to hold it in its improved posi- tion by means of braces while muscular development is going on, or to depend entirely upon the muscular education for this correction. This must be deter- mined by the muscular strength and the effect which such treatment has upon the position. Where the corrective effect of the exercises is felt for some time, it is safe to allow the patient to go without a brace ; but where the muscles are obvi- iously weak and the effect of such exercise is soon lost, it is manifestly better to use some sort of a supporting apparatus between the exercises. In most cases the writer finds it possible not to use braces at all, restricting their use to those cases where the muscles are exceptionally weak, where growth is rapid, where the deform- ity is extreme, or where it is impossible to obtain frequent gymnastic exercises. Fig. 494. Fig. 495. Shaffer spine-brace applied to ease of left dorsal scoliosis (Young). Taylor's brace : right dorsal curvature. (26) Attempts to hold a Flexible Column Straight by Mus- cles. — When the column has been made flexible or has never been stiff, 1120 SPECIAL OR REGIONAL SURGERY. Fig. 496. the development of the muscles on the convex side of the curve is, in general, as has been said, the most rational corrective measure. If the ends of a flexible rod, a b, have been connected by two elastic bands, c d, and if one (d) were twice as strong as the one on the other side (c), the rod would bend with the convexity toward c. The easiest way to correct this would be to replace c by a band as strong as d, in which case the rod would become straight again ; that is, to strengthen the traction force on the convex side of the curve is to work toward the obliteration of the curve. This demonstration, which any one may make for himself, makes it unnecessary to discuss whether the mus- cles on the convex or concave side of the curve should be attacked. The spinal column is not a rod flexible in one plane, but the conditions of the experiment are to a certain extent applicable. Assuming, then, that the muscles of the convexity should be developed, the general muscular development must also be regarded, especially in connection with the extensor muscles of the back. The chest should be expanded, the abdominal muscles strengthened, and, as far as possible, a cor- rect carriage should be taught. The Swedish system of Ling excels in its ability to isolate certain groups of muscles from work and other groups of muscles for work. It matters little what system the surgeon uses, as long as he is able to pick out a certain group of muscles to exercise. Certain exercises should be general ; cer- tain others should be distinctly unilateral. If gymnastic exercises are able to do good, they must be equally power- ful for harm. Consequently, accuracy is essential. It is not intended here, nor would it be possible, to give any one scheme of exercises suitable for the treatment of lateral curvature. Each case must be treated upon its individual merits, and the exercises must be adapted to the location of the curve. A position is assumed which by contraction or by relaxa- tion of certain groups of muscles, which it is not desired to exercise, isolates them from further work. Then a unilateral movement is taken which shall exercise a certain group of muscles as often as the movement is repeated. As an example of this, we will take the following: Technically, it is known as hands, neck, rest, left foot, walk, standing position, trunk-turning, and bending to right. In the primary position, before bending is begun, the left lumbar muscles are made to contract on account of the position of the left leg. The right lumbar muscles are relaxed by the hyperextended position of the right leg. The hands at the neck hold the neck muscles along with the arm muscles in a condition of contraction, which prevents them from doing further work; they are thus isolated by being in contraction. By bending and turning the trunk to the right several times the right dorsal muscles are alone active and contract strongly. This exer- cise is suitable for some cases of right dorsal curvature, inasmuch as it contracts the muscles of the convexity of a dorsal curve. Incidentally the left lumbar muscles are also contracted. Another exercise is known as the stretch stride standing, trunk bending to left side. The separation of the legs holds the pelvis square. The arms being extended upward above the head, isolate from further work the arm, scapular, and High degree of rotary-lateral curvature. ORTHOPEDIC SURGERY. 1121 upper dorsal muscles by placing them in contraction. A bending to the left, made either with or without resistance, is accomplished entirely by the left lumbar muscles. Such an exercise serves as an instance of isolation of muscles for exercise in a case of left lumbar curvature. The exercise for the isolation of the erector spinee muscles is known as the neck, rest, prone, sitting extension of trunk with resistance on lumbar region. The scapular and upper dorsal muscles are isolated by the position of the arms, which are held behind the head. The leg muscles are isolated from work by the sitting position, and the straightening of the body against resistance is accom- plished almost entirely by the erector spinte muscles. These exercises, selected at random, serve to illustrate the exactness and. the reasonableness of the Swedish system of gymnastics. In itself it has no place for forcible correction, which to the writer's mind in severe cases is a necessary part of any successful system of treatment. In so far as treatment by muscular education goes, it may be said that the principle is simply the systematic and continual exercise of the muscles on the convex side of the curve, taken in connection with a certain amount of developmental general exercise, and in connection, if need be, with forcible correction to restore flexibility to the stiffened column. In a general way, the contraction of muscles on the convex side of the curves will throw the body into a corrected position, spoken of by Roth as the " keynote " position. Massage to the weaker muscles is an adjuvant to the treatment. Cases should be treated as often as possible — once or twice a day if feasible, three times a week at least. The more frequent the exercises the better the results. After treatment the patient should lie still at least one hour. Relapses are not infrequent where treatment is discontinued too soon. It is not likely that the maximum of improvement will be reached even in a slight case in less than six months of active treatment and six months of a continuation of exercises. Elec- tricity may be of some use, but it is only a detail of treatment, The writer has passed by without mention the great majority of appliances and measures in use in former years and to a certain extent still in use to-day. This has not been done carelessly, but simply to strip the treatment of all unnecessary detail and to present only what seemed essential. It may be repeated that the treatment, in a word, consists in rendering a stiff column flexible and educating the muscles to hold the column in an approximately proper position. As an adjunct to this treatment the use of braces may be necessary. Congenital Dislocation of the Hip. This is an affection of considerable rarity, which may occur alone or in connection with other deformities, such as club-foot, hare-lip, and the like. It is by far the most common of the congenital dislocations and may affect one or both hips. Dislocation of one hip is twice as common as double dislocation, and for some unexplained reason girls are affected much more frequently than boys ; of 341 cases collected by the writer, 301 were girls. Lorenz, 1 in 671 cases analyzed, found 87.8 per cent, of girls among those affected. There were among these 245 double dislocations and 421 single dislocations. As to the causes of this deformity, there has been much speculation. Certain cases are undoubtedly caused by injury at birth, and although these cannot prop- erly be classed as congenital dislocations, yet they resemble them so closely that 1 Lorenz, Path, und Ther. der Aug. Huftverrenkung, 1895. 71 1122 SPECIAL OR REGIONAL SURGERY. they are not recognized separately. Other cases are undoubtedly dislocated by traumatism during intra-uterine life, but the majority of cases must be accounted for, as are other congenital deformities, by an arrest of development of the acetab- ulum. The Y cartilage at the bottom of the socket fails to carry on the growth of the three segments which form the acetabulum. 1 The head of the femur in these cases may reach the normal size, and the stunted acetabulum is not large enough to hold it in place. In other cases, and more often, the head of the femur is small and imperfect ; it may be entirely wanting, and intermediate conditions are present. In the great majority of cases the head of the femur is found to rest upon the dorsum of the ilium, either upon the bone itself or upon the gluteus minimus muscle. The acetabulum in general is smaller and shallower than nor- mal, and seems to be filled with fat, connective tissue, and cartilaginous substance which can be scraped away with a curette. The capsule of the joint— upon which, Fia. 497. Fig. 498. Double congenital dislocation of the left side. Unilateral congenital dislocation of the left hip, showing the natural position in standing (Lovett). (By permission of the Trustees of the Fiske Prize Fund.) of course, the chief part of the body-weight rests in walking — is much hyper- trophied, thickened, and stretched. Where the congenital dislocation is of long standing the part of the capsule which lies between the head of the femur and the 1 Grrawitz, Virch. Arch., 1878, lxxiv. p. 1. ORTHOPEDIC SURGERY. 1123 new socket may be worn away, and the capsule appears in this case to be attached to the rim of the new acetab lum. In short, the capsule with the pelvi-trochan- teric muscles has become only a tough suspensory ligament. The pelvi-trochan- teric muscles are all stretched. II ' he new acetabulum forms directly over the old one, the pelvis remains in practically the normal plane, and but little lordosis is present ; if, however, Vie new socket develops posteriorly, the pelvis tilts and marked lordosis results. The upper part of the pelvis is constricted and the lower part elongated in later Lfe. The ligamenturr teres may be normal, but is most often wanting or subject to v rious irregula. ities. Symptoms. — Children with double dislocation (Fig. 497) are, as a rule, late in walking, and when they do, they show a rolling gait and an exaggerated swaying of the body from side to side which resembles the gait of extreme bow-legs. The trochanters form a well-marked prom- inence posteriorly, and the view of the back of the child shows a bow- ing forward of the lumbar spine, which is all the more striking on account of the projection of the trochanters through the glutei muscles. The legs are farther apart than they should be normally when viewed from in front, and the perineum is unduly broad. The children rarely complain of pain and are well developed in other respects. When single deformity is present, the child limps distressingly on the affected side at each step, and shows a gait which is simulated only by severe infantile paralysis of one leg. The affected leg is generally shorter and smaller than the well one, and on account of the elasticity of the suspensory ligaments it is impossible to correct the limp entirely by a high sole on the short side. Prognosis. — Without operation there is little prospect of improve- ment. Some cases grew worse as puberty is reached, while others improve somewhat. Treatment. — The earlier methods of treatment by continuous ex- tension in bed or by means of ambulatory apparatus making traction have been for the most part abandoned, because not only must the treatment be very long and irksome, but the results have not been satisfactory and relapses have been common. Apparatus may be of some use. Lorenz and Hoffa are both advocates of the use of a corset in cases which cannot be operated upon, especially cases of double dis- location. These corsets hold tightly to the pelvis and are padded to hold down the trochanters. Improvement, however, may be brought about by continued traction lasting from two to five years, but few patients are so situated that they are either willing or able to pursue so long a treatment. Traction by heavy weights as a preliminary to operation in older and more difficult cases is advocated by some writers (Lorenz). Treatment by traction alone is not to be recommended. The method of Paci has attracted considerable attention. The child is etherized, and the movements of reduction of an ordinary traumatic dislocation are made slowly, forcibly, and accurately. First the limb is flexed, then abducted, rotated externally, and extended. After correc- tion a plaster-of-Paris bandage is applied along with traction of 4 to 10 kilogrammes. After some months a corset is applied and the child allowed to go about. The hip is protected thus for nearly a year and a half after operation. The operation of Lorenz is simple, not destructive, and avoids the destruction of the muscles surrounding the hip. He advocates an ante- 1124 SPECIAL OR REGIONAL SURGERY. rior incision which exposes the joint, and the capsule is opened by a T-shaped incision. The head is made smaller if need be, the acetabu- lum is scraped out, and reposition is accomplished. With regard to operation in general, it may be said that the reposi- tion of the head is easy, although it is sometimes hard at first to recog- nize the original acetabulum. The difficulty comes in retaining the head of the femur in the socket. After any operation the wound should be closed and perfect quiet insisted upon for about four weeks, when passive motion should be begun. It is necessary that the joint should be pro- tected for some months by some splint or appliance which prevents the weight from coming upon the hip-joint. The whole question of opera- tion must at present be considered as being sub judice. Coxa Vara. Coxa vara, or incurvation of the neck of the femur, is an affection to which attention has been directed of late. It is rhachitic in origin, and affects most often adolescents, although it probably is more of a factor in children with rickets than has been supposed. Pain, limping, shortening of the affected limb, and elevation of the trochanter are all present : eversion of the limb is noted. It is to be distinguished chiefly from congenital dislocation of the hip-joint and from hip disease, which it simulates, by pain and tenderness. Rest and protection to the joint are followed by good results in the early stages, but osteotomy may be necessary. Bow-legs. The condition known as bow-legs, or genu varum, is most often the result of rickets and occurs chiefly in young children. Bow-legs may also result from ostitis deformans in elderly people. It is cha- racterized by an outward bowing of the bones of the leg, which at times is associated with or replaced by a forward bending of the tibia and fibula, and one speaks of the latter condition as anterior bow-legs. The condition of anterior bow-legs is characterized by a bowing for- ward of the tibia and fibula. This is generally most prominent at the junction of the lower and middle thirds of the leg. It occurs, as a rule, in the cases where severe rickets is present, and is generally associated with some outward bowing of the leg or with knock-knee. Symptoms.— Children with bow-legs stand with the feet wide apart, even in the milder cases. In walking they sway from side to side with a rolling gait, balancing themselves over each leg as it rests in turn on the ground. The fact that they stand with the feet apart is probably due to muscular weakness, and because the centre of support is removed so far outside of the centre of gravity. The bowing is of two types (Figs. 499, 500). In one it affects the femur and the tibia; in the other it affects the latter bone alone. In the former case the children stand forming a well-defined oval with their bowed legs. Where the tibia alone is affected the general symmetry of the curve is less. The easiest method to find out whether the curve involves the femur to any extent is to cross one leg of the child over the other, placing the inner ORTHOPJEDIC SURGERY. 1125 sides of the knees in contact when the child lies down. In cases where the curvature is principally in the tibia the thighs will come closely together. In extreme cases of bow- legs the knee-joint may be involved, Fig. 500. but in general this is not a factor .*_„_. to be considered. The bones of Fig. 499. '"'-,, Anterior bow-legs. Bow-legs affecting both tibia and femur. children in the active stage of bow-legs are by many thought to possess a certain springiness, which is often demonstrated to students by bending the legs with the hands and watching the bones spring back, when a distinct yielding is felt. It is probable that this is due to the elasticity of the muscles themselves, rather than to any springiness of the bone. The bones of rhachitic children are plastic rather than elastic. Treatment. — The treatment may be expectant, mechanical, or operative. It is hard to state definitely where the need of mechanical treatment begins in bow-legs. Expectant Treatment. — In certain cases it is easy to see that the mechanical conditions are so bad that some support is imperatively necessary, but except in cases where the curvature is quite marked it is safe to allow the child to continue under observation, taking tracings every three months and massaging the legs and treating the general condition of rickets ; but this is only proper where one can depend upon the co-operation of the parents. Cases where the children " toe in," walk with a rolling gait and stand with the feet wide apart, are not suitable cases for expectant treatment. Massage and manipulation should be performed at home once or twice a day during either the expectant or mechanical treatment. The parents should be instructed to rub the legs and to attempt to bend them into a correct position, not using enough force to make the child cry. Mechanical treatment is suitable for all children under four years of age ; sometimes after this. Although in children it is difficult after the age of four to accomplish much by braces, it must be said that remarkable results can be obtained, even in the case of much older chil- 1126 SPECIAL OR REGIONAL SURGERY. dren, by persistent confinement to bed and by the long-continued use of some splint or bandage which tends to pull the knees together. Me- chanical treatment is easily applied by a simple steel upright attached to the body which runs to the top of the inside of the thigh and terminates in an arm curving around and upward. To this upright the legs are firmly pulled by means of leather pads, which act upon the most promi- nent part of the deformity. The mechanical treatment of anterior bow-legs is unsatisfactory. Operative measures should not be undertaken with children with bow-legs under the age of three years, and preferably not younger than four, as in these cases the bones are not sufficiently hardened. In most cases a simple fracture of the tibia and fibula is sufficient to correct the line of the leg even where a mild curvature of the femur exists. Osteoclasis and osteotomy are the measures adopted for the cor- rection of bow-legs. Osteoclasis may be done by the hands by very strong surgeons, but the fracture is not so accurately located as that done by some apparatus. The osteoclast of Eizzoli consists of a bar and two padded rings sliding upon it. Between the padded rings a padded plate is screwed down, fracturing the bone at the point of appli- cation. It is a simple and satisfactory apparatus for the operation. In fracturing a leg the force of the osteoclast should be so adjusted that it will not break off either at the upper or lower epiphyses of the tibia?, which are not firmly united at so early an age. With as little manipulation as possible the bone should be set straight and the leg should be done up in a plaster-of-Paris bandage and treated as a simple frac- ture. The results of osteoclasis, properly done, are almost uniformly satisfactory. Osteoclasis is suitable for cases of anterior bow-legs of a mild grade in chil- dren over four. The bone is broken, as in ordinary bow-legs, at the seat of the great- est curvature, and in many cases the leg can be placed straight so far as the antero- posterior outline is concerned. Division of the tendo Achillis should be done after the bone is broken. Osteotomy is to be preferred to osteoclasis if the femur be curved, if there be a curvature of the tibia in two planes, if anterior bow-legs be very marked, or if the bones be very hard. Osteotomy consists in chiselling the bone nearly through and completing the fracture manually. Theoretically, it is not a more dangerous operation than osteoclasis, but bad results due to sepsis occur from time to time. In the worst cases it may be desirable to remove a wedge-shaped piece of bone. In severe cases of anterior bow-legs the tibia may be divided from behind, and in this way the removal of a wedge is made unnecessary. In such cases the tendo Achilles will probably have to be divided to bring the foot straight. After osteotomy the leg should be dressed antiseptically and treated as a compound fracture. Knock-knee. Knock-knee is a condition represented by an inward prominence of the knee, caused most often by overgrowth of the internal condyle of the femur. This results generally from rickets, but inward deformity of the knee may occur after fractures, in tubercular diseases of the knee, and sometimes in advanced cases of infantile paralysis affecting the muscles of the leg. In the latter instance it is generally associated with ORTHOPAEDIC SURGERY. 1127 Fig. 501. some flexion of the knee. The common rhachitic form of knock -knee, which will be the only one considered here, occurs most often in children between two and four years old. It is less common than bow-legs. In most cases it is probably caused by the attitude assumed by these chil- dren in standing. Inasmuch as their muscles are weak, they support themselves by standing with the legs apart and the feet everted, being the position in which the least muscular activity is required. This brings more weight to bear upon the external than on the internal con- dyles, and tends to cause the atrophy of the external condyles of the femur and the overgrowth of the internal. 1 Bending of the shaft of the bones above and below the knee-joint may also occur and increase the deformity, but this is less often the case than in bow-legs. Flat-foot in nearly all cases coexists, probably most often as a result of the same cause — muscular weakness. In severe cases, where the feet are widely separated, an inversion of the front part of the feet is noticed as they reach toward the median line for support. In severe cases the tibia and fibula rotate outward in the long axis of the leg. Prognosis. — The prognosis is not so good as in bow-legs. It is unlikely that any marked degree of the deformity can be outgrown. On the contrary, the mechanical conditions are such that the deformity is much more likely to increase than to diminish. Treatment. — The treatment may be ex- pectant, mechanical, or operative. Expectant treatment is only suitable in mild cases, where the children remain under observa- tion and they have the benefit of continual mas- sage and manipulation. Mechanical treatment is suitable for all cases in children under four years of age. It should be begun as soon as the knock-knee becomes at all marked, even if the child is just beginning to walk. The simplest appliance consists of an upright steel which is fastened to the shoe be- low and runs the length of the leg, to terminate above in a band which grasps the pelvis. Operative treatment is applicable to all cases of knock-knee of more than the mildest grade in children over four years of age. It is not advisable to undertake it at an earlier period. Osteoclasis is not so satisfactory as osteotomy in knock-knee, because the fracture should be lo- cated as near the joint as possible, and except with the most elaborate osteoclasts this is prac- cally impossible. The operation most often preferred is the osteotomy of Macewen. An osteotome is used. It should be about half an inch in breadth, and the blade should be marked to show how deeply the edge has penetrated. A common wooden mallet is the most suitable instrument to use. The osteotome is driven into the femur at its inner aspect half an inch above the adductor tubercle of the femur. No incision in the skin is neces- sary unless it is preferred. By successive light blows of the mallet the 1, Mayer, Billroth, Schede; 2, Annandale; 3, Ogston, Reeves, Chiene ; 4, Macewen ; 5, Taylor. 1128 SPECIAL OR REGIONAL SURGERY. osteotome cuts through nearly the whole thickness of the bone, which is then fractured manually and the leg is placed straight. Unneces- sary manipulation is to be avoided. The straightened leg is placed in a plaster-of-Paris bandage and treated as a compound fracture. Hemorrhage is generally slight, and accidents may be avoided by grasp- ing the osteotome so firmly that it cannot slip, and by cutting the pos- terior edge of the bone with the chisel pointed forward. Ogston's operation, which is perhaps the one best suited to very severe cases, aims at loosening the internal condyle of the femur with a chisel or saw cutting from above the adductor tubercle to the intercondyloid notch. Hahn advocates the psrformance of osteotomy on the outer as well as on the inner side of the femur, but this view has not met with general acceptance. The various operations for the correction of knock-knee may be seen by a glance at the diagram (Fig. 501). Congenital Club-foot. Congenital club-foot, or talipes equino-varus, is the term applied to a condition of the foot in which the sole is inverted, the front part of the foot is displaced inward and upward, and the heel elevated. The deformity has its origin probably in an arrest of development of the feet of the fetus in utero, resulting in the delayed rotation of the legs and feet. Dur- ing the early part of intra-uterine life the feet lie in the position of equino-varus, and a persistence of this fetal condition is likely to result in club-foot. The de- layed rotation of the feet may be due to various causes, such as mechanical obstruction or some abnormal condition of the nervous or circulatory system of either mother or child. If this view of the origin of the deformity is accepted, it brings it into the same class with spina bifida and other similar malformations with which it frequently coexists. Heredity is an undoubted factor in the production of club-foot, and much influence has been attributed to maternal impressions as a causative factor, although probably in most cases impressions are not the cause of the deformity. Abnormal development in the uterus, the paralysis of certain muscles, and primary bony changes have been advocated as the cause of club-foot, but the view that it originates in retarded development is the one generally accepted. Pathology. — The deformity is a dislocation inward of the anterior part of the foot which occurs at the medio-tarsal articulation. All the tissues, muscle, skin, fascise, and the bones in older cases, are affected by the malposition. The alteration in shape of the bones is of the most significance, because it offers the greatest obstacle to reduction. The os calcis becomes more vertical than horizontal, and its anterior articulating facet is oblique to the axis of the bone. In the severest cases the inner side may be concave. The astragalus tips forward on a transverse axis, so that only the posterior part of the articular surface is in contact with the tibia, the anterior part of this surface making a prominence under the skin ; the head and neck twist inward ; the scaphoid is carried inward, and with it the cuneiform bones and metatarsals attached to them. This results in a broadening of the anterior part of the foot. The ligaments are contracted on the concave side of the foot and stretched on the other. The muscles atrophy from lack of proper use, and bony growth is likely to be retarded. The muscular reactions are normal. The tendons are somewhat displaced, but no other abnormality is ORTHOPEDIC SURGERY. 1129 present. Synovial bursa? may form on the outer edge and back of the foot. Talipes equino-varus resulting from infantile paralysis may present appearances closely resembling those of congenital club-foot. The deformity is, however, more amenable to treatment and more easily corrected. Prognosis. — Without treatment there is no hope of cure or im- provement in the deformity. The foot tends all the time to become more fixed in its vicious position, and the bony changes which result serve to lock it in place. With treatment begun during childhood the prospect of a cure is always good if the intelligent co-operation of the parents can be obtained. Even in adidts excellent results may be ob- tained by operative measures. Treatment. — The treatment of club-foot consists simply in recti- fying the deformity by the mildest measure that will serve, and in keep- ing the foot in the correct position. The measures to be employed in a young infant must necessarily differ widely from those in an adult, but whatever means of correction are adopted the deform- ity should be over-corrected, however destructive may be the means required to do this. A half-cure in club-foot amounts to nothing. The various methods of correction will be considered in the order of their severity : (1) Manipulation ; (2) Plaster-of-Paris bandages ; (3) Mechanical correction ; (4) Tenotomy; (5) The use of extreme force; (6) Open incision ; (7) Bony resection. The inherent tendency of all cases of club-foot to relapse in the years follow- ing correction cannot be too strongly insisted upon. (1) Manipulation of the foot should be begun as early as possible, however young the infant may be. Any mother can be instructed to replace the foot in the normal position every time that she changes the Fig. 502. Mechanical correction of club-foot. diaper. The outer border of the foot should be pressed upward and outward, thus correcting in the same movement the varus and the equi- 1130 SPECIAL OR REGIONAL SURGERY. nus elements of the deformity. Complete cures of bad club-foot may- result from this measure alone. (2) Plaster-of-Paris bandages, carefully applied, in the case of young infants may produce improvement or cure. A period of manipulation should precede their use, even in the youngest infants, to render the foot more flexible. The bandage should be applied to the foot placed in the most correct position possible, and held in this position while the plaster is hardening. Such bandages, properly applied, stretch the contracted structures, and at the removal of the plaster a more correct position can be secured in the application of the second one. It is probable that these bandages accomplish their work in about three days, and that the most rapid progress can be made by changing them at this short interval. Plaster of Paris is also applied to hold the foot in a correct position after ope- ration in most cases. (3) Correction of the deformity by mechanical apparatus alone is pos- sible in mild cases in children, and the need of some mechanical reten- tion-appliance is necessary for correction in every case, no matter what means may have been employed (Fig. 502). The Taylor club-foot shoe is the most satisfactory appliance, both as a correction and retention shoe. It consists of a steel sole-plate to which the foot is strapped. From this sole- plate arises an upright which reaches to just below the knee. The sole-plate is adjusted to the foot in the deformed position, and then by the use of the upright as a lever the foot is brought up and the outer border raised by bringing the upright into its place at the side of the leg. This can be worn inside of the boot, and when weight is borne upon the foot the efficiency of the apparatus is increased. A roughly-made apparatus for the reduction and correction of club-foot con- sists in the "snow-shoe" appliance, which is merely a shingle fastened to the heel of the foot by sticking-plaster strips running down each side of the leg. The front part of this projects out, so that traction may be made by a plaster extending to the leg. Whether or not mechanical correction shall be persisted in or shall give way to operative measures is in the case of most young children a question of expediency. Mechanical treatment is slow. It requires constant and intelligent care on the part of the surgeon and parent; but, if persisted in, in mild cases it yields most satisfactory results. It is not, as a rule, suitable to cases where much bony de- formity is present. (4) Tenotomy is the mildest of the operative measures, and is justi- fiable in the treatment of any case of club-foot where it is desirable to save time or where attempts at mechanical correction are unsatisfactory. In older cases and in relapsed cases it is not, as a rule, a sufficient meas- ure. The tendo Achillis and the plantar fascia are most often the struct- ures to be divided. In severer cases the astragalo-scaphoid and calca- neocuboid ligaments should also be divided subcutaneously. After division the foot should be at once replaeed in an over-cor- rected position. The fear that non-union of the tendons may occur if this is done has no foundation. Cases which are allowed to relapse after tenotomy are more resistant than if they had never been operated upon. The foot should be held in the correct position by some stiff bandage or by a Taylor club-foot shoe. Any appliance is efficient which holds the foot in a slightly over-corrected position. After three weeks walk- ing may be resumed if tenderness lias disappeared at the site of the operation. ORTHOPAEDIC SURGERY. 1131 (5) The use of extreme force under ether after tenotomy is often necessary in order to tear resistant ligaments which are not within reach of the knife. This force may be applied by the hands, by Thomas's wrench, or by Bradford's apparatus, which works with a sole-plate and long lever. It is surprising how great an amount of force can be safely used in these cases. Whatever apparatus is used is only intended to supplement the force exerted by the hands, and by the intelligent use of extreme force the performance of operations upon bone has been largely done away with. (6) Open incision consists simply in dividing all the resistant struc- tures in the sole of the foot. It is spoken of as Phelps's operation. The incision need not necessarily be transverse, but can be carried obliquely forward near the inner border of the foot, through which incision all resistant structures can be divided. If the transverse cut- ting is done fairly well forward, the bleeding is often insignificant. The incision described by Phelps runs from the inner malleolus to the inner side of the neck of the astragalus. Through this incision may be cut all soft structures as they offer resistance. (7) Resection of bone occupies of late years a steadily less important place in the treatment of club-foot. The performance of needlessly muti- lating and extensive bony resections will not be considered here. In Young's Orthopcedic Surgery can be found a list of sixteen different ope- rations upon the bones of the foot for this deformity. The two operations to be considered in this article will be osteotomy of the astragalus and os calcis and excision of the astragalus. Where marked obliquity of the neck of the astragalus exists, and the front part of the os calcis is curved inward, it is not likely that division of the soft parts will rectify the deformity. In these cases a wedge-shaped piece should be removed from the outer side of the os calcis. If resistance persists after this, an osteotome can be inserted into the neck of the astragalus, which can be cut through or a wedge-shaped piece of bone may be removed from it. Correction will then be easy. The treatment of club-foot is, in a word, as follows : The deformity should be corrected by manipulation and retention by a stiff bandage in infants. Later, tenotomy or open incision may be necessary if mechan- ical treatment has failed or has not been undertaken. After the per- formance of tenotomy or open incision correction by instrumental force may be necessary. If rectification cannot be obtained in this way, osteotomy of the os calcis and astragalus must be performed. The mildest measure that will over-correct the deformity is the best, but over-correction is essential, no matter what means are necessary to produce it. Any treatment is incomplete which does not provide against the occurrence of a relapse. This can only be followed out by having the patient wear an efficient retention shoe, such as the Taylor shoe, for some two or three years at least after operation. Whatever apparatus is worn should be discontinued gradually and carefully. 1132 SPECIAL OR REGIONAL SURGERY. Fig. 503. Club-hand. Club-hand is the name applied to a rare congenital condition which is in a measure analogous to congeni- tal club-foot, and which may occur in connection with it. The deformity consists in a deviation of the hand from the line of the forearm. This deviation is almost always toward the flexor surface of the arm, and the case is spoken of as dorsal club-hand when the deformity is toward the extensor surface of the forearm, and as palmar club-hand when the devi- ation is toward the flexor surface. It is also spoken of as radial club- hand when the deviation is inward, and as ulnar club-hand when the deviation is outward at the wrist. Radio-palmar club-hand is the most frequent form. A certain amount of deformity of the bones is generally present. The carpus may be incompletely developed or it may be almost entirely wanting. In the radial forms the radius is often wholly or partly wanting, and the lower end of the ulna may be enlarged to articulate with the carpus. A deformity simulating club-hand may result from intra-uterine fractures or cic- atrices, also from cerebral irritation. The cause assigned for the occurrence of club- hand is the same as that given to account Club-hand. f or the presence of congenital deformities in general. The hand is not held so rigidly as is the case in club-foot, and it can be moved through a certain arc. Treatment. — In the milder cases tenotomy of the resistant and con- tracted muscles or the stretching of them by manipulation or splints may be efficient. In dividing the tendons it is better to lengthen them by open incision than to divide them subcutaneously, as the possibility of non-union is greater here than in tenotomy in general. Where the radius is deficient and the deformity severe amputation may be advisable. R. H. Sayre has resected the ulna and part of the carpus in a case of the radial variety, and has obtained a fairly useful arm (Fig. 503). Each case, of course, must be treated on its merits, and the policy to be pur- sued would depend largely upon the deficiency of the bones. Affections of the Arch of the Foot. The abnormal conditions pertaining to the arch of the foot will be considered under three headings. These divisions are — (1) pronated ORTHOPAEDIC SURGERY. 1133 foot, (2) flat-foot, (3) contracted foot. The ma- Fig. 504. jority of cases showing these conditions have for- merly been grouped under the title of "flat-foot," which will here be restricted to signify a definite condition. (1) Pronated Foot. — The name " pronated foot" will be applied to an abnormal condition where in standing the foot rolls out and the inner malleolus tends to become more prominent than it should. The line of weight, instead of passing through the inner part of the metatarsus, falls, as a rule, inside of the foot. A certain amount of abduction of the front part of the foot is necessarily anatomically associated with pronation. This condition is most easily noticed if the patient stands with the foot upon the ground, bearing little or no weight. If the body-weight is thrown upon the leg, it will be noticed that the inner malleolus becomes more prominent, while the relation of the foot to the leg changes, and, instead of continuing in the line of the leg, as it should, the foot proper tends to roll outside of it. The condition can be more easily appreciated from an illustration than from a verbal description (Fig. 504). A long-exposure plate was used, and the patient stood without weight upon the leg and with weight upon the leg. The two separate photographs are therefore shown upon the plate — one of the normal position and the other of the abnormal or pronated position. Pronated foot has not been recognized as a separate pathological condition, because in most instances it has been regarded, as it most often is, as an early stage of flat-foot, but with the more extended study of flat-foot it becomes evident that many cases of painful affection of the foot due to abnormality of the arch of the foot are not shown by any demonstrable alteration of the arch. These cases must be classified as pronated foot. The study of the arch of the foot and its variations has been made for the most part by a study of the imprint of the foot as shown upon a piece of smoked cardboard or by placing the wet sole upon a piece of paper (Figs. 505-507). This method of studying the arch of the foot does not in any way show the existence of pronated foot, where the imprint may be perfectly normal. For example, Fig. 505 shows the case of a woman twenty-seven years old. Pain had lasted for two years in connection with standing, and had extended to the knee and hip. It had been so severe that there was much swelling of the feet at times. A smoked trac- ing of the foot showed a perfectly normal imprint. The photograph showed a marked degree of pronation of the foot. Here, then, is a case of disabling painful difficulty in the feet, accompanied by a very marked degree of pronation at the ankle-joint, which was not shown by a smoked tracing. (2) Flat-foot should be restricted to those cases where a tracing of the foot, taken as described, shows a distinct breaking down of the arch. Pronation of the foot to some degree must be present where the arch is lowered, for obvious mechanical reasons. Flat-foot is not necessarily a disabling affection. It may vary in degree from a slight flattening of the normal arch to a condition where the whole bottom of the foot touches the ground. The leg and foot without and with the superim- posed weight of the body. 1134 SPECIAL OR REGIONAL SURGERY. The foot at birth is not fiat, as has been stated in most books ; but the arch is well formed, and in reality the scaphoid lies from 1.5 to 2 cm. above the plane of the heel. This" fact has been demonstrated by Dane. For the first two or three years of life the fact that the imprint of a child's foot is like that of an adult flat-foot does not necessarily mean that the arch of the child's foot has broken down, although children Fig. 505. Fig. 506. Flat-foot. Normal foot. Fig. 507. <$ • • Contracted foot. Imprints of the palmar surface of flat and pronated feet. may have flat feet. In thin children the imprint of the foot at this age is not that of a flat foot, but of a normally developed arch. At four or five years of age the arch should form, and the tracing should then be that of the normal adult type. The causes of pronated and. of flat-foot will be considered together. In general terms it may be said that the deformity is caused by a dispro- portion between the weight to be borne and the muscular power which bears it. The immediate causes of deformity of the arch of the foot ir the order of their approximate importance are as follows : (1) Bad boots, which cramp the forward part of the foot, displace the great toe outward, and fail to support the arch. The muscles intended to support the arch are disabled and do not contribute proper muscular support. The shape of modern children's boots tends to throw the great toe outward and to favor the occurrence of deformity at this early age. Fig. 509 shows the typical relation of a woman's ordinary boot to the ORTHOPAEDIC SURGERY. 1135 foot of the individual wearing it. It is obvious that such relation is opposed to proper muscular support and proper weight-bearing. Footprint in a case of pronation : the two outlines inside show the position of the inner border of the foot with and without weight-bearing. (2) Weakness or inefficiency of the muscles resulting from — (a) Long standing, especially on hard-wood floors ; (6) Rapid growth ; (c) Poor health and debility ; (d) Convalescence from acute illnesses ; (e) Rapid gain of weight ; (/) Accident, injury, or disuse of limb. (3) Excessive weight-bearing, as in the case of professional " strong " men and "jumpers." (A) A shortened condition of the gastrocnemius muscle. (5) Rickets, for the most part to be observed in young children. (6) Infantile paralysis. (7) Direct traumatism. (8) Locomotor ataxia and similar organic nervous diseases. 1136 SPECIAL OR REGIONAL SURGERY. Fig. 509. Pronated foot and flat-foot are associated often with rheumatoid arthritis and neurasthenia. There is a type of intractable flat-foot seen in young adults, accom- panied by marked muscular atrophy, where treatment is of little avail. Its eti- ology is most obscure. Pathology. — The pathological changes in pronated foot show noth- ing more than the results of long-continued strain of the tissues at the outer side of the foot and contraction of the inside. In the severest cases of flat-foot the pathological changes are only those which result from the pro- longed maintenance of the vicious position. In the beginning the changes are only an exaggeration of those occurring in normal abduction, or, if abduction of the forward part of the foot becomes prominent, a general rotation inward of all the bones on an antero-posterior axis takes place. Certain ligaments are stretched, while others are contracted ; new articular facets develop where the changed relations of the bones bring new parts into apposition ; and ultimately the bones may change in shape under the new conditions, but there is no characteristic primary pathological change. The inner border of the foot may become convex, and in the severest cases the scaphoid is almost completely dislocated outward. Even the surface of the sole may become convex in the severest cases. Symptoms. — The symptoms of pronated foot and of flat-foot are the same. At the onset the pain and discomfort are more the result of the pronation than of the actual breaking down of the arch. This fact has been largely overlooked, and many cases have escaped treatment because The relation of an average , . J j, , c , L -, , . . boot to the foot : outline of the tracing ot the toot showed a normal imprint, of&otiFght a S hali ; n g Utline the pronation being entirely disregarded. The earliest symptom in pronated foot or flat-foot is generally to be found in weariness and discomfort in the feet on long standing, the feet being hot and flushed. The patient is inclined to spare the feet, and there is often difficulty in getting the boots to fit. Boots which have formerly been worn with ease become uncomfortable and cannot be endured. Pain is the commonest symptom, but it is gener- ally preceded by burning and discomfort in the feet. It comes on espe- cially after standing. It may radiate up the leg and thigh. It is con- fined to no especial location, although it is most commonly referred to the arch of the foot. Sensitive spots are present, but they are not located, as has often been asserted, in any characteristic places. Sensi- tiveness under the os calcis the writer has come to regard as an unfavor- able prognostic sign. The veins become enlarged and the feet sweat pro- fusely. After resting they feel stiff and clumsy. The symptoms in general are of the character described by patients as " rheumatic." Patients begin to walk with the feet everted, as in this position less motion at the various joints of the foot is required. They turn over on ORTHOPEDIC SURGERY. 1137 the inside of their boots, and the gait is clumsy and lacks elasticity. Swelling of the feet and legs may occur, and abduction of the forward part of the foot is favored. These symptoms are all likely to be caused by a condition of pronated foot in which the arch of the foot shows no actual breaking down. Other symptoms which may be , present are backache, discomfort, and even slight synovitis of one knee, especially in neurasthenic patients ; pain and inflammation in the metatarso-pha- langeal joint ; and ingrowing toe-nail. In the severest cases of flat- foot the foot becomes rigid in the vicious position, and reposition is not possible except under ether. Treatment. — Where the mechanical cause of a condition is so obvi- ous as in pronated foot the treatment should be particularly plain, inas- much as it should be directed to combating these faults of position. In other words, the pronation must be corrected. This may be done — (1) By the use of proper boots ; (2) By raising the insides of the boots ; (3) By cultivating the muscles which support the arch of the foot and throw it over on the outer side ; (4) By the use of pads, plates, and supporting apparatus. This treatment applies equally well to the mild cases of flat-foot as well as to those where no breaking down of the arch exists. (1) The Use of Proper Boots. — The preliminary to any and all treatment must be the selection of a suitable boot. The mechanical conditions which the foot is meant to fulfil should be studied in order that the foot may be put in the most favorable possible condition for Fig. 510. Boot of improved pattern (the inner edge is not quite so straight as it should be theoretically). restoration to its normal relation to the leg. Hampering and disabling footwear must be discarded. In many cases this measure alone is enough to secure correction of the pronation. The essentials of a good boot are as follows (Fig. 510) : The inside line should be straight or nearly straight. The boot should be built to hold the foot in an adducted position ; that it is to say, the forward part should be at an angle to the hind part if their axes are shown by lines drawn in the middle of the sole and the middle of the heel. This adducted position of the foot is the position of strength and the one which tends to combat the weakness represented in pronation. There should be plenty of width across the metatarso-phalangeal joint in order that the weight may be properly borne upon the ends of the metatarsals, and the sole of the boot should be as wide as the sole of the foot. The shank should be broad, not cut away at its inner aspect ; it should be fairly stiff. This, in general terms, is the accepted form of boot by most writers who have studied the subject, although all sorts of modifications exist. In America, how- 72 1138 SPECIAL OR REGIONAL SURGERY. ever, it has been almost impossible to buy or have made a boot of this description, and the various "hygienic" and "reform'' boots have, as a rule, in no way con- formed to these requirements. The shoe worn by children, which is symmetrical on both sides, tends to push the great toe out of the straight line, to hamper the muscles, and to favor pronation. The shoes worn by older children, known as misses' sizes, are as bad, if not worse. Women's boots in general, with the median pointed toe and the cutting away of the inside of the shank, favor the deformity. (2) By Raising the Inside of the Boots. — If pronation persists in spite of the application of a suitable boot, or if pronation is in the first place marked, the inner half of the sole and the inner half of the heel of the boot should be raised by having put on them a wedge-shaped piece of sole leather, which should be one-eighth or one-quarter of an inch in thickness at its base, the bottom of the wedge to correspond to the inner border of the sole and of the heel, and the apex of the wedge- shaped leather to the outer border of the sole. The patient should be cautioned against walking in the bare feet. Many cases of pronation Fig. 511. Supporting plates for the fiat and pronated foot can be easily corrected at this stage by such a simple contrivance, which throws more weight on the outer border of the foot. (3) Muscular exercise should form a routine part of all treatment of pronated and flat-foot in the milder cases. The addition of massage makes it more efficient, and should form a part of the routine treatment in cases where it is obtainable. The cultivation of certain faulty muscles which should normally support the arch is, however, the essen- tial part of this aspect of the treatment. Among these exercises are forcible adduction of the foot against resistance, inversion of the sole and drawing up of the arch, walking on tip-toe, and rising on the toes. It is upon the education of the faulty muscles that the permanence of the cure must depend. Massage is of the greatest use in nearly all cases. (4) The ITxe. of Pads, Plate*, and Supporting Apparatus. — In cases where the arch has broken down the application of some supporting appliance to the arch is in most eases necessary. As a rule, appliances which are incorporated in the boot are unsatisfactory and clumsy. ORTHOPEDIC SURGERY. 1139 Such shoes are made here and abroad, but they are exceedingly heavy and stiff. It is much better to have the supporting appliance inde- pendent of the shoe. The problem is to place the arch in a normal position which will rest the tired muscles, give the lengthened liga- ments a chance to contract, and place the foot under the most favorable conditions for improvement. Plates and springs of all sizes and shapes have been devised, and it matters little which one uses. A pad made of boiler felt may be cut of three or four layers, the bottom lay- ers overlying the top ones, thickest at the outside, which shall be applied to the arch of the foot in such a way as to afford a properly shaped support. The felt packs down, and, although it generally gives comfort at first, is not a permanent relief. In such cases similar plates may be made of leather and worn in the boots. Apparatus of this kind is likely to break down the shank of the shoe in severe cases. Of all forms of plates, the writer finds the most useful a rigid plate made of silicon bronze, which is a trade name for a composition metal (Fig. 511). This plate follows the outside line of the sole of the foot, coming across to the inner opposite the great toe joint. At the inside it comes to the scaphoid bone and fits the outline of the heel. The essential of any plate is that it should fit comfortably and accurately. Without this the best results cannot be obtained. This may be done by having the plate shaped to a cast taken of the foot in a fairly correct position, or, what in the writer's opinion is better, by having it shaped to the foot by the workman. Sensitive spots may be present which are not represented in the plaster cast, and if the plate presses upon these sensitive spots discomfort is caused. If the plate is tried on while being forged, these spots may be avoided, and in the writer's mind much greater efficiency be obtained. The plates are not applied, in most cases, to cases of fiat-foot as a permanent support, but in the hope that in connection with the use of muscular exercises a cure will be brought about and the plate may be dispensed with. It is a common experience for the arch to grow higher under this treatment, and at the end of three or four weeks for the plate to fail to afford proper support. Pain begins again, which is relieved by raising the arch of the plate. In many cases of flat-foot the plate may be permanently discarded after a period of six months to several years. It may be repeated that absolute com- fort, due to accuracy of fit and the pursuance Fig. 512. of special muscular exercises, is necessary to obtain this result. In the severest cases of flat-foot the plate alone is not sufficient to keep the foot in place, and an outside upright running to the top of the calf should be added. This should terminate below in a horizontal piece of steel running along the outside of the foot. This piece and the plate should be included in a leather lacing which surrounds the foot and ankle as a loose boot might, but serves to pull the internal malleolus toward the outside upright. In other words, it is a plate with an outside upright which tends to invert the foot (Fig. 512). If, however, the foot is stiff in the deformed position, no plate or appliance can be used until the foot has been rectified under ether and the arch restored to at least some extent. This is done by the exercise of manual force, and reten- tion for two or three weeks in the correct position is required. This is accomplished by the use of plaster-of-Paris bandages, Flat-foot plate with ankle support. 1140 SPECIAL OR REGIONAL SURGERY. Fig. 513. Contracted foot is the name applied to the condition originally described by Dr. N. M. Shaffer as " non-deforming club-foot." It is characterized by an increase in the height of the arch of the foot, so that the imprint is changed and only the front and back part of the foot touch the ground, leaving a clear space where the foot does not touch. This condition of contracted foot may be accompanied by pronation of the foot, and in many cases is associated with a limitation of dorsal flexion of the foot. It is diagnosticated by the tracing or by the fact that when the knee is extended the foot cannot be flexed beyond a right angle. This con- dition exists more often than one would suppose. In a recent series of tracings of healthy young women at least one case in ten showed what is known as a contracted foot. In the majority of instances it gives rise to no discomfort and the person is not aware of its existence. The treatment most satisfactory in chronic cases is stretching of the plantar fascia and tendo Achillis by Shaffer's shoe. Relief of the symptoms is generally immediate, and, although at first only lasting a few hours, at subsequent treatments it lasts a longer time, until after a few treatments weekly stretchings are all that are necessary. As a rule, they may be finally discontinued without relapses. Tenotomy of the tendo Achillis may be required in the severest cases. Talipes Equinus, Calcaneus, Varus, and Congenital Valgus. Talipes equinus is a condition in which the foot is plantar flexed, the metatarsus being pointed downward and the heel elevated. In a case of medium severity the patient walks upon the balls of the toes and is unable to touch the heel to the ground. There may rarely be such severe cases that the foot is completely turned over and the patient walks on the dorsal sur- face of the metatarsus. In connection with talipes equinus a condition is often noticed which has largely escaped attention. The phalanges are often in a " clawed " position. Pure talipes equinus as a congenital affection is rare. In the acquired form it results from infantile paralysis affect- ing the anterior muscles of the foot. It occurs as a post-hemiplcr/ic contraction and in connection with spastic para- plegia, and sometimes with pseudo- hypertrophic paralysis. It may be the result of traumatism from a posterior scar, or it may be the outcome of a cellulitis in the muscles of the leg ; it may be the symptom of muscular irritation in tubercular disease of the ankle ; it may, like almost all deformities of the foot, occur as a symptom of hysteria. Patients who have been confined to bed for a long time with the weight of the bed-clothing resting upon their toes, upon their recovery may show signs of talipes equinus. The same is true of patients who, after fracture of the leg, for example, have worn for a long Talipes equinus. ORTHOPEDIC SURGERY. 1141 time a plaster-of-Paris bandage over the ankle, where care has not been taken to prevent the toes from pointing. Such patients show a temporary talipes equinus. There is a compensatory form of talipes equinus where shortening has per- sisted after hip disease or some similar affection, and the foot of the shortened side, from reaching down at each step, becomes plantar-flexed. The treatment of the milder cases has already been discussed in speaking of contracted foot. It is doubted if the Shaffer shoe accom- plishes much in the severer cases. The limitation of mechanical treat- ment in talipes equinus is very marked. A satisfactory measure in nearly all cases is division of the tendo Achillis, and non-union is prac- tically never to be feared. Division of the plantar fascia subcutaneously is often necessary in the severer cases. Where both the plantar fascia and tendo Achillis must be divided, the former should be cut first in order to be able to stretch it after cutting, without at the same time stretching the divided tendon. The tendo Achillis may be lengthened to a definite extent by splitting it longitudinally and making the trans- verse cuts at different levels. In this way the two halves may be slid past each other and sutured at any definite point. Spastic Paralysis. — The question of the advisability of dividing the tendo Achillis and other contracted tendons in talipes equinus occurring in spastic paralysis has been left to the last. In cases where the intelligence is comparatively good, and where ataxia is not a disabling factor and exists only in a mild degree, much benefit may often be derived from cutting the tendons. This not only enables the child to use its legs more normally, but seems in some cases to result in improvement of the mental condition. It does not restore any power to the legs, but simply enables the mus- cles to be used to better advantage. In no case within the writer's knowledge has harm resulted, and much benefit has often been observed. Arthrodesis, or the production of ankylosis at the ankle-joint, may be desirable in some of the severer cases of infantile paralysis where the muscles of the leg in general are severely involved. Talipes Varus. — Talipes varus is the name applied to a condition characterized by a turning inward, of the sole, the foot being adducted and rotated inward at the medio-tarsal joint. Pure talipes varus, with- out an element of equinus, is a rare deformity either in the congenital or acquired form. The condition described in this article as congenital talipes equino-varus is, however, spoken of as talipes varus by such writers as Walsham and Adams. When talipes varus occurs, it results most often from infantile paralysis. The treatment of the deformity differs in no way from that of talipes equino-varus, the common form of which it resembles very closely. Talipes calcaneus is the name applied to a condition characterized by dorsal flexion of the foot, the heel being depressed and the metatarsus elevated. There is a condition known as pes cavus, which is character- ized by an arching of the sole of the foot. When severe, this is in most cases connected with talipes calcaneus, and will be considered with it. Talipes calcaneus, however, may exist without any marked concavity of the sole of the foot, and pes cavus may exist without calcaneus and even with equinus. The deformity in talipes calcaneus may vary from a slight degree of 1142 SPECIAL OR REGIONAL SURGERY. dorsal flexion to a degree where the dorsum of the foot can be flexed to touch the anterior surface of the leg. In cases of medium severity the patient walks upon the heel with the toes elevated, and when the affected leg is placed upon the ground it is necessarily unsteady and uncertain. Fig. 514. Extreme degree of talipes calcaneus. In pes cavus the anterior part of the foot is drawn backward and the arch is increased. It may occur alone as a congenital deformity, and in the acquired form it is most often of paralytic origin. It may be associated with the " clawed " toes already spoken of, but it occurs most frequently as the result of infantile paralysis in connection with talipes calcaneus. Tkeatment. — In the congenital cases of talipes calcaneus massage and manipulation are generally sufficient to overcome the dorsal flexion, possibly in connection with retention by plaster-of-Paris bandages. The same treatment may be useful in milder paralytic cases. In the latter cases a Taylor club-foot shoe, or some similar appliance which does not allow dorsal flexion of the foot beyond a right angle, is of use. Such a shoe prevents the foot from being rolled in or out and limits the vicious tendency. Tenotomy of the anterior tendons may possibly be required. Various operations have been proposed for the relief of talipes cal- caneus : (1) The tendo Aehillis may be shortened. (Vide p. 404.) A piece of the tendo Aehillis may be removed by Willett's operation, or the tendon may be obliquely cut through, as advocated by Gibney, and the upper segment slid downward upon the lower, and the two portions sutured together by catgut while the foot is in a position of plantar flexion. Promising as these operations appear to be at first, the tendons are very apt to become elongated later where paralysis of the posterior muscles is complete. (2) A healthy muscle may be attached to the tendo Aehillis by grafting it to the side to supplement the action of the paralyzed gastrocnemius and soleus. A portion of the outer margin of the tendo Aehillis is removed, and to this freshened surface the ends of the divided peroneal tendons are sutured by fine silk. Probably other muscles could be sub- stituted for the peroneal tendons, provided that healthy muscle could ORTHOPEDIC SURGERY. 1143 be chosen which in their contraction should pull upward on the tendo Achillis. The grafting of a healthy muscle gives far more satisfactory results than simply shortening the tendon. (3) Arthrodesis of the ankle-joint is a useful measure in cases of complete paralysis of the leg the result of infantile paralysis. This operation consists merely in an incision as if for resection of the ankle- joint. Pes cavus may require for its relief the division of the plantar fascia and possibly some of the tendons. The mixed forms of deformity of the foot described under the com- pound names of calcaneo- valgus, etc. have no special features of surgical interest, and have been sufficiently well covered by the description of the simpler forms. The terms dorsal flexion and plantar flexion, wherever they appear in this article, have been used for purposes of clearness. It is probable that the development of tendon- grafting — that is, grafting the proximal end of the tendon of a healthy muscle upon the distal end of the tendon of a paralyzed muscle — will have an important place in the surgery of the future. Talipes Valgus. — Acquired talipes valgus has been spoken of already under the section relating to flat-foot. Congenital talipes valgus, occurring without an element of calcaneus, is so rare that its existence has been denied by some writers. It un- doubtedly exists, and is sometimes associated with absence of the fibula or some similar malformation. Its treatment differs in no way from that of the acquired variety. Paralytic Deformities op the Feet and Legs. The deformities of the feet which result from infantile paralysis have been for the most part considered in the previous section under the headings of Talipes Equinus, Calcaneus, etc. Infantile paralysis, in general the most frequent cause of these acquired deformities of the feet, causes disability in two ways : (a) by leading to contractions of the legs and feet in deformed positions, like talipes equinus, flexed knee, and the like ; (b) by rendering the limbs flaccid and unable to bear weight. The extent and distribution of the paralysis determine this disability. The diagnosis is made partly from the history. In infantile paral- ysis a child in its first dentition is suddenly attacked, most often in the night, by a feverish spell, which is followed by loss of power, perhaps in one of the legs. The tendon reflexes in the knee of the affected side are lost or diminished, and the paralyzed muscles show the reaction of degeneration. With regard to the prognosis, it may be said that no case of infan- tile paralysis, however severe, is beyond the possibility of improvement by mechanical or operative means. In early cases of infantile paralysis, and in cases characterized by flaccidity rather than by contractions of the muscles, the requirement is for apparatus which shall give support to the leg, so that it may be used and held in a comparatively normal way. Thus the stretching of paralyzed muscles may be avoided, and contractions of the joints in 1144 SPECIAL OR REGIONAL SURGERY. deformed positions are rendered less likely. The chief requirement in apparatus for paralysis of the leg is that it shall hold the knee extended and control the ankle, so that it shall not turn to one side or the other. This renders the leg able to bear the body-weight. The control of the ankle is best obtained by the use of the Taylor club-foot shoe, used either at the inside of the foot or outside with an outside upright. To this shoe is attached whatever appliance may be necessary to hold the leg straight. Where the hip-muscles, and especially the adductors of the thigh, are paralyzed, the leg uprights should be joined to a leather jacket or a leather band embracing the pelvis. Hallux Valgus. This is the name applied to an outward deviation of the great toe at the metatarso-phalangeal joint. The deviation to some extent is present in practically all adult feet at the present day, and it is only when the throwing outward of the great toe becomes extreme that it is commonly spoken of as a deformity. In the normal foot it was pointed out by Meyer that a straight line drawn backward, prolonging the middle line of the great toe, should pass through the middle point of the heel. Although this may be the case in young children, it is almost impossible to find a foot of this description in an adult, at least in the large cities. So long as children are compelled to wear shoes of the present shape hallux valgus will be commonly found. It is hard to say where the condition recognized as normal ends and where the condition to be de- scribed as hallux valgus begins. In the etiology of the affection no fur- ther cause is needed than what has already been named. The deformity is associated with osteo-arthritis in some cases, but probably does not stand in a causal relation to the condition. Pathology. — One finds that the first phalanx is displaced more or less according to the severity of the deformity on to the outer side of the head of the first metatarsal. The internal ligaments and muscles are stretched and the external ligaments and muscles shortened and con- tracted. The tendons of the sesamoid bones are displaced over the inner aspect of the head of the metatarsal bone, and a bursa may de- velop which is apt to become inflamed on pressure and is known as bunion. The chief symptoms of the deformity result from pressure over the inner aspect of the deformed joint. The bursa often becomes inflamed and suppurates, discharging from a small opening in the centre. This condition is likely to con- tinue permanently. Inflammation of the distorted joint often occurs, which may result in the deposit of osteophytes and in bony grating. The bursa often com- municates with the joint and suppuration may result. When the deformity is severe, it is useless to try to remedy it by making the patient wear a boot with a straight inside edge. Bather a large piece of leather should be nailed to the last on which the boot is made, which pad should come over the situation of the affected joint, allowing sufficient room to prevent pressure. Under these conditions uncom- fortable symptoms are often avoided. Splints for the relief of milder forms have been devised which press the toe in by using the foot as a point from which to pull. Sayre uses a buckskin cot which connects with elastic webbing running along inside of the foot and attached to a piece of adhesive plaster on the heel. For severe cases, where the bursa is inflamed and the joint involved, it is much simpler to excise a wedge-shaped piece from the metatarsal and the phalanx, in- ORTHOPEDIC SUROERY. 1145 eluding and obliterating the joint. Excision of the head of the metatarsal bone may be done, which may leave the patient with a fairly movable joint, but excision of the joint, as a rule, gives the best results and affords an opportunity for the re- moval of the bursa at the same time. Hallux varus is a condition in which the great toe deviates inward to an abnormal extent. It occurs very rarely as a congenital affection . It rarely requires severe treatment. Manipulation and retention with a splint are generally sufficient. If need be, the internal lateral liga- ment of the foot may be divided and the toes replaced in a correct position. Metatarsalgia. Metatarsalgia, or Morton's painful affection of the foot, as it is often called from Dr. Thomas G. Morton, who first described it in 1876, is a condition characterized by acute pain located between the distal ends of the outer metatarsal bones. The affection seems to be due to a neuralgia of the plantar digital nerves, and especially the branches in the neighborhood of the fourth metatarsal, where they seem particularly liable to injury. The affection attacks most often young adults, and is more common in women than in men. It seems to have its origin in a certain number of cases in the persistent use of ill-fitting shoes ; it arises also from slight sprains and wrenches of the foot. It may, however, occur apparently spontaneously. It may be acute and quickly subside, or it may become chronic. Local tenderness is generally present, but no swelling. The most characteristic symptom is a "cramp" in the foot, which may make it imperatively necessary to remove the boot at once wherever the patient may be. The affection is probably in most cases associated with some abnormality in the arch of the foot, such as contracted foot, pronated foot, or flat-foot. In some instances it is associated with obliteration of the transverse arch of the foot, as pointed out by Goldthwait. It seems probable that with the more careful study of the arch of the foot some abnormality will be found to explain all cases. In the treatment the first aim should be to seek for a cause for the affection in some abnormality of the arch, and not only should this be corrected, but the use of proper boots should be insisted upon. If no cause can be found, acute cases are best treated by bandaging and sooth- ing applications. Very severe cases may require excision of the head of the fourth metatarsal bone. Most cases, however, in practice can be relieved by the detection and treatment of the condition of which the pain is a symptom. The Mechanical Treatment of Joint Disease. The mechanical treatment of joint disease depends for its efficiency upon three things which it tries to accomplish. In this it follows Nature's lead, aiming to do artificially what she indicates in symptoms and pathological processes. These three aims are — (1) fixation of the affected joint, (2) protection from, weight-bearing, and (3) distraction of the joint surfaces where possible. Mechanical Treatment of Hip Disease. — The term " hip disease " will be used here as synonymous with tuberculous inflammation of the 1146 SPECIAL OR REGIONAL SURGERY. Fig. 515. hip-joint. The mechanical treatment of hip disease may be conducted either during recumbency in bed or by ambulatory apparatus. In gen- eral, modern opinion leans toward the latter method. Treatment by recumbency is to be adopted when the joint is sen- sitive to manipulation and when attempts at going about with suitable apparatus cause pain and irritation. It is to be adopted when deformity of the leg in an adducted, abducted, or flexed position is present ; also when it is desired to avert the formation of a threatened abscess. Traction during recumbency may be made by the long Taylor splint about to be described under ambulatory treatment, but it is generally less comfortable than the method just mentioned. Treatment by recumbency is not to be advocated as a routine measure, but simply under the conditions noted. It is to be discontinued as soon as the deformity has disappeared or as soon as the child can go about with- out pain. It is desirable, however, that children should sleep strapped to the frame at night during the acute stage of hip disease. The ambulatory treatment of hip disease may be considered under three headings: (1) treatment by protection; (2) by fixation ; and (3) by traction. (1) Treatment by protection alone has been used under the name of the physiological method of Hutchison, where the child was allowed to go about using a crutch with a high sole on the well foot, and allowing the diseased leg to swing. The method is very slightly better than no treatment at all, and has been practically abandoned. Treatment by Fixation. — Nature furnishes the indication that the joint should not be moved during hip disease, by holding the hip firmly by tonic spasm of the muscles con- trolling the joint. In general relief is experienced by fixation. The most efficient method of treating hip disease by fixation is that of H. O. Thomas of Liverpool (Fig. 516). The Thomas splint consists of a bar of soft iron reaching posteriorly in the middle line of the leg from the angle of the scapula to the lower third of the leg. It is shaped to fit the curve of the buttock, Above, it terminates in a chest-band, which should encircle three-fourths of the chest. There is also a semicircular thigh-band, which should be placed an inch or two below the perineum, and a leg-band should terminate the splint at the bottom, which should encircle two-thirds of the calf. The splint is applied as shown in Fig. 517, secured to the body by means of a bandage connecting the ends of the chest-piece and run- ning over the shoulders. The leg is secured to the splint by leather straps or by a common bandage, a high sole is put upon the well foot, and the patient is allowed to go about on crutches. The splint furnishes fairly good fixa- tion ; it is cheap and simple, and is in general use throughout Eng- land, where the results are satisfactory. In America this method of treatment is not regarded with favor, as a rule. It makes no traction and supplies necessarily imperfect fixation. Again, inasmuch as no traction is exerted to counteract muscular spasm, and thus to keep the head of the femur from being crowded into the acetabulum by muscular Judson's peri- neal crutch. ORTHOPEDIC SURGERY. 1147 force, and thus wearing away the upper rim, there must result in severe cases subluxation, shortening, and elevation of the trochanter above Ne"laton's line. In general, the splint is hard to adjust, difficult to keep in place, and does not allay pain as traction does. Treatment by Traction. — The use of traction in hip disease rests upon the theory that by efficiently applied traction the surfaces of the hip-joint can be separated from each other. In this way two surfaces of diseased and softened bone are kept from wearing upon each other. Pain is diminished, the pro- cess of healing is promoted, because the greatest amount of quiet in the joint is pro- duced by this method. Fig. 517. Fig. 516. Thomas splint applied with patten and crutches (Ridlon). The splint in its simplest form, not yet padded or covered (Ridlon). In connection with treatment by traction, protection should be obtained by the use of a high sole and crutches ; fixation should be ob- tained by having a tightly-fitting pelvic band surrounding the pelvis ; and the activity of the child should be limited by insisting upon some hours of recumbency during the day. The combination of the three methods of protection, fixation, and traction combined in the treatment to be described affords theoretically and practically the best chances of securing a good result in hip disease. It has been demonstrated ' that in the diseased hip-joints of children traction of ten to twenty pounds induces lengthening of the leg from one-eighth to one-half inch. Eliminating sources of error, it becomes evident that this lengthening in the leg must be caused by a separation of the joint-surfaces. Conse- 1 Bradford and Lovett, New York Med. Journ., Aug. 4, 1894. 1148 SPECIAL OR REGIONAL SURGERY. quently, it may be assumed that traction applied in sufficient force serves to separate the head of the femur from the acetabulum, and traction to be of use must be applied in force sufficient to accomplish this. It is not likely that it is done by traction of less than ten pounds. The traction must therefore Fig. 518. be used intelligently with this in view. Traction when the patient is going about can be most easily produced by the long traction splint know as the Davis, Sayre, or Taylor splint. The special form Fig. 519. The plaster-of-Paris bandage (Lovett; by permission of the Trustees of the Fiske Prize Fund). Vance's moulded leather splint. of this splint is a matter of very slight consequence, provided that its aim be kept in view. The object is to provide a rigid perineal band and an upright running the length of the leg. The perineal band is to fix the pelvis and to provide a basis for counter-extension when the leg is pulled down by the foot-piece at the bottom of the upright. To the leg is applied a sticking-plaster extension, such as is used in the bed- extension. This is fastened to a windlass on the foot-piece of the splint. Perineal bands pass from the front to the back of the rigid pelvic back, and afford a basis for holding the pelvis when the leg is pulled downward. The splint is one which may be made by a blacksmith, yet it is capable of the greatest nicety of construction. The forms most commonly used are shown in the illustrations. The pelvic band should fit tightly to the pelvis, and the upright of the splint may be curved to con- form to the outline of the leg. The perineal bands should be made of webbing covered with canton flannel, and any apparatus which will pull the straps down- ward may be used for the windlass at the bottom of the splint. The writer has described a gas-pipe splint (Fig. 521), which can be made for a dollar or two, which serves fairly well, but from which traction is to be made by means of ORTHOPAEDIC SURGERY. 1149 leather straps attached to the foot-piece and buckled into the sticking-plaster extension. Such, roughly, is the splint in general use in the hands of American orthopaedic surgeons. It does not Fig. 520. furnish complete fixation to the pel- vis, but partial fixation. Undei proper circumstances it probably does induce separation of the femur from the acetabulum. Where it is used pain should be allayed at once, and night-cries or irritability of the joint are a sign that matters are not going well, and that the Fig. 521. Splint for hip-joint disease. Diagram of cheap gas-pipe hip-splint. patient is probably allowed too much activity or that the apparatus is not properly cared for. The splint of Dr. Phelps is probably the most important modifica- tion of the long traction splint (Fig. 523). It aims at securing better fixation by an arm encircling the thorax in addition to the pelvic arm, and it theoretically provides lateral traction in addition to that in the length of the leg. It is doubtful if the splint really exerts lateral traction ; and, indeed, the question of the value of lateral traction is one which is still unsettled. There are other modifications of the long traction splint in use in Germany, but they contribute nothing essential to the traction treatment. Treatment by traction should be used until some months after mus- 1150 SPECIAL OB REGIONAL SURGERY. cular spasm has disappeared from the joint, for relapses are common, and if traction is discontinued too soon, rigidity returns and the disease again becomes active. When the acute stage is sufficiently quieted to allow the application of a convalescent's splint, partial protection to the Fig. 522. Fig. 523. Brace for hip-joint disease, with extension and counter-extension provided for. Fhelp's hip-joint brace. joint will be all that is required. Consequently, if the traction splint is cut oif and is made to fit into a slot fastened into the sole of the boot in such a way that the splint shall be longer than the leg and that the bottom of the foot shall not touch the bottom of the boot, sufficient pro- tection for practical purposes may be provided. In this way the patient in walking does not have the full impact of the step come upon the hip- joint, but takes it upon the perineal band of the splint. A splint of this sort should be worn two or three years after the active treatment has ceased, and should be discontinued gradually. Hip-abscess. — With regard to the occurrence of hip-abscess, it is probable that the careful carrying out of the traction method as described will in the majority of cases avert its occurrence Malum Coxae Senile. — The form of disease of the in elderly persons in connection with chronic rheumatoid arthritis has generally been regarded as an intractable and hopeless affection. It has been pointed out by H. L. Taylor that rest and traction of the diseased hip occurring ORTHOPEDIC SURGERY. 1151 hip, followed by protection by means of the splint described above, should be followed by much relief of the irritation, and in many cases by a permanent improvement of the diseased joint. Disease of the Knee-joint. — In tumor albus or chronic inflamma- tion of the knee-joint the indications are, as in hip disease, for protec- tion, fixation, and traction. Partial fixation can be obtained by means of the ham-splint or by Fig. 524. Ward-wagon (Children's Hospital, Boston, Massachusetts). the plaster-of- Paris or leather, silicate, or dextrin bandages applied to the leg. Plaster-of-Paris bandages as routine treatment for tumor albus are not suitable for continued use, as they loosen and become dirty, and afford less fixation that one would suppose on account of the elasticity of the muscles by which the femur is surrounded. To control the joint in a proper way the bandage should extend from the ankle to the groin, and should not stop at the middle of the thigh. It should be as tightly applied as is comfortable. This bandage, in connection with the use of a high sole on the well foot and crutches, furnishes protection and fixa- tion, and is a fairly efficient mode of treatment. It does not, however, provide for traction, which, although not as important as at the hip- joint, is of use in most cases. Unless the patient has a high sole on the well foot and uses crutches the joint is not protected even if a plaster-of- Paris bandage is applied, and the case is not being properly treated if the ends of bones are allowed to jar together in the motion of walking. The Thomas knee-splint is the most satisfactory ajjparatus in general for the treatment. It consists of a ring of iron set at an angle of 45° to the inner one of two uprights which project below the foot. The ring of iron is padded and fits closely the upper part of the thigh, so that in walking the patient receives support from the perineum and bears no weight upon the knee. The ring is irregularly ovoid in shape, drawn out at the inner posterior angle. This splint is shaped to the leg and fitted with leather lacings to the thigh and the calf, which fur- nish excellent fixation. The splint projects below the bottom of the foot, and the transverse bar at the bottom mar be used to make traction 1152 SPECIAL OR REGIONAL SURGERY. from the sticking-plaster extension, which is applied to the leg, reaching to the knee. A high shoe is placed upon the well foot, and the patient is allowed to go about either with or without the use of crutches. Fig. 525. The Thomas knee-splint. The chief difficulty in the treatment of tumor albus comes in the cases where permanent flexion of the knee occurs. Under these cir- cumstances the following course may be pursued : (1) The knee may be straightened by force while the patient is under the influence of ether, and a plaster-of-Paris bandage applied. Gold- thwait's genuelast enables one to exert great force gradually and with safety. The apparatus extends the knee and at the same time presses forward the head of the subluxated tibia. (2) By the application of a plaster bandage to the leg in the fixed position the muscular spasm is quieted and relaxed, so that after some days, when the bandage is removed, the knee can be placed in a straighter position. By a succession of plaster bandages the irritation is quieted, and at each application the knee may be straightened some- what. This method is to be used until the leg is straight. (3) An apparatus known as the Billroth splint is occasionally used. A plaster bandage is applied to the limb, and in this bandage are incorporated two hinges attached to broad curved iron plates. These hinges are placed over the lateral aspects of the joint, so as to allow antero-posterior motion when the bandage is cut at the knee. After the bandage has hardened a circular division ORTHOPAEDIC SURGERY. 1153 of the plaster is made at the knee and the front of the bandage is cut away. Into the slot at the back of the knee are inserted wedges of increasing size until the limb is straight. The splint exercises considerable pressure and may cause sloughs. (4) Flexion may be corrected by traction made in the line of deform- ity, which quiets the irritability of the muscles and allows the limb to be gradually straightened. The way in which this traction is applied is by the traction splint above mentioned. Ankle-joint Disease. — Chronic tubercular disease of the ankle-joint and tarsus must be treated by fixation and protection. Traction is not applicable. Fixation may be furnished by a plaster-of-Paris bandage applied to the ankle and reaching to the upper part of the leg, or it may be furnished by a skeleton bandage made of steel, which consists of a metal sole-plate and two uprights run- ning to the top of the calf, where they terminate in a posterior curved band. A leather lacing holds the foot on to the foot-plate, and another lacing confines it to the calf and the uprights. This splint offers no special advantage over the plaster " bandage, except that it is cooler and more comfortable. Protection to the diseased ankle-joint is most readily furnished by having the patient wear also a Thomas knee-splint, which comes below the foot and protects from weight-bearing : unless this is done it is impossible to keep the child from walking. When deformity of the ankle-joint, either in the position of plantar or dorsal flexion, is present, it is a symptom of muscular irritability, and this muscular irritability is most easily allayed by a succession of plaster bandages, affording fixation and applied as described in knee- joint disease, in the hope of each time securing a better position. 73 CHAPTER LIV. PLASTIC SURGERY. By Arpad G. Gerster, M. D. Definition. — In a general sense, the term " plastic surgery " com- prises all reparative measures, whether applied to the skin, tendons, nerves, or the skeleton of the human body. In its strict application, however, we understand by it those steps which aim at the reparation of defects and lesions of the skin only, and of the mucous membranes ad- joining the natural orifices. Under this now generally accepted definition Szymanovsky's term of dermatoplasty coincides with the modern concep- tion of the plastic art. The Objects of Plastic Surgery are — The repair by living tissues of (1) congenital and acquired defects of the skin and adjoining mucous membranes ; (2) of the consequences of simple lesions of continuity with- out defect ; (3) of faulty arrangements of the orifices, congenital or acquired ; (4) of functional disturbances or of cosmetic blemishes due to the deposition of cicatricial tissue ; (5) of perforations or fistulse estab- lishing abnormal communication between cavities or a cavity and the outer air. Whenever a defect is covered by living tissues taken from the body of the patient the process is termed autoplasty. Heteroplasty, on the other hand, is the operation wherein living tissues foreign to the bearer of the defect are employed. The transfer of a skin-flap from one individual to another constitutes heteroplasty. But where a defect of any kind is corrected by the insertion of dead organic or inorganic matter the process cannot be termed truly a plastic one, as the element of organic cohesion is lacking. Nevertheless, some authors include these measures under the appellation of heteroplasty, though enthesis — insertion or coaptation — would be a better term. General Principles Governing Technique. — (.1 ) Transplanta- tion and Skin-grafting. — The fact that a totally detached part of the body can form an organic union with another than the base from which it was severed, provided that it be adapted immediately and attached by suitable means, was known early enough to serve as a foundation for the older Indian method of rhinoplasty. Accounts that a severed nose-tip, a cut-off finger-tip, were reunited to their original sites are common enough not to admit of serious doubt. Nevertheless, the success of min- istration of this kind was so precarious and uncertain that — at least in Europe — no systematic plan of plastic repair was based upon this form of grafting. Knowing what important influence is exerted by the presence or absence of pyogenic infection upon the success of primary 1154 PLASTIC SURGERY. 1155 adhesion, we do not wonder that many or most of these extensive im- plantations turned out to be failures. Since we have learned to guard the efforts toward reunion of the living tissues against the deleterious influence of pathogenic parasites, we not only see minute particles, but extensive films, of epidermis become attached to a granulating surface. Finally, large detached flaps of skin, comprising its entire thickness, are transferred and made to become adherent with great certainty of success. Though, the honor of having established a method of epidermatic grafting undoubtedly belongs to Reverdin, it is of much interest to know that Frank H. Hamilton performed as early as Jan. 21, 1854, at the Buffalo General Hospital, a successful transplantation of a rather extensive detached piece of skin upon the centre of a still more extensive ulcer of the leg. He described the characteristic border growth of the graft, and upon this based the conclusion that the graft may be considerably smaller than the defect to be healed. Interesting as Reverdin's efforts were, they lacked practical utility, and epidermatic grafting in a generally useful form can be said to exist only since 1886, when Thiersch demonstrated that the cicatri- zation of a granulating surface or of a fresh wound, however extensive, could be brought about with much certainty by engrafting large films of epidermidal material gained by the bold employment of a broad razor. Thiersch's success would not have been possible without a reliable aseptic. (Thiersch's method having been already described at consid- erable length on p. 224, detailed description will be omitted.) The locality to -which skin is to be transferred must be either a fresh wound, as would result from an extirpation of lupus or cancer, or, if it be occupied by a granulating ulcer, this must be converted into a fresh wound by paring or energetic scraping. After completed dis- infection with a sublimate solution, traces of this must be removed by irrigation with salt solution, and then the bleeding surface is covered and subjected to steady pressure by a dry sterilized compress of gauze. After this all the rest of the work must be done in a dry manner. It does not matter whether the preparatory paring and scraping leaves deeply de- pressed hollows or not, as experience has taught that the newly adherent flaps, though much depressed at first, become gradually raised to the nor- mal level by a copious subcutaneous deposit of connective tissue and even new-formed fat. The seat of the transplantation being thus prepared for the reception of the flap, the surgeon's attention is now directed to the place whence the skin-flap is to be taken. The inner and anterior surface of the upper extremity, the anterior aspect of the thigh, and the trunk will furnish an abundant supply. To facilitate the immediate suture of the defect produced by the raising of the flap, this should be fusiform in shape, and, if necessary, can extend the whole available length of the extremity, its width being limited only by the requirement of leaving behind enough skin to per- mit immediate closure of the wound by suture. In obese individuals this closure of the defect will be facilitated by the excision of some of the subcutaneous fat. The detachment of the flap is done as follows: The entire circumference of the flap to be raised is defined by an incision penetrating to the fascia. Then the lower angle of the flap is seized with a dry mouse -tooth forceps, and, being raised, its adhesions to the sub- 1156 SPECIAL OR REGIONAL SURGERY. cutaneous fat are divided with even strokes of the scalpel, the edge of the knife being directed toward the flap rather than against its base. The object of this rule is to remove the skin without any adherent fat. As soon as four or five inches of the flap are raised, the forceps is dropped, and the skin-flap is doubled upon itself, so as to bring in contact its raw surfaces, the surgeon's fingers grasping the flap by its epidermidal sur- face. Thus unnecessary contact of the raw surface with fingers and instruments is avoided. Now the entire flap is detached, when it is seen to lose by shrinkage about one-third of its extent, and is immediately transferred to its new habitat, provided that hemorrhage of the base to which the flap is to be adapted has entirely ceased. To check hemorrhage torsion is preferable to ligature. As soon as the flap is in situ gentle elastic pressure is applied to expel inter- vening air, and in a few minutes a remarkable degree of adhesion develops between the newly-apposed surfaces, caused partly by the cementing effect of a very thin layer of blood, but mainly by atmospheric pressure. Now, and not before, are the edges of the flap trimmed off to fit. Sutures are not necessary, except where involuntary or uncontrollable reflex movements might dislodge the flap, as, for instance, near the mouth or on the face. When a gently compressive dressing can be well applied, this will be found sufficient. Extremities are to be immobilized by suitable splints. The manner of dressing recommended by Krause was found very defective, its changing so cumbersome and dangerous to the newly adherent flap that the present writer abandoned it in favor of the usual form of aseptic dressing ; that is, the application of rubber protective, and over this of dry absorbent gauze compresses fastened by a roller bandage. The presence of the protective prevents adhesion and matting together of gauze and flap, and no dif- ficulty will be encountered in the safe and painless removal of this first dressing, more or less crusted with dried blood and otherwise adherent. The first change of dressings should take place on the fourth day. The appear- ance of the flap at this time is usually pale, sometimes bluish and livid, often cov- ered with a crop of bullae or vesicles, and very discouraging to the uninitiated. The vesicles should be opened with the scissors and the dressings renewed. By the seventh day a rosy hue begins to penetrate the superficial necrosed film of grayish epidermis, which can now be removed with a pair of forceps. Here and there small islands of shrunken dead skin can be recognized by the absence of hyperaemia and turgor, indicative of circulation. The bulk of the flap will always survive and adhere, and it makes no difference whether the base to which the flap was transferred consist of muscle, fascia, connective tissue of any kind, periosteum, dura mater, or freshly exposed cortical or spongy bone. According to varying cir- cumstances, definitive cicatrization will require from three to six weeks. Sensation returns but very slowly. To replace hairy portions of lost skin — eyebrows, beard, and the hair — is feasible and easy. (B) Plastic by Gliding and by the Formation of Pediculated Flaps. — Though the scope of plastic surgery has been considerably narrowed by the adoption of skin-grafting, the usefulness of the older methods stands nevertheless unimpaired in many exigencies. A defect acquired by disease, accident, or surgical operation can be repaired in two ways — either by gliding or by the formation and transference of the flap nourished through a pedicle. In the first case the gap is closed by distention or the stretching of skin adja- cent to the defect, which is rendered possible by a previous detachment of an ade- quate portion of skin from its underlying base — a process known by the name of "undermining." No new defect is caused by this process, in which the elasticity and tensile property of the skin is utilized to cover an area larger than natu- rally pertains to the portions of skin used for this purpose. The method of gliding represents the simplest form of plastic operation, and deserves preference whenever practicable. Nutrition of the flaps is generally abundant on account of PLASTIC SURGERY. 1167 the usually broad attachments, and no new defect need be made to furnish plastic material. Where the method is impracticable we have to shape a flap detached on three sides of its circumference, and remaining attached at the fourth side — roughly speaking — when nutritive channels are preserved in what we term the pedicle. This flap being raised and transferred to the place which it is to invest, a defect is left at the site from which it was taken, which must be closed either by a subsidiary plastic operation, by gliding, or by another pedicled flap, or, finally, under favorable circumstances, can be made to heal under skin-grafts or by the process of granulation. A useful flap must be first of all viable — that is, well nourished. It must contain not only the whole thickness of the skin, but also a portion of the subcutaneous connective tissue in which are distributed the nutrient vessels of the integument. The direction of the incisions must be in- fluenced by due regard to the course of the nutrient vessels, which ought to be preserved intact as far as possible. Flaps showing signs of arterial bleeding are well nourished ; those that turn chalky and pale are less so, but may improve on the development of collateral circulation, when their turgor and rosy coloring will be regained. But the flap must remain well nourished even after fixation and after having been sub- jected to the necessary amount of stretching. While a pale flap may be of doubtful vitality, a blue or cyanosed flap is almost certain to decay. Cyanosis is the expression of the fact that, while arterial supply is preserved, the return circulation is embarrassed or suppressed. After a rear- rangement of sutures a moderate relaxation of tension by the reduction of the number of sutures or a straightening out of a too close twist of the pedicle, will have the desired effect. If not, the flap may be bled by one or more scarifying incisions ; or, finally, even the complete division of the pedicle, converting the plastic into a case of skin-grafting, may be chosen rather than the certainty of gangrene by passive congestion. To fashion the flaps with due regard to nutrition and the avoidance of tension, they must be cut neither too large nor too small. If too large, there will be defective nutrition to the distal parts of the flap, with subsequent marginal necrosis. If too scanty, the sutures will exert so much tension as to cause acute ansemia, which will again result in disaster. It must be borne in mind that all flaps shrink very con- siderably after detachment, the minimum of shrinkage being one-third of the original extent. When all the preceding points have been well observed a correct adaptation by sutures will have to complete the work. When the suture is completed in a satisfactory manner the question of dressings will need attention. Where even a slight amount of exter- nal pressure might endanger the circulation of a precariously nourished flap, any external dressing of a bulky and confining character would be inadmissible ; in fact, it is best to leave the wound exposed, protecting its surface only by a generous dusting with iodoform powder or by a filmy shingling made of rubber-tissue protective. All sticky substances, as plasters and collodion, are to be avoided, as they only serve to irritate the patient and their retentive value is very problematic indeed. A properly made suture does not need the support of adhesive plaster slips or col- lodion, and a defective suture will not be saved by them. But where there is no objection to it a gently compressive aseptic dressing will be found a great comfort both to the patient and surgeon. The use of rubber protective should not now be 1158 SPECIAL OR REGIONAL SURGERY. omitted, as thereby the adhesion of inspissated dressings to the newly united tissues will be prevented, and the change of dressings rendered easy and painless. As to drainage, only this need be said, that hollow spaces ought to be elim- inated by buried catgut sutures, and that by avoiding the use of too many, of too close, and of all unnecessary sutures sufficient gaps will be left for the ready escape of the first secretions. The time at which a plastic operation may be or ought to be undertaken will depend upon certain considerations, which may also receive some attention. When a congenital or acquired defect interferes with nutrition or any other important function, it is proper to operate at once. After excision of neoplasms, or the removal of lupous skin, imme- Fig. 526. Arrangement of the bundles of cutaneous fibres (Heitzmann). diate repair might be undertaken if the defect be not too extensive. But where the loss of integument is very great it is wise to let the wound be reduced in size by the process of cicatricial contraction before under- PLASTIC SURGERY. 1159 taking its plastic closure, as the delayed operation will be much easier than an immediate one. In the presence of syphilis it is the generally accepted rule, before under- taking the closure of existing defects, to eliminate first all active symptoms of the disease, especially in the vicinity of the field of operation. Plastic by sliding is appropriate only for the repair of defects of moderate extent, and only where the skin to be used is yielding and well nourished, even when subjected to considerable tension. It is desirable to give to the defect a simple and somewhat regular contour — as, for instance, that of a triangle, quadrangle, or an ellipse. Where, to do away with excessive tension, simple undermining of the flaps is insufficient, subsidiary relieving incisions are to be made. Their direction is deter- mined by the law of Sanger. This anatomist first described the remark- able systems of cutaneous fibres which determine the tensile properties of the skin. An incision laid parallel with the direction of a longitu- dinally arranged bundle of cutaneous fibres will not gap much, sometimes not at all, while if it is made transversely upon the main trend of the fibres, retraction will be very pronounced. Hence subsidiary or relieving incisions should always cross the course of the cutaneous fibres. Where several systems of fibres converge or enter into the formation of a whorl, semicircular or S-shaped incisions may be placed at some distance from the wound, and generally parallel with its longitudinal extent ; or relief from tension may be secured by simply making an incision which is a prolongation and direct continuation of one or more sides of the defect. When a large defect is to be repaired, these two ways of relieving tension ought to be combined. Triangular Defects. — Small triangular defects can be closed by Fig. 527. Fig. 528. simply drawing together and suturing their angles. A small gap will remain uncovered in the centre, and can be left to cicatrize over by the Fig. 529. Fig. 530. v-^v process of granulation, or else can be covered with a skin-graft. The following diagrams will readily elucidate the technical principles govern- 1160 SPECIAL OR REGIONAL SURGERY. ing the repair of larger triangular defects. In Fig. 527 the flap is under- mined and detached from the base, and is glided over into the opposite angle of the defect in the direction of the arrow (Fig. 528). Fig. 531. Fig. 532. ' t \ Fig. 533. Fig. 534. Fig. 535. In Fig. 535 the triangle on the right side is to heal by granulation ; likewise the two small triangles in Fig. 537 ; or skin-grafting can be resorted to. Fig. 536. Fig. 537. Fig. 538. Fig. 540. Fig. 539. Fig. 541. All the preceding schemes are based upon methods devised by Dieffenbach. Burow's method of lateral triangles may, under cer- PLASTIC SURGERY. 1161 tain circumstances, possess enough merit to warrant its adoption, but is open to the great objection that integument is unnecessarily sacrificed by it. For completeness' sake it may be illustrated here. The skin en- closed in triangle cde, as in Figs. 542 and 543, is entirely excised ; then c is attached to a, and de becomes opposed to the line ce. Where the defect to be covered is large, Burow removes two triangles of skin, one from each side of the original defect, as illustrated by Figs. 544 and 545. Fig. 544. Fig. 545. tfrrti Quadrangular Defects. — In quadrangular defects, as well as in triangular ones, if they be small and the skin yielding and well nour- Fig. 546. Fig. 547. Fig. 548. ished, closure can be effected by a gradual diminution of the four cor- ners. The small central gap necessarily persisting can be left to take care of itself or can be covered with a skin-graft (Fig. 546). Fig. 549. Fig. 550. - H - H -H t I When these expedients are insufficient, subsidiary incisions, aided, by undermining or even the formation of quadrangular flaps and gliding, 1162 SPECIAL OR REGIONAL SURGERY. will have to be resorted to. In selecting the direction from which the flap is to be taken the tensile capacity of the skin should be carefully- examined. Should the tension be excessive, a relieving incision, as indicated in Figs. 553 to 557, will diminish it. Fig. 551. Fig. 552. JWH4- Fig. 553. V \ Fro. 554. Fig. 555. Fig. 556. 23 \ > / Fig. 557. V ...---" •% : ~ r ~] / Fig. 558. Fig. 559. Fig. 560. Fig. 561. - -H l - l - H j I -Uf 1 MffcH f H In covering a very large defect the three preceding methods can be suitably combined (Figs. 559-561). Burow's method is also applicable for the correction of quadrangular PLASTIC SURGERY. 1163 defects. In Fig. 562 the triangles a and 6 are excised before approxi- mation of the flap. Fig. 562. ,' a \ Fig. 563. Fig. 564. Fig. 565. ""1 Fig. 566. i T r Fig. 567. Fig. 568. ''' M Ik Fig. 570. m sr *S : >. ^ Fig. 569. n Hr ■H iHhh Fig. 571. • M l vl -l Figs. 568-573 represent Bruns' and Langenbeck's method for cover- ing trapezoid defects. 1164 SPECIAL OR REGIONAL SURGERY. Lanceolated, Elliptic, and Semilunar Defects. — Figs. 574-577 represent Guerin's method ; Figs. 578, 579, Szymanovsky's. Semilunar flaps (Fig. 580) were first proposed by O. Weber. Fig. 572. Fig. 573. Fig. 574. Fig. 575. Fig. 576. Fig. 577. Fig. 578. S A V Fig. 579. - r - Of i n Fig. 582. Fig. 580. When there is an abundance of integument, Burow's excision of triangles may be successfully applied. In Fig. 584 the triangle a is excised ; in Fig. 586, the triangles a and b. PLASTIC SURGERY. 1165 In Figs. 585-591 the reader will see typical forms of plastic by transference of pediculated flaps. The form of the flap will have to be fashioned according to the shape of the defect which it is to cover. Fig. 584. ~S\a! V Fig. 586. Fig. 585. Fig. 587. Fig. 588. Fig. 589. Fig. 590. Fig. 591. Fig. 592. Fig. 593. Fig. 594. Circular and Irregularly-shaped Defects. — Where it can be done without the sacrifice of too much integument, it is best to convert a cir- cular defect into a triangle or quadrangle, and then proceed according to the rules laid down for those. In the preceding figures the triangles marked a are excised. Should this not be feasible the flap method must be resorted to (Figs. 595 and 596). 1166 SPECIAL OR REGIONAL SURGERY. In dealing with a defect of a very irregular and complicated circum- ference it is best to make a study of the lines it is composed of, when it Fig. 595. >0 Fig. 596. Fig. 597. Fig. 599. will not be difficult to dissolve the figure into its simple components, such as triangles and quadrangles. These are then to be dealt with accord- ing to known rules, as in Figs. 597-599. CHAPTER LV. THE SURGICAL INJURIES AND DISEASES OF THE EYE AND ORBIT. By Charles Stedman Bull, M. D. ANOMALIES, INJURIES, AND DISEASES OF THE EYELID. Congenital Deformities of the Eyelids. Epicanthis is a congenital malformation which consists in the pres- ence of crescentic folds of redundant skin which run downward from the internal end of each eyebrow along the internal canthus and over the lachrymal sac, and often entirely conceal the caruncle. The deformity varies in degree, is apt to be hereditary, and is often associated with defects in development of the eye and its adnexa, such as deficiency or absence of the levator palpebral superioris, narrowness of the interpalpe- bral aperture, and marked flattening of the bones of the nose. In some cases the head is habitually thrown backward, as in cases of ptosis, in order that the patient may see objects below the horizontal meridian. When operative interference is indicated an elliptical piece of skin, with the long diameter vertical, should be excised from the root of the nose or glabella. The adjacent folds should then be freely undermined and loosened, and the lips of the wound closed by hare-lip or fine pin sutures. The result leaves a vertical scar in the median line. Coloboma of the eyelid is a congenital deformity of rare occurrence which usually involves the upper lid, and is sometimes associated with cleft palate, hare-lip, coloboma of the iris and choroid, and dermoid tumor of the cornea. To remedy this condition the edges of the colo- boma should be freshly pared and accurately brought together by fine twisted sutures passed through the tarsus, so that the lips of the fissure may be accurately united. Tumors of the Eyelids. Benign Tumors. — Under the head of benign tumors of the lids may be classed hordeolum, chalazion, xanthelasma, molluscum contagiosum, fibroma molluscum, warts, cysts, and angeiomata. Hordeolum, or stye, is a phlegmonous inflammation of one of Zeiss' glands at the ciliary margin of the lid, where it forms a painful circum- scribed swelling. It is apt to be associated with conjunctivitis or mar- ginal blepharitis, and corresponds to a small boil. The growth may sometimes be checked by the application of iced-alum solution (one 1167 1168 SPECIAL OR REGIONAL SURGERY. drachm to the pint), but (.he process generally suppurates and points, and should be punctured at an early date, and then hot fomentations should be applied until the pain and swelling have subsided. < 'halazion is a chronic cystoid distention of one or more of the Fig. 600. Fig. 601. Chalazion (seen from withinj (Mackenzie). Chalazion (Dalrymple). Meibomian glands. It develops very slowly, is usually painless, and rarely occurs singly. It may develop in any portion of a Meibomian gland, and involve the whole gland or several adjoining glands. As it grows it causes a yellowish projection on the conjunctival surface, and if of any size soon becomes visible through the skin. The contents may be glairy mucus or a cheesy material, or a mixture of granulation-tissue and giant cells. When the chalazion occurs at the margin of the lid it may be opened through the lid margin with a small scalpel, the contents squeezed out, and the interior scraped with a small spoon or spatula. If, however, the cyst be of any size or situated away from the lid margin, the lid should be clamped by lid-forceps, of which one blade is of horn or steel, to lessen hemorrhage, and an incision made horizontally through the skin over the chalazion, the fibres of the orbicularis pushed aside, and the entire cyst carefully dissected out. The wound in the skin is then to be closed by two or three delicate sutures. Xanthelasma is a flat tumor of a dirty-yellow color projecting slightly above the skin of the lid, and found most frequently in the vicinity of the inner canthus. It consists in a hyperplasia and fatty metamorphosis of the connective-tissue cells of the skin. It is apt to occur in groups, and the patches may be excised and the wound closed by dissecting free the surrounding: skin and bringing the edges together with sutures. Angeiomata, or vascular tumors of the eyelids, are met with under two forms, teleangiectatic and cavernous tumors. They are always congenital, but are apt to develop very rapidly after birth, and hence should be removed as early as possible. Teleangiectases appear as bright-red spots in the skin of the lid. If they are small, they should be cauterized by the thermo-cautery or galvano-cautery ; if they are large, they may be cauterized along a number of lines instead of over their whole surface, and the resulting cicatrization obliterates the intervening vessels. Cavernous tumors lie beneath the skin, push it forward, and give it a bluish color. They consist of a convoluted mass of large blood-vessels which can be felt beneath INJURIES AND DISEASES OF THE EYE AND ORBIT. 1169 the skin. In these cases the best results seem to be gained by electrolysis, though in cases of moderate size they may be excised if care be taken to use a large lid- clamp. These angeiomata are also apt to be connected with similar vascular tumors in the orbit, and in such cases excision would be of doubtful propriety. Rodent ulcer is a clinical form of epithelioma which not infrequently occurs on the eyelids. It takes the form of a shallow ulcer with uneven floor and irregular hard walls. The infiltration of the walls of the ulcer is the characteristic symptom. It is a form of epithelial carcinoma, and the ulcer advances in one direction while it cicatrizes at the opposite end. Its progress is extremely slow. Sarcoma originating in the eyelid is a rare affection, though an orbital sarcoma frequently extends to the lids. It develops in the con- nective-tissue portion of the lids, especially the tarsus, and is often deeply pigmented (melano-sarcoma). Primary sarcoma of the lid occurs mainly in childhood or youth, beginning as an elastic swelling beneath the skin, which grows rapidly and soon infiltrates the interstitial tissue of the orbicular muscle. It is prone to extend to the orbital tissue, and thence to the eyeball. Affections of the Muscles of the Eyelids. Spasm of the orbicularis muscle may be both tonic and clonic, the latter being the more important. It is sometimes called facial tic, is paroxysmal and very painful, and is sometimes accompanied by points of tenderness over the supraorbital or infraorbital nerves. The cause is often of cerebral origin. The intensity of the symptoms can some- times be relieved by correcting refractive and other muscular errors by glasses. If the cause be peripheral, relief is gained, and sometimes a cure established, by continuous counter-irritation or neurotomy, or by exsection of a piece of the offending nerve. Paralysis of the orbicularis muscle, or layophthalmos, is caused by some lesion of the seventh nerve, which may be central, or lie in the course of the nerve, or be peripheral. When of long duration it is usually accompanied by ulceration and even abscess of the cornea. The treatment indicated is such as would be called for in any case of facial paralysis. If the cornea become affected, it may be necessary to shorten the palpebral aperture by tarsorrhaphy. This consists in paring the edges of the lids for a distance of ten or fifteen millimetres near the outer canthus, and then uniting them by sutures, which should be left in place for a week. Ptosis, or Paralysis of the Levator Palpebrce Superior is. — Ptosis is the name given to that condition in which the upper lid droops or hangs down over the eye, so that the interpalpebral aperture is narrowed and the cornea is more or less concealed from view. True ptosis is due to paralysis of the levator muscle of the upper lid, and is usually asso- ciated with paralysis of other branches of the third nerve, though it may exist alone. It may be partial or complete. In the former the lid may be slightly raised by voluntary action, and this is assisted by the action of the frontalis muscle, and the forehead comes to have a wrinkled appearance. A difference should here be recognized between congenital and acquired ptosis. The former is not caused by paralysis of the nerve, but is due to the arrest of de- 74 1170 SPECIAL OR REGIONAL SURGERY. velopment or entire absence of the levator muscle. It usually involves both sides, and is often transmitted by heredity. Treatment. — If the ptosis be of recent occurrence, we should attempt its cure by the internal administration of potassium iodide or mercurials, or both, and by the application of the galvanic current to the muscle, one pole being placed behind the ear and the other over the closed lids. If in the course of two or three months there be no improvement, we must resort to surgical interference. A great many surgical operations have been suggested for the relief of ptosis, but most of them are only partially successful. If the ptosis be only slight and par- tial, Von Graefe's operation may perhaps suffice. A transverse incision is made in the skin, 5 mm. above the border of the lid and parallel to it, from one end of the lid to the other ; the lips of this wound are separated and the fibres of the orbicu- laris muscle are extensively exsected. A strip of skin may also be excised. The wound is then closed by sutures, which are passed not only through the skin, but also through the orbicularis fibres. The effect of this operation is to cause a sub- cutaneous shortening of the upper lid, weaken the action of the orbicularis, and thus assist that of the levator. In all cases of marked paralysis of the levator, resort must be had to some method of operating which will bring the lid more or less directly in connection with the fibres of the frontalis muscle. All attempts hitherto made to advance the tendon of the levator muscle have proved more or less unsuccessful. The operation which perhaps gives the best results was devised by De Wecker, and is done in the following manner : A portion of skin and muscular fibre is removed from the upper half of the tarsus, its breadth depending on the fulness of the lid. A strong Fig. 602. De Wecker's operation for ptosis (De Wecker). thread is entered above the brow, pushed beneath it and the skin of the lid, keeping close to the tarso-orbital fascia, and is brought out at the upper edge of the wound ; this passes over the muscular fibres, then under the skin and muscle at the lower edge of the wound, emerges, and then passes transversely along for 5 mm. over the skin, and then is carried in a reverse direction over the same course. Two such sutures are introduced. They are tied over a piece of rubber tubing, and tightened from time to time as they become loose. The wound is thus pulled together, and as the sutures cut through the tissues scars are formed which hold the lid up permanently. Entropion. This is the term employed to describe a condition in which the entire edge of the lid is turned inward, so that not only the cilia, but the skin- edge of the lid, is brought in contact with the cornea. It is one of the sequelae of chronic trachoma, and is generally due to the cicatricial con- tracting tendencies of that disease. In this condition the lashes are inverted, the palpebral aperture is shortened, the tarsus is thickened and INJURIES AND DISEASES OF THE EYE AND ORBIT. 1171 incurvated, and the lids hug the eyeball closely. The results are ulcer- ation, vascularity, and opacity of the cornea, and in bad cases a tendency to the development of a staphyloma. Treatment. — The essential cause of ordinary entropion is deformity of the tarsus, and all operations must be adapted to modify and correct this deformity. The operations of Arlt, Jaesche, and many others begin by splitting the lid vertically into two layers, an anterior and a posterior, for a distance of 3 to 4 mm. from the ciliary margin. A horizontal incision is then made through the skin of the lid throughout its entire length, parallel to and a short distance above the ciliary margin. The ends of this incision are then united by a curved incision through the skin on a level with the upper edge of the tarsus, and the enclosed strip of skin is then excised. The horizontal bridge of skin is then carefully separated from the underlying muscle, and, remaining attached at its extremities, is drawn up and sutured to the upper skin margin of the denuded space. The senile variety of entropion may generally be relieved by the application of contractile collodion on the skin surface or by the excision of a properly propor- tioned piece of skin, and bringing the edges of the horizontal wound together by sutures. Spastic entropion is more obstinate in resisting treatment, and may generally be relieved by an operation devised by Von Graefe, which consists in removing a triangular piece of skin from the lid, the base being parallel to and just above the lid margin in the upper lid or below it in the lower lid, and the apex pointing upward or downward as the case may be, and then closing the wound by sutures. Ectropion. This is the term applied to eversion of the lid, with exposure of the conjunctival surface, and the condition may be either partial or complete according as a part or the whole of the lid is involved. It may be either acute or chronic. Acute ectropion is usually muscular in character, and is met with in children with conjunctivitis and in diseases of the cornea with blepharo- spasm, in which the lids sometimes become everted and remain so until replaced. Another form of muscular ectropion is met with in facial paralysis. Chronic ectropion is sometimes seen in old persons with relaxed lids, with or without conjunctivitis. The commonest CAUSES are wounds, both incised and lacerated ; burns with subsequent cicatricial contraction ; chronic inflammation of the ciliary margins of the lids ; ulceration of the lids, such as lupus ; tuberculous and syphilitic nodules ; and caries of the orbital margins. The lower lid is more frequently involved than the upper lid. The treatment will be considered under the general head of Blepharoplasty, or Operations upon the Eyelids. Distichiasis is a term applied to that condition in which there is a double row of cilia on the edge of the lid, one of which is developed from the intermarginal part, close to the openings of the Meibomian glands, and the cilia in which sweep the eyeball. The condition is usually caused by chronic marginal blepharitis and blepharo-adenitis, chronic granular conjunctivitis or trachoma, and burns. In rare 1172 SPECIAL OR REGIONAL SURGERY. Fig. 603. instances it is congenital. The rubbing of the cilia against the cornea produces constant irritation, and may give rise to ulceration. Trichiasis is a condition which differs from distiehiasis in the irreg- ular position and shape of the cilia which touch the eyeball. The latter may be partially or entirely inverted and in different directions. There may be thickening of the tarsal border, but the tarsus itself is not altered much in its curvature, and this makes the difference between trichiasis and entropion. The causes of trichiasis are the same as for distiehiasis. The treatment for distiehiasis and trichiasis, unconnected with entropion, consists of epilation ; snaring the wild hairs with the loop of a thread ; destruction by hot needles or by electrolysis ; and excision of the follicles. Blepharoplasty is the general term applied to the surgical proce- dures which are undertaken for the relief of ectropion and similar con- ditions of the lids, which require the resto- ration of the lids to their normal position or the formation of a new lid, in whole or in part, from the neighboring tissues. Ectropion of a moderate degree, in- volving only part of the lower lid, may generally be relieved by the excision of a piece of conjunctiva or of a V-shaped piece from the entire thickness of the lid, and then carefully bringing together the raw edges by hare-lip pin sutures. Com- plete ectropion of the entire lid, due to ex- tensive scars or other causes, requires a much more extensive operation (Figs. 603 and 604). In ectropion of the lower lid Arlt's operation gives excellent results. A triangle is formed by the incisions ab and be, and a piece from 2 to 3 mm. deep is removed. The triangular flap is loosened as far as neces- Fig. 604. Arlt's operation for ectropion (Arlt). Richet's operation for ectropion (Arlt). sary, and the wound is sutured so that c comes up to d, and the side of the flap marked bo lies against the skin-wound, cd. The gap left by the closing of the flap is to be closed by hare-lip pins. INJURIES AND DISEASES OF THE EYE AND ORBIT. ] 173 True blepharoplasty consists in making a new lid, and numerous operations have been devised for the purpose. The new flap may be taken from the temple or forehead or side of the nose or cheek, or it may be transplanted from some distant portion of the body without a Fig. 605. Fricke's method of blepharoplasty (Arlt). pedicle, as from the side of the cheek or anterior surface of the forearm. Such an operation becomes necessary after the removal of epitheliomata or other tumors. These flap operations may be briefly divided into three groups. Fig. 607. Fig. 606. Dieffenbach's method of blepharoplasty (Arlt). Arlt's method when a portion of the eyelid is to be sacrificed (Arlt). (1) Those in which a somewhat tongue-shaped flap is carried in from the side of the nose for repair of the lower lid or from the temple for restoration of the upper lid (Fig. 605). (2) Those in which a quadrilateral flap is moved over or shifted, so as to cover in a triangular defect in the lower lid (Figs. 606, 607). (3) Those in which the surrounding skin is extensively incised, undermined, and dissected up, and the flaps thus made are drawn or slid together so as to cover the space to be filled. The latter is especially useful in cases of neoplasms of the lower lid, and the best method is that devised by Knapp. In the repair of lesions about the inner halves of the lids, or in cases where there is no skin available for flaps either on the forehead or temple or outer part of the cheek, Dr. H. D. Noyes makes use of a naso-buccal flap in which the incis- 1174 SPECIAL OR REGIONAL SURGERY. ions are made down the side of the nose and cheek as far as the upper lip, the free end being below and the attached end or base above. The incisions are so made as to include vessels which come from the supraorbital, ethmoidal, and nasal branches of the orbital arteries, and also some branches from the other side of the median line, by making the incision obliquely across the nose. When this flap is twisted on its base upward and placed in position, there is left a large gap in the face, which is filled by sliding the cheek in toward the median line and uniting the edge by pins and figure-of-8 sutures. Diseases op the Conjunctiva. In all forms of conjunctivitis there are one or two rules of treatment which the student and practitioner would do well to remember. The first is always to use cold or even iced fomentations, unless there is dis- tinct and urgent need to hasten suppuration. Another is never to use atropine unless the cornea shows evidences of becoming involved. The tendency among most physicians is to use atropine in all forms of in- flammatory affections of the eye, and to use warm or hot fomentations in conjunctivitis; and both these tendencies should be frowned down and prevented as far as possible. But three forms of conjunctivitis will be considered in this chapter, and these very briefly — viz. Purulent Ophthalmia, Diphtheritic Conjunc- tivitis, and Chronic Granular Conjunctivitis, or Trachoma. Purulent Ophthalmia. — Under this head are included the purulent conjunctivitis of new-born infants and the purulent inflammation of the adult, both non-specific and gonorrhoeal. The symptoms in all are the same, and differ only in intensity. There are marked injection of the palpebral and ocular conjunctiva ; chemosis of the conjunctiva; swelling; infiltration and discoloration of the lids; a purulent discharge, more or less profuse, which glues the lids together; heat ; and pain, which at times is very severe. The lids become even purple in hue, and so hard from infiltration that they cannot be moved. In bad cases the cornea soon becomes hazy, and then rapidly opaque, from strangulation of its nutrient blood-vessels and lymphatics by the great pressure. In the adult the symptoms are all worse than in oph- thalmia neonatorum, and in gonorrhoeal conjunctivitis the symptoms are more intense and the course of the disease much more rapid and destruc- tive than in the non-specific form. The prognosis in all forms of the disease is unfavorable, but is much better in ophthalmia neonatorum than in the other forms. While it may be confined to one eye, it generally involves both. The great danger is suppuration of the cornea with consequent loss of sight. Treatment. — In ophthalmia neonatorum cold applications should be made by cloths soaked in cold water and laid upon the closed lids, and frequently changed. Frequent irrigation of the culs-de-sac with cold bichloride solution (1 : 10,000) or cold boric-acid solution, and the appli- cation of a solution of silver nitrate to the everted lids (gr. i-v to the ounce), several times daily, are indicated. In the purulent conjunctivitis of older children or of adults the application of cold through the medium of iced cloths, laid upon a block of ice and then applied to the lids and changed once a minute, should be insisted upon, and the irrigation of the culs-de-sac should be increased in frequency according to the amount of secretion. If the lids are very hard and tense, it may be necessary to perform canthotomy by dividing the external canthus with a strong pair of blunt-pointed INJURIES AND DISEASES OF THE EYE AND ORBIT. 1175 scissors, and the severing of the external canthal ligament, so as to diminish the pressure on the eyeball. As soon as the lids can be everted they must be cauterized with a strong solution of silver nitrate (gr. x-xx), until the discharge ceases or becomes thin and ichorous, when it may be discontinued. Diphtheritic Conjunctivitis. — Though the disease sometimes occurs alone, it is usually connected with diphtheritic inflammation in the nose and fauces. The external symptoms resemble those of purulent conjunc- tivitis, except that there is more marked infiltration of the tissues of the lids and much less secretion until the purulent stage is reached. If the lids can be everted, there is no distinct membrane visible, but the con- junctiva and tarsus seem enormously thickened, present a bloodless appearance, and look like brawn, and the same condition exists in the ocular conjunctiva. The cornea rapidly becomes opaque and necrotic. In these oases it is sometimes necessary to discontinue the cold applica- tions and resort to hot fomentations in order to hasten the suppurative stage, and thus, if possible, save the cornea by a reopening of the nutrient blood-vessels. When the suppurative stage has been reached the treatment is the same in all respects as for purulent conjunctivitis. The prognosis is always unfavorable, most of the eyes so affected being lost through destruction of the cornea. Granular Conjunctivitis, or Trachoma. — This is a chronic inflam- mation of the conjunctiva which originates by infection and produces an infectious purulent secretion. The conjunctiva becomes very much thickened, the papillas hypertrophied, and a peculiar kind of granule is developed, mainly in the tarsal conjunctiva, but also in the fornix and occasionally in the ocular conjunctiva. It is one of the most frequent forms of eye disease which the surgeon is called upon to treat. It exists in two forms. The first form consists in the development of papillce on the surface of the conjunctiva tarsi, without at first any thickening of the conjunctiva. The second form is characterized by the presence of the trachoma granules, which are gray or yellow, translucent, round bodies beneath the conjunctiva. Fig. 608. Section of conjunctiva in granular conjunctivitis (Fuchs). Symptoms. — These are photophobia, lachrymation, impaired vision, and a sticking together of the edges of the lids, dependent upon the amount of secretion. If the case be an old one, there are either ulcers of the cornea or a condition . known as pannus, which is a superficial keratitis, with or without the development of blood-vessels on the 1176 SPECIAL OR REGIONAL SURGERY. cornea, with hypertrophy of the epithelial layers, and opacity of the whole surface. The sequelje of trachoma are trichiasis or distichiasis, which is a faulty arrangement of the cilia ; entropion, posterior symblepharon, xerosis of the conjunctiva, and opacities of the cornea (Fig. 608). Treatment. — During the last few years attempts have been made to shorten the duration of the treatment of this most chronic disease by various surgical procedures. Of these it is only necessary to mention one, the so-called method of expression. This consists in gently scari- fying the conjunctiva over the masses of trachoma granules, and then holding the everted lid firmly by one end, applying Noyes' forceps or Knapp's roller forceps to the opened follicles, and by compression squeezing out the contents of these follicles from one end of the lid to the other. As soon as one row is emptied the forceps should be applied to another row, and this should be kept up until all the follicles have been emptied of their contents. The cul-de-sac and lids are then washed clean witli a bichloride solution (1 : 5000) and cold dressings applied, which must be frequently removed. The conjunctival surface is subse- quently treated with astringent solution or by touching it with alum or sulphate of copper in crystal as long as any roughness or secretion appears. Pterygium. A pterygium is a triangular thickening or hypertrophy of a fold of the ocular conjunctiva, which grows from the inner or outer canthus toward the cornea and extends for a varying distance upon the cornea. The apex of the triangle is on the cornea and the base toward the can- thus. It may be very thin and delicate, containing but few blood-ves- sels, and is then known as pterygium tenue, or it may be thick, opaque, and vascular, and is then termed pterygium crassum, both forms being simply different stages of the same growth (Fig. 609). A pterygium grows very slowly, with or without symptoms of irri- tation, toward the centre of the cornea, which it only reaches in excep- tional cases. It may remain stationary for years, being at times subject to inflammatory attacks. If it remain stationary, it grows thinner and lighter in color from disappearance of its vessels, and may event- ually be converted into a thin, tendinous membrane. It produces no injurious results until its apex begins to involve the pupillary area of the cornea, when the vision becomes affected, and the visual de- fect increases in proportion as the apex of the growth approaches the centre of the cornea. An additional annoyance produced by a pterygium which has become attached to the cornea is a certain limitation of mobility of the eyeball in the opposite direction, owing to the restraining fibres of the growth. The pterygium is covered by the conjunctival and corneal epithelium, which is markedly hyper- trophied, and on reaching the cornea the growth extends beneath the epithelium into the parenchyma of the cornea. Hence it is wise to remove a pterygium before it encroaches far upon the cornea, as it .always leaves an opacity beneatli it, which interferes with vision. Etiology. — A pterygium grows from the degenerative process exist- INJURIES AND DISEASES OF THE EYE AND ORBIT. 1177 ing in a pinguicula, makes its way into and on the cornea, and draws the conjunctiva after it. This degeneration can generally be seen at the apex as a narrow gray, hazy zone which forms its anterior border and which is sharply defined from the clear cornea. Fig. 609. Fig. 610. '^'n<\-^ 17). Gummatous iritis, or gumma of the iris, is by no means a rare affec- tion, and is met with only in syphilitic patients. The term " syphilitic iritis" should be confined to this form of the disease, characterized by the pres- ence of a gumma in the tissue of the iris, either at the sphincter margin or at the periphery, and presenting as a distinct yellowish elevation, which is usually vas- cularized from base to summit. In syphilitic patients the iritis present is generally of the plastic type, and differs in no respect from any other case of plastic iritis ; but a gumma of the iris gives a distinctive character to the case, wtis with hypopyon and chemosis of ° ln ' bulbar conjunctiva (Demours). and hence the name "syphilitic iritis should be confined to this type of the disease. Etiology. — Iritis may be caused by long-continued cold, and even by long-continued exposure to the heat and glare of the sun, as in the tropics, and is then a purely local, idiopathic disorder. The other local causes are traumatism and sympathetic inflammation. By far the most common cause is some general constitutional disease, and the most fre- quent of these is syphilis. Then follow, in the order of frequency, rheu- matism, gout, acute infectious diseases, tuberculosis, and diabetes. In all of these cases the iritis is of the plastic type, except in tuberculosis and in true syphilitic iritis with the development of a gumma. Prognosis. — The prognosis is generally very good, except in bad cases of rheumatic iritis and in tuberculous iritis. In the latter form the case ends in more or less marked destruction of the eye. Treatment. — This is divided into local and constitutional. Hot fomentations or dry heat should be employed to allay the inflammatory process and to promote absorption of the plastic exudation. Atropine should be instilled into the eye to dilate the iris and break up the pos- terior synechia?, and, secondarily, to allay pain. The strength of the solution should vary from one grain to four grains to the ounce, or even stronger, according to the severity of the attack, and the latter should also regulate the frequency of the instillations. If there be severe pain, 75 1186 SPECIAL OR REGIONAL SURGERY. this may often be allayed by applying cups or leeches to the temple. The eye should be protected from the light by dark glasses or a shade, but never by a bandage, and the room in which the patient remains should be moderately darkened. The constitutional treatment should vary with the cause of the disease. If it be syphilis, the treatment by mercurials and potassium iodide should be pushed rap- idly to toleration, in order to forestall dense adhesions or the development of gum- mata. If rheumatism or gout be the cause, the patient must be brought as rapidly as possible under the influence of sodium salicylate, salicylic acid, or salol, in order, if possible, to prevent the spread of the disease to the choroid; for if the latter become involved, the vision is usually permanently impaired. There is no special treatment indicated for iritis due to diabetes or tuberculosis or the acute infectious diseases. The local treatment is the same for all varieties of iritis. The surgical treatment for the results of iritis or irido-choroiditis comes within the domain of the ophthalmic surgeon only, and should properly be left to him. The operations to be advised consist of iridectomy or iridotomy. In some rare cases enucleation of the eye becomes necessary as a prophylactic against sympathetic ophthalmia. Glaucoma. Glaucoma is the term applied to a morbid condition or variety of conditions of the eyeball, characterized by increased intraocular tension or hardness of the globe. It may be either primary or secondary, inflammatory or non-inflammatory, acute, subacute, or chronic. Symptoms. — The following symptoms are common to the disease, though they are not all constantly present in each variety : (1) Increased intraocular tension ; (2) change in the size and shape of the pupil and in the appearance and mobility of the iris ; (3) loss of transparency in the cornea; (4) change in the depth of the anterior chamber ; (5) turbidity of the aqueous and vitreous humors ; (6) engorgement and tortuosity of the conjunctival and episcleral vessels ; (7) excavation or cupping of the optic disk of the " overhung " variety and the surrounding " glaucom- atous ring ;" (8) pulsation of the veins, and sometimes of the arteries, on the optic disk; (9) pain ; (10) ancesthesia of the cornea; (11) dimi- nution of central vision; (12) loss of accommodation ; (13) narrowing of the field of vision, generally of the concentric variety, and most marked on the nasal side ; (14) iridescent vision, or seeing colored halos around artificial lights. Prognosis. — The disease tends naturally, if unchecked, to absolute blindness, and hence the prognosis is unfavorable, though it depends on the type of the disease and the stage of development. The prognosis is most favorable in acute inflammatory glaucoma, and least so in simple chronic glaucoma. Treatment. — No satisfactory result is ever gained except by ope- ration. Eserine sulphate, in a solution of one-quarter to one-half a grain strength, will sometimes relieve the symptoms or postpone temporarily the advance of the dis- ease, and may always be used if an operation be not possible. But the only method of treatment which offers any hope of success is an operation to relieve the increased intraocular tension, and this may be either an iridectomy or a sclerotomy accord- ing to the nature of the case. This disease must be relegated to the domain of the ophthalmic surgeon, who alone is best fitted to cope with its difficulties. INJURIES AND DISEASES OF THE EYE AND ORBIT. 1187 Sympathetic Ophthalmia. Sympathetic ophthalmia is the term applied to those affections of the eye, and mainly of the internal structures, which result from injury to or disease of the fellow-eye. It presents itself under two distinct forms, one of which is called sympathetic irritation, and the other sym- pathetic inflammation ; and they are two essentially different conditions. Sympathetic irritation is a neurosis or functional disturbance charac- terized by photophobia, lachrymation, blepharospasm, impaired accom- modation, subnormal vision, supraorbital neuralgia, photopsic manifes- tations, sometimes narrowing of the visual field, and an inability to continue close work. Any or all of these symptoms may be present in the uninjured or sound eye. During the occurrence of these symptoms in the second stage the injured or diseased eye is usually injected about the ciliary region, and there are photophobia, tenderness on pressure, ciliary neuralgia, and sensitiveness to light. These symptoms in both eyes may subside, only to recur again and again. Sympathetic inflammation is an ophthalmitis, usually confined to the uveal tract — i. e. the iris, ciliary body, and choroid — though it may involve the nerve and retina, either aione or in connection with the uveitis. More rarely it involves the conjunctiva or cornea, or both. It is characterized by pain, photophobia, lachrymation, circumcorneal injection, exudation into the aqueous or vitreous humors, punctate deposits on the posterior surface of the cornea, iritis, exudation into the field of the pupil, cataract, increased tension, narrowing of the anterior chamber, extreme sensitiveness on pressure, and loss of sight. These symptoms may end in subnormal tension and atrophy of the whole eye- ball. Sometimes the first intraocular symptoms are those of neuro- retinitis before the uveal tract has become involved. These symptoms may be acute or chronic. Etiology and Pathogenesis. — According to the most recent in- vestigations, all the nerve-structures of the diseased or injured eye may assist in the transmission of the trouble to the fellow-eye. The causes may be as follows : (1) Foreign bodies in the eye ; (2) punctured, incised, or lacerated wounds of the ciliary region; (3) wounds or ulcers of the cornea, with incarceration or prolapse of the iris ; (4) operations on the eyeball, such as discission, iridectomy, iridodesis, extraction of cataract, and anterior sclerotomy; (5) traumatic cataract and dislocation of the lens ; (6) ossification of the choroid and ciliary body ; (7) intraocular tu- mors; (8) incarceration of the ciliary nerves and stump of the optic nerve in cicatricial tissue, after enucleation ; (9) more rarely, pressure of an artificial eye upon the stump. Prognosis. — The prognosis of sympathetic ophthalmia is always unfavorable, especially if the uveal tract have been involved. If the sympathetic inflammation be of the nature of a simple serous iritis or a neuro-retinitis, without participation of the ciliary body or choroid, it may be possible to promise a partial recovery of vision. It is much more favorable if treatment be undertaken during the stage of sympathetic irritation. Treatment. — This varies according to the existing stage of the affection in the second eye. If the condition of the second eye be that 1188 SPECIAL OR REGIONAL SURGERY. of sympathetic irritation only, without any signs of sympathetic inflamma- tion, prompt enucleation of that injured or primarily diseased will, in the great majority of cases, prevent the occurrence of sympathetic ophthalmia in the second eye. If. however, sympathetic inflammation have already begun, enucleation should not be done if there be any vision in the first eye, for the operation will have no effect upon the diseased process in the second eye, and very often the resulting vision in the injured eye will be better than that in the eye secondarily affected. No operation, such as iridectomy or sclerotomy, on the sympathetically inflamed eye ever brings about any favorable result upon the course of the inflammatory process. The surgeon should wait until all inflam- matory symptoms have subsided before attempting any surgical inter- ference. The following indications may be laid down for the enucleation of the first eye before the outbreak of sympathetic inflammation in the fellow- eye : (1) When the wound is in the ciliary region, and is so extensive as to greatly damage or entirely destroy the vision ; (2) When the wound is in the ciliary region, and is already accom- panied by iritis and cyclitis; (3) When the eye contains a foreign body, and all attempts at its removal have proved futile ; (4) When the eye is shrunken and atrophied, and tender on pressure or continually irritated. Cataract. - The name cataract is applied to an opacity of the crystalline lens or its capsule and may be either partial or complete. Its causes may be either local or constitutional. It may be stationary or progressive ; ripe or unripe; soft, hard, or hyper-mature ; simple or complicated ; traumatic, idiopathic, or congenital. The opacity may begin at the periphery or in the nucleus of the lens, or in both regions at once. Senile cataract generally begins at the periphery and ex- tends toward the centre, and until it encroaches on the field of' the pupil is not recognizable except by the skilled ophthalmic surgeon. The one subjective symptom is a slow and progressive failure of vision. If, on examining the eyes of such a patient the pupil be found to be of a gray or whitish color, instead of black, and the opacity to be distinctly behind the plane of the iris, the trouble is either in the lens or in the anterior layers of the vitreous humor, and by dilating the iris with some mydriatic it can be determined exactly where the opacity is situated. Dense opacities in the vitreous humor are rarely so far forward as to give a white reflex from the pupil. If, on the contrary, the gray or whitish opacity be in front of the plane of the iris, it must be either in the cornea or in the anterior chamber, and a closer inspection with oblique illumination will determine its location. There are many varieties of cataract which are of interest solely to the ophthalmologist. The tendency of all cataracts is to increase slowly until the whole lens is involved, but to this rule there are exceptions. In myopic eyes lens opacities grow very slowly, and are often stationary INJURIES AND DISEASES OF THE EYE AND ORBIT. 1189 for years. In rare cases the opacities of the lens have been known to diminish, and even to disappear, with corresponding improvement in the vision. The prognosis as to vision is unfavorable unless an operation be done. The prognosis as to vision after operation is favorable, the great majority of patients recovering useful, and many of them very acute, vision. Treatment. — In congenital cataracts and the soft cataracts of youth the best results are gained by keratonyxis or discission, which consists in the introduction of a needle through the cornea, lacerating the capsule and stirring up the lens-tissue, and then waiting for absorption to take place, trusting to the production of a more or less open pupillary space, through which the patient may see. In hard cataracts of all varieties in the adult the only operation which promises any satisfactory results is the extraction of the lens. The operation of extraction may be either simple or combined, accord- ing to whether the lens be removed through the natural pupil without excising a piece of iris-tissue, or through an artificial pupil made by iridectomy. A full description of these operations will be found in any text-book on ophthalmology. No operation for the extraction of cata- ract should be done by any save an ophthalmic surgeon, and then only after the most careful investigations of the functions of the eye and the general health of the patient. Panophthalmitis. Panophthalmitis, or phlegmonous inflammation of the eyeball, is a somewhat complex process in which all the tissues of the eye become involved in the purulent process. While usually traumatic in origin from some laceration or rupture of the eyeball, the germs being probably introduced at the time of the injury, it frequently arises from abscess of the cornea, which perforates into the anterior chamber, or is due to the propagation of the purulent process from a suppurative choroiditis, which may be thrombotic or metastatic in origin. Symptoms. — -The course of the disease is rapid and severe, and the symptoms resemble those of orbital cellulitis. The eyelids become red and swollen ; the conjunctiva is injected and chemotic, especially around the corneal margin. There may be a thin purulent discharge from the lids. If the cornea be clear, the aqueous is seen to be hazy, and there may be a deep yellow reflex from the fundus. The symptoms increase rapidly in severity : the cornea becomes infiltrated ; the orbital tissue takes on a hard and brawny condition ; the eye begins to protrude, and is more or less immovable ; there are rapid loss of sight, high fever, intense pain, sometimes leading to nausea and vomiting, and at times great general prostration. The purulent process tends to perforate for- ward through the cornea or in the ciliary region. If the process begin in a purulent keratitis, the cornea generally ruptures early in the course of the disease, and the decomposed contents of the eyeball early find an exit through the corneal abscess, and the pain is therefore less severe. Panophthalmitis always ends in destruction of the eye, and hence all treatment should be directed toward hastening the suppurative process. The surgeon can 1190 SPECIAL OR REGIONAL SURGERY. materially assist in this object by incising the cornea freely, and then eviscerating the entire contents of the eye by means of a sharp spoon, leaving the sclera as a shell behind. The hollow 'sclera should then be freely irrigated with a warm bichloride solution several times daily, while hot fomentations are kept constantly on the closed lids. This operation of evisceration is the only safe surgical proce- dure in panophthalmitis. Enucleation of an eyeball should never be done in this disease until all signs of purulent infection have vanished, owing to the danger of inciting purulent meningitis by extension of the process to the brain through the medium of the sheath of the optic nerve. Intraocular Tumors. Tumors of the Iris. — Neoplasms in the iris are relatively rare. Cyst of the iris is comparatively a rare affection. It is either the result of sacculation in consequence of injury or operation, or it arises from the proliferation of cells introduced into the anterior chamber, as, for instance, from the introduction of an eyelash through a wound in the cornea and iris. A cyst may be situated in the substance of the iris or may consist in a simple lifting up of the epithelial layer. Ncevi, or simple melanomata, are always congenital, and present the appearance of small black patches or elevations which remain stationary and cause no irritation. They consist of a circumscribed hyperplasia of the uncolored and pigmented stroma-cells of the iris. They are best left undisturbed. Tubercles of the iris, or granulomata as they were formerly termed, are now much better understood, and their nature is perfectly identified by recognizing within them the characteristic bacilli. Sarcoma is extremely rare as a primary affection of the iris, and is generally melanotic in character. There is usually but a single tumor, and it may grow from any part of the iris and may occur at any age. It appears as a small, rounded, dark-brown or yellowish-brown elevation, which may remain stationary for a time, or may grow rapidly and ex- tend into the anterior chamber, perforate the cornea, and protrude as a fungous mass. If the sarcoma be of the white variety, its growth is usually very slow. Tumors of the Ciliary Body. — Morbid growths of primary origin in the ciliary body are very rare, and their exact nature is difficult to determine. Most of the tumors met with in this region have extended to it either from the iris on the one hand or the choroid on the other. Tumors of the Choroid. — Tubercles of the choroid are found chiefly in cases of acute miliary tuberculosis, and especially in cases of tuber- cular meningitis. They appear ophthalmoscopically as distinct whitish- yellow spots or nodules in the stroma of the choroid, grouped around the region of the optic nerve and macula. They vary greatly in size, and may aggregate into larger masses. They may or may not be accompanied by retinitis or neuro-retinitis. Sarcoma of the choroid is by far the most frequent morbid growth met with in this membrane. It is most frequently of the pigmented variety (melano-sarcoma), but is sometimes free from pigment (leuko- sarcoma). A mesh of small, dark vessels forms at some spot in the retina, and the latter shows a gray opacity. If it occur near the macu- la lutea, vision is impaired at once. As the tumor grows its elevation may be made out, but often the retina becomes detached over it and INJURIES AND DISEASES OF THE EYE AND ORBIT. 1191 obscures the outline. If of the pigmented variety, however, its dark color shows through. Tumors of the Retina. — Glioma is a malignant tumor of the retina, and is found exclusively among young children and youths, the great majority of cases occurring in children under ten years of age. It is a comparatively rare disease. The ophthalmoscope shows a yellowish-white growth at the bottom of the eye. which is covered by minute blood-vessels, with here and there a minute hemor- rhage. At first there is neither increase of tension nor pain, but as the tumor grows the eye may become hard and the circumcorneal veins injected. The growth involves the choroid and ciliary body, and may extend to the iris and enter the anterior chamber. Later the cornea may slough, episcleral growths appear, and the orbit become invaded. At this stage the tumor grows with great rapidity, and extends in every direction, notably backward through the optic foramen and deep sinuses to the brain. Metastatic growths also appear in various parts of the body. Microscopically, the growth appears to originate in the outer or inner nuclear layer, and shows a delicately fibrillated reticulum, with numerous blood- vessels and small round cells with large nuclei. Very often the tumor shows the structure of a mixed growth, and is then called a glio-sarcoma. Sight is lost early in the course of the disease. Treatment. — Enucleation of the eye should be advised as early as possible as the only means of preventing death, and the optic nerve should be divided as near the apex of the orbit as possible. If the growth have invaded the orbit, the entire contents of the orbit, including periosteum, must be removed. Injuries to the Orbit. Injuries to the Orbital Margin. — Contusions of the orbital margin are frequently followed by more or less extensive extravasations, which are subcutaneous, subperiosteal, or subaponeurotic, and may extend in every direction under the skin, and even under the conjunctiva. If an artery of any size have been ruptured, the extravasated blood forms a pulsating tumor, which may render the diagnosis extremely difficult. Blows upon the margin of the orbit frequently involve the supraorbital and infraorbital nerves, and to the laceration of these nerves has been attributed the amaurosis which has been known to follow such injuries. This blindness is due to paralysis and subsequent atrophy of the optic nerve, and the real cause is probably a fissure or fracture of the orbit extending backward to the optic foramen. Fractures of the bones of the orbit may be either direct or indi- rect, and may be caused by blows or falls on the head or face, gunshot wounds, and penetrating wounds of the orbit, with or without lodgement of a foreign body. The usual symptoms are hemorrhage and displacement of the eye- ball, and, in rare instances, crepitus. Gunshot wounds of the orbit complicate the diagnosis, on account of injury to the contents of the orbit. When sudden and complete blindness occurs after such an injury and the eyeball appears intact, it may be due to laceration or rupture of the optic nerve, or to rupture of the choroid through the region of the macula. In those cases which do not terminate fatally the most serious symp- tom which may occur is blindness. If the loss of vision be unilateral, it 1192 SPECIAL OR REGIONAL SURGERY. always occurs in the eye on the injured side, and is due to laceration of the optic nerve by the fractured bones or to atrophy of the nerves by pressure from extravasated blood. If the blindness be bilateral, the frac- ture extends into the middle fossa of the skull, and the loss of vision is due to direct laceration of the optic chiasm or optic tract, or to compres- sion of the chiasm or tract by an extensive blood-clot. The ophthalmo- scopic symptoms in such cases would be venous hyperemia, arterial ischsemia, and hemorrhages on the disk and in the retina, followed by neuro-retinitis and atrophy. Injuries of the Soft Parts of the Orbit. — Under this bead are in- cluded the connective tissue of the orbit, the muscles, eyeball, optic nerve, and lachrymal gland. Foreign bodies, even of large size, may enter the orbit and pass entirely out of sight, and are often extremely difficult to find. One of the most constant symptoms of the presence of a foreign body is dis- placement or limited motility of the eyeball. A iater symptom is disturbance of vision caused by pressure on the eyeball or optic nerve. If the foreign body be sought for and found immovable, it has probably perforated one of the walls of the orbit, and great care must then be taken in its removal, especially if the roof have been perforated. If the case be an old one and the eyeball have become blind and atrophied, no attempt should be made to remove the foreign body unless the eye is first enucleated, as the foreign body is certainly encapsulated and practically in- nocuous. The toleration of the presence of foreign bodies of large size manifested by the orbit is sometimes extraordinary. Hemorrhage into the Orbit. — Extravasations of blood within the orbit may come from ruptured blood-vessels in the orbit or from vessels out- side of the orbit. They may be either spontaneous or traumatic, the latter being the most frequent. Blood may be extravasated beneath the periosteum, or in the orbital cellular tissue, or within the capsule of Tenon. The causes are hremophilia, scurvy, disease of the. trails of the vessels, or violent coughing or retelling, and, finally, traumatism of any kind. The symptoms are extravasation of blood beneath the conjunctiva and into the tissue of the eyelids, exophthalmos, and more or less limita- tion of motility of the eyeball. The exophthalmos is usually directly forward. Hemorrhage into the orbit after blows or falls upon the head has prognostic significance as a sign of the presence of a serious injury, as there is probably fracture at the base of the skull. The usual course of an orbital hemorrhage ends in absorption of the extrava- sated blood in from three to six weeks; but if it have been very extensive, with excessive protrusion of the eyeball, the latter may be destroyed by neuro-paralytic keratitis and abscess of the cornea. Orbital cellulitis is an inflammation of the fatty and cellular tissue of the orbit, and may be acute, subacute, or chronic in character. It may be unilateral or bilateral. It may undergo resolution, and dis- appear without leaving any lasting trace of its presence ; but in the great majority of cases it ends in suppuration and the formation of an abscess. The idiopathic causes may be long-continued exposure to cold, periostitis, the exanthematous fevers, meningitis, through the medium of thrombosis of the cavernous sinus or ophthalmic veins; facial erysipelas, extension of the inflam- matory process from diseased teeth in the upper jaw, suppuration in the ethmoid cells or sphenoidal sinus ; metastatic inflammation due to general pyaemia or pucr- INJURIES AND DISEASES OF THE EYE AND ORBIT. 1193 peral septicaemia, panophthalmitis ; and in rare instances inflammation in and around the lachrymal gland. Symptoms.- — In mild cases there are dull pain in the orbit, slight swelling of the lids, and .slight divergence and protrusion of the eyeball. In the more severe cases the attack is usually ushered in by a chill, fol- lowed by fever, deep-seated pain, headache, more or less immobility of the eyeball, swelling and discoloration of the lids, hypersemia and che- mosis of the ocular conjunctiva, exophthalmos, defective vision due to neuro-retinitis, anaesthesia, ulceration and suppuration of the cornea, ending in panophthalmitis. Treatment. — If the case be of the mild type, with little or no con- stitutional disturbance, two or three leeches should be applied to the brow or temple, and frequently changed hot compresses to the closed lids, and iron and quinine should be administered. If the case be of the severe phlegmonous type, six or eight leeches should be applied to the brow and temples, and the hot compresses must be continually em- ployed and frequently changed. If the swelling and exophthalmos be marked, free incisions must be made into the orbital tissue, through the conjunctiva, at the point of greatest tension, with a straight, narrow bistoury, kept parallel with the wall of the orbit ; and these incisions must be kept open by a large probe, with frequent irrigation with a warm solution of mercuric bichloride (1 : 2000). At the same time the patient's strength must be supported by stimulants, quinine, mineral acids, and opiates. If panophthalmitis supervene, the eyeball must be freely opened through the cornea and the contents evacuated by pressure and a blunt spoon. This is called evisceration of the eyeball. When all signs of inflammation have subsided in the orbit, the blind or atrophied eyeball may then be removed by enucleation. The operation of enucleation is done as follows : The patient must be anaesthetized and the lids held open by a spring speculum. The eyeball must be grasped by fixation-forceps, and the ocular conjunctiva is then to be incised all round the corneal margin with blunt-pointed scissors. The divided conjunctiva must then be pushed away from the eyeball with the scissors and a strabismus-hook, thrust under the four straight muscles and the two oblique muscles in turn, and each is divided close to its tendinous insertion in the eyeball. It is well to leave a small knob of tendon of the external rectus attached to the eye, so that it can be seized with forceps and the eye easily adducted. All adhesions between eyeball and the oculo-orbital fascia are then to be divided with the same blunt-pointed scissors. The eyeball must then be forcibly adducted, and a large pair of blunt-pointed, broad-bladed scissors, curved on the flat, must be introduced on the temporal side between the eyeball and orbital wall, and, with the blades slightly opened, carried backward until the apex of the orbit is reached. A little manipulation will engage the optic and ciliary nerves between the blades of the scis- sors, and they are then to be divided as far back of the eyeball as possi- ble. As soon as all bleeding has ceased the ocular conjunctiva is to be brought together by a single stitch which covers all the remaining con- tents of the orbit, and a pressure bandage is then applied. This must be removed the next day, and the orbit thoroughly irrigated with a warm antiseptic solution. The bandage must be renewed for three or 1194 SPECIAL OR REGIONAL SURGERY. four days, and may then be discarded. The stitch may be removed at the end of a week. Pulsating Exophthalmos. Pulsating exophthalmos is a diseased condition, generally the result of traumatism, characterized by the following complex group of symp- toms : (1) Protrusion of the eyeball forward, and usually a little down- ward and outward ; (2) peculiar audible sounds over the region of the orbit and over a more or less extensive region of the skull ; (3) a dis- tinct pulsation demonstrable in the eyeball or over any spot in the region of the orbital aperture. The lesion is situated either in the orbit or in the cavity of the skull. If in the orbit, it may be a true aneurism or a spurious aneurism. The latter may be dif- fuse or circumscribed, or it may communicate with both artery and vein and form an arterio- venous or varicose aneurism. If the lesion be in the cavity of the skull, it may be an aneurism of the ophthalmia artery at its origin from the internal caro- tid, or an aneurism of the carotid artery itself, or an arterio-venous aneurism by a rupture of the internal carotid artery in the cavernous sinus. Symptoms. — These are exophthalmos, more or less marked ; hard, dense swelling of the upper lid, the skin being livid and shining and the veins enormously swollen ; loss of the tarso-orbital fold, and sometimes eversion of both lids ; discoloration and chemosis of the ocular conjunc- tiva ; slight cloudiness of the cornea, with tendency to ulceration ; a hypersemic, dilated, and sluggish iris. The eyeball can be replaced by pressure in the orbit, but the protrusion recurs as soon as the pressure is relaxed. The pulsation of the eyeball is sometimes visible as well as tangible, and is rhythmical with the pulse. In addition to the pulsation, the fingers when laid upon the eyeball will feel a more or less distinct thrill. Sometimes a soft, compressible, pulsating tumor may be felt upward and inward from the eyeball. If a stethoscope be applied to the eyeball or the upper margin of the orbit, a more or less distinct blowing noise is heard. By compression of the common carotid artery in the neck on the corresponding side the pulsation and noise either imme- diately cease or become much less marked. The retinal veins are enor- mously dilated and pulsating, while the arteries are much reduced in calibre, and there may be all the signs of papillitis. The vision may be greatly or not at all affected. The subjective symptoms are severe pain in the orbit and head, and a constant roaring or buzzing sound, which is very annoying and is often accompanied by vertigo. Etiology, Diagnosis, and Prognosis. — The spontaneous cases occur very suddenly, are more common among females than males, and the causation is unknown unless we attribute it to extensive disease of the walls of the blood-vessels. In the traumatic cases any injury which is likely to produce a fracture at the base of the skull may cause pul- sating exophthalmos, and in many of these cases the progress of the dis- ease is very insidious and the symptoms are slow in developing. Little is known of the true pathology of jmlsating exophthalmos, for even at the autopsy the true nature of the lesion cannot be determined. Another form of vascular tumor met with in the orbit is a very rare condition known as the pulsating encephaloid tumor. When a soft orbital tumor is found to be fluctuating and very vascular, with marked pulsa- INJURIES AND DISEASES OF THE EYE AND ORBIT. 1195 tion, it is almost certainly malignant and sarcomatous. It has a smooth surface like a true pulsating exophthalmos, but it does not yield so readily to pressure under the fingers. Multiple pulsating growths in and about the orbit would indicate their malignant character. A true pulsating exophthalmos occurs most frequently at the upper and inner side of the orbit. Treatment. — The two chief surgical methods of treatment are com- pression of the common carotid artery and ligation of the same artery. Ligation of the common carotid artery gives the most satisfactory re- sults and is to be done in the usual place and manner. As a rule, the pulsation and bruit disappear immediately, the tumor collapses, the ex- ophthalmos diminishes, the swelling of the lids and the chemosis vanish, the motility of the eyeball returns, and vision is gradually restored. Faint subjective sounds may return after a few hours, but the cure is generally complete in six weeks. In a small number of cases the symp- toms return after ligation, sometimes on the same side, more rarely on the opposite side, and in these cases we may ligate the external carotid of the same side or the common carotid of the opposite side. In pul- sating malignant tumors ligation of the common carotid artery has proved entirely unsuccessful. Tumors of the Orbit. Tumors of the orbit are divided into two classes : (1) Those whicli originate in the orbit, either in the orbital tissue itself, the sheath of the optic nerve, or the periosteum of the bony walls ; (2) those which arise in some one of the neighboring bony walls or sinuses, and which involve the orbit secondarily. This distinction is important, both from the diag- nostic standpoint and from the side of operative interference, for the location and extent of an orbital growth frequently decide not only the question of an operation, but also its nature and extent. Many of the so-called orbital tumors arise in the ethmoid cells, the sphenoid antrum, the frontal sinus, the nasopharynx, or the maxillary antrum. The growth of these tumors is generally slow and insidious, though occasionally it is exceedingly rapid. Orbital tumors may be either fluid or solid. The former almost always arise in the frontal sinus or ethmoid cells, and contain pus or mucus. The latter are either solid or densely gelatinous, and are always malignant in character. Tumors originating in the Orbit. — These include solid neoplasms, cysts of all kinds, and sanguineous tumors, classed under the collective names of orbital aneurisms. Tumors of the orbit are relatively frequent, forming nearly 50 per cent, of all orbital diseases. Symptoms and Diagnosis. — The most marked symptom of orbital tumors, which is only absent in the rarest cases, is exophthalmos. The degree of protrusion of the eyeball enables us to draw some conclusions as to the extent of the growth. The direction in which the protrusion occurs is of importance in determining the location of the tumor, it being usually on the opposite side of the orbit from the protrusion. The exophthalmos is occasionally accompanied by rotation of the eyeball, and generally by more or less marked limitation of its motility. Di- 1196 SPECIAL OR REGIONAL SURGERY. plopia generally results from the displacement of the eyeball. Another symptom which accompanies tumors of the upper part of the orbit is ptosis. Still another symptom which is occasionally met with is pulsation of the eye- ball or orbital contents, which may be felt or heard, and sometimes seen. It occurs in angeiomata, encephalocele, angeio-sarcoma, and in all forms of orbital aneur- ism. Digital examination will sometimes aid us materially in forming an opinion as to the situation, extent, shape, resistance, and movability of the tumor, assisted by puncture with needle or trocar or by removing a small piece of the supposed tumor for microscopical examination. Disturbances in the sensory nerves and anomalies of circulation will aid us in diagnosis. Spontaneous pain, when pres- ent, is generally constant, but it is occasionally intermittent and sharp, like ciliary neuralgia. Topographically, orbital tumors may be divided into four classes — viz. (1) Those which arise in the orbital cellular tissue, and which form the great bulk of all the tumors ; (2) tumors originating in the lachry- mal gland, and these have been considered under the head of Diseases of the Lachrymal Apparatus ; (3) tumors originating in the optic nerve ; (4) tumors arising in the bony walls of the orbit. Tumors which Arise in the Orbital Cellular Tissue. — Cysts. — This class includes encephalocele, extravasation-cysts, pigment-cysts, exuda- tion-cysts, retention-cysts, dermoid cysts, echinococci, and cysticercus. Encephalocele is a hernia from the brain into the orbit through an opening in the suture between the ethmoid and frontal bones, the lachrymal bone being generally entirely absent. It is always congenital. The amount of displacement of the eyeball depends on the position of the hernial ring. There may or may not be pulsation in the tumor. It increases rapidly in size and life is prolonged merely for a few months. These cases do not admit of any treatment. Extravasation-cysts include the blood-cysts, hsematocele, and hsematoma, and also the pigment-cysts or melanotic cysts. Very few cases of true blood-cysts of the orbit are on record, for most cases of cystic formation in the orbit with bloody contents have been originally instances of dermoid cysts in which exploratory punctures have produced a hemorrhage. Exudation-cysts. — Of this class there is but a single variety in the orbit, the hygromatous degeneration of the tendinous bursa?. Retention-cysts, ox follicular cysts, form a large class, and include the atheromata, steatomata, and cholesteatomata. They are simply varieties of true dermoid cysts. Dermoid cysts are foetal structures resulting from the invagination of the exter- nal blastodermic membrane. They are round, with thick, vascular walls lined with endothelium, and maybe unilocular or multilocular. They increase slowly in size, and their contents consist of epithelium or epidermis, hairs, fluid fat and fat- crystals, fluid, gelatinous, or solid constituents, chalky deposits, and even skin and teeth. Echinococcus cysts are surrounded by a framework of connective tissue, and the cavity is filled by the mother-cyst, in which are the cysts of the third generation floating in a liquid. They may extend to the frontal sinus, and even into the cavity of the skull. Ciliary neuralgia is almost a constant symptom in this disease. Cysticercus in the orbit is very rare. The sac is surrounded by a very thick connective-tissue envelope. The symptoms are fluctuation, redness and sensitive- ness of the skin of the lids, pain, and displacement of the eyeball. Anc/eiomata. — Simple angeiomata include the npevus maternus and the teleangiectasia? of the lids and orbit. They are rarely met with in the orbit alone, the eyelids and neighboring skin being usually involved. They are always congenital, and appear as soft, slightly compressible tumors on one side of the eye. INJUBIES AND DISEASES OF THE EYE AND OBBIT. 1197 Cavernous angciomata include the erectile tumors and the aneurisms by anastomosis. They are met with in all parts of the orbit, but are more frequently found behind the orbit, and are surrounded by a thick capsule of connective tissue. They pulsate spontaneously, are firmly elastic, of slow development, and generally painless. Orbital Tumors of the Connective-tissue Type. — These are solid, with more or less uneven surface, and with neither fluctuation nor pulsation. They are neither compressible nor very hard. They may involve one or more of the neighboring cavities, but are much more likely to orig- inate in some one of the neighboring cavities and extend to the orbit secondarily. Treatment. — The treatment of all these tumors consists in complete extirpation at the earliest possible period. Tumors which Arise from the Bony "Walls of the Orbit. — Cysts of the Orbital Walls. — Echinococeus and serous cysts, as well as chole- steatomata of the orbital walls, have probably originated as cysts of the frontal sinus. Osteosarcoma. — Almost the same statement may be made of the so-called osteosarcoma of the orbital walls. The participation of these bony walls in the process is generally only part of very extensive disease of the other bones of the skull, and it is impossible to point out the place of origin of such growths. Osteoma of the Orbit. — Under the general head of osteoma are classed, for convenience, osteophytes, periostoses, hyperostoses, and exostoses, as well as true ivory osteomata. (See Chapter on Tumors.) Tumors of the Optic Nerve. Tumors of the optic nerve, originating in the nerve-fibres or sheath of the nerve, are rare. They may involve any portion of the nerve be- tween the eyeball and the optic chiasm, but in by far the greater number of cases the orbital part of the nerve is the seat of the growth. These tumors vary in size from that of a hazelnut to that of a large egg. Sometimes the nerve passes through the centre of the tumor and is spread out in it, and more rarely it is found on one side of the growth. The tumor grows either from the dural sheath, or from the pial sheath, or from the stem of the nerve. Tumors met with in this locality may be epitheliomata or endotheliomata, sarco- mata, gliomata, myxo-sarcomata, fibro-sarcomata, and neuromata. In all these varieties cystoid degeneration is frequently met with. Most of the cases reported have occurred in young persons before the age of puberty. The endotheliomata usually grow from the dural sheath, the sarcomata from the pial sheath, and the neuromata from the neuroglia of the nerve. In all cases the optic nerve is more or less flattened and atrophied. Symptoms. — These vary with the size, shape, and location of the growth. Optic neuritis, or papillitis and atrophy of the optic nerve, with resulting loss of vision, are early symptoms. The progress is slow and usually painless. The protrusion of the eyeball is generally straight forward in the direction of the axis of the eye, and, unless the tumor be large, the motility of the eyeball is not much interfered with, though diplopia may be present from the beginning. In rare instances the growth may be so rapid as to interfere with the nutrition of the globe, and ends in perforation of the cornea and atrophy of the eye. 1198 SPECIAL OR REGIONAL SURGERY. Affections of the External Muscles of the Eyes. Strabismus, or Squint. — The subject of strabismus can receive but very brief mention in a work on General Surgery, as its intimate con- nection with errors of refraction, with congenital amblyopia and arrest of development of the retina or optic nerve, or both, and with possible undeveloped conditions of the nuclei of origin of the motor nerves, or with abnormally increased nervous inhibition, make it the most obscure and complicated chapter in ophthalmology. Strabismus, or squint, is that condition of the eyes in which the visual axes of the two eyes, when prolonged, do not meet in the object of fixation. If these prolonged axes meet before reaching the object of fixation, the condition is termed convergent strabismus. If these axes when prolonged never meet, but diverge from each other, the condition is known as divergent squint. Either of these conditions may exist alone or may be accompanied by loss of power or paralysis of the antagonistic muscles of one or both eyes. In the former case the deviation is termed primary squint; in the latter it is known as secondary or paralytic squint. Primary squint is almost always associated with some error of refraction, usually feypermetropia, and generally with marked impair- ment of vision of the squinting eye. In the comparatively rare cases in which the deviation exists in both eyes there is commonly a difference in the degree of refractive error and in the acuity of vision of the two eyes. A convergent squint may exist at times in one eye, and at times in the other, and is then called alternating. It may at times exist and at times be absent, and it is then called periodic. In primary squint there is almost never any diplopia. In secondary or paralytic squint, if the vision of both eyes be good, diplopia is almost always present. Primary squint is almost always an affection of early childhood. Secondary or paralytic squint may occur at any period of life. Etiology. — The causes of primary squint are very obscure, and are intimately associated with errors of refraction, increased nervous inhibi- tion, and certain conditions of general nerve-supply as yet but little understood. Secondary or paralytic squint is due either to some local focus of disease in the orbit or brain, to some general blood disorder like syphilis, or to traumatism. Treatment. — In the case of primary convergent squint the treat- ment is partly optical by means of properly fitted lenses, and partly surgical, and should be undertaken solely by the ophthalmic surgeon. In the case of secondary or paralytic squint the treatment should be directed, first of all, to the constitutional cause of the affection, and sub- sequently such surgical operations should be undertaken as may be indicated to restore the disturbed motility of the eyeball. Paralysis of the External Ocular Muscles. — Paralysis of the ocular muscles may be due to some general blood disorder, such as syphilis or rheumatism ; to foci of disease in the brain ; or to traumatism, whether accidental or surgical. Any single muscle may be paralyzed or all the external muscles of the eye may be involved in the same process. Nystagmus. — This is a term applied to involuntary oscillatory or INJURIES AND DISEASES OF THE EYE AND ORBIT. 1199 rotary motions of the eyeballs due to rapid alternate contractions of one pair of straight muscles, or to similar action on the part of the oblique muscles, or to both combined. It may be either congenital or acquired. The former is accompanied either by cataract or by imper- fect development of the retina or optic nerve. The acquired form may be due either to corneal opacities or to fatigue of the nerve-centres of the eye by working in a strained position, as in miners. It is also a symptom of disseminate sclerosis of the brain and spinal cord. Treatment is of no avail. CHAPTEE LVI. SURGICAL INJURIES AND DISEASES OF THE EAR. By Clarence J. Blake, M. D. The congenital deviations of the auricle from the normal type include malpositions of the auricle as a whole ; deformities of certain portions of the auricle, the remainder being normal ; anomalous shape of the auricle, resulting either from injury or from arrest of development during intra-uterine life ; and, finally, the presence of either supernu- merary auricles or of supernumerary portions of the auricle. The malformations most commonly demanding surgical treatment are those in which there is a marked arrest of development accompanied by impairment of hearing, those in which supernumerary portions are to be removed, and those in which the auricle, in other respects normal in position and structure, projects unduly from the side of the head. When the auricle is very prominent and the cartilage thick and firm, it is usually necessary to effect an attachment between the posterior por- tion of the concha and the surface of the mastoid region. This is best done by removing an elliptical portion of skin, including a part of the posterior surface of the auricle and of the mastoid, in one denudation, the edges of the cut upon the auricle and mastoid being brought into apposition and secured by stitches : a light but firm bandage is then car- ried over the auricle and around the head, and, except for renewal, should not be removed until the healing of the wound is complete, Where the cartilage of the auricle is thick and unyielding, it may be thinned either by means of the curette or knife, care being taken that this is done evenly ; otherwise when the auricle is pressed backward, a break may occur in the cartilage at the thinnest point, with the resulting deformity of a projection upon the anterior surface of the auricle. The commonest form of complete, microtia is that in which the tuber- cles of cartilage which subsequently form the helix, antihelix, and the tragi are still distinct, and, since it is the result of an arrest of develop- ment at an early period of intra-uterine life, it is not uncommonly accompanied by an arrest of development of the corresponding side of the face, of the external auditory canal, and sometimes of the sound- transmitting structures of the middle ear. The supernumerary portion* of the auricle most commonly found are small nodules of cartilage or of connective tissue, covered with skin, in front of the ear, which may itself be quite normal in shape, size, and location. These projections are easily removed by excision, a small flap of skin being taken from one side and stitched or otherwise secured in the space left by the removal. 1200 SURGICAL INJURIES AND DISEASES OF THE EAR. 1201 Incised and contused -wounds of the auricle are likely to result in a considerable degree of deformity, either from imperfect coaptation of the edges of the wound or from subsequent perichondritis or necrosis of the cartilage, unless they are treated shortly after injury and with especial reference to the peculiar structure of the auricle. As a result of blows upon the auricle there is not infrequently a severe contusion or fracture oj the cartilage, with extravasation of blood under- neath the integument and perichondrium : this occurs usually on the anterior surface of the auricle and in its upper portion, and is similar in appearance and location to the extravasations which have been found to occur, without history of injury, in the insane, and have been produced artificially in dogs by section of the restiform bodies, except that the traumatic othcematoma is usually larger, more tense, and accompanied by pain. In the traumatic othsematoma the extravasation of blood which peels up the perichondrium and skin is usually the result of a fracture of the cartilage, while in the idiopathic form there is sometimes a disease of the cartilage as the basis of the hemorrhage or effusion. The othcematoma usually presents itself as a smooth rounded swelling, filling the upper anterior portion of the auricle above the concha, and obliterating the normal elevations of the helix, antihelix, and their cor- responding fossae; it occurs either immediately after an injury, when it is accompanied by sensations of pain and tension, or idiopathically, with- out pain or other disturbance, sometimes during sleep, the patient awak- ing with a sense of fulness in the auricle as the first evidence of an abnormal condition. The treatment of the recent othsematoma should be directed, first, to the evacuation of the contents of the sac, and, secondly, to the prevention of deformity, which is likely to occur from the contraction of remaining blood-clots, the puckering of the skin, and the consequent malposition of the fractured or weakened cartilage. The auricle is frequently the seat of small warty growths occurring usually on the walls of the concha, of small cysts, and occasionally of gouty deposits, all of which may be treated according to the simple rules applicable to the removal of such abnormalities elsewhere. The lobule is occasionally the seat of fibrous tumors, rarely attaining any considerable size or occurring frequently except in the negro race. When these tumors are large it is sometimes necessary to sacrifice the whole lobule, the tumors being removed by careful dissection, leaving a small flap of skin to be turned under the lower edge of the cartilage of the auricle to form a small lobule. Epithelioma of the auricle is of infrequent occurrence, a review of 14,747 cases of all diseases of the ear showing that it occurred but twice. Relief is most commonly sought on account of the severe pain which accompanies the development of the nodular projection upon the ante- rior surface of the auricle, the primal appearance of a carcinomatous growth being rare on the posterior surface. The removal of the auricle in cases of epithelioma sometimes implies the creation of a surface of greater or less extent to be covered by granu- lation-tissue, and the utilization of any skin-flaps which may be obtain- able without danger of a recurrence of the growth should of course be 76 1202 SPECIAL OR REGIONAL SURGERY. considered. Where the upper portion of the auricle only is implicated and the lobule may be left, it can be utilized for covering ; the lobule, Fig. 618. Complete destruction of auricle by epithelioma (Park). which is merely a reduplication of skin, vascular and well nourished, and with a small artery passing into it from a point on its anterior border, may be separated in removing the cartilaginous portion of the auricle, left hanging by its anterior attachment, and, after removal of the auricle be used by splitting and spreading to cover a considerable denuded sur- face. Where it has been necessary also to denude a large portion of the mastoid surface a long incision may be made in the scalp posteriorly to the mastoid, the subcutaneous tissue dissected up, and the scalp slipped forward to cover as large a portion of the mastoid as is possible by this means, the scalp opening being allowed to close by granulation-tissue ; the aural wound should Be dressed antiseptically, a gauze tampon being placed in the external auditory canal, and when granulations appear over the surfaces which it has not been possible to cover with skin, dercnatiza- tion may be effected by first drying the granulation surface and then carefully covering it with a strip or strips of bond or so-called parch- ment paper, which is kept in place under pressure by means of sterile dressings and firm bandages. At the end of the third or fourth day the paper is usually either firmly adherent or comes away, leaving beneath it flattened granulations covered with a fine pavement epithelium. In using this form of automatic grafting the paper dressing should, if pos- sible, be applied in one piece and carried over on to the sound skin, new skin-growth being found, under these conditions, to project itself in con- centrating lines from the sound edges toward the centre of the granulat- ing surface. SURGICAL INJURIES AND DISEASES OF THE EAR. 1203 Foreign Bodies. The foreign bodies which find their way into the ear, and for the removal of which interference is required, are of two classes — the ani- mate and inanimate, the former including various insects and their larvse, and the latter almost any substance small enough to be introduced into the external auditory canal. The presence of an animate body is usually evident to the patient by sensations of movement within the ear, and of pain accompanied by noises incident to the movement of the living creature. The speediest relief from these symptoms is afforded by turning the affected ear up- ward and filling it with either warm water or warm oil for the purpose of drowning the insect, which may afterward be removed by means of the forceps under a good illumination, or by simple syringing. The larvae of the house-fly and blow-fly are sometimes found in the ear in cases of suppurative disease : their presence may usually be determined objectively as a whitish moving mass in the depth of the ear, and an occasional indication of their presence is the streaking of the purulent discharge with blood flowing from the mucous membrane, wounded by the hooks with which the larvae attach themselves, the subjective symptoms being a sharp stinging pain in the ear accompanied by a sensation of movement. An attempt at removal of the larvae by means of the for- ceps not uncommonly results in their being torn to pieces, traction upon their bodies drawing the hooks downward and fixing them more firmly in the skin or mucous membrane. As their breathing apparatus is at the ventral end, they may be made to loosen their hold by filling the ear with warm oil or glycerin. The inanimate bodies most commonly found in the ears of children are beans, peas, pieces of slate-pencil, beads, boot-buttons, small shells, and pebbles. Where the foreign body is situated in the outer half of the canal it may sometimes be easily removed by turning the affected ear downward, seizing the auricle between the finger and thumb, and rotat- ing it forward and backward, this movement serving to make the wall of the cartilaginous part of the canal impinge upon one side and then the other of the foreign body and loosen it from its place. If the foreign body have been pushed beyond the narrow portion of the canal and is lodged near to or in contact with the drumhead, its removal should be attempted, otherwise than by syringing, only under a good illumination and with great care, it having not infrequently happened that injudicious attempts at removal of a hard foreign body by means of forceps and other instruments have resulted not only in wounding the lining of the canal, but in rupturing the membrana tympani and forcing the foreign body into the tympanic cavity. When the foreign body is so firmly imbedded at the inner end of the canal or in the middle ear as to make its extraction by the natural channel impossible, it may be necessary to reflect the auricle and cartilaginous portion of the canal, or even its entire lining, forward. This should be done under ether and with the usual aseptic precautions, an incision being made behind the auricle close to its attachment, and the dissection along the posterior wall of the canal being carried to the point of attachment of the cartilaginous to the osseous portion, which may then be separated, exposing the inner end of the canal, with its soft tissues intact, freely to view; or, without dividing the canal, the soft parts may be entirely dis- sected away from the bone as far as the emulus tympanicus, the soft tissue at this point being divided by the angular knife introduced through the canal or by further dissection from behind forward : should the foreign body be so large, of such material, or so firmly imbedded in the middle ear as to make its piecemeal extraction necessary, the first incision should be made not merely behind the 1204 SPECIAL OR REGIONAL SURGERY. auricle, but should begin above it, in order that a larger operative field may be obtained and that room be secured, if necessary, for cutting away portions 01 the After removal of the foreign body the ear should be. thoroughly cleansed with an antiseptic solution, the soft parts replaced, and the outer wound closed by stitches. The External Auditory Canal. The commonest form of acute infectious process of the external audi- tory canal is furuncle, or boil, which is found principally in the outer portion of the canal, and rarely in the concha or upon the auricle. These boils of parasitic origin occur singly, more commonly successively in groups, and have all the characteristics of the same form of inflammatory process elsewhere, but are liable to be especially painful because of the circumscribed region in which they occur, the thinness of the skin, and the resisting character of the underlying tissues. The occurrence of a large furuncle at the junction of the cartilaginous and osseous portions of the canal, followed by subsequent ulcerative de- struction of the thin upper dermoid wall, will sometimes leave a cavity of considerable depth either filled with granulation-tissue or with masses of exfoliated epidermis, the removal of which by means of the forceps or by syringing reveals the true condition of affairs, the depression in the wall of the canal being found to have somewhere upon its surface redundant granulations, at the bottom of which, by means of a probe, a spot of carious bone may be felt. In the majority of these cases relief is obtained by the simple process of thorough and sometimes repeated curetting through the external canal, but it is occasionally necessary where the necrotic portion is more extensive to reflect the auricle for- ward in search of a sequestrum or for the purpose of removing the dis- eased bone by means of the chisel. Exostoses of the external auditory canal, like the hyperostoses, are usually the result of a circumscribed periostitis, such as may occur in the course of a chronic suppuration of the middle ear, though their occur- rence as multiple growths in succeeding generations favors the imputa- tion of an hereditary tendency. The hyperostoses rarely require operative interference, but the exostoses of large size which have their origin on the anterior superior or posterior inferior lip of the osseous meatus, as well as the rounded exostoses which occur singly or in groups deeper in the canal, sometimes project so freely into its lumen as to make their removal a necessity. A careful examination of the contour and location of an exostosis is an important preliminary to its removal, and this may be done with a bent probe passed beyond the growth or by means of the loop of a wire snare slipped over it. The removal of exostoses is best effected by means of a fine dental drill making successive openings through the base of the growth, which is then broken away by means of the burr worked by a dental engine. Another form of obstruction of the external auditory canal, but one involving the soft tissues only, is that which follows the granulomata occurring in the canal as the result of an ulcerative process incident to suppurative middle-ear disease or otherwise, and consists usually in an annular constriction or narrowing of the canal by secondary granulation- SURGICAL INJURIES AND DISEASES OF THE EAR. 1205 tissue. Dilatation of the constriction by sea-tangle tents, either with or without previous multiple incision, is frequently of doubtful result, and in some of these cases the following procedure has proved of service, its object being to remove the redundant tissue and at the same time to preserve the continuity of the dermoid lining of the canal. The Membrana Tympani and the Tympanum. The membrana tympani, while exceedingly firm and resistant, is comparatively inelastic : it may therefore be ruptured throughout by such application of general force to its whole surface as would accom- pany the sudden condensation of air in the external canal or middle ear ; it may be torn across as an effect of contre-coup in consequence of a blmc on the opposite side of the head ; or it may be wounded by the im- pact of some foreign bod// introduced through the external canal. In the first and second instances there is usually a solution of continuity of all the coats of the drumhead, the laceration extending from one periph- ery to the other, and commonly parallel with and close to the long process of the malleus, while in the latter case the injury is usually limited to a small area around the point impinged upon ; in both classes of cases the rent is an irregular one, and, as the mucous coat of the drumhead is exceedingly vascular, the injury is likely to be accompanied by hemorrhage into the tympanic cavity. If the rupture of the drum- head be an extensive one, with bleeding into the tympanum, and the injury be recent, the middle ear should be gently inflated by means of the Politzer air-douche or catheter, and the meatus carefully cleansed, a dry cotton-tipped probe being used in preference to the syringe : if syringing is rendered necessary by the presence of an extraneous substance or of cerumen or epidermis in the canal, this should be done only with steril- ized water or an antiseptic solution : after cleansing, the ruptured edges of the membrana tympani, if not already in contact, should be placed so by gentle manipulation with a cotton-tipped probe from without and by inflation of the middle ear from within, it being borne in mind that the less the parts are handled the better ; but the apposed edges of the cut may be covered by a paper dressing previously dipped in sterilized water or a weak corrosive-sublimate solution. A blood-clot in the healthy tympanic cavity is a matter of little moment, except in so far as temporary interference with sound transmission is concerned, and the structure of the drumhead is such — there being a fibrous coat in two layers, the outer of which is made up of radiating and the inner of circular fibres placed between an outer dermoid and an inner mucous coat — that when wounded or ruptured the edges of the cut or wound tend to return to a normal position and come together. The ear should finally be closed with cotton and the patient directed to avoid blowing the nose for at least forty-eight hours. In those cases of chronic, non-suppurative middle-ear disease where operation is undertaken with a view to possible improvement of the hearing, and in other cases of the same class where the exact deter- mination of the character and location in the sound-transmitting appa- ratus of the obstacles to the passage of the sound-waves is a matter of difficulty, the question of some method of exploratory operation which 1206 SPECIAL OR REGIONAL SURGERY. shall take advantage of the intelligent participation of the patient is a matter of importance. Tactile investigations as to the comparative sensitiveness of different portions of the tympanic cavity show its lining membrane and intrinsic structures, with the exception of the superior and posterior portion— fornix tympani and aditus ad antrum mastoideum — to be comparatively insensitive. Operations within the middle ear, therefore, except such as include interference with the membrana tympani and invasion of the upper por- tion of the tympanic cavity, may, in the great majority of cases, with proper care, be conducted not only without general, but also without local, anaesthesia ; and in the cases, therefore, of chronic non-suppurative disease of the middle ear with intact membrana tympani, for which this operation of exploratory tympanotomy is proposed, when the sensitive membrana tympani has once been passed there is opened to the observer an aseptic and comparatively insensitive cavity. The details of the operation are as follows : The patient is seated in a chair, the head being firmly supported by an assistant, who alters its position from time to time according to the directions of the operator. Under good illumination the first incision is made with the paracen- tesis knife close to the periphery of the membrana tympani, opposite the round window, and carried upward along the periphery, with or without successive applications of cocaine solution on a cotton-tipped probe to the cut edges as the sensitiveness of the patient may demand : this first portion of the cut ends at a point close to the short process of the mal- leus, and is thence carried downward along the posterior border of the long process of the malleus. The resultant flap usually curves outward and downward, and per- mits free access to the parts beneath : when this does not occur the flap may be pulled gently outward by means of the blunt hook. Through the opening thus afforded it is possible to test the mobility of the ossicles, to make tactile examination of the parts beyond sight, and to perform such operations as the tests of hearing and the tactile examinations may indicate, including, for example, divisions of folds and adhesions, mobilization of the ossi- cles, tenotomy of the stapedius and tensor tympani muscles, circumcision of the stapes, and division of the incudo-stapedial joint, without local anaesthesia, except in so far as the membrana tympani is concerned, the absence of general anaesthesia permitting tests of hearing at progressive stages. At the conclusion of the examination or operations within the tym- panum, as the case may be, the flap in the membrana tympani is replaced by applying to its outer surface a disk of thin glossy writing-paper pre- viously dipped in a weak corrosive solution : this disk is introduced on a moist cotton-tipped probe, kept in contact with the flap for a few seconds until it adheres to it, and then, carrying the flap with it, is pressed upward until the paper also adheres to the drumhead above the cut, thus sealing the wound and keeping its edges in apposition. If aseptic precautions have been properly taken, the wound in the drumhead closed in this manner usually heals by first intention. Operation for the removal of the membrana tympani, malleus, and incus for the purpose of improving the hearing in cases of non-suppura- tive diseases of the middle ear, as originally proposed by Kessel, is very similar to the operation for the removal of the malleus and incus in cases SUBGICAL INJURIES AND DISEASES OF THE EAR. 1207 of suppurative disease, and should be done with the most careful atten- tion to asepsis. This operation, undertaken for the improvement of hearing, is of little benefit unless it take into consideration also the release of the stapes and its possible utilization as the point of contact for some form of artificial drumhead. In acute inflammation of the middle ear incision of the mem- brana tympani may be required either for purposes of phlebotomy or for the release of secretions retained within the middle ear. In cases of acute congestion occurring in the upper portion of the tympanum, and characterized subjectively by intense pain and objec- tively by congestion and swelling of the upper, more vascular portion of the membrana tympani and the upper portion of the inner end of the external auditory canal, prompt action for the relief of the engorged tissues sometimes cuts short what otherwise would be the inception of a serious and prolonged inflammatory process. The purpose of the incis- ion being to divide one of the principal blood-supplies of the membrana tympani, the cut should be made along the posterior superior periphery, from below upward, and ending at the short process of the malleus. After cessation of the temporary hemorrhage the ear should be dressed with dry cotton wicks. Incision of the membrana tympani for the Release of fluid contained within the tympanum should be made by the means of the paracentesis needle, preferably in the inferior posterior segment, parallel to the periph- ery of the drumhead, and should be proportionate in size to the density and tenacity of the fluid to be evacuated ; while in view of the sometimes considerable swelling of the mucous lining of the tympanic cavity accom- panying conditions which render paracentesis necessary, care should be taken that the opening is not only sufficiently large to permit the free flow of fluid, but also deep enough to effectually penetrate the swollen mucous membrane. Redundant granulation-tissue and polypi are among the common accompaniments of chronic suppurative disease of the middle ear, and may spring either from the mucous membrane of the tympanic cavity, from the edge of a perforation of the membrana tympani, or, from the inner end of the external auditory canal, and vary in structure and size according to their point of origin and the space afforded them for growth. They may be removed either by touching with astringents or caustics, or, operatively, by means of the forceps, the curette, or the wire snare, the latter instrument being especially applicable to the larger and firmer growths. The stump remaining after successful application of the snare should be curetted or treated with caustics until it has entirely disap- peared, it being remembered that a too free use either of the curette or escharotics may result in stimulation which will favor redundant tissue- growth and even clinical simulation of a malignant growth, or may cause inflammation of the surrounding tissues. Granulations springing either from the wall of the canal, from the mucous membrane of the tympanic cavity, or from the ossicles as the result of a circumscribed necrotic process in the bone, may likewise be removed by means of a small tubular snare, curved forceps, or the curette, and their bases subsequently cauterized. 1208 SPECIAL OR REGIONAL SURGERY. Limited necrosis of the inner end of the canal, of the wall of the tympanic cavity, or of the ossicles, is best dealt with by means of small and appropriately shaped curettes ; or, in the latter case, if the necrotic process is extensive, complete removal of these bones may be necessary. When, as is sometimes the case, the lower part of the malleus has , been destroyed by necrosis and only the head or a part of it with the neck remains, the location of this remaining portion should be deter- mined by tactile examination with a bent probe, and its removal effected either by means of a pair of long curved forceps, an incus-hook, or a cup-shaped curette. In the event of caries of the head of the stapes the carious portion may be removed by means of the forceps or curette. After operation the tympanic cavity should be subjected to careful tactile examination to detect any points of necrosed bone, which should in their turn be curetted ; redundant granulation-tissue should be removed, the tympanic cavity thoroughly cleansed by syringing with a weak antiseptic solution, and the ear stopped with absorbent cotton. The subsequent treatment, aside from any further curetting which may be necessary, should consist in syringing with a potassium perman- ganate or mild astringent solution, touching of granulations, instillation of alcohol, and the insufflation of powdered boracic acid, as the condition of the individual case may demand. In all cases of limited necrosis of the ossicles or of portions of the tympanic wall, it is possible that the operative procedure above mentioned may be unnecessary, and that the desired improvement may be effected by use of the middle-ear syringe and insufflation of powders. Local treat- ment of this kind, sufficiently persisted in, has been found efficacious in the majority of cases in which the necrosis has not been extensive. The Mastoid. The mastoid operation may be properly considered to include not only the opening of the mastoid cells themselves and the establishment of free communication through the mastoid antrum with the middle ear, but also the removal of the bony wall forming the boundary between the mastoid and the external auditory canal, and of the superior posterior bony lamina which forms the outer and lower limit of the epitympanic space, with also such diseased portions of the mastoid walls elsewhere as may be necessary. The initial lesion, of which the establishment of an acute infectious process in the cellular structure of the mastoid portion of the temporal bone is a complication, may occur as the result of an inflammatory process in the soft parts of the external auditory canal, a circumscribed periostitis being followed by denudation and death of bone, or, more frequently, may be the sequence of an acute congestion or of an acute infectious process in the middle ear. In acute congestion of the middle ear with an accompanying congestion of the lining membrane of the mastoid cells, where the pain, the temperature, and the pulse, the tender- ness to pressure in the mastoid region, especially over the mastoid antrum, the digastric fossa, and at the mastoid tip, as well as the objec- tive symptoms in the middle ear, indicate the necessity for an opening into the mastoid for purposes of local phlebotomy or with a view to SURGICAL INJURIES AND DISEASES OF THE EAR. 1 209 further interference, the operation should be done only under the most rigid asepsis, and should be preceded by a free crescendo incision along Fig. 619. Fig. 620. Outer surface of mastoid and membrana tympani. Interior of mastoid and inner surface of membrana tympani. the superior posterior periphery of the drumhead, in ease that structure is intact. An incision in this location affords not only the freest oppor- FlG. 621. fNT*w "V "V ,/■ *^t_-- Vertical section of mastoid process. tunity for drainage from the mastoid antrum, but also, as in the opera- tion of exploratory tympanotomy, provides a flap which can easily be replaced with the least possible interference with the integrity of the drumhead and its subsequent value as a vibrating membrane. The extent of the operative invasion of the 'mastoid cavity in the acute congestive cases must depend upon the degree to which the bone of the mastoid cortex, and the more delicate walls of the mastoid cells, have become affected, and may vary from a simple opening of the outer mas- toid wall to the establishment of a ih'C communication with the mastoid antrum and the middle ear. The actual value of a simple incision through the soft tissue over the mastoid down to the bone onlv is that of an extensive superficial mastoid phlebotomy, except in those cases of neglected suppurative middle-car dis- ease with mastoid complications, where the pathological process has sought 1210 SPECIAL OR REGIONAL SURGERY. its own relief by perforation of the cortex, and the incision which gives vent to the contained pus is but the preliminary to a thorough opening and evacuation of the mastoid itself. In an uncomplicated case of mastoid operation the preliminary incision should be made from above downward, at a distance of about a half inch backward from the insertion of the auricle and following its curve : the upper portion of the cut should be vertical, and the lower portion inclined outward through the soft tissues ; small vessels should be seized and twisted, and larger vessels ligatured, though this is rarely necessary, the use of hot water and the pressure of the retractors being usually sufficient to stop hemorrhage from the flaps : this having been effected and the bone bared of periosteun, its surface, unless there has been spontaneous perforation of the cortex, should be-carefully searched for evidence of congested or softened bone, such point being chosen for the preliminary opening. This, together with the subsequent operation within the mastoid, except as regards curetting, may be effectually accomplished by means of the chisel or gouge and mallet, though in many cases the broad-bladed and long-handled drill worked by hand and guided by an educated tactile sense is a convenient and valuable substitute. The opening in the cortex should be sufficiently large to permit free access to the mastoid cavity, and the process of removal of the diseased Fig. 622. Hammond's retractor. tissue may, in the majority of cases of mastoid disease, be sufficiently and effectively accomplished by means of sharp spoons, the process of Mastoid curette. curetting being accompanied from time to time by careful pi-obing and by ocular inspection when possible, the greater part of the operation, Fig. 624. Mastoid drill. however, as a rule, being done by the sense of touch, and requiring therefore for its complete performance a tactile knowledge of distances and of location of important parts. In both the earlier stages of mastoid disease and in those cases in which the cavity is found to be filled with broken-down cell-walls, granu- SURGICAL INJURIES AND DISEASES OF THE EAR. 1211 lomata and pus, but without caries of the antrum or epitynipanic space, after thorough evacuation the mastoid may be allowed to fill with blood- clot, the surface of the wound being flushed with hot water and a simple baked dressing applied. In cases of long-continued or neglected mastoid disease with spon- taneous perforation of the cortex in the digastric fossa or at the tip, the pus making its way downward by gravity into the tissues of the neck, the preliminary incision should be carried backward over the digastric region and continued downward sufficiently to permit free access both to the mastoid tip — which wherever carious should be removed — and to the upper portion of the course followed by the pus downward, counter- incisions in the neck below being made to afford drainage. In cases of prolonged chronic mastoiditis the resultant thickening of the cancellated structure furnishes a hard bone, often of considerable thickness, through which it is necessary to chisel or drill before reaching the objective point in the pneumatic cells of the mastoid or of the mas- toid antrum, while in cases of prolonged suppuration with necrosis of the antrum or the accumulation of cholesteatomatous masses the sim- ple mastoid operation above mentioned may need to be extended to removal of the anterior mastoid wall and the outer boundary of the upper tympanic space, and the creation of one large permanent opening with inverted skin-flaps, or it may be but the preliminary to an opening of the cranial cavity in cases of sinus thrombosis or otitic brain-abscess. CHAPTER LVII. ON SKIAGRAPHY, OB THE APPLICATION OF THE RONTGEN RAYS TO SURGERY. By Roswell Park, M. D. Enough time has elapsed since the announcement by Professor Rontgen, of Wiirzburg, of a new manifestation of energy, which he called the " x rays," and which others have generally consented to name the " Rontgen rays," to demonstrate their value and their applicability for limited but important purposes in surgery. To the method in general the name skiagraphy is now generally applied, while the pictures taken by the new process are sometimes termed skiagraphs or radiographs. While Rontgen is undoubtedly to be credited with the first application of what is now known and with the introduction of a suitable method, he, nevertheless, is not the first man to recognize that energy proceeds from the cathode in high vacuums. Hertz, a brilliant German physicist, endeavored to demonstrate Maxwell's theory that light-waves are identical with electro- magnetic disturbances in ether, which ether is the all-pervading elastic medium everywhere regarded as pervading space and penetrating all bodies, no matter how solid. Hertz showed that electro-mag- netic disturbances in ether were capable, like light, of refraction, reflection, polar- ization, dispersion, etc. In 1891 he stated that the cathode rays of a Crookes tube were capable of passing through opaque substances in their path inside of the tube. Hertz died an untimely death, and his investigations were continued by Lenard, who in 1893 announced that these same cathode rays escaped from the tube to a certain extent, and that he had obtained photographs through opaque sub- stances by their agency. His simple statement, however, attracted no attention. Ebntgen was following along the lines of Hertz's and Lenard's investigations when, upon the 8th of November, 1895, while working with a Crookes tube cov- ered with a shield of black cardboard, he noticed that a piece of barium platino- cyanide paper became phosphorescent. It was this which led him to further investigation and the announcement of his " x rays." Further tests within the ensuing few days showed the penetrative power which they possessed, as well as their property of affecting photographic plates as does light ; furthermore, that they could not, like light-rays, be reflected, concentrated, or diffracted outside the tube in which they originate. The possibility of provoking the phenomenon of the Rontgen rays appears to be inseparably connected with the ultra-gaseous state of matter, which Crookes called the radiant or fourth state. All gases are now regarded as composed of countless molecules continually moving and jostling each other with incredible velocity. When a glass tube containing air is exhausted, the number of these molecules is diminished, and each molecule is given a longer free path. If ex- haustion be carried to, say, one-millionth of an atmosphere, the minute portion of air remaining is exalted to what we may call the radiant state, and here new and strange phenomena may be evoked. A tube thus exhausted, no matter what its shape, is known as a Crookes tube, and, as ordinarily constructed, is more or less cylindrical or pear-shaped, with a platinum electrode at either extremity. It is from the cathode that the x rays proceed, and it appears that from the impact of either the ether waves proceeding in a longitudinal direction or of solid particles projected from the cathode upon the glass the peculiar energy proceeds. The glass becomes fluorescent, and the "rays" escaping from the tube have the power of provoking fluorescence in certain other materials — the diamond, for instance, in feeble degree — while potassium platino-cyanide or barium platino-cyanide and calcium tungstate in particular can be thrown into a high degree of fluorescence. 1212 PLATE XXXIV. Clubfoot, Child aged Six Years, showing Overlapping of the Metatarsals; patient of Dr. De Forest Willard, by whose permission the illustration is used. ISkiagraphed by Prof. Arthur W. Goodspeed. Copyright 1896, by William Beverley Harison.] PLATE XXXV. Skiagraph of the Hand of a Young Lady, aged Twenty-six Years, showing a Needle Imbedded in the Muscles for Twenty Years. (Skiagraphed and loaned by Mr. Herbert B. Shallknbergkr, Rochester, Pa. Exposure, 5 minutes. 1 PLATE XXXVI. An Old Dislocation of the "Wrist, with Fracture and Disappearance of the Styloid Process of the Ulna. Note the darker shadows of the pisiform bone and the unciform process. [Skiagraphed and loaned by Mr. Herbert B. Shallenberger, Rochester, Pa. Exposure, 40 minutes.] PLATE XXXVII. Skiagraph of Thorax and Arms. Observe especially the Cervical Intervertebral Substances, Ribs, Clavicles, and Shoulder-joints. [Skiagraphed by Prof. A. W. Goodspeed, and kindly loaned by Dr. H. W. Cattell. From the International Medical lournal. Equal definition in one minute.] SKIA GRAPHY. 1213 Advantage has been taken of this fact by Edison and others in the construction of the so-called fluoro&cope, which is nothing but a conveniently shaped box with a shield adapted about the eyes, so that no light may enter, while at one end is a cardboard which has been spread with mucilage, upon which, before drying, crystals of one of the above-mentioned fluorescent salts have been sprinkled. In the presence of a Crookes tube, suitably energized, objects which are more or less opaque to the RSntgen rays will cast a shadow upon this fluorescent screen, while the soft tissues of the body and many non-metallic objects permit their freer pas- sage. Thus a hand held between the screen and the tube will cast a perfect sil- houette or shadow, while solid particles, needles, buckshot, pieces of glass, etc., will be made conspicuous as upon a photographic plate. In utilizing the cathodal rays for surgical purposes either the fluoro- scope or the photographic plate may be employed. With the former a momentary shadow can be obtained without being recorded, by which information of much value may often be gained within a few seconds ; but for permanent record or for purposes of more accurate study photo- graphs (/. e. skiagraphs) must be made. For this purpose the ordinary dry plate may be employed, certain manufacturers now making plates for this special purpose which are considered more sensitive. One of these plates in any ordinary plate-holder, of size large enough to accom- modate the desired picture, is used according to the necessities of the case. It will be sufficient for a hand or arm to simply lay it over the plate- holder and rest both upon a table, the Crookes tube being fastened above the part to be photographed. In the case of a foot the plate may be placed upon the floor, the foot rested upon it, and the tube be suitably placed. In any event, no metal, such as rings, etc., should be allowed to disfigure or render uncertain the picture to be taken. Thus, while it is not necessary to take off the stocking, it will be necessary to take off a shoe which contains iron nails, a glove with metal buttons, etc. In order to avoid lack of definition, it will be well to bandage the limb to the plate-holder or to fasten it thereto with strips of adhesive plaster. It is not necessary to take off wooden or plaster splints. In the case of the trunk the patient may lie upon the plate-holder or a flat table. In the case of the skull the plate-holder should be strapped or bound to the head, and the whole held in some suitable bead-rest because of the long exposure required. The time required for exposure can never be determined without some experimentation, for it will vary with the size of the coil, the voltage of the primary current, the size of the lamp, and the degree of vacuum within it. With perfect apparatus good photo- graphs of the hand, foot, etc. can be taken in from two to five minutes, while with defective apparatus this time may be lengthened to half an hour or even an hour. For the body and the skull longer time is required — at least with most of the apparatus on the market at the date of this writing. The Crookes tubes become intensely heated at the point of impact of the cathode rays, and it is possible to soften the glass to a degree per- mitting change" of its shape, or to so heat the tube when placed close to the patient as to make it uncomfortable or unendurable. For most pur- poses a distance of from ten to fifteen inches from the surface is about the best. When it is remembered that these rays proceed in straight lines, it will be easily seen how much distortion of image may occur when the endeavor is made to skiagraph too extensive an area with one 1214 SPECIAL OR REGIONAL SURGERY. tube. On the other hand, with two or more there may be some con- fusion of images. The method in general use for skiagraphing a hand can be seen from the accompanying illustration (Fig. 625). Fig. 625. Illustrating method of skiagraphy by use of large induction coil. Of the practical applications of Rontgen's discovery the profession have been made pretty generally aware through numerous publications in current medical literature. Up to the present their most common application has been for the purpose of skiagraphing the bones or of detection of foreign bodies — needles, etc. — in the soft parts. By means of Rontgen's discovery it will be hereafter possible to recognize irregu- larities, deformities, new growths, malformations, the existence of frac- tures or dislocations, the character of pseudarthroses, variations in den- sity of bone, size and location of sequestra, etc., in at least the bones of the limbs. Much may be told also regarding the perfection of union and solidity of callus after fracture, and even changes M T hich have taken place in the dimensions of the marrow-cavity. By mere study of the osseous skeleton, alone, of mother and foetus the obstetrician may accu- rately depict the position of the foetus shortly before birth. Probably the fluoroscope will suffice for this purpose, it not being often necessary to take a skiagraph. Inasmuch as mineral matter is the more impervious to these rays, calcareous infiltration of various organs or tissues causes marked rela- tive differences which the expert will in time learn to recognize. Thus, calcareous infiltration of arteries and atheromatous disease may be made actually visible. The exact progress of ossification and of epiphyseal union in the bones of children may also be depicted quite accurately, as well as pathological changes in bone tissue, callus, etc. For the same reason mineral calculi can be made visible, particularly in the bladder and kidneys ; probably also in the ureters, the salivary ducts, etc. On the other hand, calculi composed of organic material, like cystin, and biliary calculi seem strangely pervious to these rays, and are as yet not easily capable of detection by their means. For the dentist fangs of teeth and foreign bodies, as well as the presence of un- SKIA GRAPHY. 1215 suspected fillings, may be clearly indicated, and the presence of super- numerary or non-erupted teeth. It is in the detection of foreign bodies, especially metallic, that the skiagraph and fluoroscope are often of greatest value. Gunshot missiles of all sizes, from buckshot up to bullets, needles and par- ticles of metal, glass, etc., are capable of easy detection by this means. A year or two ago a jack-stone, which had become impacted in the oesophagus of a little child, was exactly located and its removal very much facilitated by a skiagraph taken by Dr. White of Philadelphia. With improvement in technique differences may be quickly made out in the soft parts which we are as yet rarely able to accurately recognize — for instance, the location of the heart, the liver, etc. — while with the fluoroscope and the energetic tube the movements of the viscera may be seen within the cavities of the body during life. It does not seem necessary to go into further details, but the reader is referred to the plates herewith subjoined for information which may illustrate some of the uses of Rontgen's ray in surgery. INDEX. ABDOMEN, distention of, in peritonitis, 910 exploration of, for jaundice, 927 gunshot wound of, 280 surgery of, 872 surgical diagnosis and examination of, 249 wall of, contusions of, 872 gunshot wounds of abdominal viscera, 875 treatment, 875 injury to contained viscera from, 872 gall-bladder, 874 intestine, 873 liver, 874 pancreas, 874 spleen, 874 stomach, 873 penetrating wounds of, 874 hemorrhage from, 874 prolapse following, 874 wounds of, followed by hernia, 939 Abdominal injuries without penetration, 872 pregnancy, 1059 wall, contusion of, 872 hematoma of, 872 Abscess about bladder, 1000 alveolar, 862 appendicular, abnormal situations of, 904 operation for, 905 atheromatous, 438 of bone, 525 treatment, 525 of brain, 650 prognosis, 652 symptoms, 651 treatment, (157 of breast, 1063 intramammary, 1063 retro- or submammary, 1063, 1064 superficial, 1063 classification of, 63 acute, 63 cold, 64 gravitation, 64 subacute, 63 cold, infection of, 521 collar-button, 398 definition, 62 difference between, purulent infiltra- tion, 62 fluctuation in, 65 of glands of Bartholin, 1026 of hip, 1150 77 Abscess, laryngotracheal, 791, 792 of liver, 923 causes, 923 diagnosis, 923 pysemic, 923 treatment, 923 of lung, 823 treatment, 823 tubercular, 824 manner of formation, 63 of omentum, 915 palmar, 399 of pancreas, 917, 918 diagnosis, 918 prognosis, 91 S symptoms, 918 treatment, 918 of parametrium, 1055 psoas, C87 of rectum, 959 classification, 959 ischio-rectal, 059 treatment, 959 superior pelvi-rectal, 960 treatment, 960 retroperitoneal, from pancreas, 918 retropharyngeal, 748, 797 symptoms, 748 treatment, 748 shirt-stud, 398 signs of, 65, 68 of spleen, 920 symptoms, 920 subperiosteal, in finger, 397 subphrenic, 819, 878 causes, 819 symptoms, 820 treatment, 821 symptoms, 65, 68 Accidents from anaesthetics, 240 A. C. E. mixture, 236 Aeheilia, 773 Achondroplasia, 532 Acne, 356 treatment, 357 Acromegaly, 538 Acromial process, fracture of, 565 Actinomycosis, 127 of bone, 532 of chest-wall, 834 definition, 127 diagnosis, 129 of jaw, 863 of lip in man, 128 1217 1218 INDEX. Actinomycosis, organism of, 127 prognosis, 129 pus in, 129 of skin, 376 of tongue, 857 treatment, 129 Acupressure, 260 Acute intoxications, 202 Adenitis following gonorrhoeal infection, 176 Adenoma, 344 Adhesions of intestines, causing obstruction, 886 Aeroceles, 767 Ainhnm, 85, 86 Air-embolism, 33 Air in wounds of neck, 785 germs in, 292 Air-passages, burns of, 732 foreign bodies in, 732 Alexander's operation, 1041 Allantoic cysts, 311 Allen surgical pump, 211, 212 Allingbam's operation for hemorrhoids, 954 Allis's inhaler, 238 method of reducing posterior dislocation of hip, 614 Alveolar abscess, 862 Amazon thorax, 1061 Ambulatory treatment of fracture of leg, 595 of thigh, 595 of hip-disease, 1146 " American operation " for haemorrhoids, 953 Ammoniosemiti, 401 Amoeba coli in hepatic abscess, 923 in pus, 61 Ampullitis, 175 treatment, 180 Amputation, 1079 classification, 1079 arm, 1091 elbow, 1090 fingers, 1087 foot, 1094 forearm, 1090 hand, 1089 hip-joint, 1103 interscapulo-thoracic, 1093 knee, 1100 leg, 1097 shoulder, 1091 thigh, 1102 toes, 1094 in compound fractures, 1080 Credo's method of dressing and approxi- mation, 1083 in doubtful cases, 1080 drainage in, 1082, 1083 dressings of stump in, 1083 general considerations of, 1079 instruments required for, 1081 local indications for, 1080 lower extremity, foot, 1094 artificial limb, 1094, 1095 atypical conservative operation, "1097 Amputation, lower extremity, medio-tarsal (Chopart's), 1096 partial, 1095 metatarsal, 1095 subastragaloid disarticulation,1096 tarso-metatarsal (Lisfranc's), 1095 tibio-tarsal ( Lyme's), 1096 modification ( Pirogoff's, 1097 hip-joint, disarticulation, 1103 nap-formation, 1105 hsemostasis, 1104 Wyeth's method, 1105 knee, disarticulation, 1100 methods, 1101 Stephen Smith's "hooded" flap, 1101 . leg, 1097 methods, 1098 Brim's, 1100 point of election, 1099 supramalleolar (Guyon's), 1098' thigh, 1102 shaft and upper portion, 1102 methods, 1103 Neudorfer's, 1103 through condyles, 1102 methods, 1102 Garden's transcondyloid, 1102 (iritti's osteoplastic, 1102 toe, 1094 big, 1094 disarticulation of, at metatarso- phalangeal joint, 1094 with corresponding metatarsal, 1094 methods of, 1083 elliptical, 1086 flap, 1086 manner of cutting, 1086 oral or racket, 1086 selection of, 1084 subperiosteal excision, 1087 Teale's, 1087 transverse circular, 1085 skin-cuff circular (a la mancliette) 1085 solid musculo-tegumentary 1085 stump after bad, 1106 good, 1106 care of, during healing, 1107 interval before application of artificial limb, 1107 of upper extremity, arm, 1091 elbow, disarticulation of, 1090 fingers, 1087 corresponding metacarpals, 1088 entire, 1088 two or more joining simultaneous- ly, 1088 forearm, 1090 hand, radio-carpal disarticulation, 1089 interscapulo-thoracic, 1093 shoulder, disarticulation, 1091 Anaesthesia and anaesthetics, 230 accidents from, 240 arrested respiration, 240 INDEX. 1219 Anaesthesia and anesthetics, accidents from, arrested respiration, treatment, 240, 241 Howard's method, 221, 241 Kelly's method, 241 Sylvester's method, 220, 241 cardiac failure, 241 treatment, 241 A. C. E. mixture, 236 administration inhalers, 238 with oxygen, 238 chloroform, 234 accidents during administration, 235 death from, 235 physiological action of, 235 choice of an, 236 contraindications for chloroform, 237 for ether, 237 death-rate from, 232, 233 discovery of, 230 ether, 232 accidents from, 233 action of, 232, 233 sequel* from administration, 233 ethyl bromide, 235 manner of administration, 236 examination of patient before administra- tion, 231 local anaesthesia, 243 chemicals used for, 243 Schleich's method, 244 nitrous-oxide gas, 236 administration of, 236 contraindication for use, 236 relative safety of, 231 Anastomosis of cranial bones, 623 of intestine, 901 technique of, 901 Anel's method in treating aneurism, 452 Aneurism by anastomosis, 449 , aorta, abdominal, 460 arterio-venous, 447 intracranial, 646 axillary, 458 bruit in, 450 cirsoid, 333, 448, 462 classification of, 439, 443 clinical phenomena of, 440 of common carotid, 459 diagnosis, 449 diffused, 445 dissecting, 446 etiology, 441 external carotid, 459 false, 445 of gastroepiploic artery, 461 of hepatic artery, 461 hernial, 445 inguinal, 461 innominate, 457, 458 treatment, 458 internal carotid, 459 iliac artery, 462 intracranial, 459 intraorbital, 460 of mesenteric artery, 461 pressure-effects of, 449 Aneurism, pressure-effects of, on artery, 450 pulsation in, 450 recurrent, following operation, 453 results of, 440 rupture of, 451 sac, suppuration of, 453 saccular, 443 sac in, 444 special, 456 spontaneous cure of, 440 symptomatology in, 449 tabular, 446 thoracic, 456 symptoms, 456 treatment, 457 traumatic, 259, 446 circumscribed, 446 diffuse, 447 treatment, by acupuncture, 445 by compression, 454 instrumental, 454 by flexion, 455 by galvano-punctiire, 455 by injections, 455 by introduction of foreign bodies, 455 manipulation of, 455 operative, Anel's method, 452 Antyllus's method, 452 Brasdor's operation, 452 extirpation, 453 Hunter's method, 452 ligation, 453 Wardrop's operation, 452 varieties, 429, 443 varix, 44S of vertebral artery, 460 Angeioma, 333, 449 cavernosum, 333 Ankle, excision, 509 Ankle-joint disease, treatment, 1153 Ankylo-blepharon, 1179 treatment, 1179 Ankylo-cheilia, 774 Ankylosis, 495 contracture or false, 495 diagnosis, 496 of jaws, 864 true or bony, 496 treatment, 497 operative, 499 Anthrax, 124 definition, 124 incubation, 125 postmortem appearance in, 125 prognosis, 126 symptoms, 125 treatment, 126 Antisepsis in accidental operative wounds of bladder, 296 of intestines, 295 of pericardium, 296 of peritoneum, 296 of pleura, 296 of rectum, 295 of stomach, 296 of vagina, 295 in compound fractures, 555 1220 INDEX. Antisepsis, definition, 293 Antiseptic surgery, 296 drainage in, 297 indications for, 297 manner of obtaining it, 297 materials used for, 298 object of, 296, 297 Antiseptics, toxaemia from use of, 230 urinary, 987 Antrum of Highmore, empyema of, 863 tooth in, 226 Antyllian method for treatment of aneurism, 452 Anns, artificial, 895 chancre of, 964 chancroid of, 963 fissure of, 962 imperforate, 952 mucous patches of, 964 Aorta, abdominal, aneurism of, 460 ligation of, 722 aneurism of, 456 symptoms, 456 treatment, 457 Aplasia cranii, 623 Apoplexia neonatorum, 646 Appendectomy, 907 indications for, 907 McBurney's method, 907 Appendicitis, acute, 902 course, 903 diagnosis, 904 etiology, 902 pathology, 902 prognosis, 903 symptoms, 904 time for operation in, 905 treatment, medical, 905, 906 surgical, 905 technique of, 905 catarrhal, 906 causing acute obstruction, 890 chronic, 906 symptoms, 906 treatment, 907 relapsing, 906 Appendix, vermiform, diseases of, 902 inflammation of, acute, 902-906 treatment, 904, 905 chronic, 906 treatment, 907 inflammatory adhesions about, 905 removal of indications for, in period of health, 907 operation for (McBurney's), 907 Aprosopia, 764 Archepvon in tuberculosis, 488 Arlt's operation for blepliuroplasty, 1172 Arm, amputation of, 1091 forearm, amputation of, 1090 Arrow wounds, poisoned, 200 Arterial vari.v, 448 Arteries, aneurism of, 439 atheroma of, 437 diffused, 438 localized, 437 atrophy of, 433 Arteries, calcification of, 437 carotid, intracranial, injury of, 646 wounds of, 800 emboli in, 443 fatty degeneration of, 437 inflammation of, 435 acute, 436 syphilitic, 436 tuberculous, 437 injury to, 258, 259 intercostal, wounds of, 814 internal mammary, wounds of, 815 treatment, 815 ligation of, 711 abdominal aorta, 723 axillary, 718 brachial, in middle of arm, 719 common carotid, 713 iliac, 724 external carotid, 713 iliac, 724 facial, 714 femoral, 724 common, 724 in Hunter's canal, 726 superficial, at apex of Scarpa's tri- angle, 725 inferior thyroid, 715, 716 innominate, 712 internal carotid, 715 iliac, 723 lingual, at its first part, 714 occipital, 715 radial, 719 subclavian, 716 temporal, 715 tibial, anterior, 727 posterior, 726 behind malleolus, 727 ulnar, 721, 722 vertebral, 715 malformations and malpositions of, 433 middle meningeal, hemorrhage from, 646 subclavian, wounds of, 802, 803 surgical injuries and diseases of, 433 technique in ligation of, 711, 712 thrombi in, 433 changes in, 434 obstructive, 434 parietal, 433 thrombosis of, 433 vertebral, aneurism of, 804 Arterio-sclerosis (atheroma), 437 Arteriotomy, 210 Arteritis, 435 Arthrectomy, 500 for tuberculosis, 495 Arthritis, acute suppurative, 471 arthropathic, 489 deformans, 478 following burns, 380 tubercular, 486 Arthrodesis, 501 of ankle-joint in paralysis, 1143 Arthropathic arthritis, 489 Arthrotomy for tuberculosis, 495 Artificial anus, 895 INDEX. 1221 Artificial legs, importance of stump in, 1095 limbs, application to stump, 1107 respiration, 220 methods of, 220, 221 Asepsis, definition, 293 sterilization, 293 of field of operation, 295 by formalin (formaldehyde), 293 by heat, 293 mechanical, 291 Aseptic blood-clot in treatment of disease of bone, 531 fever in wounds, 258 solution, 300 surgery, 293 wound fever, 97 Aspiration, 212 Astomia, 773 Astragalus, dislocation of, 618 Atelo-prosopia, 764 Atheroma, 437 causes, 437, 438 cyst, 358 treatment, 439 Atheromatous abscess, 438 ulcer, 438 Atresia of pylorus, 879 of urethra, 971 Atrophic cancer of Billroth, 1072, 1073 elongation of bones, 537 Atrophy, classification, 27 of cranial bones, 623 definition, 26 following acute infectious processes in bones, 519 and hypertrophy, difference between, 26 pathological, 27 as a result of continuous pressure, 27 trophoneurotic, 27 physiological, 27 Auditory canal, exostoses of, 1204 foreign bodies in, 1203 treatment, 1203 granulomata of, 1204 inflammations of, 1204 Auricle, congenital deviation of, 1200 fracture of, 1200 malformations of, 1200 treatment, 1200 othsematoma of, 1201 surgery of, 1200 tumors of, 1201 epithelioma, 1201 wounds of, 1201 Auto-infection, 91 Auto-intoxication, 91 cause, 91 ferments in, 91 intestinal putrefaction, 93 treatment, general, 95 by purgatives, 94 by urea, 94 by venesection, 92 urea in, 92 value of venesection in, 92 Autoplasty, 1134 Avicenna's method of reducing dislocation of shoulder, 606 Axillary artery, aneurism of, 458 ligation of, 718 BACILLUS anthracis, 59 of bubonic plague, 60 coli communis, 58 in appendicitis, 903 diphtheria 1 , 59 of glanders, 122 lepra", 59 of malignant oedema, 59 mallei, 59 oedematis maligni, 59 pneumoniae Fried lander, 59 proteus, 58 pyocyaneus, 58 antagonizing anthrax poison, 126 of Kauschbrand, 60 of rhinoscleroma, 60 of tetanus, 115 of tuberculosis, 59 in bone, 520 el seq. as a pyogenic organism, 60 typhi abdnminalis, 58 Bacteria of mouth, 849 causing dental caries, 861 of pus-formation, 55 classification of, 55 facultative pyogenic, 55, 58 obligate pyogenic, 56 bacillus coli communis, 58 pyocyaneus, 58 colon bacillus, 58 diplococcus pneumonia?, 57 gonococcus, 58 micrococcus lanceolatus, 57 tetragonus, 58 staphylococcus pyogenes albus, 56 aureus, 56 citrens, 56 '•'.-_. streptococcus erysipelatis, 56 pyogenes, 56 in strangulated hernia, 932 Bacterial determination as an indication in treatment, 61 Bacteriology of peritonitis, 910 Balanitis, 174 treatment, 179 Bandages, 228 Bandaging, 226 kinds, 227, 228 materials used, 226, 227 Banti's disease, 922 Barbados leg, 418 Barton's bandage, 229 Basedow's disense, 795 Base-line of skull in cranial topography, 668 Bassini's method of radical cure of inguinal hernia in male, 945 Bell's palsy, 76f intestine, 895 Stensen's duct, fistula of, 782 inflammation of, 782 wounds of, 781 Stercorsemia, 94 Sterility, 1021 treatment, 1021 Sterilization, 293 of accessory apparatus and instruments, 299 of catheters, 298 by chemical germicides, 300 of dressings, 299 by germicidal solutions, 300 corrosive sublimate, 301 of instruments, 298 of ligature and suture material, 300 of sponges, 300 Sterno-iuastoid, hsematoma of, 387 Sternum, dislocation of, 600 Sternum, fracture of, 563 Stimson's treatment for dislocation of clavi- cle, 601 Stomach, congenital malformation of, 876 fistula? of, 878 foreign bodies in, 879 gastrotomy for, 880 operations on, 880 for adhesions, 884 gastro anastomosis, 885 gastroenterostomy, 884 gastrorrhaphy, 884 gastrostomy, 880 gastrotomy, 880 pylorectomy, 883 and gastroenterostomy, 884 pyloroplasty, 882 rupture of, 873 stricture of pylorus, 879 treatment, 879 surgery of, S76 tumors of, 876 cancer, 878 differential diagnosis from ulcers, 878 treatment, 879 ulcer of, 876 treatment, 876, 877 Stomatitis, 853 catarrhalis, 853 ulcerosa, 853 Stone in bladder, 995 conditions which favor, 996 treatment, 996 choice of methods, 997 litholapaxy, 997 lithotomy, 997 in kidney, 1004 treatment, 1005 Strabismus, 1198 Strangulation of gut through foramen of Winslow, 886 Streptococcus erysipelatus, 56 pyogenes, 56 Stricture of oesophagus, 845 treatment, 846 of pylorus, 879 treatment, 879, 880 rectal, 964 urethral, 982 effects on urethra, 983 impermeable, 985 treatment, 986 location of, 982 organic, 982 spasmodic, 982 treatment, 984 by gradual dilatation, 984 by perineal section, 985 by urethrotomy, 984, 985 Strumitis, 796 Stye, 1167 Styptics, 209 Subclavian artery, ligation of, 716 Subcutaneous injuries, 257 Subdural hemorrhage, 646 Subluxation of jaw, 864 Subperiosteal excision of members, 1087 1252 INDEX. Subphrenic abscess, 819, 878 following rupture of stomach, 873 treatment, 821 Suppuration, 61 in abdomen, treatment, 66, 67 cause, 62 phagocytes in, 62 Supracondyloid fracture of femur, 583 of humerus, 569 Supramental triangle of Macewen, 657 Supra-orbital nerve, operations on, 703 Suprapubic aspiration for retention of urine, 991 cystotomy, 1018 Surgical anatomy of skull, 627 diagnosis, 245 external examination, 245 abdomen, 249 breast, 248 chest, 248 elbow-joint, 247 eye, 245 genito-urinarv tract, 251 kidney, 251 penis, 251 scrotum, 252 testicles, 252 groin, 252 head and face, 245 inguinal region, 251 lower extremity, 252 neck, 246 perineum, 252 spine, 251 upper extremity, 247 diseases of skin, 356 fevers, the, 97 cause, 97 differential diagnosis from poisoning by drugs, 97 symptoms, 97 synonyms, 97 terminations, 98 treatment, 98 kidney, 1001 methods, 207 pathology of blood, 29 sequel* of diseases, 192 cholera, 193 dental caries, 196 diphtheria, 195 dysentery, 192 endocarditis, 195 gonorrhoea, 196 influenza, 193 measles, 193 mumps, 195 pneumonia, 193 puerperal state, the, 197 scarlatina, 193 syphilis, 196 typhoid, 194 variola, 195 Sutures, classification of, 303 of intestine, 896 methods, 896 of application, 216 Sutures, methods, continuous, 216 Cushing's, 897 Czernv-Lerobert, 217, 897 Halsted's, 897 interrupted, 217 Lembert, 897 Murphy button, 897 quill or plate, 217 secondary, 217 removal of, 217 Senn's plates, 897 sterilization, 300 Sylvester's method of artificial respiration, 220 Sylvian fissure, topography of, 667 Symblepharon, 1177 treatment, 1179 Syme's amputation of foot, 1096 Syndactylism, 385 treatment, 386 Synovial tuberculosis, 489 Synovitis, 469 chronic, 476 dry, 471 gouty, 474 post-gonon hoeal, 474 purulent, 470 simple, 470 treatment, 474 urethral, 474 Syphilis, 145 ansemia in, 147 blood-vessels in, 146, 163 of bone, 525 treatment, 525 of breast, 1066 chancre, 149 complications of, 151 diagnosis, 152 differential, 152 extragenital, 152 Hunterian, 151 incubation of, 1 49 induration of, 150 pathological anatomy of, 152 phagedenic ulceration of, 151, 153 prognosis, 153 treatment, 153 varieties, 150 congenital, 166 prognosis, 166 symptoms, 166 treatment, 170 constitutional, 154 diagnosis, 154 effect of, on wounds, 156 fever in, 155 incubation of, 154 pain in, 155 definition, 145 duration, 156, 161 early eruptions in, 146 eruptions in, 156 etiology, 146 experimental inoculation in, 148 gumma in, 146, 161, 163, 164 in bones, 162 1XDEX. 1253 Syphilis, gumma in, histology, 163, 164 in skin, 161, 162 hereditary, 165 infection from blood, 148 ovum, 148, 165 secretions, 148 initial lesion of, 149 inoculation in, 146 insontium, 149 iodide of potassium in, 168 lymph-vessels and nodes in, 152, 155 mediate contact in, 149 mercury in, 168 mixed sore in, 151 mode of infection, 148 mucous patches in, 164 of muscles, 390 of palate, 852 pathological anatomy of syphilitic in- flammation, 163 predisposing causes of, 147 primary, 146 Profeta's law in, 166 secondary, 145, 154 of skin, 156, 162 stages of, 145 suppuration of, 147 tertiary, 160 gummatous syphilide in, 161 syphilides in, 156 of tongue, 857 affections in, 164, 165 transmission of, 165 treatment, 167 by baths, 169 by hypodermic administration, 169 by inunction, 169 Syringomyelia, 675 Szymanowsky's method of repair of lance- olated defects, 1164 TAENIA ECHINOCOCCUS, 315 T-bandage, 228 Tagliacozzian method of rhinoplasty, 773 Tailor's ankle, 403 Tait's operation for complete laceration of perineum, 1036 for incomplete laceration of perineum, 1032 Talipes equino-varus, congenital, 1128 pathology, 1128 treatment, 1129 equinus, 1140 treatment, 1141 valgus, 1143 varus, 1141 calcaneus, 1141 treatment, 1142 Taxis, 942, 943 Taylor club-foot shoe, 1130 Teeth, caries of, 861 treatment, 861 eruption of, faulty, 861 extraction of, 224, 862 accidents from, 225 instruments required, 225 methods of, 225 Teeth, gum, disturbance of, in operation for cleft-palate, 869 and jaws, abscess of, 862 diseases of, 861 inflammation about, 862 malformation of, congenital, 860 surgical diseases of, 861 tumor of, odontoma, 861 wiring of, in fractures of jaw, 560 Telangeiectasis of skin, 363 treatment, 363 by chemicals, 363 by electricity, 364 by knife, 364 Temporal artery, ligation of, 715 Temporo-sphenoidal abscess, 650 treatment, 658 Tendons, 385 and tendon-sheaths, 395 contraction of, in fingers, 394 in toe, 394 -grafting, 1142 inflammation of, 395 injuries of, 262 symptoms, 263 treatment, 263 lengthening of, 405 regeneration of, 288 -sheaths, anatomical arrangement of, in hand, 399 regeneration of, 288 tuberculosis of, 140 teno-synovitis, 395 chronic, 395 treatment, 396 transplantation of, 405 Tenotomes, 405 Tenotomy, 404 method of performing, 404 Terato'mata, 320 Tertiary syphilis, 160 Testes, gunshot wounds of, 283 Testicle, congenital malformations of, 973 misplacement of, 973 danger of malignant disease of, 974 diseases of, 1012 cystic, 1012 epididymitis, 1013 treatment, 1013 orchitis, 1013 treatment, 1013 syphilis of, 1012 tuberculosis of, 140, 1012 treatment, 1012 tumors of, 1013 Tetanus, 114 cephalicus, 116 chronic, 118 death in, 118 definition of, 114 diagnosis, 118 from hysteria, 118 etiology, 115 incubation in, 116 of new-born, 114, 116 organism of, 115 parasitic nature of, 115 1254 INDEX. Tetanus, post-mortem appearances in. 118 prognosis in, 118 in races, 114 symptoms, 116 toxalbumins of, 116 toy-pistol, 115 treatment, 118 constitutional, 119 local, 119 specific, 119 Thecitis, 395 "The rose," 108 Thiersch's method of skin-grafting, 224, 1155 Thigh, amputation of, 1102 condylar, 1102 Garden's transcondylar, 1102. Gritti's osteoplastic, 1102 amputation of shaft and upper portion, 1102 bilateral solid flap, 1103 circular, 1103 ISeudorfer's method, 1103 fracture of, 579 Thomas's splint, 1147, 1151 Thoracentesis, 825, 827 Thoracic duct, tumors of, 836 wounds of, 803, 816 Thoracoplasty, 830 Thoracotomy, 828 for empyema, 830 point of election for; 829 technique of, 829 Thorax, actinomycosis of, 834 gummata of, 833 gunshot wounds of, 279 hemothorax, 828 hydrothorax, acute, 825 thoracentesis in, 825 thoracoplasty, 830 thoracotomy, 828 tuberculosis of, 833 tumors of, 831 carcinoma, 834 chondroma, 833 fibroma, 833 lipoma, 832 neuroma, 833 osteoma, 833 sarcoma, 833 treatment, when involving external surface, 834 wall of, diseases of, 817 Thrombi, metamorphosis of, 31 Thrombo-arteritis, 104 Thrombophlebitis, 33 treatment, 33 Thrombosis, 31 of arteries, 433 and embolism of mesentery, 916 Thumb, excision of, 505 Thyro-hyoid duct, 319 Thyroid artery, inferior, ligation of, 715 body, goitre of, 794 malformation of, acquired, 793 congenital, 793 myxcedema from removal of, 763 Thyroid body, surgery of, 793 tumor of, 794 duct, 319 Thyroiditis, 785 Thvroids, accessory, 318 Thyro-lingual duct, 319 Thyrotomy, 738 Tibia, fracture of, 591 of lower end, 594 of shaft, 592 treatment, 593 of upper end, 591 Tibial artery, ligation of anterior, 727 posterior, 726 behind malleolus. 727 nerve, operations on, 705 Tic douloureux, 766 Tissues, effect of modern bullets on, 264 regeneration of, 288 Toe-nail, ingrown, 223 causes, 223 treatment, 223 Toes, amputation of, 1094 with corresponding metatarsal, 1094 Tongue, actinomycosis of, 857 cysts of, retention, 858 treatment, 858 enlargement of (macroglossia), 857 epithelioma of, 858 treatment, 859 Billroth' s method, 860 excision, partial, 859 Kocher's method, 859 Langenbeck's method, 860 Regnoli's method, 860 S^dillot's method, 860 gumma of, 165 inflammation of, acute, 855 Ludwig's angina, 856 parenchymatous glossitis, 856 injuries of, acute, 855 malformations of, 855 ranula of, 858 rhythmical traction of, 243 syphilis of, 857 -tie, 855 tuberculosis of, 856 tumors of, benign, 857 Tonsillotomy, 753 Tonsils, foreign bodies in, 754 hypertrophy of, 753 treatment, 753 tumors of, 754 Torsion for hemorrhage, 208 Torticollis, 1108 acute, of the trapezius, 804 cause of, acquired, 1108 congenital, 1108 sequelae of, 1109 treatment, 1110 Tourniquets, 208 Toxalbumin of snakes, 198 Toxic antiseptics, 203 Toxicity of urine, 92, 93 in Bright's disease, 93 Trachea, burns of, 732 foreign bodies in, 732 IXDEX. 1255 Trachea, foreign bodies in, treatment, 733 rupture of, spontaneous, 791 subcutaneous, 791 surgery of, 731 tumors of, 745 wounds of, 731 Tracheal tugging in aneurism, 457 Tracheoceles, 787 Tracheotomy, 735 after-treatment of, 738 anaesthetics in, 736 contraindications for, 736 operation, manner of performing, 736 tube in, 735 Trachoma, 1175 Traction in reducing dislocation of shoulder, 605, 606 Transfusion of blood, 217 normal salt solution, '218 Trauma as a cause of tumors, 306 Traumatic fever, 97 insanity, surgical treatment, 665 mania, 203 Treatment of abscess of bone, 525 of brain, 657 of ischio-rectal fossa, 959 of liver, 923 of lung, 823 of neck, 785 of pancreas, 918 of rectum, ischio-rectal, 959 superior pelvi-rectal, 960 acne, 357 actinomycosis, 129 acute inflammation of breast, 1063 of vermiform appendix, 905 mastitis, 1063 obstruction of intestine, 891, 892 osteomyelitis, 516 suppurative pancreatitis, 918 adenoid growths of pharynx, 751 after-, of excisions of ankle, 510 of hip, 507 of knee, 509 ambulatory, of tuberculosis of hip, 1146 ampullitis, 180 aneurism, 452-455 Antyllian method, 452 of aorta, 457 of innominate artery, 458 ankle-joint disease, 1153 ankylo-blepharon, 1179 anthrax, 126 appendicitis, acute, 905, 906 chronic, 907 atheroma, 439 balanitis, 179 bites, 199, 200 bone abscess, 525 bony ankylosis, 497 bowel intussusception, 959 brain abscess, 657 bunions, 378 burns, 381 of larynx, 732 calculus in bladder, 996 in kidney, 1005 Treatment of cancer of prostate, 994 of stomach, 879 of uterus, 1051, 1052 carcinoma of breast, 1077 of intestines, 894 of uterus, 1051 caries, 527 of bone, 527 dental, 861 cataract, 1189 cephalalgia, 665 chancre, 153 chancroidal bubo, 1024 cholelithiasis, 928 chronic articular rheumatism, 478 gonorrhoea, 182 inflammation of breast, 1065 of vermiform appendix, 907 mastitis, 1065 teno-synovitis, 396 club-foot, 1129 club-hand, 1132 coccygeal dimple and sinus, 676 cold abscesses, 135 compound dislocation of joints, 467 compression of brain, 644 concussion of brain, 640 congenital dislocation of hip, 1123 hypospadias, 971 syphilis, 170 contused wounds, 304 contusion of brain, 641 corns, 222 cystitis, urinary, 995 cysts of pancreas, 919 dacyro-cystitis, 1182 deep gonorrhoeal urethritis, 179 delayed union, 556 Brainerd's method, 556 delirium tremens, 202 dental caries, 861 depressed fracture of skull, 634 dislocation of clavicle, 601 of joints, compound, 467 of shoulder-joint, 603, 604 of spine, 682 of spleen, 921 displacement of spleen, 921 dissection wounds, 113 diverticula of oesophagus, 841 Dupuytren's contraction, 393 ectopic pregnancy, 1060 elephantiasis, 417 of genitals, 418 emphysema of chest, 817 encephalitis, 657, 658 encephalocele, 660 enlargements of prostate, 991 entropion, 1171 epididymitis, 180, 1013 epistaxis, 758 epithelioma of lips, 854 of penis, 9S1 of tongue, 858 erysipelas, 111 extraperitoneal rupture of bladder, 977 extra-uterine pregnancy, 1060 1256 INDEX. Treatment of fat-embolism, 37 fecal fistula, 896 femoral hernia, Bassini's method, 950 fistula, 70 of rectum, 961 flat-foot, 1137 folliculitis, 179 foreign bodies in auditory canal, 1203 in larynx, 733 in oesophagus, 843 in trachea, 733 fracture of clavicle, 564 of depressed skull, 634 of humerus, lower end, 569 shaft, 568 upper extremity, 567 of inferior maxilla, 560 of larynx, 731 of nose, 558, 762, 772 of olecranon, 571 of patella, 589 of pelvis, 578 of radius, 573, 574 of ribs, 562 of scapula, 566 of shaft of ulna, 572 of skull, base, 638 vertex, 634 of spine, 680 of thigh, lower third, 584 middle third, 584 upper third, 584 of tibia, 593 frost-bites, 383 furuncle, 359 gall-stone, 927 gangrene, 88 of Inns, 825 gastric fistulse, S78 genu valgum, 1126 varum, 1125 glanders, 124 glaucoma, 1186 goitre, 795 gonorrhoea, 177 chronic, 182 granular conjunctivitis, 1176 gunshot wounds of abdominal viscera, 875 of bone, 273 of chest, penetrating, 812 of cranial bones, 275 of face, 277 of head, 275 of heart, 280 of joints, 274, 468 of neck, 277, 278 of spinal column, 278 of thorax, 279 hallux valgus, 1144 hemorrhoids, 953, 954 hernia of brain, 649 femoral, 950 incarcerated, 942 inflamed, 942 operative, 942 palliative, 942 strangulated, 942 Treatment of hernia, umbilical, 937 hip abscess, non-operative, 1150 disease, ambulatory, 1146 Hodgkin's disease, 424 hydatid cysts of liver, 923 hydrarthrosis, 477 hydrocele, 1016 hydrocephalus, 661 hydronephrosis, 1007 hydrophobia, 122 hydrothorax, 826 liyperaemia, 23 hypertrophy of prostate, 990 of tonsils, 753 hypodermic, of syphilis, 169 imbecility, 661 impermeable stricture of urethra, 986 impotence, 1021 incarcerated hernia, 942 infantile paralysis, 1143 inflamed hernia, 942 inflammation about kidney, 1011 of eyeball, 1189 of Fallopian tubes, 1058 of iris, 1185 of muscles, 390 of orbit, 1193 of pancreas, 918 of perimetrium, 1057 of peritoneum, 911, 912 tubercular, 913 of prostate, 9S8 of viscus, 995 of vulva, 1026 ingrown toe-nail, 223 injuries of muscles, 262 of nerves, 261 of tendons, 263 of urethra, with perforation, 976 without perforation, 976 innocent tumors of breast, 1076 insects in nose, 757 intercondyloid fracture of femur, 584 internal hemorrhoids, palliative, 953 radical, 953 intraperitoneal rupture of bladder, 977 intussusception, 888 of bowel, 959 invagination of rectum, 958 involuntary discharge of semen, 1022 ischio-rectal abscess, 959 joint-disease, mechanical, 1145 tuberculosis, Bier's, 143 kidney calculus, 1005 knee-joint disease, 1151 lacerated wounds, 304 laceration of cervix, 1043 complete, of perineum, 1036 incomplete, of perineum, 1030 lateral curvature of spine, 1115 leptomeningitis, 656 loose bodies in joints, 485, 486 lymphadenitis, 420, 421 lymphangitis, reticular, 411 malformations of auricle, 1200 malignant disease of oesophagus, 848 oedema, 127 ISDEX. 1257 Treatment of malignant tumors of scalp, 022 mastodynia, 1067 mechanical, of tuberculosis of hip, 1144, 1150 of joints, 492 medical, of acute inflammation of ver- miform appendix, 905 of inflammation of peritoneum, 911 meningocele, 660 mental and psychic disturbances follow- ing injuries of the head, 665 metacarpophalangeal dislocation, 610 metatarsalgia, 1145 movable and floating kidney, 1010 myo-fibromata of uterus, 1046 myositis, 390 neuralgia, 701 of breast, 1067 new-growths of omentum, 916 of spleen, 921 non-operative, of fracture of spine, 681 of tuberculosis of bone, 523 obstruction of intestines, 891 oedema, malignant, 127 operative, of enlargements of prostate, 992 of fracture of spine, 680 of hemorrhoids, 953 of hernia, 942 of obstruction of intestines, 892 of tuberculosis of bone, 523 of joints, 492-494 orchitis, 180, 1013 osteo-arthritis, 481 osteomalacia, 534 osteomyelitis, acute, 516 othsematoma of auricle, 1201 ovarian cysts, 1055 pachymeningitis, externa, 655 interna, 655 palliative, of hemorrhoids, 953 of hernia, 942 of obstruction of intestines, 892 pancreatic cysta, 919 panophthalmitis, 1189 paralytic deformities of feet and legs, 114:; paraphimosis, due to gonorrhoea, 179 penetrating gunshot wounds of abdomen, 2S1 of cranial bones, 276 wounds of joints, 467 perimetritis, 1057 perinephritis, 1011 periostitis, 518 peritonitis, 911, 912 tubercular, 913 peri-urethral inflammation, 179 pes planus, 1137 phimosis, 1017 due to gonorrhoea, 179 phlebitis, 427 post-gonorrhoeal arthritis, 180 Pott's disease of spine, 690 fracture, 595 prolapse of rectum, 956, 958 of uterus, 1040 prostatitis, 988 Treatment of pterygium of conjunctiva, 1177 ptosis, 1170 pulsating exophthalmia, 1195 punctured wounds, 304 purulent conjunctivitis, 1174 pus in Fallopian tubes, 1058 in kidney, 1003 pyaemia, 107 pyelitis, 1001 pyelo-nephritis, 1001 pyonephrosis, 1003 pyophylactic membrane, 494 pyosalpinx, 1058 radical, of internal hemorrhoids, 953 retention-cysts of tongue, 858 retention of urine in prostatic enlarge- ment, 990, 991 reticular lymphangitis, 411 retropharyngeal abscess, 748 rickets, 191 rupture of bladder, extraperitoneal, 977 intraperitoneal, 977 of diaphragm, 839 of intestines, 873 of sterno-mastoid, 801 salpingitis, 1058 sapramia, 100 sarcoma of bone, 543 scoliosis, 1115 scurvy, 189 sebaceous cysts, 358 septic infection of kidney, 1001 septicaemia 102 sequestrum formation, 531 shock, 186 snake-bite, 199 spasm of oesophagus, 845 spastic paralysis, 1141 spina bifida, 673, 674 sprains of joints, 464 sterility, 1021 stone in bladder, 996 in gall-bladder, 928 in kidney, 1005 strangulated hernia, 942 stricture of larynx, 735 of oesophagus, 846 of pylorus, 879, 880 of rectum, 964 of urethra, 484, 984 subcutaneous rupture of muscle, 388 subphrenic abscess, 821 superior pelvi-rectal abscess, 960 suppurative inflammation of pancreas, 918 supracondyloid fracture of neck of femur, 584 surgical, of acute inflammation of vermi- form appendix, 905 fevers, 98 of imbecility, 661 of inflammation of peritoneum, 912 for psychoses, 665 symblepharon, 1179 sympathetic ophthalmia, 1188 syndactylism, 386 svnovitis, 474 1258 INDEX. Treatment of syphilis, 167 of bone, 525 of breast, 1066 hypodermic, 169 talipes equino-varus, 1129 equinus, 1141 varus, 1142 telangiectasis of skin, 363 temporo-sphenoidal abscess, 658 tetanus, 118 thoracic aneurism, 457 thrombo-plilebitis, 33 torticollis, 1110 toxic necrosis of bone, 529 true ankylosis, 497 tubercular arthritis, 492 infection of kidney, 1003 inflammation of peritoneum, 913 tuberculosis of bones, 523 of breast, 1066 constitutional, 143 of joints, 474, 492, 497 of prostate, 993 of skin, 373 of testicle, 1012 tumors, 309 angeioma, 334 of bladder, 1000 carcinoma, 354 chondroma, 329 epithelioma, 342, 343 of kidney, 1009 of larynx, 744 lymphangeioma, 336 of mediastinum, 835 of pancreas, 920 papilloma, 340 sarcoma, 355 of scalp, malignant, 622 of spleen, 921 typhoid ulcer, causing perforation, 915 ulceration of rectum, 964 ulcers, 79, 80 of stomach, 876, 877 umbilical hernia, 937 union of wounds, 302 urethritis, deep, 179 urinary fever, 987 uterine fibroids, electrolysis in, 1046 varicocele, 1015 varicose veins, Landreth's method, 431 venous naevus, 432 vesiculitis, 180 volvulus, 890 wounds, 301 of abdominal viscera, 875 of bladder, 283 contused, 304 and injuries of heart and pericardium, 707 of internal mammary artery, 815 lacerated, 304 punctured, 304 Trephining, 668 technique of, 668 Trichiasis, 1172 Trichina spiralis, 404 Trichinosis, 404 Trigger-finger, 394 Trismus, 114 Trophoneurotic diseases of bones, 532 Trusses for hernia, 942 contraindications for use, 942 Tubal pregnancy, 1158 Tubercular arthritis, 486 arthropathic, 486 constitutional complications of, 492 diagnosis, 492 osteopathic, 486 pathological anatomy of, 486 repair in, 490 symptoms, 490 treatment, 492 peritonitis, 913 ulceration of rectum, 963 Tuberculin, 144 dose, 144 manner of preparation, 144 Tuberculosis, 130 of ankle, mechanical treatment, 1153 of bladder, 141. 1000 of bones, 138, 139, 520 abscess of, 525 acute miliary, 521 chronic, 522 pathology, 521 symptoms, 522 treatment, 523 non-operative, 523 operative, 524 • varieties, 521 of breast, 1065 treatment, 1066 bursas, 140 of chest-wan, 833 cold abscesses in, 133 diagnosis, 134 lumbar, 135 psoas, 135 retropharyngeal, 135 treatment, 135 cutis, 372 degenerative changes in, 132 diagnosis, 142 differential, 142 from epithelioma, 354 of elbow, mechanical treatment of, 1140 of epididymis, 1012 fungous granulation in, 136 of genito-urinarv tract, 979 avenues of infection, 979 sites and paths of infection, 979 giant-cells in, 130 gummata in, 135 * of hip, ambulatory treatment, 1146 mechanical treatment, 1144, 1150 of kidneys, 141, 1003 lupus, 137 of lymphatic structures, 137 of mesentery, 916 method of healing, 132 absorption, 132 calcification, 132 caseation, 132 INDEX. 1259 Tuberculosis, method of healing, encapsula- tion, 132 suppuration, 133 archepyon in, 134 cold abscesses in, 133 danger of prophylactic membrane. 134 treatment of prophylactic mem- brane, 134 miliary tubercle in, 131 of mucous membrane, 136 of omentum, 915 of ovary, 140 paths of infection in, 142 respiratory tract, 142 of peritoneum, 913 of prostate and appendages, 993 of skin, 136, 371 etiology of, 371 lupus vulgaris, 371 scrofuloderma, 373 treatment of, 373 tuberculosis cutis, 372 verrucosa, 373 of spine, 684 of tendon-sheath, 140 of testicle, 140 of tongue, 856 treatment, 143 constitutional, 143 tuberculin in, 144 value, 144 local, 143 amputation in, 144 Bier's permanent hyperemia, 143 excision in, 144 ignipuncture in, 144 iodoform injections # in, 143 sclerogenic treatment of Lanne- longue, 143 of ureter, 141 Tuberosities of the humerus, fracture of, 566 Tubes, Fallopian, inflammation of, 1057 treatment, 1058 Tubo-abdominal pregnancy, 1059 Tubo-uterine pregnancy, 1059 Tumors, 305 adeno-carcinoma, 345 \ adenoma, 344 \ seats, 344, 346 \ of sebaceous glands, 345, 346 of auricle, 1251 angeioma, 333 arterial, 334 treatment, 334 "cavernous, 333 nsevus, 333 , of bladder, 999 of bone, 540 of breast, 1068 carcinoma, 347 acinous, 348 characteristics of, 347 classification of, 348 colloid, 348 duct, 349 Tumors, carcinoma, lymph-node infection in, 349 metastasis in, 347, 349 microscopical appearance, 347 pain in, 349 seats of, 349, 351 treatment, general, 354 inoculation methods, 455 serum-therapy, 405 chondroma, 327 treatment, 329 classification of, 309, 310 of complex mesoblastic type 333 of conjunctiva, 1178 definition of, 305 dermoids, 316 classification of, 317 implantation of, 317 ovarian, 320 sequestration, 317 tubulo-dermoid, 318 of diaphragm, 839 endothelioma, 352 clinical characteristics of, 353 microscopical appearances of, 348 of epiblastic origin, 336 classification of, 336 epithelioma, 340 lymph-nodes in, 341 microscopical appearance, 341 seats, 342, 343 synonyms, 342 treatment, 342, 343 epulis, 327 of eyelids, 1168 of face, 768 fibroma, 326 of glandular tissue type, 344 glioma, 325 of the immature connective-tissue type, 321 of intestine, 893 intracranial, 665 operation for, 666 control of hemorrhage in, 667 intraocular, 1190 of choroid, 1 190 of ciliary body, 1190 of iris, 1190 of retina, 1191 of jaw, 864 of keloid, 327 of kidney, 1008 of lachrymal gland, 1180 of larynx, 743 lipoma, 325 of lung, 836 lymphangeioma, 334 cavernous, 335 cysts, 335 nsevus, 334 treatment, 338 of mediastinum, 835 myxoma, 331 classification of, 331, 332 of nasal cavities, 755 nasopharyngeal, 752 1260 INDEX. Tumors, nature and origin of, 306 of neck, 787, 792 of nerves, 705 neuroma, 336 classification of, 337 nomenclature of, 308 odontoma, 330 classification of, 330 of oesophagus, 847 of omentum, 915 of optic nerve, 1197 of orbit, 1195 osteoma, 329 classification of, 330 exostoses, 330 of pancreas, 920 papilloma, 337 classification of, 338 cutaneous horns, 339, 340 treatment, 340 intracystic villous growths, 339 psammomata, 339 villous, 338, 339 warts, 338 of parotid gland, 798 of prostate, 993 of rectum, 955 sacro-coccygeal, 699 of sacrum, congenital, 699 sarcoma, 321 classification of, 321 alveolar, 323 lympho-, 321 melano-, 323 myeloid or giant-cell, 321 round-cell, 321 spindle-cell, 322 general characteristics of, 324 metastasis in, 324 secondary changes in, 324 treatment, inoculation-method, 355 of scalp, 622 gaseous, 621 of simple mesoblastic tissue type, 325 of spinal cord, 699 of spine, 699 of spleen, 921 treatment, 921 of stomach, 878 of teeth, 861 teratomata, 320 theories as to origin, 306 of thorax, 831 of thyroid body, 794 of tongue, 856 of tonsils, 754 treatment, 309 of vulva, 1027 Tympanum, acute inflammation of the, 1207 granulation tissue, inflammation of, 1207 polypi of, 1207 treatment, 1207 Typhoid, secondary infection in, 194 ulcer, causing perforation, 914 symptoms, 914 treatment, 915 ULCEE and ulceration, 72 atheromatous, 437 callous, 75 causes, 72 constitutional, 74 local, 72 traumatic, 72 definition, 72 discharge from, 75 erethistic, 74 fungous, 74 healthy, 74 hemorrhagic, 74 indolent, 74 perforating, of foot, 73 phagedenic, 74 of rectum, 74, 962 in secondary syphilis, 964 sloughing, of stomach, 876 treatment, 876, 877 treatment, 79, 80 by continuous immersion, 80 specific, 81 tubercular, in peritonitis, 913 typhoid, perforation of, 914 symptoms, 914 treatment, 915 varicose, treatment, 430 Ulna, dislocation of, 607 fracture of, 570 coronoid process, 571 olecranon, 571 treatment, 571 shaft, 572 treatment, 572 Ulnar artery, ligation of, 721 nerve, operations on, 705 Umbilical hernia, 937 radical cure of, 951 Unreduced dislocations, pathology of, 598 Uranoplasty, 852, 866 after-treatment, 852 Brophy's method, 866 Urea in auto-intoxication, 93 medicinal use of, 94 Ureter, congenilal malformations of, 973 tuberculosis of, 141 valve-like obstruction of, 973 Ureteritis, due to gonorrhoeal infection, 176 Urethra, congenital malformations of, 970 absence of, 970 atresia of, 971 epispadias, 972 hypospadias, 971 treatment, 971 pouches, 971 diseases of, 981 chancres, 982 polypi, 982 strictures, 982 diagnosis, 984 divulsion, 986 effect of, on urethra, 983 impermeable, 985 treatment, 986 INDEX. 1261 Urethra, diseases of, strictures, organic, 982 calibre of, 982 location of, 982 spasmodic, 982 symptoms, 983 traumatic, 982, 983 treatment, 484-486 after-, 985 gradual dilatation, 984 urethrotomy, external, 985 internal, 984 ulcers of, 980 urethral fever following instrumenta- tion, 985, injuries of, 974 with perforation, 976 treatment, 976 without perforation, 975 treatment, 976 remote results from, 976 Urethral or urinary fever, 220, 986 synovitis, 474 Urethritis, deep gonorrhoea!, 175 treatment, 179 non-specific, 172, 173 Urethrometer, 181, 984 Urethroscope, 181 Urethrotome, 182 Urethrotomy, external, 1017 dangers of, 984 internal, dangers of, 984 Urinary antiseptics, 987 fever, 986 treatment, 987 infiltration following fracture of pelvis, 578 Urine, collection of, from each kidnev sepa- rately, 1009 danger of extravasation of, 975 retention of, in prostatic enlargement, 990, 991 treatment, 992 Urine, toxicity of, 93 Uro-genital tract, infections of, 979 Uterus, 1038 cancer of, 1051 treatment, palliative, 1051 radical (hysterectomy), 1052 myo-fibromata of, 1044 secondary changes in, 1044 treatment curative, 1046 abdominal hysterectomy, 1048 castration, 1050 myomectomy, 1048 for pedunculated fibroma, 1046 for submucous fibroma, 1047 vaginal hysterectomy, 1047 palliative, 1046 prolapse of, 1038 treatment, 1040 Alexander's operation, 1041 colporrhaphy, 1041 perineorrhaohy, 1040 ventro-fixation, 1042 surgery of, 1038 Uvula, malformations of, 747 VAN BUEEN'S operation for rectal pro- lapse, 956 Varices, 428 Varicocele, 1014 treatment, 1015 amputation of scrotum, 1015 open ligation and excision, 1015 subcutaneous ligation of veins, 1015 Varicose veins, 428 Variola, 195 secondary infection in, 196 Varix, aneurismal, 448 arterial, 448 Vas deferens, ligation of, for prostatic en- largement, 993 Vasectomy for prostatic enlargement, 993 Veins, 426 excision of, 432 hyperemia of, 426 inflammation of, 426 injury to, 260 jugular, inflammation of, 801 rupture of, 432 subclavian, wounds of, 802, 803 surgical injuries and diseases of, 426 varicose, of lower extremity, 125, 428 causes, 125, 428 symptoms, 429 treatment, 429 of upper extremity, 429 Velpeau's bandage, 226 Venereal ulcer, 1023 ulceration of rectum, 963 warts, 981 Venesection, 210 Venous na;vus, 431 cause, 432 seats, 432 treatment, 432 Ventral hernia, 939 radical cure of, 951 Ventro-fixation, 1042 Vermiform appendix, disease of, 902 hernia of, 941 inflammation of, acute, 902 treatment, medical, 905 surgical, 905 chronic, 906 treatment, 907 removal of, indications for, in period of health, 907 Verruca, 361 acuminata, 361 digitata, 361 seborrhoea, 361 vulgaris, 361 Vertebral artery, aneurism of, 460 ligation of, 715 caries, 685 Vesicants, 213 Vesiculitis, treatment, 180 Vessels, injuries of, 258 arteries, 258 diagnosis, 259 symptoms, 259 treatment, 259 lymph-, injuries and diseases of, 407 1262 INDEX. Vessels, lymphatics, 260 veins, 260 Vicarious menstruation from breasts, 1061 Viscera, gunshot wounds of, 280 injury of, following blows upon abdominal wall, 872 Volvulus, 890 treatment, 890 Von Griife's coin-catcher, 844 Von Mosetig-Moorhof 's method of excision of elbow, 502 Vulva, abscess in glands of Bartholin, 1026 cysts of glands of Bartholin, 1027 inflammation about, 1026 symptoms, 1026 treatment, 1026 cedema of, 1026 surgery of, 1026 tumors of, 1027 WANDERING spleen, 921 Wardrop's operation for treatment of aneurism, 452 Warts, 338, 361 on penis, 981 Wax, in treatment of bone disease, 530 Webbed fingers, 385 Weber's method of repair of elliptical de- fects, 1164 Weeping sinew, 400 Wen, 345 Whitehead's mouth-gag, 850 operation for hemorrhoids, 953 White's operation for enlarged prostate, 992 Whitlow, 397 Wiring bone fragments in fracture of jaw, 561 fragments in compound fractures, 555 spine, 698 Witzel's method of gastrostomy, 881 Wladimirow and Mikulicz's osteoplastic ex- cision of foot, 510 Wolffian body, cysts of, 311 Wool-sorters' disease, 124 Worms, round, causing intestinal obstruc- tion, 888 Wound-infection in joints, 466 Wounds of bladder,' 282 prognosis, 283 symptoms, 283 treatment, 283 change of dressing in, 303 classification of, 301 conditions furthering infection, 292 constitutional effect of, 303 gunshot, 264 of abdomen, solid and hollow viscera, 280 non-penetrating, treatment, 280 penetrating and perforating, 280 diagnosis, 281 prognosis, 281 treatment, 281 after-, 282 by operation, 281 of cranial bones, 275 Wounds, gunshot, of cranial bones, diagnosis, .275 penetrating, 275 prognosis, 275 treatment, 276 treatment, 275 determination of location of balls, 269 effects of, on tissue, 264 exit and entrance in, 268 of face, 277 treatment, 277 fate of bullets in body, 268 of head, 274 treatment, 275 of heart, 280 diagnosis, 280 prognosis, 280 treatment, 280 missiles, 264 of neck, 277 prognosis, 277 treatment, 277, 278 prognosis in, 270 small shot wounds, 270 of spinal column, 278 prognosis, 278 symptoms, 278 treatment, 278 of thorax, 279 diagnosis, 279 prognosis, 279 treatment, 279 treatment of, general considerations, 271 of bones and joints, 272 of soft parts, 271 incised, 302 lacerated and contused, 303 treatment, 304 of penis, 282 punctured, 304 symptoms, 304 treatment, 304 treatment, 301 union of, 302 Wrist, dislocation of, 609 excision of, 503 fracture of, 576 Writers' cramp, 389 Wyeth's bloodless method of amputation at hip-joint, 1105 method for disarticulation of shoulder, 1092 XANTHELASMA, 1168 Xerosis conjunctiva 3 , 1178 Xiphoid cartilage, fracture of, 563 X-rays in gunshot wounds, 269 in surgery, 1212 YAWS, 767 Y-ligament, its influence on disloca- tions and their reduction, 612 ZYGOMATIC arch, fracture of, 559