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BY WILLIAM TOD HELMUTH, M.D., PROFESSOR OF SURGERY IN THE NEW YORK HOMOEOPATHIC MEDICAL COLLEGE: CONSULTING SURGEON TO THE LAURA FRANKLIN FREE HOSPITAL FOR CHILDREN ; SURGEON TO THE HOMOEoPATHIC HOSPITAL ON WARD's ISLAND ; LATE, TO THE HAHNEMANN HOSPITAL, TO THE NEW YORK COLLEGE AND HOSPITAL FOR WOMEN ; MEMBER OF THE AMERICAN INSTITUTE OF HOMOEoPATHY ; FELLOW OF THE NEW YORK MEDICO-CHIRTJRGICAL SOCIETY ; MEMBER OF THE NEW YORK STATE HOMOEOPATHIC MEDICAL SOCIETY, OF THE HOMOEOPATHIC MEDICAL SOCIETY OF THE COUNTY OF NEW YORK, AND HONORARY MEMBER OF THE SOCIÉTÉ MEDICALE HOMOEOPATHIQUE DIE FRANCE, OF THE HOMOEOPATHIC MEDICAL SOCIETIES OF MASSACHUSETTS, RHODE ISLAND AND CONNECTICUT, ETC. A/FZ H ED/7”/OM, EAVZARGED, RE-AA RAAWGAE D, REVISED, MAAVY AAA’ 7S A2Z- WAC/77 EAV, AAWD MUCH AVAE W MA 7TEA’ A D /O AE/O. AZZ CSTRA TEZ), WZZZZ 71& CUZS OAV WOOD. PHILADELPHIA : F. E. B O E R I C K E, HAHNEMANN PURLISHING Hous E. I 887. Copyrighted BY F. E. BOERICKE, 1886. SHERMAN & Co., PRINTERs, PHILADELPHIA. TO T H E FA C U L T Y OF THE NEW YORK HOMOEOPATHIC MEDICAL COLLEGE (ſhiſ; ſloth I S R E S P E C T F U L L Y IN S C R IB E D BY T H E I R C O L L E A G U E, THE AUTHOR. PREFACE TO THE FIFTH EDITION. THE demand for a fifth edition of this work has given great satisfac- tion to its author. He has endeavored in the following pages by many emendations to render this book more worthy the confidence of the pro- fession than its predecessors, as well as a fair exponent of the “Surgery of the Present.” - A writer and lecturer in any department of science, after years of constant labor, may become so familiar with his subject that he may assume for his readers certain elementary knowledge, and thus produce a work which, though intelligible to the advanced student, is not entirely comprehended by the beginner. This is the fault of many text books. In the present edition the author has endeavored to remember that he is writing for the first course student as well as the graduate, and has tried wherever possible to insert here and there a little of the literature of surgery (than which no more interesting sub- ject exists), to relieve the monotony of detail, and the bare statement of facts. Whether these efforts have been successful remains to be determined. In conclusion, the author returns thanks to Dr. F. S. Fulton for his excellent Chapter on “Trachelorraphy,” to Messrs. William Wood & Co., of New York, for the use of engravings; and to the cutlers Tie- man & Co., and John Reynders & Co., of New York, and William Snowden, of Philadelphia, for their trouble and generosity in supplying the book with electrotypes of instruments and apparatuses. THANKSGIVING DAY, New York, November 25th, 1886. 299 Madison Avenue. CO N T ENTS. P A R T I. MINOR AND PRELIMINARY SURGERY. CHAPTER I. Cleanliness—Instruments—Ligatures—Various Articles used in Dressing—Tents— Incisions—Hypodermic Medication—The Aspirator—Paquelin's Thermo-Cau- tery—Galvano-Puncture—Galvano-Cautery—Electrolysis, e & . 33–60 CHAPTER II. DISINFECTANTS AND ANTISEPTICS. Antiquity of Disinfection–Cleanliness—Charcoal—Lime—Ashes—Earth—Smoke— Collins's Disinfecting Fluid–Thompson's Deodorizer—Heat—Coffee—Bromine— Ozone—Iodine–Nitrate of Lead—Chlorine—Chloride of Zinc–Chloride of Lime —Labarraque’s Solution—Permanganate of Potash—Nitrous Fumigations—Tar Acids, ſº e & g * tº tº e & & tº tº . 61–70 CHAPTER III. ANAESTHESIA. Ether—Discovery of Anaesthesia—Inhalers—Ether by the Rectal Method—Chloro- form—Symptoms of Danger—Death—Nitrous Oxide—Bichloride of Methylene— Bromide of Ethyl-Sickness and Death from Anaesthesia—Local Anaesthesia— Richardson's Apparatus—Anaesthetic Ether—Hydrate of Amyl—Hydramyl— Anaesthetic Mixtures for Small Operations—Hydrochlorate of Cocaine, . 70–86 P A R T II. GENERAL SURGERY. CHAPTER IV. Introduction—Inflammation—Inhibitory Nerves—Connective Tissue–Leucocytes— The Migration Theory—Action of the Capillaries—Hyperaemia—Active Conges- tion—Changes in the Tissues—Changes in the Blood–The Tissue Metamorphosis Theory of Stricker—Symptomatology—Inflammatory Fever—The Terminations —Repair — Immediate Union—First Intention—Granulation—Cicatrization— Fatty Degeneration—Treatment, General and Local, . { } e . 87–109 xvi CONTENTS. CHAPTER V. DEGENERATION OF TISSUE. Suppuration—Pus-Corpuscles—Varieties and Analysis of Pus—Fluctuation—General Treatment—Abscess, Acute, Chronic, Diffuse, Residual: Time of Operation— Treatment—Hyper-Distension with Carbolic Water—Sinus and Fistula, 109–120 CHAPTER VI. Traumatic Fever—Septicaemia and Pyaemia—Hectic—Treatment, ſº . 120–129 CHAPTER VII. DEGENERATION (CONTINUED). Ulceration: Sloughing—Ulcers: Simple—Irritable—Indolent—Varicose—Treatment: Local—Straps—Bandages—Skin-Grafting—Sponge Grafting—Medical Treatment —Dry Earth, . e & º & & tº º jº & gº . 129–140 CHAPTER VIII. DEGENERATION (CONTINUED). Gangrene and Mortification—Line of Demarcation; of Separation—Question of Am- putation in Traumatic Gangrene—Dry Gangrene—Treatment—Hospital Gan- grene—Sloughing Phagedaena, . g g e ſº § tº . 141–147 CHAPTER IX. TUMORS. Introductory Remarks—Classification–Diagnosis—Characteristics. Histological For- mation : A. Innocent Tumors—Types of Higher Tissues and Types of Connective Tissues—Types of Epithelial Tissue. B. Sarcomata: Types of Embryonic Tis- sues—Connective Tissue. C. Carcinomata—Different Varieties of Cancer. D. Cystic Tumors and their Varieties—Cysto. Sarcoma, . g e . 147–201 CHAPTER X. SCROFULA—STRUMA—TUBERCULOSIS. Definition—Treatment—Scrofulous Ulcer–Division of Tubercle—Gray and Cheesy Granulations, . ſº e e ſe e g © * º e . 201–204 CHAPTER XI. WENEREAL DISEASEs. History of Syphilis—Gonorrhoea—Gleet—Balanitis—Gonorrhoea in Women—Gonor- rhoeal Rheumatism—Gonorrhoeal Ophthalmia—Sycosis, * Ç . 205–221 CHAPTER XII. CHANCROID—SoFT CHANCRE. Definition—Characters of Seat—Phagedenic—Chancroids in the Urethra, 221–226 CONTENTS. xvii CHAPTER XIII. Syphilis—General Considerations—Chancre—Differential Diagnosis between Chancre and Chancroid—Bubo—Constitutional Syphilis—Affections of the Skin–Tertiary Forms—Syphilitic Iritis—Syphilis of the Larynx—Syphilization—Fumigation— Inunction—Infantile Syphilis, e e º e tº e te . 226–245 CHAPTER XIV. Wounds: Definition—Classification—Danger of Dressings for—Sutures—Straps— Antiseptic Treatment—Methods of Healing—Incised—Punctured—Contused— Lacerated—Poisoned Gunshot, . * * ſº e © ge . 245–291 CHAPTER XV. The Varied Methods of Dressing Wounds, . g e * º s . 291—302 CHAPTER XVI. A Concise Review of the Antiseptic Surgery of the Present, º & . 302–314 CHAPTER XVII. HAEMORRHAGE. The Means and Instruments for Arresting Haemorrhage—Definition—Haemophilia— Haemostatics, Natural and Artificial—Internal Medication—Styptics—Flexion— Compression—Percutaneous Ligation—Acupressure—Various Instruments—Liga- ture—Esmarch's Method–Dittel's Elastic Ligature, . © º . 315–346 CHAPTER XVIII. TRANSFUSION. History—Uses—Apparatus—Transfusion of Blood; of Milk; of Saline and Other Substances, . & © e º ſº ſº & e te tº . 346—352 CHAPTER XIX. AMPUTATIONS. Definition—Question of Amputation—Instruments—Methods—Mortality After, 352–365 CHAPTER XX. SPECIAL AMPUTATIONS. Amputation of the Lower Extremities, * te o g e tº . 365–392 CHAPTER XXI. PLASTIC SURGERY. Antiquity of—General Considerations—Varied Methods of Transplanting Flaps, 392–395 xviii. CONTENTS. P A R T III. SURGERY OF SPECIAL REGIONS AND TISSUES. CHAPTER XXII. DISEASES AND INJURIES OF THE SEIN AND CELLULAR TISSUE. Erysipelas–Poisoning with Rhus—Furuncle, Boil—Anthrax, Carbuncle–Effects of Cold, Pernio—Burns and Scalds—Cicatrices—Paronychia, Whitlow—Lupus—Ele- phantiasis Arabum—Malignant Pustule—Internal Malignant Pustule—Verrucae, Warts—Bed-Sores—Ingrowing Toe Nail–Onychia—Subungual Exostosis—Per- forating Ulcer of the Foot, . g e e te tº º & . 396–427 CHAPTER XXIII. INJURIES AND DISEASEs of THE MUSCLES, TENDONS, AND BURSAE. Contusions—Thecitis—Dislocations of Muscles and Tendons—Rupture of Muscles and Tendons—Muscular Atrophy–Reflex Muscular Atrophy—Acute and Chronic Bursitis–Ganglion—Sprains—Dupuytren's Contraction, . & . 427–436 CHAPTER XXIV. INJURIES AND DISEASES OF THE ARTERIES. Arteritis, Adhesive and Diffuse—Atheroma—Embolism—Aneurism: Varieties, Gen- eral Treatment, Medical Treatment—Compression—Manipulation—Rapid Method for External Aneurism, Injection, Ligature—Special Aneurisms, . . 436–463 CHAPTER XXV. LIGATION OF ARTERIES. Surgical Anatomy of the Vessels and Methods of Operating, * tº . 463—479 CHAPTER XXVI. INJURIES AND DISEASES OF THE WEINS. Thrombosis—Thromballosis—Coagulation in Weins—Thrombus—Phlebitis–Varix— Entrance of Air—Wounds—Phlebolithes, . o {} is © . 479–484 CHAPTER XXVII. DISEASES OF THE CAPILLARIES. Erectile Tumors—Naevi-Telangiectasis, . tº e * e . . 484-487 CHAPTER XXVIII. THE NERVOUs SYSTEM AFTER INJURIES AND OPERATIONS. Symptoms of Shock—Temperature During—Secondary Shock—Treatment—Tetanus —Wounds of the Nerves—Nerve Stretching—Nerve Suture—Neuralgia, 488-503 CONTENTS. xix CHAPTER XXIX. DISEASEs OF THE LYMPHATICs. Lymphangitis — Angeioleucitis–Adenitis–Neoplasms — Lymphadenoma–Lymph- Oma, tº w wº e tº ſº © & ſº º tº e . 503–507 CHAPTER XXX. INJURIES AND DISEASES OF THE BONES. Periostitis—Osteitis, Suppuration and Sclerosis — Osteo-Myelitis — Caries—Scrofula and Syphilis in Bone—Necrosis—Mollities Ossium and Rachitis—Fragilitas Ossium—Atrophy of Bone—Tumors, Innocent and Malignant, . . 507–533 CHAPTER XXXI. Fractures: General Considerations in the Treatment of Divisions—Causes—Symp- toms—Examination of Patient–Mode of Repair—General Treatment—Flexion or Bending of the Bones—Pseudo-arthrosis—Cracked Bones—Special Fractures in the Various Regions of the Body, . * > e tº g e . 534–608 CHAPTER XXXII. INJURIES AND DISEASES OF THE JOINTs. Wounds—Synovitis—Arthropyosis—Ulceration of the Articular Cartilages—Genu- throtomy—Anchylosis: False and Spurious—Subcutaneous Osteotomy—Chronic Rheumatic Arthritis–Hip-joint Disease—Loose Cartilages in Joints—Talipes: Varus—Equinus — Valgus—Calcaneus—Tenotomy—Spurious Talipes—Weak Ankles—Genu Valgum — Knock-knee – Bow-legs—Trigger-finger — Hysterical Joints–Gonalgia—Disease of the Sacro-iliac Synchondrosis, . . 608–648 CHAPTER XXXIII. DISLOCATIONS OR LUXATIONS. General Considerations—Varieties—Diagnosis—Treatment—Extension and Counter- extension—Manipulation—False Joint—Ancient Dislocations—Special Disloca- tions of Different Joints, * i.e. & ſº g † º e . 648–680 CHAPTER XXXIV. INJURIES AND DISEASEs of THE SPINE. Concussion of the Spine, including “Railway Concussion ”—Nervous Shock—Spina Bifida — Cleft Spine–Rotary Lateral Curvature — Angular Curvature — Pott's Disease—Caries of the Spine—Lordosis—Psoas or Lumbar Abscess, . 681–693 CHAPTER XXXV. ExCISIONS OF BONES AND JOINTS. General Remarks—Instruments—Resection of Bones in their Continuity—Excision of the Bones of the Hand—Of the Wrist—Of the Forearm—Of the Elbow—Of the Humerus—Of the Shoulder—Of the Scapula—Of the Clavicle—Of the Ribs— Of the Calcis–Of the Toe—Of the Knee—Of the Leg—Of the Hip, . 693–718 XX CONTENTS. CHAPTER XXXVI. INJURIES AND DISEASES OF THE HEAD. . Wounds—Gunshot Wounds of the Scalp—Fractures of the Skull—Concussion and Compression—Application of the Trephine—Cerebral Motor Localizations, 718–729 CHAPTER XXXVII. INJURIES AND DISEASES OF THE NOSE. Malformations — Foreign Bodies—Epistaxis—Lipoma Nasi-Ulceration — Ozaena — Polypus Nasi–Myxoma—Naso-pharyngeal Polypus—Osteo-plastic Resection— Rhinoscopy, . p tº g * “º & e e * G . 729–739 CHAPTER XXXVIII. INJURIES AND DISEASES OF THE MOUTH AND THROAT. Hare-lip—Double Hare-lip—Restoration of the Upper Lip—Epithelioma—Enlarged Labial Glands—Cysts of the Lip—Vascular Tumors—Restoration of the Lower Lip—Cleft Palate and Staphylorraphy—Gingivitis—Tumors of the Tongue— Glossitis—Abscess of the Tongue—Hypertrophy–Amputation of the Tongue— Malformation of the Fraenum — Ranula—Salivary Calculus and Fistula — Ton- sillitis — Quinsy–Rhinoscopy — Pharyngitis — Gangrenous Pharyngitis – Post- pharyngeal Abscess—Elongation of the Uvula—Spasm and CEdema of the Glottis, . e * . ſº tº tº & e e º © tº . 739–776 CHAPTER XXXIX. INJURIES AND DISEASES OF THE JAWS. Abscess of the Antrum Highmorianum–Tumors of the Antrum—Osteo-Plastic Opera- tion for Exposing the Cavity of the Antrum—Epulis—Cystic Tumors—Necrosis of the Jaw-Bones—Phosphorus Necrosis—Excision of the Upper Jaw—Excision of the Lower Jaw—Of the Entire Lower Jaw—Anchylosis of the Inferior Maxil- lary, is & e gº & † e * ſº g tº & . 777–789 CHAPTER XL. INJURIES AND DISEASEs of THE NECK. Cut Throat—Torticollis, Wry Neck. Diseases of the Glands of the Neck—Parotitis, Mumps—Abscess of the Parotid–Gangrene of the Parotid–Malignant Diseases of the Parotid—Extirpation of the Parotid—Affections of the Duct of Steno— Diseases of the Submaxillary Gland—Cystic Tumors of the Neck—Goitre—Bron- chocele—Derbyshire Neck. Diseases of the CEsophagus–Rupture of the CEso- phagus—CEsophagitis, Inflammatio CEsophagi—Stricture of the CEsophagus — Foreign Bodies in the CEsophagus—Introduction of Tubes—CEsophagotomy. Surgical Affections of the Larynx and Trachea—Syphilitic Laryngitis—Foreign Bodies in the Larynx and Trachea—Bronchotomy—Laryngotomy—Tracheotomy —Tracheotomy with the Thermo-Cautery—Intubation of the Glottis—Laryngo- scopy—Neoplasms—Extirpation of the Larynx, . e e © . 789–819 CONTENTS. xxi CHAPTER XLI. INJURIES AND DISEASES OF THE THORAx. Wounds of the Chest—Hydrothorax—Empyema—Aspiration of the Thorax–Thora- centesis—Puncture of the Pericardium—Pleurotomy—Thoracic Gradual Drain- age – Apnoea: from Drowning, from Hanging — Mammary Lymphangitis— Mastitis—Carcinoma of the Mamma — Benign Tumors — Amputation of the Breast, . º e e tº e º e © & º e ... 819–832 CHAPTER XLII. INJURIES AND DISEASES OF THE ABDOMEN. Wounds of the Abdominal Viscera—Suturing the Intestine—Artificial Anus—Ab- scess of the Abdominal Parietes—Hepatitis—Diseases of the Gall Bladder–Gall Stones—Cholecystotomy—Hepatic Abscess — Paracentesis — Obstruction of the Bowels — Operations for—Colotomy — Perityphlitic Abscess – Gastrotomy and Gastrostomy—Splenectomy—Resection of the Pylorus—Digital Divulsion of the Pylorus, . o o & e e e º e º e o . 832–855 CHAPTER XLIII. HERNIA—RUPTURE. Abdominal Hernia—Frequency and Sites—Varieties and Nomenclature—Medical Management—Diagnosis—Taxis—Puncturing the Intestine–Reduction by Es- march's Bandage—Trusses — Herniotomy—Kelotomy — Enterectomy for Gan- grenous Hernia—Radical Cure—By Ligature of Sac-Heatonian Method — Wood's Operation — Inguinal Hernia—Surgical Anatomy — Differential Diag- nosis—Operation—Femoral Hernia—Diagnosis—Operation—Ovarian Hernia— Umbilical Hernia—Obturator Hernia—Ischiatic—Diaphragmatic—Pudendal, 856–891 CHAPTER XLIV. DISEASES OF THE RECTUM AND ANUs. Examination—Imperforate Anus and Rectum—Foreign Bodies in the Rectum—Pro- lapsus Ani–Haemorrhoids—Fistula in Ano–Tumors in the Rectum—Stricture of the Rectum—Linear Rectotomy—Ulcers and Fissures of the Anus—Excision of the Rectum—Carcinoma of the Rectum, . © g * e . 892–914 CHAPTER XLV. INJURIES AND DISEASES OF THE URINARY ORGANS. Malformation—Exstrophy of the Bladder—Epispadias—Hypospadias—Hermaphro- dites—Calculous Nephralgia — Unstable (Floating) Kidneys—Nephrectomy — Nephrotomy—Cystitis—Retention of Urine—(Ischuria Vesicalis)—Tubercular Cystitis—Catheterism—Abscess and Fistula in the Perinaeum—Laceration of the Urethra—Cystotomy—Foreign Bodies—Stricture of the Urethra—Internal and External Urethrotomy — Calculi—Stone in the Bladder—Various Methods of Lithotomy—Operations for Lithotrity—Tumors of Bladder—Prostatitis, 914—987 xxii CONTENTS. CHAPTER XLVI. DISEASEs of THE MALE GENITAL ORGANs. Malformations—Acute and Chronic Orchitis—Fungoid Growths of the Testicles— Cystic Disease—Carcinoma—Castration—Carcinoma of the Scrotum—Hydrocele —Haematocele–Varicocele—Elephantiasis Scroti—Amputation of the Scrotum— Phimosis—Paraphimosis—Epithelioma Penis—Amputation of the Penis—Sperm- .atorrhoea, . g e g ſº ſº tº º tº tº º . 987–1015 CHAPTER XLVII. INJURIES AND DISEASEs of THE FEMALE GENITAL ORGANs. Examination of Uterus—Carcinoma—Scirrhus—Epithelioma, Vegetating and Ulcer- ating—Amputation of the Cervix—Uterine Tumors—Fibro-Myomata—Vaginal Removal, and Laparotomy—Hysterectomy —Vaginal Extirpation of the Uterus —Oöphorectomy—Laceration of the Perinaeum—Vaginismus–Elephantiasis of the Labia, . e “e e tº w tº * © e * . 1015–1052 CHAPTER XLVIII. Lacerations of the Cervix Uteri, © & e e Qº * ... 1052–1066 CHAPTER XLIX. OVARIAN TUMoRS. Formation—Varieties—Formation of Colloid—Of Dermoid—Fibrous and Fibro-Cystic —Diagnosis—Pseudocyesis—Pregnancy—Parovarian Cysts—Encysted Dropsy of the Peritoneum—Ascites—Microscopical Examination of the Fluid–Albuminoid —Malignant Disease—Treatment—The Performance of Ovariotomy and Sub- sequent Management, . * º e * ſº tº $n sº ... 1066–1092 IN DE X 0 F A UT H () R.S. The following List is intended to embrace the chief references that have been made in this Volume to the published labors of others. Abraham : sponge grafting, 139. Adams, J. C. : perityphlitic abscess, 851. Adams, William : Dupuytren's contraction, 435; subcutaneous osteotomy, 620. Agnew : popliteal aneurism, 447; gangrene, 141; statistics of amputation, 363-365; tracheotomy, 807. Aitken : compound acupressure, 363. Allam : scorpion bites, 260; removal of cancer, 189. Allis: diagnosis of hip-joint disease, 662; acupressure forceps, 334. Andowit : elephantiasis arabum, 420. Annandale: excision of joint between the os calcis and astragalus, 708. Appia : aphorisms in gunshot wounds, 277 et seq. Archer: nephrectomy, 927. . Aschemborn : foreign bodies in the oesophagus, 800. Atlee, W. : arsenic in the treatment of cancer, 190; encysted dropsy of the peritoneum, 1077; value of Drvsdale's corpuscles, 1079. Attomyr : treatment of syphilis, 231; treatment of cancer of the lip, 749. Bacceli: auscultation and percussion in empyema, 821. Backmeister: carbolic acid, 67. JBaer : impregnation after trachelorraphy, 1066. Baffley : treatment of stricture of urethra, 943. Baker : necrosis, 521. Baldassare : treatment of spina bifida, 684. Baldwin : medical treatment of ovarian tumors, 1083. Ball: sponge grafting, 139. JBalley : treatment of cancer, 185. JBantock : antiseptic spray, 307. Barton : fracture of the lower end of the radius, 575. Barwell: aneurism of the innominate artery, 458; excision of the ankle-joint, 709. Bassini: peroxide of hydrogen, 311. JBauer: hip-joint disease, 624; treatment of genu valgum, 711. Bayes: treatment of cancer, 181. Beane : anterior and posterior linear rectotomy, 908. JBecker : treatment of pseudo-arthrosis, 547. JBeebe, A. G. : treatment of cancer, 182. Bellfield : putrid infection, 305. Belmas : suprapubic lithotomy, 962. Bellingham : treatment of aneurism, 447. Bence: treatment of cancer, 85. Berger: extirpation of the larynx, 818. Berger: formation of colloid, 1071. Bernays: cholecystotomy, 840. Beullard : treatment of gangrene, 144. º Bigelow: ilio-femoral ligament in relation to dislocations of the hip-joint, 657; litho- lapaxy, 974; artery forceps, 37. Billroth: cystic tumors, 192; classification of tumors, 148; and Von Pitha, description of arteries of head and neck, 464; extirpation of the spleen, 855. Bishoff: intra-venous saline injections, 352. Black: scrofula in bone, 517. Plack, F. : treatment of hydrocele, 996. Blakely : treatment of traumatic gangrene, 144. Boeck: syphilization, 241. Baekel ; subcutaneous osteotomy, 527. xxiv. INDEX OF AUTHORS, Bokai : post-pharyngeal abscess, 774. Bompart : treatment of tetanus, 494. Bond : hepatic abscess, 841. Bouchut: hare-lip, 740. Bowen : treatment of fistula in ano, 902. Boyer : amputations, 356; caries of bone, 517; rachitis, 524; exostosis, 529; osteo- sarcoma, 530. Bradley: subcutaneous osteotomy, 526. Bradshaw; treatment of cancer, 182. Brainerd : treatment of false joint, 547. Brickle: encysted dropsy of the pelvis, 1089. Briddon : excision of the rectum, 913. Broadhurst : anchylosis, 616; subcutaneous osteotomy, 621; anchylosis of the lower jaw, 788. Brodie : treatment of gangrene, 144; treatment of varix, 482. Brown, B. : trachelorraphy, 1059. Brown, I. Baker: treatment of uterine tumors, 1025. Brown, H. L. : splenectomy, 855. Brown, T. R. : internal urethrotomy, 950. Brownell ; treatment of fistula in ano, 905. Bruns: operation for the removal of naso-pharyngeal polypi, 734. Bryant : traumatic fever, 120; statistics of pyaemia, 125; cyst walls, 192; cancerous tumors, 172; treatment of cancer, 180; torsion for arresting haemorrhage, 327 ; Pott's fracture, 603; method of amputation at hip-joint, 366; classification of bone diseases, 509; dislocation of the pubic bones, 653; excision of ankle, 709; gastrotomy, 852; imperforate anus, 896; Listerism, 304. Buchaman : restoration of lip, 750. Buck: subcutaneous osteotomy, 620; excision of the knee, 711; instrument for hare- lip, 745; perityphlitic abscess, 850. Budd : hepatic abscess, 842. Bull: thymol, 70; thymol as an antiseptic, 70; etherization by the rectum, 75. Bullen: elephantiasis of the labia, 1050. Bumstead : gonorrhoea, 216; report on syphilis, 221; on the unity or duality of syphilis, 227; quoting Diday on chancre, 228. Burckhardt: extirpation of thyroid gland, 795. Burrall : excision of the os calcis, 706. Burt : treatment of haemorrhoids, 900. Busch : lymphatic fistula, 507. Butcher: haemorrhage, 323; excision of knee, 710. Butler, John : electrolysis, 58. Byford: treatment of uterine fibroids by hypodermic use of secale cornutum, 1027. Calhoun, A. W. : cocaine in cataract, 86. Callender: torsion, 327; acupressure, 333: rupture of muscles, 429. Campbell: use of calendula, 113. Cameron: treatment of goitre, 795; shock, 488. Canstatt : symptoms of secale cor. in gangrene, 143. Capelletti: fractures of the os innominatum, 567. Carey: idiopathic symmetrical myelitis, 514. Carnochan : treatment of elephantiasis, 420; pulsating bony tumors, 533. Catesby: snake-bites, 260. Ceccherelli : ovarian hernia, 885. Chadwick: anatomy of rectum, 911. Championnière: localization of cerebral injuries, 726. Chapard: tetanus, 493. Chapelle : reduction of hernia, 865. Charcot and Pitres: localization of the cerebrum, 726. Chiene: nerve stretching, 497.; operation for relief of genu valgum, 642; antiseptic surgery, 303. Chisholm : removal of the superior maxillary bones, 783. Churchill: hare-lip, 740; statistics of amputation, 363. Clapp, H. : pleurotomy, 823. lark, E. A.; acupressure, 333; interdental splint, 554; fracture of the humerus, 572; fracture of the olecranon, 581; apparatus for treatment of fracture of the femur, 593. Clark, H. E. : nerve suture, 500. Clark, Le Gros: concussion of the brain, 722. INDEX OF AUTHORS. XYV Clarke, E. : treatment for vaginismus, 1048. Clarke, Lockhart: muscular atrophy, 430. Clements, B. A. : dislocation of the clavicle, 651. Cloquet: epigastric artery in hernia, 879, 887. Coe: formation of fibroids of ovary, 1073. Coles: deaths from anaesthesia, 81. Colley : treatment of clubfoot, 639. Columbat: fibrous tumors of the uterus, 1022. Comstock: treatment of hydrophobia, 267; phimosis, 1010; gynepod, 1036. Conheim : metastasis of tumors, 152. Conklin: impacted fracture of the neck of the femur, 586. Conner: dislocation of elbow, 675. Cooper, Astley: repair, 100; fractures of the pelvic bones, 568; dislocation of the pubes, 653. Cooper, Bransby: time for operating on hare-lip, 742. Cooper, Samuel: gangrene, 144; hypertrophy of the tongue, 761; caries, 515. Cornil and Ranvier: ovarian tumors, 1068. Cox, W. C. : nerve stretching, 498. Craigie: hepatic abscess, 842. Creguy ; treatment of fissures of the anus, 909. Critchett: manner of strapping ulcers, 136. Crosby: dislocation of hip, 652. Crosley: automatic reduction of hip, 662. Cullen: tetanus, 492. Curling: method of tying naevus, 487; castration, 993. Cushing, A. M.: use of calendula, 113. Danbridge and Conner: examination of rectum by hand, 894. Davis: vaginismus, 1047. Dawson: the diagnosis of hip-joint disease, 662. Dawson, R.: the proper time for operating for hare-lip, 741. Day: elephantiasis arabum, 420. Day. John ; self-disinfectant, 65. Debrand: vaginismus, 1048. DeCato : traumatic tetanus, 494. Delaney : amputation of the tongue, 762. Diday: quoted by Bumstead on chancre, 228. Dieulafoy: aspiration of the knee-joint, 610. Dittel: elastic ligature, 345. Dia: ; acnpressure, 336. Dobson: skin-grafting in ulcers, 137. Dorsey : insect wounds, 260. Dougall: relative power of antiseptics, 306. Dougherty: dislocation of the patella, 665. Druitt: haemophilia, 317; method of tying naevi, 487; hydrocele, 845. Dubois: treatment of hare-lip, 742. Dudgeon : treatment of boils, 401; gomorrhoeal ophthalmia, 219. Dulles: suprapubic lithotomy, 968. * Dunham : treatment of malignant pustule, 423; employment of lachesis in phlebitis, 481 ; disinfectants, 62. Dunnell: the medical treatment of strangulated hernia, 861. Dunvell: forced flexion, 323. Duplay: diffuse phlegmonous periostitis, 570; nerve stretching, 497. Earle: cases of fracture of the acetabulum, 569. Bckel : treatment of aneurism, 453. Emmet: ideas regarding capsulated fibroid tumors of the uterus, 1025; method of per- forming the operation for perineal lacerations, 1035, -1039; ovariotomy, 1089. Englisch : albuminuria in hernia, 860. Erichsen : fatty tumors, 156; sebaceous cysts, 200; naevi, 487; concussion of the spine, and railway concussion, 682; treatment of hydrocele, 998. Esmarch : ideas regarding the application of his bandage in various operations, 342 resection of shoulder, 704. Eve: remarkable cases in plastic surgery, 394; cure of hydrocele by a bayonet stab,998. Fano ; concussion of the brain, 722. xxvi INDEX OF AUTHORS. Fergusson: local manifestations in inflammation, 97; opening of abscesses, 117; the question of amputation, 355; the operation of staphylorraphy, 758. Fischer: naphthalin, 311. Fitch : description of his dome trocar and aspirating apparatus, 55. Fitz: rupture of the oesophagus, 797. Flemining : changes occurring in the carbolized catgut ligature, 454; hydrophobia, 263 Fletcher: the analogy between fever and inflammation, 98. Forbes, W. F. : nitrite of amyl in hydrophobia, 208. Formad : bacilli, 206. Foster: comparison of acupressure with torsion, 327. Foulis: extirpation of the larynx, 818. Fournier: classification of chancroids, 223. Fox: classification of elephantiasis of the labia, 1049. Franke: sponge grafting, 139. Franklin : gunshot wounds, 275; amputation in wounds, 289. Freyer : transfusion of blood, 350. - Fry: excision of veins, 482. Fulton : trachelorraphy, 1052. Gamgee: artificial ischaemia, 341; indications for the application of the trephine, 725. Ganghofner and Prebam : the urine in melanotic cancer, 178. Garrigues: mediate transfusion, 349. Gatchkowsky: resorcin in cancer, 186. Gasten, I. McF. : cholecystotomy, 840. Gay : statistics of tracheotomy, 807. Gibb : amputation at the hip-joint, 345. Gibb, G. W. : fractures of the acetabulum, 569. Gibney, V. P. : morbus coxarius, 630. Gibson, Prof.: snake-bites, 260; treatment of hydrophobia, 264; necrosis, 521; frac- ture of patella, 599; artificial anus, 836; psoas abscess, 692; hepatic abscess, 841. Gibson, W. A. : treatment of fracture of the patella, 599. Gilchrist: calendula as a vulnerary, 113; treatment of fibroid tumors, 96. Girard: antiseptic method of dressing wounds, 291. Gluck: nerve suture, 500. * Gluge: steatomata, 156. 'Goddard ; earth treatment, 140. wº Goodell: ovarian tumors, 1074; oëphorectomy, 1033. Goodheart: aspiration of the thorax, 821. Goodwillie: fracture of the lower jaw, 555. Gould, A. Pierce : why strictures of the urethra are common at the bulb of the urethra, 941; haemorrhage in hip-joint amputation, 366. Gowley : internal urethrotomy, 947. Green: classification of tumors, 149; gummatous products in syphilis, 237. Gross, S. D. : hydatid tumors, 199; keloid, 420; myeloid tumors, 169; differential diagnosis between encephaloid and scirrhus, 176; treatment of cancer, 180; haem- orrhagic diathesis, 317; hare-lip, 742; time of operating in cases of hare-lip, 742; anchylosis of the inferior maxillary, 787; treatment of hydrocele, 997. Gross, S. W. : nephrectomy, 925. Gruber : treatment of gonorrhoea, 213. Gullen: abscess of the antrum highmorianum, 778. Gunning : fractures of the lower jaw, 553. Guthrie: gunshot wounds, 276. Hagedorn: antiseptic surgery, 296. Hale: treatment of ulcers, 204; of gangrene, 144; of goitre, 795. Hall, G. A. : tar-plaster, 41; strangulated inguinal hernia, 885; nephrotomy, 927. FIamiltion, O. T. : sponge grafting in ulcers, 138. Hamilton, F. H. : amputation at hip-joint, 368; skin grafting, 395; keloid, 420; frac- ture of nasal bones, 549; enlarged lymphatic glands, 391 ; fracture of the ole- cranon process, 581; fractures of the femur, 584, 585, 590; fractures of the patella, 599. Pſammond: treatment of bed-sores by electricity, 423. Bancock: excision of ankle, 709; excision of knee, 717. Handcock : fractures of the pubic bones, 567. IHarris: diaphragmatic hernia, 891. Bart and Barbour: ovarian tumors, 1081. INDEX OF AUTHORS. xxvii Hartlaub and Trinks: treatment of hydrophobia, 268. PIartmann: ulcers, 204; rachitis, 526; treatment of hydrothorax, 820. Harvey: gunshot wounds, 281. Hastings: treatment of hydrocele, 996; treatment of gonorrhoea, 214. Hastings (U. S. N.): emphysema, 821. Pławard: lymphadenoma, 506. Hayfelder: Pirogoff’s amputation, 379; excision of the os calcis, 707. , Hays: treatment of compound fracture, 609. Heath, C. : treatment of aneurism, 450; method of removing tongue, 764; ovariotomy, 1084. Heath, G. Y.: forced flexion in haemorrhage, 323. IHeath, T. Ashton : abscess, 118. Beaton: radical cure of hernia, 872. Heitzmann: experiments with lactic acid, 432; classification of tumors, 154; ovarian tumors, 1068. PHennen: gunshot wounds, 274, 277. Henriques: treatment of burns, 407; of fractures, 546. Henry, M. H. : coxo-femoral dislocation, 656; varicocele, 1003. Bering: snake poisons, 261. Hewitt: concussion of the brain (quoted by Bryant), 722. Bew80m uses of earth as a surgical dressing, 140 ; acupressure, 337; paper as a surgi- cal dressing, 48. Hey: natural phimosis, 1009. Hildebrant : hypodermic use of ergot in the treatment of uterine fibroids, 1026. IIiller: potassa fusa as an antiseptic, 70. Hinton: causes of intestinal obstruction, 846. Hirsch : treatment of whitlow, 413. Hodgen: shock, 491; fracture of the vertebrae and sternum, 535; operation for lacerated perinaeum, 1041. Hodgkin : lympho-sarcoma, 505. Hoffman : treatment of cancer, 184. Holcomb : treatment of gonorrhoea, 212; of caries, 518. Holden : perityphlitic abscess, 851. Holmes, T. : migration of leucocytes, 92; suppuration, 109; pyaemia, 120, 126; classi- fication of tumors, 148; neuromatous tumors, 154; hospital erysipelas, 398; lym- phangitis, 504; salivary fistula, 767. Holmes (System of Surgery): heat in inflammation, 96; vascular tumors, 155; necro- sis, 519; laryngeal neoplasms,815; imperforate anus, 895; dislocation of clavicle, 652. Home: ulcers, 133; snakebites, 260; stricture of the urethra, 941. Hornbrook: fracture of the patella, 601. IHorrocks : uterine tumors, 1023. IHoskin : vaporizer, 70. IHowe: transfusion of milk, 350. IIubbard: naevus, 485. Buber: drainage tubes in thoracic cavity, 824, note; puncture of the pericardium, 824. * Humphreys: amputation of the tongue, 762. IHunt, W. : treatment of wounds, 304. Hunter, James B.: rectal etherization, 76. Hunter, John : inflammation, 103; gaseous cysts, 195; gonorrhoea, 209; anchylosis, 615. Hurd : constitutional symptoms of phimosis, 1010. - Hutchison, J. C.: treatment of hip disease, 629: intestinal obstruction, 848. Hutchinson : unity or dualism of syphilis, 227: syphilization, 241; acupressure, 331; operation for phimosis, 102. Hyrtl: sphincter ani tertius, 911. Ingals: intubation of the glottis, 811; cystotomy, 939. Ireland : snake-bites, 267. Ituralde : treatment of anthrax, 402. Jackson : scorpion-bites, 264; burns, 409. Jackson, A. Reeves: hysterectomy, 1028. Jacoby, G. W. : trigger-finger, 644. Jeanes : treatment of bone disease, 508, 522. Jernigen : Pott's fracture, 603. Johnstone: synovitis, 623. xxviii - INDEX OF AUTHORS. Jones: natural haemostatics, 317. Jones and Sieveking: hypertrophy of the tongue, 761; hepatic abscess, 843. Jordan, Furneaux: rhinoplasty, 737. Joslin : stricture of the oesophagus, 798. Jourdan: history of syphilis, 206. Judson: rotary lateral curvature, 685. Rafka : treatment of spermatorrhoea, 1015. Kallenbach : boils, 401. Reegan: litholapaxy in children, 981. Reetley: amputation of the hip, 369; radical cure of hernia, 875. Reith : chloroform, 78; value of antiseptics, 307. tº Rella : treatment of tetanus, 493. Relsey: examination of rectum, 895. Renyon : treatment of gonorrhoea, 213; of gonorrhoeal rheumatism, 218. Jöershaw : muscular atrophy, 431. - - Reyes: excision of the rectum, 913; lithotrity, 971; treatment of hydrocele, 999; va- ricocele, 1004. Kidd : treatment of uterine tumors, 1024. Kingsett: peroxide of hydrogen, 311. Kirkland : hepatic abscess, 841. Rocher : healing of wounds, 304; submitrate of bismuth as a dressing, 311. JKoehler: excision of the head of the femur, 718. Rohn ; use of india-rubber bandage, 45. Kramer : pylorectomy, 854. Rupper : Esmarch's bandage, 341. Labbe and Coyne : innocent tumors of the breast, 831. La Garde : Oesophagotomy, 803. La Mott: lacerated wounds, 258. Langenbeck : treatment of aneurism, 453; radical cure of hernia, 876. Langé: cholecystotomy, 840. Lanyin : treatment of hydrocele, 997. Lapponi : dislocation of shoulder, 674. Iawrie : medical treatment of hernia, 862. Leal : statistics of tracheotomy, 807. Le Cato : treatment of tetanus, 494. Lemaine : carbolic acid, 66. Lente : dislocation of the pubic bones, 653. Leon : cancer of the uterus, 182. Lewis, R. J. : excision of the rectum, 913; bromide of ethyl, 78. Liebold: pyaemic fever, 123. Lippe: treatment of hypertrophy of the prostate, 987. Lister : antiseptic treatment of wounds, 305; antiseptic ligature, 338; salaembroth, 314. Liston : heat in inflammation, 95; gangrene from ergot, 143; anchylosis, 615; fragili- tas ossium, 527; application of the trephine, 725; operation for phimosis, 1011. Little: talipes, 633. & Little : plaster-of-Paris splints, 540; artery forceps, 36; fractured patella, 600. Lord : carbolic acid, 67. Ludlam : vaginismus, 1048; causes of death after ovariotomy, 1091. Macewen : supra-condyloid osteotomy, 641. Macfarlane : nerve stretching, 497. Mackenzie: ascites, 845. Mac Limont : treatment of cancer, 183; enucleation of cancer, 186. Magill: burns, 406. Malgaigne : classification of uterine tumors, 1022. Marcet : hydrophobic symptoms, 262. Markoe : amputation at knee joint, 372; osteitis, 511; caries, 515; repair in wounds, 306. •º Marsden and MacLimont : treatment of cancer, 186; cancer of lip, 644. - Marsh: laparotomy, 848. Marshall: cure of abscesses, 119. Martin : necrosis, 521; hysterectomy, 1032. Mason, Erskine : pulsatiug bony tumor, 533; Esmarch's bandage, 345. Mason, F. W. : treatment of cleft palate, 757. Mason, S. A. : transfusion of blood, 347. INDEX OF AUTHORS. xxix Mastin : structure of the urethra, 946. Matthews: inhalation of ether, 73. McBurney : digital divulsion of the pylorus, 854. McClelland: the uses of calendula, 113; nephrectomy, 927. McDonnell: intra-venous injection of milk, 351; of cocaine, 86. McGuire : excision of the os calcis, 707. McKensie, Stephen : pressure in ascites, 845. McLean, A. : removal of the lower jaw, 785. McLean, Le Roy : Oesophagotomy, 803. McLellan : exostosis, 529; osteo-cystoma, 530. Metcalf: diagnosis of hernia, 880. Metcalf, F. J. : statistics of amputation, 360. Meyer, Carl: electric illuminator, 58. Michaux, perforating ulcer, 426. Michel ; ranula, 766; enucleation of cancer, 187. Miller : ulcers, 131 ; enchondroma, 160; question of amputation, 353; treatment of hydrocele, 997. Miller (U. S.) : snake-bites, 265. Mills: spasmodic torticollis, 790. Minor: uterine tumors, 1024. Mitchell: rest after shock, 682. Mitchell, Clifford : albuminoids in ovarian fluid, 1081. Moore: treatment of Colles's fracture, 577. Moore: treatment of cancer (quoted by Holmes), 180. Morgan : treatment of hospital gangrene, 145; of shock, 490. Morgagni : encysted dropsy of peritoneum, 1077. Morris : burns, 409. Morrison : lupus, 415. Morton, T. G. : transfusion of blood, 350. Mott: aneurism of the innominata, 458; fracture of the radius, 575; hare-lip, 741; stricture of the oesophagus, 799. Mowat: treatment of goitre, 795. Mouchet: treatment of spina bifida, 684. Moxon: classification of cancer, 173; periangioma, 436. Muhlenbern : treatment of cancer, 182. Munger : splint for fracture of the femur, 595. Mundé; hysterectomy, 1028. Murdock: removal of plaster-of-Paris handages, 47. Musser and Keene: cholecystotomy, 839. Napheys: formula for the treatment of ulcers, 135; of gangrene, 145. Neftel: enucleation of cancer, 189. Neidhardt : treatment of ovarian tumors, 1083. Nélaton : pulsating bony tumors, 533. Newman: unstable kidney, 923. Newmann, R.: stricture of the urethra, 951. Nichols : taxis in hernia, 863. Niciare: Esmarch's bandage, 342. Nikolaus: traction in taxis, 864; galvano-cautery, 987. Noeggerath : diagnosis of ovarian tumors, 1081; formation of ovarian tumors, 1071. Norris : statistics of amputation, 362; non-union after fracture, 545. Obetz, H. L. : whiskey as an anaesthetic, 76. O'Ferrall: elephantiasis of the labia, 1050. Ogston: splay foot, 647; genu valgum, 641; varicocele, 1005. O'Neil: ingrowing toe-nail, 425. Osgood : amputation of the scrotum, 1008. Otis, F. N.: stricture of the urethra, 942; internal urethrotomy, 949; transmission of syphilis, 226; cell accumulation in syphilis, 229; lithotrity, 971, 972. Otis, G. A : concussion of the spine, 681. Ozanam : treatment of hydrocele, 996. Packard : primary anaesthesia, 79; dry suture, 250. Paget: classification of tumors, 148; sanguineous cysts, 194; proliferous cysts, 196; enchondroma, 159; bony tumors, 162; myeloid tumors, 149; incisions in the treatment of anthrax, 402; cancer in bone, 531; loose cartilages in joints, 631; elephantiasis of the labia, 1049. XXX INDEX OF AUTHORS. IPanas: treatment of ranula, 766. IPardo: treatment of anthrax, 402. Parker, Willard: perityphlitic abscess, 850. Parsons: dislocation of the pubis, 653. Pattison : enucleation of cancer, 187. Pean: excision of the scapula, 705. Pease: treatment of cancer, 182. Peaslee: diagnosis between ascites and ovarian cysts, etc., 1075 et sequiter; formation of colloid, 1071. Pepper: formation of colloid, 1071. Perry : fissures of the anus, 909. Peters : statistics of tracheotomy, 807. Physick: animal ligatures, 338. Piffard : treatment of lupus, 416. Pilcher : mechanism of Colles's fracture, 578. Pirrie: pyaemia, 120; acupressure, 334. Pollock : syphillis in bone, 518. Polk: local anaesthesia, 86; nephrectomy, 925. Pooley: gastrostomy, 852. Poore: sacro-iliac disease, 645. Popeau : elephantiasis Arabum, 419. Porak : hypodermic use of ergotin in epistaxis, 731. Porter : treatment of enlarged tonsils, 769. Post: Dupuytren’s contraction, 435. Pott: question of amputation, 354; inguinal hernia, 877. Pribam : the urine in melanosis, 178. Prince : plastic surgery, 394. Prudden : action of carbolic acid, 307. Purple : concussion of the spine, 681. Raue: treatment of hydrocele, 996. Rayer : elephantiasis of the labia, 1049. Reade: exstrophy of the bladder, 916. Reid : treatment of aneurism, 449. Reverdin: plastic surgery, 394. Richardson: styptic colloid, 321; anaesthesia, 80. Ricord: gonorrhoea, 209; chancroid, 221 ; chancre, 230. Riedinger : employment of catgut in haemorrhages, 325. Rindfleisch: cicatricial tissue, 102; exostosis, 162. Roberts : treatment of aneurism, 445. Robinson : treatment of epistaxis, 730. Robison : treatment of tetanus, 492. Roemer: ovarian tumors in the young, 1067. Rokitansky : enchondromatous tumors, 160; formation of hare-lip, 741; hypertrophy of the tongue, 761; hepatic abscess, 842; fibrous tumors of the uterus, 1021. Roussel : apparatus for transfusion, 349. Routh: encysted dropsy of the peritoneum, 1076. Rouz hare-lip, 740; dangers of the operation, 742. Ruggi : fungous synovitis, 613. Ruppaner: treatment of enlarged tonsils, 769. Salzer : anchylosis, 617. Sampson: uterine tumors, 1024. Sands: Esmarch's bandage, 342; laparotomy in obstruction of the bowels, 848; peri- typhlitic abscess, 851; use of iodoform, 309; lithotrity, 971. Savage: classification of tumors, 148. Sawyer : treatment of fistula in ano. 905. - Sayre; treatment of sprains, 434; fracture of the clavicle, 560; subcutaneous osteot- omy, 620; hip-joint disease, 623; tenotomy in talipes, 637; spondylitis, 686, 687; excision of the hip, 717; scoliosis, 685. Schneider: pyaemia, 128. Schuh : excision of the rectum, 913. Scriba: genuthrotomy, 615. Scultetus: instruments for haemorrhage, 322. Sedillot: treatment of the periosteum in necrosis, 524; the use of the trephine, 725. Sequard: treatment of tetanus, 493. Seyler: chemical constituents of pus, 110. INDEX OF AUTHORS. xxxi Shaffer: reflex muscular atrophy, 431; hip-joint disease, 626; traction in talipes, 634, 637 Sharp; haemorrhage, 315. Shears: classification of tumors, 150. Sherry: keloid, 421. Shrady: ligation of the lingual artery prior to amputation of the tongue, 765; false joint, 548. Simes: listerism, 308. Simon : the inflammatory process, 87, 96. Simpson: acupressure, 329. Sims: treatment of hare-lip, 745; vesico-vaginal fistula, 1043; vaginismus, 1048; oöphorectomy, 1034. Skey : use of styptics, 320. Smith, H. H. : treatment of false joint, 548; directions for the application of dressings, 43. Smith (King's College): treatment of ganglion, 433. Smith, N. : metallic snare, 336. Smith, R. W. : fractures of the femur, 587. Smith, Sidney: insect wounds (note), 259. Smith, Stephen: dangers of Esmarch's bandage, 341. Snelling : treatment of hydrocele, 845. Snow : anaesthesia, 80. Solly: pressure in the treatment of abscess, 119. Southey : thoracic gradual drainage, 822. - Spence: septicaemia, 120; injection of pus into the veins, 123; fusiform aneurism, 463. Spier: artery constrictor, 335; treatment of aneurism, 446. Spohn : tourniquet, 327. Stanley; rachitis, 525; removal of lower jaw, 786. Stapf; treatment of cancer, 182. Starr ; suprapubic lithotomy, 965. Stearms: artery clamping, 336. Steel: statistics of pyaemia (Bryant), 125. Stenn: pylorectomy, 854. Stimpson: excision of the rectum, 913. Stokes: treatment of syphilis, 239; Esmarch's bandage, 342. Stricker : connective tissue and leucocytes, 90; tissue metamorphosis, 93; swelling in inflammation, 96. Strisower: treatment of haemorrhoids, 899. Syme: excision of scapula, 705; restoration of lower lip, 751. Tait: listerism, 305; ovarian tumors, 1066, 1073; cholecystotomy, 840. Talbot: ingrowing toe-nail, 424; tracheotomy, 809. Talko: congenital cysts of the orbit, 194. Taylor: hip-joint disease, 623, 625, 627. Teale: modified acupressure, 336; rectangular flap amputation, 359. Tenneson : aspiration, 822. Terillan: parovarian cysts, 1076. * > Terry, M. O. : treatment of carbuncle, 403; of sprains, 435; chronic prostatitis, 985; ingrowing toe-nail, 425. Tessier ; haemostatics, 321. Teste: punctured wounds, 256; poisoned wounds, 264. Theilhaber, exudation in hermial sacs, 868. Thomas, C. M.: calendula, 312. Thomas, H. O. : disease of the hip-joint, 626. - Thomas, T. G. : enucleation of fibroid tumors of the uterus, 1025; elephantiasis of the labia, 1050; ovarian tumors, 1067. Thompson: burns, 407; gunshot wounds, 275. Thompson, Sir Henry : phosphatic deposits, 954; lithotrity, 971; hypertrophy of the prostate, 985; tumors of bladder, 982. . Thompson, John ; phimosis, 1010. Thompson, J. H. : chapter on dressing wounds, 291. Thorer: preparation of calendula, 112. Tiffany.’ naso-pharyngeal polypus, 736. Tullawa: ; torsion in haemorrhage, 328; dislocation, 648; dislocation of shoulder, 673. Todd and Bowman : hare-lip, 741. Travers : fractures of the acetabulum, 568. Trelat : lymphadenoma, 506. xxxii INDEX OF AUTHORS. Trevan ; lithotrity, 971. Treves: excision of knee, 714. * Tufnell ; diet, with rest, in the treatment of aneurism, 444. Ulrich: excision of the humerus, 704. |Wan Buren : amputation at the hip-joint, 368; treatment of aneurism, 448; lithotrity 971; American method of treating fractures, 495; excision of the rectum, 913. Wander Poel, S. O. : gonorrhoea, 211. Wan de Warker : trachelorraphy, 1065. Van Gieson : sectional ligature, 336. Veiel: elephantiasis Arabum, 419. Welpeau : fracture of the lower jaw, 552; Colles's fracture, 575; hare-lip, 740, 741 ; suprapubic lithotomy, 962. Verebelyi; congenital club-foot, 639. Verneuil; gastrotomy, 852. Wielinghoff: treatment of cancer, 182. Villeneuve : puncture of the pericardium, 824. Viluyskin: separation of the sacro-iliac symphysis, 654. Virchow: suppuration, 109; thrombosis, 479. Vogel; steatomata, 156. |Vogt : traumatic tetanus, 494. |Volkmann : excision of the knee, 713; antiseptics varied in wounds, 306. Von Bruns: extirpation of the larynx, 818. |Won Nussbaum : antiseptic method in hospital gangrene, 147; treatment of shock,490; fracture of clavicle, 566. Wagstaffe : shock after injuries, 489. Walker, H. C.: litholapaxy, 978. Warren, Joseph H. : radical cure of hernia, 873. |Warren, J. Mason: myeloid tumors, 169; treatment of hare-lip, 741; of hydrocele, 997; ether anaesthesia, 71 et sequitur. |Watson, B. A. : skin grafting, 138. Watson, E. : antiseptic ligature, 339. Warham : intubation of the glottis, 811. |Webb : amputation of the scrotum, 1007. |Weber: perityphlitic abscess, 850. Weir; antiseptic treatment of wounds, 339; artificial ischaemia, 341; carbolized jute, 41; rectal etherization, 76; treatment of aneurism, 451; nephrectomy, 924. Weiss: bullet forceps, 284. * § Went: cough impulse, 861. Wheelock: hermaphrodites, 922. White: spontaneous cure of vesico-vaginal fistula, 1046. White, J. William : dislocation of tendons, 428. Whitehead: amputation of the tongue, 765; stricture of the rectum, 908. Wilks: phosphorus necrosis, 781. Willard: calendula as a vulnerary, 113; resection of shoulder, 705; flexion of bones, 544. Williams: synovitis, 610. |Wilson: fragilitas ossium, 527. Winslow: pylorectomy, 854. Wolf: stricture of the oesophagus, 798. Wood, H. C. : muscular atrophy, 430. Wood, James R. : removal of lower jaw, 785. |Wood, John ; radical cure of hernia, 875. Woodbury: treatment of urethral excrescences, 1052. |Woolston: discovery of anaesthesia, 72. Wright: comparative length of the lower limbs, 588. Wulsberg: transfusion of milk, 350. Wurmb : epithelioma, 748. Wyeth : instruments for excision, 696. Young: glycerine in internal haemorrhoids, 900. Younghusband: treatment of hospital gangrene, 145. Zesas : enterectomy, 834. Ziegler: sponge grafting, 138; chemistry of ovarian fluids, 1081. Ziemssen: encysted dropsy of the peritoneum, 1076; treatment uterine tumors, 1026. A SYSTEM OF SUR. G. ERY. P A R T I. MINOR AND PRELIMINARY SURGERY. CHAPTER I. CLEANLINESS – INSTRUMENTS-LIGATURES — VARIOUS ARTICLES USED IN DRESSING — TENTs— INCISIONs—HYPodeRMIC MEDICATION – THE ASPIRATOR-PAQUELIN’s THERMO-CAUTERY-GALVANO-PUNCTURE—GALVANO-CAUTERY-ELECTROLYSIs. THERE is nothing that more clearly indicates the accomplished surgeon, than the neatness and precision which mark the minor points of his operations. The handling of instruments, the application of bandages and straps, the introduction of sutures, and the quiet self-reliance resulting from a thorough knowledge of what has to be done and “how to do it,” imme- diately show to the critical observer the skill and experience of the operator; while the absence of one or more of these essentials as pointedly indicates the man of limited experience and clumsy fingers. There is as much difference between the surgical performances of different surgeons, as there is between a well-conducted dinner party and a hurried luncheon in a rail- way station; the one all regularity, precision, and satisfaction; the other, all hurry, irregularity, and confusion. Attention, therefore, to minor sur- gery should always be encouraged, because a successful treatment of casu- alties, as well as other surgical cases, can be accomplished only by a skilful application of the varied apparatus which have been contrived and intro- duced within the province of surgery. Much practice is required before that degree of neatness, promptness, and carefulness are attained, which are essential components in the character of a good surgeon. The first requisite, and one that I cannot too strongly impress upon the student and the operator, is cleanliness. Cleanliness of the person of the surgeon, especially of his hands, cleanliness of the instruments, cleanliness of the table, cleanliness of the patient. I have seen a room in which an operation has been performed, that resembled more the shambles of a butcher than the residence of a human being; blood was everywhere, over the operator, over the assistants, and over the patient, and under him too; soiled towels and dirty sponges were lying around in confusion; basins full of bloody water were standing here and there; bloody knives, forceps, and needles had been thrown upon the stained tables and there remained, and, in fact, the whole appearance of the apartment was one of disorder, con- fusion, and blood. This need not be so, and as the surgeon gains experi- ence and self-reliance, he will not permit it to be so. By having an assistant ready to take each instrument from the operator, wipe it, and replace it in the pan containing the disinfecting fluid, and by having competent nurses to remove soiled towels and napkins, and by the surgeon seeing that during the performance of the operation the patient is sponged and kept clean,—a 3 34 A SYSTEM OF SURGERY. Severe surgical operation can be carried through its several steps with such neatness and cleanliness, that it will be a pleasure to all beholders. The apparatus of dressing consists of two parts, one of instruments for, and the other the pieces of, dressing. - Instruments.-Of late years the number of instruments has multiplied so largely, and they are so well adapted to the ends for which they are con- Structed, that but few of them can be mentioned here. In the ordinary pocket-cases of the day, we have a good variety of instruments, not only for dressing all ordinary wounds, but for performing the minor operations. Probes.—Of all the instruments the surgeon uses, in none is the tactus eruditus so much needed as in handling the probe. Delicate and pliable, it should be constructed of silver or gold, a metal that will not corrode, and should have a blunt and somewhat rounded head at one extremity, at the other it should possess an eye for the introduction of threads, wires, or sutures. (Wide Fig. 1.) The probes used in gunshot wounds should be FIG. 1. C= F-> larger, heavier, and stronger than those in the ordinary pocket-cases, and may be constructed with porcelain imbedded in one end, as the celebrated probe of Nélaton, which detected the ball in Garibaldi’s wound. The greatest gentleness and caution are necessary in the passage of the probe, and time and practice are required before the instrument can be skilfully used. Directors.-These, as the name implies, are instruments which direct the course of the knife. They are generally constructed of steel, and are of larger calibre than a probe, having a tolerably broad groove on the one side. (Fig. 2.) In delicate operations the instrument is slid underneath different structures, and the probe-pointed bistoury being used, the parts are divided without endangering those beneath, or taking the edge from the knife. In herniæ, in operations for the ligation of arteries, especially about the neck; in delicate dissections of parts lying over important and vital structures, the director is a most indispensable instrument. The handle of the director is flat, and contains a slit, which, with a little manipu- lation, can be used as a wire-adjuster in the closing of wounds; or, as is often found in the French cases, the extremity is flattened out into a spatula containing a groove, which was introduced by Vidal, and which is useful in hernia. Scissors.--It is scarcely necessary to describe this instrument, it is so well known. There are several varieties; curved (Fig. 3), flat, and angular (Fig. 4), which must be used at the discretion of the operator. In opera- tions where there is not much thickness of structure to cut through, where mucous membrane has to be pared, or removed, Scissors are preferable to the knife; but if the parts are of any thickness, they are liable to be bruised INSTRUMENTS. 35 and torn by scissors; the scalpel or bistoury is, therefore, much to be pre- ferred. FIG. 4. Forceps.--There are many kinds of forceps used for different purposes. Forceps are constructed to answer the place of the forefinger and thumb of the right hand of the operator. Thus we have the dressing forceps (Fig. 5), which resembles an ordinary scissors, with the exception of the blades, FIG. 5. <=-3 which are flat, blunt, and serrated; it is useful in removing foul or soiled bandages; in lifting the straps away from ulcers and wounds, and to draw away sloughs, thus preventing fetid and irritating discharges from contact with the surgeon's hands. Forceps should always be used in such cases. Dissecting Forceps.-These forceps are entirely different in shape from the former, bearing more resemblance to a pair of tweezers. They are made with a spring, which holds the blades apart, except when compressed by the finger and thumb of the operator. This instrument is used in lifting skin and tissues to be dissected, in picking up minute portions of dressing, etc. Needle Forceps (Fig. 6) are of several varieties, and are closed with a slide or a spring. They mostly have a depression in which to fix the head of a FIG. 6. pin, and when the blades are brought together and fixed, they give a greater leverage, and are very serviceable in passing the pins or needles through FIG. 7. Russian Needle Forceps. the tissues. The forceps for needles which I prefer in all cases is that known as the Russian needle forceps (Fig. 7), invented by Dr. Anatol De Gaine, of St. Petersburg. 36 A SYSTEM OF SURGERY. There are besides, artery forceps (Fig. 8), bull-dog forceps, tumor forceps, bullet forceps, and many others, all devised for catching and holding parts which are beyond the reach or manipulations of the fingers. FIG. 8. The best artery forceps are those known as Wood's (vide Fig. 9) hamo- static forceps, which are used almost exclusively on the continent. Dr. FIG. 9. -º-º-º---→eſ; Eºſ". G.VWEN\PANANA & W.V. Wood's Forceps. Little,” of New York, has invented an excellent instrument (Fig. 10), which combines the jaws of the old-fashioned forceps, with the catch-handles of FIG. 10. Little's Haemostatic Forceps. the European forceps. Fig. 11 represents Paen's forceps, which have heavier jaws, and securely hold the tissues grasped. FIG. 11. Paen's Haemostatic Forceps. Dr. Bigelow has also invented a valuable forceps (see Fig. 12). The * International Journal of Medicine and Surgery, March 1st, 1881. INSTRUMENTS. 37 operator seizes the artery, closes the forceps, and by slightly moving the button forward, locks the jaws. The ligature is then placed around the FIG. 12. Bigelow’s Forceps. blades and partially tied. By pressing forward the button, the small hook will push off the loop from the blades upon the artery and the second knot is tied. FIG. 13. Knives.—These are of very many varieties and all manner of shapes. The scalpel (Fig. 13) is a short knife having a broad belly, rounded cutting edge, and a straight back. A FIG. 14. bistoury has a longer and much narrower blade than the scalpel, and is made in various shapes. Fig. 14, c, represents a straight bistoury; Fig. 14, a, a curved sharp-pointed bistoury. FIG. 15. iº ---. Fig. 14, b, shows a curved probe-pointed bistoury. There are also straight probe-pointed bistouries, all of which are found in the pocket-case. 38 A SYSTEM OF SURGERY. The scalpel and bistoury are, for convenience, often placed in the same handle (Fig. 15). The Exploring Trocar (Fig. 16) is one of the most needful instruments that the surgeon holds in his possession. It may also become, in inexperi- enced hands, a very dangerous one. It must be used to assist diagnosis, to explore tumors, especially of the fluctuating kind. It consists of a long needle having a sharp point, which fits into a fine silver canula. Its inser- tion is easily accomplished. The Tenaculum (Fig. 17) is a sharp hook which is set in a handle, to catch bleeding vessels and draw them forward, in order that the ligature may be applied. It is especially serviceable in taking up arteries of small calibre. FIG. 17. GTIEMANN-CONY Catheters, both male (Fig. 18) and female, are also to be found in the cases, and for portability, are arranged to unscrew. The male or female end may thus be joined to the straight portion of the catheter. The methods of catheterism and the construction of the instrument according to rules, will be mentioned in the chapter on that subject. Ligature Thread.—The silk that is now mostly employed by surgeons, is that known as “braided,” which comes of varied calibre, and does not kink or twist, and is possessed of great strength. The manner of its carbolization is described in the chapter upon wounds and the method of dressing them. Antiseptic silk for ligatures and sutures can be procured at all the cutlers, as can the different sizes of gut. There is also an excellent article known as Surgeon's pure iron dyed silk, manufactured by Snowden, of Philadelphia. This surgical silk is jet black, and has received the especial sanction of Professor Pancoast, and comes in sizes from No. 1 to No. 14 (see Fig. 19). No. 1 is very delicate, and No. 14 FIG. 19. § {, , , , , , is very strong. The last number Dr. Pancoast uses for varicocele and in strangulating good-sized bleeding masses. Nos. 2, 3, and 4 he employs for hare-lip, and Nos. 1 and 2 for plastic operations. This latter thread has been allowed to remain in the tissues for weeks. For further information on this subject, the student may refer to the º above named, and to that on Haemorrhage in another part of this WOIUlDO €. LIGATURES. 39 Another most excellent article is that known as plaited Satin Sewing silk, which has great advantage over the twisted silk. It always remains beau- tifully smooth (Fig. 20) and never twists (Fig.21). Silk-worm gut is also an excellent form of animal ligature, and is highly spoken of by some authorities. I have not used it often, as the whale tendon and catgut have afforded sufficient satisfaction. Whale Tendon Ligature.—I cannot close this portion of the subject without a word on the whale tendon ligature introduced by Ishiguro, chief surgeon of the Imperial Japanese army. The strength of this thread is remarkable. FIG. 20. FIG. 21. #ffº W. §º %rºš ºf ºnfrºze. S §ºſſº & º - §'''''''''''/. -ºš º lſ) § & Vº : g º- sº $2 ...ºy | | \tº... º Aº ºv ...sºjº" | *(tº, º Aºf ...º * * * * * * * * * * * * * * * \- O The Plaited Satin Sewing Silk. The Ordinary Twisted Silk. A weight of 4 pounds 4 ounces was suspended on a strand 1 meter in length and 0.18 gram in weight (3 grains), but it was not broken. The ligature was soaked in a solution of pepsin (2 drachms), dilute hydro- chloric acid (1 drachm), and water (5 ounces), and then kept at the tempera- ture of the body for twenty hours, but showed not the least sign of dis- solution. . It was tested likewise by soaking in acetic acid and lactic acid (both in a diluted state), and also in liquor potassa,—in all of which cases the strength of the ligature was proved by like results. The soaking lasted from five to six days, but no dissolution took place. The first actual trial was made upon a patient for whom excision of the femur was necessary. In this case one of the ends of the ligature was cut off, close to the knot, while the other was left hanging out of the wound. After the lapse of seven days, an examination was made, and it was found that not the least trace of the ligature was to be detected. Subsequent trials proved that three days after the application were sufficient for the full absorption of this ligature. - . The same experiment was made on the femoral of a dog. On examina- tion five days afterwards, it was found that the ligature had exercised its full power on the vessel, while there was not the least trace of it remaining in the body; the whole of it having been absorbed by that time. Messrs. Stohlmann & Pfarre have these ligatures on hand and it was from them that I procured my supply. 40 - A SYSTEM OF SURGERY. Needles.-These are made straight, curved at the points, or curved in the body, with either round or two-edged, or bayonet-shaped points (Fig. 22). FIG. 22. They vary much in size and shape. The eye is oftentimes placed in the point of the needle, which may be set in a permanent handle (Fig. 23), or used with a needle-holder. - - The needles which I prefer are not those in general use, such as are seen in the figure, but those which are round and firm, with a bevelled and slightly FIG. 23. . curved point, made after the fashion—only much larger in size, than those devised by Dr. Emmet for repairing lacerations of the cervix. Different shaped needles and holders will be found described in the chapter on wounds. There are very many other instruments, some of which display great ingenuity, which are mentioned in the chapters treating upon the various surgical operations. To arrange them here would cause unnecessary repe- tition. Articles for Dressing.—The articles mostly used for dressing are lint, charpie, marine lint, antiseptic cotton, tow, bran, wood wool, compresses, bandages, adhesive straps, etc., etc. - Lint.—There are two varieties of this substance: one made by the manu- facturer—patent lint—and coming in packages, procurable from the pharma- ceutist and instrument maker. It is a soft, delicate, pliable mass, consisting of linen, the transverse threads of which have been drawn out by ma- chinery, leaving the longitudinal threads covered by a cottonous substance, which is extremely soft. The second, or scraped lint, is made by scraping a piece of linen cloth, and taking off the soft substance which is thus pro- duced. This is also known as domestic lint, and can be made in a short time. It is, however, at present but little used, being superseded by the manufactured articles for dressing, which, for their cheapness and adapta- bility, are superior to the scraped material. Marine Lint is now in great favor among many surgeons. It is prepared of oakum, which is tow saturated with tar, made by picking out the fibres of old tarred ropes. The favor which this dressing has met, has induced the preparation of the substance especially for surgical purposes. It comes in packages, and is called marine lint. It possesses both the antiseptic and astringent properties of the tar acids which it contains, and though of rather CHARPIE—CARBOLIZED JUTE. 41 coarse fibre makes a good dressing. I have used it as cushions on which to place stumps after amputation, and have dressed many wounds with it. It is applied to the parts and kept in situ by means of the roller bandage. Charpie.—This article is nothing more than the threads of old linen unravelled. A piece of linen should be cut about four or five inches square, and both longitudinal and transverse fibres should be drawn out. It has been asserted that this substance, when made of new linen, acts as a better absorbent than that of the old, but the softness of the latter renders it preferable. * Charpie is made into many forms by rolling and twisting it in different ways; thus there is the roll, the tent, the pledget, tampon, pellet, and others. A pledget is nothing more than a mass of charpie, which is made smooth on the surface, and by turning underneath or trimming the edges, is given the shape which is most desired. It can, with a little experience, be moulded by the hands into almost any form. The roll is composed of a smaller mass of charpie, rolled into the form of a cylinder, the fibres all running in a longitudinal direction, and then being tied in the middle. The roll is useful for absorbing pus in deep wounds and arresting haemorrhages. The tent is a conical form of charpie, made by doubling the roll and twisting the free ends to a point; it is generally used as a dilator. Bullets, tampoms, pellets, are masses of charpie, generally circular in form, and are chiefly used for the suppression of haemorrhage and the absorption of pus. - sº the introduction of the varied forms of antiseptic cotton and gauze, the old-fashioned charpie is scarcely ever seen, yet it is a good dressing for all, and can be made readily when other appliances are not at hand. Cotton, from its cheapness, its softness, and its pliability, is much used in dressing, especially fractures. It is most excellent in padding splints. It has been used as a direct application to wounds and ulcers, and in some instances with great advantage. - Absorbent cotton now is in general use by all surgeons, indeed by many, it is used in preference to sponges, especially in those operations in which the blood-flow is moderate. For mopping out wounds, wiping abraded surfaces, the construction of pledgets, tents and rolls, particularly if local medication be desired, absorbent cotton is preferable to any other of the substances used in dressing. Antiseptic cotton which is either borated, carbolated, thymolized, listerized, or prepared with corrosive sublimate, makes excellent dressings. Carbolized Jute (Corchoris Capsularis).-This substance can be procured already manufactured, but for those who desire to prepare it for themselves the following formula is recommended by Dr. R. F. Weir.” For 1 pound = 500 grams of jute. 50 grams = 3xiij of carbolic acid. 200 grams = 3i of resin. 250 grams = 31xij of glycerin. 550 grams = 3czxxviij of alcohol. Mixed as follows: The finely pulverized resin is dissolved in alcohol by applied heat; after cooling, the carbolic acid which is dissolved in the re- maining portion of the alcohol is added, and after, the glycerine. The solution is poured then on the jute and worked up with it thoroughly, so as to moisten all its fibres; it is then carded and put to dry, taking about * Am. Journal of the Medical Sciences, April, 1879, No. cliv., New Series. 42 A SYSTEM OF SURGERY. four hours and is ready for use in from twelve to eighteen hours after. During its various trials it has fully met all the requirements of an anti- Septic dressing, and is now in use in place of the carbolized gauze. Another formula, using benzine instead of alcohol, is as follows: For 1 pound (or 7000 grains avoirdupois) of jute— Take : Crystallized carbolic acid, . . 700 grains. Paraffin, . sº tº & o e e tº . 700 grains. Resin, tº e e e te tº tº e & . 2800 grains. Benzine, . gº ſº e e e º & ſº © 3 pints. Notwithstanding the great economy used in the last, yet the former for- mula (Münnich) is recommended. Tow comes, also, prepared for surgical use, and, when properly cleaned and Sorted, makes a fair dressing. Bran,—This cleanly article of dressing was introduced by Dr. J. Rhea Barton, of Philadelphia. In many cases of compound fracture, or after operations, where much suppuration is expected, bran applied in the fracture-box, or in junk bags, is all that can be desired. It is cheap and easily obtained, and readily carbolized or rendered antiseptic. Sawdust is sometimes used for packing in fracture-boxes. Wood Wool.—A very excellent dressing, not only for absorbent but for antiseptic purposes, is known as wood flour or wood wool. It is made of the very finest sawdust from scroll and other kinds of very fine sawing. It is light, cheap, and useful in many ways. That which I have used has been prepared for me by C. Am. Ende, of Hoboken, N. J. - Compresses are formed of pieces of cotton or linen cloth folded in various ways to best suit the requirements of each particular case. They are used to make and to equalize pressure; to prevent abrasion; to separate surfaces, and to fulfil other indications. They have received various names according to the shapes in which the cloth is folded. A perforated compress, as its name implies, consists of a pad or many folds of cotton or linen cloth, in which several perforations are made. These compresses are sometimes made of hair, or wool, or moss, and covered with muslin or linen. To relieve parts from pressure, as in the case of bed-sores, and allow a free vent for discharges, this variety of compress is very useful. It is sometimes made of india-rubber, and can readily be inflated with air. A graduated compress is one which has a broad base and small apex, and resembles a prism. This variety of compress is useful in dressing fractures of the leg and forearm, to separate the bones before the bandage is applied. The pyramidal compress “is one that is accurately formed by placing square pieces of muslin, gradually decreasing in size, on top of each other, and stitching them together to form a pyramid. It may also be made by folding a piece of two and a half inch bandage on itself, to form a pyramid graduated from end to end, and then placing a piece of cotton, or other substance, in the centre of the last turns. Thus formed, it is very useful in making pressure upon certain points, as in cases of haemorrhage from the deep-seated vessels of the leg or forearm.” Plasters and Straps.-The old-fashioned adhesive plaster is still used, but has very many disadvantages, so many indeed, that it is fast disappearing from the armamentarium of the surgeon. It spoils in warm weather and warm climates; it cracks and peels off when old; it requires a certain degree of heat to soften it (sometimes when old no degree of heat will do it); it often slips and becomes black with the contact of pus and discharges. To obviate these disadvantages many plasters have been introduced to the profession. The two, however, which are especially superior, and which I use exclusively in my own practice, are those made by Seabury and DRAIN AGE TUBES-TAR. 43 Johnson, New York. The one is known as the salicylated india-rubber plaster, which comes in rolls and spools of different widths, and possesses a great advantage in the fact, that it tears Straight, not requiring scissors, and that no artificial heat is necessary to make it adhere to the skin. The other plaster is that known as “Mead's adhesive plaster,” which, from its flexibility, its antiseptic, water-proof, and non-irritating qualities, render it a most supe- rior article. In those cases where extension is to be applied (as in the treatment of fractures, the application of splints for hip disease, etc.), it is decidedly the best in use, as it so adapts itself to the contour of the parts, that there is little likelihood of its slipping. The preparation of the varied carbolic acid solutions, the protective, the antiseptic gauze, the carbolic spray, the Mackintosh, drainage-tubes, catgut, antiseptic silk, sponges, and carbolized oil, is described minutely in the chapter on the “Varied Methods of Dressing Wounds.” The newer articles introduced for dressings will be found in the chapter on “The Present Status of Antiseptic Surgery.” - Drainage Tubes, of which mention is also made in the chapter upon the “Various Methods of Dressing Wounds,” are usually made of india-rubber tubing of varied lengths and calibres, in proportion to the size of the cavi- ties into which they are to be placed. Ordinary india-rubber tubing, care- fully rendered antiseptic, and with holes in the circumference about half an inch apart, is always serviceable (Fig. 24). Sometimes a few horsehairs make a good conduit, but for true antiseptic treatment, those drainage-tubes Drainage Tube. called decalcified bone tubes, rendered thoroughly antiseptic by being kept in carbolized oil, surpass everything of the kind in use. These tubes are prepared by C. Am. Ende, of Hoboken, and are securely packed in bottles of carbolized olive oil. They are prepared chiefly from the leg-bones of fowls. These bones after being thoroughly cleansed are steeped in an acid solution of strength sufficient to dissolve the calcareous element, thus leaving a tube of pure animal cartilage, which is readily absorbed. The satisfaction on removing a dressing (say, an amputation of the thigh) that has remained unsoiled for sixteen days, and finding sutures and drainage-tubes altogether absorbed, and the entire wound healed by first intention, is very great to the surgeon, particularly when he compares the new with the older and more disagreeable methods of dressing wounds. Tar.—Dr. George A. Hall, of Chicago, is very partial to a dressing called tar plaster, which is made as follows: - Pure refined gypsum, o e e º º º o º . pounds 2. Oil of tar, e e º o º º º e e e e § Larger quantities in same proportion. Triturate well in an iron or porcelain mortar, adding the materials in small quantities, and triturating until mixed so thoroughly that when placed upon a marble slab and smoothed with a spatula, no dark spots or streaks can be seen ; then place in an air-tight dry tin or earthen can, and keep in a dry place. The mixture will, in this form, keep any length of time, and always be ready for use. 44 A SYSTEM OF SURGERY. Directions for its Use.—Place a spoonful or more, according to the quantity required for use at one time, upon an earthen plate or marble slab, and with a spatula or knife, mix “olive oil” or “cotton-seed oil?” with the powder until it becomes the consistency of cream ; spread upon surgeon's lint and apply to the surface intended. Dr. Hall mentions the following as the cases in which he has found the plaster most serviceable: “All suppurating surfaces, where it is desirable to promote healthy granulation; in indolent ulcers; in burns, after sloughing begins; in all open wounds after operations where the parts are required to heal by second intention. In our hospital, as well as private practice, I have found it a most valuable dressing. It possesses aseptic and antiseptic properties, and being an inexpensive article, renders it especially applicable for hospital practice. The parts should be well dried before it is applied. To avoid the plaster coming in contact with the integument outside of the wound, surround the raw surface with plaster.” Rules,—The following rules for dressing are laid down by Dr. Smith, and cannot be too strictly observed by the young practitioner, as they not only promote to a great degree the comfort of the patient, but also facilitate the process of the removal of the old, and the application of new dressings: “1st. Let the surgeon make, or see made, everything that is requisite for the new dressing before removing the old one. “2d. Let him have a sufficient number of capable aids, to whom special duties shall be assigned before commencing the dressing, as this prevents confusion. Thus, in dressing a stump, or wound, there should be one assistant to support the limb; another to furnish hot water, and change it as required, heat the adhesive strips, etc., etc., by which means the surgeon can give his attention wholly to his own duty. “3d. Let him arrange the bed, as a general rule, after the dressings are changed; or, if in a case of fracture, before the patient is placed on it. “4th. Let the position of the patient be such as will cause him no un- necessary fatigue. “5th. Let the surgeon, as a general rule, place himself on the outside of the limb, with his face to the patient, as this will give more freedom to his movements, and prevent accidental jars. “6th. Let all the assistants be especially careful to guard against hasty and incºnsiderate movements, in order to prevent unnecessary pain to the atient. p The Bandage.—This is generally the single-headed roller, and should be three inches in width and three or four yards in length. It is a bandage of these dimensions that fulfils most readily the indications, viz., the exer- tion of uniform pressure over the affected part, the prevention of spasmodic action, and at the same time to support other dressings. Great care should be taken to apply the roller regularly over the part, exerting about equal force on every circular and reverse turn. If the fracture be of the compound variety, then the bandage of Scultetus (see page 47) may be employed, as by its use the wounds may be examined and dressed without disturbing the fragments, whenever occasion may require. It may be useful here to speak of the proper method of making the roller. Having prepared the strip of cloth, Lunbleached muslin which has been washed and ironed being preferable, fold the end of it eight or ten times firmly upon itself, in order that an axis upon which the roller is to be re- volved be made ; then with the left hand holding this axis, which is placed upon the right thigh, the palm of the right hand, slightly moistened, is applied and the bandage rolled tightly; by a little practice a good firm roller may thus be made in a very short time. Or, another method is to take up the cylinder, after a few turns have been made upon the thigh, and THE BANDAGE. 45 hold it between the thumb and forefinger of the left hand, allow the strap to pass over the right forefinger, and by seizing the roller with that hand, and turning it with the left the manipulation is completed. (See Fig. 25.) FIG. 25. In applying the bandage, every suc- ceeding turn should, at least, overlap the one immediately below it, and where there is the slightest inequality of Sur- face, the reverse turns must be made. There is quite a knack in doing this nicely, but it may be accomplished as follows: 1. Place the initial end of the bandage on the limb, and hold it there by the thumb of the left hand until, by a turn or two of the roller, there is no possibility of slipping. 2. Gradually ascend upon the limb until there is an enlargement to be covered, which is effected: 3. By placing the thumb or two fingers of the left hand on the point where the reverse turn is to be made, and holding it firmly there. 4. Ioosen the long end of the bandage which is held in the right hand, and with a turn of the wrist the reverse is made. (Fig. 26). FIG. 26. These bandages can be made with quickness by the simple apparatus as seen in Fig. 27, which screws to the table, or Fig. 28, which is made of brass. º single-headed roller is nothing more than the bandage rolled upon itself. - The double-headed roller is a bandage rolled from both extremities until the cylinders meet. The spica bandage is made with the single-headed roller, and consists in applying it in such manner that it shall ascend or descend upon the parts to be covered. The directions for its application are the same as making reverses, as shown in Fig. 26. Care must be taken in applying the Spica, that equal pressure be made throughout. Solid Rubber Bandages.—These bandages are essential to the surgeon in the treatment of any affections requiring gentle and even pressure, accompanied with elasticity. I have employed them in the treatment of sprains and vari- cose veins, in “caking” of the mamma, but more especially in hydroarthrosis of the knee-joint. Dr. Samuel Kohn” reports an excellent result from its * Medical Record, April 5th, 1879, No. 431. 46 A SYSTEM OF SURGERY. use in a case of syphilitic inguinal bubo, the swelling being dissipated in about ten days. Martin's bandages are made from twelve to eighteen feet FIG 28. #iº infill ſ ||||}|† T-2 º W º 8.5 l | fºndensato. E- É St. ſº 㺠Bandage Rollers. in length, from two to three inches wide, and are supplied at their distal ends with tapes. (Wide Fig. 29.) There is an objection to these tapes how- ever; if they are tied sufficiently tight to keep the bandage snug they (the tapes), being inelastic, will, after a short time, materially affect the circula- tion; therefore it is better to dispense with this method of fastening the bandage, and secure it with a safety-pin. There is a most excellent bandage FIG. 29, FIG. 30. India-rubber Rollers. §ºf made by the Davidson Rubber Company. This bandage is sixty feet long, and is from one and a half to three inches in width. With it are sold the safety-pins wherewith it may be secured (Fig. 30). There is another variety of elastic roller which is very serviceable, when some evaporation is desired, especially in sensitive skins, in which eczema- tous eruptions are liable to be either increased or produced by the soiled bandage. This roller is known as the open-mesh elastic bandage (Fig. 31). It was suggested by Dr. Shoemaker. Plaster-of-Paris Bandages.—In the chapter upon “Fractures,” I shall speak of the plaster-of-Paris splint, and call attention, as I have for many ł. in my lectures, and in previous editions of this work, to the difference between the plaster splint and plaster bandage or roller. The directions for making the splint I have also noted in the chapter alluded to. To make the bandage, or roller, the best substance is cheese-cloth, cut into strips from two to two and a half inches wide, and from eight to twelve yards long. A newspaper or sheet may be spread upon the floor or on a table, and a few feet of the bandage laid Smoothly down upon it; with a spoon the plaster-of-Paris THE BANDAGE. 47 should then be spread on the strip so laid down, and the bandage rolled with moderate tightness, to the point upon which the plaster is sprinkled; a few feet more is then arranged in a similar manner, and filled with the plaster and rolled, and so on the process is continued until the entire roller is made. After several rollers are thus made, they should be set on end in a box and covered with plaster-of-Paris, and a tight-fitting lid placed over the box or can. I keep these rollers in a tin box, and in a dry place. The preparation of the bandage is much simplified by using a simple box, arranged after the plan as seen in Fig. 32. When the bandage is to be applied the rollers should be placed on end in a basin, and sufficient water poured therein to cover them ; they should be allowed to remain thus in soak for a few moments, then the surgeon Box for making Plaster-of-Paris Roller Bandages. should take one in hand and thoroughly Squeeze it, dip it back into the water, give it another squeeze, and begin the application. If it be desired to have a very firm dressing, a basin containing plaster-of-Paris, made the consistency of thick molasses, should be at hand, and after five or six turns of the roller, a handful of the semi-solid material should be laid over that portion of the bandage which has been applied, and smoothly and evenly spread upon it. The further application of this bandage is then continued. To make the plaster set with more rapidity, Dr. Sayre uses the rolling flat- iron (Fig. 33). The removal of a firmly-set plaster-of-Paris bandage is a work that requires both skill and time, and very often the patience, of both FIG. 33. Sayre's Rolling Iron. the patient and the operator. Sayre has invented shears, Henry has done the same, and Esmarch likewise, but there is always a good deal of difficulty. The instrument I use is a circular saw worked by a lever and ratchet, in- vented and manufactured by Colin, of Paris. It is said by Dr. F. Murdock,” that by applying nitric acid in the line in which the bandage is to be divided, the plaster is rendered soft, and the division easily effected with an ordinary jack-knife. The plaster-of-Paris bandages are prepared ready for use, and neatly and securely packed, by C. Am. Ende, of Hoboken, N. J. The many-tailed bandage, or the bandage of Scultetus, is made in the fol- lowing manner. A strip of roller, of sufficient length to extend around the * Medical Record, 1882, September 19th. 48 A SYSTEM OF SURGERY. limb to be covered, is laid smoothly upon a table; a second strip, overlap- ping the first about half an inch, is laid parallel to the first; and so on a third, fourth, and fifth, until as many “tails '' are made as will be required. Along the centre of these a longitudinal strip is laid at right angles, and stitched down. When the bandage is completed, it is applied by laying the longitudinal strip on the posterior surface of the limb, and beginning at the lowest end, bringing the tails one over the other, on the affected part. It will be seen that by such method every tail that is laid over, holds those previously applied, in position. This bandage is especially useful in wounds and in compound fractures, in which it is necessary to examine the parts frequently without materially disturbing the position of the limb. Tents are prepared of various substances to dilate passages or to keep wounds and sinuses open. The Tupelo tent, which is made of the root of the Tupelo tree, cut into a smooth cylinder, and subjected to powerful pressure, is the best in use. FIG. 34. Tupelo Tents. It retains its roundness, and, above all, its smoothness after expanding, and does not become offensive. These tents are now made with an opening through their centre for drainage. (See Fig. 34.) Sponge Tents.-Tents are also made of compressed sponge covered with wax, which being inserted into fistulae, wounds, or canals requiring dilata- tion, the heat of the body melts the wax and the sponge expands. These are manufactured by machinery, and made in graded sets (Fig. 35). They can be charged with any medicinal or antiseptic substance required. Sea-tangle tents are also used for expansion. Paper.—In the surgical wards of the Pennsylvania Hospital, Dr. Addinell Hewson has made use of paper as a surgical dressing with most excellent results. He was led to its use by reading in a daily periodical that paper had been substituted for lint during the Prussian campaign, and after various experiments in regard to strength, power of retaining moisture, elasticity, and pliability, he arrived at the conclusion that common news- paper “answers all the requirements equally well if not better than lint.” He says: “I have tested paper dressings in all varieties of simple incised and lacerated wounds; in compound fractures, on Suppurating surfaces, whether inflamed, indolent or otherwise, and in all the major and minor Operations which I performed both as primary and secondary dressings, and with never any results which could lead me to consider paper inferior THE PUs BASIN–INCISIONs. 49 to the other means which I had been in the habit of employing for these purposes.” For stanching hamorrhage, paper, especially the softer blotting-paper, has been found very useful; in fact the application of ordinary paper as a domestic remedy for trifling hamorrhage has long been known as efficient. Dr. Hewson, in his interesting essay, also gives his method of substituting paper for oiled silk as a covering for wet dressings. The cheapness of paper is also made apparent by exact computation. Even when the best quality of blotting-paper, made of purest linen fibre, is used the difference would be as three to thirty-three in favor of paper. In the Hahnemann Hospital I have made use of the waxed paper, which is prepared in the house, and for its cheapness and efficacy, in those cases where oiled silk or india-rubber cloth is generally employed, it answers admirably. The Pus Basin.--This very necessary modern appliance for dressing is made of metal or hard rubber, and is so curved at its sides that it ac- RS & Co p commodates itself to different inequalities of surface. For receiving pus, for catching the water from the syringe, as a receptacle for pins, wires, and straps, it is almost indispensable. For operations about the face, eye, ear, or nose, the removal of scalp tumors, and other operations, the pus Cup is quite es- sential. Figs. 36 and 37 represent the different shapes of the basin, made of hard rubber. Fig. 38 shows the soft rubber basin of Warren. Incisions.—The method of making inci- sions varies very much in accordance with the operation to be performed and the will of the operator. The positions in which the knife is held, however, may be laid down for the benefit of the student and young practitioner. Before proceeding with any operation, the edges of the instruments should be examined by a competent assistant or by the operator himself, and having satisfied himself of their keenness and cleanliness, the cuts, when made, should be of sufficient length for the purposes required. None but those who have witnessed the embarrassing effects of small incisions can appreciate the value of fair, sweeping, and clean cuts in any operation, whether trivial or important. Positions of the Knife.—In some instances the knife may be held as an ordinary carving-knife, the thumb upon the handle, the index finger on the back of the blade near its shoulder, the remaining fingers steadying the instrument, as seen in Fig. 39. Another position of great convenience is when the scalpel is held as the violinist holds the bow; the blade of the 4 50 A SYSTEM OF SURGERY. knife should be turned a little sidewise, and it should be held lightly between the thumb and fingers, as seen in Fig. 40. Again, the scalpel is held as a pen, especially in dissections. The extreme mobility given to the instrument with the forefinger and thumb, while the FIG. 39. First Position. hand is steadied by the remaining ring and little fingers, and the rapidity with which the upward and downward motions may be made, render this **** - . . . "...s.º." ****.*.*.*.*.*.*.*.*.* *tºº Second Position, position a favorite one with many skilful operators. The position is seen in Fig. 41. Incisions are called simple —; crucial, X; or V-shaped; or resemble the letters H, L, T, I; or they may be in the form of an ellipse, or they may be semicircular. --- - tfit : %. # #. . . " º ð’ 2%.’... º | , ; ; ; ; ) $8.2% #ºſſ ºf ſº "#". ºf d Third Position, No rules can be given for the shape and direction of incisions, as the surgeon must, in every presenting case, adopt such as will produce the best result with least deformity, - Hypodermic Medication—The value of hypodermic medication in many surgical disorders forbids us to leave this portion of the subject without mention of the instruments employed, and the doses of the substances found most efficacious. The hypodermic syringe was invented by Alexander Wood, of Edinburgh; he conceiving the idea from the instrument used by HYPODERMIC MEDICATION. 51 Mr. Fergusson for injecting navi. It consists of a small glass or hard rubber syringe, with one or two movable capillary points; these are intro- duced beneath the integument, the cylinder having been previously charged with the dose to be administered, and the piston slowly pressed home. The best way to insert, the point is to pinch up a portion of the integument between the thumb and forefinger of the left hand, and, taking the syringe in the right, push it into the fold thus held up, as in Fig. 42. Many improvements have been devised in the construction of the hypo- dermic syringe, in order to save time and trouble in counting the number of drops to be employed as a dose. Thus, in some, the number of drops FIG. 42 | H. º | | | | % % | j|| | ſ Fº * - % % % - *4% % * , , % % º % - % sº ź % ** Method of giving Hypodermic Injection. or minims is marked upon the piston, and the cylinder made of glass; by drawing up the piston, the liquid follows, and the exact amount may be measured; in others the minims are cut into the cyinder (Fig. 43). The glass cylinder is in reality a minim measure, which is regularly graded. This, for better preservation, is encased in a metal covering, which FIG. 43. *WWW '.' ' Yºº- *E > * is fenestrated on one side to show the marks upon the glass. The piston is longer than the cylinder, in order that it can, if necessary, be pushed through to be washed and oiled. - - Sometimes there is considerable trouble experienced in filling the cylinder from the bottle, and some waste of the material. To obviate this, a bottle with a mouth set at right angles with the body, and of sufficient size to admit the nozzle end of the syringe, has been prepared. (Wide Fig. 44.) After using the syringe, it should be carefully rinsed, and the piston worked several times in the cylinder to drive out all the fluids; the wires should then be immediately inserted into the points. In making the hypodermic injection, it must be borne in mind that at most half the stomachic dose should be employed, and in many instances 52 A SYSTEM OF SURGERY. it is better to begin with a dose one-third or one-fourth the quantity admin- istered by the mouth. It should also be borne in mind, that the liquids should be fresh and pure; if they are old, they are likely to contain ferments, which, being injected into the tissues, would, in all probability, cause pain and suppura- tion; indeed, in certain conditions of the system, such results may follow most carefully introduced injections. To obviate such difficulties chemists FIG. 44. \\ * sº | *Tº --- ~ : Hypodermic Case. *=== have prepared minute tablets, capable of complete solution in small quan- tities of water. These receive the name of soluble compressed tablets. They are very convenient for use. There is no danger of over-dosing the patient, and the solution injected is always pure. The doses may be as follows: Muriate of morphine, . Sulphate of morphine, . Atropine sulphate, º Strychnine, g e Sulph. soda (Hewson), . Sulphate quinine, . # to # of a grain. . § to # of a grain. * to gº of a grain. *5 to sº of a grain. grs. ii. . ... grs. ij to grs. iv. &§tº*tº& & §*ºe©gº* & & Squibb's liquor of opium, . g g º . gtt. v to gtt. lx. Magendie's solution, . . * o * se g . gtt. iii to gtt. xx. Tinct. hyoscyamus, g © e g g cº © , gtt. X to gtt. XX. Tinct. cannabis, . ſº e o e g tº { } , gtt. X to gtt XX. The Aspirator.—The idea of withdrawing abnormal and other fluids from the different cavities of the body has been promulgated among surgeons and physicians from remote ages. Instruments constructed for this purpose were termed pywcla, because they were generally employed for the with- THE ASPIRATOR. 53 drawal of pus, and although variously modified, they were all constructed on the principle of the exhausting syringe. Dieulafoy, on the 2d of November, 1859, presented through Professor Gubler, to the Academy of Medicine, an invention of his own, to which he gave the name “Aspirator,” and which has become one of the most important instruments in the hands of the profession. It consists of hollow capillary needles, and a suitable air-pump to create a vacuum. The varied forms of the aspirator are constructed on these principles, and the numerous operations which can with safety be performed, are daily proving the immense value of the apparatus. I have employed this instrument in very many diseases, among which may be noted hydatid cysts of the liver, abscesses of the liver, retention of urine, poisons in the stomach, ovarian cysts, hydrocephalus, spina bifida, strangulated herniae, effusions into the pericardium, purulent pleurisy, dis- eases of the joints, diseases of the tunica vaginalis and peritoneum, San- guineous effusions, acute abscesses, suppurating buboes, and other diseases. A glance at the above list of diseased conditions, for which the aspirator can be employed, detects the fact that a majority of them are of the most serious character; in addition, when we remember the comparative harm- lessness of the punctures and the immediate relief, if not cure, which generally follows aspiration, the wonder is that such an apparatus has not been before constructed. As a means also of diagnosis, the aspirator must hold a high place; the facility with which the operations may be performed adding much to the general usefulness of the apparatus. 54 A SYSTEM OF SURGERY. The needles of the aspirator are hollow and of various sizes, the smallest being about the calibre of the ordinary hypodermic syringe; to these needles is affixed a stopcock, which shuts off the air; they are also furnished with a screw, by means of which they are attached to one end of an india- rubber tube, the other extremity of which fits into a glass cylinder, in #.” by means of a piston (or air-pump) a vacuum is created. (Vide ig. 45.) The simplicity of the contrivance, and the great suction which can be brought to bear upon even semifluid substances by means of the vacuum, will be apparent. When the instrument is to be used, the vacuum is first created, the needle is then inserted into the part desired, the stopcock turned, and the fluid, whatever it may be, is drawn within the glass cylinder. Of course, the range of disorders to which the aspirator is adapted, is now pretty well settled. The instrument has had its “rum,” as every fashionable medicine, every novel instrument, and every improved method of operation has had before it. Doctors have run mad over Bavarian beer and cod-liver oil; there have been carbolic acid madness, chloral frenzy, and the bacteria craze; Civiale predicted the exclusive use of the litho- triptor in cases of stone; Chassaignac would amputate legs with the écraseur; and even at present, Professor Dittel would accomplish the same result with the “elastic thread.” Esmarch's artificial ischaemia has been extended to keeping the blood in the body during serious and prostrating diseases, and the aspirator, modified into a great variety of shapes, has been tried for all classes of disorders, and its use is thoroughly understood. No instrument introduced into the surgeon's armory, has become more valu- able, both as a means of diagnosis and of relief, than that now under con- sideration. As is usual, there have been many modifications of the aspirator, and as the simplest is always the best, that represented in Fig. 45, according to my experience, is to be preferred. If large quantities of fluid are to be re- moved, the cork may be fitted to a FIG. 46. larger bottle. The modification of the trocar needle, by which a rounded in- stead of the usual sharp-pointed ex- tremity is left within important cavi- ties, is one much to be desired. I have also used Reynders’ modification of the aspirator, as seen in Fig. 46. Its advantage is compactness. Its bottle is small, but nevertheless it is as efficient as an apparatus with bottle of any larger size. This is achieved by the hole in the bottle, F, through which the contents can be emptied most con- veniently by opening the stopcock C. and removing the fitting D, connected with the pump, from the bottle B. The stopcock at D controls communication from the bottle with the pump as well as through the needle. To exhaust the bottle of air, the stopcock C is closed, and the stopcock at D turned as shown in the figure, and the pump worked. By turning the stopcock at C horizontally, as shown by the dotted lines, communication through the needle to the bottle is established. To inject with this aspirator, the bottle is drawn full of liquid with the *º, | : §s ºf º gº º * Sº :0 .º.º. º.º.º. - º º º º # '. º º:. º sº. iſ: |rſ. |: ºt º i ::: i: |;# THERMO-CAUTERY. 55 aspirating end of the pump attached; the stopcock C being opened and the end G in a basin. The injecting end of the pump is then put on, and the liquid forced out through the hole F, stopcock G, and end G, to the latter a needle may be attached, in order to throw the liquid where desired. When smaller quantities of fluid are to be withdrawn for chemical or microscopical examination, Dieulafoy's small aspirator (Fig. 47) is an ex- cellent one. One of the best of the many modifications of the aspirator is that of Dr. Simon Fitch.* His invention consists in what he terms his “dome trocar,” with the addition of “a hose-coupling attachment” for the aspirator. I can testify to the efficacy of the instrument, having used it frequently. FIG. 47. The description of the apparatus I have given in part from Mr. Tiemann's catalogue, a perusal of which will satisfy the reader of the completeness of the instrument: “He has had the distal orifice of the inner canula closed over by a rounded or dome-shaped roof, so that, when it is projected beyond the cutting-point of the outer canula, the two tubes fit closely together and the end of the combined instrument feels perfectly smooth like the end of a sound or catheter, and may be freely moved within the cavity penetrated, as the ovarian cyst, the abdomen, the thorax, the bladder, or even the pericardium, without danger of wounding any viscus or organ, puncturing any vessel, or even scratching or abrading the lining of the cavity, or of any parts contained therein. The base of this dome being of the same external circumference as the inner tube, of which it is the continuation, and fitting the outer tube accurately, when the point of the instrument enters a cavity, there can be no escape of fluid till the dome is advanced, occluding the cutting-point of the outer tube; then there is disclosed a fenestra or oval aperture on the under side of the inner tube, cut out of the lower wall, and one-third of each side-wall, of the full size of the bore of the tube, and by which the fluid may be freely evacuated.” Thermo-cautery.—The neatness and efficiency of this instrument have already made it a general favorite with surgeons in those affections which require the actual cautery. Its advantages are, that it may be used steadil for any length of time, the incandescence being kept up at the will of the operator by compressing the air-bulbs. The principle involved is simply the fact that platinum is one of the metals that when slightly heated, gradu- ally becomes incandescent by the contact with certain hydrocarbon vapors. * New York Journal of Medicine, April, 1875. 56 A SYSTEM OF SURGERY. A, represents a bottle nearly full of common (not deodorized) benzine. The cork that fits this bottle is perforated by a double tube, to one branch of which an air-blowing apparatus, C, is attached, while to the other is affixed an india-rubber tube, the distal end of which is fitted to a hollow handle, G, into which handle the cauterizing knives or buttons, D, E, are screwed. These latter are made of platina, are hollow, and are filled inside with platina-sponge. These ends are riveted into cylinders, each containing two tubes, one to conduct the vapor of benzine to the cautery (called also the combustion-chamber); the other, to carry off the products of combustion. Sometimes, when a greater length of the instrument is required, an addi- tional tube, F, may be added. B, is an ordinary alcohol lamp. The bottle, A, may be hung by the hook on its side to the vest-pocket of the operator, Paquelin's Thermo-cautery. who works the air-bulb with the left hand, while he applies the cautery with his right. The end of the cautery, D, is held in the flame of the lamp for one or two minutes to heat the platinum ; the bulb is then gradually inflated, and rapid incandescence is produced, which may be maintained just so long as the air-bulb is worked, which forces the benzine vapor from the vial, through the tube into the handle, and thus to the platina. With this instrument I have performed very satisfactory operations. Galvano-puncture.-Galvano-puncture, on account of the pain inflicted, is seldom resorted to, except in the treatment of surgical diseases, where the usual mode of application with moistened electrodes has been resorted to and failed. The procedure is the same as in electrolysis. Galvanic Moxa is employed as follows: Denude the part to the extent desired, by means of blisters or other excitants, in two places, one above the other, then apply zinc and silver plates as described for ulcers. Apply the zinc plate to the part from which the discharge is desired, and the silver plate to the other. Sodium is eliminated at the silver, and chlorine at the zinc plate. A poultice applied to the part will give a free discharge of pus. GALVANO-CAUTERY BATTERY. 57 Galvano-Cautery Battery.—The galvanic cautery is rapidly taking the place of the écraseur of Chassaignac. In the removal of parts where considerable haemorrhage is to be ex- pected, it is the instru- ment par excellence. In amputations of the tongue and penis, in certain forms of haemorrhoids, in the removal of carcinomatous growths within cavities, and for the extirpation of certain haematoid neo- plasms, there is nothing that will compare to it. Fig. 49 represents the very favorite battery of Piffard, with cords and agitators. This instrument is very compact, its size being only 63 x 10 inches, and its weight but 15 pounds. In the cut, the letters a, b, c, d, e, f, and g, represent the varied forms of plati- num knifes, while h shows the handle into which any of the blades may be inserted. The Electric Light.—This beautiful method of illumination is now growing in favor, the objections to it, however, FIG, 50. 58 A SYSTEM OF SURGERY. being in the care that has to be taken of the battery, and often the un- certainty of obtaining a good light. The apparatus which I use, and which has given me excellent results, is that introduced by Dr. St. Clair, and known as the “St. Clair Surgical Electric Battery.” It can be used readily for all speculum examinations, for the microscope, and, with a dynamo, can be made to pump an aspirator or FIG. 51. roll a bandage. Fig. 50 represents the battery, and Fig. 51 the different lamps and cauteries. Carl W. Meyer has also introduced an electric illu- minator for the mouth and throat.* - Electrolysis.t-When two or more needles connected with the poles of an apparatus, generating a galvanic current of sufficient intensity to overcome the resistance of the circuit, are inserted into living animal tissue, the fol- lowing results take place, viz., the blood vessels of the part become dilated and engorged, producing intense hyperamia, and the absorbents are stim- ulated to increased activity. In short applications with weak currents, the effect ends here, but should the action of the current be continued, and the tension and quantity slightly increased, the albumen of the part becomes coagulated, and with a still stronger current, the water of the tissues becomes decomposed, the oxygen becoming attracted towards the positive pole, and the hydrogen towards the negative, to find vent at which it bubbles violently through the intervening structures, tearing fibre of muscle, separating cells, nuclei, and filaments, etc., and mechanically destroying anything that may oppose its egress. The salts of the tissues are resolved into their contained acids and alkalies, the acids forming around the positive pole, and the alka- lies around the negative, where both act as powerful escharotics, producing sloughing. Thus the tissue acted upon is made to destroy itself through its * Wide Medical Record, July 18th, 1885. - t These remarks on Electrolysis were prepared by the late John Butler,M.D., L.R.C.P.E., author of a Text-book on Electro-Therapeutics and Electro-Surgery. ELECTROLYSIS. 59 own contained reagents. The operation thus described may practically be divided into four stages: - 1st. The dynamic or absorbent stage, corresponding to what is called by Remak—electro-catalysis. 2d. The coagulating stage. 3d. The stage of mechanical disintegration, and 4th. The escharotic stage, or the stage of complete and ultimate elec- trolysis. We use the first stage only in the treatment of serous effusions, strictures, watery cysts, etc.; the second stage, in the treatment of aneurism, varicose veins, haemorrhoids, navi, and other diseases, where coagulation of the contained blood is desired, and where the production of a slough is not intended; the third and fourth stages, in growths of a malignant nature, fibrous tumors, polypi, fatty tumors, and in any case where a total or partial destruction of the part may be necessary. In the operation the greatest amount of effect produced is in the immediate vicinity of the needles; in very mild currents, the cauterizing effect is only produced in the parts directly in contact with the needles; with strong currents, the size of the slough depends upon the structure of the tissue, the amount of water and salts it contains, the size of the needle, and the duration of the application. The eschar produced by the positive pole differs essentially from that caused by the negative, inasmuch as the ulcer resulting from the separation of the slough of the first, leaves a cicatrix which heals by contraction like that produced by an acid caustic. No such results take place from the action of the negative pole; on the contrary the cicatrix is soft and pliable. It is, of course, entirely impossible to obtain purely the results of any one of these stages per se; for instance, in electro-puncture of an ovarian cyst, the result aimed at, is to produce absorption, and so act on the internal part of the cyst as to destroy its secreting powers and prevent refilling. Electrolysis of the watery parts of the contents must and does take place to a greater or less degree, but it forms no part of the desired effect, and so in operating upon aneurism or navus, thorough coagulation of the blood is the only thing desired. Electro-puncture, as thus described, is presumed to have been performed with needles made of unoxidizable materials. Should the needle of the positive pole be made of material capable of being acted upon by the acids set free at this point, the results are modified in a great degree. For example, suppose the positive needle should be made of iron, the needle becomes dissolved by the acids set free, and the phosphate, sulphate, and chloride of iron are formed, principally the chloride. From this fact, we would infer that iron needles would be useful when coagulation of blood is the result aimed at, and there is no doubt they assist the accom- plishment of such a result to a considerable extent. Suppose we use zinc needles, we have chloride of zinc formed, which is a powerful escharotic, and assists materially in hastening the destruction of morbid growths. I have used these needles with a weak galvanic current and long applications, for the destruction of malignant tumors, and believe it to be, in many cases, the most appropriate treatment. The diseased tissue is chemically dissolved under the action of the current, which at the same time influences the morbid nervous impulse which caused the secretion of the diseased cells in the first place; and the electro-chemical action of the already disintegrating structure on the needle forms, molecule by molecule, one of the most powerful escharotics, which destroys, molecule by molecule, any of the diseased mass that may possibly escape the action of the current, and not only that, but it acts as a powerful antiseptic on the slough that otherwise . might become offensive before separation had time to take place, and still further it certainly hastens that separation. Another advantage of the operation is that it is comparatively painless, in some cases entirely so. 60 A SYSTEM OF SURGERY. Electrolysis of the tissue takes place so slowly that the chloride of zinc is also formed slowly, and immediately uniting with the tissue that is already half numbed by the action of the current, very little pain, if any, is pro- duced. In fact, the strength of the current can be so arranged that no pain is caused. In my opinion, the electro-chemical treatment far surpasses ordinary electrolysis in certain cases, where total destruction of the part in as short a time as possible, and with a minimum amount of pain, is desired; still a slight eschar around the uninsulated part of the needle is unavoidable. In such operations it behooves us to make this latter as slight as possible, which can be done by diminishing the amount of quantity of current used; that is to say, in any operation requiring a cauterizing effect, a large quantity is required; in operations where we simply desire to produce the absorbent or electro-catalytic effect, we require tension, but small quantity. We will, for the present, dismiss this question of electro-chemical treat- ment, and return once more to the consideration of the effects of the current as applied with unoxidizable material. - This operation so far, we have only considered as performed by the use of needles introduced into the tissues. The same effects in a lesser degree can be obtained by external application of metallic and other rheophores to the skin, mucous membrane, or denuded tissue. And when we use the current for the sake of its lesser effects, it is frequently applied in this Iſlä, Illſle I’. One of the greatest difficulties in the technics of electrolysis, so called, to the tyro electro-therapeutist is to avoid doing too much. The operator must have a battery provided with a Brenner's, or other equally accurate rheostat, constant and reliable, capable of giving every variation of quan- tity and intensity of current. He must be quite familiar with its action, and with the effect each variation is capable of producing on living animal tissue. He must also be able to control the electro-motive force to the exact point capable of producing the effect desired, and no more. For instance, what could be more deplorable than that sloughing of the urethra should take place when the effect intended to be produced is merely the absorption of a stricture? or in operating on a naevus on the face of a young lady, that an eschar should be caused when we merely aim at coagulation of the morbid growth 2 And yet the slightest overstepping of a scarcely defined boundary will cause just such a result. Better far to do too little than too much. It is impossible to state with precision the exact quantity and intensity of current to be used, and that depends upon the size of the growth, the density, and the amount of watery and saline ingredients con- tained. This must be learned entirely by experience. . The diseases for which electrolysis are especially applicable, are chiefly strictures of the urethra and oesophagus, naevi materni, haemorrhoids, hydroceles, certain forms of aneurism, and a variety of tumors, especially cystic and fibrous. In the former editions of this work, several cases of successful treatment of each of the above affections were given, but owing to the increased amount of matter necessary to be inserted in this edition, the details have been omitted. DISHNFECTANTS AND ANTISEPTICS. 61 CHAPTER II. DISINFECTANTS AND ANTISEPTICS. ANTIQUITY OF DISINFECTION — CLEANLINESS — CHARCOAL – LIME–ASHES-EARTH – SMOKE-COLLINS's DISINFECTING FLUID—THOMPSON'S DEODoRIZER—HEAT—CoFFEE —BROMINE—OzoNE—IoDINE–NITRATE of LEAD–CHLoRINE–CHLORIDE OF ZINC —CHLoRIDE of LIME – LABARRAQUE's SoDUTION – PERMANGANATE OF POTASH- NITROUS FUMIGATIONs—TAR ACIDs. THE precise meaning of the word disinfection, is any process by which contagion arising from disease may be destroyed. Common consent, how- ever, has applied the term to the use of agents which will counteract or destroy noxious effluvia or gases arising from decomposing animal or vege- table matter, wherever found; as well as to the destruction of microzymes arising from diseased processes. The use of disinfecting agents in surgical practice, not only in regard to the benefit that may accrue from their use to the patient, but in affording comfort to the surrounding sufferers and attendants, is certainly of much import. In many cases in which large wounds are to be dressed, and where many suppurating sores are grouped together in one apartment, the atmosphere is rendered so noxious that the health of those who, through force of circumstances, are compelled to inhale the vitiated air, is often materially impaired. Untoward accidents may occur from this cause alone. From a knowledge of these facts, and from a proper understanding of the true nature of noxious effluvia, much attention has lately been given to this subject. Within the past ten years very important disinfecting agents have been introduced to the profession. It is not proposed in this chapter to enter upon the theories of ferments, germs, and sporules, but merely to mention some of those materials which are found most reliable in surgical practice in neutralizing the poisonous exhalations from suppurating sores, large wounds, abscesses, or decaying or decomposing substances. The object of the surgeon is to find such agents as may either arrest decompo- sition, or finish the process entirely. The efforts to render the atmosphere of large cities and towns as pure as possible by drainage is very ancient. Justinian tells us that “the praetor took care that all sewers should be cleaned and repaired, for the health of the citizens, because uncleaned and unrepaired sewers threaten a pestilential atmosphere and are dan- gº." He also states, that it was forbidden to throw refuse into the I'Oa,OS. In 1732 Petit made some experiments with antiseptics, and in 1750 Sir John Pringle wrote his “Experiments on Septic and Antiseptic Substances, with Remarks relating to their Use in the Theory of Medicine.” In 1767 the nitrate of potash was highly recommended. In 1732 Guyton Morveau instituted fumigation with various acid vapors. Dr. Carmichael Smyth employed nitrous fumes, at Winchester, in 1780. Chlorine was introduced by Fourcroy, in 1791–2, and was first employed in England by Dr. Cruikshank. First in the catalogue of disinfectants are cleanliness and fresh air; nothing can equal them—nothing can be of more benefit to the patient. Free ventilation, so arranged that no absolute draught is produced, and the constant use of the bath, are the great adjuvants to surgical practice, and as these facts are becoming universally acknowledged, our hospitals are 62 A SYSTEM OF SURGERY. being so scientifically constructed, that these requisites are attained in the greatest perfection. For proper disinfection, however, cause and effect must be considered. If we use substances which will prevent the former, we have what are termed antiseptics; if we employ agents which neutralize the latter, we have only deodorizers. By using substances which render the surrounding atmosphere more pleasant to our olfactories, we have no proof that the unwholesome condition is removed ; and there is no reason why the admix- ture of the two substances may not, perhaps, be even more hurtful than the original disagreeable odor which we have been endeavoring to neutralize. A true antiseptic must possess the power, as before said, not only to prevent the disagreeable odor from being perceptible to the senses, but to destroy, as far as possible, the cause upon which the odor depends. Strange as it may appear also, those very agents which generate decom- position and produce the emanations which are hurtful, are the same that when their action is prolonged or intensified, do away with the process entirely.” This is well illustrated by the action of heat and moisture, the great producers of decomposition. Increase either, and the process is at once suspended. So also it may be remarked of the so-called chemical disinfectants. They either increase, in a great degree, the oxidation upon which the decomposition depends, or take away the oxygen altogether. Disinfectants may be classed into absorbents and, antiseptics. The latter, antiseptics, were known to the ancients, and the process of embalming was nothing more or less than a peculiar antiseptic treatment. In fact, the burial of bodies in the earth is another form of the same process. The conservation of meats, fruits, and vegetables of the present day is also a variety of “listerism.” The division that we have made is all that is necessary for practical purposes; the former absorbing or neutralizing the volatile or gaseous products of decomposition; the latter preventing the decomposition, or modifying it by chemical union with the substances liable to be decom- osed. p In searching for materials to purify the atmosphere, it is requisite in many instances, that those be selected which are cheap and can easily be obtained. Among these we find charcoal, lime, copperas, ashes, and earth. In covering over cesspools, in sprinkling damp or moist surfaces, in hospital wards and privies, these substances are used with great benefit. They are classified under the head of absorbents. The charcoal and lime may advantageously be mixed together. In cases of gangrene, of the moist variety, where the stench is great, I have enveloped the parts in pulverized charcoal, with much comfort to the patient and attendants. Earth.-Through the experiments of Dr. Addinell Hewson, of the Penn- sylvania Hospital, it has been found that one of the best disinfectants known, is dry earth; it should be free from grit or other foreign material, and should be perfectly dry and finely pulverized. It can be applied to ulcers, suppurating surfaces, recent wounds in which suppuration is to be expected; in fact, to all wounded or burnt surfaces. moke.—The smoke from a wood fire is known to have fair disinfecting properties, but oakum soaked in tar, and then lighted and allowed to smoulder, is preferable. Various compounds have been used for disinfecting purposes, among which may be noted Collins's Disinfecting Powder, which consists of two parts of fresco and dry chloride of lime, and one part of burnt alum, well * Wide an excellent article on this subject by Carroll Dunham, M.D., in the Transactions of the American Institute of Homoeopathy for 1869, p. 117. DISINFECTANTS AND ANTISEPTICS. 63 mixed together; if the weather be very dry, a little water may be added. The powder may be placed on plates or pieces of glass, and should be renewed every day.* The following compound is known as “Thompson's Deodorizer and Disinfectant:” Gypsum, . *> te ge te * g . 6 parts. Fresh-burned ground lime, . gº º e * º o © . 2 “ Prepared charcoal, . e g e © * tº º * . 2 “ Wood ashes, . * {º * º e e we o e tº . 1 part. Common salt, e gº tº te ve g tº e tº ſº . 1 “ This compound slowly develops chlorine gas, and is very cheap as well as efficacious. Heat is a powerful disinfectant, combining the properties of both deodori- zation and disinfection. Burn, if possible, old clothes, and the wornout coverings of mattresses or bed tickings, or thoroughly expose them to a dry ºnosphere of 280° F. Steam may also be used with most excellent resultS. Fire was used in many ways by the ancients as a purifier, and large fires were often kindled in the streets of their cities, which, with the perfumes of flowers, renewed the air. Coffee.—A very good deodorizer is the smoke or vapor which arises from coffee, when it is being roasted over a moderately hot fire. In the dissecting- room I have found it very serviceable, and by keeping a good-sized shallow vessel half full of coffee, and stirring the same occasionally, the atmosphere is entirely deprived (at least so far as olfaction goes) of its unhealthy odor. Bromine is an expensive though a good disinfectant. When the stopper is removed from the vial containing it, spontaneous evaporation takes place. It is, however, somewhat difficult to manage, and from its cost, is not very much used. Ozone.—Dr. T. Herbert Baker, in his prize essay, gives the preference to this agent for steady and continuous effect. It belongs, according to Dr. Day, to those bodies which disinfect and deodorize by resolving and decom- posing into primitive and innoxious forms the deleterious matters. It does not, however, possess these qualities in so great a degree as chlorine and bromine. . Ozone can very easily be released, by placing a stick of phosphorus in a cup filled with water, and allowing an end of the phosphorus to remain uncovered. During the night less should remain exposed than during the day, and it should be removed from the apartment altogether for several hours at a time, because ozone in excess is hurtful. Iodine is a powerful disinfectant, and can be used with benefit in the following manner: Expose to the air a teaspoonful of the crystals of iodine in a cup or on a piece of porcelain, which may be put beneath the bed, or in a convenient place, and will have a most excellent result. During the severe cholera season of 1866, in St. Louis, I employed this substance continually, and also ordered all the vessels used by the patients ; immediately emptied and rinsed with a solution of the tincture of 1OCIII) e. The Nitrate of Lead has been also used with success as a disinfectant. The compound known as Ledoyen's disinfecting fluid, is nothing more than this salt in solution, in the proportion of a drachm to the ounce of water. This is said to be particularly efficacious in the correction of fetid odors depending upon the presence of sulphuretted hydrogen, or hydrosulphate * Medical and Surgical Reporter, vol. xix, p. 76. 64 A SYSTEM OF SURGERY. . of ammonia, which it decomposes. It may also be sprinkled in apart- ments, or mixed with offensive discharges. This substance, however, does not prevent or arrest animal decomposition, nor does it render contagious or marsh miasms innoxious. - Chlorine.—One of the best antiseptics of the present day is chlorine. Its destructive powers are great, and it was discovered by Scheele in 1774. It is produced in several ways: first, by pouring on peroxide of manganese, muriatic acid; second, by adding one and a quarter alum-cake, or sulphate of alumina, to one of chloride of lime; third, by “occasionally dropping a crystal of chlorate of potash into muriatic acid.” The action of this gas is twofold: “the chlorine combines with hydrogen and thus forms new com- pounds; with water it renders oxygen nascent, so that it is a powerful oxidizing agent, and so oxygen comes forward.” There are many com- pounds of it used for disinfecting purposes. The formula for the United States army hospitals is as follows: eighteen parts of common salt to fifteen parts of binoxide of manganese; after having mixed them thoroughly, pour upon them a solution composed of forty-five parts of concentrated sulphuric acid and twenty-one parts of water. Under the direction of Dr. James R. Wood, the wards of the Bellevue Hospital were thoroughly and effectually fumigated, in the spring of 1875, with chlorine. 25 sacks of salt, and 5000 pounds of manganese were em- loyed. p The Zinci Chloridi Liquor is much employed for disinfecting purposes, and from considerable experience in its use, I am prepared to speak highly of its properties. The disinfecting fluid of Sir William Burnett is an aqueous solution of the chloride of zinc. It contains 200 grains of zinc to each imperial fluid ounce, and has a specific gravity of .2. It was introduced in 1840; and besides its deodorizing properties, prevents the decomposition of both animal and vegetable matter. According to Sir William Burnett, it is a sure preventive of dry rot. This substance has no smell of its own, while it totally destroys offensive odors arising from various causes. For pro- ducing a good deodorizing fluid on a large scale, four gallons of water may be mixed with a pint of the original fluid. In the dissecting-room, to preserve bodies for anatomical purposes, one part of the fluid may be added to 15 or 18 parts of water. - The Calcis Chlorinatae Liquor is another preparation which is highly lauded, and possesses powerful disinfecting properties. The chlorinated lime, like the chloride of zinc, arrests both animal and vegetable decomposition, and has been supposed by some to have the power of destroying pestilential miasms. In exhumations for judicial or other purposes it has been used with success, as it completely dº the disgusting odor arising from the putrefying mass. . The method of applying it, is to envelop the corpse in a sheet saturated with a solution of the substance made by adding a pound of the chloride to a bucketful of water. The chloride of lime, perhaps, is more extensively known and used as a domestic agent for the removal of offensive smells than any other. This material acts by the purifying effects of the chlorine, which is disengaged by the acids, and as carbonic acid is known to be a product of decaying animal and vegetable matter, it may be said that the effluvia furnish the means for their own neutralization. Labarraque's Solution of chlorinated soda is another excellent preparation. Its efficacy consists mostly in the powers of chlorine, and is so easily ob- tained, being put up by the chemists in a convenient form for ready use, that it is quite a favorite disinfectant. Permanganate of Potash.--This substance is a most excellent disinfectant, but it is not an antiseptic; it is the base of the well-known Condy's Fluid, and is much used in practice. It is formed, according to the U. S. P., by DISINFECTANTS AND ANTISEPTICS. 65 mixing equal parts of very finely powdered deutoxide of manganese and chlorate of potash, with rather more than one part of hydrate of potassa, dissolving in a small quantity of water, and exposing the whole, after evaporation to dryness, to a temperature just that of redness. The mass is treated with hot water, the insoluble oxide separated by decantation, and the deep purple liquid concentrated by heat, until crystals begin to form upon the surface, when it is left to cool and crystallize. The crystals have a dark purple color, and can be dissolved in sixteen parts of water. The efficacy of this preparation has rendered its use very extensive, some surgeons preferring it to carbolic acid. A little of the solution poured over the foulest bodies almost instantly disinfects them. I have found it very useful in many ways. In fetid perspiration of the feet, a tablespoonful of a solution composed of permanganate of potash grs. viij, to the ounce of water, added to an ordinary foot-bath, is very efficacious. As a gargle, in follicular tonsillitis, it has been used by many, in the proportion of grs. iv to water 3 viij. As an injection, to allay the fetor arising from cancers, a good formula is, permanganate of potash grs. viij to water 3.j, add to this an equal quantity of water, and use as a lotion or injection. In ozaena it has been used in the proportion of one grain to one ounce of water. . . . At certain times, to purify the atmosphere of large hospitals, where pes- tilential or other infectious diseases are being treated, and where numbers are dying of the disorders, it has been found necessary to disinfect the air by fumigations. Of these, the fumigatio Guytoniensis, or oxymuriatic fumigation, is prepared by adding common salt 3iij to black oxide of man- ganese 3.j, sulphuric acid 3.j, and water 3ij; this may be carried through an apartment or placed in a corner of a room and allowed to remain for several hours. Platt's Chlorides.—A very cheap and excellent disinfectant in every sens of the word, is a saturated solution of the chlorides of metallic Salts (Zinc, Lead, Aluminum, Calcium, and Potassium), known as “Platt's Chlorides.” I have used this solution in large quantities, in both hospital and college work, and also as a dressing, with very good results. Its cheapness, when gººd in bulk, together with its efficiency, make it a very desirable disin- ectant. - The Nitrous Fumigation is made by placing nitrate of potash 3iv, and sulphuric acid 3ij, in a saucer upon hot sand. This should only be used after the patient has left the apartment, as the fumes prove irritating to the respiratory apparatus. This irritation is not so much observed at first, but after a few inhalations the lung substance and mucous membrane of the air-passages become very much irritated, and in time even disintegration may result. - inegar is an agreeable and by no means a mean fumigant. It is well known to possess antiseptic properties. Its preservation of both animal and vegetable substances is well known, the pickling liquids all having this article for a base. It was used in ancient times as a prophylactic, and it is said of Cardinal Wolsey that “he carried in his hand an orange, deprived of its contents and filled with a sponge which had been soaked in vinegar impregnated with various spices, in order to preserve himself from infection when passing through the crowds which his splendor attracted.” - * . Dr. John Day” recommends the following as a self-generating disinfec- tant: One part rectified oil of turpentine, seven parts benzine ; add a few drops oil of verbena. Each of these agents has the power of absorbing * The Medical Record, November 23d, 1878, No. 420. 5 66 A SYSTEM OF SURGERY. oxygen from the air and converting it into peroxide of hydrogen, a highly active oxidizing agent not unlike ozone. This preparation is cheap, lasting, easy of application, and does not injure fabrics of any kind. It may be applied with a brush or sponge, or by sprinkling or pouring over articles. It is very efficient, and the odor not disagreeable. , Antiseptics.—Tar Acids.-We have already spoken of fumigation with tar, and come now to mention the so-called tar acids, some of which have been very extensively used and with great success. There are several substances given off from tar; thus from wood tar we have creasote, and from coal tar, carbolic and cresylic acids. Creasote is a valuable antiseptic, and we fancy is not so frequently used in this country as it should be. I have applied it with as good success as carbolic acid, in the treatment of wounds, especially after amputations, and have reason to speak well of its disinfecting properties, in the proportion of a drachm of the drug to ten ounces of water, or we may use a fluid drachm to about a pint of water, thus having a preparation of about equal proportions with the aqua creasoti of the U. S. P. Gruelin asserts that water containing one part of creasote to ten thousand, smells of smoke. Before it was dis- covered by Reichenbach, it was used as a secret preparation in Italy, and called aqua bimelli. In Silesia, also, there was a preparation much in vogue which received the name of aqua empyrewmatica, which contained creasote. Carbolic Acid.—This substance, now so much in vogue in surgical prac- tice, was discovered in 1834 by Runge, but was not introduced into general practice until the method of liberating it from the other products of coal- tar was discovered by Laurent in 1841. Carbolic acid is introduced in two forms—the crystals, and what is termed the impure carbolic acid. Of these preparations, Dr. Squibb, the best authority on the subject, writes: “The crystallized phenol, or miscalled ‘carbolic acid crystals,' is nearly colorless when first put up, but by keeping or exposure to light and air, it acquires a red or brown tinge. For dispensing, a fluid ounce of water should be added to the contents of each one-pound bottle, and the whole warmed until it is liquid. It will then remain liquid at ordinary tempera- tures, and should be dispensed by minims, not drops. Each minim repre- sents about onegrain of the crystals, and may be so considered in prescrip- tion use. - “The so-called impure carbolic acid is really coal-tar creasote, or a mixture of the three or more homologous phenols of coal-tar in varying proportions, It contains from 92 to 96 per cent. of these phenols, the remainder being the more volatile tar oils, which are harmless. Cresol, or the so-called cresylic acid, is generally in largest proportion, and phenol, or the crystal- lized carbolic acid, in next largest proportion. This mixture is better than the crystallized carbolic acid for all known uses, whether internal or external, and may, therefore, take the place of the more costly substance with ad- vantage. It is colorless when recently made, but changes, chiefly by the effect of light, through various tints of brownish-red to nearly black, with- out becoming thick or tarry, and without material change in value or effect. All the useful portions of it are soluble in about twenty-five times its volume of water by active shaking together. The insoluble residue is impurity (tar oils).” In #. Dr. Jules Lemaine wrote a treatise on carbolic acid,” in which the virtues of the acid are highly extolled in very many disorders. In 1864 F. C. Calvert & Co., of Manchester, England, after numerous experi- *... Wide an exhaustive review of the work, in the British Journal of Homoeopathy, vol. xxiii, p. 286. ." - - - ANTISEPTICS. 67 ments were finally enabled to render the article pure enough and cheap enough for general use. The drug, however, became in a short period so universally popular, that many worthless articles have been thrown upon the market, and it is therefore well to be prepared with proper tests to ascertain the purity of the article. The following are the suggestions of William Crookes, F.R.S., who has given a great deal of care and attention to the subject. He says: - “Put a teaspoonful of the carbolic acid in a bottle, pour on it half a pint of warm water, shake the bottle at intervals for half an hour, when the amount of oily residue will show the impurity; or, dissolve one part of caustic soda in ten parts of warm water, and shake it up with five parts of carbolic acid. As before, the residue will show the amount of impurity.” Experiments have shown that very small portions, even goºd part, will prevent decomposition. Mr. Crookes found that meat steeped in a one per cent. Solution, and then dried, preserved a fresh odor. A solution of albu- men was very slowly and not completely coagulated by a one per cent. Solution, and a few drops added to half a pint of fermenting sugar or yeast, stops the action. Cheese-mites, fish, infusoria, caterpillars, beetles, and gnats are immediately destroyed, So soon as carbolic acid was introduced, it became a very fashionable and favorite application by both physicians and surgeons, and the medical periodicals were filled with different prescriptions for various diseases. Professor Lister, of the University of Glasgow, offered several preparations, which were received with general favor: 1st, a simple solution, one part of the acid being added to 50 or 100 parts of water; 2d, carbolated oil, one part of the acid to six parts of boiled linseed oil; 3d, carbolic putty or paste, being a mixture of carbolic acid and whiting. Wide the antiseptic treatment of wounds in this volume. - : Professor Andrews makes use of simpler preparations than Prof. Lister, as follows: Take one ounce of the crystals, agitate it in a bottle with ten or fifteen ounces of water, settle for a few moments, and the clear five per cent, solution will appear at the top, and the surplus acid settle in the form of a ninety-five per cent, solution. This can be readily mixed with other substances. An ounce of the crystals may be mixed with an ounce of any oil, or an eighth part of collodion mixed with one part of carbolic acid. In our own School, besides the valuable paper already alluded to as appearing in the British Journal of Homoeopathy, we have an exhaustive pamphlet by Backmeister, and an article of Dr. Lord in the U. S. Medical and Surgical Journal for January, 1869. It has been recommended as very serviceable in cancer by Dr. Beebe, and has been used in a great variety of preparations for very many disorders. A very useful preparation in glycerin, I have used with excellent result in wounds and sloughing ulcers, gangrenous and unhealthy stumps; it is simply ten drops of carbolic acid to the ounce of glycerin. This is very easily prepared, and is a most excellent application. It is useful also as a solution in which to soak the catgut in preparing the animal antiseptic ligatures. Carbolated alcohol is highly spoken of as a dressing for wounds.” This drug has been used for diarrhoea, f for pregnancy sickness, dyspep- sia, vomiting, colic, dysentery, Ś constipation, gonorrhoeal ophthalmia, bites of venomous snakes, whooping-cough," sloughing syphilitic ulcers, naevus,” * Medical and Surgical Reporter, August 21st, 1869. f Loc. cit., January 23d, 1869, p. 78. f British Medical Journal, February 13th, 1869. & Hahnemannian Monthly, vol. v., p. 219. | Medical Archives, January, 1870, p. 51. T Medical Investigator, July, 1867, p. 117. ** Medical Press and Circular. 68 A SYSTEM OF SURGERY. eczema,” pityriasis versicolor, f favus, burns, wounds, ulcers, and ab- Scesses, and almost every disorder in the category. It has also been used with many other substances, as iodine, cod-liver oil, lime, calendula, alcohol, potash, and glycerin. For a résumé of the various carbolic acid preparations, the following, from the Chemist and Druggist, may offer some suggestions. As a rule, it is better to dissolve the crystallized carbolic acid (Calvert's) in the proportion of one part by weight of the acid to six of glycerin (car- bolate of glycerin). In this state it can be diluted equally indefinitely. In general, a dose (according to the old school) of carbolic acid is 1 grain in an ounce of water. As a gargle, 1 or 2 grains to an ounce of water. As an injection, 1 grain to 4 ounces of water. As a lotion, 15 grains to an ounce of water. As an ointment, 30 grains to an ounce of benzoated lard. As a limiment, 1 part to 20 of olive oil. As a plaster, 1 part of carbolic acid to 3 of shellac. The crystallized carbolic acid to be used as a caustic. The carbolate of glycerin, as above, should be used in 1 or 2 drop doses. Antiseptic oil, for abscesses, 1 part of the acid to 4 of boiled linseed oil. ºptic putty, 6 spoonfuls of the antiseptic oil, mixed with common whiting. Aqueous solution of carbolic acid is one part of acid to forty of water. (One ounce of acid to a quart of hotwater well agitated and filtered.) To disinfect sick-rooms: place a portion of the dissolved acid in a porce- lain dish, and float it in a larger vessel of hot water. Disinfecting purposes generally: 1 pound of crystals to 6 gallons of water. Fluid, 1 part to 80 of water. Powder, 1 ounce of crystals with 4 pounds of slaked lime. . For drains: take 1 pound of the fluid carbolic acid to 5 gallons of warm Water. Toothache is often cured with one drop of carbolate of glycerin, and diarrhoea arrested in half an hour with two drops. In all cases of parasitic life it is advisable to commence with very dilute carbolate of glycerin. In a somewhat extensive surgical practice I have used carbolic acid many thousands of times, but I have never used any mixture internally, saving the one with glycerin, of which mention has been made, and the aqueous solution, and at times a few drops of the acid with the tincture of calendula. It has proved so very efficacious in these simple mixtures, that I have never had any inclination to use it in other forms, believing that the more simple the solution, the more undivided will be the action of the medicine. In cases of compound fracture, or after resection, I have mixed the dilute acid with the bran dressings, especially when there is great suppuration, and I cannot speak too highly of its efficacy in this particular. The disinfection is com- plete, and the bran which has absorbed the pus forms into cakes, which are readily removed with a spatula or spoon; fresh carbolated bran is then poured into the box, and the whole thus kept pure and clean. I have used it also to destroy maggots in wounds, with astonishing results. To some, the odor of carbolic acid is offensive. It may be removed by combining two parts of gum camphor and one of carbolic acid in crystals, and mixing with whiting; a liquid is thus formed with powerful disinfecting properties, but entirely free from the odor of carbolic acid. * Medical and Surgical Reporter, vol. xxi, No. 1. f Ib., vol. xix, p. 426. And many other periodicals. ANTISEPTICS. 69 The Glyceroborate of Calcium and the glyceroborate of sodium have both been highly spoken of as antiseptics, and were introduced to the French Academy by M. G. LeBon. Both of these agents are very soluble, are destitute of odor, and are especially free from all toxic action. When in contact with the atmosphere, they both deliquesce with rapidity, absorbing from the air an equivalent weight of moisture. Alcohol and water dissolve twice their own weight of the salts, - The calcium salt is the most efficacious, is absolutely innocuous, a strong solution being able to be applied to the eye without any bad results. It can be used also as a preservative of meat and other alimentary products, by coating the same with a varnish made of it.* Chloralum.—Professor Gamgee, in a London periodical, enumerates the properties of the chloride of aluminum as employed for medical purposes. This salt in itself is not new, having been long known to chemists, and used by the manufacturers of aluminum. Its true name is the hydrated chloride of aluminum ; this, from its length, is objectionable for ordinary use, there- fore the term chloralum has been adopted. This substance possesses highly antiseptic properties, and has proved useful in my hands, but I judge from the very limited experience I have with it, in preserving specimens and in keeping wet preparations. Accord- ing to the Druggist's Circular, its chief merits consist in being inodorous and as harmless as common salt. Its power of preserving organic substances may arise both from its metallic base and the chlorine it contains. A solution of one part of chloralum in twenty of water preserves flesh, which may be suspended in the air to dry, and afterward, if desired, cooked and eaten. A small portion of the solution added to milk, prevents its decomposition, and the beer bottlers now employ its undiluted form in preference to the bisulphite of lime. Professor Gamgee asserts, from his experience in its use, that it attracts to itself all moisture; and the moist particles inclosed or embodying fever germs, are absorbed if a cloth damped with it be suspended in the sick- chamber. In the Middlesex Hospital, in London, it is used by Mr. Camp- bell de Morgan in the antiseptic treatment of wounds. Mr. Edward Lund, of the Manchester Royal Infirmary, employs it to remove the fetor in open cancer. It has also been applied as a collyrium, and as an astringent in diarrhoea. The chloralum powder is also very useful for sprinkling the wards of hospitals, and disinfecting cow-sheds and slaughter-houses. Chloralum gained favor in England; and though comparatively new, the solution is being produced by the thousand gallons daily; and a thirty per cent. odorless disinfecting powder, at the rate of four tons a day. A com- pany is also established which manufactures chloralum. - Messrs. Tilden & Co. prepare a solution which they term bromo-chloralum, which is also very highly recommended. Professor Charles A. Lee states that it is a certain, perfect, and prompt deodorizer and disinfectant, and for hospital use is very efficacious. - Thymol is extracted from the essential oils obtained from the common thyme, thymus vulgaris, the horse mint, monarda punctata, and an Eastern drug called ptychotis djoman. In commerce it consists of irregular broken crystals, nearly transparent and colorless. It has an aromatic taste. Its specific gravity when it is fused is lighter than that of water. It is a powerful antiseptic, and said to be superior to carbolic acid. The advantages claimed for the thymol are: first, its efficiency as an antiseptic; second, the absence of irritating effect; third, that it does not injure the instruments used; and fourth, that a solution of one strength is required for all purposes, the pro- portion being, 1 part of thymol to 1000 parts of water. The formula is: * London Lancet, August, 1882. 70 A SYSTEM OF SURGERY. Thymol, . . . . . . . . • 1.0 grams or grs. xvss. Alcohol, . . . . . . . . . 10.0 “ giij. Glycerin, . . . . . . . . 20.0 “ Żss. Water, . . . . . . . . . 1000.0 “ 3xxxiv. The proportions for making the gauze are: 1000 parts gauze, 500 parts spermaceti, 50 of resin, 16 of thymol.” From late experience with thymol, this substance has not equalled the expectations of those who have employed it.f 3. Dr. Hoskin, in the Boston Medical and Surgical Journal, describes a new and simple apparatus, the object of which is to vaporize certain chemical substances and thus thoroughly to disinfect the air, walls, ceiling, and, in Short, the entire contents of any apartment, however large. The instrument by the aid of which this is to be accomplished may be briefly described as consisting of a bottle, a wick, and a bulb of platinum-sponge attached to the free end of the wick. Into the bottle should be poured an alcoholic solution of the substance which it is desired to vaporize (for instance, car- bolic acid); the wick is then to be lighted, and the flame extinguished as Soon as the ball becomes red hot, which requires but two or three minutes. The ball is now fed continuously by the wick, and will continue red hot as long as any fluid remains in the bottle, and in this condition it will readily vaporize the substance in solution, minute particles of which are thus scattered throughout the atmosphere. . . . . It has been estimated that a bottle holding two ounces will throw out a constant stream of vapor for about sixteen hours, at an expense not exceeding twenty cents. Potassa fusa is recommended by Dr. Hiller, of San Francisco, as a powerful antiseptic, and as possessing great influence over the process of granulation and cicatrization. The doctor employs a weak solution of the caustic ; merely sufficient to make a “soapy" feeling when rubbed between the fingers, and grades this to the susceptibility of the patient. He records cases in which he has injected it into wounds and fistulous openings with marked success.] - Among the more recently introduced antiseptics, especially employed in the treatment of wounds, are iodoform, the bichloride of mercury, turf, the peroxide of hydrogen, oxidized oil of turpentine, and others—for a de- scription of which, the reader is referred to the chapter on “The Present Status of Antiseptic Surgery.” CHAPTER III. ANAESTHESIA. ETHER—DISCOVERY OF ANAESTHESIA—INHALERs—ETHER BY THE RECTAL METHOD– CHLoRoFoRM–SYMPTOMs of DANGER—DEATH-NITROUs Oxide—BICHLoRIDE OF METHYLENE–BROMIDE of ETHYL–SICKNESS AND DEATH FROM ANAESTHESIA— LOCAL ANAESTHESIA—RICHARDSON's APPARATUS—ANAESTHETIC ETHER—HYDRATE of AMYL–HYDRAMEL–ANAESTHETIC MIXTURES FOR SMALL OPERATIONS-HYDRO- CHLORATE OF COCAINE. In the practice of surgery there are powerful auxiliary means, which, if called to the assistance of the surgeon, will not only render the condition of the patient similar to that which is noticed immediately after the receipt * Thymol as an Antiseptic, by William T. Bull, M.D., Medical Recorder, April, 1878. + Medical Record, November 23d, 1878. † Wide U. S. Medical and Surgical Journal, vol. v., p. 170. ETHER. . 71 of the injury, but will relax every voluntary muscle in the system as com- pletely as in death, rendering these tissues thoroughly inert, and, at the same time, exempting the patient from pain, which would otherwise be the necessary attendant upon operations. Such a condition is effected by allowing the patient to inhale an anaesthetic agent until its full effect is produced upon the system ; by such means the use of hot baths is dis- pensed with ; antimonials, in repeated doses, that formerly were adminis- tered until the already suffering patient was nauseated to a most distressing degree, are not needed; tobacco in fume, by chewing, or in the form of enema, is either forgotten or intentionally thrust aside; and for an expen- diture of the precious fluid ad deliquium animi, is substituted a simple and effectual means, which, if skilfully and judiciously employed, is compara- tively free from danger. * Anaesthesia may be divided into general, in which the whole system is placed in a condition simulating death, and local, in which only portions of the body are rendered insensible to pain. The fluids in most general use at the present time to produce anaesthesia, are the oxide of ethyl, or ether, commonly and improperly called sulphuric ether; and chloroform, chloro- formyle, or the perchloride of formyle. - Ether.—Ether belongs to America, and chloroform to Great Britain. As is well known, the priority of claim to the introduction of ether as an anaesthetic agent, has been hotly contested between Dr. Horace Wells, of Hartford, Conn., and Dr. William T. G. Morton, of Boston, many of the profession taking opposite sides. The American Medical Association, at its meeting, held in Washington, 1870, passed the following resolution, “That Dr. Horace Wells, of Hartford, Conn., was the discoverer of anaesthesia.” Very distinguished gentlemen, while giving the discovery of the nitrous oxide anaesthesia to Dr. Wells, accord priority of the sulphuric ether anaesthesia to Dr. Morton. In the strenuous effort made by the citizens of Boston to rear a monument to the memory of the latter gentlemen, he is styled “the inventor and revealer” of anaesthesia. From a careful study of all the facts in the case, there can be no doubt that Dr. Morton introduced the inhalation of sulphuric ether into surgical practice, and we believe that this is all that he claimed. Dr. J. Mason Warren having been personally interested in the introduction of ether, thus writes in the appendix to his Surgical Operations; he says: “The facts, so far as I am acquainted with them, are as follows: In the autumn of 1846, Dr. W. T. G. Morton, a dentist in Boston, a person of great ingenuity, patience, and pertinacity of purpose, called on me several times to show some of his inventions. At that time I introduced him to Dr. John C. Warren. Shortly after this, in October, I learned from Dr. Warren that Dr. Morton had visited him, and informed him that he was in possession of, or had discovered, a means of preventing pain, which he had proved in dental operations, and wished Dr. Warren to give him an opportunity of trying it in a surgical operation. After some questions on the subject, in regard to its action, and the safety of it, Dr. Warren promised that he would do so. On the Tuesday following, October 13th, after the surgical visit at the hos- pital, a patient was brought into the amphitheatre for operation, this being the first opportunity which had occurred since Dr. Warren's promise to Dr. Morton. Dr. Warren said to us: “I now remember that I have made a promise to Dr. Morton to give him an opportunity to try a new remedy for preventing pain in surgical operations,’ and asked the patient if he should like to have the operation done without suffering. He naturally answered in the affirmative. The operation was therefore deferred until Friday, October 16th, when the ether was administered by Dr. Morton with his apparatus, and the operation performed by Dr. Warren. It consisted in the 72 A SYSTEM OF SURGERY. removal of a vascular tumor of the neck, which occupied five minutes. During a part of the time the patient showed some marks of sensibility; but subsequently said that he had no pain, although he was aware that the operation was proceeding. On the following day, a woman, requiring the removal of an adipose tumor from the arm, was rendered insensible by ether, given by Dr. Morton; and Dr. Warren requested Dr. Hayward, who was present, to perform the operation. This was successful, the ether being continued through the whole operation, which was a short one, and the patient being entirely insensible. A few days afterwards, Dr. Warren in- formed me that he had learned from Dr. Charles T. Jackson that he had suggested the use of ether to Dr. Morton. “The success of this process in the prevention of pain, was now quite established. Its use, however, was suspended for a time, for reasons which Dr. Warren has already given in his first paper on ether; and the experi- ments were not again resumed until November 7th, when Dr. Warren declared his willingness to state the nature of the agent employed. Two important operations were now done successfully at the Massachusetts General Hospital under its agency: one an amputation of the thigh, by Dr. Hayward; and the other, a very difficult and bloody operation—removal of a portion of the upper jaw on a woman—by Dr. Warren.” Shortly after these successful operations, an application for a patent was made, which was obtained in about thirty days, and issued in the names of Dr. C. T. Jackson and Dr. Morton. For some unknown reason, the former gentleman withdrew his name from the patent in favor of the latter. On account, however, of the odium in the minds of the profession connected with patents, either in medicine or surgery, very slight effort was made to enforce it. Ether was in daily use, and but little, if any, notice taken of the infringement. On the 28th of December, 1846, an application was made to the United States Government for an appropriation of $100,000 as a national recompense, which met with decided favor. At that time both Dr. Jackson and Dr. Wells laid claim to the discovery ; this prevented the accomplishment of the design. In 1849, in 1851, and 1853, other efforts were made, but the persistency of the opposition faction rendered them futile. Dr. Morton then, having exhausted his means, and being reduced in circumstances, brought suit against the Government for infringement of his patent, but without success. Contributions were set on foot to relieve him, but from some unknown and unaccountable cause, failed; as did also a second suit against the varied hospitals and infirmaries in which ether had been employed. Dr. Morton finally died, discouraged, disheartened, and penniless. . His remains rest in Mount Auburn Cemetery, near Boston, over which, at last, I am glad to say, a handsome obelisk is reared, with a suitable inscription, to the memory of the man who has conferred an inestimable boon upon suffering humanity. It seems, however, very probable, from a vast amount of printed and other testimony that I have seen, that the operation above detailed by Dr. Warren, was not the first one in which ether was successfully employed. Dr. E. E. Marcy, formerly of Hartford, now of New York (in December, 1844), performed an operation prior to the operation of Dr. Warren. But there have lately arisen others, whose claims to priority must be remem- bered; among them, Dr. Crawford W. Long, of Georgia, who, in March, 1842, removed a tumor from the neck of Mr. Venables, while the latter was completely anaesthetized with sulphuric ether. r - In the Medical and Surgical Reporter,” we find that one Dr. Samuel Wool- sten, an aged physician of New Jersey, knows that ether, with morphine * May 27th, 1870. ETHER. 73 dissolved in it, was used in surgical operations, to destroy pain, as far back as 1836. He refers to the files of the National Intelligencer of June, 1836, for º ºftement for extracting teeth without pain “by the administration Of ether.” Before closing this brief account of the discovery of the anaesthetic prop- erties of ether, I desire to call attention to a pamphlet bearing the following title: “An Essay on the Exhilarating and Medicinal Effects of Ethereal Inhalation,” by Caleb Bently Matthews, M.D., of Alexandria, Virginia, in 1824. Dr. Matthews was one of the editors of the Medical Recorder for 1827 and 1828, and the essay is dedicated to Thomas C. James, M.D., Professor of Midwifery in the University of Pennsylvania. After some preliminary remarks, Dr. Matthews, in regard to the manner of inhalation, says: “For this purpose it is only necessary to procure an oiled-silk bag, or a bladder of the capacity of one or two gallons, and affix to it a brass air-cock and an ivory or wooden mouthpiece; such as are usually employed for the purpose of inhaling the nitrous oxide.” The doctor then details his symp- toms and the great exhilaration which was produced, and the most marked appearances of face, eyes, and the condition of pulse, with all of which we, in these days, are perfectly familiar. After this, and on the 13th of January, 1824, he states that he breathed the ethereal vapor “from a quart bottle containing sixteen ounces of strong sulphuric ether.” He inhaled a large quantity, until his friends, alarmed for his safety, persuaded him to relin- quish his experiments, but he sank into a profound slumber. I introduce these remarks to show that an idea of ethereal inhalation was present as far back as 1824; and that, if the experiments had been carried sufficiently far, the great boon to suffering humanity would have been introduced much earlier; and, more especially, because I desire to record a tribute to the memory of Caleb Bently Matthews, who afterward became one of the most zealous followers of Hahnemann, and was my professor of materia medica in the first years of my student life. - Ether was used to a considerable extent in this country, but for a period of time gave place to chloroform, on account of the much more rapid anaesthesia produced by the latter, and the much less duration of the stage of excitement, and, perhaps, more especially from an imperfect knowledge of the proper method of administration. In the employment of ether, it must be remembered, that rapid evaporation takes place, and that by the ordinary methods of inhalation, very oftenmore of the fluid escapes into the apartment than is inhaled by the patient, and thus the stage of excita- tion is very much lengthened. The ordinary method of administration is as follows: Wrap a towel into the form of a cone, insert a piece of sponge in the apex of this cone, and inclose the napkin in a thick piece of wrapping-paper; pour a small quan- tity of Squibb's aether fortior upon the sponge, and hold it firmly over the mouth and nose. I have used many inhalers, as they are called, some being much better adapted to the purpose than others, but I have now in my own practice discarded them in toto for many reasons. They soon become soiled and look untidy; the iron or wire, if such substance be used in their construc- tion, rusts; but more especially because, when a patient is in a Semiuncon- Scious state, spitting and vomiting are very common occurrences, and may take place so suddenly that the apparatus cannot be removed in time, and a most discomforting and often disgusting state of affairs presents; besides, it is not always agreeable to the patient to know that the same inhaler is employed upon all occasions on the faces of all people. The following simple and cleanly contrivance I use always, and call it the ether cap.” Take an ordinary newspaper, and fold it lengthwise, that 74 A SYSTEM OF SURGERY. it may be six or seven inches in width. Then fold an ordinary towel in the same manner lengthwise, but allow it to be both larger and broader than the paper. Insert the paper into the towel, as we would place the leaves FIG. 52. | |||||||||||||||||||||||||||Iſſuill||1|||||I|| lºſt||||Illutiliſſºlitijiþi | | | yº N - - | | | init"I 't of a book within the cover, as seen in Fig. 52 (the dotted lines representing the paper). Fold one of the projecting portions of the towel lengthywise over the paper, as seen in Fig. 53, then turn down one of the distal ends of g w g L ſº ; : |. ||||||||||| FIG. 53. : ...” †. . t jºi; ! ; §, J. ºf Z Illililllllllliſſilſiliilidiffiliiliffſſtiffilińſiºlºf the towel over the paper, and neatly pin it there (vide Fig. 54.) Then turn upon itself the towel and paper in folds of seven inches in length, or there- FIG. 54. | - | |||||||||| is abouts, making the last fold to come even with the end of the paper, as seen in Fig. 55. Then all that is required, is to fold over the remaining ends of the towel upon the paper and pin them securely. Over this I place a thin piece of FIG. 55. - FIG. 56. india-rubber gauze or oiled silk, and we have a very serviceable and cleanly apparatus, as in Fig. 56. Into this ether cap first place cotton, and press it firmly to the bottom; upon this lay a good-sized sponge, and the “cap” is ready for use. Having explained to the patient the manner of breathing, viz., to inhale ETHER. - 75 as rapidly and fully as possible, as long as he retains consciousness, and not to be alarmed at any unpleasant sensations which may be excited at first, the cap is fitted as accurately as possible to the face, the towel accommodating itself to all inequalities of surface, and having been once placed, it is to be kept closely applied, and never once removed, excepting to pour on fresh ether, until anaesthesia is complete. - It should be borne in mind, however, that there are certain conditions of the body that render the practitioner cautious in the administration of ether. It has been noted by Mr. Lawson Tait, that during the anaesthesia by ether, the kidneys entirely suspend their action, and that in persons suffering from nephritis the effects are often bad. This point I believe was also noted by Dr. Emmet. I can bear testimony to the truth of these re- marks, for in two eases of supra-pubic lithotomy both patients died of uraemia, one on the third, the other on the fifth day, after apparently suc- cessful operative procedure. Bronchitis should also, if present, lead to a careful selection of the anaesthetic. Etherization by the Rectal Method.—It appears that the idea of rectal etheriza- tion was originated by Roux in 1847. Experiments were then made by Dr. Vincente Heydo and M. Marc Dupuy; and in the same year Pirogoff pro- duced anaesthesia by the introduction of the vapor of ether into the rectum. From that period until the present, there appears to have been no further effort to introduce the method into general practice, until the article by D. D. Molière appeared in the Lyons Medicale, March 30th, 1884. From the analysis of the thirty cases published by him, it was found that the stage of excitement was reduced, in some cases it was entirely absent; that vomiting was much less frequent, and that a smaller quantity of ether was required than by inhalation. The apparatus for the adminis- tration, at first consisted of a bottle to hold the ether, the cork of which was perforated by two tubes, one in the shape of a funnel, with a stopper, the other serving for the attachment of an india-rubber tube, two feet long, to which was affixed a rectal nozzle. The bottle holding the ether was then placed in a vessel (pitcher) containing water, varying in temperature from 110° to 140°. The nozzle being inserted into the rectum, the ether rapidly boiling sent its fumes into the intestines, and, being imbibed, produced the desired unconsciousness. This, however, was found to be an imperfect method, for the reason that there was likely to be a very unequal evapora- tion of the ether. When the water cooled and had to be removed and hot water added, the immediate application of the fresh heated water to the bottle, caused too rapid and sudden evaporation, and therefore an apparatus was constructed to regulate the supply of the anaesthetic. It consisted of a teapot, capable of holding two quarts, into which a siphon was inserted, by which the cold water could be drawn from the bottom of the vessel, while the hot water could be poured in through the spout of the teapot. It was also ascertained that an earthen vessel holding two quarts of water, at a temperature of 130°, will lose 5° of heat in about ten minutes, and that therefore if a steady administration is necessary, the thermometer must be used from time to time and carefully watched. Rectal etherization was at once employed by several surgeons in New York. Dr. William T. Bull” reports seventeen cases in which it was used, and from which I make the following analyses: In nine cases there was no stage of excitement; in eight cases there was more or less excitement, though in some instances very slight. In six cases there was no vomiting. In eleven cases emesis occurred, some patients vomiting once, others more frequently. In six cases diarrhoea occurred, in one instance fourteen loose * Medical Record, May 3d, 1884. 76 A SYSTEM OF SURGERY. and bloody discharges taking place; in several others blood was noticed in the stools. Dr. James B. Hunter* reports six cases, without any very unpleasant symptoms being noted. In the first case it took eight minutes to complete the anaesthesia, which was maintained for twenty-five minutes, the quantity of ether used being an ounce and a quarter. In the second case, it required four minutes to produce an effect, when a diarrhoeic passage resulting, the inhaler was employed. In the third case, the time was six minutes, the quantity required two ounces, and the process maintained twenty-three minutes. In the fourth case (ovariotomy) the quantity of ether required to anaesthetize the patient in six minutes was an ounce and a half. The inhaler was then resorted to. In the fifth case it took seven minutes to produce insensibility, which was maintained twenty-seven minutes by two ounces of ether; and in the sixth case, unconsciousness was produced by the rectal method, but was kept up by the inhaler. No unpleasant symp- toms followed. Dr. Weir also relates two trials of this method, in one of which, he lost his patient, a child of eight months old, upon whom the operation for hare- lip had been performed. It did not recover well from the anaesthesia, had several bloody passages during the night, and died the following morning. Dr. Weir states, that during the latter part of the anaesthesia fresh hot water was used, which caused too free evaporation of the ether, a condition of things which has already been noticed as being likely to occur unless the siphon teapot be employed. In the Hahnemann Hospital the method has only been used a few times; in these, the ether fumes were detected on the breath in about three minutes, and no unpleasant symptoms were noted afterward. With the few trials of rectal etherization which have thus far been made, of course a very imperfect estimate of its value can be arrived at. It may, however, when a proper apparatus for the administration of the ether has been constructed, be especially useful in many cases of operation about the mouth and throat. It appears to me, however, that the chief drawback will be in the difficulty in regulating the quantity, after the patient has become unconscious, knowing as we do, how much more susceptible some persons are to the effect of the anaesthetic than others, and how evanescent and subtle is the vapor;-it might be a difficult matter to stop its absorption, even if the rectal tube be withdrawn, if the intestines were thoroughly inflated with it. The chief advantages claimed for the method, are the slight stage of excitement, the absence of nausea and vomiting. By the “mixed anaes- thesia,” these inconveniences are also vastly modified, and we have not the diarrhoea and tenesmus to apprehend. Time, however, will soon demon- strate the true value of etherization by the rectal method; until this has been fully established, careful experiments will be necessary, and these, too, often repeated. The decision of the profession is rather against, than in favor of, the method. Whiskey has been lately highly spoken of by Dr. H. L. Obetz, who has had considerable experience with it as an anaesthetic. He has operated upon several patients while this agent was employed, and speaks highly of its effects and its freedom from danger. The author recollects a suc- cessful amputation performed without pain in the Pennsylvania Hospital many years ago by Dr. Norris, the patient being intoxicated. Chloroform.—The other anaesthetic agent, chloroform or perchloride of formyle, although known as a chemical product as far back as 1831, and * Loc. cit, May 3d, 1884. - f North American Journal of Hom., March, 1886, p. 305. CHLOROFORM. 77 Occasionally used in minute doses as an antispasmodic, was unknown as an anaesthetic till the year 1847, when Professor Simpson, of Edinburgh, after experimenting upon himself and some friends, announced its power of producing a state of insensibility to pain. 8. when pure, emits a pleasant and fragrant odor, has a sweetish taste, evaporates rapidly, and is dense and colorless. The quantity required varies in different individuals; an average may be set down as from one to three drachms. The purer the article used, the more promptly will it produce the desired effect. When it becomes neces- sary to remove the handkerchief, for the purpose of moistening it again, its reapplication should be quick. Any effort made by the patient to push aside the handkerchief must be resisted; these efforts are made just before the period of insensibility. That the chloroform has acted favorably is known by an increased loudness of respiration. Chloroform is the most rapid and effective anaesthetic known; but it has in the hands of many, and even distinguished surgeons, proved fatal. It is, therefore, in my opinion, not so safe as ether in its administration. The following may be laid down as reliable data in the inhalation of chloroform. The patient should fast several hours before the inhalation, and a quarter of an hour before should take either a small dose of brandy and water, or a teaspoonful of a solution containing ten or fifteen drops of chloroform to half a tumblerful of water. The patient should always be placed in a recumbent posture, and every article of clothing, either around the neck, chest, or waist, made perfectly loose. The “chloroform cone * should then be placed over the face and nose, and the first few inha- lations taken with full inspirations. Then the pulse and breathing must be carefully noted, and in this connection it may be remarked, that many deaths have resulted after a very few inhalations, and that the watchful practitioner must be ever upon his guard; he must look especially to the movements of the chest, the color of the face, the contraction of the pupil, and if there is much struggling, more care must be used. If the face grow purple, the signs of impending danger are imminent; if the breathing becomes stertorous, the case becomes alarming; and if, in connection with these symptoms, gasping and irregular respiration take place, with death- like pallor of the countenance, most active and persevering efforts will be necessary to prevent immediate death. It must not be forgotten that irreg- ular respiratory movements may occur long after death has apparently taken place. I candidly confess that I have never experienced any more unpleasant feelings than when on several occasions I have seen patients on the very verge of death from the inhalation of chloroform. On one occa- sion I was operating for a simple fistula; in another on an epithelial cancer of the lid; and in a third, for perineal urethrotomy. Since the last case I havé used only the ether prepared by Squibb, and I must say I can operate with much less anxiety, even if a longer period of time be consumed in producing complete anaesthesia. - In such cases as related, great coolness is required on the part of the operator. The mouth should be opened and the tongue drawn forward; cold water should be dashed in the face, artificial respiration produced, either by the method of Sylvester, or by that more satisfactory of inserting a large flexible catheter into the trachea. During this time, the thorax and abdomen may be struck smartly with the end of a wet towel; an injection of an ounce and a half of brandy should be given per rectum, and the lungs inflated by means of the catheter, together with alternate pressure down- wards upon the thorax made with the open palms to cause expiration. These manipulations should be long and forcibly persevered in, even if life be apparently extinct. An excellent method of restoring animation is the 78 A SYSTEM OF SURGERY. inhalation of pure oxygen gas. In most of our large cities it is made and rendered portable for medical and surgical purposes; if it can be procured in season, it may be of great service. - One of the best antidotes for chloroform narcosis is the nitrite of amyl, —a few drops sprinkled on a handkerchief and held before the face. Comparison of the Methods,-Of the two agents, there can be no doubt that chloroform is the most satisfactory to administer, but that ether is less dan- gerous, and with the improved apparatus for the administration of the latter, it should, in my opinion, be employed in every case. I have given chloro- form in thousands of cases without a fatal result, although, as I have just stated, on several occasions I came very near losing my patients. The ab- sence of anxiety when ether is employed, and the constant watchfulness which is ever necessary during the administration of chloroform, are suffi- cient reasons for the judicious surgeon to employ the ether. With reference to methylene, terchloride of carbon, or other preparations, I can say nothing, because I know nothing, excepting that I have lately read an account of a death at the Charing Cross Hospital, in London, from its use, in the judicious hands of Mr. Edward Canton. Mr. Keith% states, that in his earlier cases he had to deplore the effects of chloroform vomiting in ovariotomy, and that he now uses exclusively anhydrous sulphuric ether, made from methylated alcohol, administered through Dr. Richardson's apparatus. The oftener he has used it the more he has been convinced of its superior efficacy. There is infinitely less vomiting with ether than with chloroform, and therefore he holds, and very justly, too, that in cases where the adhesions are not numerous and exten- sive, there is not so much danger to be apprehended by the vomiting; but where the contrary is the case, the exertion of the emesis has great tendency to open the bloodvessels and immediately produce hamorrhage. The Bromide of Ethyl.—This substance was discovered by Serullas in 1827. In 1849 and 1865 it was brought before the profession by Dr. Thomas Nunnelly, who employed it as an anaesthetic in the Leeds Eye Infirmary— but to Dr. Turnbull, and especially to Dr. R. J. Levis, of Philadelphia, belong the credit of introducing it as an anaesthetic agent; the latter gen- tleman regards it as the best method of abolishing pain during surgical operations. He statest that “the ethylized patient recovers much more rapidly, than is the case with chloroform or ether. Intellection and mus- cular coördination are regained very soon after the inhalation has ceased. In some instances these functions return as quickly as after the adminis- tration of the nitrous oxide gas, and, on awakening, the patient is able to at once stand erect and to walk.” He relates cases of capital operations per- formed under its use; in one, an amputation of the middle of the thigh, the patient was under its influence thirty-three minutes, and ten fluid drachms of the ethyl were administered. Consciousness returned in two minutes, but no unpleasant symptoms save slight nausea were noticed. Shortly after this case was recorded, the late Dr. J. Marion Sims, of New York, lost a patient from its use, and following shortly upon that, Dr. Levis himself was unfortunate in having a death from its administration. In the first instance, an impure article was employed; in the second, the patient was in the last stage of phthisis. . These unfortunate occurrences, however, have deterred surgeons from employing the bromide of ethyl, and, perhaps, from giving it the trial its merits deserve. Mixed Anaesthesia.--From considerable experience in the use of anaesthesia, employing it during the winter months daily, I think I may say that the * London Lancet, August 23d, 187). . . f The Medical Record, 1880, wol. xvii, p. 342. DEATH FROM ANAESTHESIA. 79 method known as mixed anaesthesia is the best. About thirty minutes before an operation is to be performed, having fasted five hours, the patient receives a hypodermic injection of a solution, ten minims of which repre- sent Tht, gr. of atropine, and & grain of morphine. By the time the patient is laid upon the table, there is a slight flush on the face and warmth on the surface, caused by the known action of belladonna on the capillaries; much less ether is also required to keep the patient perfectly narcotized. After the operation the slumber lasts often for an hour, there is compara- tively slight shock, very little coldness, and but slight vomiting. Especially have I found this method excellent in the performance of prolonged opera- tions, as ovariotomy, resection of bones, etc. Primary Anaesthesia.-There is what is called a primary anaesthesia, which is quite profound in some cases, and quite trivial, indeed so much so as to be unnoticeable, in others. In many instances, however, the insensibility is of sufficient length to allow the performance of operations, which do not require much time. Thus, opening abscesses, introducing ligatures into sinuses, incisions for whitlow, brisment force for anchylosis, and similar opera- tions, in point of time, may be performed. Dr. John H. Packard,” who has given a good deal of attention to this subject, says that the exact length of time before this early stage sets in, and the duration of the unconscious- ness, probably vary in each case. The patient may be allowed to administer the ether to himself, or may be told to hold up his hand, and so soon as the hand drops the operations mentioned, or similar ones, may be performed without pain, with immediate and complete recovery of consciousness, and with no unpleasant after-effects. - The Sickness of Anaesthesia.-After the exhibition of chloroform or ether, there remains in some individuals a deadly sickness and great faintness. In these cases my experience tells me that brandy or stimulants do harm. For the first few moments after their exhibition the patient may appear relieved, but the stimulant effect disappearing, an additional nausea and prostration are added. My usual practice is, to mix ten or fifteen drops of chloroform in about six tablespoonfuls of water, and to give a tablespoonful once in thirty minutes. This practice in many instances is productive of good results. As a prophylactic against the vomiting, a few doses may be given before the anaesthetic is administered. My colleague, Dr. Burdick, uses with success, vinegar, which he allows the patient to inhale while passing from under anaesthetic influence. He also bathes the head, and allows the patient to hold in his mouth a cloth saturated with it. There are some cases, however, that withstand both of these methods; one of such lately came to my notice. The patient had been two hours inhaling ether, and had undergone a very serious operation, requiring long and careful dissection. The prostration and vomiting from the ether were very intense, but ipecac, relieved her in a short time. Veratrum, camphor, and ammonia, are also very useful in the vomiting that may occur from the use of chloroform. Electricity is also of signal service. One of Garratt's electric disks placed upon the epigastrium soon allays the vomit- ing. The advantage of the latter is found in the fact, that the appropriate medicine may be internally administered. Death from Anaesthesia.-There is no doubt in my mind that deaths from anaesthetics are not sufficiently understood even by the profession at large. When such unfortunate accidents have occurred, the heart and brain are the organs which are immediately supposed to be at fault, but I am per- * American Journal of the Medical Sciences, July, 1877, p. 130. 80' : A SYSTEM OF SURGERY. suaded such is not the case, not only from one or two cases that have made a most forcible impression upon my mind, but upon the authority of those gentlemen who have given the matter the most thorough investigation, and whose opportunities for experiment have been exceptionally large and varied. There can be no doubt of two facts which have an important bearing in these cases, the one being, that in very many instances both chloroform and ether are successfully administered to persons who are suffering from organic diseases of the most severe kind; the second, that deaths occur often in those who have no recognizable disease whatsoever, and in persons who, to all appearances, are in a state of health as near perfect as is generally found. , Dr. Benjamin W. Richardson and Dr. Snow, both of whom have made the subject one of exact study and research, testify to this truth. The former gentleman thus writes, in one of his lectures: “When I was engaged in the practice of the administration of chloroform, I was careful to make diagnosis of disease before administration of the narcotic, and on referring to the facts I find that I administered it in the presence of the most 8evere forms of organic disease. In phthisis pulmonalis, in various stages; in cancer, in various stages and types of the malady; in chronic bronchitis, asthma, and hydrothorax; in mitral disease, hypertrophy, and dilated aorta; in epilepsy; in idiocy, with epileptic disease; in various forms of dropsical effusion; in paralysis and acute mania, etc., etc.; and in not one of these administrations was the danger of the administration in any way increased.” Dr. Snow, in his book on Chloroform and other Anaesthetics, confirms these facts; and again on the second point, this same gentleman emphatically says: “Sometimes persons die under chloroform who have no appreciable disease whatever before death, no disease, that is to say, which the most per- fect diagnostician could put his finger on, and say there was a cause of anariety from the presence of disease.” From the most recent researches on this subject, and from the experi- ments of Dr. Russell on the “influence of the vagus on the vascular system,” it seems now to be a fair conclusion that the asphyxia which we often see in these deaths from anaesthetics is caused by the direct action of the anaesthetic on this nerve. Dr. Richardson further states: “In conclusion, I infer that in every case of death from chloroform, the cause of death is either of the motor or of the controlling nervous mechanism of the heart. I conceive that any primary organic changes of structure leading to death are situated in that mechanism, and must be looked for there, and I think that there is fair ground to assume that in some cases there may be death where there is no actual disease of structure, but simply so extreme a natural delicacy of balance between the nervous functions, that the excita- tion produced by the chloroform is sufficient to arrest motion and destroy life.” In the case of one of my patients who died on the table after a few inha- lations of ether, the patient was in an excessively nervous condition ; his heart was small and degenerate, but continued its function for some minutes after the arrest of breathing was complete; showing, to my mind, the fact that the vapor of the ether, in a person of most extreme nervous irritation acted as an excitant or irritant on the nervous periphery of the respiratory surface. There was a spasmodic cessation º the organs of respiration. There was asphyxia, complete and immediate. It took some time, how- ever, for the non-oxygenated blood to stimulate the vagus sufficiently to arrest the heart-beats, which, sooner or later, under such circumstances, must take place. In my clinics, and in fact in my entire surgical practice, I have abjured chloroform for years. On two occasions, once in St. Louis, while I was operating for fistula in ano, and once in Buffalo, while removing the lower LOCAL ANAESTHESIA. 81 eyelid for an epithelioma, I was on the verge of seeing the patients pass from life to death, and from the Sensations I then experienced, and the many statistics I have read, I prefer and always administer ether. I grant it is not so pleasant an anaesthetic, its administration takes longer and its effects may be more evanescent; perhaps, also, there is more emesis during the inhalation; but I think I express the opinion of most operating surgeons when I say that ether is gradually, even in England, superseding chloroform. According to statistics of Andrews of America, and Richardson of England, as collected by Dr. Coles, I find the following: Deaths from ether, 4 in 92,815 inhalations, or 1 in 23,204; deaths from chloroform, 53 in 152,260 inhalations, or 1 in 2872, making about eight deaths from the latter to one of the former. In Great Britain for the decade ending 1880, the deaths from chloroform numbered 101, those from ether 11, chloroform and ether 7, methylene 10.* This subject, however, cannot be entered upon in a work like the present. Fatal cases no doubt will continue to occur from time to time, and must always be set down as belonging to those so well classified by Sir James Paget as “surgical calamities.” Nitrous Oxide.—Much has been said and written concerning the use of the nitrous oxide as an anaesthetic agent. Some surgeons have become quite partial to it, and for some operations it will do very well; but, in my opinion, it will never supersede ether. The many objections, however, to its use, which were mentioned in the former editions of this book, have now been overcome, and since the process of condensation of the gas has been effected, a hundred gallons may be carried in a quart bottle. This method of using the gas also removes one of the greatest obstacles to its use, viz., its impurity. Impure gas will not become liquid. The fact that it is in that state, guarantees the surgeon that it is free from adulteration. In cases, however, in which patients are suffering from undoubted Bright's disease, with albumen and casts in the urine, ether is not admissible, as has already been explained. In such, it is fortunate that the surgeon possesses an article that will produce insensibility without danger. In cases of lithotomy, where the kidneys are damaged, the nitrous oxide is the preferable agent. Bichloride of Methylene.—This preparation, which has been used as an anaesthetic, is made by placing a mixture of alcohol and chloroform in contact with pure zinc. Heat is then applied, and a brisk action is soon established, during which an equivalent of chlorine from the chloroform (CHCl,) passes to the zinc, and after the escape of gases, the bichloride of methylene (CH,Cl) distils over. This may be carefully inhaled, and pro- duces rapid anaesthesia. Local Anaesthesia.-The boon conferred upon suffering humanity, and upon surgical science by the introduction of chloroform and ether is so great that few actually and fully appreciate its value. But the improve- ments introduced into the field of anaesthesia by the local application of various agents, by which certain painful operations may be performed while the patient still retains his consciousness of everything save suffering, cannot but be hailed with feelings of the highest gratification, both by the profession and the community at large. The use of a volatile fluid called rhigolene as a local anaesthetic, was introduced by Henry J. Bigelow, M.D., of Boston. It readily chills the tissues to insensibility, and is far less expensive than either chloroform or ether. Freezing by rhigolene is more speedy and certain than by ether (the use of which was suggested by Mr. Richardson), inasmuch as common ether often fails to produce an adequate degree of cold. Ether boils at * Medical Record, vol. xix, 1881, p. 419. 6 . 82 - A SYSTEM OF SURGERY. about 96°, and rhigolene at 70°; hence its greater rapidity of evaporation, and consequent absorption of caloric. The rhigolene is more convenient and more easily controlled than the freezing mixtures hitherto employed. Being quick in its action, inexpensive, and comparatively odorless, it would perhaps supersede local anaesthesia by ether or chloroform in small opera- tions (except for its danger of transportation); for larger operations, it is obviously less convenient than general anaesthesia. Applied to the skin, the first degree of insensibility is evanescent, but if continued, or used upon a large scale, the danger of mortification or frostbite must be imminent. Ether, as a local anaesthetic, was introduced by Dr. B. W. Richardson, who has given great attention to the subject. The doctor states that, at any temperature of the air, the surgeon can produce cold six degrees below zero, and, by directing the spray upon a half-inch test-tube containing water, he can freeze it in two minutes. - Many nebulizers for atomizing fluids have been introduced besides those of Richardson and Bigelow. The first one of these was exhibited to the Academy of Medicine, at Paris, in 1858, by Sales Girons. This instrument was very expensive, and constructed to force the medicated fluid through a tube with a fine aperture directly against a metallic plate; the stream thus ejected with considerable force against the plate, by means of an air- pump, was broken into spray. Dr. Bergson's instrument is much more simple, and consists of two tubes bent at right angles with each other, having the glass drawn to a fine extremity at the angle where the tubes meet. By immersing the perpen- dicular tube in the ether, or other medicated fluid, and by blowing through the horizontal one, the air in the former is exhausted, the fluid rises from the outside pressure of the atmosphere, and passing through the capillary extremity, is atomized. It is on this simple philosophical principle that the little instrument, long known, and now coming into much more general use, called the Patent Perfume Vaporizer, for the purification of the sick- chamber, is constructed—in fact, a very excellent nebulizer can be made by procuring one of these perfume vaporizers at the druggist's, and having the approximating ends of the tubes ground to a capillary extremity, and then applying thereto an Andrew Clark hand-bag. It is somewhat after this fashion that Dr. James G. Richardson, of Union Springs, New York, has contrived a very neat little apparatus, which may be described as follows: It consists of two tubes, five inches long, and three-sixteenths of an inch in diameter, made of thick glass, and each drawn off at one end to a point, which is to be smoothly ground down till the resulting aperture is about the diameter of a horse hair; bend one of these tubes, by holding it over the flame of an alcohol lamp, at a right angle, half an inch from its small extremity, and again at its middle in an opposite direction to the same extent; then attach both tubes to a grooved cork, so that the capillary opening of the bent or lower one, shall be opposite the minute orifice of the straight tube, to the other extremity of which the nozzle of a syringe is affixed, the tubes being held in position by placing them through a large cork. Dr. Siegle, of Stuttgart, also invented an instrument by which steam is used instead of air, and is employed to produce the vaporization. Dr. Andrew Clark, of London, has introduced a modification of Bergson's tubes. To the horizontal limb he has attached an india-rubber tube, terminating in two hollow balls placed at a short distance from each other, the middle one being the air-reservoir, the other the air-pump. By alter- nately compressing and relaxing the end ball, the air-reservoir is distended, and continuous spray is produced. The instrument which I have employed is Richardson's (Fig. 57), which is used as follows: I.OCAL ANAESTHESHA. 83 After filling the bottle two-thirds full with the solution, operate the end ball briskly; this will extend the netted ball, and force a current of air into the cavity of the silver tube. This column of air, being dispropor- FIG. 57. tionately large compared with the aperture of the tube, becomes compressed, and exerts first, an influence upon the surface of the fluid (which is forced by it into the capillary tube); second, a pressure upwards, escaping through the orifice at its tip. This continued upward current of air divides into spray the drops collected at the extremity of the capillary tube. The force with which this spray can be thrown is surprising. The jet is steady, there being a nearly uniform pressure kept up by the regulating power of the netted bag, which, by its elasticity, compresses the air in it during the interval of manipulation upon the hand-ball. The great desideratum in the use of the instrument, is to employ nearly absolute and negative ether, with which local anaesthesia may be produced FIG. 58. FIG, 59. jº Delano's Atomizer. Agnew's Metal Atomizer. in two minutes. The rhigolene of Dr. Bigelow causes the same effect, and to a greater degree and in less time; but if the ether be absolute, has a specific gravity 0.720, of negative effect upon the tissues, and a boiling-point of 90° to 92° Fahr., it is very serviceable. Many disappointments may result where the ether is impure and the apparatus imperfect. Of late years since local treatment, by spray, of almost all the cavities of the body, has become so fashionable among specialists and patients 84 A SYSTEM OF SURGERY. atomizers of all sorts, shapes, and sizes, worked by, hand, steam and compressed air, have come into general use. The simplest are always thé best, two of them are seen in Fig. 58 and Fig. 59. The employment, however, of intense cold for the purpose of producing local insensibility to pain is by no means new in surgical science. It is believed that Dr. James Arnott, of London, thirty years since, was the first to introduce it to the notice of the profession. His mixture was ice finely pulverized and mixed with salt. This is a very effective method to produce temporary local anaesthesia. I have often employed it in the removal of Small encysted tumors, for the introduction of the needles of the aspirator, the insertion of a trocar, and superficial incisions. Dr. Richardson, at a meeting of the Harveian Society of London, stated that the anaesthesia was produced by the rapid evaporation of the ether, although in the earlier of his experiments he in part attributed the effect produced to the well-known and peculiar powers of ether when inhaled, speaking of it as marcotic spray. There can be no doubt that it is the cold alone that produces the local anaesthesia, and that this freezing is attributable to the rapid evaporation of the liquid used. Now, the force of sensation is supplied by the blood, and where a part is frozen, the blood cannot pro- duce sufficient heat to keep up the sensation of a part. Again, Dr. Richard- son believes that nerve force is brought down with every stroke of the heart, and in verification of this view, he mentioned that local anaesthesia could be much more rapidly induced if, while the cold is being applied, the vessels leading to the part were compressed. There are also some other precautions necessary. When a part is to be frozen, it should be carefully and perfectly dried; otherwise, a film of ice is produced, and the anaesthesia is obstructed. If the ether is not very pure, this hoar frost is likely to appear, and a good test for the purity of the article in question is to ascer- tain whether it will boil, when poured into the palm of the hand. This can be known by pouring it into the palm of the hand, holding it near the ear, and listening. Another caution given to the members of the Harveian Society was, that the use of chloroform had occasioned a carelessness in operators; the surgeon would often laugh and talk while the anaesthesia was being produced. While local anaesthesia is being effected, it is better that perfect silence be maintained. - Dr. Richardson has invented new compounds of ether. Though the effect of the cold produced by the ether spray is directly hamostatic, as reaction returns there is bleeding, which, if the wound be too soon closed, is a cause of trouble. The observation of the immediate effects of cold led Dr. Rich- ardson to think, “that if they could be supplemented by a styptic which would spray evenly with ether, and which would take up the constringing action when the vessels began to relax, an important desideratum in both medical and surgical practice would be supplied.” He had a solution made consisting of absolute ether, having a boiling-point of 92° Fahr., charged to saturation at a low temperature with tannin, and afterwards treated with xyloidin, a little short of saturation. It ran through the spray-tube without blocking, produced good local anaesthesia, and possessed an agreeable odor. * - - This aylo-styptic ether spray may be applied to open wounds on the skin, to arrest ha-morrhage after teeth extraction, and by means of a uterine tube, uterine haemorrhages from cancerous or other diseases. The styptic ether will keep for any length of time: a small quantity only is required, and it may prove of great use to army and navy surgeons. The other ether ºpºunds are a caustic ether, an iodized ethereal oil, and an ozonized ether. . Anaesthetic Ether for Local Application.—The above is the name given to COCAINE. . - & 85 a thin, bright liquid, which runs like water, and is the hydride of amyl diluted with ether. - The hydride of amyl is so light that it boils vehemently in the hand, and actively in a glass globe by merely placing the hands upon it. It is pro- curable in any quantity from the careful distillation of American petroleum. After many ingenious experiments, Dr. Richardson ascertained that the best preparation for local anaesthesia is one part of the hydride to four parts of ether, and this he calls the “compound anaesthetic ether for local anaesthesia.” It induces perfect insensibility in from ten to twenty seconds. This material is a solvent of many medical substances, which may be applied by means of the atomizer. When prepared with iodine, it is a useful disinfectant. Hydramyl can also be used as a general anaesthetic. With these sub- stances, however, I have had no experience whatsoever; the others, so far, having fully answered all practical purposes. Dr. Delcomante, professor at Nancy, claims that the power of sulphuret of carbon in producing local anaesthesia, is much greater than any other sub- stance now in use. He reports that the refrigeration is more complete than with ether, and is obtained in less than one minute. - Anaesthetic Mixtures for Small Operations.—There are other mixtures which are of great service in reducing the sensibility of the skin, besides ether and its compounds. I always keep in my consulting-room two compounds, one in camphor and ether, as follows: - B. Camphor, . . . . . . . . . . . . 3i. Ether, . * & o e e e --> sº ſº & . 3ij.—M. Or the same quantity of camphor may be dissolved in two drachms of chloroform. The second mixture I employ is: # R. Chloral hyd. . . tº º tº tº © e s & . 3ij. Camphor, e fe © © tº º º tº º tº • 3ij. Morphi sulph., tº tº * e * e e ſº ge . 3SS. Chloroformi, . º © Q © e G e ſº e . 3.j.—M. Either of these solutions, painted several times over the parts and allowed to dry, will produce a degree of insensibility to the use of the knife when superficial incisions are being made. An excellent method of producing local anaesthesia, is to wrap the parts in lint saturated with ether and evap- orate this with a pair of bellows or a syringe. Caustics, especially the Vienna paste, and nitric acid are employed in the production of local insen- sibility to pain. Cocaine (C.H.I.N.O.) was discovered in 1855 by Niemann, while the plant from which it is made, the Erythroxylon coca, has been known and used for a long period by the natives of Peru and Bolivia. Dr. Henry D. Noyes, in September, 1884, sent a notice to Dr. Squibb, of Brooklyn, that a medical student named Koller had discovered the anaes- thetic properties of the hydrochlorate of cocaine in ophthalmic surgery. The idea was at once taken up, and experiments verified the truth of the assertion. The muriate of cocaine, however, is only, as far as is present known, serviceable as a local anaesthetic applied to mucous surfaces, and to produce local anaesthesia upon the skin, it should be injected subcuta- neously. As before mentioned, it has been employed in gynaecological operations, and also used very extensively in operations about the eye and ear. Any of the medical journals for the last half of 1884 will give the student a full account of the employment of the drug. A 4 per cent. solu- tion is sufficiently strong, and a few drops should be used upon the part 86 A SYSTEM OF SURGERY. about ten minutes before the operation is begun. I have employed it only to a limited extent, but with good success in phymosis, hare-lip in a child six days old, the extirpation of a large nasal polypus, in which the effect was surprising, and in the extirpation of a small papule, and as an injection into the bladder previous to operations. It must be borne in mind, that the application of cocaine is not always unattended with dangerous symptoms. In the case in which I employed it for hare-lip in a child seven days old, the extreme pallor of face and lips and coldness of the surface, forbade its continued use. About this time Dr. Knapp had called the attention of the profession to its dangers, and shortly after Dr. Peck, Dr. Stevens, Dr. River, and Dr. McDonald,” pub- lished cases, showing beyond question, that in some persons the exhibition of the drug was followed by alarming and dangerous symptoms. Dr. A. W. Calhouni from a large experience in cataract operations states that he has abandoned the use of Cocaine in all cataract operations by ex- traction, on account of the unfavorable results in those cases in which the drug was used. Dr. Polk and others have employed this agent in gynaecological operations and Dr. Carmalt, of New Haven, records the removal of a tumor of the cheek under its influence. The use of the agents of which we have spoken for the production of local anaesthesia must be considered as one of the greatest improvements introduced into surgical science. In my own experience, in opening whit- lows and buboes; in operations for paraphimosis; lancing of mammary abscesses in females of delicate and nervous temperament, to whom it would have been manifestly unsafe to administer chloroform; the extirpation of Small tumors, and other such operations, its use has been most satisfactory; and, no doubt, for fistulae, hare-lip, removal of cancer of the lip, and even for tracheotomy, it may be very serviceable; but when we remember that it is almost impossible to make careful and minute dissections among frozen tissues, perhaps it will not be applicable where the use of the knife is neces- sary. However, we have the authority of Dr. Richardson that it has been satisfactorily used in ovariotomy, amputations of the foot, operations for hernia and Caesarian section. The advantages of the process in the latter were said to be very great. 1st. There was no bleeding; and 2d, the cold caused the uterus to contract, two of the greatest desiderata in the opera- tion. We also find records of its successful application for periosteal affec- tions, conjunctivitis, cancerous tumors of the scalp, epithelioma of the lip, fistula in ano, fatty tumor of the side, incisions into carbuncles, applica- tions of nitric acid to chancres, the introduction of the hypodermic syringe, and very many other operations which are recorded throughout the medical periodicals. * Medical Record, January 17th, 1885. f Medical Record, May 29th, 1886, P A R T II. GENERAL SURGERY. CHAPTER IV. INTRODUCTION – INFLAMMATION — INHIBITORY NERVEs—CONNECTIVE TISSUE-LEUCO- CYTES—THE MIGRATION THEORY-ACTION OF THE CAPILLARIES-HYPERAEMIA— ACTIVE CongeSTION.—CHANGES IN THE TISSUES-CHANGES IN THE BLOOD-THE TISSUE METAMoRPHOSIs THEORY OF STRICKER—SYMPTOMATOLOGY-INFLAMMATORY FEVER —THE TERMINATIONs— REPAIR — IMMEDIATE UNION.—FIRST INTENTION – º — CICATRIZATION — FATTY DEGENERATION —TREATMENT, GENERAL AIND LOCAL. FROM the time of Hippocrates to the present day, the profession has been endeavoring to satisfactorily account for the varied elementary and struc- tural changes which take place during the different stages of inflammation. The physician, the chemist, the microscopist, and pathologist, with perse- vering industry and the most earnest desire to arrive at correct explanations of the many appearances presented during the different stages of the process, have not yet arrived at unanimity of opinion. An approximation to a more correct understanding of many of the changes in the vessels, the blood, and the tissues, has been reached since the introduction of the microscope; but yet there are very many points altogether shrouded in conjecture. Erasistratus taught, and his theory was supposed for years to be the true one, that in inflammation the arteries contained blood, otherwise, that is, in a normal condition, these vessels circulating air. This doctrine was over- thrown by the humoral pathologists, who classified the process in accord- ance with the fluid supposed to be contained in the capillaries, thus: If there was an increased flow of blood, a phlegmonous inflammation was produced ; if the yellow bile predominated, the erythematic or erysipela- tous; if black bile, the scirrhous; and if phlegm, the oedematous, thus giving rise to the well-known axiom “ubi irritatio ibi fluſcus.” Then came the curious doctrine of the Methodists, of insensible corpuscles blocking up insensible pores. After years, Stahl calls forth the “ anima,” the life-giving principle and designates inflammation as a condition of spasm. Hoffmann, Cullen, and others, conceived this to be the true pathology of the condition, and were loud in their praises of the so-called discovery, which was believed for a length of time, but was contradicted by Boerhaave, who brought forward again a doctrine, not far removed from that of Erasistratus; and so, one theory has followed another with contradiction, argument, and experiment, down to the present day, when, with all our boasted facilities, our knowl- edge is just about as uncertain as it was in the times of old. So uncertain indeed is this point, that in Holmes's System of Surgery* (article Inflamma- tion), Mr. John Simon writes as follows: “The process of inflammation, as regards the intimate nature of those circulatory and textural changes by which it is constituted, is at the time of the issue of this second edition * Vol. v., p. 72, “The Process of Inflammation.” 88 . A SYSTEM OF SURGERY. matter of the utmost controversy; or, perhaps, I should rather say all pre- vious doctrines upon the subject are just now in the very crisis of a recon- sideration of which the morrow cannot be foreseen,” and, therefore, the Subject is not discussed. At the end of the fifth volume, J. Burdon San- derson has gone very fully into the detail of our knowledge as understood by recent investigators. This gentleman finds that the application of stimuli causes a dilatation of the capillaries with an increase in the blood flow, and So defines the first stage of the inflammatory process. Some again declare that the blood-globules are crowded together in the inflamed parts by the viscidity of the blood itself, thus reverting to the doctrines of old. Others again attribute the action of the capillaries, and the stasis of blood, to what are termed “inhibitory nerves,” thus bringing the cerebro-spinal system into the field to battle for the spasm of the capillaries, and so indeed we grope on in darkness and ask in vain the questions: Is the increased flow of blood in the capillary vessels, which is said to be noticed in the first stage of inflammation, due to a spasm or to a paralysis of the coats of these vessels? Are we sure of the method of innervation of the bloodvessels Said to produce an acceleration or retardation of the blood 2 Can we now, in this our nineteenth century, define with certainty, or draw a line dis- tinctly, between the process of repair which nature evokes to cure the varied lesions to which the body is liable, to which she applies for the safeguard of her temple and the purification of her courts;–from that process which terminates in disease, overthrow, and death ? How do we positively define the inflammation which cures from the inflammation which kills 2 Who can positively say whether these changes have their seat in the vessels or in the textural elements of a part 2 Is there an unusual cell production, and if so, does or does not this increased cell life cause disease or death, or the construction and repair of tissues? So far as my reading goes, even with all the lights that microscopy has endeavored to throw upon this question, there are at present no less than five doctrines, each with its own upholders, which are adduced to explain the pathology of the inflammatory process. The oldest, perhaps, of these newer methods, is “the coagulable lymph theory.” This coagulable lymph is supposed to contain all the formative elements. In the blastema, floating hither and thither, are found molecules which aggregate and form nucleoli, which arrange themselves into nuclei. A cell-wall then forms, thus constituting rudimentary elements, which ultimately are changed into the varied tissues. From the experiments of Goodsir and Redfern, together with the persis- tent and patient labors of Virchow, the school of “cellular pathology' has its origin, and numbers many illustrious names among its adherents. This method is called by Sir James Paget “the local production theory,” and embraces the cleavage of the nuclei, or “a process of endogenous germina- tion,” thus rendering the inflammatory process one in which the vessels themselves take little part, the pus corpuscles being formed from connective tissue cells, which, with their nuclei, were supposed to undergo continual cleavage, making thereby a continual pus-genesis, hence called, “the Sup- purative theory.” Recklinghausen then places his eye to the microscope, and stands amazed, as in the field he discovers among the stable connective tissue cells a moving corpuscle. Again he examines, and again he sees the peculiar cell, with its peculiar motion, wandering hither and thither with its stretching and re- tracting arms, passing into and without the vessels. This discovery, combined with the labors of Williams, Addison, Waller, and Cohnheim, brought forth the celebrated “migration theory,” adopted and promulgated by Cohnheim and Billroth, which would teach us that INFLAMMATION. - 89 the process, instead of being independent of the vessels, has its seat in them ; they not only being the channels from which exudes the cell- stimulating liquor sanguinis, but from which pass and repass, with insinu- ating amoeboid movement, the “leucocytes,” which constitute in part at least the bond of union in the repair of tissue and assist to mould into shape the new formation. - - Here are three theories, the fourth being that promulgated by the “ger- minal pathologists,” among whom Lionel Beale stands prominently fore- most. These declare that invisible particles in the blood escape from the vessels without a rupture of their coats, and that by their proliferation and subdivision the agents for the new formations are developed. In conclusion, it is necessary to speak of the more recent theory of Stricker, which, being adopted by the International Cyclopedia of Surgery, is likely to receive a new impetus in this country and in England. This theory takes us first back to the earlier stages of embryonic formation, at which period the foetus consists of amoeboid cells, cells which are capable under proper surroundings to go forward toward the formation of more perfect structure, or to retrograde into pus formation. He is of opinion that so soon as inflammation begins, the tissues return to their embryonic state, and that, therefore, the blood or the bloodvessels have very little to do in the formation of pus, but that it is the tissue itself which is converted into pus corpuscles. It is unnecessary in a work of this kind to detail the many experiments, chiefly made upon the cornea, by both Stricker and Norris, by which they appear to prove the correctness of their theories. I am dis- posed, however, to rely, and until further evidence is produced, on the migration theory of Cohnheim, which I shall endeavor to detail as concisely as possible, giving also an outline of the mutation theory also. I must say, however, that casting a retrospective glance over the history of medicine, the more I become acquainted with the subject of inflammation, as taught by the old writers, and observe the changes of opinions and the metamorphoses of theories which have taken place, I am not by any means sanguine of the permanency of the present explanations, and have little doubt that hººk: other unknown discoveries in microscopy will shatter the conclusions which are now under special consideration, or at all events materially modify them. + INFLAMMATION. For the better appreciation of what is to follow, the student should be made to understand the meaning of certain terms and certain processes which are familiar to the more recent pathologists, and which are necessarily frequently employed while treating of the inflammatory process. º Inhibitory Nerves.—The nervous system is now supposed to play a most important part in the establishment of inflammation, and it is neces- sary to consider for a moment the action of those nerves known as the “vasomotor.” If an injury is inflicted on any portion of the body, the “centripetal" or “afferent” nerves convey the impression to the cerebro- spinal axis, and by the vasomotor centre (the precise seat of which is at present unknown) is reflected through the “centrifugal' or “efferent’” nerves, to the vessels, which causes certain changes to take place in them, which will be hereafter noticed. A fact, however, must be borne in mind, viz., that if there be a division of the spinal attachment of any portion of the ganglionic cord, the effect is similar in regard to the vessels as though the great sympathetic nerve itself were divided, which would seem to prove that the ultimate origin of the nerves is in the cerebro-spinal system. It must also be remembered that these nerves can be affected by a reflex action of the afferent spinal nervous system. 90 A SYSTEM OF SURGERY. Connective Tissue is that structure pervading all portions of the body, composed of cell element and intercellular structure. It is in reality, whether in hard or in soft structure, the skeleton of the tissues, and may be divided into the vascular and non-vascular. This tissue, according to Virchow, presents a corpuscle which receives the name of the “connective tissue corpuscle,” and is considered by most histologists as “a fixed and stable element.” “The connective tissues,” according to Stricker,” are developed from the middle germinal layer, in which blood and muscle also originate. The typical connective substances are recognized histologically by the circum- stances that they contain extensive and continuous layers of material (in- tercellular substance) which, when compared to the cellular structures distributed through its substance (protoplasma), or the morphological ele- ments in other tissues, always appears as a mere passive substance, and one which participates but slightly in the processes characteristic of life. . . . The connective tissues frequently pass by substitution or genetic succession into One another; they appear, therefore, to be morphologically equivalent; so that, in many instances, certain organs or parts of organs, belonging to animals nearly allied to one another, are formed sometimes of one, some- times of another of these tissues.” Leucocytes, “wandering cells,” “exudation corpuscles,” “connective tissue derivatives,” “migration corpuscles.” These terms are synonymous. The first step that was made toward the more intimate acquaintance with the action of these leucocytes, was the discovery made some years back by Dr. C. J. B. Williams, that in inflammation there appeared to be a great disposition of the white blood-corpuscles to arrange themselves, and to adhere to the walls of the irritated capillaries. Addison, in 1843, and Waller, in 1846, not only confirmed the views of Williams, but demon- strated the actual passage of the corpuscles through the coats of the capil- laries. Cohnheim and Recklinghausen then, after much research and experiment, founded the well-known and now generally accepted “migra- tion theory,” viz., that the white blood-corpuscles (leucocytes) pass in some mysterious manner through the coats of the vessels, being possessed of that peculiar motion termed “amoeboid,” which is seen in the amoeba and other rhizopods. These so-called “wandering cells' stretch out and retract their arms in a most peculiar manner, and so migrate, often to a considerable distance, from the vessel from which they emerge. These corpuscles, by means of their mobility and flexibility, have the power of surrounding minute bodies, and are, as understood by Mr. Sanderson, “masses of con- tractile living protoplasm.” It may be noted here that “pus-corpuscles,” “lymph-corpuscles,” “white blood-corpuscles,” and rudimentary cell-forms in general, possess this power of movement, and indeed are identical. For more than half a century, pathologists have taught that inflammation consisted, first, in an increased action of the capillary vessels, with increased rapidity of the blood stream, followed by a relaxation of the coats of these vessels, with complete stasis and exudation of liquor sanguinis, and even now, when the action of the vasomotor nerves has been more thoroughly examined, there has not been much advance in the actual certainty of our knowledge regarding the action of the capillaries. On this subject Dr. Sanderson thus pointedly says: “Our knowledge of the innervation of the bloodvessels is, notwithstanding the progress which has been made in the last few years, too imperfect to enable us to harmonize all the facts. But the impossibility of constructing a complete theory on the subject does not * A Manual of Histology, by Professor S. Stricker, p. 53. THE MIGRATION THEORY OF COHNHEIM. 91 prevent us from drawing some inferences, which will be of use in enabling. us to understand what happens in inflammation, at all events better than we should do without it. From what has been stated, it is tolerably clear, that whatsoever difference there may be in other respects, there is one effect in exciting the sensory nerves distributed to any part, which is pretty con- stant, viz., increased activity of the circulation, so that, whether the actual quantity of blood existing in the part at any given moment be greater or less, the quantity of blood which passes through it in a given time is cer- tainly greater.” - After a careful consideration of those conditions which seem to be neces- sary for healthy nutrition, it would seem that inflammation may be defined as “a peculiar perversion of nutrition and secretion,” and although this may be taken as in the main correct, yet we must be careful not to confound it with hypertrophy, which may result from extraordinary functional activity, calling for a larger than a normal supply of nutritive elements. There are, again, still other conditions in which the bloodvessels may become temporarily turgid with blood, although inflammation (properly so called) may be absent. Thus “active hyperamia,” “local congestion,” “vital turgescence,” are terms used to explain an overloaded condition of the bloodvessels, which may be necessary in Some organs at certain times for the proper performance of their functions, and at others when a me- chanical obstruction may interfere with the return of the blood-stream. We find this in the mamma during lactation, in the uterus during preg- nancy; thus giving an increased blood-supply to meet an increased demand, or when a mental emotion may overload the capillaries in various parts of the body; Or, again, in certain dropsies arising from mechanical gravitation of blood or postural peculiarity. The term hyperamia is applied to local congestions, while by plethora is understood a general fulness of the capil- laries all over the body. - - - Hyperaemia may also be caused by a division of the sympathetic, thus depriving the capillaries of their nervous force, a fact going to prove the innervation theory. The Migration Theory of Cohnheim.—Let us now suppose that an irritation be caused on the surface of the body : we first have the transmission of this irritation through the afferent or centripetal nerves to the vasomotor centre, thence by means of the efferent or centrifugal nerves to the bloodvessels, which first causes a contraction of their coats and an acceleration of the stream, which is followed by a slackening of the circulation caused by a loss of tone of the capillaries. The leucocytes (“wandering corpuscles”) arrange themselves around the walls of the vessels, which, narrowing the calibre of the tubes, causes a still greater retardation of the current until it oscillates and then ceases, and the condition known as stasis results. During the period that this stagnation takes place there is an exudation of the liquor sanguinis and the migration of the white blood-corpuscles through the coats of the vessels. The blood itself is also altered in the surrounding vessels, it appearing to consist of the migratory cells, packed together in agglomerated masses, which by some is attributed to the cohe- siveness of the corpuscles themselves, and by others to a lack of tone found in the vessels. - It is a matter of considerable discussion among pathologists, as to how these white blood-corpuscles escape through the coats of the capillaries. It is supposed by some that the walls are porous and thus allow the passage of the leucocytes; others contend that these vessels possess “a certain activity of life,” and that shortly after injury, indeed, according to Professor Stricker, on the second day an alteration occurs in the walls of these radicles, 92 A SYSTEM OF SURGERY. and that from the actual pressure of the white globules from within and a fatty degeneration of the walls themselves, a FIG. 60. $20 & n opening is made for the passage of the leucocytes. This is again denied by others; all that it is neces- sary for us to know at the present is that the passage takes place. In the annexed cut, Fig. 60, Cohnheim's ex- periment is seen. L. Purves, to investigate the place where the white blood - corpuscles pass through the wall of the ves- sel in Cohnheim’s experi- ment on inflammation, in- jected a solution of silver into the vessels of a frog pre- pared after the manner of Cohnheim. The colorless corpuscles without exception wander out between the boundaries of the epithelioid cells. They never pass through the sub- stance or through the nucleus of an epithelioid cell. Ac- cording to the author, the red corpuscles only pass out by those channels which have been previously made for them by the colorless corpuscles. hanges in the Tissues. OEdematous Infiltration. — The tissues are rendered more succulent and soft by the quantity of the watery blood matter which is ex- uded; this condition has re- ceived the name of “Oedema- tous infiltration.” In the connective tissue are found masses of white blood-cor- puscles, and in some cases entire blood elements. These exudations contain, in cer- tain cases, large proportions of fibrin, which, under cer- tain conditions, may become in part coagulated, giving rise to the condition known as fibrinous dropsy, differing from the mere effusion of serum, which is produced by /2.15 Cohnheim's experiment, showing the emigration of the leu- cocytes out of a vein in the mesentery of a frog. The times of the successive observations are marked on each figure, and the individual leucocytes are distinguished by different letters;. r and g denote two leucocytes which were external to the vein at the commencement of the observation. a was only just at- tached to the outside of the wall of the vein at the commence- ment, and was free from it at the second observation, c had almost passed through the wall at the first observation, was Only just attached at the second, and was free at the third. b had commenced to adhere to the interior of the wall of the vein at the first observation, had partially penetrated it at the Second, was adhering to its outer wall at the third, and was becoming pedunculated and preparing to detach itself at the fourth. From an experiment made for Mr. Holmes by Mr. J. R. W. Webb.-(HolMEs.) an obstruction of venous THE TISSUE METAMORPHOSIS THEORY OF STRICKER. 93 return, either by mechanical or other means, constituting anasarca or ascites. - Effusion of Blood and Changes in the Fluid.—In some cases, in the sur- rounding tissues we find that besides the masses of white blood-corpuscles already mentioned, there are red blood-globules, which fact is attributed by some to a rupture of the coats of the capillaries, but, as already mentioned, Cohnheim asserts that these make their exit through the same apertures that have given passage to the colorless corpuscles. Blood, if it is present early, no doubt comes from the capillaries, if late, it is conceded to be from the newly developed bloodvessels in the exuda- tion. Changes in the Mass of Inflammatory Blood.—Another peculiar change in the body, is that in the mass of inflammatory blood, which mainly is found in the increased quantity of fibrin, which varies from two to ten grains per thousand. It is probable, however, that when there is so large an increase, that a portion thereof may consist of white blood-globules, there being great difficulty in separating them from the fibrin itself. - It has been ascertained by carefully conducted experiments, that the blood of a person affected with inflammation is overloaded throughout with fibrogeneous material as well as at the site of the pathological change, and to this, which, as will be shown further on, is an old theory, inflammatory fever is attributed. With the increase of fibrin it must be remembered that there is found to be a diminution of albumen and a larger quantity of water. Blood from a person suffering from a high degree of inflammation, forms a much denser “crassamentum,” or “clot,” or “cruor,” than is found in healthy vital fluid. When this clot has been allowed to stand for awhile, the upper surface is covered with a whitish film, which is composed chiefly of fibrin and white blood-corpuscles, and receives the well-known term “buffy coat.” Many times the superior surface becomes concave, and then the blood is said to be “cupped.” We have, therefore, thus far: Changes having their seat in the vessels (contraction and relaxation) pro- duced by the vasomotor system. Changes produced in the blood-stream consequent upon the action of the vessels. First increased velocity (a short stage), then diminution and stasis. Changes in the relative quantity and arrangement of the white blood- lobules. g Changes in the texture of the surrounding parts by the effusion of the liquor sanguinis. - The Tissue Metamorphosis Theory of Stricker.—It will be seen from the few foregoing remarks that though Stricker and Norris have been earnest in the promulgation of a part of the migration theory, that their more advanced experiments bring them back again to the theory of Virchow; -which was in reality one of tissue metamorphosis, but holding that the changes neces- sarily produced by inflammation took place in the connective tissues. This belief was upheld for a dozen years or more by many distinguished micro- scopists. The doctrine held sway from 1855 to 1867, when it was entirely upset by Cohnheim, who proved that the pus corpuscle was nothing but an extra vascular white blood corpuscle, and established his migration theory of which I have just given an outline. - In 1869 Stricker, chiefly from careful examination of inflamed corneas, made the discovery that in no tissues of the body could inflammation and suppuration be referred entirely to the migration of leucocytes, but that there was also a certain alteration taking place in the capillaries which was essential to the production of the inflammatory process. He says on this 94 A SYSTEM OF SURGERY. point: “However, in the year 1869, I had already found out, in conjunction with W. F. Norris, that Cohnheim had examined the cornea imperfectly; that the cornea-corpuscles in fact did change; that their neuclei increased; that they became amoeboid in the course of the inflammatory process. True, we said they do not all change at once; they do not change everywhere in the entire cornea, but only where a centre of suppuration is forming. But in the rest of the cornea we see the old cornea corpuscles at the side of single new cells, which look like pus-corpuscles. But, inasmuch as at that period we likewise could not observe movements in the branched cornea- scorpuscles (in their normal condition); and inasmuch as we have learned that they become amoeboid (like white blood-corpuscles) during inflamma- tion, we said that the newly-revealed corpuscles had passed into this neigh- borhood, and had become visible beside the unchanged branched corneal- corpuscles. , Norris and I have furthermore shown that suppuration does not always begin at the edge of the cornea as Cohnheim asserts, but that it begins where the irritation has exerted its influence.” After much more research it was finally discovered, not only that the cells divide and sub- divide, and thereby rapidly assist in the construction of new tissue, or to increased pus formations, but they appear to resemble the true embryonic cells in their behavior and life history. Stricker claims that he can dem- onstrate beyond cavil, that this cell division which has already been alluded to, though occurring, does not take place according to the explanation of Virchow (the nucleus being cleft into two parts, with a separation of each), but that the cells become amoeboid before division, and that so soon as inflammation commences, these independent movements begin, and from this he was led to formulate his new and, as he declares, complete theory. In the strong language of the German student, and forgetting in his enthu- siasm all that has gone before, and what probably will be the fate of this, his latest effort, he says: “But the condition of affairs has now changed. In the year 1874 I began to study keratitis in the mammalia, and here obtained results which ex- plained the clinical phenomena satisfactorily. Starting from this point I examined all kinds of tissue, and the results were of such a nature that I also can now clothe the doctrine of inflammation in a simple form. Meta- morphosis of tissue, return to the embryonic condition; division into amoeboid cells of the masses which have become movable; hence the de- struction and suppuration. This is briefly the outline of my new doctrine. “On the other hand, all the details of my further researches were very favor- able for my theory. It appeared that this theory was in harmony with results of researches in the domain of comparative histology and histogenesis. It appeared that in the pathological destruction of tissue by suppuration, not only the cells, but also the entire tissue returned to the embryonic condition. The machine was, as it were, separated into its parts again. In regard to the pathological tissue, therefore, I was about in the position of the mechanic, who takes apart the machine and finds that which the builders have asserted to be present. It appeared, furthermore, that the return of the tissue to the embryonic state at the same time included the conditions requisite for a healing of the tissue. In every phase of inflammation the destruction can cease, and a regeneration or a cicatrization can be started. And this new formation is, throughout, similar to the embryonic new formation. “In consequence of such observations my conviction of the correctness of my theory of inflammation has been so much strengthened that I believe that I may now venture to publish it with all its deductions. But I must , finally remark that the opposition to this theory has only been heard in , moderate tones during the past five years.” HEAT, 95 The Symptoms of Inflammation.—The most prominent symptoms that denote the presence of inflammation are the well-known ones of pain, heat, swelling, and redness. - - Pain is the most characteristic symptom of inflammation, and is caused by the compression of nervous filaments, from the encroachment of the swelling upon them, which acts as a mechanical force; consequently, the pain increases as the tumefaction advances, particularly if the surrounding textures are firm and unyielding. The function also of the sentient nerves is perverted, and they become, themselves, one of the seats of inflammatory action. Moreover, at each throbbing impulse of the heart and arteries, the nervi vasorum of the distended and elongated vessels add something to the general amount of pain. But such causes, as well as their results, are liable to vary. The pain present in inflammation is not uniform. It is, as has been before mentioned, in a great measure influenced by the elasticity of the textures in which inflammation occurs. Thus, when a bone is affected with disease, it is more painful than when the skin is attacked. The intensity of the inflammatory action, and the sensitiveness of the affected part also, to a great extent, influence the amount of pain, and, indeed, there are occasional cases wherein no pain whatever is present. The student must bear in mind that there are other varieties of pain besides the inflammatory. With the agonizing pain of spasm, there is no inflammation present; in neuralgia, also, there is severe pain without the slightest trace of inflammatory action. The differential diagnosis is as follows: In inflammation, pain begins slight, but continues gradually to increase. In neuralgia or spasm, the pain begins generally with severity. In inflammation, pressure invariably aggravates the suffering. In spasm, colic, or neuralgia, the suffering is often relieved by pressure. In inflammation there is but one slight intermission, in the other diseases there may be a distinct and even a periodical intermission. In neuralgic diseases there is often a sudden intermission of the suffering; if this occurs in inflammation, it is always a suspicious symptom. As a rule we find the most pain at the focus of the inflammation; but this, it must be borne in mind, is not always the case; for when parts are nearly allied to one another in function, although separate in location, the pain may be felt at a distance from the seat of inflammatory action. In inflammation of the brain the most of the pain may be referred to the spine; in the hip, to the knee; in the bladder, to the kidneys; and in the liver, to the right shoulder. - Heat.—“The symptoms and consequences of inflammation,” wrote Mr. Liston,” “and amongst others heat, are modified by the distance of the affected part from the centre of the circulation. All actions, healthy as well as morbid, proceed with more vigor in the superior extremities—the head, the neck, and the trunk—than in the more remote parts of the body; for in the former the blood is transmitted more speedily, if not in greater quan- tity, and is not so liable to be impeded in its return.” This is evidently true, as ascertained by the thermometer. The normal temperature of the body, at the heart and upper parts of the trunk, varies from 984° to 100°, at the extremities about 93°,+ but there is a rise of the mercury from the heat of an inflamed part, the patient complains of extreme heat, burning, and throbbings, and the thermometer may indicate a rise of four or five degrees. This can be readily accounted for. During the inflammatory process the nerves of sensation, partaking in the general abnormal action, become per- * Liston's Elements of Surgery, p. 52. f Cyclopædia of Practical Medicine, p. 738. † Loc. cit. 96 A SYSTEM OF 'SURGERY. verted; indeed, increased sensibility is one of the signs of inflammatory action. . This accounts for the sensation of heat so frequently noticed and complained of by the patient; and if we also remember that a very fruitful Source of animal heat is referred to the changes that take place in the blood circulating in the capillaries, and as these changes are carried on with great rapidity in inflammation, we can readily imagine that the heat of the part which is the seat of the abnormal action may be elevated. Heat must also be connected with other symptoms to assist in the diag- nosis of inflammation, for we all know and are every day told of burnings in different portions of the body, when there is not the faintest trace of any inflammatory action. A great many facts lead to the opinion that animal heat is the product of increased sensibility. Whenever the vital powers are much excited it is found in augmented quantity. The temperature of the hen's breast during incubation, although divested of feathers, is much increased. Emotions of the mind, as anger, hope, and joy, also develop heat, although it is rather a sensation than a real increase of caloric ; experiments having shown that the temperature in the mucous canals of animals is nearly the same in a healthy or inflamed state. If the blood is accumulated unduly in a part, there is found an increase of heat; and if a part is unusually heated, there will be found an additional quantity of blood. With regard to the fact already noted, that an inflamed part actually generates heat, Mr. John Simon has given us some most carefully conducted thermo-electrical observations.” He finds, “1st. That the arterial blood Supplied to an inflamed limb is less warm than the focus of inflammation itself. 2d. That the venous blood returning from an inflamed limb, though less warm than the focus of inflammation, is warmer than the arterial blood supplied to the limb; and, 3d, that the venous blood returning from an inflamed limb is warmer than the corresponding current on the opposite side of the body.” When this heat is reduced by perspiration or other critical phenomena, there will be less of that disorder (hereafter to be mentioned) known as inflammatory fever. Swelling.—This effect arises from several causes; first, the effusion of coagulable lymph and serum; secondly, the increased quantity of blood in the vessels; thirdly, the deposition of new matter; fourthly, the interrup- tion of absorption, particularly noticed by Soemmering. The swelling is, #. the most part, confined to the cellular texture, and is commonly the greatest where the inflammation commences; but this symptom, when viewed alone, cannot by any means, indicate the disease; others must be conjoined with it. In the simplest form of oedema no in- flammation is present. On the other hand, as noted by Stricker, “we are not sure whether the bones, for example, necessarily show any externally visible swelling in inflammation. I must remark right here that inflamma- tory swelling is distinguished by its hardness, and in many cases the hard- ness, not the visible swelling, is the decisive characteristic. If I see a reddened district in the skin; if I palpate, and find it hot and hard, I say it is inflamed, even though no swelling be visible. And it is indeed possible that swelling at times may become unrecognizable—as, for example, when the inflammation is in a nodular, uneven neoplasm. The inflammatory swelling and hardness are, as I shall show, dependent on active tissue-meta- morphosis. I say, therefore, that tissue-metamorphosis is a generally reli- able symptom, and put in the place of swelling. The active tissue-metamor- phosis likewise includes the symptom-impaired function; for I shall show * Holmes's System of Surgery, 2d ed., vol. i., p. 18. f International Cyclopaedia of Surgery, vol. i., p. 33. THROBBING 97 that the tissues, when undergoing inflammatory changes, have their func- tion impaired.” - The redness is evidently caused by the increased quantity of blood con- tained in the capillaries, and the introduction of the red globules into those radicals which previously would not permit their admission. The color of the blood, also, in inflammation assumes a deeper tint, but there are some instances in which the inflammatory process may have been present to a certain extent, and the parts be paler. This, however, is not generally the case. The enlargement and engorgement of the capillaries were made plainly distinguishable by Mr. Hunter. He says: “I froze the ear of a rabbit and thawed it again; this occasioned considerable inflammation, an increased heat, and thickening of the part. This rabbit was killed when the ear was in the height of inflammation, and the head being injected, the FIG. 61. two ears were removed and dried. The uninflamed ear dried clear and transparent, the vessels were distinctly seen ramifying through its sub- stance, but the inflamed ear dried thicker and more opaque, and its arteries * mºderably larger.” The different sizes of the capillaries are seen in 1g. Ol. But redness is not absolutely essential to inflammation, which may take place slightly in the cornea, for instance, without it, and also in the arachnoid membrane of the brain. - The speedy appearance of the redness destroys the opinion advanced by Some that the red vessels are a formation of the inflammatory process. Throbbing.—This depends upon the obstruction to the passage of the blood through the capillary vessels, and is not owing to its increased rapid- ity of action. Throbbing, with a little attention, can generally be ascer- tained. The larger vessels are incited into a stronger action, which again is communicated to others, till the whole system may become involved. The throbbing is particularly distinct in cases of paronychia. There are many instances, however, when some of the local manifesta- tions of inflammation cannot be appreciated, but the constitutional Symp- toms—quick full pulse, dry furred tongue, high-colored urine, thirst, etc.— may, perhaps, lead to the detection of the disease, “but,” says Mr. Fergus- son, “some of these even are not entirely to be depended on, seeing that they may be present without the existence of inflammation ; whilst again, that disease may be in full vigor, and yet the symptoms may be such that the most experienced may be deceived.” Again, he says, referring to the same subject, “exceptions to these observations must be familiar to every one who has seen even a little practice.” 98 A SYSTEM OF SURGERY. Symptoms, however, of the most unequivocal character, indicating the existence of inflammation in some internal part of the body, may exhibit themselves, yet a post-mortem examination may not detect its existence. This is owing to the capillaries having emptied themselves into the veins after death, or in consequence of the actual contraction of the vessels them- selves, which is known to occur during the dying moments of the individual. This fact is well worth remembering, as a correct diagnosis may have been formed, and yet the physical evidence of it may be wanting. Inflammatory Fever.—Some authors classinflammatory fever with pyamia, septicaemia, and traumatism in general, making, however, a classification between the simple variety (that appearing immediately) and the more alarming and profound symptoms which result after poisonous materials have found their way into the circulatory system. Every surgeon, however, knows that at certain times, especially in those persons having a nervous temperament, in a very short period after an in- flammation has appeared, all the symptoms of a high degree of fever are developed. This has been explained by many, as resulting from general overheating of the blood. The more, however, I think over the subject, the more I am disposed to believe that the views expressed long ago by John Fletcherº are correct, and that inflammatory fever, properly so called, is due to a general perturba- tion of the capillary system and a general disturbance of vital force. It must be remembered that when Fletcher wrote, the inhibitory nerves had not received attention, and that his conclusions were arrived at by reasoning, observation, and analogy. He thus writes: “It must be abundantly obvious that it is the first stage of fever which is (as in inflammation) that of increased action, at least with regard to the extreme vessels of the surface of the body (the essential seat of the morbid change), and the second that of diminished action with respect to these vessels; and this, whether the exciting cause be stimulant or sedative. It is true—the increased excitement of these vessels being always attended by a diminished excitement of the rest of the body, and the diminished excite- ment of these vessels by an increased excitement of the rest of the body— it is difficult to divest one's self of the notion, that the cold stage of fever is one of deficiency of action, and the hot stage of increase of it; and it was this which gave occasion to Dr. Armstrong to call the three stages of con- tinued fever (corresponding to the cold, the hot, and the sweating stage of an intermittent) by the names of the stage of oppression, that of excitement, and that of collapse—names which, it must be remembered, apply only to the state of the body in general, and not of the capillary vessels of the surface, which, during the stage of oppression, are in a state of preternatural excite- ment; during that of excitement, in a state of corresponding collapse; and during that of collapse, in a state of reaction. “Whenever,’ says Dr. W. Phillip, “increased temperature, swelling, and redness appear, the capillary vessels are debilitated, and preternaturally distended.' Now, in the hot stage, the whole surface is affected with increased temperature, redness, and swell- ing. The deduction is obvious, and the analogy of fever, in every respect, with inflammation, is too manifest to require further comment. In fact, inflammation and fever differ only in their seat and in their degree ; the seat of inflammation being anywhere, and more or less circumscribed, and its degree commonly considerable; whereas, the seat of fever is in the whole surface of the body, and its degree commonly slight. It is here, however, meant that the degree of inflammation, in any given number of * Elements of General Pathology, p. 176. Ed. J. J. Drysdale, M.D., and J. R. Russell, M.D. Edinburgh, 1842. RESOLUTION. 99 capillary vessels, is commonly slight in fever compared to that of inflam- mation, properly so-called; but the number of them much more than com- pensates for the slightness of the inflammation of each, and the constitu- tional affection is, of course, great in proportion.” Divisions.—Inflammatory fever has been divided into the sthenic and asthenic; the former generally appearing in robust young people, the latter in the aged and poorly nourished. It presents the usual stages of erethism, beginning with the usual coldness or chill, as already explained, and fol- lowed by frequent, full, and hard pulse, hurried respiration, flushed face, dry mouth, hot head, restlessness, and often delirium. The tongue is coated, the breath bad, the secretions deranged, and the temperature rises to 103° or 104°. These symptoms subside, with critical discharges from nose, kidneys, lungs, or skin; or if the focus of the inflammation continue high, the nervous system becomes prostrated, and other symptoms of traumatism develop themselves. These will be treated of in their proper places. The Terminations of the Process.-Inflammation has been made to cover processes which were apparently directly opposed to each other. It embraces the healing of wounds and their disastrous suppuration and ulceration; the mending of a broken bone, and the process which prevents the formation of callus. In the consideration of the subject Mr. John Simon, the author of the article on inflammation in Holmes's System of Surgery, thus writes: “As regards the difference between these actions (formative and destructive), when they occur in health and when they occur in inflammation, it may suffice to observe empirically that the appreciability of the opposed results is in itself a differential mark of inflammation. In healthy tissues, during their normal self-mutation, the anatomist does not at any given moment find either palpable detritus to express their waste of material or multiply- ing embryonic forms to express their action of repair. The change of matter, the degeneration and removal of what is effete, and the substitution of what is useful, occur there so evenly and proportionably that separate steps are not marked in the process, nor can any contrast be found between the respective elements of declining and nascent tissues.” We therefore may arrange the terminations of inflammation under the following heads: 1. Resolution and metastasis. 2. Repair (development of new formations). 3. Degeneration, including a. Suppuration. b. Textural softening. c. Ulceration (molecular death). d. Mortification (death en masse). Resolution, also described as Delitescence by some authors, may be either complete or incomplete. In this action the overloaded capillary vessels give off a slight transudation, which relieves them of their engorgement, and allows the agglomerated blood-corpuscles to move slightly in the over- distended vessels. Absorption, also, which had been temporarily sup- pressed, is again called into play, and the extravascular deposits are removed ; by these two actions the tone of the capillaries begins to be regained, and the heart continuing its action the circulation is gradually restored, and healthy nutrition again established. But the sudden disap- pearance of inflammatory action must always—as has been remarked of pain—be regarded suspiciously, as other parts are very liable to take on a similar action, and thus a metastasis is established, perhaps the organ more recently attacked being of a far more important character than the one primarily affected. - Although resolution cannot always be expected, still it, frequently does º c Q tº wº e Q •,• º Ç o 100 A SYSTEM OF SURGERY. occur; and when this is the case, it is the most desirable termination of the inflammatory process; at all events, the first treatment should be directed to the establishment of resolution, which, if it does not prove sufficient for this end, may mitigate some of the after consequences of inflammation. It frequently happens, however, that by the appropriate treatment the tendency of parts to take on inflammatory action may be removed, and thus the patient may be relieved of a considerable amount of suffering and the prob- able tedium of a long and debilitating confinement, and the physician from the harassing and perplexing complications that so frequently present themselves as the sequelae of inflammation. REPAIR. Inflammatory New Formations.—To account for the varied new forma- tions which are developed by the inflammatory process in the repair of the tissues, many theories are at present under consideration. To explain them Bennett founded his “Coagulable Lymph Theory,” on the fact that all the new tissues were formed from the blood plasma exuded from the coats of the vessels. Goodsir, Virchow, and Redfern taught that new formations could be developed from the tissues themselves; while Beale referred all new formations to the subdivisions of the minute germs of living matter, not especially, however, from the nucleoli or nuclei, but from invisible par- ticles found in the blood. Then followed the migration theory of Cohnheim, and the wonderful power of the wandering white blood-corpuscle appeared to be demonstrated so satisfactorily that the process of repair was considered as fully explained. But Stricker, who had also been industrious in discow- ering this amoeboid motion of the cells, found that the new formations were derived from active connective tissue metamorphosis without hyperaemia. For further information, however, the student is referred to the previous section of this work which treats of the inflammatory process. Whichever of these theories may be correct it is impossible for us to determine at present, but we can form a fair conclusion that the develop- ment of new formations may take place by the cellular infiltration under- going a variety of modifications. It may be metamorphosed into primary cellular tissue, then into granulation tissue, and thence again into connec- tive tissue, which assumes more or less the conditions of healthy structure. Adhesion.—A certain degree of inflammation was thought necessary to the restoration of injured parts; hence called healthy inflammation, and supposed to be an instinctive stimulus rather than a morbid action. Un- healthy inflammation, on the other hand, was said to consist of many species—influenced by the kind of disease or by the particular condition of the part in which the inflammation took place. Sir Astley Cooper expresses the opinion of the profession of his time. He says: “Inflammation is a restorative process; no wound can be repaired without it; even the little puncture made by the lancet would inevitably destroy life if this salutary process did not prevent it.” John Hunter, that leviathan in physiology, as Johnson was in literature, in his great work on Inflammation, has been supposed to hold the same opinion; but a more critical examination has led us to believe that even he supposed wounds might be healed without inflammatory action, to substantiate which, passages from his writings can be adduced. For instance, when describing union by the first intention, he seems perfectly aware of the ability of wounds healing without inflammatory action, for he says the union in such cases is without pain or constitutional disturbance, and proceeds as if nothing had happened. Again, he says: “There is only a feeling of tenderness in the part, and that is entirely from the injury done, and not from the operation tº P : gº & º s".” . • * g © o © O sº gº REPAIR. 101 of union; also, that inflammation comes on as a necessary consequence of parts being too weak to unite by the first intention, or not having the power and disposition to heal.” Owing to Mr. Hunter's obscure phraseology, it is imagined by some that he has been made to support opinions adverse to the great physiological doctrines which he labored so much to establish. He considered inflamma- tion as dependent upon increased circulatory action.* As we descend in the order of vitality we find that inflammation is not necessary to a restoration of health. When vegetables sustain injury no such process is established, but the vacancy is filled by the regular and gradual growth of the plant. In polyps and gemmiparous animals incision and division are the means of multiplying the species. The gray and green polypi have been united into one animal. The injuries of insects, likewise, are repaired similarly without inflammatory action. The oyster and mussel are said not to be susceptible to inflammation, and the same may be said of serpents, toads, Salamanders, and others. • Of late we have a much more definite idea of the process of repair than formerly. Now we can say that in every individual case the inflammatory process is not necessary. The most perfect form of repair is that known as “immediate union,” by which we understand that if parts, immediately after severance, are placed in direct apposition, the capillary circulation may be established, and union take place without inflammation, the conditions through which such results occur being those most favorable for healthy nutrition. There are many other cases, however, in which the symptoms of inflam- mation must and do present themselves; then we have a degenerative condi- tion of the nutritive process, both in degree and in character, with a corre- sponding breaking down of the very tissues which have a tendency to be produced by the process. - In primary adhesive inflammation the older pathologists believed that the connective tissue of a wound or surface about to be healed was formed by the lymph exuded during the inflammatory process. According to Virchow, however, the changes are now ascribed to the rudimentary cor- puscles or leucocytes which are generated by the cells on each side of the cut or wound. These multiply and become packed into the interspaces of the exuded fibrin, which is now merely a passive material. These cor- puscles, however, undergo separate changes; in the one instance they enter into the new tissue about to be formed, and in other instances they become pus-corpuscles. According to Billroth, Cohnheim, and others, the changes that take place in an incised wound are: 1st. Dilatation of the capillaries, which causes a retardation of the blood- Stream. & 2d. The wandering white blood-corpuscles migrate into the margins of the flaps, and may even pass into the connective tissue, which becomes much infiltrated with serum. 3d. The leucocytes are then in part converted into the stable and per- manent connective-tissue corpuscles, and the remainder either enter again into the circulation or degenerate or soften to form pus. 4th. Together with this, an exudation of fibrogenous serum occurs, which assists to hold the corpuscles firmly. The ultimate firmness of the new formation is produced, according to Schmidt, by a fibro-plastic substance, which arranges itself around the * Lectures on the Principles of Surgery, by John Hunter, F.R.S., 1839, p. 149. 102 A SYSTEM OF SURGERY. newly-formed corpuscles, forming for them a stratum in which further growth and proliferation may occur, and which also may be removed by absorption after the firmness of the parts is complete. During the healing process, also, the blood-clots are broken up and absorbed. The healing process, just described, was attributed by many pathologists of old to the fibrin of the blood, which, according to the Hunterian theory, Was supposed to be necessarily present in the healing of wounds by what was called per primam intentionem, or first intention; and although there can be no doubt that blood-clots may themselves become perfectly organized, as is seen in the arteries after their occlusion, yet this method of organiza- tion is at present believed to be only noticed in the smaller coagula, and that, according to Billroth and some others, in the larger clots the organiza- tion only occurs on the periphery, while disorganization takes place in the centre of the clot. Granulation and Cicatrization.—If a wound does not heal by the first in- tention, it closes, by another process, by which new tissue is formed, known as granulation. * The exuded white corpuscles, or the fixed inflammatory corpuscles, be- come imbedded in fibrin from the liquor sanguinis, the serous portion of which drains away or may be absorbed; the capillaries assume a somewhat tufted form, and are looped and twisted upon themselves, and finally Small, rounded, red, vascular points are seen scattered throughout the sur- face. These cells are then called granulation-cells, and become numerous and fill up the cavity which is being healed. It must be remembered that new capillaries are also formed, which first are composed of a thin mem- brane containing nuclei, arranged frequently in a longitudinal direction, and arising from the sides of the permanent capillaries. These finally be- come fully formed, and transmit an extra supply of blood as long as it is needed; when they are of no further use they diminish and disappear. Healthy granulations are not very sensitive, are of a bright red color, and ordinarily do not bleed easily; sometimes, however, they become sen- sitive, and bleed from the slightest touch, or they may become flabby, pale in color, and very luxuriant in growth; these are, of course, deviations from the normal or healthy process, and require treatment. Finally, the granulation-cells gradually coalesce and become incorporated with each other. (See Fig. 62.) During this process it must not be under- stood that all the corpuscles take on the action we have described; on the contrary, there are many of them which undergo degeneration and soften- ing, and become pus, and are thus carried away. After the granulations have reached the surface of the body, provided they are healthy, they still further join themselves together, and become glazed over, and as the nodules next the healthy skin reach the surface they become dry and are paler, the epidermal cells become flattened upon themselves, and thus the process continues until cicatrization results. The annexed cut shows beautifully the steps of the process just described. Rindfleisch says: “The cicatricial tissue is far from being a connective tissue of ideally high quality. On the contrary, its fibres are stiff, inelastic, and misshapen; its cells are repre- sented by shrunken, staff-shaped nuclei, and its vital capacity is propor- tionally reduced. Moreover, the cicatricial tissue exhibits an extreme proneness to contract in all its dimensions. . . . . It need hardly be said that this general diminution in bulk is a physical rather than a vital phe- nomenon. The removal of water has a great deal to do with it, for the white glistening tissue of a cicatrix is dry, compact, and harder to cut than any other variety of connective tissue.” The scabbing process may be called nature's mode of healing wounds. We often see the process in animals when they receive slight wounds, the blood, THE WARIETIES OF IN FLAMMATION. 103 dirt, and other materials which collect on the outside form a thick scab, ex- cluding the air; when the scab falls off, the wound beneath is healed. This process takes place, however, only in slight wounds where there is little or no suppuration. Dr. Hewson imitates this process in his earth treatment, and I must confess I have seen wonderful results from this application in FIG 62. 9. dº cº C§º ºft 3%as f § º#º §§ UQ; 5,336 pººl §§ G) Ö) SS; © § §§25 - ŽSS: ~ §§ G) 㺠sºe, 6 º 33°243 º §S - : §§ | O §§2N), §6) • S - à §§§ §§ º § sº Š qº. Sºs: § zºº; $º #3's º º JºžSViºC)?(o); &\ºº i. 2: §3. §ſ: $ E). § § % º Le Tââ §§ : §§ º ić ſº §§ ſº § O #(ºſ) 36 jº §§§ §§§ §§§ §§ .1 Cºo ©9 §§ §§§ {? Šºš%); § V ſº & - % dº Vº NC N(\º §3) ||& § % § § | § O * \ſ, - º > §§ * . . . º ºft||| Šs O 3 | O 3 º => § 3|. OC O & 33 OO E= EE § \º -- \º Vertical section through the edge of a granulating surface in process of repair (after Rindfleisch).--a. Secretion of pus. b. Granulation tissue (embryonic tissue) with capillary loops, whose walls consist of a layer of cells longitudinally disposed; their thickness decreases as we approach the surface. C. Cica- trization beginning at the base (spindle-cell tissue). d. Cicatricial tissue. e. Fully-formed cuticle, its #. yer consisting of grooved cells. f. Young epithelial cells. g. Zone of differentiation.— (HOLMES. recent wounds and burns. The process, however, does not appear to be exactly understood. But it is probable that the pus and serum become inspissated, and that the healing process takes place beneath them. The Warieties of Inflammation.—It is rather difficult, strictly speaking, to divide or classify inflammations, because in each the same actual pathological conditions are found, viz., stasis and transudation; but there are marked differences exhibited by different tissues when undergoing the process, and from these we may differentiate the croupous or fibrinous, the parenchymatous, the catarrhal, the phlegmomous, the scrofulous, the infective, and the chronic. These terms scarcely need explanation. In the croupous, there is found to be a coagulable exudation developed upon mucous surfaces, accompanied, in the majority of instances, by a necrosis of the membrane beneath. The catarrhal form differs from the above in the fact—an important one—that the exudation is mucous and does not coagulate, and contains scattered leu- cocytes. This variety is more liable to become chronic; indeed, in some instances the white blood-corpuscles become pus-corpuscles, and we have the well-known purulent catarrh. By the term parenchymatous inflammation, is understood those changes 104 A SYSTEM OF SURGERY. resulting from the inflammatory process taking place in the true tissue of an Organ, independent of its connective tissue. It consists mainly in a granular degeneration of the protoplasm of the cells, similar in most respects with that variety of diseased action known as albuminoid, which often ends with fatty degeneration. Parenchymatous inflammation therefore attacks the true structure of a part, while interstitial inflammation affects the con- nective tissue. In the catarrhal variety of inflammation, the mucous surfaces suffer; the exudation that takes place is composed of mucus, containing scattered leu- cocytes and epithelial cells; the discharge does not coagulate, and some- times, when the catarrhal inflammation is produced by a specific poison, as in gonorrhoea, the mucous discharges rapidly become purulent. This is also seen in the conjunctiva. The so-called phlegmonous inflammation is nothing more than an acute in- terstitial inflammation, generally resulting in the formation of abscess. The term infective, as applied to inflammation, readily explains itself. The passage of some infectious material into the blood (pus, ichor, or any form of bacillus) will set up an inflammatory action which is decidedly in- fective in its nature. Other terms sufficiently explain themselves, and need no further mention in this place. Other results of the Inflammatory Process.-Before proceeding to the con- sideration of the other more important terminations of the inflammatory process which demand separate treatment, a few remarks upon some of the further results of the inflammatory process remain to be noticed. In muscle the true texture disappears, and is replaced by granules and a large quantity of “oil-drops;” even the striae in the surrounding muscular fibre give way, and a semi-solid substance, composed chiefly of oil, TěIY) all].S. In glands and the mucous membranes, no matter where found, this tendency to softening and disintegration, and the appearance in the débris of vast amounts of oily material, is found. In bone, the first trace of the destructive process is generally noticed be- tween the animal and earthy constituents of the Osseous structure. The parts are disintegrated and discharged in larger or smaller particles, while the chemical constituents are also materially changed. In ligaments and the hard structures, again, are found liquefaction and tendency to fatty degeneration; and in nerves the very nerve-tubules themselves become filled with depositions of oil, ... The conversion of cells into this oily substance, which ultimately causes fatty degeneration, is occasioned first by an accumulation of fatty particles in the interior of the cells, which, being thus filled, lose their translucency, and the cell-wall becomes thinned. - This degenerate body has been called by Gluge the “inflammatory glob- ule,” by others the “granule-cell.” The cell-wall, as the process continues, disappears, and the mass (“granule mass”) breaks up and is more readily amenable to absorptive power. - This fatty degeneration is sometimes accompanied by the deposition of calcareous material in the corpuscles. The causes of inflammation are divided into the predisposing and exciting. Among the former may be classed plethora, debility, either general or local, intemperance, undue exertion of mind and body; the latter, comprising irri- tants, pressure, heat or cold, excessive irritation, retention of secretions. The duration of the inflammatory process varies according to the struc- ture of the part, its situation, the temperament, age, sex, and habits of the patient. In organs of a high degree of vitality, the progress is more rapid than in those which are less highly organized. In the sanguine tempera- TREATMENT—LOCAL TREATMENT. - 105 ment it is more severe than in the phlegmatic, and in the intemperate it is more to be dreaded than in those who have led a regular and temperate life. Treatment.—In the treatment of inflammation, often the different charac- teristics of the suffering are important, thus: Inflammation of the cellular, Osseous, nervous, and muscular tissues is circumscribed and the pain throb- bing. In morbid growths and in tubercle the objective symptoms are dif- ferent, nor is there much pain or increase of heat. In other varieties of abnormal growth the appearances again are dissimilar, and the pains are acute and lancinating. Inflammation of the lining membrane of the larynx is admitted to be quite different from inflammation of the lining membrane of the trachea. Inflammation, seated in the same tissue of the same organ, assumes at different times different characters, as is observed in cutaneous affections. How are these differences to be understood and encountered ? Can they all be grouped together and treated as that pathological condition termed inflammation ? If systems of medicine and not the law of simile be true, they ought to be so understood and treated, and the successful result of such practice would confirm the truth of the system. But they are not treated upon any general principle. In diseases of the dermoid system, the chief reliance is reposed upon what are termed specifics. An impartial mind can entertain no other idea than that the different subjective symptoms—as exhibited, for example, in different yarieties of pain, such as tearing, burn- ing, darting, lancinating, pressive, piercing, boring—are the result of essen- tially different morbid actions; each one, therefore, of necessity requiring its appropriate remedy. To these differences a critical attention must be given for the most successful application of means. It is unpardonable ignorance at the present time, when the bright rays of progressive medicine are illuminating our pathway, to have an imperfect knowledge only of symptoms, and to confound all distinctions. - The following are the medicines that appear best adapted to remove the tendency to inflammation. 1. Cham., graph., hepar, petrol., silic., staphis., sulph. 2. Baryta carb., calc. C., lyc., nit, ac., rhus, sepia. Should these not be sufficient, and the inflammatory action appear to be progressing, the medicines to be relied on are: 1. Acon., ars., bell., bry., hepar., merc., phos., silic, sulph. 2. Asa., arn., calc. C., china, graph., mang., natr. m., petrol., puls., rhus tox. These, perhaps, it will be sufficient to name, although there are many others of minor importance that are serviceable in treating the concomitant symptoms of inflammation. Of course, it would be highly improper to administer any of the above- mentioned medicines merely for the few indications that have been men- tioned; the totality of symptoms must be considered ; but it would certainly be a work of supererogation—indeed, it would be impossible to mention in this chapter the medicines that are to be exhibited in every case of inflam- mation, for the disease, as is well known, occupies not only the attention of the surgeon, but constitutes a large proportion of those affections that are ºntered by the ordinary practitioner in the daily performance of his uty. Local Treatment.—In all cases, the first circumstance that must receive attention is the removal of such exciting causes as happen to be present. Of course, we could not expect to treat successfully any case of disease while the exciting cause is still operating. A slight inflammation arising from a small splinter cannot be cured until the extraneous body is removed. In wounds, it is often found that foreign substances excite an unnecessary degree of inflammation; these should be taken away as speedily as possi- 106 A SYSTEM OF SURGERY. ble; splintered pieces of bone often give rise to the abnormal action and require removal. The head of a bone being out of its place may cause in- flammation in the part in which it lies; it, therefore, must be returned to its natural position before inflammatory action can be subdued. There are Very many other exciting causes that may be detected, and the sooner they are remedied the better. Rest of the inflamed locality, if possible, should be absolute; when the muscles are affected, they should be placed in such a position that they may be entirely relaxed. Position is all-important in the management of local inflammation; the part should be placed in such posture that gravitation will act as a sanguineous drain, and at the same time oppose further injection of the inflamed part. Moist Heat and Cold.—The efficacy of a poultice in the treatment of inflammation is a disputed point in our school; some, I believe in these days a very few, practitioners discard the use of such adjuvants, while others have recourse to them frequently, and speak loudly in favor of such means. Among the latter I class myself. & I am in the habit of using a poultice composed of two parts of ground flaxseed and one part of ground poppy leaves, encased in a bag made of cheese-cloth, bobbinet, or some thin material, and applied hot, once in three hours. Over the poultice a piece of oiled silk or thin india-rubber cloth should be laid, and held in place by a turn or two of the roller, secured by safety-pins. - If the pain is very severe, I add to this poultice, just before it is taken from the cup, a teaspoonful of laudanum, having it thoroughly stirred through the other ingredients. - - Cold wet bandages, if they be properly applied, are also productive of much benefit and relieve pain. They are more especially called for in the earlier stages of acute or sthenic inflammation, and should be used in a careful manner. Two folds of canton-flannel or patent lint, or a worn woollen cloth, should be dipped into cold water, and wrung out sufficiently to pre- vent dripping; this compress should be placed upon the inflamed part, and over it a dry flannel (large enough to extend two inches over the edges of the wet compress) should be laid, over which again a piece of oiled silk, mackintosh, or india-rubber gauze should be spread. No rule in regard to changing this dressing can be laid down, for so soon as the compress be- comes hot it must be again wrung out in the cold water and reapplied. In some cases of acute inflammation the cloth may have to be changed every ten minutes, in others not for an hour. Great care must be observed not to allow any part of the clothing of the patient or the pillows and sheets to become wet, for if such an occurrence be permitted, the patient will, in all probability, take cold, and the efforts at relief be frustrated. Many is the case of acute inflammation I have been able to subdue at its outset by this treatment, and much severe pain. I have speedily alleviated. It must be remembered, however, that often upon a first application of either the moist heat or the moist cold, a temporary aggravation of pain may re- sult. This the surgeon must understand and explain to the patient. Hot water alone is also to be used for the relief of pain and for the treat- ment of the more chronic or fully established inflammations. In the use of this agent the same precautions are necessary as have been given above as applicable to the cold dressings. Dry Heat and Cold.—Of late I have seen excellent results from the appli- cation of dry heat and cold, which is accomplished in a most satisfactory manner by an apparatus devised by a surgeon of Vienna, and which is seen in the following cuts. The only objection I have to offer to this method is the weight of the tubing (constructed of leaden pipes lined with tin). If the DRY HEAT AND COLD. 107 parts are highly sensitive, as in peritonitis or acute inflammatory joint- disease, the patient is often unable to bear the weight of the lead convolu- tions, and in some cases I have been obliged to devise a temporary swinging apparatus to assist in removing the heft. This has in a measure been obvi- ated by having the coils constructed of india-rubber, the latter, h9Weyer, is open to the objection of not being readily bent to accommodate itself to the inequalities of the surface to which the cold or heat has to be applied. Fig. 63 shows the coil applied to the scalp; 2 8 represents the bottle con- taining ice-water, into which the india-rubber tube, having a weight on its FIG. 63. | N #E || end, is dropped. In place of the bottle, an ordinary tin pail containing ice-water, answers a better purpose. Sp shows the leaden coil (to which the india-rubber supply-tube is fixed) applied to the scalp and fastened under the chin by the tape b ; a s is the reservoir (it may be a bucket) into which the waste water flows. The nurse is only required to fill the upper reser- voir as it becomes exhausted. For the application of the dry heat the apparatus is a little more compli- cated. Fig. 64 represents its method of application. Cold water passes from 2 s through the plate ps, in which is imbedded a spiral tube, which is heated by the flame of the lamp L. From ps the water, flows through a vertical metal tube to which a thermometer is attached, indicating its tem- perature. The latter is very important for the proper regulation of the size of the flame of the lamp. The temperature of water can thus be raised from say 45° to 140°Fahrenheit in three minutes. As the water should pass through the heating-pan ps slowly, the lamp should stand about in the 108 A SYSTEM OF SURGERY. same height as the water-level. The thermometer should be observed during the first ten minutes of the application, and in the meanwhile the flame turned on to the necessary size for producing the desired degree of heat. FIG. 64. : á ſº. - . . H; - Yº Z # ... 3 #: A H. # Sã žº Đit #A 2 Niº iſ ### ºf ſº - | tººl-ºpiº, sº ºff ºs-2ſ Rºssº. ... --~~~ 21 J. RICITY OFRS-CO. The lamp itself is seen in Fig. 65. 2 s is the tube supplying the cold water. Under ps is the leaden coil (the arrangement of which is seen in FIG. 65. º t ==== i E-E f w"| | lſ. sº ºr PS) exposed to the flame of the lamp, the set-screw of which controls the movement of the wick. T, the thermometer fixed in its place, and f an DEGENERATION OF TISSUE- 109 eye-hole of colored glass, through which the attendant may notice the con- dition and bearing of the flame upon the heated coil through which the Water is passing. CHAPTER V. DEGENERATION OF TISSUE. SUPPURATION: PUS-CORPUSCLES—VARIETIES AND ANALYSIS OF PUS—FLUCTUATION.— GENERAL TREATMENT—ABSCESS, ACUTE, CHRONIC, DIFFUSE, RESIDUAL: TIME OF OPERATION.—TREATMENT—HYPER-DISTENSION WITH CARBOLIC WATER—SINUs AND FISTULA. . IF resolution is not accomplished, or either of the methods of repair men- tioned (vide pp. 99–103), then the white corpuscles, which, as we have seen, are found in immense numbers, degenerate and become “pus-corpuscles,” or in some instances “the matter’’ may be de- . generate granulation-cells or connective-tissue FIG. 66. corpuscles. Pus-cells, when young, are small punctated bodies, which, as has been already remarked, possess the amoeboid motion (Fig. 66), especially at a high temperature. These young cells send out offshoots, which separate themselves, and rapidly proliferate, accounting for the extremely rapid formation of pus which # * º after º is º estab- ished. After a time, however, as they grow iº - older, they assume the spherical form, ână 3.Te gºść. jº about ºth to sºuth of an inch in diameter. ...º. tº “Pus-globules, as seen out of the body, are dºom a sinus in bone (necrºsis). but little different in appearance from leuco- #########º" cytes. The leucocyte, when treated with acetic acid, displays the appearance of a nucleus in its interior, that appearance being usually regarded as the result of a shrinking of the protoplasm of which it is composed. The pus-globule shows more distinct trace of a membrane, and is frequently many-nucleated when treated with acid, a condition which Rindfleisch regards as indicating a tendency to degenerate and break down. But the same author says that many of the corpuscles of pus display no difference whatever in character from the blood leuco- cytes, having only single nuclei, showing the same amoeboid movements, and being in fact obviously the same things, both in structure and function. This should be borne in mind in connection with the fact that suppuration is not in most cases wholly a destructive process, but serves also as one of the usual modes of repair.”—Holmes. According to Virchow,” “suppuration is a pure process of luxuriation, by means of which superfluous parts are produced, which do not acquire that degree of consolidation or permanent connection with one another, and with the neighboring parts, which is necessary for the existence of the body.” . . . . Pus is not the dissolving, but the dissolved, i.e., transformed tissue. A part becomes soft and liquefies while suppurating; but it is not the pus which occasions this softening; on the contrary, it is the pus which is pro- duced as the result of the proliferation of the tissues. * Cellular Pathology, p. 489. 110 A SYSTEM OF SURGERY. Besides these degenerate corpuscles, there is a breaking down of the intercellular substance, and a complete metamorphosis of tissue; granu- lation-cells, molecular débris, fatty particles, and blood-corpuscles, all being Commingled—in fact a general softening of the tissues. To the eye, pus is a yellowish-white creamy liquid, sometimes of a slight greenish tinge, with scarcely any peculiarity of odor, and heavier than Water. According to chemical examination, the pus-globule is said to be a protein compound, consisting of the binoxide and tritoxide of protein, but these bodies are included in regularly organized cellules, and they float in a clear liquid called the liquor puris. This secretion is closely analogous to the serum of blood, and differs from it chemically only in the fact that its protein compounds are oxidized. The chemical constituents of pus are alkali, water, albuminate, and three other albuminoid substances. These substances differ in their powers of coagulation and solubility. One of them requires from 48° to 49° C., and is insoluble in a 0.1 per cent. of common salt and in a dilute solution of soda. The second is insoluble in water, but dissolves in a 0.1 per cent. solution of hydrochloric acid. The third is soluble in the latter solution, insoluble in a solution of common salt. Besides, pus contains other sub- stances, such as nuclein, albuminous constituents, cerebin, cholesterin, and lecithin, which belong to the pus-corpuscles, as well as phosphuretted fats and inorganic salts, the chief of which are chloride of sodium, phosphates and carbonates of the alkalies, phosphate of lime, and the oxide of iron. The abnormal constituents are mucin, chondrin, gluten, chlorrhodinic acid, pyocyanin and pyoxanthosis (in blue pus), biliary acids, grape sugar, and urea. After exposure to the air, pus undergoes acid fermentation, and then contains leucin, formic, butyric, and valerianic acids. - According to Hoppe Seyler, pus-serum contains, in one hundred parts, 90.96 per cent. of water; albuminoids, 7.02; lecithin, 0.10; fats, 0.04; cholesterin, 0.07; alcoholic extract, 0.06; water extract, 0.92; inorganic salts, 0.77.* \ The whole amount of solid constituents in pus is 140 to 160 parts in 1000, of which only 5 to 6 per cent. consists of mineral substances. Pus, as has already been described, is what has been termed by many writers laudable or healthy pus, and as such resists putrefaction for a length of time; but there are very many circumstances that may cause the matter to assume different characters. It is a bland fluid, and can wash the most delicate granulations without harming them. If, however, it is exposed to the air, it becomes vitiated ; the albumen of the serum is converted into the hydrosulphate of ammonia; an offensive odor is given off, and then we have unhealthy pus. Specific pus is that variety which contains some specific virus, as the syphilitic or vaccine. Sanious pus is thin, acrid, and bloody, and receives also the name of ichorous pus. When it is mixed with serum it is called serous pus, and when it contains flocculi or cheesy particles, it receives the name of scrofulous pus. The terms sero-purulent and muco-purulent explain themselves. Such are the changes that may be noticed in suppuration, and, by under- standing them, the student and young practitioner will often be able to trace more minutely the origin of the disease and render a more perfect diagnosis. Pus is rarely absorbed, and in the generality of instances, if not assisted in its discharge by the surgeon, finds for itself an opening, leaving a scar, that ever after denotes that disease has once been present in the system. * Wide Lancet, March 16th, 1878. suPPURATION. 111 When suppuration is fairly established, the more acute sufferings of the patient subside, the throbbing which was before frequent, disappears, and the sharp piercing pains become more dull and constant. Generally about the centre of the tumor a small conical eminence appears, that is most com- monly of a paler hue than the surrounding textures; when such appear- ances present themselves the abscess is said to be pointing. º Fluctuation.—The fluctuation of a fluid can often be perceived beneath the integument by careful examination with the fingers, but in some cases it so happens that the presence of matter may be so deep-seated that this sensation cannot be appreciated by the practitioner. The attendant occur- rences and the presenting symptoms cannot be too carefully studied when such a condition is suspected, for the discovery of the existence of deep- seated matter is a circumstance of the highest importance, and one which involves the practitioner's reputation, and frequently the life of the atient. p Gentlemen of the highest reputation as surgeons have been, even after minute examination of a case, entirely mistaken as to the presence of fluid. Several instances are recorded in this work (one further on in this chapter), in which three incidents in the life of Dr. Dease, of Dublin, are mentioned. In the first his great skill as a diagnostician was shown; in the second, the mistake ; the third, the suicide. - Mr. Cooper says: “In no part of the surgeon's employment is experience in former similar cases of greater use to him than in the present; and how- ever simple it may appear, yet nothing, it is certain, more readily distin- guishes a man of observation and extensive practice, than his being able easily to detect collections of deepseated matter. On the contrary, nothing so materially injures the character and professional credit of a surgeon as his having in such cases given an inaccurate or unjust prognosis; for in diseases of this kind, the nature and event of the case are generally at last clearly demonstrated to all concerned.” The only characteristic constitutional symptom that is said to denote the formation of matter, is that of shivering. On this subject, however, as there is some difference of opinion among the profession concerning its usefulness as an indication of formation of pus, Mr. Fergusson is quoted. “It is,” says he, “in my opinion, less worthy of estimation than some seem to imagine; it frequently occurs in instances of disease where suppuration never ensues; it often occurs even in a state of health, and equally often when it does happen it may be overlooked. Shivering is a symptom which the surgeon is often deeply interested in, not so much, however, from the dread of suppuration, as that it denotes some peculiar condition of the system fraught with much danger to life; as, for example, if within the first ten days after a capital amputation, or after lithotomy, a patient is seized with shivering, there is much reason to anticipate a fatal result; and although this may not occur in all such instances, every practical surgeon must bear me out in the formidable estimation I have made of this symptom. But whether it has preceded suppuration or not, the surgeon will seldom be thus satisfied that matter has formed.” Treatment of Suppuration.—The more minute treatment of suppuration will be detailed under those diseases in which it occurs. A few remedies may however be mentioned. The sulphate of iron has lately been used with great success in suppuration. An account is given of a child who was burned all over the body, and in a most terrible condition was brought to the Children's Hospital, at Lausanne. It is stated that the suppuration was so profuse, that the ward in which he was placed became absolutely uninhabitable. Upon placing him in a bath, containing two handfuls of sulphate of iron, the pain ceased immediately. 112 A SYSTEM OF SURGERY. The bath was repeated twice a day, and the patient allowed to remain in it fifteen or twenty minutes at a time. The suppuration became very much less, fetor vanished, and the child rapidly recovered. Dr. Sidney Ringer recommends highly the sulphides of potassium, of Sodium, or of calcium, in the treatment of suppurative processes. After their administration the discharge may become thin and unhealthy, but afterwards assumes a “laudable '’ character. The dose is, for carbuncles, Tºth of a grain of sulphide of calcium, given every two hours. Calendula Officinalis.-In this place it is proper to speak of the marigold, and its power over suppuration. Of all the varieties of topical applications which are recommended in the treatment of suppurations and lacerations, and of all the different medicinal substances which are supposed to possess an influence upon these processes, there is not one that is entitled to a higher place than the calen- dula officinalis. - The peculiar properties of this agent were some time back introduced to the homoeopathic profession by Dr. Thorer, in the British Journal of Homoe- opathy, and since that period many practitioners, through the periodicals, have noticed its effects. There can be no doubt that when homoeopathists begin to devote them- selves more exclusively to surgery, this plant will be as highly in vogue after operations, in the treatment of wounds when large and exhausting sup- puration is to be expected, in burns, in anthrax, etc., as the arnica has become in the treatment of bruises. According to the Pharmacopoeia, the flowers, buds, and young leaves are used, the juice expressed after maceration in alcohol, and the tincture thus obtained, when properly diluted, is used as a topical application. Dr. Thorer prefers what he terms the agua calendulae officinalis, and his directions for its preparation are as follows: “Fill one-third of a clean bottle with petals or leaves of the flowers, the remaining two-thirds with fresh pure spring water. Cork the bottle well and expose it for two or three days to the rays of the sun. The water is by this process rendered slightly aromatic. It is then poured off from the leaves into a bottle, which must be sealed, and placed in a lower temperature. While the liquid is being exposed to the rays of the sun it must be narrowly watched, and as soon as there are signs of incipient fermentation measures must be taken to arrest it.” This preparation is rather preferable to the dilute tincture, although the latter has proved very serviceable in the hands of many practitioners. When there is great suppuration, as in burns that have involved a consider- able portion of the integument, the action of this medicine is wonderful. The most convincing case of this kind came under the notice of Professor Temple, of St. Louis, the details of which have already been given to the profession in the North American Journal. I would also mention here its usefulness in the treatment of anthrax, to assist in the separation of the slough. I have had under my care many cases of carbuncle. In one instance, the disease extended over the whole forehead. In another case, a large, extremely painful anthrax appeared just over the tendon of the quadriceps extensor, and involved the tissues beneath to such a degree that an abscess formed underheath and threatened the joint. In a third, three large and painful tumors developed themselves on the more usual site, the nape of the neck. The internal treatment was arsenicum for the intense burning, the part being constantly covered with a thick compress, saturated with a hot solution of calendula and water. The effect of the latter in hastening the generally tardy separation of the slough, in allaying pain, and more particularly in bringing the disease to a speedy termination, was surprising. Moreover, the solution of calendula can be poured into TREATMENT OF SUPPURATION.—ABSCESS. 113 deep wounds with great benefit, and with much alleviation of pain. I have used it freely in almost every variety of surgical operations, after many kinds of amputation, in resections, removal of tumors, and in all classes of wounds. I have experimented with it side by side with the carbolic acid, now so much in vogue, and must give my testimony most decidedly in favor of calendula. A young lady, suffering from a contraction of a cicatrix (from a burn), which drew down the eyelids towards the angle of the mouth, and partially everted the lower lid, was brought to me by a student of the college. By dividing the integument from the external canthus, towards the nose, for about an inch and a half with the fascia and superficial fibres of the orbi- cularis, the deformity was to a great extent relieved. The lids were then closed and kept in apposition by straps of isinglass plaster. The wound, from the efforts of the parts to regain their normal position (although de- formity was of some years’ duration) opened fully an inch, and to this raw surface compresses Saturated with calendula were applied. Rapid granula- tion and cicatrization resulted, without the slightest tendency to erysipelas. I sincerely trust that more of our profession will give to this agent the trial it deserves in medicine and surgery. Satisfactory cases, treated with calendula, are recorded by G. W. Camp- bell, M.D.,” A. M. Cushing, M.D.,i and Dr. C. H. Lee. J. G. Gilchrist, M.D., also speaks in favor of this substance as a vulner- ary, and Dr. J. H. McClellandS and Dr. L. H. Willard|| also mention cal- endula as a favorite solution for external application. - Carbolic Acid,—In the chapter in which I treat of the present employment of antiseptics, I shall give my opinion regarding the value of carbolic acid as a vulnerary. It need not be referred to here, only in so far that I desire to strengthen my statement, that it is not to the antiseptic properties alone of carbolic acid that its value in the management of wounds can be ascribed (for as an antiseptic, per se, it is really inferior to many other substances), but that it possesses a specific power of its own of maintaining the integrity of the leucocytes, and preventing their transformation into pus, thus arrest- ing suppuration and assisting in the more rapid formation of new tissue. This peculiar action I believe has been entirely overlooked by many, who, in their anxiety to preserve intact the germ theory as the cause of all sup- puration, forget that there are many influences at work in the production of purulent formation. Abscess.--When pus is fully formed, and collected into the parenchyma of a part, the condition is termed abscess, which, on account of the frequency of its occurrence and its numerous complications, is of great interest to the Surgeon. Lining the cavity that contains the pus, especially if the abnormal con- dition has continued for any length of time, is found a tissue having a membranous appearance and a membranous function, and possessing a power of maintaining the formation of pus; hence it is termed the pyogenic membrane. It is not constant in all abscesses, and may be a sign of imper- fect formation of the abscess wall, but is endowed with very considerable capability of secretion, but as an absorbent surface it is comparatively feeble. In regard to this latter point, however, it may be useful to re- member that the pus-globule, when extra-vascular and complete, is of com- paratively large size, not soluble in its own serum, and therefore but little * American Homoeopathic Observer, vol. iii., p. 562. f Loc. cit., p. 563. f U. S. Medical and Surgical Journal, vol. i., p. 121. 3 Transactions American Institute of Homoeopathy, 1868, p. 79. || Pittsburg Hospital Cases. 8 114 A SYSTEM OF SURGERY. amenable to ordinary absorption; the serous portion of the pus may be taken up readily enough, but the solid part probably remains but little affected. And thus the feebleness of absorbent power may depend, not so much on defect of either structure or function in the pyogenic membrane, as on the nature of the fluid on which it has to operate. Sudden suppression of purulent formation is always to be regarded as an untoward event. It is more liable to occur in the case of free and open Sup- puration than in an unopened abscess. It may be the result of some acci- dental occurrence, the nature of which we may be unable at the time to ascertain, or it may be caused by injudicious stimulation designedly applied to the part; but the suppression, no matter how it may be induced, is always likely to be followed by disastrous consequences. The process of pointing, and the great necessity of observing fluctuation, have been alluded to in the chapter upon suppuration; but there remains to be mentioned one of the most important circumstances connected with abscess, which, if neglected, may be attended with fatal results, or at least with great danger and trouble. It sometimes happens that an abscess is situated directly in the course of an artery, and when such is the case the greatest care and discrimination should be exhibited in the diagnosis between the collection of pus and aneurism ; the most experienced have been misled by circumstances, and deceived by appearances. Dupuytren himself, whose ability and surgical skill have always been regarded by the profession with the hiº esteem, failed in his diagnosis, and once plunged a lancet into an aneurism, mis- taking it for an abscess. The following is recorded of Dr. Dease, of Dublin: “He was called to see a case, supposed to be one of aneurism by all the physicians who had attended it, and upon careful examination determined it to be a large col- lection of pus overlying an artery. Taking the responsibility, in spite of the advice of those who had consulted with him, he plunged his knife into the pulsating mass. There was a gush of matter, and the patient, who looked a short time before upon his case as hopeless, was entirely relieved. Much credit was justly the meed of Dr. Dease, and great gratification must he have felt at thus relieving the unfortunate sufferer. Some time after, he was sent for to another case, which, like that just mentioned, had been regarded as an aneurism; and, as in the other, he decided that it was a collection of pus, and proposed relief in the same manner. This being assented to, he penetrated the tumor with his knife, when out rushed a torrent of blood, and with it the life of the patient. He had erred in his diagnosis. It was an aneurism—not an abscess 1 Dr. Dease returned to his home, and on the next morning was found upon the floor of his chamber with his throat cut from ear to ear by his own hand . The diagnostic signs between abscess and aneurism are: From the earliest stage of abscess the tumor is hot, throbbing, hard, and incompressible; in aneurism the tumor is of natural temperature, and is soft and fluctuating. The skin Čovering an abscess is inflamed and discolored; that which covers an aneurism is of natural color, or perhaps paler. In abscess the formation of the tumor is much more rapid than in aneurism. In aneurism the tumor is pulsating; in abscess it is fluctuating, but has . no pulsation. The enlargement in abscess cannot be diminished by pressure; in aneu- rism the contrary is the case. When, however, the diagnosis is sufficiently established, it may become a question to the surgeon whether the pus shall be evacuated by the lancet, or whether it would be proper to endeavor to produce absorption. ABSCESS. 115 Acute abscess is one in which the inflammatory action runs a rapid course, suppuration is soon established, the matter evacuated, and the patient recovers. In this form of the affection the fever is high, the face flushed, and sometimes, but rarely, there is delirium. Those patients who suffer from acute or phlegmonous abscesses are generally dyspeptic, having some disorder of the stomach or liver. The character of the pus varies in this variety of abscess; sometimes it is flaky, sometimes sanious, and often laudable. If the inflammation has occurred in the neighborhood of se- creting organs, and their texture has become implicated, then the discharge may be mixed with the peculiar secretion of the organ affected; there may be bile, semen, or milk, as the liver, testicle, or mamma is implicated. In many cases, especially in those accustomed to high living and de- bauchery, or in those whose constitutions are broken down with exposure, hard labor, deprivation, want of air, light, or food, the pus from the abscess is not circumscribed by a pyogenic membrane, and burrows hither and thither in the muscular tissues, giving rise to what is termed purulent infiltration or diffuse abscess. The prognosis in such instances is bad, the suffering intense, and the treatment rather unsatisfactory. The extensive infiltrations of pus set up a terrible constitutional irritation, and the patient may die, worn out with hectic. Chronic abscess, or cold abscess.-In this, the symptoms are not as well marked as we find them in the acute or diffuse variety, and those which note the commencement of a chronic abscess are always obscure. There is no fever, but a slight degree of pain; no heat of surface; on the contrary, the part appears to be colder, hence the name “cold abscess.” The suppurative process is so slow that weeks and months elapse before fluctuation or point- ing can be detected, during which time the general health of the patient is not much impaired. In this variety of abscess, the pyogenic membrane is said to be more clearly developed than in the more acute suppurative TOCéSS. p Residual abscess is the name given to the remains of a collection of pus, the fluid portions of which have been absorbed. In such a case there remains a tough or doughy texture, which has somewhat a “boggy' feel. They are said to occur most frequently after spinal abscesses. - Local Dangers.—The local dangers belonging to abeesses arise either from the encroachment of the tumor on arteries or veins, or its proximity to . important cavities, into which the pus may be unexpectedly poured, or when fasciae and bones become implicated. There are several cases on record in which the coats of an artery have been ulcerated through, and severe, if not fatal, haemorrhage has followed. A case of the kind was related to me by Dr. Zantzinger, in which upon opening a fluctuating tumor of the neck containing pus a large amount of blood was discharged per saltwm. Mr. Liston, also, in opening an abscess, found a gush of blood follow the incision. - Again, we have large abscesses, which, if they open into the great cavities, would certainly be fatal. In abscesses of the liver, for instance, great care should be taken to prevent such an accident. I attended, in consultation with Dr. T. F. Allen, a gentleman who had an immense abscess in the ab- dominal parietes. This, if it had not been laid open, would undoubtedly have poured its contents into the peritoneal cavity. The patient could feel the “bag,” or pouch, as he expressed it, whenever he moved in his bed. Again, abscesses are dangerous when they are bound down by strong and deep fascia, as we find in the perinaeum, or beneath the fascia lata of the thigh, in which case they are very likely to produce great devastation by the burrowing of pus, or when suppuration has taken place beneath the periosteum, and bone is likely to be destroyed. 116 A SYSTEM OF SURGERY. It is stated on the best authority that large abscesses have in a few in- stances disappeared, and that there is, in certain cases, a physiological resorp- tion of pus. This, however, must be explained, and the experiments of Virchow have thrown much light upon the subject. “Pus as pus is never re- absorbed,” and when purulent formations have disappeared, which undoubt- edly is the case in some instances, the process takes place in the following manner: The pus-corpuscles are supplied with a great quantity of water, which is both external to them and intercellular. This fluid part is absorbed, leaving an inspissated form of pus, in which the corpuscles draw near to each other and become very much shrivelled; these may act as solid bodies, and entering the circulation may give rise at a later period to ulceration. In other instances a fatty metamorphosis of the cytoid corpuscles takes place, in which a mass composed of a milky substance, fat, and an albuminous substance is formed, sometimes even containing sugar, which can be taken up by the absorbent vessels. Time for Operation.—There is no doubt in my own mind that the tendency of the surgery of to-day is to interpose operative interference too early, especially in large abscesses. If the suppuration be deepseated, or, as has been already mentioned, vital parts are in imminent danger from the rupture of the sac, then the surgeon, so soon as he is certain that the pus has formed, may proceed to evacuate it. Delay may be dangerous to the vitality, not only of the part, but to the sufferer. Unless, however, some of the local dangers attendant upon abscesses threaten, “delay” should be preferable to speed. On this subject we have the high authority of Mr. Fergusson: “I am of opinion that in ordinary abscess—a bubo, for instance—if an opening is not made until the matter has approached near to the surface, the subse- quent progress of the case is much more rapid and satisfactory, provided that a proper opening be made. I have seen a good deal of the practice of making early openings, and have invariably observed that more pain was thereby induced, and I have often fancied an additional amount of suppu- ration, whilst the after treatment has been remarkably tedious.” When it is deemed necessary to open an abscess, the incision should always be made where the integument is thinnest, or, in other words, where the abscess points; at which place often a discoloration is manifest. The practitioner must also bear in mind that various aberrations of puru- lent collections take place in their progress to the surface, and that they often proceed in a direction opposite to that of gravitation, owing to the resistance of bones, fasciae, and aponeuroses; which last oppose them in a most remarkable manner, and cause their extension in various directions, giving rise to the most severe local and constitutional sufferings. A case of lumbar abscess came under my care after having been seen by many physicians in the East and the West, in which there was an opening just above the origin of the quadratus lumborum muscle, and two outlets in the front of the chest, on the left of the sternum. In making a post-mortem examination I found that the pus had burrowed in the intercostal spaces between the external and internal intercostal muscles (the fibres of which, it will be remembered, for the most part, cross at right angles), and thus made for itself an anterior outlet. In most cases the opening should be made freely, and the matter liberated at one operation; but when the abscess is large, and the constitution of the patient feeble, the exposure of so large a surface and the speedy evacuation of a quantity of matter, might be dangerous in the extreme; it is then recommended to ascertain to what degree the Sac may be diminished, by lessening gradually the quantity of fluid by removing portions of it by means of the aspirator, or after the manner recommended by Abernethy, That is, by making a small oblique opening, and allowing as much of the ABSCESS. - 117 contents of the cyst to flow out, as the natural elasticity of the walls will permit; the wound will, perhaps, afterwards heal by the first intention, the aperture may close perfectly, the patient not be injured by the operation, and there will be much less fluid in the abscess; this procedure may be FIG. 67. continued until the sac becomes sufficiently diminished in size to allow it to be laid open in the same manner as smaller abscesses. When a lancet is used, it should be held in the position represented in Fig. 67. When the pus is deep-seated, the forefinger of the left hand, and perhaps the middle also, being placed over the abscess with gentle pressure, the back of the knife should be caused to rest against the side of the forefinger (as seen in Fig. 68), the point should then be thrust through the skin, and the coverings of the matter divided as far as may be deemed expedient; the blade may then be turned slightly on its long axis, when probably the pus will spring up along its surface. These methods are recommended by Mr. Fergusson, who remarks, “In opening abscesses, whatever be the instrument used, I invariably prefer puncturing first and then cutting from within out- ward, to the method pursued by some, of making a sort of dissection, by successive incisions, through the skin and other textures.” In abscesses about the neck, especially those chronic formations of pus beneath the deep cervical fascia, or when collections of deep-seated pus are found in the abdominal cavity, or where such are even suspected, the aspi- rator is without doubt the instrument to be employed. Since the general application of this “suction method,” if I may so term it, deep-seated collec- tions of pus in locations which render the knife always hazardous, are deprived in a great measure of their danger. As a means of diagnosis, also, in abscess, the aspirator should never be forgotten ; if one is not at hand, the exploring needle should be employed. Those now found in the ordinary pocket instrument-cases answer the purpose admirably. But the surgeon may be able, in many instances, to overcome the neces- sity of operating, by the administration of appropriate medicines, by the action of which the suppurative process may be hastened, and the abscess allowed to open spontaneously. This should always be effected if prac- º * Practical Surgery, p. 88. 118 A SYSTEM OF SURGERY. ticable, and the medicines that have been most efficacious in producing such a result are hepar, merc., and silic. When there is much constitutional disturbance on account of the violence of the inflammatory action, acon. and bell. are to be used, either separately, or in complicated cases in alternation; the doses to be repeated pro re nata ; the proper antiphlogistic regimen also being observed. ' Lachesis is pronounced an excellent remedy when there has been much distension of the skin, which has a bluish tinge, or where the structure has been destroyed by the magnitude of the abscess. The medicines for abscesses are: (1) Bell., hep., merc., sil., sulph. (2) Calc., lyc., phos., puls., Sep. º For Acute Abscesses : Ars., asa., bell., bry., cham., hep., led., mezer., phosph., puls., sulph. - For Chronic Abscesses: Asa., aurum, calc., carb. veg., con., hep., iod., laur., lycop., mang., merc., merc. corr., nitr. ac., phos., sep., sil., sulph. Silicea.—This remedy hastens suppuration, or restores it when it has be- come arrested in consequence of the suppression of nervous influence. The pus may be laudable or ichorous. It is also serviceable, after matter has been discharged, to promote granulation and cicatrization. Calendula officinalis is highly recommended by Dr. Thorer when the suppuration is profuse and exhausting, especially in traumatic abscesses. Sulphur is especially suited for chronic abscess, and for a tendency to Suppuration, depending upon a psoric or scrofulous diathesis. The hypophosphate of lime appears to exercise a great influence over the so-called “cold abscess.” Its use in the treatment of purulent formations has been of great assistance to the surgeon. Dr. Searle, of Brooklyn, called the attention of the profession to this agent some years ago, and I have reason to speak well of its efficacy. The dose, as recommended by Dr. Searle, is 5 grains of the first decimal trituration repeated every three hours. Hyperdistension with Carbolized Water.—Washing an abscess with car- bolized water, according to the late Mr. Callender, is a recognized necessity; and to throw in such a quantity of fluid as will distend the abscess sac in all its parts is equally recognized; and this procedure is hyperdistension of an abscess cavity. The operation is begun by cutting into the abscess (if no sinus exists), the opening being made of sufficient size to admit a finger. The pus escapes, and the nozzle of a syringe is next passed through the open- ing, the skin drawn around it, and the contents of the syringe are passed into the sac. The amount of injection may be a little in excess of the quan- tity of ejected pus; sometimes a second injection may be given. Subsequent treatment consists in renewal; and in a brief time the discharge of pus ceases; a limpid serous fluid drains off, and presently only a sinus remains. Hence it will be observed that by hyperdistension of an abscess sac, the carbolized water can be pressed into cavities implicated; and that treatment can thus effect for such abscesses the same result as an ordinary injection will insure for a simple abscess. As for the result of this treatment, as far as bone caries is concerned, at present, observations do not permit of abso- lute conclusions; but that abscesses can be reduced to non-suppurating sinuses, whilst the health of the patient is improved, is clearly established. Mr. F. Ashton Heath records quite an interesting case of multiple abscess treated by this method. A woman (aged thirty-one years) had every symptom of chronic pyaemia, and in the inner aspect of the left thigh there was a large abscess. This was opened with a scalpel, and carbolic acid lotion, 1 in 20, mixed with half its bulk of warm water, was injected per syringe into the cavity, until the fluid returned almost pure; a drainage-tube of rubber was then introduced, and the abscess was dressed with “cere-cloth "soaked in glycerine and carbolic SINUS AND FISTULA. 119 acid, and covered with oil-silk; this was renewed daily. Five weeks after- wards the patient was up, had a good appetite, and was rapidly gaining strength.* In old cases, as well as in recent ones, this method is very ser- viceable, and I have employed it often with very excellent success. It is not at all necessary that the carbolized solution so highly spoken of by Mr. Callender should be used. I have found calendula equally as efficacious, and in one or two instances the bichloride of mercury, in a solution of 1 to 2000, productive of results which the carbolic acid failed to effect. Dr. Marshall records an interesting case in which an old and obstinate abscess was cured by the internal administration of hepar sulph. and injec- tions of a strong tincture of hydrastis.i. Pressure.—The importance of applying pressure in the treatment of ex- tensive abscesses was long ago recommended by Mr. Solly, who wrote: “I am not aware how far the plan, which it is my object in this paper to advo- cate, is in general use or not, but I am so convinced of its value, that I shall venture to bring it forward. I refer to the careful application of pressure over the surface of extensive abscesses after their contents have been dis- charged, and the early disuse of the poultice and its congener, warm-water dressing. I always prefer cotton-wool to any other kind of pad, as it fits better with all irregularities of surface; and I find that a greater amount of deep pressure can be kept up by strips of plaster than by a roller. By these means the surfaces of the abscess are kept well in contact, they adhere together and the discharge soon ceases.” An excellent method of applying pressure in large abscesses, especially where there are many sinuses, is through the medium of compressed sponge. The pieces of sponge—which can generally be procured at any reputable pharmacy—are placed dry over the abscess, and held in situ by means of adhesive straps applied at right angles. Care must be taken to have a sufficient length of strap project beyond the margin of the sponge, that a firm hold may be had upon the surrounding integument. As the secretions are absorbed by the sponge, it naturally enlarges, and being held firmly in its place by the adhesive straps, considerable pressure is exerted upon the abscess and sinuses, and their walls, thus approximated, are much more likely to heal than when constantly distended by accumulations of pus. Sinus and Fistula–These terms are used synonymously by most surgeons, although, strictly speaking, a fistula should have two complete openings and a sinus but one. Again, the term sinus conveys to the mind a somewhat sinuous track which has more or less length. A fistula, in some instances, has scarcely any length, and merely consists of an opening, as we find in vesico-vaginal and recto-vaginal fistulae. When from any glandular organ an unnatural passage is formed for the secretion, the term fistula is applied, the kind being designated by the organ affected; thus salivary fistula, biliary fistula, etc. If a fistula has but one opening, instead of receiving the name sinus as it properly should, it is called incomplete, and it is this very jumble of terms that gives rise to much misunderstanding among students of medicine. These canals are lined by a membrane, more or less organized, or imper- fectly formed granulation-tissue, from which is discharged unhealthy pus, generally of a serous or flocculent character. The older the canal the more callous are its walls. We find that there are also sinuses that owe their existence to the presence of some local cause, as portions of dead bone, bits of wood, bullets, or other foreign material. The course that a sinus takes is influenced by two causes: 1st, the position * Braithwaite's Retrospect of Practical Medicine and Surgery, July, 1877, Part 75. # Am. Hom. Observer, 1867, p. 244. † London Lancet, 1855. 120 A SYSTEM OF SURGERY. of the patient, thereby allowing the pus to gravitate in certain directions; and 2d, the density of the structures that intervene between the seat of the disease and the external outlet. It is singular how a sinus may meander through the textures, following the law of gravitation in the main, but passing through tissues giving it the least resistance. The main cause of all fistulae is suppuration : an abscess is formed, it bags or pouches, separates tissues, and thus the canal is formed. The treatment will be mentioned when considering the diseases of those parts most likely to be affected. CHAPTER VI. TRAUMATIC FEVER—SEPTICAEMIA AND PYAEMIA—HECTIC–TREATMENT. THE confusion of terms (necessarily indicating a confusion of ideas) that surround the subjects, traumatic fever, pyamia, septicæmia, and phlebitis is most surprising. In olden times pyaºmia and phlebitis were considered as synonymous terms, but this theory is now untenable. It was supposed that the veins surrounding the seat of injury absorbed the infectious material, which was carried into the circulation, but Tessier proved in 1838, that in the majority of cases blood-clots were found above the site of pus, and Gosselin and others, from careful dissections of bodies of those having died of pyamia, could detect no pus whatever in the vessels. The microscope also proves that there are no more leucocytes in the blood of pyaemic patients than in others. - It was not until the lamentable assassination of the President of this Re- public, and during that treatment which was still more lamentable, that in this country the profession arrived at anything like a precise knowledge of these different affections. - For instance, Agnew, in his late Surgery, discards the term pyaemia en- tirely, and regards all the conditions as belonging to traumatic fever, only differing in degree. He classifies them as follows: 1. Simple traumatic fever. 2. Secondary traumatic fever. 3. Complicated traumatic fever. Bryant* groups traumatic fever, septicamia, and pyamia together, and says: “In septicaemia, ichoraemia, puerperal fever, and pyamia, the ab- sorption of putrid inflammatory products, or of pus and pus-forming mate- rial, or of some other poison, whether from some other part or not, is the undoubted cause of the disease, the poison being taken into the body, either by the veins or by the absorbents from without.” Traumatic or surgical fever may, however, pass into septicaemia, and this into pyamia, the first being the mildest form of blood-poisoning, the last the most severe. In this sweeping classification all the diagnostic marks between septi- camia and pyamia are lost, for, as I shall attempt hereafter to show, there are characteristic differences between the two affections. In opposition to the ideas of Mr. Bryant are those of Mr. Holmes, who says: “Septica-mia is something even more fatal than ordinary pyamia.” He believes, however, that they are the same disease under a different form. Spence does not recognize septica-mia at all, and disliking to change surgi- cal nomenclature, adheres to the old word pyaemia. Pirrieś adheres also * Roberts's Edition. Philadelphia, 1881, p. 56. + Surgery; Its Principles and Practice. Philadelphia, 1876, p. 59. i Lectures on Surgery. London, 1871, p. 33. 3 Principles and Practice of Surgery. London, 1873. TRAUMATIC FEVER—SEPTICAEMIA. 121 to the term pyamia, and qualifies his definition by saying: “The terms ichoraemia and septicaemia would more appropriately express what is now believed to be the exciting cause of the blood derangement, although for convenience sake we will retain the use of the term pyamia.” Erichsen, Grant, and Ashhurst are all about of the same opinion, and be- lieve that the conditions are: 1st. Leucocytosis. 2d. Thrombic and consecutive abscesses. 3d. Absorption of poison, generating septicaemia. - It is not necessary to further multiply quotations regarding the various opinions expressed by the surgical jº. of to-day. They all, however, are agreed upon one point, that in both the disorders under consideration, there is an absorption of poisonous material into the blood. Upon the very outset of this question it would be appropriate to deter- mine whether the putrefying process or the agents that produce putrefaction come entirely from without. If this be the case, then there are some cases of pyaºmia which are unexplainable. This, however, has already been dis-, cussed. No one at present denies that germs in the atmosphere will pro- duce putrefaction, and no surgeon who has had any experience will not admit that putrefactive changes result without the presence of an external wound, although the absence of an exterior solution of continuity does not necessarily preclude the absence of bacteria, as recent researches prove that they are found in large numbers in acute bone disease. I have looked somewhat into the literature of this subject, and I find that but few writers arrange the two diseases separately. I have witnessed many cases of both septicaemia and pyaºmia (and have treated them where they have been fully developed) and have been careful to study their course and termination, and am prepared to say that septicaemia and pyamia are in the main separate and distinct affections, but that with complications the for- mer may pass into the latter; and I do not agree with those authors who class all these disorders under traumatic or surgical fever, or as a “systemic affection.” TRAUMATIC FEVER. After a patient has received a severe injury, whether accidental or at the hands of the surgeon, the nervous system sustains a shock more or less se- vere, the vital forces are prostrated, the skin is cold and blue, the pulse is . feeble, the respiration is quick, there is tendency to cold perspiration, the heart's pulsation is feeble, or may cease from the action of the sympathetic on the cardiac plexus, and every symptom plainly indicates depressed vitality. If the remedies are properly chosen, and the patient's constitution sufficiently strong, a reaction takes place in from one to six hours, which is generally in exact proportion to the profundity of the depression, and the new symptoms are all those of vascular erethism, viz.: a bounding pulse, red cheeks, dry mouth, restlessness, thirst, hot skin, and often delirium, pulse 120, temperature 102} to 1034 degrees. The latter condition is what I call true surgical or traumatic fever. It is the direct result of the trau- matism, and is the effort of nature to restore her lost equilibrium. This is a distinct disease of itself. SEPTICAEMIA. Let us however suppose that some decomposing animal matter, say in the dissecting room, has gained access to the system. What happens? A slight pain at the seat of injury, or no pain at all, or the appear- ance of a small vesicle indicates the presence of the poison. For a day or two, there may be a general feeling of malaise and sluggishness of the circulation caused by zymotic changes taking place in the system. 122 A. SYSTEM OF SURGERY. Suddenly the disease breaks forth with a severe chill, more perhaps coldness than shuddering, followed by fever. The pulse beats from 120 to 130 strokes per minute, the temperature stands at 104°, and is followed by profuse sweating, with some delirium, with soreness, redness, and swelling of the parts, which, upon examination, show slight red superficial lines, marking the course of the inflamed lymphatics. Sometimes at the site of the gangli- onic centres an enlargement and soreness of the glands are noticed. These appearances are followed by severe constitutional symptoms. The temper- ature even goes rapidly up to 105° (Fig. 69), while the nerve-power of the pa- tient goes as rapidly down. All the symptoms pass rapidly from bad to worse; the body is continually bathed in perspiration; restlessness, insomnia, and mental aberrations are all present. At this period often a colliquative diar- rhoea sets in with constant delirium, which, with rapid breathing and some- times with hiccough, continue until the patient dies of profound asthania, or sinks into coma from the toxaemic effects of the absorbed morbid pro- ducts. After death the blood is found in a defibrinated condition, is darker colored than natural, and contains much serum. This is a description of the symptoms of a rapid or acute case of septicaemia. Sometimes the ma- FIG, 69. 3. | | | | | | | 12 3 || iº it ºf -- º º . . . . ... i-, --. . . . . . . . ; | | | || Heat line in septicaemia, terminating in recovery. jority of them may be almost entirely absent. I have known cases—one in particular now occurring to my mind—in which the main feature was rapid emaciation, so rapid indeed, that the loss of flesh was almost visible to the ..lookers on. In another case the chief indications were periodical pains in the intestines. In the more chronic variety similar symptoms are noticed but their sequence is more tardy. The conditions just described may be occasioned by the absorption of any poisonous material from direct contact, whether from an external wound, from a retained placenta, from diphtheria, from sloughing ulcers, from cancerous discharges, and a variety of other affections. A typical case has occurred to me within the past year. . A lady ap- plied to me for the removal of her right breast, affected with ulcerating scirrhus, with enlarged axillary glands. She was a good deal emaciated (which I always regard as a bad prognostic) but otherwise strong, and en- dowed with uncommon nerve and moral strength. The breast was easily amputated, and half a dozen large glands removed from the axilla; two of these were evidently undergoing degeneration. The operation was borne well, and for ten days not a single untoward symptom occurred. There was but slight suppuration from the axillary wound, which was supplied with carbolized drainage-tubes, and the breast wound healed almost by first intention. On the tenth day, without any premonitory symptoms what- ever, a severe chill, followed by high fever, with the temperature at 105}*, pronounced the disease. The arm of the affected side became red, painful, and oedematous, and from it the lymphatics in red lines could be distinctly PY AEMIA. 123 Seen. Tremendous sweating and muttering and low delirium followed, and the patient died on the third day. I believe that the axillary glands and lymphatics had been affected before the removal of the breast, and that so soon as the patient began to recover from the shock and pros- tration of the operation the old poison broke out afresh. In septicamia after death, besides the defibrinated condition of the blood, the liver will be found softened, the mucous membranes reddened, and the salivary glands engorged and softened. PYAEMIA. Pyaamia in its distinctiveness is a disease bearing some resemblance to that just mentioned, but having its own diagnostic marks. It is caused by the absorption into the system of decomposing pus. I use the words with care, “decomposing pus,” because ordinary so-called healthy pus can be, and has been injected into the circulation without disastrous effects, and because, with our present knowledge of pathology, we consider the white blood-cor- puscle and a pus-corpuscle as identical, one being, however, alive and for- mative, the other dead and destructive. Mr. Spence, in his late lectures upon surgery, confirms the statement that the injection of healthy pus into the system is not found to produce those violent symptoms which were hitherto ascribed to it, and that therefore the term pyaemia is an incorrect One. This is a fact in the abstract, but it must not be inferred that the in- troduction of healthy pus is not followed by any abnormal manifestations, for from recent experiments made by Billroth, of injecting pure pus into the circulation, fever was invariably produced, and in some instances in- flammation and suppuration. Weber and Schiff found purulent pleuritis, and Billroth subcutaneous abscesses after such injections. At present, how- ever, it may be asserted that the pus serum, after undergoing a process of change or decomposition, contains the elements FIG. 70 which produce pyamia. Again, the presence of — a thrombus or embolus may excite inflammatory action, and give rise to suppurative inflammation in the vessel, or the inspissated pus, which has . . . . . already been alluded to, or flocculent particles . . . . . . . . may become poison to the circulation. By some . . . . A the term ichorrhaemia is employed to designate this condition, as it is the ichor of the pus that is found most generally to produce the disastrous effects of the disease. My friend, Professor Liebold, has given to the profession an excellent article on pyaemic fever.” There is no doubt, however, that when pus decomposes, a contagiously miasmatic element is produced, which has a peculiar action on the economy, producing a ferment having a tendency to thicken or coagu- late the blood. Let me, for the symptomatology of the affection, again describe a typical case, also lately occurring to me. After an amputation of the thigh, between the third and the sixth day, when the patient had been doing moderately well, a severe chill, lasting for nearly two hours, set in, followed by a mod- erate fever with a temperature at 102° or 102}*. The sweat was profuse but not colliquative, and there was some prostration even early in the disease. This condition lasted for some days, with regular intermissions of the par- oxysms of chill, fever, and sweat; indeed, so regular are these recurrences, that I have known some cases to be mistaken for and treated as simple ma- larial fever. The bowels of this patient were rather constipated, and the urine high-colored; the tongue was dry and covered with a yellow fur; the - -º-º: * . . . . . . . . . . . - - V. . . . . . Thermograph of pyaemia. * Transactions N. Y. State H. M. Society, vol. viii., p. 571. 124 A SYSTEM OF SURGERY. complexion was icterode and the conjunctiva yellow. The symptom that first placed me on my guard was the peculiar sweetish smell of the breath, which I believe is almost pathognomonic. Examining the wound at this time, the discharge of pus, which had been healthy and profuse, had ceased entirely and there was an ichorous serum in small quantity exuding be- tween the sutures. When the stitches were cut away, the surface of the stump was glazed, of a brownish color, and covered with spoiled lymph. The patient complained of great prostration. Every night there was an accession of chill, fever and sweat, the temperature being about 103° (Fig. 70), and the pulse 120. Occasionally there was delirium, but the patient could be easily restored to consciousness. Shortly after the accession of these symp- toms a bronchial cough set in with ráles, especially on the left side, with severe aching pains in the bones. From these symptoms, however, the patient made a slow recovery. During the progress of pyamia the poison (as already mentioned having a tendency to cause viscidity of the blood) continues to increase these zymotic products, and the stream circulating more slowly in the larger vessels is arrested in the capillaries, which soon become clogged, and in- farctions result. Infarctions.—An infarction is a consolidated area of tissue discolored and infiltrated by the rupture of the smaller vessels, in other words, the result of an embolus. These points of rupture are found in various por- tions of the body, and being caused by poisonous products, set up new foci of inflammation, which soon terminate in abscesses in different parts of the body, thus adding to the very grave constitutional symptoms already developed, the additional and characteristic manifestations of the formation of abscesses. If the lungs be the seat of these pus cavities, we get all the physical manifestations of pneumonia or bronchitis. If the liver, the jaundiced condition of the face, yellowness of the conjunctiva, and other hepatic symptoms are present; sometimes a tumultuous beating of the heart indicates either the nerve prostration or imperfect action of the cardiac plexus, and very frequently albumen, pus and casts in the urine proclaim that the renal apparatus is implicated. An especial symptom in pyaºmia, and one which I have seen in the majority of the cases that have fallen under my observation, is pain of a fugitive character, flying from one part of the body to another; and, indeed, in several instances, I have known, together with these pains, swelling and redness of the joints appear, which, with the fever and perspiration already alluded to, are very liable to lead the physician to suppose that a true malarial rheumatism is present. From these indications a differential diagnosis may be thus prepared: SEPTICAEMIA. PYAEMIA. 1. Caused by any poison absorbed by direct 1. Caused by decomposing pus or pus ele- COntact. ments. 2. Virus carried by the lymphatics. 2. Carried by the veins. 3. A single chill. 3. Many chills. 4. No regularity of recurrence of fever. 4. Paroxysms of chill, followed by fever and sweat, with regular intermission. 5. Temperature 104° to 107°. 5. Temperature 102° to 103}*. 6. Paleness of face. 6. Jaundiced hue, with yellowness of scle- rotic. 7. Rather offensive breath. 7. Peculiar sweetish odor of breath (like new hay). 8. Rapid progress. 8. Slower progress. 9. Delirium and exhaustion. 9. Less delirium and more prostration. 10. Pains not general. 10. Severe and fugitive pains in legs, abdo- - men, and back, with swollen joints. 11. No infarctions. 11. Infarctions of the viscera; lungs, liver, 1 spleen, and kidneys. 2 . A single abscess or perhaps two; gener- 12. Multiple abscess in internal organs. ally superficial. - PYAF.M.I.A. 125 But it must also be remembered by the surgeon, that a septicama may end in a pyama, that is from Septicaemic infection abscesses may arise, either at the point of entrance of the poison, or in the glands, or in the serous membranes. If the pus be healthy and is the result merely of the inflammatory process, its speedy evacuation may cure the patient; if, how- ever, the poison has not exhausted its toxic effects, or the pus become putrid, either from the degenerate constitution of the patient, or from the abscess being improperly managed, or from the discharges being allowed to decompose, then the absorption of this secondary poison may give rise to the symptoms as detailed as pyamic. I doubt, however, such a condition, because in my own practice I cannot recall a single case of true septica-mia even in those in which the inflammatory process has terminated in suppu- ration, in which I have found multiple abscess, and this point has often puzzled me. I have seen septicaemia follow ovariotomies, I have seen it from dissecting-room wounds, I have suffered for weeks with it myself, I have seen it after lithotomy, in large abscesses, in diphtheria, from retainca placenta, and from many other operations, and in many conditions in which the septicamic inflammation has developed pus, and large quantities of it, and yet in the post-mortem examination, multiple abscesses were never found. I am not prepared to make an explanation of this fact, but have thought that perhaps, when the poison is taken up by the lymphatics, the lymph contained in the ducts may have a modifying power over the blood stream, tending rather to liquefy that fluid, whereas when the pus poison is taken into the blood itself, it produces, as I have already noted, a thickening and viscidity of that fluid, tending to the formation of infarc- tions, and thereby producing metastatic or multiple abscesses. The tables of Bryant and Steele are here inserted : Analysis of 217 Cases of Pyatmia. “Of 217 cases— - 68 or 31.3 per cent. were after compound fracture as a whole. 24 or 11 per cent. not amputated. 44 or 20.2 per cent. amputated. 26 or 12. {{ were after amputation for disease. 28 Or 12.9 {{ “ after other operations. 21 or 9.6 {{ “ after injury without operation. 60 or 27.6 {{ “ after disease without operation. 12 or 5.5 “ “ idiopathic. 2 or .9 “ “ puerperal. “Through the kindness of Dr. Steele, who has aided me in this statistical investigation, I am able also to give the following interesting facts respecting pyaºmia : G “Out of 790 cases of compound fracture, 192 died, or 24 per cent. 68 of pyaemia, or 8.6 per cent. Of 184 treated by amputation— 89 died, or 47.7 per cent. 44 of pyaemia, or 23.9 per cent. Of 606 treated without amputation— 103 died, or 17 per cent. 24 of pyaemia, or 39 per cent. Out of 324 cases of amputation of thigh, leg, arm, and forearm for disease-- 126 died, or 38.8 per cent. 26 of pyaemia, or 8 per cent. “Pyaemia is thus seen to be three times as fatal after amputation for compound fracture as for disease. “Out of 29,434 surgical cases admitted into Guy's during ten years, there were 1749 deaths, or 5.9 per cent. 126 A SYSTEM OF SURGERY. “203 of these were from pyaemia, or 11.6 per cent.; about one in nine of the deaths being from this cause. “But of the whole number of cases treated, pyaemia was fatal only in .68 per cent.” The disease whenever found is one of the gravest importance, and re- quires the most careful watching. In hospitals septicaemia is more frequent, and Said to be more fatal than in private practice, and, like hospital gan- grene and hospital erysipelas, is apparently contagious when occurring in crowded wards, or where many wounded are necessarily grouped together within a small space. - At present, however, a new era has dawned upon the treatment of wounds; cleanliness, ventilation, disinfection, and drainage are considered as essen- tial. Nowadays, when hospitals are built upon the more improved plans, and the rules of antiseptic surgery rigorously followed, the appearance of Septicamia is not nearly so frequent as in former years; indeed, from very careful examination of statistics, it was lately stated by no less an authority than Sir James Paget, in a discussion at the Clinical Society of Great Britain, “that there was quite as great a frequency of pyamia after operations in private as in hospital practice, and that not only with pya-mia, but with other accidents, as they are called, of operations, he had seen no reason to believe that hospitals are places of greater infection, as it is called, or of greater unhealthiness than is met with in private practice.” And Mr. T. Holmes” states as his opinion, that the “popular impression as to the fre- Quency of pyamia in our hospitals is extremely exaggerated.” Treatment.—From considerable experience in this disorder, I have no hesitation in affirming that very often, if proper attention is paid to pro- phylaxis, the disease may be averted. The first point of importance is wiet. After a serious operation the surgeon must enjoin the utmost rest of mind and of body. This is oftentimes very difficult to obtain, especially in private practice. The friends and relatives are anxiously awaiting the result of the ordeal to which the patient is being subjected. They watch and listen with breathless anxiety; the stillness is oppressive to them; there is agony in the half-suppressed moan that issues from the operating-room ; when finally the door is opened, the surgeon makes his appearance, and informs them that the operation is completed, the patient survives, and is doing as “well as could be expected;” then, upon the impulse of the moment, the sufferer may be surrounded by excited, though thankful, relatives and friends, and amid the confusion and congratulations which ensue, the patient, weak from the ordeal which he has just undergone, may be seriously affected with nervous excitement. A change of position may produce haemorrhage, or other untoward symptoms may be occasioned. Therefore, quiet must be enjoined by the surgeon, and only one person, or at most two at a time, be permitted to see the patient, and these must be admonished not only to control, as well as they may be able, any mental emotion which may arise, but also to remain but a few moments in the sick-room. In the treatment of these diseases, of course, the first item of importance is to remove the exciting cause, that is, if it can be done. When the septi- camia is produced by a few drops of virus, or from the presence of diph- theritic poison, or from very large abscesses or sloughing wounds, this is not possible. The cause remains, and the great desideratum is to antidote it. Whether in septicaemia or pyamia, we have circulating in the system a virus which destroys life speedily, and the object should be to pour into the current such substances as are known to be antidotal. If the source of the infection is from an open wound or abscess, the care in its treatment must be redoubled. I am speaking now with the belief * St. George's Hospital Reports, vol. viii., London, 1877. PYAEMIA. 127 that every surgeon pays strict attention to cleanliness, disinfection and drainage. The atmosphere must be purified, and any dressing, having a tendency to prevent the increase of the formation of pus, should be em- ployed. It may be carbolic acid ; if it is, a solution of one part to one hundred is sufficient. If it be corrosive sublimate, which I now generally use, it should be one to two thousand, or one to twenty-five hundred. If it be iodoform it should be one part to eight of flour. I have also used with benefit, an absorbent jute, saturated with the bichlo- ride solution and then dried, which dressing should be changed twice during the day. When the chill begins the tincture of the root of aconite in water should be employed, and carbolic acid given internally. I formerly pre- pared a first decimal dilution made with glycerine, mixing twenty or twenty-five drops in half a tumblerful of water, giving a teaspoonful every hour. Of late I have abandoned this treatment, and inject hypodermically from forty to eighty minims of the nascent phenic acid of Déclat every night and morning. I cannot speak too highly of this method of treatment in both septicaemia and pyamia, and have employed it with signal success for several years past; it never fails to reduce the temperature, and appears to possess complete antidotal properties. I have never known any bad results to follow its use, and I have now in mind a case where sixty minims were injected night and morning for four months, without pain, and without any inconvenience either from the formation of local abscesses at the seat of puncture. In this case the patient was verging upon seventy years, had undergone supra-pubic lithotomy, and had suffered from all the symptoms of double pneumonia. As I believe in the antidotal powers of quinine in certain severe and pernicious intermittents, as I believe in the antidotal effects of mercury and potash in the treatment of syphilitic fever, in the same degree do I believe in the antidotal power of phenic acid in the treat- ment of septicaemia and pyamia. When the poison has been removed from the system, and the prostration and exhaustion are extreme, arseni- cum and muriatic acid are to be relied upon. In some cases, however, when the patient is recovering from the disorders, there yet remains a ten- dency to induration of the surface, and sometimes to enlargement of the glands; when such symptoms exist I have found the hyposulphate of soda of most excellent service. It may be given in solution, ten to twenty grains dissolved in six ounces of water, an ounce taken every two hours. Another point which experience has fully demonstrated as valuable is stimulation. The quantity of stimulant must be regulated by the ability of the patient to bear it, and it must be given until its physiological action is recognized. Some patients will be able to take half a bottle of brandy or whiskey per day, while others can only bear half or a quarter the quantity. I well recollect a patient in the hospital with two enormous abscesses on the thigh and one on the abdomen, whom, when I saw, I thought was dying; the jaw was dropped, the eye hazy, the body covered with a cold sweat, with a respiration of thirty-two, a pulse of 140, and temperature of 105°, who took half a tumblerful of whiskey every three hours for three days and nights, and never showed any other signs than those of improvement, and recovered after two months' treatment. As the convalescence progressed the quantity of stimulant was diminished, until even a tablespoonful pro- duced the ordinary effects of alcohol. Of course, in pyaemia, as the symptoms indicating the development of the internal organs arise, whether of pleuritis, bronchitis, pneumonia, hepatic, or kidney derangement, they must be met with the proper homoeopathic medicines, which, however, it is not the province of this chapter to discuss. Muriatic acid is a medicine whose pathogenesis would indicate its applicability to sep- ticaemia. I have used this medicine, and obtained from it apparently good effects. Carbolic acid may also be employed, or the hyposulphite or sulphocarbolate of soda. 128 A SYSTEM OF SURGERY. Other medicines which may be called for in the disease are arsen., china, carbo veg., lach., phosph., and veratrum viride. Good results may also sometimes be had by the inhalation of oxygen gas. In all large cities it can be obtained in iron cylinders, with the breathing- bag. If the practitioner in the country desires its use, it may be prepared in the ordinary manner.” - : As a last resort in these most serious maladies, the operation of trans- fusion may be performed. (Wide chapter on that subject.) w In the Transactions of the American Institute of Homoeopathy, for 1870, Dr. N. Schneider has published a very interesting article on pyaºmia, in which he narrates several cases. In one, after an amputation at the middle third of the tibia, severe symptoms showing themselves, aconite, arsenicum, can- tharides, mercury, and china were employed, and the patient recovered after six months. In the second, the patient died; the treatment was aconite, ipecac., arsenic, and veratrum. In the third case, aconite, cantha- rides, china, and rhus were employed. In the fourth case the patient per- ished from secondary ha-morrhage. Muriate of ammonia is also highly spoken of by some members of the profession, and excellent results have been obtained from veratrum viride. HECTIC FEVER. The peculiarity of this variety of fever consists in its remissions from the middle of the morning until the afternoon; the reappearance of the symp- toms at that time, their continuance throughout the earlier portions of the night, and the profuse sweating in the morning. From these symptoms I have known, especially in malarial districts, such fever to be mis- taken for a simple intermittent. Although this regularity of type does not always present, yet it is found in the majority of cases, and, indeed, there are at times two distinct daily or quotidian paroxysms. The main points by which the one form of fever may be diagnosed from the other are: first, the exhaustion caused by the sweating and diarrhoea; second, the great emaciation of the patient; and, third, especially the severe forms of organic trouble which are always to be found, and generally present- ing in profuse suppuration. Another peculiarity of hectic consists in the fact, that though the febrile condition may continue for a considerable time, there is comparatively slight derangement of the assimilative powers. Hectic may be diagnosed from typhoid fever by the absence of those symptoms indicating that the nervous centres are affected. Throughout the entire course of the disease the mental faculties do not fail, indeed, I have often observed an increased power and an exaltation of the senses as the physical condition is giving way. * When hectic is fully established, every day there is a slight chilliness, or even in some cases perceptible shuddering; this is followed by a paroxysm of febrile exacerbation, with dry mouth, hot skin and breath, the latter, however, being devoid of the peculiar odor belonging to pyamia; the palms of the hands and the soles of the feet burn, and the characteristic red- ness, bright, circumscribed, and scarlet, upon one or both cheeks, with a pulse about 110, and a temperature of 101°, indicate the fever at its height (Fig. 71). This febrile condition lasts a few hours, and is succeeded by the third or the sweating stage, called also by some the colliquative. Instead of the sweat, a diarrhoea may supervene, but whichever results, the patient is greatly debilitated. Between the paroxysms, however, the patient may, * For an interesting paper on oxygen gas as a remedy in pyamia, vide New York Medical Journal, April, 1870, p. 165. - f Page 204. ULCERATION. 129 until the advanced stage, be comparatively comfortable, and at times may have some appetite. Finally, the emaciation becomes more rapid, the fea- tures assume the hippocratic cast, the entire system is exhausted, and the patient actually dies from asthania, the mental faculties continuing un- impaired to the last. Treatment.—The treatment of hectic fever is unsatisfactory, because the surgeon is generally unable to remove the exciting cause. This, of course, is first to be attended to, and if success crowns the effort, and the system can be relieved of the constant source of irritation, the result will be favorable. Operative measures are, therefore, called upon, and often delay is danger- ous. The removal of the affected part, even amputation or resection, has FIG. 71. DAY. 2 3 4 5 6 # * * 7 is is 20 T : Tº Tjºirº Tº Tº Tiº i ! T ºf . . . . . . . . . . . . . . . . . . . .T. 9| | | | | | | | | | | | | | | | | | | | | | | | | A i. |-|--|--|-- ... | 00 . . . . . . . A . A A : W A * : A\ |\ . A |\| | \ . . . . . . . . . ./S / \ . A A / W. v. W , f \ |\ \ . . . . . . . . L!... . . . . . . . . . . Y. . . /V AN/ | V | 7 | y º 7 : V | | | | sº | / . º 38|| || || Thermograph of Hectic.—(HOLMES.) often been followed by an immediate improvement in the condition, and as I have elsew where remarked, waiting to “tone up ’’ the system as it is called is often to allow the patient to die. Every surgeon is aware, how, in certain cases, after hectic has been wearing away the life of the patient, the removal of the affected parts is at once followed by better appearances and a better general condition. It is also a fact, that patients who have suffered long from suppuration and hectic, bear the capital operations better than those who are in robust health. There is less shock to the nervous system; indeed, in some most severe operations, I have observed that none whatever has followed; the patient awaking from the anaesthesia with a refreshed and animated appearance. The different medicines for hectic can hardly be noted here, as the causes from which it arises are most numerous. The symptoms must be studied, the pathology regarded, and the organic disturbance receive careful atten- tion in the selection of the medicines. CHAPTER VII. DEGENERATION (CONTINUED). ULCERATION: SLOUGHING.-ULCERs: SIMPLE — IRRITABLE — INDOLENT — VARICOSE. TREATMENT: Local—STRAPs—BANDAGEs — SKIN-GRAFTING—SPONGE-GRAFTING— MEDICAL TREATMENT—DRY EARTH. Ulceration is that process by which a solution of continuity is effected in a living solid; it is of much more frequent occurrence in the cellular and adipose tissues than in muscles, tendons, ligaments, nerves, or bloodvessels, and is not generally applied to abrasions affecting only the epithelium. The Hunterian theory regarded such breach of continuity as effected by what was termed ulcerative absorption, or, in other words, that the absorb- ent vessels were chiefly concerned in the establishment of the process; 9 130 A SYSTEM OF SURGERY. modern pathologists, however, regard ulceration as the molecular death of a part, a gradual softening and disintegration of tissue, molecule by mole- cule, the effete matter being mixed with purulent and other secretions, and thus carried out of the system. This process is generally one of true inflam- mation, or connected in some degree with inflammatory action. If the inflammatory process continue, suppuration, 'softening, disinte- gration, and detachment of the tissues in minute portions follow in succes- sion in the abnormal action; the separated molecules become mixed with the pus, and are removed with the discharge of the matter; it would appear, therefore, that with such a process absorption would be but little connected. It has already been mentioned that during the inflammatory process, absorption is arrested either in toto or partially, and is only renewed when resolution is taking place. If the process continue, and suppuration and ulceration follow, the absorption is still held in abeyance. Again, there is always a discharge accompanying ulceration, which need not exist if ab- sorption were going on ; and when we add to this that many structures of the body are peculiarly liable to ulceration, and particularly resistant of absorption, it may be seen that the old doctrine cannot hold sway before the new one of molecular death and disintegration. - There are several other circumstances which are opposed to the theory of ulcerative absorption, and indeed form conclusive evidence that the absorb- ents do not perform that action in ulceration that was attributed to them by Mr. Hunter. Ulceration is a step beyond suppuration. The inflammatory process having reached its climax, in infiltration and partial softening of the tex- tures, if ulceration supervenes the molecules become further softened, and carried away with the discharge from the part. This is effected easily from open surfaces, but when ulceration is progressing in an unbroken part, a small abscess or pustule is formed, and after its contents are evacuated the ulcerated surface is revealed. The terms acute, inflamed, chronic, phagedemic, sloughing ulcer, are all modi- fications of the process of ulceration, the severity of which is in proportion to the grade of the inflammation and the vitality of the part. If the inflammatory process is moderate, and the ulceration is established steadily, it may be termed acute; if, however, the degree of abnormal action is greater, the ulcer is said to be inflamed, on account of the unusual amount of pain, heat, swelling, and redness that surrounds the part; if the inflam- mation is of a still higher grade, the destruction of the tissues is still more rapid, and a phagedenic sore is produced; and if still the inflammatory action progresses, partial death to the part is effected, and a sloughing ulcer is the result. However, after ulceration has been established by inflammation, the latter may subside, and the ulcerated surface be repaired in a short period; but if the inflammation is sluggish, the ulceration proceeds slowly and becomes chronic in character. - The process by which an ulcerated surface is repaired, viz., granulation, and the covering of these granulations with cuticular formation, or the absolute healing of the part, viz., cicatrization, have been already considered. The same causes that create inflammation are productive of ulceration. These actions are portions of the same process, commencing with vital turgescence, and terminating in gangrene. Ulceration is the medium between suppuration and gangrene; in the former the action does not proceed far enough to disintegrate the textures; and in the latter the death of the part is effected in mass, and not molecule by molecule. - sº SLOUGHING—ULCERS. 131 Sloughing.—Death of a part, an undoubted termination of inflammation, as well as of all other vital change, may be reached at once from intensity of action, deficiency of power, or a combination of both. The difference between ulceration and sloughing consists simply in the . fact, that in the former case the death is molecular, particle by particle being cast off; in the latter the part dies in a mass and is detached, the dead or decaying substance being denominated slough if the process has taken place in the soft parts, and sequestrum if the dead structure is bony. Sloughing occurs more rapidly or slowly in direct ratio with the intensity of the inflammatory action. The textures broken up by the processes of inflammation and ulceration are softened and infiltrated ; there is no supply of blood, they die, and in obedience to the great law of nature are cast off. The medicines for different forms of ulceration will be found in the sections upon ulcers. ULCERS. Those sores that are produced by the action of the ulcerative process— or, in other words, solutions of continuity effected by ulceration—are termed wlcers. All the textures of animal life are liable to be attacked, although some are more susceptible of invasion than others; but it is more particularly the formation of those sores that appear on the surface of the body that at present demands attention. The arrangement into classes of the varied forms of ulcers simplifies much their description, and to a certain extent their treatment; but the classifi- cation differs with different authors. Dr. Gibson mentions three varieties, viz., simple, indolent, and irritable ulcers, arranging other ulcerated surfaces under the diseases that cause them. Sir Everard Home forms them into six classes: 1. Ulcers in parts that have sufficient strength to carry on the actions necessary for their recovery. 2. Ulcers in parts that are too weak for that purpose. 3. Ulcers in parts whose action is too violent to form healthy granulations, whether this arises from the state of the parts or of the constitution. 4. Ulcers in parts whose action is too indolent, whether this arises from the state of the parts or of the constitution. 5. Ulcers in parts which have acquired some specific action, either from a diseased state of the parts or of the constitution. 6. Ulcers in parts which are prevented from healing from a varicose state of the superficial veins of the upper part of the limb. Mr. Miller mentions ten varieties, viz.: 1. Simple purulent or healthy sore. 2. The weak. 3. The scrofulous. 4. The cachectic. 5. The indo- lent. 6. The irritable. 7. The inflamed. 8. The sloughing. 9. The pha- gedenic. 10. The sloughing phagedaena. Probably the most simplified method of classifying ulcers is that of arranging the whole into two divisions, the first comprising the simple, indolent, and irritable ulcer, and the second embracing those sores that have acquired a specific character from the diseases with which they may be associated—scrofulous, syphilitic, cancerous, etc.—leaving the considera- tion of these with the diseases themselves to be studied in their appropriate places. This appears also the more requisite because there are many im- portant symptoms that may present themselves in any or all the varieties of ulcers, without regard either to name, classification, or the specific disease upon which they may be dependent ** * * * * Simple, or Healthy Ulcer.—This is, in truth, an example of healthy granu- 132 A systEM OF SURGERY. lation following a wound or abscess, or of inflammatory disintegration of a part previously unbroken in its surface. “The discharge is thick, creamy, easily detached from the granulations, almost inodorous, and not profuse—in fact, it is laudable pus. The granu- lations are numerous, small, acuminated, florid, sensitive, and vascular; if touched at all rudely, they bleed and are painful. The blood is arterial, neither too profuse nor abnormal in quality, and the pain is but the just appreciation of injury done to healthy tissues. The general sensation in the part when not injured is slight tenderness, or a feeling of rawness, rather than actual pain—not unfrequently a sensation of itching is present to a degree even troublesome. As soon as the granulations arrive at the surface of the skin, cicatrization commences, and proceeds steadily until the part is repaired.” The treatment of such sores is quite simple. The part should be kept at rest, and in a position that may relax those muscles upon which the ulcer is situated; and, above all, the strictest cleanliness enjoined. Milk and tepid water commingled in equal parts should be allowed to dribble over the sore from a sponge or piece of lint saturated with the liquid. This appears to be the best abstersive method, as the frequent passing of a sponge over the healing parts may prove a source of irritation, as well as causing a destruction of the delicate granulations, and the healing process thereby be retarded. The simple ulcer generally heals rapidly, without the exhibition of any medicine. Sometimes, however, after cicatrization has progressed for a time, there appears to be a diminution of action in the healing process; if this be the case, a few doses of silicea, repeated every twelve or twenty-four hours, will overcome the difficulty and complete the cure. Irritable Ulcer.—This form of ulcer is generally preceded by an irritable state of the system, or if such be not the case, the constitutional may be produced by the local irritation. The digestive function is frequently impaired in those persons afflicted with irritable ulcer, and consequently the sore is often found among those in the higher walks of life, who eat and drink to excess, or among de- bauchees. The appearances presented by an irritable ulcer are as follows: The edges are ragged, undermined, and Serrated ; the bottom appears deeper in some points than in others, and the parts around are red, inflamed, and fre- quently oadematous; the discharge, which is always considerable, is a thin, greenish, or reddish matter, which is frequently so acrid that it excoriates the surrounding skin, and is sometimes mingled with solid matter. Granu- lations are wanting, and in their place may be found a grayish film, or a dark-red spongy mass, which is acutely sensible, and bleeds at the slightest touch, the blood being of a dark grumous character. The medicines that have proved most effectual in removing this form of ulcer, are, arsen, asaf, carbo veg., lyc., hepar, merc. 80l., nit. acid, silic, mez., com., sulph., thuja, Staphis. In addition to the internal treatment, when the granulations are very exuberant and large, a local application of nitric acid, acid nitrate of mer- cury, or lunar caustic may be made once or twice daily, and the parts dressed with carbolated glycerin. * - Indolent Ulcer.—This variety of ulcer is of much more frequent occur- rence than either of those already described. It has received from several authors the appellation “callous,” and is the fourth variety in the classifi- cation of Sir Everard Home. “Ulcers in parts whose action is too indołent to form healthy granulations, whether this indolence arises from the state of the parts or of the constitution.” TJ LCERS. 133 The appearances presented are a complete contrast to those of the irritable Sore, although in the first instance it may have assumed the characteristics of that variety of ulcer; indeed, a healthy or simple sore may pass through different stages, and ultimately become indolent, because cicatrization may have been opposed or protracted by its situation, or other adverse circum- Stances. From such reasons it is obvious that the ulcer must be most common among individuals belonging to the laboring population, upon whose efforts depend the subsistence of their families, and who therefore are unable to make use of appropriate means, so necessary to be observed at the first appearance of the sore, that the ulcerated surface may be repaired. As long as the erect posture is practicable, the poor man must strive for the maintenance of his household; and finally a simple purulent ulcer be- comes inflamed and irritable, and assumes those appearances which are the sure characteristics of the indolent sore. But it is not among such alone that this variety of ulcer is found, nor does it so frequently arise from continued exertion, as from filthy and dissolute habits, or protracted in- temperance. An indolent ulcer presents the following appearances: - The edges are elevated, protruded, smooth, and rounded, giving to the Sore an appearance of deep excavation. The surface is smooth, glossy, pale, and generally void of granulations, although in some instances there is a feeble attempt at such formation; or it is covered partly with a pellicle, or crust, of a whitish or dark-gray color, so tenacious that it is inseparable from the ulcer without considerable force. Sometimes the sore is dry, but generally there is a profuse discharge of a thin and serous fluid, nearly destitute of fibrin; the surrounding integument is swollen and discolored. The most striking characteristic of the indolent sore is the elevation of the margins, which are very callous, and present a whitish appearance, resembling a dense high ring of cartilage. The pain is so slight that the patient frequently experiences but trifling annoyance, and is able to per- form his usual vocation. When an irritable ulcer has become indolent, the appearances vary from those described above. The granulations are large, round, pale, and flabby, extremely sensitive, and bleed from the slightest scratch, and some- times rise into a fungous form above the skin. This is what is termed by some writers the “fungous ulcer;” by Mr. Home it would be denominated as “an ulcer in parts too weak to carry on the actions necessary for its re- covery,” or by others as the “weak sore.” “This fungus,” writes Professor Gibson, “may, and often does, accompany an ulcer with carious bone, sprouts from the mouth of a sinus, or covers the surface of many specific ulcers. From whatever source it springs, its characters are uniform, and its disposition so truly indolent that it cannot without impropriety be referred to any other head.” Varicose Ulcer.—There is another variety of indolent ulcer, which pre- cedes or follows a varicose enlargement of the veins of the leg or thigh, which has been denominated the varicose ulcer; it generally makes its ap- pearance on the inner side of the leg, and is often very difficult to cure. It resembles an indolent ulcer in a somewhat advanced stage; the edges of the skin, however, bounding the sore are not tumid; the part is blue or purple; the Sore is seldom deep, usually spreads along the surface, and is oval in shape. The branches and trunk of the vena saphena are enlarged, and this varicose state prevents the healing of the ulcer. A varicose limb becomes very much swollen, the coats of the veins are often thickened, the vital power is much impaired, the temperature is diminished, the parts assume that dark-blue appearance to which we have already alluded, and 134 A SYSTEM OF SURGERY. are excessively prone to the inflammatory process, ending in ulceration, which is generally of a tedious nature. Sometimes we find that the irritable Sore is accompanied with varicose veins. The pain appears to be deep-seated, and extends up along the course of the veins, and is increased by maintain- ing the limb in the erect posture. Treatment.—In the treatment of indolent ulcers, it is necessary that the utmost cleanliness be observed; and if the patient be one whose constitu- tion has been impaired by unwholesome diet, exposure to a foul atmosphere, or by intemperance, these obstacles should be overcome by the substitution of nutritious, easily digested food, proper ventilation, and regularity of habits; in fact, as far as possible, every effort should be made to effect the removal of the predisposing cause. The indolent sore is capable of cure under homoeopathic treatment; in- deed, in some instances, without having recourse either to the bandage, straps, or escharotics, but it is absolutely necessary that the patient be put to bed, rest being a factor in the cure; but in most instances such a favora- ble termination is the exception, not the rule. The restoration of continuity in the parts destroyed by the indolent sore is often very gradual, and attended with variations in the healing process. The ulcer may appear to be doing well, when, from some irritation, a retro- grade action takes place; but if the practitioner have reason to believe the medicine correctly chosen, it must perseveringly be administered, always endeavoring not to interfere with its action by a too frequent repetition of the dose. The surgeon, if the sore progresses slowly, is often strongly tempted to administer the medicine at too short intervals, and in a lower potency than that which he is employing; but when allowing himself to be thus led astray, disappointment is invariably the result. So long as there is a per- ceptible improvement in the appearance of the ulcer, the medicine must be continued, as there is nothing that more retards the progress of cure than the repeated change of the means employed for the accomplishment of that |UITTOOSé. p #. medicines that are most serviceable in the treatment of indolent ulcers are ars, carb. veg., lyc., graph., phosph. ac., Sang., sepia, silic., sulph. FIG. 72. Purely medical means will, according to my own experience, fail in many instances unless accompanied with those surgical manipulations which I wish to impress on the mind. 1st. A horizontal position of the limb; 2d. An even support given by a roller, applied from the foot to the knee; and 3d. In cases where the sore is rather of an indolent character, the application of adhesive straps. One and all of these means can be used as follows: Cleanse the sore with simple soap and water, and having raised the limb to a horizontal posture (having previously prepared adhesive straps of suffi- cient length to pass around the limb), apply the first strap from left to right across the leg, the second from right to left, and so on ascend up the limb, allowing each of the straps to slightly overlap the preceding. (Fig. 72.) TREATMENT OF ULCERS. 135 When the whole sore has been covered, a roller must be thus applied: Having made a couple of turns around the ankle-joint, make several figure- of-eight reverses, around the instep under the sole and back again to the ankle, and having almost covered the foot, ascend on the leg, making the circular and reverse turns from the ankle to the knee. (Fig. 73.) The bandage must be re-applied every second day, and the straps twice or thrice a week. I may remark that there are very few ulcers of the class which I here mention, but will be at least very materially benefited in a short space of time by this method of treatment. In fact, since I have FIG. 73. adopted this apparently simple procedure, and made the patient persist in it, I have succeeded very much better than while using merely medical Iſleå.I] S. I have also used, in connection with this treatment, the application of the first trituration of merc. dulc., with which the excavation may be filled, and over which the straps may be applied. This has proved eminently suc- cessful. - The sulphide of carbon has of late been much used in the treatment of indolent ulcers.” Its disagreeable odor may be counteracted by either iodine, essence of bitter almonds, or Peruvian balsam. * The formula is: B. Carbon. Sulphidi, . . tº a g e tº . . fl. 3ss. Tinc. iodinii, e Q tº * © e ſº © , fl. 3.j. Essent. menth. piper., . tº º ſº e tº . . m giv.—M. Local use. For sloughing, or gangrenous ulcers, Dr. Brinton, of Philadelphia, uses: B. Brominii, . e e e e º ſº & tº . fl. 3.j. Aquae, . & g te © e. e . 3ij. Potassii bromidi, . . . grs. xxx,−M. Dr. Dowse, of London, applies the following to old atonic ulcers: B. Chlorali, ſº tº e e tº º & © & . 3iv. Sol. chlor. zinc., . © tº * > º © e & . Ziv. Aquae, . e º {} G tº e te & e %i-M. fl. I have also of late years had some success with the use of the submitrate of bismuth, and sometimes with iodoform and the balsam of Peru. These two drugs may be employed together in a mixture of equal parts, the latter in a measure destroying the disagreeable odor of the former. Further on, the method employed by Mr. Critchett in preparing and ap- * Naphey's Surgical Therapeutics, pp. 211, 212. 136 A SYSTEM OF SURGERY. plying straps is noticed. That gentleman gives most explicit directions, and the method is also recommended in the British Journal of Homoeopathy” as an adjunct to the treatment of the variety of ulcer under consideration. It consists in tightly strapping the limb, in the manner presently to be de- scribed; the use of straps being considered preferable to the application of the roller, as the bandage is liable to slip or become loose. Instead of the plaster (empl. plumb.) recommended by Mr. Critchett, the Straps should be made from simple wax, or isinglass plaster, or, what is still better, the surgical adhesive plaster of Mead. The following are the words of Mr. Critchett: “You must seat the patient opposite to you, and support his foot upon a small stool about a foot and a half in height, and so constructed as to receive the print of the heel, and leave the rest of the foot free. You should be provided with strips of plaster about two inches in width, and varying in length from twelve to eighteen inches, according to the size of the limb. “You then take the centre of the first piece, and apply it low down to the back of the heel, and then with the flat part of both hands press the plaster along both sides of the foot. This plan is very preferable to taking hold of the ends and endeavoring to apply them, as it insures a perfectly Smooth adaptation of the plaster to the part, and also because it enables you to regulate that very important point, the amount of tightness you may wish to employ. As you proceed with the remainder, you must always remember the principle is to make one portion fold over another; you must, therefore, alternate them around the foot and ankle. Your second piece should be placed in a similar manner underneath the heel, and then carried upwards at a right angle to the last, so as to cover a portion of each malleo- lus. The third piece should be again applied to the back of the heel, over- lapping the first by about one-third. The fourth piece, under the foot, and carried upwards, each piece being pushed along so as to allow it to take its own course ; this must be continued until the foot and ankle are covered; the strips must then be carried in a similar manner up the leg, increasing in length as the calf increases, and extended as far as the knee, and in Some few cases even above this.” Referring to this method of dressing, the editors of the British Journal re- mark: “Over this a bandage is to be applied in the usual manner. Small ulcers, situated in the hollow between the malleolus and the os calcis, require more pressure than the rest of the limb, which may be produced by apply- ing small pieces of plaster in a crucial manner over the wound before put- ting on the strapping.” Twice a week, in the majority of cases, will be sufficiently often to renew this manipulation. If there be a profuse discharge, a piece of dry lint may be placed upon the Sore. Skin-grafting in Ulcers.—This process is said to be of French origin, and has been largely practiced by Mr. Pollock, of St. George's Hospital, but later researches bear evidence that Professor Hamilton, of New York, conceived the idea of skin-grafting many years since. I have practiced it in many cases with most excellent results. The method I employ will be found in the following gase: Mrs. H. was admitted into the Hahnemann Hospital, New York, some months since. The inside of the left leg, from above the centre of the calf to the heel, was covered with ulcers of five years’ standing, varying in size from that of a half-dollar to that of a half-dime. The largest and deepest of these unhealthy-looking sores was situated just below the internal malleolus. The edges of the ulcers were jagged, uneven, and overhanging, with flabby * Vol. vii., pp. 423–425. SKIN-GRAFTING IN ULCERS. 137 and readily-bleeding granulations. The integument was purple, and the patient was in a bad condition generally. June 18th.-I clipped with scissors several minute pieces of integument from the left forearm, and having thoroughly cleansed the base of the ulcers, inserted three grafts into the deepest parts of the largest sore, and in two of the smaller ones, one each. The small particles of skin were kept in posi- tion by a thin strip of isinglass plaster. On the second day there was not much alteration in the grafts; but on the third evening they appeared to be reddened, and healthy granulations were perceptible. - June 21st.—After four days I proceeded to graft the remaining Sores, de- positing in the larger ones two or three “seeds of flesh,” and in the smaller but one. Some of these appeared to die away, but in all the ulcers healthy action resulted, and in about three weeks the leg was healed. The skin, however, although very much more natural in color, did not assume its normal appearance; but the sores healed in a comparatively short time. July 25th.-Patient was discharged cured. November 3d, remained well. It has been asserted that in certain cases the graft may be lost to view, but that in the course of a few days the granulations will become healthy and the cicatrization complete. Mr. Mason, however, who, in the Lancet for FIG. 74. Scissors for Skin-grafting. October, reports nine cases—five still under observation—has not noted such variations; the graft in his cases always becomes the centre of healthy growth. In some cases, in some of the ulcers the minute portions of integu- ment did indeed disappear; but in a day or two the ulcers began to assume a healthy character and healed quite rapidly. Messrs. Stohlmann & Pfarre have manufactured a scissors to facilitate the operation of clipping the integument. (Fig. 74). - If such an instrument be not handy, pass a pin through the integument, raise it gently, and snip off the portion thus raised below the pin, which serves as a handle by which to apply the graft. In the Medical Times, of Philadelphia, for December 15th, 1870, is a de- scription of the changes which take place in the grafts, by Mr. Dobson. It is as follows: “At about the second day the cuticle begins to separate; by the fourth day only a faint pale spot marks the insertion, or there may be no evidence left of it at all; by the sixth day a faintly vascular tuft of granulation appears. This becomes glazed, and in a few days more the usual covering of cicatrix is formed. The patch is usually circular, and presents slight ridges, and continues to increase in size circularly, until it reaches its maxi- mum of growth, for it has a maximum of growth. I have never seen a patch larger than a florin, and I have seen large numbers of them. I should say that their average growth will not exceed the size of a sixpence.” 138 A SYSTEM OF SURGERY. Dr. B. A. Watson,” in an able article on skin-grafting, insists on perfect cleanliness, and the removal of “every particle of dead tissue,” by the appli- Cation of emollient poultices, wet compresses, and the caustic (for which, per- haps, ten days may be required). He applies the grafts in rows, about half an inch apart, in order to dispense with the use of more plaster than is abso- lutely necessary. By placing the grafts in rows a single strip of plaster may cover half a dozen grafts, the line of direction depending upon the shape of the ulcer. The grafts are allowed to remain undisturbed for forty-eight hours, when the compress and bandage must be removed, and the grafts examined through the plaster, which, being of isinglass, can easily be done. The doctor observes a fact which has often presented itself to my notice, that every trace of the graft may disappear, yet a healthy granulation may spring up in the same point, which the author believes the “germ theory” will fully explain. * He mentions, also, two other methods of healing ulcers by “germ-plant- ing.” One consists in “removing the epidermic scales from some portion of the body, more frequently the thigh, which had been previously shaved to remove fine hairs, after which the parts were scraped with a scalpel, and the scales collected on a piece of writing-paper, and these carefully dis- tributed on the surface of the ulcer.” . . . . The third method consists in applying a fly-blister to some portion of the body, collecting the serum, transferring it to the ulcer, and retaining it in contact. These methods may all be tried, but we see in this article the peculiarity which is observed in most of the surgical essays of the old school, viz., the great dearth of internal treatment. Sponge-grafting.—Professor D. I. Hamilton f has given an idea which may ultimately be of great service to the profession. Acting upon the fact that blood-clots do become organized, which appears to be proven by the occlu- sion of arteries in the cure of aneurism, Professor Hamilton filled several ulcers with pieces of sponge prepared in the following manner. Fine sponges were taken and washed, and then allowed to lie for 48 hours in a solution of dilute nitro-hydrochloric acid, to dissolve the calcareous matter; they were then carefully washed in liquor potassae, and finally allowed to remain until wanted in a carbolic acid solution, 1–20. The sponges should be cut into small slices, the size varying with the surface to be repaired, and placed in or upon the wound, and so allowed to remain until the healing is complete. The process, as observed by Mr. Hamilton, and which I have verified, is: first, that the interspaces of the sponge become filled with connective tissue-cells, among which are found a large number of giant-cells. In some of these cells the nuclei are very numerous, each having a bright nucleolus. The cells are surrounded by spindle-cells of the connective tissue type, and, as the experimenter writes: “In fact, the appearance was like that of a typical giant-celled sarcoma.” Mr. Hamilton also remarks: “In order to carry out the inquiry still fur- ther, I have performed certain experiments on animals. One set of experi- ments consisted in placing pieces of sponge within the peritoneal cavity and leaving them there for various periods of time; while another set comprised the introduction of the same into muscular parts. A third series of experi- ments was made by inserting two thin glass plates with a layer of Sponge between them, into the subcutaneous tissues, while Ziegler's original experi- ments, of inserting these beneath the tissues without any sponge interven- ing, were also repeated. Whether the sponge was placed in the peritoneal * New York Journal of Medicine, July, 1875. † Edinburgh Medical Journal, November, 1881. † Centralblatt, 1874, Nos. 57 and 58. SPONGE-GRAFTING. 139 cavity or in a muscular part, the result, where the case went on favorably, was invariably the same, viz., that the sponge in a few days after insertion began to organize in the same manner as I had found to occur in the human subject.” }. C. B. Ball, F. R. C. S. I.,” reports four cases which are interesting in this relation, as they show beyond doubt the organization of blood-clots, on which, as I have before noted, Mr. Hamilton bases his practice of sponge- grafting. sº In a very interesting and instructive article on this subject by Kendal Franks, M.D., and P. S. Abraham, M.D., f may be found some remarkable cases of this character, with plates illustrating the appearances of the cells already described, and verifying many of Dr. Hamilton's observations. A rather remarkable case in which sponge-grafting was employed occurred in my practice not long since, and although not altogether successful on account of accident, yet was very satisfactory as illustrating the sponge-grafting process. A young lady presented herself to me with one of the worst cases of lacerated perineum which I have ever seen; not only was the perineal body (?) entirely gone, but the recto-vaginal septum was split more than half way to the cer- vix, which was, of course, very low down. All control of the bowel neces- sarily was lost and her condition was most miserable. As frequently happens in these cases, constant diarrhoea was present, which greatly excoriated the parts. Digestion was much impaired, assimilation was very deficient, and the consequent emaciation was great. Two operations had been performed upon her, the last one by myself, in which I had taken great pains to bring together the parts; but not only did the diarrhoea (for the arrest of which I had delayed the operation, and which I had thought cured) return on the Second day, but a severe uterine haemorrhage set in (which proved to be a miscarriage) on the fifth day and completely ruined the operation. As soon as she had sufficiently recovered from these mischances to allow an examina- tion, I found that there had been an attempt at union which had failed; that the sides of the cleft as far up as the carunculae had not cicatrized, although they had granulated and were evidently in process of skinning over, leaving a very wide rent. I therefore had the bowels constipated; I had some of my Sponges (prepared for ovariotomy) ready to graft, and my idea was to cut a wedge-shaped portion of the sponge and fit it into the cleft of the peri- neum, and having scarified the portions of the raw surfaces which were disposed to cicatrize, to sew the sponge into the cleft with catgut. I was called out of New York that afternoon and asked Dr. Wilcox to sew in the sponge, which he did. On the morning of the second day the sponge was saturated with pus, which was gently squeezed out, and the parts thoroughly irrigated with carbolized water thrice a day. On the third day there was such a putrid condition of the parts that I considered the operation must be unsuccessful; however, I gently squeezed out the pus and had the parts irrigated again and vaginal douches given several times during a day. By the fifth day, and very much to my surprise, the fetor diminished greatly, the sponge seemed to be dry, and slightly protruding from the wound, and when I took hold of the sponge with a pair of forceps and endeavored by gentle traction to move it laterally, I found that I was quite unable to stir it with- out applying more force than was consistent with safety. On the seventh day the catgut sutures were all gone, and it was evident that the sponge was protruding more and more from the opening, although there was a percep- tible effort on the part of the integument to spread over the circumference, as shown by a white line about I's of an inch in width, around the margins * Dublin Medical Journal, October, 1882. † Journal of Anatomy and Physiology, April, 1882. 140 A SYSTEM OF SURGERY. of the wound. With a pair of curved scissors I cut off the small frag- ment of the sponge which projected, and making a section of it, had it placed under the microscope. Not only were the larger interstices filled with giant-cells, but these appeared to lie in a network of smaller cells or fibres, which branched out in all directions. What astonished me still more was the vascularity of the sponge. Quite a little—say a few drops—of blood of good color and consistence came from the cut sponge. I was, up to this time, most sanguine of a cure, but a diarrhoea again came on, and although the piece of Sponge not vascularized was constantly filled with stinking faecal matter, yet the deep portions remained firm until some parts of the Sponge had disappeared. Withal, there was some improvement in the case, and I have mentioned it here to incite others to renew the experiment in lacerated perineum. Medical Treatment.—With arsenicum, calcarea carb., carbo veg., carbo an., asafoet., phytolac., mez, sulph., silicea, and other medicines, we may cure these ulcers without the skin-grafting process, or if it be necessary to resort to these means, the internal exhibition of the appropriate medicine has a ten- dency not only to facilitate the “taking” of the graft, but also to promote healthy granulations, and induce a condition of the constitution, which is of the greatest possible importance in the healing of ulcers. A great deal Of º has also been attained in my hands, by packing the ulcer daily wit R. Hydrarg. chlor, mit., º ſº tº e © © tº º . 3]. Cretae preparat., . tº e o * e o & tº º . 3.j. M. ft. pulv. - Having previously sprayed the surface with calendula, and then evenly strapping the part, as already directed. When the ulcers are very old and have resisted all treatment for years, being sometimes benefited by medical and surgical appliances and then relapsing into their former indolent condition, a successful method has been introduced which consists in making deep incisions on either side of the sore in the sound skin, and keeping these open by means of pledgets of lint. By this procedure the integument yields to the cicatrizing process in the ulcer which had before been prevented from the hardness, inelasticity, and torpor of the parts, and the new wounds heal as kindly as recent cuts. Earth Treatment.-The treatment of varicose and indolent ulcers by the application of earth is often followed with very remarkable results. Good subsoil, dried and divested of grit, finely powdered and sifted, may be applied directly to the part and held in situ by waxed paper, or gauze, the ends of which are fastened to the integument by collodion, as recommended by the late Paul Beck Goddard, of Philadelphia,” or the gauze may be first placed over the sore, and the earth applied over it to the thickness of half an inch or more. The earth not only is comfortable and cooling to the patient, but is a complete disinfectant. Many cases of the successful use of this easily-obtained topical application are recorded, the effect being immediately noticed. It is essential during the treatment that the patient should be kept in bed, and if there be any large and varicose veins they should be destroyed, either by subcutaneous incision between two pins passed beneath the veins with a figure-of-eight suture of wire or silk above them ; or the application of caustic lime and soda over the course of the enlarged vessels. Wide Treatment of Varia. * Earth as a Topical Application in Surgery, by Addinell Hewson, M.D., Philadelphia, 1872. GANGERENE AND MORTIFICATION. 141 CHAPTER VIII. DEGENERATION (CONTINUED). GANGRENE AND MORTIFICATION.—LINE OF DEMARCATION; OF SEPARATION.—QUESTION OF AMPUTATION IN TRAUMATIC GANGRENE – DRY GANGRENE – TREATMENT— HospitaL GANGRENE–SLOUGHING PHAGEDAENA. Gangrene is but a step in advance of ulceration, and may be divided into three stages: 1st. The death of the part. 2d. A period of arrest of the plastic deposit. 3d. A period of separation and granulation. Agnewº discards the title gangrene as having a tendency to mislead, but it appears to me, that it will be difficult to exclude from surgical nomen- clature, a term that has had a specific meaning for centuries past. If the ulcerative process extends, then the dead particles of the ulcer are still given off molecule by molecule, but if we have a larger portion thrown off it is called a “slough.” When gangrene is about to commence we have, first, redness of the part; after this it becomes of a bluish tinge, and above this a mottled appearance; blisters appear; it becomes cold; and has a fetid odor. The constitution becomes weaker, the vitality of the parts is less and less, and we have gangrene, which is death of the parts en masse. The dead portion itself is called a “sphacelus” or “slough.” If we take a portion of the gangrenous mass and press it between the fingers we find that it crepitates, because of the gas generated and contained in its sub- stance. We always have this in the tissues where gangrene has appeared, and it is an important fact to remember in connection with medical juris- prudence, that wherever there is decomposition of the tissues we have a lesser or greater accumulation of gas. After a certain time, as the process of sloughing goes on, a “line of demar- cation ” forms, separating the healthy from the gangrenous part; this is caused either by an arrest of the process itself, or because the healthy parts are able to withstand the action of the process. There is severe pain and hectic fever accompanying gangrenous ulceration, and during the time that the line of demarcation between the dead and the living tissues is being formed. After the line of demarcation, that of separation is begun (Fig. 75); at this point the dead part is thrown off from the living. This line of separation is always oblique. The line of demarcation forms the surface- boundary of the “line of separation,” which being oblique, leaves a stump the reverse of that made by the surgeon in amputation. It either goes through the limb, or it “scoops out” the dead portion; and when the slough comes away there is beneath a healthy granulating surface. Internal organs are not very liable to gangrene; the lungs being more frequently attacked than any other. Causes.— Among the causes of gangrene are injuries of all kinds, especially crushed wounds. Clean cuts are never liable to be followed by ulceration; but such injuries as are occasioned by railroad and steamboat disasters, congestions, and obstructions of circulation, give rise to mortifi- cation. Sometimes gangrene is very rapid in its course, particularly the traumatic variety. A man’s limb may be crushed to-day; to-morrow gangrene may set in ; and on the third day he may die. Obstruction of the circulation is a frequent cause of gangrene. This ob- struction may originate from a variety of conditions; as embolism, tumors pressing on the arteries, clots in the arteries from fibrin, etc. Heat and cold, especially if excessive, are prolific causes of mortification. Frequently we * Principles and Practice of Surgery, vol. i., p. 27. 142 - A SYSTEM OF SURGERY. See this result from frostbite, as well as from the introduction of substances into the system which have a tendency to contract the muscular coat of the bloodvessels, as ergot of rye. Tight bandaging in cases of wounds, fractures, and dislocations, has often produced mortification, and many limbs have been sacrificed to this care- less practice. The cut (taken from Druitt), Fig. 76, represents sphacelus from starvation. - When gangrene does not involve the whole thickness of a limb, the line of demarcation is formed around the sphacelated portion, and the part FIG, 75. FIG. 76, sloughs away, leaving an ulcerated surface beneath, in which the process still continues until the unhealthy structure is cast off. The constitutional symptoms in mortification generally assume a typhoid character. The pulse is quick and tremulous, the skin hot, tongue dry and of a brownish tinge, and the patient restless and uneasy. Delirium, sub- Sultus tendinum, nausea, and hiccough are frequently present. In general the disease results from improper nourishment and inflammation. Gun- shot wounds, fractures, dislocations, simple punctures, concentrated acids, poisons, stimulating applications, infiltration of acrid fluids into the cellu- lar membrane, lightning, burns, long-continued pressure, intense cold, all operate, more or less, through the medium of inflammation, in producing gan- grene and mortification. There are also some specific causes of gangrene, which will afterwards be noticed. Mortification has been divided into acute and chronic, the former compris- ing the humid, inflammatory or traumatic; the latter, the dry and idiopathic. Generally speaking the acute is humid, and the chronic, dry—the fluids being retained in the former, and gradually parted with in the latter; how- ever, this is not invariably the case. Acute or Moist Mortification.—In the acute form of mortification there is always considerable swelling, which has been preceded by those symptoms which have already been mentioned as belonging to inflammation. Then the temperature of the parts diminishes, a slight blueness of surface attracts attention, and the skin may be covered with vesicles; there also may be a species of crepitus felt by pressing upon the parts. At this stage the general DRY MORTIFICATION.—TREATMENT OF GANGEENE. 143 condition of the patient suffers, the countenance expresses the death of a portion of the body; hiccough, delirium, and death supervene. This is the ordinary acute gangrene, but there must be some distinction made between this and true traumatic gangrene, which results from severe railway and steamboat accidents. In these the parts are so crushed and the textures so pulpy that they die almost immediately, and not only does the implicated part suffer, but the gangrene spreads with alarming rapidity. To wait in such cases for the line of demarcation would certainly consign the patient to the grave. Every moment is precious, both to the surgeon and patient, and immediate amputation must be performed. Delay is death. Prompt action may be life. In this place, also, let me impress one truth upon my readers. In amputating in traumatic gangrene always leave a considerable space of healthy tissue between the gangrenous parts and the site of the amputation, because it is remarkable with what facility gangrene will attack the stump after the removal of the dead parts. Dry Mortification—or as it has been termed, senile gangrene—is generally seen in advanced years, and in many cases is the result of deficient circu- lation. This variety of gangrene may commence with a burning sensation, which continues for a time, and ceases suddenly; or without any well-marked symptoms of inflammation, the toes and feet become cold, discolored, and shrivelled, and finally converted into a hard dry mass, insensible, and of a purple hue. Frequently there is no sloughing, and each part retains its original form, the skin remains entire, the nails adhere to the toes, and the part becomes hard and cold, and is perfectly free from fetor. Some- times, however, the fetid odor and sloughing are considerable, and attended by severe constitutional symptoms, although these are of rather rare occur- I'êIl Cé. It is frequently very difficult to assign any cause for this variety of the disease. In some instances, however, it can be traced to diseased rye. During very moist seasons Secole cornutum, ergot, cockspur (a medicine whose excellent qualities in many diseases is fully appreciated by the practitioner), is generated in considerable quantities, constituting a disease in which the grains of rye become larger, firmer, and of a much darker color than natu- ral; the diseased being mixed with the sound grain, is often eaten by fami- lies, and for a time without producing any detrimental effect, but finally dry mortification makes its appearance, and the population of entire dis- tricts become afflicted with the disease. Such aggravated forms of gangrene, arising from the continued use of secale cornutum, is of much more frequent occurrence in European coun- tries, particularly France, than in North America. “The patients who have suffered from it have experienced pain and heat with swelling, generally in the lower limbs, though occasionally in the upper. These symptoms abating, the parts became cold, insensible, and discolored, and were gradually separated from the body. The disease attacked patients of both sexes and every age; did not appear to be infec- tious, and was frequently fatal.” Canstatt, however, gives a much fuller description of gangrene caused by the internal use of secale.f Treatment.—The medicines best adapted to the treatment of gangrene are: Ars., chin., crot., lach., sec. cor., silic., acon., bell, carbo veg., euphorb., hell., hyos., Sabina, squill., sulph. ! In threatened traumatic gangrene, when there is violent synochal fever, * Liston's Elements of Surgery, p. 40. f Hartmann's Chronic Diseases, vol. ii., p. 152. 144 A SYSTEM OF SURGERY. of course aconite should be prescribed, and calendula in solution applied to the wounded part; or armica diluted may be employed locally if there be but little solution of continuity. The former medicine has been highly recommended as a vulnerary, and it has been used with great success in Europe in all kinds of lacerated wounds; it has a powerful action over sup- puration and its consequences; indeed, its beneficial influence in wounds of all descriptions is remarkable. This subject, however, will be again alluded to when treating of wounds. It may be useful also, in this affection, to wrap the feet or other parts affected in carded wool. This practice was recommended by Sir B. Brodie in his Lectures on Mortification, and is mentioned by Mr. S. Cooper in his First Lines. There have been several cases treated successfully by this method,” and no doubt it will assist in maintaining the warmth of the part, while by the proper administration of medicine the cause upon which the disease depends may be removed. . The following medicines have also been recommended: Chinin., merc., mur. ac., plumb., Sabin., Scill., Sulph. ac. - The American Columbo (Frasera carolinensis) is stated by Rafinesque to have cured widespread gangrene after bark had failed.i. - Dispascus sylvestris is used by Mr. Beullard, in certain cases of gangrene with great satisfaction. He says: “a. The wound is of some days' standing, has a ragged, irregular, anfrac- tuous, black appearance; exhales the well-known and repulsive odor of gangrene; this gangrene sometimes extends to quite a depth. With bistoury or curved scissors I remove as much of the mortified tissues as I can, taking care not to reach the quick, thus avoiding both pain and hamorrhage; each one must judge for himself if bridles (of sound tissue) may be spared. I wash the wound with chlorinated water, in the proportion of one to ten, then I fill it with the leaves cut very fine, so that all parts shall be fully in contact therewith. I then cover with a compress, and all is kept in place by a few turns of a roller. Here (he writes in France) I dress but once in twenty-four hours; under the tropics I think it would be necessary to renew the dressing night and morning. Under the influence of this simple topical application, in twenty-four or forty-eight hours, sometimes more (one must not be discouraged—success is certain), the gamgrenous becomes a simple wound; the black color has disappeared, a healthy suppuration is set up, and the wound begins to granulate. “b. The part has been contused, the skin remaining entire; sooner or later gangrene sets in ; it invades the skin or the subjacent parts to a con- siderable depth. In this case I dissect away the mortified parts, taking care, as above, to leave a slight layer over the quick to avoid pain and haº- morrhage. This cavity is washed with the chlorinated water, dressed with the dispascus, as above, and with the same result.” Dr. Blakelyi reports five cases of traumatic gangrene treated very success- fully by the internal administration of arsenic, lachesis, and iodine, with the local application of calendula solution. The efficiency of this method of treatment is remarkable. The following interesting case will show the method I employ: The patient was a deck-hand upon a ferry-boat, and accidentally caught his foot between the wharf and boat as it was coming into the dock. The contusion and laceration were very severe. Dr. Bayliss, of Astoria, was called to see the case. Traumatic gangrene appearing on the second day he sent him to the hospital. This was on Sunday, the first day of October. * United States Medical and Surgical J ournal, vol. ii., p. 318. # Hale's New Remedies, p. 379. † American Hom. Observer, vol. iii., p. 233. HOSPITAL GANGRENE. 145 When I saw him that afternoon, his foot presented all the appearances be- longing to acute traumatic gangrene, which extended from the toes to about the base of the first row of phalanges; the color was purple; the odor was that peculiar to moist gangrene; there oozed from the lacerated Surfaces an offensive sanies; the sensation in the forepart of the foot was gone; and there was a reddish blush ascending over the instep, which indicated a rapid spread of the disease. The next morning I amputated the leg at its lower third, making the circular operation, and forming a very large flap. It must be borne in mind, that the ankle and heel presented no appearance of gangrene. On the next day the patient was too well. I told him so. On the second day, when I saw him, the odor, the discoloration, the oozing, pointed to the rather discour- aging fact that the disease had attacked the stump. I cut open all the sutures, turned the flap backward, and ordered the part to be washed every three hours with water, and then carefully injected with carbolated glycerin. A compress wet with the solution was applied, and arsenicum was given every half hour. The effect of the treatment was magical. The gangrene was entirely arrested, and I was enabled to cut away the dead portions of the flap with scissors. The man made a good recovery. - In the treatment of gangrene, so soon as the line of separation begins to form, the parts should be thoroughly wrapped in a disinfecting dressing. Billroth covers the parts with lint saturated with chlorine water. I have employed this method with success, but thoroughly sprinkling the surface with iodoform or mineral earth is better. The acetate of alumina used as follows is said to be most excellent: B. Aluminis, . © & e s * ſº ge ſº . 3V. Plumbi acetatis, tº te • º tº . 3.j. Aquae, e e º & tº gº g § § . fšxiij —M. Fiat lotio. Applied three times a day.” Dr. Younghusband testifies to the especial value of arsenic in gangrene. In his cases he used the ulmus as a poultice, made with yeast.f Dr. John C. Morgan highly extols the topical application of white sugar to the gangrenous parts; also, small quantities of glycerin.i. Hospital Gangrene—Hospital Sore—Sloughing Ulcer—Sloughing Phage- dana.-There is a variety of gangrene known by the above names, which is often so intractable, and spreads with such rapidity, that even a tendency towards its appearance should cause great solicitude. The disease no doubt was known from a remote date, Avicenna, Paulus, and others having written concerning it. However, it is said by Dr. Gross that Poicteau, of Lyons, in 1783, was the first who generalized the disease, and gave a lucid and dis- tinct account of its symptoms and treatment. Since then, it has been noticed and commented upon by many surgical writers. Its peculiarity is, that it generally appears in hospitals, or in apartments where many persons are crowded together; where there is not proper venti- lation; where there is abundance of filth and a lack of pure fresh water; where the drainage is imperfect, and there is want of cleanliness in dressing wounds, ulcers, or abscesses. It is stated that few hospitals grow “old” without the appearance, in some form, and at certain periods of time, of this dreaded malady. It may follow scurvy, and may prevail on shipboard. It existed to an extreme degree on board the ship “Prince of Wales" on her homeward passage from Martinique. There was a serious epidemic of this disease in Guy's Hospital in the year 1849. * Naphey's Surgical Therapeutics, p. 103. + American Homoeopathic Observer, 1868. † Transactions American Institute of Homoeopathy, 1869, p. 115. I0 146 A SYSTEM OF SURGERY. . Thanks to the better systems of drainage, sewerage, ventilation, and hy- giene in their varied departments, which are now introduced into hospitals, this malady, at one time the scourge of charitable institutions for the sick, is less frequent in its appearance and in its intensity. Hospital gangrene may be also produced by direct contact, and appears either on the surface without any previous abrasion—which, however, is rare —or it attacks a wound or ulcer. ... In its one form, and when on the surface, a pustule is developed, or a vesicle makes its appearance, which bursts and discloses a dark and purplish slough ; this slough is accompanied with a thin, ichorous, and extremely offensive discharge, and separates rapidly, leaving, however, a jagged, ill- conditioned sore, spreading speedily, with everted edges. The surrounding skin is purple or mottled in appearance. The ulceration extends with great rapidity, and has been denominated the black phagedæna. During this time, and even, in some cases, before the appearance of the sore, the constitutional symptoms are alarming; assuming the typhoid type, with great prostration and tendency to collapse. Sometimes, and in rare cases, hospital-erysipelas may coexist with hospital gangrene, making a grave complication. When the tendency to this affection assumes an epidemic form, the matter secreted is intensely contagious and is liable to infect nurses and others attending the patients. The other inmates of the hospital are all liable to be attacked; the slightest abrasion of the surface, the scratch of a pin, or rubbing with the finger-nail sufficing to produce a rapid development of the affection. When sloughing phagedæna attacks a wounded surface, the symptoms in general are not so pronounced at the onset. The patient may have been ailing, irritable, feverish, and thirsty, with anorexia. Upon examination of the wound, it will be observed to be unhealthy, and gradually becoming very painful. The discharge, which was once healthy, diminishes in quan- tity and deteriorates in quality. The surface of the wound is of a grayish or dirty white, with rather a spongy areola, which crepitates. Its base is lardaceous, and from its color has received the name of gray pultaceous phagedæna. Sloughs form and are cast away, the degeneration appearing principally at the edges of the ulcer. Sometimes the sloughing parts are infiltrated throughout with putrid extravasation. The pulse rarely shows less than one hundred and thirty beats to the minute; the patient becomes debilitated, and, in some instances, is troubled with profuse perspiration, or with colliquative diarrhoea. - The exact cause of this affection is unknown. It may be propagated by an infected sponge, or by dirty instruments. It does not either find its way universally in over-crowded hospitals, nor are the poorly nourished always its subjects. There is some occult agency in all probability (a bacterial one) which is necessary to the production of the disease. The disease may be epidemic or endemic, and, occasionally, sporadic cases occur. The disease appears to have no preference for sex, age, or tempera- ment, climate or season, although, no doubt, in excessively hot weather its course is more rapid and its effects upon the constitution much more severe. In its more violent forms, or where the black phagedæna attacks the wounded, which it does as well as appearing upon unbroken surfaces, it spares no tissue, and if unchecked, rapidly causes a fatal termination. In both varie- ties the lymphatic glands in the neighborhood of the sore are affected, and the joints may suffer from purulent formation. Treatment.—The first thing to be attended to is the immediate removal of the patient from the ward, leaving every article of clothing behind. The sloughs are then to be cut away; and the parts washed every hour or two with a solution of the bichloride of mercury (1 to 2000). There are some medicines which appear to exercise over this malady a PREVENTION BY THE ANTISEPTIC METHOD–TUM.O.R.S. 147 powerful influence. The first of these is arsenic. The well-known patho- genetic effects of this drug need not be repeated here to indicate its applica- bility. It should be given, according to my belief, in the lowest potencies; and, indeed, sometimes Fowler's solution appears to be the preferable prep- aration. Other medicines are crotalus, lachesis, kreasote, carbo veg., secale, muriatic acid, nitric acid, rhus tox. Upon referring to the Materia Medica, the specific uses of these drugs can be found, but space forbids further notice. In this fearful disease local measures must be employed at once, without hesitation and without fear, and the best that can be applied is chloride of zinc, which should be used in Saturated solution and as an escharotic; it has, besides its caustic properties, the advantage of great antiseptic virtues, and, therefore, appears to be doubly applicable to the disease. After the application of caustic, the free use of carbolic acid paste is the best dressing; which should be changed frequently, and the sore washed thoroughly with tepid water and soap. All bandages and dressings used should be changed frequently, and the patient allowed a certain amount of stimulus during each day. The inhalation of oxygen gas also, if practicable, should be em- ployed, and the strictest attention paid to free ventilation and appropriate diet. With reference to local applications, the baptisea poultice is excellent, as is also that made of charcoal. The free use of iodoform is also useful. Prevention by the Antiseptic Method.-Von Nussbaum + relates the pre- ventive power of Lister's antiseptic plan of dressing in the Munich State Hospital, where hospital gangrene at once ceased, although at the period of its use, eighty per cent. of the surgical patients had been affected. He holds that the secret of its great success lay in a pedantic exactness of its mode of application. Not even for a second should the wound be unprotected by the carbolic acid spray. Other methods of dressing had been employed without result. He states that during the prevalence of the disease, the appearance of gangrene the following morning could be foretold by the rise of the evening temperature to 104.8° or 105.8°. The actual cautery was found most efficacious in staying the course of the gangrene, and he noticed that a fall in temperature indicated a favorable change. He holds that hos- pital gangrene is strictly a local affection.i. § For accurate details in regard to the antiseptic method, the reader is re- ferred to Dr. Thompson's chapter on antiseptic dressings. CHAPTER IX. TUMORS. INTRODUCTORY REMARKs — CLASSIFICATION – DIAGNoSIs—CHARACTERISTICS. HISTO- LoGICAL FORMATION: A. INNOCENT TUMoRs—TYPES OF HIGHER TISSUES AND TYPES OF CONNECTIVE TISSUES-TYPES OF EPITHELIAL TISSUE. B. SARCOMATA; TYPES OF EMBRYONIC TISSUES-CONNECTIVE TISSUE. C. CARCINOMATA—DIFFERENT WARI- ETIES of CANCER. D. CYSTIC TUMoRS AND THEIR VARIETIES-CYSTO-SARCOMA. SINCE the time Abernethy attempted a classification of the varied tumors which grow in and upon the body, there has been the widest difference of opinion among pathologists concerning the divisions and subdivisions * Monthly Abs. of Med. Science, March, 1876. t Brit. and For. Med.-Chir. Rev., January, 1876. 148 A SYSTEM OF SURGERY. of these neoplasms, which indeed appears more confused since the intro- duction of the microscope than settled by its wonderful powers. The fact is, as the microscope presents actual appearances on its field; as there are in the world comparatively few experts in microscopy; as the specimens exam- ined are taken at varied stages of development, each specialist endeavors in his own way to satisfactorily account for the results he obtains, which may be very different at different times and under varying circumstances. It has often struck me that, notwithstanding a great deal of care in ob- taining and preparing microscopic sections, a slight alteration in such preparation (in many cases unavoidable), which would be inappreciable to our unaided senses, would render essentially different appearances in that new world of life revealed to us by powerful lenses; a film, a fibre, a little bit of difference in the age of the specimen, a minimum of dissimilarity, unobservable to our ordinary vision, must necessarily be magnified to such proportions that attention is necessarily directed thereto, and so errors may creep into descriptions and be rapidly promulgated by those who follow in the lead of this or that pathologist. This may, in part, at least, explain why opinions on these subjects are ever changing, and are ever likely to change. Schüppel’s “giant cells,” so loudly spoken of; Lostoffer's corpuscles, which for a time set the syphilographers by the ears; and the “typical cancer cell,” that was said to belong to the cancer discharges, and which turned the heads of pathologists and surgeons, are monuments for our contemplation, on which the microscopist of the present day may read, “Cave quid dicis, quando, et cui.” As a means of diagnosis between innocent and malignant tumors (I mean, of course, primary diagnosis), the microscope is of little practical wSe; after their removal from the body their characters and peculiarities are better determined. How much better would be this condition vice versa. I am therefore disposed to agree with Mr. Savage * in the introduction to the third edition of his work, when he says: “The question of malignancy is not to be determined histologically,” and further when he writes: “In regard to the question of malignancy, attended or not by recurrens in loco e0dem alioque, the experienced surgeon decides without much reference to histology, and is generally right where the pure histologist is generally wrong. The greatest benignity and the greatest malignancy may be united in the Sarcomatous group. “I can assure you that two sarcomata of the most similar histological qualities may differ entirely in course’ (Billroth).” Of all the classifications of tumors which have been attempted, I think that of Virchow, while it covers the greatest variety of species, and shows a vast amount of experience and research, is the most unsatisfactory to the student, on ac- count of the uncertainty of its expressions and its necessarily numerous dis- crepancies, for instance, his understanding of the terms “homology” and “heterology.” According to recent investigators of the English and French schools, these terms have a definite and distinctive meaning: the former applying to those tumors which in their structure bear a strong resemblance to the normal tissues of the human body; the latter, “heterologous,” being applied to those growths which are unlike any of these tissues; of course it is understood healthy and fully formed structures. Thus Holmes f writes in his classification: “There is one class in which the substance of the tumor has an exact anatomical resemblance to some tissue of the body (homologous tumors) . . . . There is another class of tumors which do not present any resemblance to the normal tissues, and which are therefore described as heterologous.” Sir James Paget i coincides in this view; he says: “The in- * The Surgery, Surgical Pathology, and Surgical Anatomy of the Female Pelvic Organs, London, 1876. + Principles and Practice of Surgery, 1876, p. 348. f Lectures on Surgical Pathology, English ed., pp. 382–387. TUMORS. 149 timate structure of malignant tumors is usually not like that of any of the fully developed natural parts of the body. . . . . Innocent tumors have not a structure widely different from that of a natural tissue.” It is, however, unnecessary to multiply quotations. In Virchow's arrangement these terms possess merely a relative meaning, and refer to the character of the tissue from which the growth springs. It will be seen how confusing and uncer- tain this must be, when a tumor presenting the 8ame structural elements may be homologous in one part of the body and heterologous in another. Besides this, even Virchow himself is in doubt whether in the majority of instances his cancerous growths are not heterologous; and Green,” even while accepting the classification of Virchow, says: “Heterology, however, is not limited to the production of a tissue which is dissimilar to that from which it origi- nates; a tumor is said to be heterologous also, when it differs from the tissue in which it is situated, and this may occur without its being a direct pro- duct of the latter. It is heterology in this sense that is so characteristic of malignant growths.” Another obstacle encountered in describing certain tumors, is the dif- ferent nomenclature adopted by different pathologists. Thus the “myeloid tumor" of Sir James Paget is “the giant-celled sarcoma” of Virchow; “the recurrent fibroid” of Paget is the “spindle-celled sarcoma' of the German pathologists, or the fibro-plastic of Lebert; “the sero-cystic sarcomata” of Brodie include “the glandular proliferous cysts’ of Paget, to which we have added a very great variety of sarcomata, as mucous sarcoma, net-celled sar- coma, granulation Sarcoma, alveolar Sarcoma, pigmentary sarcoma, round- celled sarcoma, and so on ad infinitum. If we add to this the difference in the acceptation of the term “sarcoma,” another difficulty will be presented. The term may mean (and was for a time so understood) “fleshy;” then, again, it was used to express the myoma or muscular formations; afterward, a sarcoma was a species of growth com- posed of an extraordinary preponderance of cell-elements, and deficiency of alveolar substance; and, finally, the Germans especially apply it “to the series of connective substances which are distinguished from the tumors formed of the connective tissues, by the preponderating development of cell- element.” By sarcoma should be understood a matrix or stroma, intermediate and surrounding cells of varied character, the precise character of the cell-element giving the peculiarity to the formation, hence the diversity of names. It is from the great variety of these elements that Paget objects to the term, for he says: “After a careful consideration of the matter, we are inclined to think that the group is too vague, and is made to embrace tumors which are too diverse, both in color, consistence, vascularity, structure, mode of growth, seat, course, and effects on the patient, to be included under one common term. We are not prepared, therefore, to employ the term sarcoma in the classification of tumors, for we believe that the morbid growths which have been ranked under that name may be more satisfactorily and precisely arranged under one or other of the heads employed in these lectures.” Therefore, on account of the uncertainties at present realized, and those which, no doubt, are yet to come, and in view of the great variety of terms here and there introduced by the histologian, we shall attempt to classify tumors somewhat in accordance with their clinical characteristics, and to describe their structure also histologically, and may hope for a future when the many discrepancies which now overshadow the magnificent classification of Virchow and Billroth, will be removed, and a more simple arrangement of these growths, at least for the student and practical surgeon, be arrived at. * Pathology and Morbid Anatomy, Philadelphia, 1884, p. 117. 150 A SYSTEM OF SURGERY. The fact is this, at least so far as I am able to get at it, the nearer a tumor approaches in its structure to the perfectly developed formations of the human body, in other words, the nearer its homology, the more likely it is to be innocent; the greater the departure from this standard, in other words, the nearer the resemblance to imperfectly formed, embryonic, or abnormal struc- ture, the more certain is the growth to be malignant. * We may therefore say that a tumor is a new growth, which is an addition to the normal tissues of the body—not merely an increase in structure, which would be a hypertrophy—“with,” as Mr. Paget says, “appearance of inherent power, irrespective of the growing or maintenance of the rest of the body, discordant with the normal type and with no seeming purpose.” The exudations of inflammatory processes may be mistaken for tumors; but these generally disappear as soon as inflammation subsides; or, if they remain they constantly tend to assimilate themselves to healthy tissue. Tumors, on the contrary, continue to grow more or less steadily, with or without inflammatory action, and deviate more and more from the normal type. In rare instances they may be confounded with aneurisms and ab- scesses; but the history of the case, a careful study of the symptoms, or, if these fail, a cautious use of the exploring needle or the aspirator, will ren- der the diagnosis more certain. We should, if we are prepared to be pre- cise, exclude from the classification all retention cysts, extravasations, tubercle, gummata, farcy buds, and effusions. Clinical Classification.—Classifying tumors, then, clinically, we may say that there are two great typical divisions, viz., innocent and malignant (car- cinoma), with a third, or intermediate variety, which is known as the semi- malignant (sarcoma), which latter, under peculiar circumstances, partake partly of the nature of both. As a rule, and with an understanding of the fact that one division may overlap the other:* Innocent tumors may be distinguished by the following characteristics: 1. They are harmless in reference to surrounding structures. 2. With the exception of recurring fibroids, they are not liable to return after proper extirpation. 3. In texture they resemble the normal tissues of the body. 4. As a rule, they are unattended by any marked constitutional disturb- 8,IlC62. The following diagnostic marks characterize malignant growths: 1. In microscopic structure they completely differ from normal and fully developed tissues of the body. “Many cells resemble bland or epi- thelial cells, but can be distinguished from them by a practical eye. The eells are grouped or heaped, one upon another, without any such definite arrangement as we find in other tissues.” (Paget.) 2. They are disposed first to soften, then to ulcerate; and there is great tendency to infiltration and destruction of the surrounding matrix; this in- filtration may be either slow or rapid. - 3. They do not enlarge continuously, but become irregular and lobulated with offshoots; innocent tumors, on the contrary, are generally round and grow in one volume. - 4. They are marked by persistent and often fatal haemorrhage. 5. The fetor is always easily recognized, and is sometimes intolerable. 6. They have a tendency to invade all surrounding structures, to produce secondary deposits, and to sympathetically involve distant organs. 7. They are liable to return after extirpation. 8. They produce a marked constitutional cachexia. * A very excellent chart, showing at a glance the recent classification of tumors, has been prepared by Dr. G. F. Shears, of Chicago. I would commend its use to the student and busy practitioner. - TUMORS. 151 To make the differences still more plain, I have prepared the following dif- ferential diagnosis, premising, however, that there are certain forms of fibroid tumor which may and do appear after removal (the recurrent fibroid), and that a fungoid condition of a fibroid may exist, in which hamorrhage is profuse, and often occurs with but slight irritation, and that enchondro- matous formations may also recur. - - DIFFERENTIAL DIAGNOSIS BETWEEN INNOCENT AND MALIGNANT TUMIORS. * INNOCENT. MALIGNANT, 1. Harmless with reference to the surround- 1. The tumor is apt to destroy or involve sur- ing structures. rounding structures. 2. Texture bears some resemblance to certain 2. Texture differs from the normal structure of the surrounding structures. of the human body. 3. Non-liability to return (excepting recur- 3. Great disposition to return. rent fibroid). 4. Absence of haemorrhage. 4. Liability to profuse bleeding. 5. Little disposition to soften. 5. Great tendency to soften. 6. Not much tendency to ulcerate. • 6. Great tendency to ulceration. . 7. Rarely accompanied by offensive dis- 7. Very offensive, ichorous, or bloody dis- charges. charge. 8. Non-infiltration of surrounding struc- 8. Infiltration of the part on which they grow, tures. which is often entirely transformed. Innocent and malignant growths may coexist in separate tissues in the same individual; and the innocent may become malignant, if a cancerous cachexia is present in any part of the body. Paget describes varieties of fibrous and cartilaginous tumors, which returned after extirpation, caused ulceration and sloughing, involved neighboring tissues and distant organs, and finally terminated in death. He also states that in children of can- cerous parents, tumors apparently innocent in structure are functionally malignant. Tumors may occur in any part of the body. As a rule, malignant growths attack most frequently the glandular organs, while benign tumors generally affect the skin, cellulo-adipose tissue, nose, uterus, and ovary. Form.—In form they vary greatly; they may be smooth, lobular, round, conical, uneven, etc. Tumors involving lymphatics are generally nodular and irregular; encysted and fatty tumors, smooth and globular. Situation may modify the shape, especially if the tumor be bound down by fascia or muscular tissue. - Volume.—In volume they range from the size of a millet-seed to a bulk greater than the patient's body. Color.—The color varies with the number of blood vessels contained in the growth, and also with the amount of inflammatory action in the tumor itself, or in the superimposed tissue. Naevus is generally purple; fatty tumors, yellow; fibrous, whitish; cartilaginous, white and glistening. Consistence.—In regard to consistence, tumors may be hard, soft, or semi- solid; fibroid and scirrhus are hard ; cystic, soft; and the fatty tumor has a “feel” between fibroid and cystic. Occasionally the position of a tumor and its confinement by fascia gives it a sense of pulsation, which might lead to the supposition of aneurism. Mobility.—The mobility of a tumor depends upon its situation and the character of the tumor itself. Some, like the fatty tumors, are freely movable; others, like the exostoses, are always firmly attached. Consist- ence and mobility however can give us but little idea of the true character of the tumor. Metastasis.-Cohnheim has lately endeavored to settle the question as to the metastasis of tumors by actual experiment, which consisted “in detach- ing a small piece of periosteum from the tibia, and then introducing it into 152 - A SYSTEM OF SURGERY. the jugular vein. At first he found considerable difficulty from the ordinary mechanical and surgical results of such an operation, but, by using Esmarch's method, combined with all antiseptic precautions, he succeeded, and the animals lived quite well. They were killed after various periods, by bleed- ing. In those killed from the third to the fifth day, only embolized perios- teum was found; in those from the tenth to the sixteenth day, a resistant hard place on the lung parenchyma existed; in those after the twentieth day, the results were quite negative. Microscopically examined, the masses found between the tenth and sixteenth days were truly growths of the periosteum, with commencing formation of bone; but in cases where more time had elapsed, the new growth was seen to be undergoing absorption, and after a month had entirely disappeared. He considers this disappear- ance to be due to that physiological capacity of the organism which shows itself in the removal of callus, and he suggests that the real factor in the generalization of new formations is the abolition of this function. So long as the constitutional condition of the individual maintains this ability, tumors remain merely local affections, although fragments are being con- stantly detached and carried about by the circulation to distant parts of the body. According to this view, the inoculation of healthy animals with cancerous matter would remain without effect, as we know to be the case. The explanation is hypothetical, but it is at least as comprehensible as the malignity of certain growths.” Growth.--The first formation that is noticed in the growth of a tumor is a minute mass of protoplasm, consisting of a small round cell with an irregular nucleus, the product of the connective tissue corpuscles—whether however it is the stable or the mobile cells that are the factors in the pro- duction of this protoplasm, or, whether both assist in the formation, has not yet been determined. This protoplasm bears an exact resemblance to the embryonic cell, and at this period of development, it is impossible to decide whether the neoplasm is to be innocent or malignant; if, as the tumor grows, it takes upon itself the nature of fat, fibre, flesh, or other healthy adult tissue, the growth, without doubt, will be innocent; if, on the ..other hand, a proliferation of similar embryonic cells takes place, if they do not proceed to any complete formation, if they are irregular broken- down masses of embryonic tissue largely supplied with bloodvessels, then the tumor will assume one of the many forms of carcinoma. If there is an effort at organization, and here and there throughout the mass are the evidences of a higher development, then the growth may be set down as a sarcoma. With these remarks, and with the previous understanding of the terms “homology” and “heterology,” the following histological classification may be seen to correspond, and I think it is so simple that it may readily be understood. Cystic tumors will be considered by themselves, as (except in certain in- stances where solid tumors become cystic through geodes in their substance, as found in the uterus, ovary, and breast) they are generally either caused by retention of secretion, or extravasation. HISTOLOGICAL FORMATION OF TUMoRs. A. Homologous or Innocent Tumors. I. Type of forms of healthy adult tissue—of the higher class. Type of muscle—myomata. Type of nerve—neuromata. Type of bloodvessel—angeiomata. * London Medical Record, October 15th, 1877. TUMORS. 153 II. Type of fully developed connective tissue. Type of adipose—lipomata. Type of fibrous—fibromata. Type of mucous—myxomata. Type of cartilage—enchondromata. Type of bone—osteomata. Type of lymphatics—lymphomata. III. Type of fully developed epithelial tissue. Type of skin and mucous membrane—papilloma and horny tumors. Type of gland—adenomata. B. The Sarcomata (Semi-malignant). Type of embryonic tissue. (a.) Spindle-celled sarcoma (recurrent fibroid.) (b.) Giant-celled sarcoma (myeloid). (c.) Round-celled sarcoma (glioma). (d.) Lympho-sarcoma (alveolar). Connective tissue. C. The Carcinomata. Type of the embryonic tissues, tendency to retrograde metamorphosis rather than higher development. ſ (a.) Scirrhus. (b.) Encephaloid. (c.) Epithelioma. Epithelial tissue. { (d.) Melanotic. (e.) Colloid. (f) Osteoid. U (g.) Willous. D. Cystic Tumors. (a.) Cysts from expansion of spaces in the connective tissue—serous cysts. (b.) Independent cysts—in bone and cartilage. (c.) Sanguineous cyst—from rupture of a bloodvessel. (d.) Exudation cysts. (e.) Congenital cysts. (f) Synovial cysts. (g) Mucoid cysts. (h.) Colloid cysts. (i.) Compound or proliferous cysts—cysto-sarcoma. (k.) Retention cysts—sebaceous cysts. A description of these neoplasms will now be given in detail. A. Innocent Tumors (Homologous). I. Type of healthy adult tissue of the higher class. Type of muscle—myomata (a). Type of nerve—neuromata (b). Type of bloodvessel—angeiomata (c). 154 A SYSTEM OF SURGERY. (a.) Myoma.-A tumor composed of true striated muscular fibre is so very rare, that its existence is denied by many pathologists,” while others, as Green, f allow them to have existed in a few cases, but as such, declare that the growths were congenital. Tumors, however, are frequently found which possess—often in considerable quantity—striped muscular fibre. These neoplasms are generally located in the testicle and ovary, and being fre- Quently associated with the remnants of other tissue, such as cartilage, hair, bone, etc., should be, according to the strict histological classification, placed under the second division, or that variety arising from the fully-developed connective tissue series. Smooth muscular tumors are often associated with fibrous material, and are chiefly developed in the uterus, and it is a matter of surprise how well the body tolerates the growth of these neoplasms; the size they attain is sometimes enormous; the age at which they appear is about the adult period, and colored women are peculiarly liable to them. In some instances, there is a large association of bloodvessels, causing the profuse bleedings which are characteristic, and from which they have been termed myo-angeioma. In the majority of instances, the fibrous connective tissue is predominant (Fig. 77), and from the specimens which I have had examined, I am disposed to believe, that the true nature of these tumors is rather that of myofibroma, than true myoma. The diagnosis is readily made out, and the treatment is by the knife. Hysterectomy is now per- formed with considerable success, but the operation is dangerous in the extreme, and in inexperienced hands is sure to prove fatal. Batty’s opera- tion, or that of Tait, is more readily performed, and offers much greater chances of success. I have known these myo-fibroma gradually disappear after the removal of the ovaries and tubes. In my last six cases I have lost but one, the other five not only recovered from the operations, but the haemorrhage ceased, the tumors all materially diminished in size, and the patients were restored to usefulness. (b.) Neuroma.-The neuromatous tumor “is also embraced under the head of fibroma; in such growth, according to Drs. Paget and More, it is impossible to distinguish the fibrous neuroma from that composed of nerve elements.” It exists singly, or there may be hundreds in different parts of the body. In color, neuroma are grayish or yellowish-white, and are Said to ariseſ from a deposit of lymph around a single nerve fasciculus, which becomes organized, while other deposits take place, until a fibrous growth results. These tumors are sometimes excessively painful when handled, but at others are not so; Sometimes the pain shoots along the course of the nerves, and at others >\S$$$3/224 there is coldness of the part, and Section of Fi Sometimes a great loss of sensi- bility. - True neuromatous tumors are very rare, the ordinary variety nearly resemble the cerebro-spinal nerves from which they often grow. These growths, however, must not be confounded with the “Painful sub- cutaneous tumor of Mr. Wood.” This is a peculiar growth of fibrous struc- º| & | ( :| º: º | § § f W \ l ºW § ſº * Heitzman: Microscopical Morphology of the Animal Body. New York, 1883, p. 517. f Pathology and Morbid Anatomy. New York, 1884, p. 162. f Holmes's System of Surgery, vol. i., p. 527. ANGEIOMA, 155 ture situated underneath the skin, occurring more frequently in women than in men, varying in size from a pea to that of a chestnut. These tumors are round, and rise a little above the surrounding integument, and are most intensely painful, giving rise to hysterical symptoms of the most violent character; they are generally incased in a capsule of moderate firmness, but are not imbedded between the fasciculi of nerves, or beneath the neuri- lemma; hence they must not be confounded with the neuroma just men- tioned. On section, this variety of fibroid tumor presents fibres, matted together and interlaced around a nerve trunk Sometimes there is a con- centric arrangement of fibres, especially if treated with nitric acid. Treatment.—Of the medicines internally administered, those which have been productive of most good in my hands are undoubtedly conium and calcarea. However, of late years, I have generally resorted to operative measures. The internal administration of the muriate of ammonia has been productive of good, and to relieve pain the hypodermic injection of a few drops of a four per cent. solution of cocaine has been very efficacious. The application of veratrine ointment along the course of the nerve is often of great service. (c.) Angeioma.-Vascular tumors, as their name implies, are those com- posed of bloodvessels. They are divided into three varieties by Mr. Holmes : * capillary, arterial, and venous. In the first the tumor consists of an enlargement of both venous and arterial capillaries; in the second, the arterial twigs predominate; in the third, the venous. * - Vascular tumors are found generally in the subcutaneous tissue, and then are called naevi. When they are large and composed chiefly of arteries, they receive the name cavermous angeioma, and, if large, they become anew- ºrisms by anastomosis. This variety of tumor varies in size; it is soft and compressible, often distinctly pulsating, is irregular in shape, and if very well supplied with bloodvessels gives a distinct bruit. As it grows the skin may be so overdistended that imperfect nutrition results, and ulcera- tion opens the tumor, from which there is often profuse haemorrhage. On the scalp, in the lip, and about the face, they are often found. I have seen them on the cheek, the forehead, and even on the back. The simple angei- oma is generally a mark. The diagnosis of this variety of tumor is usually easy, although Mr. Holmes mentions a case in which a pulsating cancer of the skull (I suppose a fungus hamatodes) was mistaken for aneurism by anastomosis; the patient was operated upon and nearly lost his life on the table. Sometimes the tumors may be dissected out. The more complete treatment will be found in the chapter on Diseases of the Capillaries. I may mention here, however, that in the treatment of these tumors, even when there is consid- erable pulsation, I have succeeded well by injecting from forty to sixty drops of the fluid extract of ergot into the tumor, as recommended by Dr. Hammond. In two instances the injection was repeated after a lapse of eight days. Innocent Tumors (Homologous). II. Type of fully developed connective tissue, known as the connective tissue series. Type of adipose—lipomata (a). Type of fibrous—fibromata (b). Type of mucous—myxomata (c). Type of cartilaginous—enchondromata (d). Type of Osseous—osteomata (6). Type of lymphatics—lymphomata (f). * System of Surgery, vol. i., p. 542. 156 A SYSTEM OF SURGERY. (a.) Lipomata—Steatomata—Fatty Tumor.—These tumors are either ses- sile, “continuous,” or pedunculated, and are probably the fairest example of homologous tumors. They grow from either superficial or deep-seated fat, and are found wherever adipose tissue is deposited in the body. They may occur at any period of life, and may remain for a considerable time without growing, until from sudden appreciable or some inappreciable cause they increase rapidly in size. They are not dangerous only so far as the pressure symptoms are concerned, and do not return after extirpation. When the fatty tumor is sessile or pedunculated it is encapsuled, when it is continuous or appears as an outgrowth it is not, as a rule, encapsuled. I have only seen this latter variety on the nape of the neck; it appears like an agglomeration of fat-corpuscles, from the size of a small pea to that of a bean, held loosely together with a delicate connective tissue, and bound down by fascia. On the shoulders, arms, and legs, however, the masses of fat are quite large and lobulated, and held in position by a distinct though quite fragile capsule. In the early stages of growth, this capsule is thin and delicate; at a later period, it becomes dense and hard. This fibrous degeneration of the capsule constitutes the variety described by Rokitansky, Gluge, and Vogel, as “stea- toma,” and “lardaceous tumor,” and by Müller as “lipoma mixtum.” Müller also distinguishes another variety “cholesteatoma,” which is “appa- rently composed of crystalline fat inclosed in meshes of cellular tissue.” In the diagnosis of this form of tumor, the student must first bear in mind that there may be, indeed there often is, a deceptive appearance of fluctuation, and this is more especially the case when the growth is pedun- culated; it must also be remembered that there is a peculiar tendency in this form of tumor to drop down or shift its position, which fact will assist in the diagnosis. Although as a rule it is not difficult to recognize this peculiar growth, yet sometimes other tumors so nearly simulate it that care is necessary to arrive at a correct diagnosis. A fatty tumor which weighed, after its removal, twelve and a half pounds was mistaken for a spina bifida; the growth was situated midway in the lumbar region, and had been present since infancy. A fatty tumor situated directly in the course of the great vessels may receive pulsation from the artery beneath; this has occurred to me in two cases, once in the neck over the subclavian, and once in the inner side of the right thigh over the femoral. Drawing the growth away from the parts beneath is generally sufficient to arrest the pulsation. The following interesting case may show the action of internal medica- tion. A young lady aged twenty-three years was sent to me by her medical attendant, to examine a large tumor occupying the posterior surface of the shoulder, and covering a space from the bend of the neck to the infra- spinatus fossa of the scapula. The parents were averse to operation, and desired that medical treatment should first be thoroughly tried before the knife was resorted to. I knew of no medicine that was especially adapted to fatty tumors, but was aware that Sir Benjamin Brodie had spoken very highly of the liquor potassae in such cases, especially in that of a foot- man who had an immense tumor extending from ear to ear, which was cured by the medicine. I therefore prescribed that remedy, five drops in a teaspoonful of sweetened water three times a day, gradually increasing the dose until she took ten drops at a time. In Seven weeks from the date of commencing the treatment, the tumor had entirely disappeared. Removal.—To remove the flat continuous growths, a single incision across * The term “steatoma” is applied by some authors to encysted tumors. Wide “sebaceous cysts.” f Erichsen. FIBROMATA—MYXOMATA. 157 the tumor, extending a little beyond its base, is generally sufficient; but if the growth is large, it may be necessary to make the cut either T, X or H- shaped, then the dissection must be carefully continued around and beneath, until the whole is removed. In the encapsuled variety the single incision (being sure that it is made down to the capsule) is sufficient. The handle of the scapel and the fingers will generally be sufficient to dislodge the lobes, which often slip out in a most approved and cleanly fashion. (b.) Fibromata, or as they are called, desmoid, chondroid, tendinous, or fleshy tumors, possess all the characteristics of innocent growths, indeed, in many cases, the body appears to tolerate this variety of tumor better than any other, immense fibroids of the uterus being carried, with but little inconven- ience, excepting their weight, for many years. A fibroid, in shape, is spherical or ovoid, unless peculiarities of position or pressure alter this con- dition. To the touch, fibromata are hard, elastic and firm, unless inflam- mation attacks them, then, of course, the tissues soften ; at times a profuse hamorrhage results, and from the opening a fungoid growth may appear. This must be remembered in making a diagnosis between it and cauli- flower excrescence. A fibrous tumor grows without pain, and can be handled with impunity; indeed, I have on several occasions removed tolerably large (six inches in circumference) fibroid polypi from the uterus, the patient making little Complaint of pain, and not being under anaesthetic influ- FIG. 78. ence. . These, growths, again =~~~~<========= e **-* zº, s-was-- ---> –- ºr r==::Tº - may be sessile or peduncu- ===º ~sº lated; the latter receiving the ========= name of “polypi.” As a rule, - -: štº “ ---- ea--- also, we find the integument Over them movable, unless in- flammatory action be present. Very often the fasciculi of a fibroma separate, and larger or smaller cysts develop with: in the stru cture; the tumor Calcareous Deposit in a Fibrous Uterine Tumor, from then receives the name “fibro- Desseau.-Paget. cystic,” and if calcareous mat- ter has been deposited (Fig. 78), “fibro-calcareous.” They are invested with a capsule, which, however, is generally quite thin, and requires care in its dissection; but this is not always the case. In one or two instances I have found quite a distinct and firm capsule, and this I have noted more particu- larly in that variety of fibroma which was becoming cystic. The uterus is most frequently affected with fibroma; the jaws come next in order, and after this, perhaps, the nerves, making the neuromatous tumor. These growths also attack the subcutaneous tissue, the breast, the lobes of the ears, and the bones. The fibroid tumor, as it grows from the jaws, re- ceives the name of epulis. This tumor is hard, but not to such a degree as the ordinary fibroid; it springs from the alveoli, and is connected distinctly to the periosteum ; the tumor can be handled without pain, and often, nay, generally, is pedunculated. When it is raised with the forceps, it sometimes looks serrated along its edges, and is covered with mucous membrane. Absence of disease in the subjacent glands, and also of the tendency to infil- tration or to cachexia, diagnose it from malignant formations. As a rule, time is lost in prescribing medicines for these tumors. The knife is the only resort. . (c.) Myxomata or mucous tumors, known as fibro-cellular tumors, are, in common medical nomenclature, considered as “soft polypi,” and that is 158 A SYSTEM OF SURGERY. their best name; nevertheless, they have received many others. According to Rokitansky, a fibro-cellular tumor is “a gelatinous sarcoma;” according to Voight, it is “a connective-tissue tumor;” according to Müller, it is “a cellulo- fibrous growth,” and according to Virchow, it is “a mycoma,” one of the end- less varieties of sarcoma. These tumors are composed, as their name well indicates, of fasciculi of fibro-cellular structure, which are loose or otherwise, in accordance with the softness or succulency of the growth; in the meshes of this tissue is a fluid resembling somewhat the synovial, in which are found round or caudate cells or corpuscles (Fig. 79), which contain abun- dant nuclei; the more numerous these bodies, the denser the tumor; in Some locations these growths are covered with a ciliated epithelium. Myxomatous tumors have a soft and pulpy feel, are painless and grow with rapidity, and may attain such considerable magnitude that parts may be displaced by them; they are generally continuous, are often lobulated, and are pedunculated, hence the term “polypi.” They are chiefly found in the nose, ear, and uterus; they also may arise from the connective tissue of the organs, especially the mammae, and sometimes in the skin, when they generally become papillary. This variety of growth is probably the same as that spoken of by Paget as the true fibro-cellular tumors, which are found in “the scrotum, the labium, or the tissues by the side of the vagina, and the deep-seated intermuscular spaces in the thighs and arms.” Polypi FIG. 79. FIG. 80. Cells of a Myxomatous Microscopic appearance of a Myxoma with cells in various Tumor. stages of elongation and attenuation. present “opaque white bands intersecting a shining, succulent basis sub- stance of Serous-yellow or greenish-yellow tint; the whole mass closely re- Sembles ‘anasarcous cellular tissue.” Examined under the microscope, they are found to be composed of parallel or interlacing filaments and fasciculi, interspersed with nuclei and cells like those of granulations.” (Fig. 80.) Secondary Changes.—These tumors vary in the color, consistence, and nature of their contents; they are also subject to cartilaginous and ossific degeneration, and in some cases may ulcerate and slough. These morbid growths, however, sometimes yield to remedies. Professor Dunham reports cases cured with calc. carb., teucrium, and Staph. I have also seen excellent results from the injection of acetic acid, pure, four or five minims, directly into the tumor. The injection may be repeated once a week. Dr. John Pattison has used successfully a snuff of powdered rad. sangui- naria canadensis. ENCHONDROMATA. 159 Polypi may sometimes be cured by puncture and evacuation of the tumor. I have very often succeeded in diminishing the size of polypi, and in one or two instances of curing them with calc. carb. and teucrium, but have most frequently been obliged to resort to operative measures. There are other soft and succulent tumors which have been described, but which are all of the same character, and according to Virchow consist of “the embryonic tissue or Whartonian jelly of the cord.” The cylindroma of Billroth are those in which “are found cylindrical structures of a clear and transparent appearance, arranged like a series of anastomosing branches, which terminate often in bulbous ends, and contain numerous spindle or round cells, though they appear clear and structure- less.” At other times little flask-like bodies are discovered, which are sup- posed to be some peculiar modification of the rudimental connective tissue. These tumors are sometimes classed as the semi-malignant, but there is not much actually known of them. (d.) Enchondromata is but another name for cartilaginous tumors, and is also synonymous with osteo-chondroma, chondroma, and benign osteo- Sarcoma of some authors. . I believe the simple expression “cartilaginous tumor ’’ is preferable to any of these ambiguous terms. It must be remembered that these tumors, though classed as innocent, Occasionally recur after their removal, although I believe in most cases their reappearance is owing to admixture of imperfectly developed cells. These tumors present many peculiarities, among which may be noticed the difference in structure which is presented in a single enlargement. In the case related below, the surface of the swelling was very soft, nay, almost fluctuating; while its base was extremely cartilaginous. We find, also, in this (which is a general characteristic of the affection), the parts firmly adhesive to the adjacent bones. Sir James Paget” gives an accurate description of enchondroma. “To the touch, cartilaginous tumors may be very firm or hard, especially When they are not nodular and their bases are ossified. In other cases they are firm, though compressible, and extremely elastic, feeling like thick- FIG. 81. FIG. 82. MicroSCOpic Characters of Enchon- 8. Enchondroma of the Hand. Walled, tensely-filled sacs. Many a solid cartilaginous tumor has been punc- tured in the expectation that it would prove to be a cyst.” In the specimens in my possession, the different properties, as to touch and the eye, are appreciable. The base of the excrescence is particu- larly cartilaginous, while the superficial parts are much more elastic, and * Surgical Pathology, p. 422. 160 A SYSTEM OF SURGERY. this difference is to a greater degree apparent immediately after an operation than after the immersion of the tumor in spirits. In enchondroma all the intermediate'gradations, from the hardest cartilage to the softest consist- ency of ordinary fatty tumors, are present, and, necessarily, the microscopic characters of each of these different portions present a different cell forma- tion. The cartilage corpuscles, however, in the more dense structure are Said to bear no resemblance to those that exist in the normal cartilages of man or any of the vertebrata. (Wide Fig. 81.) According to Mr. Quekett, however, whose authority in cytology is acknowledged to be very high, the natural cartilage of the cuttle-fish possesses corpuscles of a similar character to that of enchondroma, which fact in itself is certainly a point of interest, showing that the abnormal character in the higher order of the animal species may constitute a normal characteristic of the lower creatures. Rokitansky,” Speaking of cartilaginous growths, has, as usual, a full and at the same time a very conscise description of them. - “Wounds of cartilage are not reunited by means of cartilaginous substance, nor is this substance regenerated when destroyed. Nevertheless, new growths of cartilaginous texture are both frequent and voluminous. The structure of the growths or tumors was first ascertained with the aid of the microscope by Johannes Müller, who applied to them the term ‘Enchondroma.” These excepted, not a single new growth, whether designated as cartilage-like or as cartilaginescence, chondroid, or fibro-chondroid, has more than a seeming analogy with true cartilage texture. . . . . “The capsular case of the enchondroma is un- essential, and is common to many other heterolo- gous growths. . . . . Many of the so-called cases of spina ventosa of older observers were probably of the nature of enchondroma.” These growths have also been known to have their seat upon the lower jaw, but the general site is upon the fingers (Fig. 82) or thighs (Fig. 83). The surgeons whose names are chiefly associated with the removal of enchondromatous tumors are Diffenbach, Müller, John Bell, Sir Astley Cooper, Hodson, Lawrence, Paget, and Hunter. Prof. Miller says of these growths: “Cartilaginous formations (enchondroma of * : * % Müller) occur more frequently in bone than in the Bonyskeleton of Enchondroma. Soft textures; their nature and tendency are sim- ple, yet degeneration is possible, while discussion is impossible, and therefore early extirpation is expedient.” The following interesting case came under my observation in the Good Samaritan Hospital, St. Louis, and was removed by Dr. Fellerer, myself, Dr. Comstock, and others assisting. This tumor occupied a space from shoulder to shoulder of the unfortunate possessor, and from the nape of the neck to below the angles of the scapulac. Portions of it were purplish, and other parts presented the natural color. Throughout the whole cutis a number of enlarged and tortuous veins were distinctly seen. To the touch this tumor presented all those sensations which belong to fatty enlargements, excepting at its base, where the structure FIG. 83. * Pathological Anatomy, vol. i. p. 143. ENCHONIDROMATA. 161 appeared more dense. This hardness extended also to the right clavicle, and to some distance below it. On the vertebral column, immediately under the posterior margin of the enlargement, were several well-marked cicatrices. The history of the case was given by the patient as follows: Some years since, at a wine shop in Berlin, the man became engaged in an altercation, which resulted in a quarrel, and he was stabbed several times in the back by his assailant. For many weeks his life was despaired of by the attend- ing physicians, but a tolerable recovery resulted, and the duties of life were resumed. After a time, however, a small swelling appeared on the region of the spinal column, at the site of one of the late wounds. This tumor was not accompanied with any very severe suffering, and was allowed to remain and grow undisturbed, until its rapidly increasing size induced the patient to apply to a physician, who declined taking any steps towards its removal. The man then came to this country, and during the voyage the tumor increased in volume very considerably. He travelled through differ- ent portions of the United States, and finally came to St. Louis. For nearly a year he had been obliged to sleep upon his belly, with his head bent over the edge of his bed or supported on his hand. He had suffered great pain, and in a state of desperation demanded a removal of the tumor. He was plainly told at the hospital that the chances of such an operation would be decidedly against him ; but rather than drag on such a miserable existence, and finally succumb to the disease, he begged that no delay should be used, but at once his suffering should be terminated. Accordingly he was placed prone upon his abdomen, his head projecting beyond the edge of the table, and chloroform administered. A crucial in- cision was then made, and Dr. Fellerer dissected up the two left-hand flaps, while I turned over those on the right side, by such a procedure saving considerable time. The tumor was then raised up, and with the greatest difficulty dissected from the transverse and spinous processes of the ver- tebrae, to which it was most firmly attached. Portions of this attachment were almost Ossific. The haemorrhage was very profuse, but all venous, and occurred chiefly during the dissection of the flaps; that resulting from raising the tumor from its bed not being excessive. The operation lasted two hours, and the man to all appearances appeared to rally from the chloroform very well. About three hours after the perform- ance he took some wine and appeared quite rational, then turned upon his side and died in a few moments. Fig. 84 represents from Druitt the Šºš s:º grº *==SW §) bony skeleton of enchondroma. Sº Cartilaginous tumors 3.Te subject to Groups of various Cartilage Cells—Magnified degenerative liquefaction, which may 400 times. • , occur either on the periphery or in the - interior. The central softening often proceeds to the formation of cysts; the skin covering the tumor inflames, ulcerates, and sloughs; fistulous openings form, and a viscid ichorous fluid is discharged. It is a Some- what singular fact that these two processes—Ossification and disintegration —may coexist in different parts of the same tumor. Calcareous and fatty degeneration may also occur. Dr. John Pattison reports that he has successfully enucleated an enchon- droma of the index finger with a saturated solution of sulphate of zinc. 11 162 A SYSTEM OF SURGERY. The usual and best surgical treatment is excision of the tumor, or ampu- tation of the affected part. (e.) Osteomata. –As has been already noticed, ossific deposit may be found in cartilaginous and other tumors, but growths undergoing such change do not receive the name osteoma, it being applied to fully developed bony for- mations. Osseous tumors are homologous, or, in other words, innocent; their resemblance to healthy bone formation of the body being perfect, both anatomièally and chemically. These tumors are generally outgrowths, and partake either of the nature of the compact or cancellated structure. In the compact or ivory or eburnated exostoses (which chiefly are found connected with the cranial bones) the structure is firm and of different shapes. These tumors are attached either within or without the cranium, and when in the latter position are very difficult to diagnose. “This exostosis,” says Rindfleisch, “is so remarkable a phenomenon, just because quite divergent from the usual schema, namely, without regard to the vessels and their course, the Osseous tissue is depos- ited layer by layer about one of the smallest tubers as a nucleus. This gradually becomes a warty, polypus-like, white formation, which may at- tain the size of a man’s fist, and nevertheless consist throughout of compact bony structure. This entire kind of growth undoubtedly reminds us of dentine.”* It is worthy of remark also, that there often exists between the compact layers of bone, a cancellated structure, and that in very many cases the tumors have a small base, are round, smooth, and hard, and sometimes rise to a considerable height above the surrounding bones. The pain they occasion is generally that of pressure. The second variety or cancellated exostoses, as the name indicates, are formed of structure exactly resembling the cancellated structure of healthy bone. They usually arise from cartilaginous tumors, are round, lobulated, sometimes presenting spiculae or angles. These tumors grow in most pecu- liar locations, and Mr. Paget calls especial attention to those found at the lower end of the femur, above the insertion of the adductor magnus.f These tumors grow often by stems or peduncles, which, when broken, do not appear to be reproduced. A peculiarly hard species of this variety is that growing from the last phalanx of the great toe, giving severe pain, pushing up the nail, and rendering the parts around sensitive. During the past winter, at the college, I removed two of these subungual erostoses, and found them hard, unyielding, perfectly cancellated, and being direct out- growths from the last phalanx of the toe. Mr. Paget has seen such tumors growing from the little toe, and also from the dorsal surface of the last phalanx. The upper jaw is often affected with exostosis, and in some cases there appears to be an hereditary tendency to the production of these tumors. The medical management of osteoma will be found in the chapters upon diseases of the bones, and in other parts of the volume treating on the sur- gery of those regions where they most frequently appear. Suffice it here to say, that some very remarkable cures have been made. In many instances, however, removal of the parts is necessary. (f.) Lymphomata, Lymphoma, Lympho-sarcoma, are terms used to designate a peculiar hypertrophy of the lymphatic glands, which has been so accu- rately described by Dr. Hodgkin't that it is now named “Hopg|KIN's DIS- EASE.” Wilks calls the disease lymphatic anaemia, Cassy, general hypertrophy * Textbook of Pathological Histology, p. 602. f Surgical Pathology, p. 532. f Medico-Chirurgical Transactions, 1832. LYMPHOMATA, LYMPHOMA, LYMPHO-SARCOMA. 163 of the lymphatic glands, and Wünderlich, multiple lymphadenoma. The cer- vical glands are those most generally affected, but the axillary are also not unfrequently attacked, as may be other of the glandular tissues. The dis- ease does not depend on zymotic influences, and bears in many respects a resemblance to phthisis. In some cases it may be caused by traumatism. The glands gradually enlarge, with their connective tissue, and these appear- ances may result from a bruise or a strain, or may appear without any ap- preciable cause. A small swelling may be the first indication of the disease. Acute pain, neuralgic in its character, accompanies the growth, or may ap- pear in the locality before the tumor is noticed. The neoplasm at first appears movable, but grows rapidly without seriously inconveniencing the patient. A peculiar and frequent accompaniment of the disease is leucocy- thamia, the white blood-corpuscles being always in excess, and often in enormous quantities. There is also the usual bruit de Souffle which accom- panies the condition. A single gland may be thus affected, or, as is more frequently the case, several become seats of the disorder, and finally tumors in the lungs, liver and cellular tissue are developed. Lymphadenoma is not always accompanied by leucocythaemia, as is noted by Mr. Haward, and offers a better opportunity for treatment when uncomplicated. M. Jaccoud concludes, that this disease is occasioned by a twofold condition of the blood. In the one the red globules are much reduced; in the other, this condition coexists with a vast increase in the leucocytes. According to this view the anatomical constitution is different in each variety. He is of opinion that in the latter cases, viz., where there is a great increase in the amount of the white blood-corpuscles, the new growth is altogether ex- panded in the cellular elements, but when both conditions noted above are combined, the capsule of the glands and the connective tissue are much thickened. At present, operative interference is scarcely considered just- ifiable, as most of the cases reported have proved fatal.” Mr. Warrington Hawardi presented at the Clinical Society of London, the following interesting case of lymphadenoma. “The patient, a child of four years, had on the left side of the neck an immense mass of enlarged glands, extending from the ear above, to the clavicle below, and from the spine behind, to the trachea in front. The glands were elastic, and mode- rately firm, and not adherent to the skin. There was no evidence of disease in any other part of the body, and the number of the white globules in the blood was not increased. There was a family history of phthisis on the mother's side. The child was pale and rather thin ; the growth was of a year's duration, and commenced soon after an attack of small-pox. As the disease of the glands appeared to be confined to those visible in the neck, it was determined to remove these, in the hope that the general infection might thus be prevented or delayed. As the removal of the disease involved the dissection of the whole of one side of the neck, it was effected in two operations. At the first the affected glands were removed from the anterior triangle of the neck; at the second, from the posterior triangle. The child recovered well from the operation, and soon gained flesh and color to a remarkable extent. Subsequently, however, the disease returned in the upper part of the left anterior triangle of the neck, and tumors afterwards appeared in the axilla and groin. The child died, pale and emaciated, and post-mortem adenoid growths were found in the abdominal viscera in addition to the enlargement of the glands. No recurrence occurred in the posterior triangle of the neck, and it was thought that possibly some diseased glands might have been left in the upper part of the anterior triangle, where the growth first reappeared.” * Wide Medical Times and Gazette, January 27, 1877. s f Medical Times and Gazette, December 25, 1875. Reported also in the Monthly Abstract of the Medical Sciences. 164 A SYSTEM OF SURGERY. M. Trelat” mentions two cases of removal of lymphadenomata, attended in each case with similar growths in other parts of the body. In both these cases there was a recurrence and a fatal issue, and lymphomatous growths were found in the vertebrae, sternum, spleen and liver. It is held that there are forms of lymphadenoma which are malignant, and others which are not, but the definite histological criteria for determining between the two varieties is not pointed out. The conclusion drawn from these cases is that the removal of these tumors is not advisable when there is any sus- picion of visceral implication. There are certain indications for treatment in lymphadenoma which should be remembered. I have had several cases of the disease and have observed the course generally taken by the enlarged glands,--often tending to suppuration,-always obstinate to treat. The medicines are mercury, baryta carb., calcarea, conium mac., arsenicum, and the iodide of potas- S] UIDOl. * To the enlarged glands I apply the mineral earth, as prepared by the Bal- timore Company, made into a paste. This is put on every night and retained in position by an appropriate bandage. I have had perhaps the most satisfactory results from the prolonged wse of calcarea and arsenic, giving the former in the 2x trituration, three grains night and morning for a week, and a drop of the tincture of arsenic, night and morning, after meals, for the succeeding week, continuing this treatment for several months. As the glands soften and suppuration comes on, mercury and calcium Sulphide are given, and if these means, after being persistently tried, fail, extirpation of the glands, if practicable, can be practiced. Innocent Tumors (Homologous). III. Type of fully developed epithelial tissue. (a.) Mucous membrane and skin: papilloma, horny tumors. (b.) Glandular: adenomata. (a.) Papilloma.-By those familiar with the histological formation of the skin and mucous membrane, the appearances and structure of papillomata will readily be understood. These growths have always some connective tissue mingled with the epithelial elements, and are divided into two classes: 1st. The hard or horny papilloma, in which there is a preponderance of con- nective tissue, and which grow upon the skin, embracing warts, horny growths and nail tissue; and 2d. Those in which epithelia are very numerous, embracing soft outgrowths which spring from the mucous membranes of the mouth, the larynx, the rectum, bladder, and sometimes from the uterus. The so-called “painful caruncle’ of the female urethra comes also under this classification. The soft or mycomatous papilloma are well supplied with bloodvessels and bleed readily, while the former are not vascular. The color often noticed in the hard growth is derived from pigment deposited in the deepest layer of the epithelia. Often in the myxomatous papilloma, shreds and bits of membrane are cast off with the natural secretions of the part. It is stated by some authorities that from constant irritation of these growths, they may develop a myeloid or round-celled formation, which, from recent observations, I am disposed to believe. • Horny Tumors.-These curious morbid growths generally occur in con- nection with sebaceous follicles, and their origin can frequently be traced to injuries or chronic inflammation. - * American Journal of the Medical Sciences, July, 1877, page 256. SPINDLE-CELLED SARCOMA—RECURRENT FIBROID TUMoRs. 165 They are usually found about the head and face, but may also exist in other parts of the body. They first appear as soft, semi-transparent masses enclosed in complete cysts; as they increase in size, they become dense and hard, and assume all the characteristics of horny structure. They grow slowly, and frequently attain considerable magnitude; one case has been reported in which the tumor measured eleven inches in length by two and one-half inches in circumference; and in another instance the horn was fourteen inches around the base. They are more or less flexible, and of an almost cartilaginous hardness. The surface is marked by rough rings, indicating the different stages of growth; sometimes it is knotted or covered with small pearl-like scales. In shape they are usually conical, and twisted upon themselves like the horns of a sheep; their color varies from a dingy yellow to brown or black. Under the microscope they exhibit flattened epithelial cells and nuclei. The only treatment for these tumors that I know of is excision. (b.) Adenoma, or Glandular Tumors.-These tumors are most commonly found in the breast, in the prostate, in the thyroid gland, and sometimes in the lip, the name of the part in which they grow generally being added, to determine their locality, thus, labial glandular tumor, mammary glandular tumor, etc. In the majority of cases, the growths occur within the glands, but sometimes they are found external to them. These tumors are more frequent in adult life; they grow slowly and may attain considerable size without much inconvenience; they are smooth, round, and sometimes lobulated. When they are cut into, their structure appears to be separated by interstices, in which a small quantity of fluid is found; they are, especially in the breast, encased in a distinct capsule, and generally may be dissected out with ease. They are painless unless from pressure, or, as in the mammary gland, from dragging the parts down- ward. Occasionally cysts are developed in the substance of these tumors, which appear to contain a serous fluid, resembling that spoken of above, as found in the interstices of the tumor. The microscopic elements of adenoma resemble true glandular structure arranged in a lobular form, each lobe containing more or less glandular epi- thelium. The septa are formed of fibrous tissue which is often concentric in form, sometimes, however, radiating from the centre to the circum- ference. º These tumors are amenable to treatment, and I have seen them disappear under calc. carb., conium, and especially phosphorus. In the breast they are likely to enlarge during the menstrual period. In operating they may be taken out by removing the capsule and enucleating the morbid mass. Sometimes, however, the gland must also be extirpated, especially when much of its substance is involved. B. The Sarcomata (Semi-malignant). (a.) Spindle-celled sarcoma (recurrent fibroid). (b.) Giant-celled sarcoma (myeloid). (c.) Round-celled sarcoma (glioma). (d.) Lympho-sarcoma. (e.) Alveolar sarcoma. (a.) Spindle-celled Sarcoma—Recurrent Fibroid Tumors.--The chief charac- teristics of the spindle-celled sarcoma appear to be as follows: First. Their almost invariable tendency to recurrence after removal, such reappearance not being attributable to any portions of the tumor which may have been accidentally allowed to remain in the parts. Second. They generally appear at the site of the former wound, as well as in other portions of the body. Connective tissue SerleS. 166 A SYSTEM OF SURGERY. Third. Their growth is slow at first, but afterwards they enlarge with greater rapidity. Fourth. They give but little pain, and life is not threatened by them for a long time, unless (which most frequently happens) local pressure causes danger and death. Fifth. The superjacent skin is not involved, nor does it proceed to ulceration, unless such solution of continuity is produced by tension and consequent deficiency of circulation. Sixth. They are hard, lobulated, and often immovable, appearing to be firmly attached to the aponeuroses and fibrous sheaths. Seventh. They do not infiltrate the tissues surrounding them, nor do they produce the cachexia found in Can- cers. Eighth. Their structure appears to resemble somewhat the natural tissues of the body, but the cell-element is rudimentary, incomplete and preponderating. Ninth. The oftener they recur the more succulent and soft do they become, and the more rapid is their growth. Tenth. The cells com- posing them are spindle-shaped and caudate, often with attenuated processes, with large nuclei (vide Fig. 85). There may be also, free nuclei scattered Microscopic elements of a Spindle-celled Sarcoma, magnified 400 times. throughout the intermediate cellular substance. Eleventh. The hardness or Softness of spindle-celled sarcoma consists in the deposit of fatty particles in the one variety, and their absence in the other. The secondary changes which take place in these tumors give rise to many difficulties in diagnosis. The most frequent is fatty degeneration, but there may be deposits of calcareous matter, and even pigmentation may occur; in the former case giving rise to the supposition that the tumor may be a fibro-calcareous growth, and in the latter that it may be melanotic, which also, if a rupture of a bloodvessel should occur, would be easy to mistake and diagnose as a simple sanguineous cyst. The surgeon should be upon his guard in making a diagnosis. Many cases of this variety of tumor have come to my notice, but the one I here record is of considerable interest, because of the simultaneous appear- ance of three tumors, after the complete extirpation of the first, and of the train of pressure symptoms which were gradually developed. The patient, Ella S., was about twenty years of age, and healthy in appearance. Her father partook of the rheumatic diathesis; her mother died of phthisis (the disease being hereditary in that branch of the family). She had enjoyed average health from childhood, excepting a severe attack of scarlatina, occur- ring during her fourth year, from which she is said to have made a com- plete recovery. From a careful inquiry I could not find that she ever received an injury of the neck, or that there was an appearance of any abnormal growth, until about two years prior to the date of operation. About that period a tumor appeared near the centre of the right side of the neck; it gave but little inconvenience and no pain, and scarcely attracted notice. After a time, however, as it slowly enlarged, occasional difficulty of deglutition called more critical attention to the growth, which had con- siderably increased in an upward direction. In addition to the above SPINDLE-CELLED SARCOMA – RECURRENT FIBROID TUMC).R.S. 167 unpleasant symptom, there were paroxysms of great dyspnoea; both of these symptoms being produced by pressure on the oesophageal branches of the vagus and the inferior laryngeal or recurrent nerve. . The Suffocative paroxysms increased until life was in peril, the growth of the tumor also proceeding with marvellous rapidity. In consultation with Dr. Banks, of Englewood, whose patient she was, it was decided that nothing but operative measures could prolong her life, and though the season of the year was rather unpropitious (it being midsummer), the day was appointed for the operation. The tumor at this time extended from the mastoid process of the tem- poral bone, bordering closely the ramus of the inferior maxilliary, to the margin of the clavicle, and from near the mesian line of the neck to a point about half an inch beneath the anterior border of the trapezius. The sterno- mastoid muscle crossed it diagonally, and from the pressure consequent upon the protrusion of the growth had become much attenuated. The external jugular vein, from the same cause, was reduced to a thread. The tumor was distinctly lobulated, hard, and most firmly fixed, a condition which renders every surgeon more careful in his methods of procedure; in fact, it is recommended by some distinguished authorities that this immobility should decide the question of surgical interference, especially in parotid tumors. The patient was placed on the table about noon, and ether administered. There were suffocative paroxysms during the first period of anaesthesia, which, however, gradually passed away. The head was placed in a position similar to that for ligation of the ca- rotid, and an incision of three inches made along the anterior attenuated border of the sterno-mastoid, from the angle of the jaw to the lower border of the thyroid cartilage. The tumor was so immovable that I determined, on account of its peculiar situation, to give myself all the room that I could, and to make a crucial incision, if necessary, to afford facility in getting underneath the growth. The fascia was cut through and the sterno-mastoid held aside; finding, however, that the tumor lay beneath the deep cervical fascia, and that the sterno-mastoid was attached, I divided it with a transverse incision. The next step was a transverse division of the anterior fibres of the trapezius, which was accomplished upon a director. This allowed a free and full exposure of the upper surface of the tumor, which was laid bare after a tedious dissection. The next step was to dislodge it from its base; begin- ning with the posterior border, the handle of the scalpel was introduced beneath it. The adhesions were extremely dense, and repeated touches of the knife, the use of the director, the fingers, and the handles of instruments, gradually raised the tumor until we discovered its connection with the sheath of the great vessels. Having, thus far, loosened the growth from the posterior side, the adhesions on the anterior border were attacked in the same manner; they gradually gave way until it was free, excepting its line of connection with the sheath of the carotid and internal jugular. Having then a finger placed on the carotid, as it passed under the tumor, ready for compression, if necessary, the dissection was carefully continued from below upward, until the growth was removed, taking with it the external portion of the sheath of the great vessels of the neck. It is unnecessary to say that this was both a trying and tedious dissec- tion. It occupied nearly two hours, and the heat was overpowering. There were six ligatures applied, but there was no serious hæmorrhage, excepting for a short time, from a prick of the internal jugular; continued compres- sion stopped this. The wound was brought together with silver sutures, and the patient progressed without untoward symptoms, excepting a slight con- 168 A SYSTEM OF SURGERY. vulsive cough, for three weeks, when a swelling showed itself in the site of the wound. In a few days a second growth was developed on the left side of the neck, in a position precisely similar to that occupied by the first tumor, viz., beneath the sterno-mastoid. Then were presented a train of peculiar and most unfavorable symptoms. Ptosis of the right lid; insensibility of the pupils and diplopia; then numbness of the right side of the face, which was followed by deafness of the right ear; these symptoms increased, until finally the eyeball began to protrude from the orbit. Distressing paroxysms of cough then were present, and to add to the suffering of the poor girl, diffi- culty of deglutition again ensued. At this time bulimia, of an actually fierce character, superseded with rapid and great emaciation. The tumor on the right side grew to a considerable size, but was much softer than the former growth (a characteristic of this variety of neoplasm). The eyeball was pushed FIG. 86, Section from a spindle-celled sarcoma of the femur, taken from the exterior of the tumor. a shows the “indifferent granulation material” or “adenoid tissue” stretching out from the tumor structure (b) into the adipose tissue (c) separating its cells. The tumor was of a malignant character, and contained in Other parts of its substance cartilaginous and Osteoid material. Path. Soc. Trans., vol. xxi., p. 341, and pl. viii., Fig. 1.-(HOLMES.) out from a tumor of the orbit until it lay upon the cheek. Severe neuralgic pains and sleeplessness were present, and she died in great agony, which opiates were powerless to relieve. - Fig. 86 represents the appearance of the different cells in a section of a recurrent fibroid. . g (b.) Giant-celled Sarcoma—Myeloid Tumors (Paget); Fibro-plastic (Lebert). —These tumors are of rather rare occurrence, and there is no better method of describing them, or indeed any varieties of abnormal growth, than by the history of a typical case. The following is one in which I removed the superior maxillary and turbinated bones for the disease in question. Joseph Vogl, aged forty-nine, entered the Good Samaritan Hospital, at my suggestion, on account of a peculiar tumor involving the upper jaw of the right side, extending downward and forward into the mouth, forcing forward the alveoli and the teeth contained therein, and growing, according GIANT-CELLED SARCOMA—MYELOID TUMCRS–FIBRO-PLASTIC, 169 to the statement of both the patient and his wife, with amazing rapidity. The tumor was turned toward the left side, and the lower eyelid drawn somewhat downward. The mass that could be seen by drawing the cheek aside, resembled in many respects the gum from which it appeared to grow ; never bled excepting after severe handling, and then but slightly; had a peculiar odor, but not that which belongs to encephaloid disease, and ap- peared to involve the whole bone, excepting the orbital plate, extending upward to the articulation of the nasal bones. The patient's health was rapidly failing, and I advised an operation as soon as the system could sustain the shock. - The diagnosis was difficult to make out. There was an absence of symp- toms which generally belong to malignant tumors, and that part of the growth which was capable of being examined presented many appearances of epulis. My first impression was that it was the latter-named disease, but in reading over The Surgical Observations of John Mason Warren, I recollected a passage which I think led to the correct diagnosis of this case. The lines were as follows, page 64: “Myeloid tumors in the jaw are rare, and at a late stage of their existence are often distinguished with difficulty from that external affection called epulis.” Further research justified the opinion, and the examination of the diseased mass after its removal put the ques- tion beyond doubt. The question as to the malignancy of the tumor was first to be considered, and many of the features which I have found to belong to the so-called heterologous growths were absent; thus there was entire absence of haemor- rhage; lack of proneness to ulceration (which is very characteristic of malignant formations), together with the appearance presented by those parts which could be examined (which in homologous growths is, as a rule, similar to some of the textures of the body on which the formation is found), which was normal in both color and consistency. On the other hand there was an amazing rapidity of growth, some fetor, general depression of vitality, and other symptoms which were of serious import. A myeloid tumor is one which, in appearance, resembles, after slight maceration, common Suet. The growths generally occur in bones and in cancellated structure; on section they present reddish or even purple spots in their texture, and present a similar external appearance to epulis. According to Mr. Paget, “they grow slowly and without pain; generally commence without any known cause, such as injury or hereditary predisposition; bear consider- able injury without becoming exuberant; they are not apt to recur after º removal, nor have they, in general, any features of malignant ISéâS€. g Dr. Gross differs somewhat in his opinion regarding these growths, and his words are so expressive that I shall quote them. He states “that the myeloid tumor is rather rapid in its growth, occurs in both sexes at different periods of life, but more commonly in the young and middle-aged than in the old, and is capable of attaining considerable bulk. From its tendency to destroy the structure in which it is developed, and from the fact that it Occasionally displays a malignant tendency, recurring after extirpation, and ultimately causing death, there is a strong reason to conclude that it is merely a modified form of encephaloid or fibro-plastic growth. Neverthe- less, in the existing state of science, we are not warranted in expressing a very positive opinion regarding the true nature of the disease.” These remarks are very applicable to the case in question, and the appearance of Several fibrous polypi attached to the nasal bones would appear to demon- strate the fibro-plastic nature of the disease, with a tendency to degeneration. After a careful consideration of the facts, and some consultation as to the advisability of the operation, I felt myself justified in removing the bone. 170 A SYSTEM OF SURGERY. On the 13th of March, the patient was laid upon a bed, with his shoulders and head elevated, with the affected side towards a good light. This is the position advised by Dr. Gross, and one which I always prefer, the upright position formerly employed being unfavorable for prolonged anaesthesia. After this the patient was thoroughly brought under anaesthetic influence, and an incision was commenced at the angle of the mouth, and carried around the cheek to the zygomatic arch; a second cut was then made parallel to the border of the lower lid, to the lateral margin of the nasal bone on the right side, and the flap dissected up. The zygomatic arch was then divided, partly with the saw, and partly with the bone pliers. The mass was then separated from the orbit, and the division effected through the palate with the pliers. By seizing the tumor with Fergus- Son's forceps, and depressing it, the growth was taken away. Parts of it, however, were found adhering to the under surface of the nasal bones, and indeed had invaded the left alveolar processes. These were cut away with the pliers, and several polypi, one of them quite large, were removed from the upper part of the fauces. The appearance presented by the wound was rather revolting, and a considerable quantity of blood was lost during the operation, though there were but three vessels (the largest being a branch of the internal maxillary) which required ligature. I was in con- siderable doubt whether the patient would survive the operation. The wound was brought together by several points of suture and the patient put to bed. The patient succumbed to the disease about six months after the opera- tion was performed. The growth reappeared and grew with frightful rapidity. The sufferings of the man were terrible, and he died in great agony. When a section of a myeloid tumor is placed under the microscope, the characteristic poly-nucleated cells are plainly visible; they are large and FIG. 87. £ºsºs ºğ “Giant-celled Sarcoma,” or Myeloid Tumor.—After Billroth. a, pº to a part where cysts were being ormed by the softening of the tissue of the tumor; b, to a focus of Ossification. contain often very many nuclei floating in a clear and granular fluid (Fig. 87). Sometimes the spindle-shaped cells, so well known as belonging to Paget’s “recurrent fibroids,” are seen. It is quite probable from the embryonic and heterologous nature of the cellular elements in glioma, cylindroma, and myxoma, that these tumors ROUND-CELLED SARCOMATA—CARCINOMA. 171 would recur after removal, and, therefore, might well be placed among the Semi-malignant growths. (c.) Round-celled Sarcomata are softer to the touch than the spindle- celled, and it is sometimes difficult to diagnose them from encephaloid cancer. My experience shows me two great differences which are always well marked in cases of true Sarcomatous tumors, and these are the absence of haemorrhage and the non-infiltration of the parts. Glioma.-This is a peculiar form of round-celled sarcoma, but differs materially from the myeloid formation in the character of its cells, and the localities it occupies. The cells of glioma are round and small, and the cell-elements resemble those found in the brain ; some of the cells show prolongations, which tend to the formation of a reticulated substance. The seat of the tumor is generally in the retina, and in the gray, sometimes in the white substance of the brain. (d.) The Lympho-sarcomata have been mentioned in the section on lymphadenoma. - (e.) Alveolar Sarcoma is but another form of the round-celled variety, and was first described by Billroth; it adds another to the innumerable list. These sarcomata appear in the muscles and bone, but frequently in the skin, where they may become very numerous, and proceed to ulceration, giving rise to considerable deformity. Like all other sarcomata, they recur frequently, and the treatment is complete removal by the knife or cautery. The author has purposely excluded from this chapter, of a work designed especially for students, the many varieties of sarcoma which are constantly being described. The more he has studied the subject, and the more ex- tended his experience, the more he arrives at the fact, that as all these tumors overlap, or rather intermingle their anatomical and histological elements, there may occur to every surgeon, and to the same surgeon many times, cases of sarcomata, with more or less development of other tissues, and it has been the endeavor to name each of these classes, that has given and will give forever, an unlimited field for the cultivation and production of every variety of sarcoma under heaven. C. Carcinomatous Tumors. ſ (a.) Scirrhus. (b.) Encephaloid. (c.) Epithelioma. Epithelial embryonic tissue. { (d.) Melanosis. (e.) Colloid. (f) Osteoid. U (g.) Villous. Carcinoma.-Under this head will be classed those tumors which are essentially malignant in their nature, and possess those characteristics which have been already mentioned, the chief peculiarity of the disease being unusual, nay, often tremendous cell production. These cells are often found crammed into the tissues without order or regularity; they float in a liquid known as the “cancer juice,” and not only have the ten- dency, but the power under certain circumstances, being heterologous and ungovernable, to rush upon any tissue, infect, and destroy it. The great distinction between true cancer and the innocent tumor with reference to auto-infection is this: in the latter the parts are pushed asunder, a separation of tissue taking place; in the former the surrounding tissues are infiltrated with the cancerous material. - Again, another of the peculiar marks of cancer consists in the glandular enlargements which follow its growth. If we find a tumor which is appa- 172 - A SYSTEM OF SURGERY. rently innocent in its characteristics, accompanied during its life with lym- phatic or neighboring adenoid swelling, it must at least be regarded as Suspicious in its character. - With reference to the actual pathology of this affection, the following most appropriate language is used by Mr. Bryant.* “Pathologically, a cancerous tumor is not composed of any definite or characteristic elements, such as at once stamp it as being a cancer; it does not contain any distinct cancer-cells which mark its nature, for the cells, nuclei, and fibres, which enter into the formation of a cancer, may all be traced in other and in innocent morbid growths. ‘But neither in tumors of innocent character, nor in natural tissue, do these elements combine in Such variety as is common in a single cancer’ (Moore). It does not appear, however, to be incorrect to assert that the more the cell elements predomi- nate in a growth, and the more they approach an epithelial type, the greater is the probability of its being malignant, and therefore cancerous; for the Soft cancers, which are undoubtedly the most virulent, are made up almost entirely of cells and nuclei, only enough fibre tissue existing to bind and hold these cells together.” - It has been supposed by some, that the primary origin of cancer is to be looked for in a deviation from the healthy standard of nutrition, and that there exists in some an hereditary predisposition to this abnormal action; that though this tendency may exist for years latent in the system, yet it ultimately develops itself either from known or unknown causes in the form of one or other of those tumors known as cancerous. Certain I am that in the majority of cases of cancer that have come under my own personal supervision during the last fifteen or twenty years, I have been able to trace a cancerous disease somewhere in the family. At first this predispo- sition may be denied on the part of the patient, from ignorance of the actual facts; but upon carefully inquiring it has been found that “cancer." somewhere existed more or less remotely. I think I may say that this heredity may sometimes skip a generation, and appear again with redoubled violence in the same family. With the peculiarity just noticed there is another which should be ob- served, which consists in the fact that those causes which produce ordinary diseases do not appear to have much influence in the production of cancer; and that all classes are more or less liable to its invasion ; nor, indeed, does impaired health appear to be a factor in its production. I have known in several instances, a true scirrhous tumor to exist for years, in the person of a wretchedly poor, ill-fed, dyspeptic, and hysterical woman, and, with the exception of occasional pain, be of no inconvenience. Cancer is a disease of adult life and old age. It occurs generally between the ages of thirty-eight and sixty, and is more frequent in women than in men. I have only seen one case of cancerous disease in the male breast, and that was of a most aggravated character. The patient was a clergyman, the founder of the Good Samaritan Hospital in St. Louis, and was attended by Dr. Comstock and myself. • As I have already mentioned on two occasions, there is believed at present to be no typical cancer-cell; it is the whole history of the case, the multiplicity, the proliferation, the heterology of the cells, which have to be considered in making the diagnosis. On general principles it may be said that the cancer-cell is oval, with a large, double, or concentric nucleus. Water clouds the cell; acetic acid acts in a somewhat similar manner as is noticed when applied to the pus-corpuscle—it clears it up. Another form of cell discovered in cancerous formations is the “mother” or the * The Practice of Surgery (Am. ed.), p. 666. CARCINOMA. 173 “brood" cell, which receives its name from the fact that it contains in its interior several apparently perfectly formed cells. The “cancer juice ’’ is a milky-white, sometimes glairy fluid, which lies between the stroma; it is often quite limpid, though from being loaded with disorganized products it may sometimes be more or less dark or bloody. This cancer juice must not be mistaken for the oil-globules which run away frequently during an operation for cancer (a fact that should warn the operator that he is cutting into and not around the growth). Cancer-cells are exceedingly liable to undergo fatty degeneration, and, indeed, what is called the “saponification ” of cancer is the fatty degeneration of the stroma and cells. Sometimes the fat deposition stretches along the connective tissue, giving rise to a peculiar appearance known as “reticular cancer.” I give here the different types of cancer, with the microscopic structure of different varieties, which I have taken from Dr. Moxon's celebrated chapter on the microscopic anatomy of tumors in Bryant's Surgery. His classification is as follows: { % i. leading types of carcinoma may at present be conveniently distin- U11SI) 62C1. & - gu, 1st. Those in which the fibrous meshwork is in preponderance, and the epithelioid contents of the alveola are scanty, and perhaps, also prone to perish early, so that they are found more or less degenerate within the fibrous meshes—hard carcinoma, or scirrhus. “2d. Those in which the fibrous meshwork is in smaller proportion, and the epithelioid contents are plentiful, making large collections of cells, but with no evident approach in the form of these collections to the shapes of gland acini, and no evident resemblance of the component cells, either to the columnar epithelium of mucous glands or the Squamous epithelium of 'cuticle—soft carcinoma. This kind occurs especially in glands, and the transformation of the glandular tubes or follicles to cancer alveoli can be seen in all its stages in the growing margin of the tumor. “3d. A structure essentially such as that last described, but with this difference, that the epithelioid cells have a quantity of mucus between them, which is regarded as arising from a transformation of them. This change to mucus may be carried to such an extreme that scarcely any cellular elements are left, while the alveolar meshes in which the mucus is contained becomes very strikingly visible from its nakedness and the pellucidity of the mucus—colloid, or alveolar cancer. A common seat of this is the wall § alimentary canal, where it may be traced arising from Lieberkühn's ollicles. “4th. A structure in which the epithelial cells resemble squamous epithe- lium, and form masses which are very like the follicles of cutaneous glands, or occasionally like rudimentary hairs; the tubular and bulbous forms may, however, be seen ramifying like the lymphatic vessels of the skin, as if their form were moulded to the lymphatic plexus. In these cancers peculiar bodies are found, composed of flattened cells disposed concentrically so as to form a scaly-walled globe, whose appearance is like the section of an Onion, or like a bird's nest; these are so large as often to be visible to the naked eye; when they are numerous and well characterized, they are diagnostic; some authors (Billroth) distinguish a variety of this cancer in which the stroma preponderates over the epithelial part, calling it scirrhus of the skin— Squamous epithelial carcinoma. “5th. A structure in which the epithelial cells resemble ordinary columnar epithelium, and the structure itself is quite like normal mucous membrane, in which it always primarily arises (alimentary canal, especially colon, uterus); the secondary formations which occasionally occur in these cases, in the liver especially, have the same structure, and thus a tissue like the 174 A SYSTEM OF SURGERY. glandular mucous membrane of the colon may be found in the liver— cylindrical epithelial carcinoma. “The fourth and fifth varieties are distinguished from the first three as epithelial cancer or epitheliomata. Some authors have used the term can- Croid for the fourth variety, as though it were not completely cancerous. These are less likely to infect the viscera than the first two varieties, which are the most infectious of all tumors, though they are very far from being the only kinds of infectious tumors.” Mode of Death.-Cancer patients die in many cases because their systems are actually poisoned, the blood becomes scanty, the organs break down, the secretions alter. The entire lymphatic system appears to be filled with the poison, which often manifests itself in many parts of the body at the same time. Those individuals who possess a strong constitution of course give greatest resistance, although this may not always be the case, for I have known patients who have been suffering from other diseases offer more re- sistance to the inroads of cancer than those who to all appearances were much more robust. Cancer patients also die indirectly from the poison; some are carried off by effusions, and some with pyamia. Again, cancers entirely obstruct the bowels, cancers eat out the oesophagus, cancers destroy the air-passages, cancers tear open arteries, cancers perforate the organs, in fact deaths from cancers are effected in all parts of the body and in many ways, and, sad to say, medicines are not of much avail against their inroads. The different varieties of cancer are as follows: (a.) Scirrhus, (b.) Enceph- aloid, (c.). Epithelioma, (d.) Melanosis, (e.) Colloid, (f) Osteoid, (g.) Willous. (a.) Scirrhus—Hard Cancer.—It is said that scirrhus is the most frequent form of cancer; in my own experience I have not found it so. I think that in America, at least in those sections in which I have had an opportunity of ob- serving the disease, epithelioma is the more frequent. The occurrence of fibroma and adenomain the female breast may have given rise, in part, to the statement regarding the frequency of scirrhus, the one being mistaken for the other. A scirrhus tumor is hard, nodulated, and circumscribed ; its chief peculiarity and its diagnostic mark, is its tendency to contraction, or the drawing around it of all the tissues. (Fig. 88.) Who has not seen in a female affected with this disease, a healthy, well-developed breast on the one side, and a shrivelled, drawn, potato-like excrescence on the other?" This mark, its contraction, together with its tendency to adhesions to the under- lying and Superincumbent structures, may be said to be pathognomonic of the disease. No other tumor posseses these peculiarities to such a degree. There is often noticed in the growth of a scirrhus tumor a peculiar in- crease, either in the middle, the one side or the other; by careful observa- tion it will generally be seen that the most marked increase in structure is found at that point where there is most nutrition; in other words, near the nutrient artery. There is another point to which attention should be directed, and that is, the undoubted fact that scirrhus withers of itself; espe- cially is this true of breast cancers. This withering of scirrhus has been found by most careful observers not to consist in its transformation into other tissues, nor in its conversion into healthy structure. It is merely a breaking up of the cells and nuclei, and the escape of oil-globules and débris. A somewhat peculiar feature of scirrhus is the “cupping ” of its surfaces. When cut into, after its removal from the body, the sections become concave, the surface shining, the substance elastic and glistening. This pitting is explained by the tendency, which has been before noticed, to contraction inherent to the growth. The pain of scirrhus is not severe in the early stages, indeed, a tumor may exist for a time, and be by accident discovered. There is, however, ENCEPHALOID CANCER. 175 always soreness of the lump when handled, and sharp, lancinating pains, which are peculiar. As the disease advances, these darting pains become more frequent and severe; these, though peculiar to most forms of carci- noma, are much more severe in scirrhus, being probably due to the pressure exerted by so firm a growth on the nerve-fibres. Glandular enlargement also is another most prominent symptom, which is more peculiar to Scirrhus than perhaps the other forms of cancer. After a time ulceration sets in, as has been noticed, and the action is then rapid, the discharges are thin and offensive, the ulcer is jagged and ill-de- FIG. 88. FIG. 89. N º NºN N& ‘YS N §§ S$ Š Hard cancer, extending from a border lobe & & of mammary gland to the skin, affecting in: Ulcerating Scirrhus of the Breast. tervening tissues.—PAGET. fined. (Fig. 89.) With these symptoms the cachexia is well marked, and the usual manifestations of decline are present. The yellow lines through scirrhus have already been noted; besides these, there are often whitish bands which extend into the substance of the growth, which resemble the tissue of lacteal ducts. The cells are round and oval, and are about rºoth of an inch in diameter. There are often two nuclei in each cell, and each has one or more large nucleolus. There are also often present withered cells, undergoing either fatty or calcareous degen- eration. (b.) Encephaloid Cancer.—This form of carcinoma has received several ap- pellations, chiefly from the appearances it presents. The fungus haematodes and fungus melanodes of the old writers and the soft or medullary cancer of the more recent authors are synonymous. There are two distinct forms of encephaloid disease; the one appearing as a round and defined growth, the other being nothing more than intense and perfect infiltration; the latter is often found in serous membranes, and also in the bones. The former are “boggy' in their feel, and generally inclosed within a delicate capsule, which sends trabeculae into the substance of the tissue, dividing it into com- partments, each of which may also have a covering of connective tissue. In the other variety the tumor is not so distinctly marked, though the eleva- tion rises above the surrounding structure, and presents such elasticity that fluctuation is apparently present. On more than one occasion these fluctu- 176 A SYSTEM OF SURGERY. ating tumors have been punctured with the expectation of finding either serum or pus. Encephaloid cancers are always profusely supplied with bloodvessels, which have exceedingly delicate walls, and which are in size much out of proportion to the structure through which they ramify. Besides this inter- nal vascularity, the veins on the surface of the tumor are enlarged and tor- tuous. It is from this profuse supply of vessels, especially if the cancerous growth is bound down by dense tissue, that there may be distinct pulsation in the tumor. A peculiarity of this variety of cancer is found in the fact that it may exist with scirrhus in the same patient, and that all ages are liable to its invasion. It has been found in the foetus at birth. The sufferings of those affected with encephaloid are, as a rule, not so great as is found in scirrhus, particularly if the disease appears in soft and yielding structures; there is often extreme suffering, however, when bone or periosteum is affected. The most frequent seats of the disease are bone, testicle, uterus, eye, and female breast; the bladder and the face are also often affected. As the disease progresses, a bluish spot near the surface becomes visible. The integument becomes thinner and thinner, until it ulcerates, generally with profuse haemorrhage. Almost immediately FIG. 90. from this opening there sprouts a red, soft, fungoid, readily-bleeding mass, which grows with great rapidity and undermines the health of the patient with marvellous speed. The cancerous cachexia is more marked in this variety of cancer than in almost any other, and is noticeable even in the earlier stages. The “cancer juice ’’ pressed from an encephaloid is of yellowish or milky hue ; the stroma is reticu- lated and spread out like a net, within the meshes of which are found the cancer-cells already mentioned Nuclei of Medullary Cancer, tº © tº is * ºn ...hiº.” floating in a liquid intercellular substance. The cells vary in form, being caudate or pyriform, and have many nuclei. (Fig. 90.) The progress of soft cancer is rapid, the du- ration of life under its ravages not often exceeding two years. Death often occurs from actual exhaustion. The following, from Gross, is the differen- tial diagnosis: IENCEPHALOID. SCIERHUS. 1. The tumor is soft and elastic, not uni- 1. Uniformly hard and inelastic, feeling formly, but more at some points than like a marble beneath the skin. others. 2. It grows rapidly, and soon acquires a 2. Growth is slow, and bulk comparatively large size—perhaps ultimately attain- small ; the tumor rarely, even in the ing the bulk of an adult head. worst cases, exceeding the volume of a double fist. 3. The pain is slight and erratic, until 3. The pain begins early; , is distinctly ulceration sets in, when it becomes localized, and is of a sharp, darting, more severe and fixed. burning or lancinating character. 4. There is always marked enlargement of 4. In scirrhus these vessels retain their the snbcutaneous veins. i. size, or are only slightly en- arged. 5. The ulcer is foul and fungous, with 5. The ulcer is incrusted with spoiled thin undermined and livid edges, and lymph, and has steep, abrupt edges, is subject to frequent and copious looking as if it had been scooped out haemorrhages. : the part; bleeding little and sel- OICl. - 6. There is generally early lymphatic in- 6. Usually not until late, or just before volvement. - ulceration is about to occur. - 7. Occurs at all periods of life. . 7. Seldom before the age of forty-five. EPITHELIOMA. 177 ENCEPEIALOID. SCIRREIUS, 8. Is most frequent in the eye, testicle, 8. Never occurs in the eye and testicle, and mamma, lymphatic ganglions, bones, rarely in the bones, skin, and lym- skin, and cellular tissue. phatic ganglions. 9. The disease usually terminates fatally in 9. Seldom sooner than eighteen months or from nine to twelve months. two years. (c.) Epithelioma.-Epithelioma, as its name implies, is that form of cancer which bears some resemblance to the epithelial structure of the human body. It possesses all the characteristics of the ordinary malignant forma- tions, and is found especially in the lip, the tongue, the penis, the OS uteri, and rectum. It generally begins as a wart, or a fissure, or a tubercle, and spreads by infiltration. It in many cases becomes fungoid, and then the peculiar papillary structure can be discerned by the naked eye. There are two peculiarities which I have carefully noted in this disease, and those are: 1st. The length of time that the disease may rest locally in the system with- out harm being done; and 2d. Speaking purely from my own experience, it is less likely to return than any other form of carcinomatous disease; at all events the patients have a longer immunity from it when the growth is early and thoroughly removed. There is one peculiar method in which it may make its appearance which de- serves attention. It is when there appears to be formed over an abrasion of the skin, or a round red spot, a hypertrophied epi- thelial structure (Fig. 91), a dry scale, which, upon being removed, again de- ... º hree papillae of velops; when this scurf is removed a **śgºes pupilso small quantity of moisture shows beneath, but nothing more. Gradually, however, the papillae are enlarged, and, in- deed, often become enormous; then there appears to be considerable ichor exuded, and the structures show symptoms of infiltration, which soon ravage the parts around. This may be called the second stage of epithe- lioma. In some cases it has been noticed that as the ulcerative process goes on, there is a deposition of new growth at the sides and borders of the chasms. Men are said to be more liable to epithelioma than women, though I have seen many cases in the female, especially in the uterus and vulva. In this variety of cancer there seems to be also a local irritation existing in most cases. Thus, the heat of the clay pipe on the lip of smokers, the soot in the scrotum of the chimney-sweep, or the irritation of old warts or moles, often, indeed in the majority of instances, lead to the development of epithelioma. The cells which have already been described, are irregular in shape, and 12 178 A SYSTEM OF SURGERY. Vary from ºth to 3% oth of an inch in diameter (Fig. 92). The nucleus contained is small and round. There are also “brood-cells,” and laminated Corpuscles. A peculiar fact is also noted by microscopists, that the nuclei of these cells become excessively enlarged, and appear as clear spaces. (d.) Melanosis—Melanotic Cancer.—The synonyms of this variety of cancer are “black cancer” and “carcinoma melanodes.” Melanosis is undoubtedly encephaloid or medullary cancer, with a de- posit of pigment throughout its substance. The history and symptoms are therefore very similar to those already noticed as belonging to that disease. The colors of this kind of cancer constitute its peculiarities; they are brown, bronze, and even black. In those cases of melanosis which have come under my observation the color was rather a dark plum color, and was interspersed throughout the growth without regularity, and in masses varying in size from a pea to that of a kidney-bean. It is understood that the pigment bears no especial relation to the malignancy of the disease, and that parts of an encephaloid may be entirely free from coloring-matter, while others may be very melanotic. . In primary melanotic cancers the structure is softer than other malig- nant growths of the same age. They make their appearance as infiltrations, but also may be circumscribed. The peculiarities of melanosis are, besides that of color, just noted, according to Sir James Paget, their proneness to appear near cutaneous moles, and their profuse multiplication. The color is due to the pigment cells, which are similar to those of the choroid coat, Or to those found above the basement membrane of the skin in the colored races. From the similarity which exists between the coloring matter of this form of cancer and that found in the lungs of aged people, some have sup- posed that melanosis is “a pigmental degeneration of cancer.” The second and third peculiarities are not well understood, although the last may be more apparent than real, the pigmentary deposit having a tendency to draw out and color many cells which otherwise would be unobservable. Ganghofner and Pribram” have given especial attention to the character of the urine in patients suffering from melanotic cancer, and find it contains a peculiar substance, chromogen, which varies with the specific gravity, viz., the Solid constituents of the urine. (e.) Colloid or Gelatiniform Cancer—Alveolar Cancer—Gum Cancer.—Ac- cording to Lebert this form of cancer is found oftener in men than in women, and appears most frequently in middle life; it is, however, rarer than either Scirrhus, encephaloid, or epithelioma. It attacks chiefly the mamma, stomach, and intestines, and may be present in the system with other forms of the disease. This form of cancer is essentially infiltrating, and sometimes attains con- siderable size, and from being in dense structure presents the sensation of fluctuation. Its name “alveolar cancer' is derived from the arrangement of the fibres of its stroma in large open meshes of transparent fibres, in which are seen rounded or oval nuclei. Lying in the interstices of these fibres is a transparent jelly-like substance, in which will be seen, under the microscope, cells of various sizes and shapes, the most characteristic being large, round, and flat, formed of a nucleus, around which are numerous concentric laminae, very much like an oyster-shell, besides which there are others which approach more or less closely to the forms usually seen in epithelioma (Fig. 93).-Holmes. The colloid matter itself varies greatly in different parts of the body. It generally resembles boiled starch, which has been strained, but not * London Medical Record, January 15th, 1877. OSTEOID CANCER. 179 allowed to become cool. It is slightly bluish in color, although its variations are very great. Sometimes it is greenish, sometimes pink; at others it may be opaque and brown, and resembles decomposing tuberculous matter. The growth and multiplication of colloid is most remarkable. I have removed two pailfuls of the substance from one patient, and in a second case, in which there were also many tuberculous deposits, about sixteen Quarts. In several other cysts of the ovary, I have taken away quite enormous quantities of this material. The main points of this peculiar formation are, that it presents structure which is most unlike the usual protein compounds, and is so dissimilar in structure from ordinary cancerous growths that some have denied it a place in the classification of that disease. Of this latter point Mr. Paget says FIG. 93. Colloid Cancer: a, epithelioid type; b, “round or oval” oyster-shell cells. Very characteristic.—Holmes. that its locations are the same as medullary cancer; that it infiltrates, it supersedes, and replaces the natural textures; it repeats itself in the lym- phatic glands and lungs; it is often associated with other forms of cancer; it recurs after removal, and is often hereditary. (f) Osteoid Cancer.—The appearance of true cancer, and in different varie- ties, in the osseous system, appears to contradict the opinion advanced by some pathologists that true cancerous growths are produced from external or glandular epithelia. There can be no doubt of the fact that cancer does attack the osseous system, and often develops first within the bones. It appears also that certain bone cancers are liable to occur in the same locali- ties, and to present the same histological species. The extremities of the 180 A SYSTEM OF SURGERY. humerus and femur are often affected with cancer; sometimes the cancel- lated structure appears to be the seat of the disease, while at others the periosteum is first involved. As soon as these parts are thoroughly infil- trated the cancer grows with great rapidity, and a delicate framework of Ossific matter is formed, which is filled with soft rapidly-growing cancer- nodules. Sometimes the tumor begins in the diploic structure, and may extend both within and without, perforating the bone both ways. -* - The form of these tumors is generally oval, and can be traced with the finger down to the bone from which they grow. The tissues around are in most instances in a healthy condition, although scattered throughout them Small masses of well-developed cancerous formation may be found. According to Sir James Paget “the unossified part of an osteoid cancer appears fasciculated or banded, and it is always very difficult to dissect. In some specimens, and in some parts, it has only a fibrous appearance, due to marking and wrinkling of a nearly homogeneous substance, in which abundant nuclei appear when acetic acid is added.” After an osteoid cancer has been macerated for a time, its central portion is found to be very dense and hard, difficult to cut, and incapable of being triturated. Around this the substance is more succulent. The duration of bony cancers is shorter than any other, and males are said to be more subject to the disorder than females. Amputation is generally all that can be done. (g.) Willous Cancer—Dendritic Vegetation.—In some cases there are found projecting from a fibrous or a mucous surface, sprouts of tissue in clusters and rows, or the stem may send out branches containing round protuber- ances, which are filled with cancer-cells. These are called by Rokitansky “dendritic vegetations.” This vegetation, according to Rokitansky, is composed of a structureless membrane, which is hollow and often attached to a fibrous stem. This may gradually enlarge until it becomes a sac; this sac contains a serous fluid, from which new vegetations are likely to spring. - Bloodvessels run in loops around the stems of these vegetations, and also in Some instances loop themselves around the protuberances and branches in an arborescent form. The villi themselves contain, besides the ordinary cancer-cell and nuclei of medullary and melanotic cancer, true epithelial cells. The gums and the bladder are the sites at which it is most frequently met. Treatment of Cancer.—Gross, speaking of the curability of this disease, says: “All internal remedies of whatever kind and character have proved unavailing. The vaunted specific of the empiric, and the enchanted draught of the honest but misguided enthusiast, have alike failed in performing a Solitary cure; and the science of the nineteenth century must confess, with shame and confusion, its utter inability to offer even any rational suggestion for the relief of this class of affections.”* Scarcely less strong are the words of Mr. Moore, f who writes: “No remedy is at present known to have a specific power of eradicating cancer, of neutralizing its taint, or alter- ing the nature of its growth. Scarcely less, in our present ignorance of the causes from which it springs, are we in a position to rely with confidence on any means for obviating its outbreak.” Mr. Thomas Bryant says, in his work: “The general treatment of cancer resolves itself into the improvement of the general health, and the nutrition of the body by hygienic means, good nutritious diet, and tonic medicines. No medicine has any special influence on the disease.” * System of Surgery, vol. i., p. 257. f Holmes's System of Surgery, vol. i., p. 593. j Practice of Surgery, p. 738. TREATMENT OF CANCER. 181 It is not necessary to multiply quotations on this subject from the allo- E. authorities of to-day; and I may remark, that the three that have een given were not selected on account of any peculiar force of expression, but were those that first came to hand in consulting works for the facts in the case. We may turn then with some feeling of satisfaction to our own literature, although at the outset we must regret that while throughout our periodicals there are many cases of “cancer’ reported cured, in very many of these the specific variety of the disease is not diagnosed. Cancer is, by the majority of surgeons, considered as a generic term, and has several important species. To group the scirrhus, medullary or encephaloid, melanotic, epi- thelial, and osteoid, as “cancer,” and in the report of a case to omit to diagnose the variety, is not sufficiently precise, leads us astray in our ideas, has a tendency to throw distrust upon our records, and gives us but little information for the treatment of subsequent cases. For instance, in a “Report of the Homoeopathic Institute of Leopoldstadt,”* there is a case of “cancer of the womb.” The variety of the disease is not mentioned, whether epithelial, scirrhous, vegetating epithelioma, or other. Bryonia removed the severe pains, and belladonna was given for the uterine tenes- mus; “the discharge diminished, and became less fetid, sleep and moderate appetite were established, and the patient felt so much stronger that she was enabled to undertake a journey.” Such a record really counts for nothing in the establishment of the superiority of homoeopathic treatment. Many such ulcerations are temporarily arrested by hygienic influences and the tonic system of treatment, as it is called, of the old school. This case is merely selected as one from many that are found in our literature, and can only be accepted as indicating that relief for a cancerous ulcer was obtained. So again, Dr. Bayest speaks of a case of “cancer of the lip ’’ (probably ulcerating epithelioma), which was arrested; cancer of the left breast, in which the tumor had almost entirely disappeared; and an “open cancer of the left breast,” which from the size of a half crown diminished to that of a pea. These and many cases that might be cited prove conclusively that there are certain medicines employed homoeopathically that can arrest “can- cerous” formations, but it is, as before stated, much to be lamented that more precise diagnoses have not been given in the cases. Chief among the medicines referred to in Dr. Bayes's paper is hydrastis can, I have used it frequently with excellent success, and from cases of my own, may affirm that its efficacy in cancer is chiefly in the epithelial variety; also that its action in other forms of the disease is correctly indicated by Dr. Bayes, who says: “My experience has thus led me to infer, that the remedial sphere of hydrastis is confined to the arrest and removal of scirrhus in its early stage, and chiefly when its situation is in a gland or in the immediate vicinity of a gland.” We have other reports, however, which are more conclusive. The remarkable case of Field Marshal Radetskyi is one that it is fair to set down as a cure of encephaloid of the eye. So also we find that Dr. Hughes $ has a most excellent case, quoted from Petroz, in which a woman under the care of Dr. L. Herminier had a suspicious ulcer of the tongue, involving the parts deeply. The doctor, distrusting his own diagnosis, sent her to Pro- fessor Mardolin, who returned the following: “Cancerous ulcer; no chance * British Journal of Homoeopathy, vol. xix., p. 144. f Ib., vol. xix., p. 150. f Ib., vol. i., p. 147. Being a series of letters which appeared in the Hom. Zeitung, July, 1841, by Dr. Hartung. 3 Therapeutics, p. 219. 182 A SYSTEM OF SURGERY. of cure but from operation, and this is impossible, for the base of the tongue is involved.” This case, which was probably one of epithelioma, was cured by the hydrocyanate of potassa, Thºth of a grain at a dose, º every fourth day. Eighteen years afterward there had been no relapse. : Stapf” reports a most interesting case of fungus hæmatodes oculi, which was completely cured. Belladonna removed the excessive photophobia and inflammation in six days; calcarea carb, cleared the cloudiness of the cornea; lycopodium, sepia, and silicea removed the fungous growth. The cure was complete. Mühlenbeini gives also a case of the same disease so diagnosed by several allopathic physicians and an experienced surgeon, in which belladonna, one drop at intervals of a week for four weeks, together with nux vomica, euphrasia, and aconite, completed the cure. Dr. von Vietiunghoff, i among his cases, has recorded one of encephaloid of the breast which is interesting. The pain was relieved by belladonna and bryonia in alternation, Phosphorus and hepar, also in alternation, materially improved the character of the discharge; arsenic caused sepa- ration and discharge of the tumor. After persevering with the latter for several months the cure was perfected. . - Other cases of this variety (encephaloid) of cancer are found throughout our literature. § Dr. G. M. Pease, in a short and practical paper on “Cancer,” mentions three cases, in two of which operations had been performed, and these are merely noted here, inasmuch as being under the carbolic acid treatment, one was alive five years, the other four years after operations had been per- formed. The third, however, a case of haematoid cancer, located on the right cheek, and extending to the ala of the nose, was cured by carbolic acid internally and externally with no return in three years. Dr. A. G. Beebe'ſ gives a case of melanotic cancer, cured chiefly by car- bolic acid and sanguinaria, the former for the specific disease, the latter for gastric disorders. During the first three weeks of treatment, the tumor was reduced to the size of a pin's head, and all suffering relieved. Ultimately, there was complete recovery. Dr. Leon” relates a case of carcinoma wteri which had not recurred after three years. The medicines were: arsenic, a dose night and morning for one week; conium 3 night and morning for one week. These medicines were continued four months in alternation, with an occasional dose of china as an intercurrent for haemorrhage. We must now turn to the consideration of Dr. Bayes's essays, it written especially with reference to the use of hydrastis can, in the treatment of cancer; and for brevity’s sake will merely introduce his table appearing at the end of his second paper. He also includes in these statistics Dr. Brad- shaw's ji cases, offering additional testimony to the beneficial effect of the “Golden Seal.” These papers certainly show (although the percentage of cures is small) that this medicine does possess more or less influence over the disease; but * Archiv. für die Homoepathische Heilkunst, vol. vii. + Loc. cit. (both these cases are recorded in Dr. Jeanes's Homoeopathic Practice). † British Journal of Homoeopathy, vol. xvii., p. 53. ź British Journal of Homoeopathy, vol. xxvi., p.658. Dr. Quinn's case in the Annals, vol. i, p. 177, quoted by Hughes. Fungus haematodes, Dr. Hughes, British Journal of Homoeop- athy, vol. xxviii., p. 795. | Transactions of the American Institute of Homoeopathy, 1872, p. 390. Medical Investigator, vol. xi., p. 549. ** United States Journal of Homoeopathy, vol. i., p. 41. fi Hydrastis can. in Cancer, B. J., vol. xix.; also, loc. cit., vol. xx., p. 1. If A Few Remarks on Hydrastis, B. J. H., 1861, vol. xviii., p. 598. TREATMENT OF CANCER. 183 when the question arises as to the comparative efficacy of homoeopathic treatment combined with surgical operations, I think it may be shown that a better result is obtained with the knife than without it. Of the following twenty-three cases, six are diagnosed as scirrhus, thirteen as cancer (ulcerated or otherwise), one as fungus hapmatodes, and three as cancerous tumors. The results of the treatment are as follows: three were cured; in six others there was “improvement;” in three “arrest of develop- ment;” and in six, relief from pain was noticed; while again in five others “no effect” was produced. It would be interesting to the operating sur- geon to ascertain how long the three cases remained cured; and if in any there was a recurrence of the disease, at what time the symptoms were de- veloped. Until this point be clearly settled, the vexed question as to the expediency of operative interference with the knife, cannot be satisfactorily determined. Few operations for cancer, especially of the lip and mamma, are not followed by a more or less complete exemption from the disease for one, two, or even three years; but even then the conscientious sur- geon would scarcely be justified in announcing a complete cure of the affection. Q e - 3 % | Sex. Disease. LOCation. Result. & | cº e e e tº gº . 215 And again : Patients affected with simple chancre, © e tº º e . . 207 Simple chancre with bubo, e e g © tº , e g . 65 Simple chancre without bubo, . tº º $º e © tº . . 142 The above statistics should be carefully treasured for diagnosis. Simple chancres are not generally found upon the head. Indeed, Ricord has asserted that they are never found in that locality. Indurated chancre can be generated anywhere on the surface of the body. Here, again, is a remarkable fact, a curious circumstance in the history of chancre, which cannot be explained. Ricord himself most positively states the fact of the immunity of the cephalic region from soft chancre; and if we even may suppose him to err in regard to the invariability of location, it still remains an unexplained mystery, that during twenty-five or thirty years of constant daily attendance upon the numbers of patients presenting them- selves for treatment, with all varieties and forms of syphilis, he should not have been able to detect a simple cephalic chancre. He is very positive on this subject. He remarks: “I have shown to you in my wards numerous CHANCROID, 223 examples of the soft chancre developed upon different regions of the body, upon the genital organs, upon the thighs, upon the legs, the arms, the abdomen, the back, the chest, etc... I have shown them to you everywhere except on one point, the cephalic region. . It is a fact, gentlemen, that during five-and-twenty years of practice, I have never met with a single well authenticated case of soft chancre developed upon the face or upon the head.” . Mr. Fournier has drawn up a table of observations made upon 824 patients, in whom the seat of the chancre, has been noticed with precision. This is so interesting that it is given in full: Patients affected with, Indurated. Simple. Chancres on glans and prepuce, . ge º * e g . 314 296 Chancres on integument of penis, . . * § tº . 60 15 Multiple chancres on the penis, that is to say, presenting sim- ultaneously chancres on the prepuce and integuments, the integuments and glans, etc., to tº * wº te . 11 17 Chancres on the meatus urinarius, . © ſº º gº . 32 9 Intra-urethral chancres, which cannot be perceived by the forced separation of the lips of the meatus; diagnosed by in- oculation, by the touch, by lymphangitis, e e . 17 3 Chancres on the scrotum, . © ſº e 7 6 & “ peno-scrotal groove, . 4 ( & “ arms, e e * * 6 2 6& “ lips, . Q 12 {{ “ tongue, 3 & 4 “ nose, . tº ſº e tº 1 ( & “ palatine membrane, . . 1 6 & “ eyelids, tº tº 1 £4 “ fingers, I {{ {{ leg, 1. The above is a curious table, and when carefully studied, will assist in the establishment of a correct diagnosis, not, probably, with the utmost precision, but may prove indicative of the nature of the sore, when other symptoms are perhaps obscure. It may in other cases add another confir- matory evidence to a doubtful diagnosis. A peculiarity of the chancroid, also, is found in the fact, that its admix- ture with another virus does not impair its power, and that, as has been before said, it is very likely to assume a phagedenic complication. A Phagedenic Chancroid is usually very rapid and destructive in its prog- ress, increasing in extent but not in depth, and accompanied with severe pain. Its extension is irregular and serpiginous. It occurs generally in constitutions worn out by intemperance, and follows very often irritating dressings which have been injudiciously applied to irritated or inflamed chancres, especially mercurial ointment. It was called the black slough, in England. There is a form of phagedenic sore called the diphtheritic or pultaceous, which is exceedingly chronic (Ricord has seen it last for seven years); it is covered, either entirely or partially, by a pultaceous diphtheritic secre- tion. The base is oedematous, and the edges are elevated, irregular, and serrated ; it is surrounded by a dull purple areola, and it increases by successive ulceration of the depending parts. The constitution becomes seriously implicated and the patient finally sinks. This form of chancre j in ill-fed, badly-lodged individuals, in whom there is previous organic IS63,Sé. In some cases, chancroid becomes gangrenous. In such a case the destruc- tion of the tissue proceeds so rapidly that the whole glans is destroyed in a short period. . 224 A SYSTEM OF SURGERY. Chancroids of the Urethra.-The presence of the virus in the urethra gives rise to chancroids, which are generally found at the fossa navicularis, and may in some instances be visible by stretching widely apart the walls of the canal, or by the use of the endoscope. When lower down, they are some- times very difficult to diagnose. The discharge is generally not so profuse as in gonorrhoea, and by pressing the finger along the under surface of the urethra, a distinct spot will be indicated more painful than others. If with these symptoms a symptomatic bubo be present, additional light is thrown upon the diagnosis. Treatment.—It necessarily follows from the above detailed account of chancroid, that a merely local treatment is necessary, unless there be some indications by symptoms, for the administration of internal medicine. The Sooner the sore is cauterized the better, and the less likelihood will there be to the formation of bubo. I believe it was the general practice of homoeopathic practitioners some years back, adhering to the doctrine of immediate constitutional contami- nation, and not being acquainted with the duality of the virus, to commence with the internal treatment of the disorder, the medicines most generally used being the mercurial preparations, administered both internally and externally; the latter by sprinkling mercurius solubilis upon the ulcerated surface. Since, however, a new pathology has been adopted, a different method must be resorted to; for the chancroid, a local treatment; for chancre, as before, immediate constitutional medication. It is impossible for thinking, reading, and observing men to ignore all the teachings and experience of those who have devoted so much time in examining, testing, and treating the disorder under consideration and I cheerfully receive this accumulated evidence of large experience and accumulated facts, with that thankfulness which all should experience who are desirous for the progress of truth and science. Therefore, in acknowl- edging the correctness of Ricord's views of the nature of chancroid, no want of faith in other medical doctrines should be imputed, nor in the treatment of the simple venereal ulcer upon the principle of Ricord, can the Hahnemannian be charged with deviating from the law of similia. Let us examine this matter thoughtfully. Let us test it with our judgment and with our daily experience. We are informed by a man of acknowledged reputation and talent, who has spent thirty years in investigating all the minutiae of venereal disorders, who has been placed by governmental direction as the chief of a hospital devoted to the treatment of the disease, and who is supported by many of the most competent and learned men of the times, that the simple chancre is a local sore—that it is the product of a virus highly contagious in char- acter—nothing more, nothing less. Thousands of cases can be brought forward to establish the truth of this assertion, and the records of the hos- pital furnish evidence of the fact, which is confirmed by successful treat- ment, and this treatment is par excellence the abortive. “Ah!” says the opponent, “where is your principle of similia similibus?—where are your medicines given in infinitesimal doses?” In reply to which I would say: “Recollect, in the treatment of the simple chancre—of the local sore (and of this only I am speaking), we have not an ordinary ulcer; we have locally poisonous pus to encounter.” The treatment is essentially surgical in its character. What same man, when called to a case of poisoning with arsenic or corro- sive sublimate, or lead, or zinc, would commence with the administration of homoeopathic medicines before he had antidoted or destroyed the noxious substance in the stomach 2 And would he be less the homoeopathic physi- TREATMENT OF CHANCEOID. 225 cian because he administered, to neutralize the poison, tablespoonful doses of the hydrated peroxide of iron, or the sulphate of soda, at five or ten minute intervals? The treatment of the simple, or the non-infecting chancre, must tend to the rapid destruction of the poison, or in the words of the Syphilograph, “To reduce the specific ulceration to the state of a common ulcer, and to transform a wound possessing a special principle for its maintenance, into a wound which has no longer such a resource.” With the indurated chancre the treatment must be different. In reference to the caustic to be employed, Ricord says: “Reject at once all mild caustics, which only act more or less as anodynes. That which is required in this instance, is a destructive agent. To which, then, should we give preference? I have successively tried the Vienna paste, potash, nitric acid, the actual cautery, etc. All these have FIG. 99. inconveniences which I need not point out to you, as I have gº to propose to you a new agent particularly efficacious. This caustic consists of sulphuric acid, mixed with powdered vege- table charcoal, in the proportions necessary to form a half-solid paste.” Here, then, is the substance to destroy a poison, to convert a chancre into a simple wound, which will proceed rapidly to cicatrization. I believe this treatment to be the correct one ; and since the first perusal of these clinical lectures in July, 1860, I have had opportunities to test its efficacy in very many cases of chancroid, in both private and hospital practice, and with satisfactory results. Define well the chancroid, find it to be certainly the non-contagious ulcer, and no internal medicine will be required. Professor Bumstead employs nitric acid, which may be used with a glass rod, or with a small piece of wood. Canguoin's paste is used by Diday, and is made of chlo- ride of zinc and flour in equal proportions. An excellent application can be made of chloride of zinc, flour, and the submuriate of hydrastin, after the manner recommended by Marsden and MacLimont for the removal of tumors. As soon as the eschar has separated, lint saturated with aromatic wine may be used as a dressing. I have also used with advantage a preparation of glycerine and carbolic acid, in the proportion of ten drops of the latter to an ounce and ~ | a half of the former. Whatever application be made, a most essential part of the treatment is cleanliness—frequent washings of the part tº . castile soap and water, and the frequent substitution of clean for soiled ressings. For this purpose, if we have reason to believe that the ulcer is deep in the urethra, the syringe of Bumstead, modified by Dr. R. W. Taylor, of the New York Dispensary, vide Fig. 99, is very efficacious. It consists of a hard-rubber tube, and is six inches long, having a longer curve than the short one of Thompson, at the end of which is an acorn-shaped bulb or head. This bulb is perforated upon its tapering sides by twelve very minute holes, which are arranged in four rows of three holes each, placed equidis- tantly around the head. The apex of the bulb is somewhat rounded, so that in introduction the folds of the urethral membrane are not wounded ; its base also rounds off, and presents a shoulder before it merges into the shaft. The tubes are made of various sizes, corresponding to Nos. 4, 6, 8, and 10 of the English scale, while the widest portion of the bulb is two sizes larger 15 226 A SYSTEM OF SURGERY. than the shaft. There is also a button of hard rubber which slides upon the shaft, by means of which precision of injection is obtained.” There are many advantages gained by the use of this excellent instru- ment in those cases which require direct applications to deep portions of the urethra. CHAPTER XIII. SYPHILIS—GENERAL CONSIDERATIONs—CHANCRE–DIFFERENTIAL DIAGNOSIS BETWEEN CHANCRE AND CHANCROID—BUBo—ConstLTUTIONAL SYPHILIs—AFFECTIONS OF THE SEIN–TERTIARY FORMS-SYPHILITIC IRITIS-SYPHILIS OF THE LARYNX- SYPHILIZATION.—FUMIGATION.—INUNCTION.—INFANTILE SYPHILIS. SYPHILIS is a disease caused by a morbid principle or poison, which, applied under certain conditions to any portion of the human body, will produce definite and characteristic phenomena; this principle being ab- sorbed and carried into the system will, during the existence of the local or primary symptoms, and for an indefinite period subsequent to their ces- sation, contaminate the economy; and, finally, this principle is capable of being transmitted hereditarily, and that, too, at a period when its presence in the system is not revealed by any external sign. This capability of quie- tude for a number of years within the organism, without producing in the meantime any appreciable effect upon it, is a character not peculiar to the syphilitic poison. Another feature also is that one attack of the disease, in the majority of instances, will protect from another. Mr. Hutchinson and many others believe that syphilis is a specific fever, which has a period of incubation, an exanthematous stage, and sequelae; that it is a disease of the blood during the exanthematous stage (secondary), as shown by the symmetrical eruption; that the sequelae (tertiary symptoms) are not due to a disease of the blood, as is shown by their being non-sym- metrical and non-contagious; that the secondary stage is due to the multi- plication of germs; that the tertiary growths are due to the development of some localized products left by the secondary stage; that the tertiary de- posits differ from the secondary, in being purely local affections; and that the pathology of syphilis is only to be explained by the hypothesis of a syphil- itic yeast. To these views, Sir James Paget says, that the action of specific remedies on tertiary symptoms, and the inheritance of syphilis by children begotten by parents in the tertiary stage, show that it is a blood disease in all stages; that blood diseases do not necessarily show symmetrical erup- tions—typhoid fever, for example; that the “cryptogamic germ poison’’ is urely hypothetical; that there is no evidence that deposits are left over }. the secondary stage from which gummata can develop, and that his explanation of syphilitic inheritance, upon the theory that germs still hold possession of the testis and ovary when they no longer exist free in the blood, is purely imaginary, and has no basis of observation. Fessenden N. Otis, M.D., f speaking of the transference of syphilis by con- tagion, thus remarks: - The assumption is warranted that the disease germs of contagious dis- eases are degraded cells (bioplasts), originally derived from the healthy elements of the human organism, but which by degradation have lost their capacity for proper development into useful tissue. Germinal cells from * American Journal of Syphilography and Dermatology, October, 1870. # The Medical Record, August 17th, 1878, No. 406. SYPHILIS—GENERAL CONSIDERATIONS. 227 one source cannot come in contact with those of an independent Organism without a breach of tissue. The modes of transference of syphilis from the diseased to the healthy are three: 1. By direct contact of the diseased surface with an abrasion, or other breach of tissue on a healthy person. - 2. By immediate contagion. 3. By hereditary transmission. Communication of the disease by direct contact (as in the act) is the most frequent mode of the acquirement; yet it may be produced by many inci- dental causes, as through the act of simply kissing; by pipes passing from syphilitic to healthy persons; canes, pencils, and even sticks have been known to bring the contagion. Medical students, from contact with bodies tainted with the disease, have been known to be infected ; and cases have been known in which the only clue to the acquirement of the disease was the habit of passing among numerous clerks and occasionally transferring a lead-pencil from the desk to the mouth, doubtless belonging to an infected €I'SOI). - p Mr. Hutchinson * affirms that a mother can be infected from the foetus in utero, and become syphilitic without symptoms; thus communicating the disease to a second child without showing any manifestations herself. Dr. F. J. Bumstead, in an articlef criticizing Mr. Hutchinson's expression of views on this subject, asserts that the term “duality of syphilis” really signifies a duality, not in syphilis, but in what had been known as syphilis and called by that name. Otherwise, he observes, we must adopt the ridicu- lous supposition that so-called “dualists” believe in two kinds of syphilitic virus, whereas they have simply maintained that there exists, independent of the syphilitic virus, another contagious principle, giving rise to a local Sore known as chancroid. If Mr. Hutchinson intends to limit the power of pro- ducing the soft chancre to contagion with inflammatory products arising from syphilis, Dr. Bumstead considers him in error, since sores precisely similar to the chancroid have been produced by other inflammatory pro- ducts. Mr. Hutchinson's view, however, that the chancroid, instead of being dependent upon a distinct specific virus, incapable of spontaneous generation, is the result of inflammatory products, and hence, that if every chancroid now existing were exterminated, new chancroids would arise; this, Dr. B. thinks, has strong arguments in its favor, and may be looked upon as a step in advance, suggesting an interesting analogy with the his- tory of gonorrhoea during the last fifty years. Finally, Dr. Bumstead declares his belief that “dualism'' still lives, and that Mr. Hutchinson is, in fact, one of its most advanced apostles. - The classification of venereal diseases is as follows: 1. Primitive or direct, when they occur at the inoculated spot, from the immediate action of the virus. 2. Successive, when they originate in the latter, and are pro- duced elsewhere by absorption, or contiguity of tissue, or accidental contact, as chancrous bubo, and the conversion of neighboring abrasions, or leech- bites, into chancres. 3. Secondary, when the skin and mucous membranes are affected after the reception of chancrous matter into the system ; and 4. Tertiary, when the cellular, fibrous, and bony structures are the seat of the constitutional symptoms. 5. Diseases unconnected with syphilis. Concerning this classification, however, it has been remarked that it is unphilosophical and wanting in simplicity, and that many of the grounds on which it is founded are incorrect and untenable. The first two may cer- tainly, without violence, be included under one head; the second and third * Month. Abstract of Medical Science, May, 1876. f N. Y. Med. Record, June 17th, 1876. 228 - A SYSTEM OF SURGERY. divisions are not susceptible of separation on the grounds given by Dr. Ricord. The so-called tertiary symptoms may arise without the necessary intervention of the secondary. Dr. Ricord asserts, that whilst the former may be transmitted hereditarily, the latter cannot be, except in a degen- erated form, as scrofula. This, however, is not well substantiated, and many of the profession believe both secondary and tertiary syphilis equally liable to propagation by inheritance. With regard to the fifth class, viz., “diseases unconnected with syphilis,” it is difficult to understand what is meant. The whole subject may be much simplified by dividing it into primary, secondary, and tertiary. e Before proceeding further, it is well to mention here a peculiar fact; that great and multiform as are the effects of the syphilitic virus; acknowledged as it is by the whole profession to possess a power so mighty that almost every structure of the human body is obnoxious to its effects—skin, bone, muscle, tendon, and periosteum ; that it is not confined to the person attacked, but may be transmitted hereditarily from generation to generation, yet the most powerful microscope cannot find it, nor can the most carefully conducted chemical analysis detect it. This may be an argument in favor of infinitesimal power, and certainly is one that cannot fail to be acknowl- edged by every physician and surgeon. Syphilis, as a general rule, occurs but once in the same person during a life- time, although there may be, no doubt, exceptions (which, however, prove the rule), as are noted in measles, whooping-cough, scarlatina, and other disorders; but it must be here borne in mind that a person who has suffered from a syphilitic attack, is not protected from another from the chancroid, nor, on the other hand, does a succession of chancroids prevent syphilitic inoculation. Diday, as quoted by Bumstead, says: “1. As a general rule, the syphilitic, like other kinds of virus, does not exercise the same action twice in succession upon the same individual. “2. When applied (under such conditions as to permit absorption) to a syphilitic subject, this virus produces no effect. Applied to a subject who º but who no longer has, syphilis, it produces a modified form of Sypnl 11s. p “3. The more feeble the first attack, and the longer the time that has since elapsed, the more energetic will be the action of the virus, and the more severe will be the second attack of syphilis, and vice versa.” True chancre is often superlicial, and is then rather more difficult to diag- nose, especially in the earlier stages, but the induration and hardness of the ganglia assist materially in the case. s The true chancre is excessively indolent; the surface is smooth and larda- ceous; the parts seem to have been taken out with a gouge; the edges of the chancre are gradually lost in the floor of the ulceration, and the indu- ration extends above and around it. The solution of continuity is generally single, although this is not invariably the case; it has no disposition to in- vade the neighboring structures, but soon defines its limits, and always has enlargement of the inguinal glands, which become in a short period indu- rated, although rarely proceeding by themselves to suppuration. Among the indurated chancres treated by M. Ricord during the whole year 1856, three only were found accompanied with suppurating buboes. In these three cases, the suppuration was only produced consecutively to a strumous degeneration of the glands, the pus being twice tested by inoculation, and found negative. - Ricord says: “There can be no infecting chancre without an indurated symptomatic bubo. This may be called without hesitation a pathological law.” And again : “Never neglect, therefore, when examining a patient affected with constitutional disease, who denies suspicious antecedents of DIAGNOSIS OF CHANCRF. - 229 every kind, to interrogate the glands. Specific adenopathy is, for the in- fecting chancre, an effect which follows its cause.” With regard to the earlier symptoms of syphilis, Dr. F. N. Otis says:* “The only constant feature of all lesions, during the active stage of syphilis, is shown by microscopic examination to consist in a localized cell-accumu- lation. Neither inflammation nor ulceration are essential features in syphilitic inoculation. It is the local conditions at the point of inoculation that must be looked to for the earliest evidences of syphilitic action; where, through the microscope, densely packed non-inflammatory cell-accumulation may be discovered. The same cell-accumulation is seen to occur in the lymphatic vessels connecting the initial lesion with the adjacent lymphatic glands. In all cases possible, the person from whom syphilis may have been acquired should be examined. Search should be made, not only for initial lesion, but for possible secondary manifestations.” He cites a case in which a man (apt. 23), “on the 14th day after his first and only connection, had a slight urethral discharge, which was found entirely purulent—no pain on urination. It was evidently not gonorrhoeal. A syphilitic inoculation was suspected. The woman on examination was found to be passing through the active stages of syphilis. Patient entirely recovered, and up to the present has not had the slightest evidence of syphilitic trouble.” These, then, are the chief points in the differential diagnosis of the two great divisions of chancre, and so far as they can be gleaned from a careful study, backed by considerable experience, they have been concisely ex- pressed. The establishment of a correct diagnosis between the chancre and chancroid is however of such importance to those who expect to treat chancre successfully, that the distinguishing marks have been arranged and placed side by side; and, at the same time, the peculiar nature of the adenite follow- ing each is also embraced in the classification, to facilitate, if possible, their more ready recognition. It must be remembered that the appearances pre- sented by the two varieties of chancre are similar in their very early stages. We then have the following: DIFFERENTIAL DIAGNOSIS OF CHANCR.E. SIMPLE NON-INFECTING CHANCRES. INDURATED INFECTING CHANCRES. 1. No period of incubation. 1. Period of incubation from seven days to • seven weeks. 2. Never, excepting in exceptional cases, 2. Every part of the body liable to inva- noticed upon the cephalic region. sion (therefore chancre on the head may be pronounced infecting). 3. Develops rapidly. 3. Develops slowly. 4. Surface irregular; floor fretted, or worm- 4. Surface smooth; floor lardaceous. eaten. 5. Edges neatly shaped, cut perpendicu- 5. Edges sloping, as though made by a larly, as if cut out with a punch. gouge. 6. Edges undermined. 6. Edges adherent. 7. Border abrupt. 7. Border gradually lost in the floor of the ulceration, giving to the ulcer the ap- pearance of a cupola. 8. No induration. 8. Induration surrounding the ulcer on * all sides, forming for it a kind of bed (pathognomonic). 9. No induration. 9. Induration commences from the first (if not produced in a few days, will not become so). 10. Suppurates profusely; the suppuration 10. Suppurates little, producing but a small being one of the most fertile sources quantity of serosity, most frequently from which the poison is derived. sanious and ill-formed. * The Medical Record, August 31st, 1878, No. 408. 230 A SYSTEM OF SURGERY. SIMPLE NON-INFECTING CHANCRES. 11. Pus in the highest degree contagious; persisting during the entire existence of the chancre. 12. Generally multiple from its origin, or becomes so by inoculation. 13. Tendency to invade the neighboring structures. - 14. The simple chancre is most likely to un- dergo the phagedenic complication. 15. In virgin subjects, transmitted in its form —that is a simple chancroid. 16. Transmitted to syphilitic subjects, either as a simple or an indurated chancre; the form which is reproduced probably depending on the nature of its origin —that is to say, the chancre which gives birth to it. SIMPLE NON-INFECTING CHANCEE, IBUIBO. 17. Not necessarily present. 18. Monoglandular. 19. Suppurating almost certainly, and fur- nishing generally an inoculable pus. 20. No fixed period of development. INDURATED INFECTING CHANCRES. 11. Pus rapidly loses its specificity, at all events for the infected subject, who in a few days becomes refractory to inoculation with his own virus. 12. Generally solitary; in most cases a single chancre giving rise to conta- glon. 13. Inverse disposition; its limits soon de- fined. - 14. Rarely assumes the phagedenic devia- tion. 15. Transmitted in its species in virgin subjects, that is to say, an indurated chancre. - 16. Transmitted to previously infected sub- jects, under the form of a chancre with a soft base, analogous in appearance to the complication. INDURATED INFECTING CHANCRE, IBURO. 17. No infecting chancre, without an indu- rated symptomatic bubo. 18. Affecting several or all the glands. 19. Extreme hardness; independent of each other; no tendency of themselves to inflammation or suppuration. 20. Produced in course of first or second week; rarely noticed later; generally coincident with induration. A peculiar feature in chancre is the rapid zymosis that takes place, which, however, is in the main denied by some syphilographers, among whom is Ricord. He says,” “Of all the chancres which I have seen cauterized, or cauterized myself, not one has ever been followed by the special symptoms of constitutional syphilis. From this it would appear that during the first four days which follow contagion the syphilitic seed has not sufficiently implanted its roots in the economy, and that, if you are in time to destroy it, you ward off the general intoxication—you kill the syphilis in its germ.” The last few words of this quotation give evidence that Ricord believes the chancre to be the primary cause, and not an effect. Would cauterizing the bite of a mad dog when the hydrophobic virus had been circulating in the system for months prevent hydrophobia? Would cauterizing the snake- bite when the system showed evidence of a thorough zymotic influence re- lieve the patient? There is at present the greatest amount of evidence to show that the application of escharotics immediately after the introduction of the poison does not prevent syphilis. Diday, Bumstead, and Langston Parker have proved by experiments, that a most thorough cauterization, even to the depth of half an inch, but two hours after the appearance of the ulcer, was followed by severe syphilitic symptoms. Treatment.—The treatment of chancre is in direct contrast with that rec- ommended for chancroid; the former was antidoting a local poison by the application of caustics, which are hurtful to the true chancre. The ulcera- tion gives the evidence of the constitutional disease; it tells us that the system is affected, and that constitutional means must be employed. Syphilis being immediate after the impure coit, and the chancre the evidence * Work on Chancre, p. 147. TREATMENT OF CHANCRE. 231 of the poison, the sooner the treatment is begun the better. In the majority of instances, however, relief is not sought until the initial lesion has devel- oped itself. I have been very successful with a comparatively simple method of treatment. In the first place great attention must be paid to cleanliness, the chancre must be carefully washed with castile soap and water, and upon it a pledget of lint laid, moistened with calendula solution, one part of the tincture to four of water. This must be changed three times a day. I then administer two grains of the first decimal trituration of the protoiodide of mercury every night and morning for one week. The next week, every night; the third week, every other night, and then continue at intervals until the sore has healed, which will generally take place in about six or eight weeks. The patient must be told to have patience, the case be thor- oughly explained to him from the commencement, and, I believe, in the majority of cases, the treatment will be successful. I have experimented with the deutoiodide and red oxide, with cinnabar and Hahnemann’s solu- bilis, but must give the preference to the preparation I have recommended. In many cases of syphilis the patient is excessively weak, and morbid states of the appetite and spirits manifest themselves, for which appropriate medi- cation, as symptoms present, must be resorted to. As a general rule, the first trituration of ferrum, three grains given every morning, and a similar Quantity at night, will be of great service. When the chancre appears to remain in statu quo, I am in the habit of touching the sore with the oint- ment of nitrate of mercury, mixed with five parts of simple cerate; or of applying lightly nitric acid. When there is a tendency to phagedaena, then the bichloride of mercury must be used as low as the second decimal, given often, and, perhaps, if there be a tendency to gangrene, alternated with the second trituration of the iodide of arsenic, and the sore cauterized with fuming nitric acid or the actual cautery. This must be done fearlessly. I am guided by a somewhat large experience in the disease, and am forced to the conclusion that medicines must be given materially, and repeatedly, if we desire to effect cures. No one can deny that the pathogeneses of the preparations of mercury and arsenic resemble in almost every particular the diseases we are expecting to combat, and I would have all interested give the mercury treatment just recommended a fair trial. Dr. Attomyr observes: “Syphilitic patients, with very few exceptions, are young unmarried men, who either board at the hotels or sit at table with their relations or probably superiors. In either case it is unfortunate for the observation of homoeopathic diet. To this must be added the fact that patients conceal their disorders, and in order not to excite suspicion, dare not venture on the slightest aberration from their accustomed diet. In consequence of these adverse dietetic circumstances, I resolved in treating such patients to administer larger doses than usual. - “I am still of opinion that the lower dilutions recall reaction quicker, but that their effects are less extensive and permanent than the higher. Four grains of calomel in the space of a few hours operate violently and excite diarrhoea, while the same four grains, if taken in minute portions, result in an indisposition, which continues several days, and in more intense com- motion of the organism. I moreover concluded from these premises that the larger doses could be repeated more frequently, which would seem essential, on account of the necessary dietetical errors. Within the period of two years I treated one hundred and fifty-six patients laboring under venereal disease. Every physician knows how it is with office practice, how difficult to learn anything, or obtain any certain experience in this manner. Generally one half of this class of patients stay away, so that it is impossible for us to decide with certainty upon the termination of their dis- orders. The one remains away because the effects of the treatment did not 232 A SYSTEM OF SURGERY. fulfil his anticipations, the other (and among syphilitic patients the major- ity), because he is approaching convalescence, and is desirous of avoiding the burdensome thanksgiving of his cure.” Dr. Attomyr also states that out of the one hundred and fifty-six patients, so many did not return to men- tion the success of the treatment, that only eighty-four can be cited as being perfectly cured. The medicines that have been found most efficacious in the treatment of syphilis are, besides the protoiodide of mercury already mentioned: Merc. Sol., merc. corr., merc. biniod, acid. nit., hepar sulph., acid. phosph., lyc., sulph., silic., ars, carbo. Veg, thuj., and sepia. I am aware that there are some who positively assert that mercury and its compounds are not applicable to syphilis; that the disease is aggravated by their exhibition, and that many of those disastrous conditions character- istic of the later stages of the affection, are attributable to the use of this drug. From an extended experience I must positively say, that there is, in my opinion, no drug in the pharmacopoeia that can compare with mercury in the treatment of primary syphilis, even when the rash is present. That the disease is augmented and the secondary and tertiary symptoms compli- cated by the injudicious use of mercury is also a fact, but I think it may be stated, that since the days of massive doses of mercury have passed, and those of minute doses of the drug have succeeded, the treatment of syphilis has been much more satisfactory in all its stages. As years have added experience to my method of practice, I must, after watching patients who have undergone this method of treatment, again assert positively, that mer- cury possesses great power over syphilis in all its stages. There are, however, some cases in which mercury must be considered entirely inapplicable. It should never be given in the doses mentioned, when the patient suffers from tuberculosis, whether in the active or passive form. In such cases the 3d or 6th decimal dilution should be given, and when Bright's disease is present, either in its incipient or advanced stages, the 1st or 2d trit. of the bichloride should take the place of the protoiodide. Of the different preparations of iodine, the potassium iodide is remark- able for its efficacy in the treatment of the more remote symptoms of syph- ilis. The action of the drug is not nearly so profound as that of mercury, but will not disappoint the practitioner, especially in the secondary stages. My favorite prescription is the following very simple one: B. Kali hydriod., Aqua cinnamomi, aā . . . . . . . . . . . . . . . . 3ss. M. ft. Sol. S. Seven drops in half a tumblerful of milk three times a day. Seven drops of the above solution represent just five grains of the salt, and after the patient has taken this dose for about a week, ten drops are to be given at each dose for a second week, and fourteen for the succeeding week. The patient is always told that if symptoms of catarrh, or the ap- pearance of pimples upon the forehead and shoulders should result, the medicine must be stopped for a week and then resumed. At the present, some syphilographs recommend the employment of the iodide of potassium in tremendous quantities—100 to 150 grains a day, and . even more, being given. Of this I shall say a few words at the end of the chapter, when again referring to the effect of the potassium iodide. In some old and obstinate cases, mercury and potash may be combined, and then it is better to employ the biniodide of mercury. A peremptory duty of the surgeon after he has recognized the undoubted presence of syphilis, is to explain to the patient the contagiousness of the disease, and prohibit all sexual communication during the existence of the initial lesion, and for some time after the sore has disappeared. Precise BUBO. 233 directions should be given to avoid all risks of communicating the disease by kissing, and in the use of cups, tumblers, or other articles, which are used by those suffering from lesions of the lips and throat; as has already been mentioned pencils, pens, paper-knives, etc., having been held in the mouths of syphilitic patients, can propagate the contagion, and, therefore, care in the use of such articles must be impressed upon the patient. $ The frequent use of the bath is another item in the treatment which is of especial import. Daily ablutions, not only of the parts, but, if practicable, of the entire person, should be practiced. Turkish baths once or twice a week are often very serviceable. The treatment by inunction and fumigation will be found at the end of this chapter. º Aur., caust., china, dulc., and staphis., may also sometimes be requisite in the treatment of chancre. - Bubo.—After what has been already written regarding buboes and their relative frequency and appearances in the chancroid and chancre, the sub- ject will receive but a limited notice. The proper study of these adenoid troubles must be in connection with the disorders of which they are con- comitants. - Bubo always takes place in those lymphatic glands in the immediate neighborhood of chancre, while the deeper-seated and remote glands remain uncontaminated, or at least do not enlarge or suppurate. As chancre gener- ally occupies some part of the penis, the glands of the groin are the ones most commonly affected. Sometimes several glands are enlarged and form a cluster; but according to Mr. Hunter one gland only is usually affected. A suppurating bubo does not invariably follow a chancre, and yet the system is not less liable in such cases to contamination. This circumstance, amongst others, has induced some surgeons to believe that bubo does not arise, as is commonly imagined, from the absorption of venereal virus, but from an inflammation in the extremities of the lymphatics excited by chancre.” Bubo seldom arises from a chronic chancre, but usually makes its appearance soon after the sore is established. It is more frequently observed to follow venereal ulcers on the prepuce or franum, than those situated on the glans penis,j and is late or early in its appearance according to the degree of inflammation existing in the sore. Oftentimes a bubo remains stationary for weeks, neither tending towards resolution nor suppu- ration; in general, however, it is of a bright Scarlet color, exceedingly painful, and suppuration is speedily established. Sometimes erysipelatous inflam- mation is present. The ulceration which follows a bubo does not differ from that of common chancre, and the matter from it is equally infectious. The bottom of the ulcer is hard and solid to the touch, and the surface either of a dark-red or brownish color, or of a yellowish cast. -- ‘. . Very extensive ulcerations now and then follow a bubo. I have seen instances in which each groin and the greater part of the pubes have been laid bare by the severity of the affection. In certain constitutions buboes degenerate into insensible and very troublesome fistulae that are exceed- ingly perplexing to treat. In some instances the skin covering a bubo entirely closes, but not uniting with the parts beneath, leaves a hollow from which in a short time a thin serum is discharged through small holes or pores formed in the skin. In such cases, the integuments generally assume a leaden or bluish color, and present an unhealthy aspect. t Swelling of the inguinal glands also, frequently arises from other causes than the absorption of syphilitic virus. For example, from wounds * See Allan's Surgery, vol. i., p. 200. - - f Gibson's Institutes and Practice of Surgery, vol. i., p. 339. 234 A SYSTEM OF SURGERY. or injuries of the foot, from colds, fevers, and from irritating applications. Such swellings are very difficult to distinguish from the true venereal bubo. The surgeon, therefore, must carefully inquire into the history of each indi- vidual case before he ventures to give a decided opinion respecting its nature. In the treatment of syphilitic buboes, there are three objects to be attained: 1st. To prevent their development (prophylactic treatment). 2d. To dis- perse the tumors. 3d. To heal the ulcers after suppuration and discharge of the pus have occurred. The prophylactic treatment implies: 1st. A rapid cure of the primary chancre. 2d. The prevention of a return of the ulcer. 3d. Perfect rest of the diseased part. To accomplish these objects the prin- cipal medicines are merc. Sol., kali hydriod., silic., calc. carb., acid. nit., graph., and thuja. When the swellings are either small or of considerable size, but neither excessively painful, mercury has been of great service, administered in the second decimal trituration, five grains night and morning, until im- provement is manifest. , If the bubo be excessively painful, bright red, with intense inflammation, belladonna a few drops of the tincture in water will in all probability allay the sufferings. After suppuration is established, silic. frequently cures the complaint. If the patient has been subjected to the abuse of mercury, and the tumor is hard, hepar and a poultice of flaxseed may hasten suppuration. If the mouth and gums of the patient are affected by previous drugging, and there is lancinating pain in the hard tumor, staphis. will be an excellent medicine. Nitric acid or the muriate of gold may be beneficial, spongia officinalis and spongia palustris have proved of striking efficacy in some cases of indurated glands, either of a scrofulous or venereal origin. Asaf., hydriod. pot., or nitric acid may particularly be called for in cases which have evidently been aggravated by the previous injudicious use of mercury in massive doses. Bell., hepar, silic., sulph., carb. an. are important medicines in treating sympathetic bubo ; the indications for their administration may be found in the Materia Medica.” So soon as suppuration has been fully established, the matter should be freely evacuated, and this is best done with a fine sharp-pointed curved bistoury, the point to be inserted with the cutting edge upward, and a free incision made. Sometimes in making the operation, an arterial twig may be severed, which may be generally secured by torsion, or the bleeding arrested by pressure. Care must be taken not to allow any of the pus to come in contact with abrasions, or any mucous surfaces. The cavity must then be freely syringed, thrice a day, with a solution of calendula, one part to three, and a compress placed over the wound, and held in situ by a bandage. An indolent bubo takes a long time to heal, and requires a careful internal as well as local treatment. Constitutional Symptoms of Syphilis present themselves in several forms, and usually develop in regular succession. . The parts that appear to be first affected are the skin and throat; in the generality of instances the latter is earlier attacked. After these, periosteum, bones, fasciae, tendons, -eyes, and ears become involved. There has been a good deal of discussion among syphilographers as to the contagion of the secondary symptoms. There is, however, incontestable proof that some of these appearances, especially the pustular eruptions, are teapable of inoculation, and also, that this secondary contagion will produce a chancre; that constitutional syphilis will pursue its regular course of evolution, * For an excellent description of inguinal bubo see Hannemann's Lesser Writings, p. 76. CONSTITUTIONAL SYPHILIS, 235 whether it originates from a primary or secondary symptom—in the latter case, as &n the former, the chancre being the primary manifestation. - The first development of constitutional symptoms will, in many cases, be ushered in by syphilitic fever or by pallor of countenance, swelling of the submaxillary glands, and shifting pains, apparently of a rheumatic or neu- ralgic character, in different portions of the body. When the tonsils are examined, they may be found to be the seat of an ulcer, which is coated with an ash-colored or brownish matter, that causes the sore to present a foul and unhealthy appearance, while the surrounding edges are slightly inflamed and of a coppery hue. In the more advanced stages the ulcer is excavated, or, as Mr. Hunter has expressed it, “dug out;” if the ulceration still advance, one or both tonsils, the velum palati, membranous portion of the Eustachian tube, and even the epiglottis may be entirely destroyed, giving rise to permanent deafness, incessant cough, and endangering the patient's life from suffocation, by permitting food and drink to enter the larynx. In many instances, a communication is established between the nose and mouth, from the ulceration having destroyed the soft parts and bones of the palate. At other times the disease travels along the Schnei- derian membrane, undermines the septum and cartilaginous portion of the nose, destroys the periosteum covering the thin and delicate bones, which are soon rendered completely carious, and crumble away, destroying the nose, and thereby causing pitiable disfiguration, and reducing the patient to a condition often loathsome, with foul and fetid matter flowing perpet- ually from the nostrils or into the throat, and a breath so extremely offen- sive as to render the sufferer hateful to himself and disgusting to others— Ozaena syphilitica. §: Fever.—This peculiar eruptive fever generally precedes, with more or less distinctness, the appearance of constitutional affections of the skin and mucous membranes. In many instances, the whole skin becomes discolored, or mottled, or covered by an efflorescence; at other times, cir- cular patches appear in distinct spots on different parts of the body, each of which proceeds from an indurated lump of a pale-red color. The patch slowly enlarges, and in a little time its centre becomes flat, and incrusted with whitish scales. These gradually desºluamate and are succeeded by others of a similar appearance, until finally the skin cracks and discharges a puriform secretion, which, hardening on the surface, is converted into a copper-colored scab. This seldom extends beyond half an inch in diameter, and after a time drops off, exposing an ulcerated surface, which gradually spreads and deepens, and becomes covered with a thick, fetid, greenish matter. - The parts of the body most liable to be attacked by venereal eruptions, are the back of the neck, the forehead, breast, and groin ; sometimes, how- ever, the palms of the hands and the soles of the feet are affected. Exanthemata Syphilitica.--Roseola is one of the most frequently occur- ring of the exanthematous eruptions, and may accompany other secondary symptoms; the spots are of a “coppery red,” and are scattered over the trunk and extremities without any very determinate figure. They become very apparent after exertion, bathing, or sweating, but can easily be made to disappear by the pressure of the finger. The eruption is not generally accompanied with much itching, makes its appearance without constitu- tional disturbances in the space of a few hours, and in a few days the spots fade and become of a yellowish hue. Syphilitic Maculae.—These “spots” are more frequently seen on the face and head, although I have noticed them on the trunk and extremities. They are oval or sometimes irregular in shape, and of a yellow coppery. color, differing from the exanthemata in the latter, being of a redder hue. 236 A SYSTEM OF SURGERY, These spots are often darker in the centre than at the circumference, and they do not entirely disappear upon pressure; they may become extremely dark when they have existed for some time. Syphilitic Pustules.—There are several forms of pustular disease which follow constitutional syphilis, and among them we find syphilitic rupia. These pustules, the bases of which are bullous, become covered with large and prominent incrustations, which are black and rise in the shape of a cone. The scab finally splits, and becomes loosened irregularly around its circumference, and finally drops off, leaving an open sore, secreting a pecu- liarly offensive pus. The skin surrounding becomes of a purple hue, but is not ulcerated. The ulceration, if unchecked, continues to extend beneath the scabs, upon pressing which, the discharge exudes. Very many of these may appear on one patient, and they are often very intractable. I recollect a woman whom I attended in consultation with my friend Dr. Comstock, who had at least a dozen of these sores upon her person. Syphilitic Papula.-This form of cutaneous disease has been noticed to appear suddenly with erethism or in a successive and slow manner. The elevations are firm and solid, contain no fluid, and are of a yellowish or coppery color. They are sometimes crowded together and present the appearance of confluence. They do not itch and desguamate often. In other instances they are of a brownish, livid, or violet color, and may ulcerate at their summit. These eruptions are generally circumscribed. Syphilitic Squamae are more or less round in shape, like the other erup- tions, of a coppery color, and appear in patches; there is slight itching in some cases; in others none. The patches are from six to eight lines in diameter, and appear from six to eight weeks after the cure of the primary sore. They are distinct, irregularly rounded, slightly prominent, and cov- ered with a thin scale, which, when detached, shows the skin beneath them smooth and shining. In the palms of the hands and soles of the feet the syphilitic psoriasis is distinct. A number of spots, three or four lines in diameter, not very prominent, appear, and small scales of epidermis are regularly thrown off from the palms of the hands and soles of the feet. Where the disease has existed for a considerable time, the skin cracks in different directions, and rhagades form, which are very much increased by the motions and constant uses of the hand. This disease is often accom- panied with somewhat similar eruptions about the axillae, the thighs, scro- tum, labia, and on the margins of the anus and the commissure of the lips. Syphilitic Tubercles are of a livid and coppery red color, smooth, and sometimes covered over with dry or moist scales. They appear in clusters, or are scattered and degenerate into open sores; they are from the size of a small pea to that of a walnut. These tubercles are found about the alae of the nose, and in this position rarely ulcerate. The scrotum, also, is often affected, and in this locality they are generally isolated, are quite circular, and more prominent than in other portions of the body. This form of growth may also exist with sycotic disease. Sometimes there exist beneath the skin, and deep in the cellular tissue subcutaneous syphilitic tubercles, which may perforate the skin and form ulcers with ragged edges and a whitish base. - Gummatous Products.—It is a difficult matter to draw a line of demarca- tion between what are termed the secondary and the tertiary symptoms of constitutional syphilis. The division is, it appears, merely arbitrary. The time of the appearance of secondary symptoms is generally fixed at six or eight months from the healing of the chancre; symptoms appearing thereafter being considered as tertiary syphilis. The deeper structures are then invaded by the poison, and the periosteum, bones, eyes, testicles, and other parts give evidences of the disease. . . *- GUMMATA, ETC. 237 The most peculiar formations, however, are known as gumma. A gumma is a nodule in the connective tissue, which, according to Green,” presents the following appearances: “The gummata consist of atrophied and degenerated elements imbedded in a scanty and obscurely fibrillated stroma. The central portions of the growth are composed almost entirely of closely packed granular débris, fat- granules, and cholesterin, amongst which there may be an exceedingly scanty fibrillated tissue. Surrounding this, and directly continuous with it, is a more completely fibrillated structure, while the peripheral portions of the growth, which are continuous with the surrounding tissue, consist entirely of small round cells resembling granulation-cells and lymph- corpuscles. The bloodvessels, which only exist in the external portions of the growth, are very few in number.” The main difference between the secondary and tertiary stages appears to exist in the fact, that in the former, the new formations are composed of fibrin, or a very similar element, while in the latter, the gummata resemble granulation-tissue prone to break down and to ulcerate. Syphilis of the Periosteum and Bones.—All the bones do not appear to be equally susceptible of impression from absorption of the virus; those thinly covered by integuments, or situated near the surface of the body, as the cranium, clavicle, sternum, tibia, radius, and ulna, are most liable to suffer. The first evidence that the patient experiences, as indicative that the dis- ease has reached the bony structure, is an enlargement or a tumor, called a mode; this increases slowly, never attains much magnitude, and is seldom painful until it has existed for a considerable time. Finally, however, the integuments covering the tumor become red and inflamed; deep-seated and acute pain is felt in the part, and extends from it to a considerable distance, often throughout the limbs; the sufferings are extremely aggra- wated at night when the patient becomes warm in bed. In a greater or less time the swelling loses its hard and solid consistence, becomes soft and fluctuating, ulceration takes place on the most prominent part and soon opens a communication with the interior, and a discharge ensues of an ill- conditioned glairy matter. The bone may now be felt rough and bare, and it may become completely carious. When the node is seated on the skull, both tables are often perforated with numerous holes, and resemble in some respects a piece of wormeaten wood. When a node proceeds from in- flammation of the periosteum alone, the swelling may be frequently removed. Patients who have suffered from repeated attacks of syphilis, and have taken large quantities of mercury, often have the veins greatly enlarged and thickened throughout their whole extent. When examined, also, such veins have been found to be much heavier than usual. Wenereal Warts, “Sycosis Hahnemanni,” often follow chancres, and usually are found in the same situation. They arise by a narrow neck or pedicle, and are expanded on the surface, resembling a mushroom. They are some- times exceedingly painful, and bleed profusely on the slightest touch. Frequently the whole glans penis or vulva is completely covered by these €xCI’éSCéITCéS. Condylomatous Tumors usually occupy the verge of the anus. They are firm and fleshy, broad at their bases, irregular on the surface, and often ulcerate and become very troublesome. Alopecia does not invariably follow the secondary symptoms of syphilis, even when the system is thoroughly contaminated. In many cases, how- * Pathology, p. 120. 238 A SYSTEM OF SURGERY. ever, large quantities of scurfs or scales form about the roots of the hair, which are soon loosened and drop out, leaving the scalp perfectly bare. The eyebrows also not unfrequently fall off, and are seldom regenerated. The further details of diseases of the bones, phimosis, paraphimosis, orchitis, etc., will be found in chapters on those diseases. - Treatment.—Syphilitic sore throat, which generally arises from the con- tinued abuse of mercury in the primary disease, is successfully combated by nit. acid, aurum, carbo veg., or lycopodium. When the patient complains of dryness and scraping in the throat, with swelling and inflammation of the tonsils, calcium sulphide is an excellent medicine; when, however, there are superficial ulcers of a grayish color situ- ated within the buccal cavity, nit, acid may be employed. After the exhibi- tion of these medicines, when the more violent inflammatory symptoms are mitigated, silic. or sulph. will often complete the cure. If, during the first stages of the disease, mercury has not been used in massive doses, this medicine is frequently sufficient in itself to produce the desired effect. Kali hydriod. and merc. iod. are also useful in this affection, as are also ars., iod., aurum, bell. and staphis. In the treatment of secondary syphilis, mercury is the chief medicine, particularly for the syphilitic eruptions. “Allopathic physicians,” writes Hartmann, “use iodium and sarsaparilla for these eruptions, which homoeo- pathic physicians only use for syphilis complicated with mercurial symp- toms.” The principal mercurial preparations which are of service in the treatment of these secondary syphilitic diseases, are merc. praecip. rub., merc. corr., cinnabaris, merc. nitras; though the other preparations may likewise be useful. Besides mercurials, we have thuj., nit. ac., hepar, clematis, staphis., phos. acid, mez. The selection of the remedy does not depend upon the seat of the sore, but upon the nature of the ulcer. A mercurial preparation will have to be used, and the medicine be given in much larger doses than ordinary, otherwise the fauces, mouth, nose, etc., may all be destroyed. The medicine required is sometimes indicated by the attendant syphilitic ap- pearances in other parts of the body; for instance, merc. praecip. rub., cinn., merc. nitras, nit. ac., and thuja are demanded, when out of the Sec- ondary exanthematous ulcer, whether it be indurated or phagedenic, con- dylomata have developed themselves. If accompanied with bullae, merc. corr. is the principal remedy, unless merc. praecip. rub. or viv. is more spe- cifically indicated; if complicated with mercurial ulcers in the mouth and throat, iod. and nit. ac. and potassium iodide deserve the preference. If, after the secondary syphilitic ulcer is cured, there should be still a remnant of the secondary syphilitic eruption, some other medicine must be chosen. Lepra and psoriasis syphilitica will frequently yield to dulc., clem., lyc., mez. or calc. The scurfy eruption to lyc. and calc., or to co- nium, graph., ranunc. The tuberculous require often argent. nit., thuj., kreas., zinc., if deep-seated; ars, thuja, especially if spongy, or clematis. The exanthemata; bella., apis mel., merc., nit. acid, canthar. - The symptoms, however, in each case, must be thoroughly studied, by means of the repertory and codex. The medicines for venereal nodes are asaf, acid. phosph., aur., calc., mez., silic., and sulph. The intolerable aching pains in the bones are relieved by mez, acid, staphis., aurum, sulph. or kali hydroid. Dr. Hale recommends, phytolacca dec., corydalis, rumex, Sanguinaria, stillingia, and other remedies for syphilis. I have not employed them, and must refer the reader to his work on the New Remedies. SYPHILITIC IPITIS. 239 For alopecia, lyc. is said to be almost a specific ; if its use is not followed by success, nit. acid., petrol., or phosph. may be serviceable. Condylomata are controlled by merc. sol., thuj., or sabina, and also with aurum, causticum, and phosphoric acid. To onychia syphilitica the following medicines are adapted : ars., graph., hepar, merc., lyc., and petrol. - hen the skin appears unhealthy, the slightest cut degenerating into pain ful rhagades or ulcerated fissures, merc., sulph., lyc., acid. nit., hepar, are very useful medicines. I desire here to mention a fact which has occurred to me in regard to the exhibition of iodide of potassium. I cannot obtain any result from it in any potency above the second and third, and find the farther away I go from the substance, the less are its effects visible. This I am bound to admit, nor can I explain it. It is impossible, in my experience, to suc- cessfully manage the varied manifestations of constitutional syphilis without the use of the kali hydriod. Its action is most wonderful in many instances, and what mercury is to the primary, so kali iod. is to constitu- tional or general syphilis. In these latter days a great deal has been said concerning massive doses of iodide of potash. I have made some ex- periments myself, regarding the toleration of the drug by patients suffering from constitutional syphilis. I have seen given sixty grains three times a day, and continued for a length of time, and patients, though they are rather disposed to become melancholy, otherwise improve under the use of the drug. I write this by no means to justify such enormous doses but that the young practitioner may not think he is overdosing his patients when he orders five or ten grains of the iodide three times a day. The treatment which has been recommended on a previous page is safe and efficient, and unless the disease has attacked the nervous system, larger doses than there recommended are not, in my opinion, necessary. The medicine is then entirely discontinued for a week and again renewed. I speak with a great deal of confidence of this method of treatment, because I am positive of its efficacy. For other indications for the use of medicines the student must consult the repertory and symptomen codex. Podophyllum is most highly lauded by Dr. Adrian Stokes in all the forms of syphilis. “In recent as well as in the secondary and tertiary forms of Syphilis, he who fails with podophyllum judiciously used need not hope to get any help out of mercurials.” Syphilitic Iritis.--This affection is intermediate between secondary and tertiary syphilis. By Ricord it is supposed to belong to the former, and Gollmann coincides in this opinion. The iris is the primary seat of the disease, although, if the symptoms are violent, the other tissues of the eye may be involved; in most cases but one eye is affected, and the organ presents many of the properties and appearances of common iritis. When syphilitic ophthalmia is accompanied with scler- otical injection, the latter is said to depend upon an accidental rheumatic complication; however, sometimes among the anatomical signs of ophthal- mia syphilitica is noticed a zone of violet red, from a line to a line and a half in width, of uniform tint, and in which cannot be observed any dis- tinct vessels. This zone is called the dyscrasic circle. In the commencement of the disease the iris becomes duller, and presents a grayish appearance, the radii being more or less effaced ; the small circle of this membrane is livid or copper-colored; its tissue is tumefied, and forms an elevated ring composed of thick downy flakes. The pupil is more or less contracted, and assumes an irregular or angular shape; the cornea is somewhat dimmed, * B. J. H., vol. xxii., p. 80. 240 - A SYSTEM OF SURGERY. and on its inner surface, careful examination detects small fasciculi of con- gested vessels; the tunica albuginea is of a rose color, which at its juncture with the cornea is converted into a dark-red hue. As the disease advances the iris becomes more discolored, its surface is covered with exudation, its free margin is tumefied, and upon its anterior surface there are elevations of a yellowish or gray tinge. The pupil at length becomes perfectly im- movable; pedunculated excrescences, termed condylomata of the iris, Sprout from the membrane, and adhesion takes place between the iris and the lenticular capsule. In such cases, the pupil still remains open, and presents a gray, instead of its usual black appearance. At the bottom of the ante- rior chamber, through the dim cornea, a more or less elevated layer of pus, Sometimes mixed with extravasated blood, can be perceived. The patient experiences in the suborbital region of the affected side, violent constrictive boring pains, which radiate sometimes to the neighboring regions of the head, are increased towards evening, most violent at midnight, and abate towards morning. The visual faculty is more or less altered, by reason of the intensity of the inflammation, and of the plastic exudations formed in the pupillary opening. Photophobia is rarely present in true syphilitic ophthalmia, and when the symptom is noticed other complications are often the cause of its appearance. The terminations of the disease are—resolution, condylomata of the iris, exudation within the pupil, or obliteration of this aperture. This variety of ophthalmia, although it is sometimes met with alone, is generally accompanied with other symptoms of secondary syphilis, such as eruptions of the skin, ulceration of the fauces, or pains in the periosteum. Treatment.—The object in this form of iritis is to allay inflammatory action, as well as eradicate the virus, and to arrest further extension of its effects. As the disease is most frequently met with when the inflamma- tion has threatened to close or obliterate the pupil, a resort must be had to artificial means to dilate the same, which is best accomplished by dropping into the eye, three or four times a day, or even more frequently if there is a high degree of inflammatory action, a few drops of the following: B. Atropia, . . . . . . . . . . . grs. viii. Aquae font., . e * sº 3ij. M., ft. collyrium. This dilates the pupil and allows perfect rest to the muscular fibre. A resort to the external application of either atropia, belladonna, or hyos- cyamus in the concentrated form to dilate the pupil, is equivalent to a mechanical force, the object being to irritate muscular fibre into unnatural contraction—very different from exhibiting an infinitesimal dose to produce curative action. Rhus tox. is adapted to the earlier stages when there is profuse lachryma- tion. Petroleum for pain, heat, and throbbing in the occiput, with heat in the eyes. Cinnabar for pain in the supra-orbital region. The latter is the best mercurial in this form of disease. When abscess forms in the iris, hepar, merc., silic., and sulph. are valuable medicines. - - For the chancrous ulceration that sometimes attacks the cornea, besides mercurius, arsen. and calc. should not be forgotten. ... In those cases in which mercury has been abused, nit. ac., hepar, Sulph., mez., and dulc. will prove useful. Colchicum will be of service when there is an exudation of lymph or the inflammation is of a very chronic character. - Syphilis of the Larynx is another manifestation of the presence of the virus, which generally appears late after the primary infection. It is not, however, SYPHILIZATION. 241 a very uncommon affection, and is easily recognized. The patient has but slight difficulty in deglutition, and the erosions on the mucous membrane may remain stationary for a time, or be subject to periods of extension, and to quietude. There is a dry hacking cough, hoarseness, and expectoration of a sticky and tenacious mucus. Finally, however, the ulceration spreads to the cartilages of the larynx, and, in some cases, destroys them either in part or entire ; the voice, from being husky, disappears in toto; the cough becomes worse, the patient emaciates, deglutition is accompanied by fits of suffocation, hectic fever and debilitating sweats supervene, and the patient finally dies a miserable death. The prognosis is in most cases bad. Treatment.—I have had under treatment at different times some very difficult cases of syphilitic laryngitis, and have found that the ordinary medicines, as laid down in the books, are not at all satisfactory in their action—I mean phosphorus, hepar, sulphur, etc. The medicines which have produced decidedly beneficial action are the bichromate of potash, the second trituration given twice or thrice a day, and continued for a length of time; also, the kali hydriodicum, in substance, given thrice a day; or if the indications for mercury be present, the bichloride acting better than others. Arsenic, iodine, macrotys, and podophyllum have been given from time to time with benefit. I have used also the atomizer, containing a weak solution of iodine, with excellent results; but in its application, care must be taken that the Solution is not too strong, as very disastrous effects have followed such inhalation. Ten drops of the first decimal dilution of iodine, placed in a gill of water, will be found of sufficient strength for most cases, and need not be repeated more than twice during the week. Syphilization for the cure of syphilis has been practiced from time to time and has had some warm advocates, while many are very much opposed to the practice. It consists in inserting under the skin the syphilitic virus. “The inoculations are performed first on the sides of the thorax, then on the arms, and lastly on the thighs. Six such punctures are made every three days in symmetrical positions; the matter for each inoculation being always taken from its predecessor as long as it takes effect; a fresh supply being only used when the former has entirely lost its force.” Dr. Boeck, of Norway, is a great advocate for this method of cure, but is particular not to have recourse to it until the general symptoms manifest themselves. With this method I have had no experience, but find that it has been prac- ticed in this country by Professor Boeck. At a meeting of the New York Academy of Medicine, on June 6th, 1872, Dr. Hutchinson, of Brooklyn, read a paper on this most interesting subject. He related cases in which Profes- sor Boeck, while on a visit to this country in 1869, practiced syphilization. The cases were three in number, and, as the report read, “went from bad to worse under the various treatments adopted, and were regarded as utterly hopeless. The first of these cases died. The detail of the second* is given here in full, not only to show the method, but to observe the time occupied and the symptoms manifested, and because the operation was conducted by Professor Boeck himself. Case 2. James C , act. twenty-one; sailor; admitted August 16th, 1869. Patient stated that his health had been good. Five months previously, ten days after an exposure, a small sore appeared near the meatus urinarius, followed soon after by other sores upon the glans. These healed rapidly, to be followed by another in April, without fresh exposure; this also healed speedily. Early in May he began to have sore throat, and the cervical glands became enlarged. * Medical Record, July 15th, 1872, p. 306. 16 242 A SYSTEM OF SURGERY. June 8th. An eruption made its appearance on the forehead, and since that time it has spread to the face, trunk, and limbs. Examination, on admission, discovered patches of ulceration in fauces and pharynx; the epitrochlear and inguinal glands were enlarged and in- durated. A very extensive rupial eruption was noticed in various parts of the body; was emaciated and very feeble. Treatment by means of mer- Curials (internally and by fumigation), iodide of potassium, sarsaparilla, etc., was instituted. Sept. 2d. No improvement having taken place under the usual treatment, syphilization was, with the consent of the patient, inaugurated. Nov. 30th. Inoculations with matter from a soft chancre, on chest, were systematically practiced every third day, and were invariably successful. Dec. 14th. No further effect was produced by inoculation on chest, by matter from whatever source. Large crusts formed on the sites of inocula- tions; they increased in size and became confluent. Rupial crusts on face diminished in size. General condition was somewhat improved. Feb. 1st. Reinoculations had been practiced successfully on arms and thighs, which were covered with extensive crusts, while the chest was com- paratively free from them. Large ulcers continued in the throat, and there was a constant fetid discharge from the nose. Although the patient ap- pºd to be in better physical condition, he was yet too feeble to leave his €Ol. Feb. 21st. Inoculations were seldom effectual; they were accordingly discontinued, and the iodide of potassium, with a vegetable bitter, was pre- scribed. - March 8th. Recommenced inoculations, but the patient was no longer susceptible to virus taken from any source. March 28th. The general physical condition was improved; the patient left his bed for the first time in five months; ate and slept well. The ulcer- ations in throat and pharynx had FIG. 100. healed. - & | º h in...". "...hº": s== . º appeared. The patient weighed SET- * one hundred and eighty pounds —more than at any previous period. Said he was a “well man.” July 9th, 1870. Had continued to improve in health and strength, and was discharged cured. Mercurial Fumigation has also been employed and I have in a few instances tried it myself, but have not found it equal to my expectations. This method of treatment is highly recommended by Mr. Langston Parker, and can be made easily by filling a shallow vessel with boiling water, thor- oughly heating a brick and plac- ing it in the water, which must not be of sufficient depth to overflow the top surface, on which is sprinkled from thirty to sixty grains of the mild chloride of mercury. This vessel is then placed on the floor underneath a cane-bottomed chair upon which the patient, having been previously | i . ; | || §E º S.|º S.| ſºsº ;- | ºf º,' Lee's Lamp modified by Bumstead. INFANTILE SYPHILIS. 243 rubbed off with a towel, is seated. He is then covered closely with a blanket, which is secured around the neck, and its folds allowed to reach the floor on all sides. The bath may last a quarter of an hour, when the patient must retire to bed. Mr. Lee has constructed a lamp for this purpose, which has been modified by Bumstead, of New York, and which I have used and found convenient for the purpose. It is represented in the adjoining cut (Fig. 100). Upon the small saucer, A, is placed a scruple or thereabouts of calomel, or of the black oxide of mercury. The groove surrounding the saucer, B, is filled with boiling water, and the alcohol lamp, C, lighted. The patient arranged, is seated upon the chair, and the bath conducted as already described. In a short time perspiration is produced. Dr. Maury has invented a very complete fumigating apparatus, which is represented in Fig. 101. It is arranged in such manner that it can be used with gas, and the burners are those known as Bunsen's. Inunction.—With regard to the inwnction treatment of Sigmund, of Vienna, consisting of rubbing the gray ointment of mercury successively on the arms, forearms, thorax, abdo- - men, thighs, and legs each Fig. 101. night, and using a tepid water- & “.. bath every morning, keeping the patient perfectly quiet and upon strict diet, I may say that I have known of its good effects in the hands of Dr. Comstock, of St. Louis, in a case of rupia syphilitica which had been un- der my care, and had resisted all other treatment. The doc- tor, I believe, employed in this case the citrine ointment. Infantile Syphilis.-Nothing is more pitiable to the humane surgeon than the sight of an in- fant developing symptoms of syphilis. Nothing more for- cibly illustrates the words of holy writ, a child ushered into this world, bearing at birth the marks of serious disease con- tracted by its parent or parents. Congenital syphilis presents #|| the most remarkable phe- ==#| || nomena in regard to its origin. - It may be communicated from Maury's Fumigator. the mother alone, or from the father alone, or from both parents. It may be contracted from the paternal side without the mother being infected, and what is still more remarkable, the father having been infected years before marriage, may have every reason to believe himself cured, and yet may transmit the disorder to his offspring. It may also be present, though latent in the mother, and yet will develop in the child. From these facts, it will be seen that it is not at all necessary that the mother should have contracted the disorder during her pregnancy, for a woman being married twice may have contracted syphilis even from ===---- t; } | * , , º, ...rerº". --- º 244 A SYSTEM OF SURGERY. §: husband, and the second being healthy, may yet have syphilitic CI)11CiréI). - - Again, a healthy woman having nursed a syphilitic child, contracts the disease, and then transmits it to other children gotten by a husband who is healthy. In both cases the blood, the source of life, growth, and nutrition, is completely poisoned, and hence all its products, whether solid or fluid, must necessarily participate in the evil effects to which such a state gives rise. But in the female these effects are still greater than in the male ; the whole function of the male in the process of reproduction consists in the deposition of a certain amount of semen, perhaps a solitary spermatozoon, while the female is also obliged, not only to furnish a fluid, but after con- ception has occurred, she is compelled to nourish the new being, the most intimate connection being established between them by means of the pla- Centa. With regard to the time at which a woman suffering with general syphilis may communicate the disease to the child, there is no certainty. Professor Gross says: “The probability is that it is very short. This is proven by the circumstance that such a woman frequently aborts within a few months after conception, evidently in consequence of the deleterious effects of the virus upon the foetus. I suppose that the contamination is coeval with conception, occurring at the moment of the commingling of the two seminal fluids; for if it be assumed, as we have a right to do from the facts of the case, that the male can communicate the poison in this manner, why should a similar faculty not be ascribed to the female? She, too, furnishes an im- pregnable substance, a seminal liquor, which can no more escape contami- nation when her system is affected with secondary syphilis through the seminal fluid of the male.” - A syphilitic child at birth does not usually present symptoms of infec- tion, but after the first few months an eruption upon the face or scalp, mucous patches about the arms, spots of dark reddish hue over the body, which are all more or less inveterate in their nature, indicate the presence of the disorder. Diday, to throw more light on the subject, has tabulated 158 cases. In these the disorder showed itself: Before the end of one month in . o ſº º ſº { } tº º . 86 Before the end of two months in . tº º e © * & { } . 45 Before the end of three months in * e & & ſº º e . 15 At four months in tº o Q 7 At five months in 1 At six months in . I At eight months in 1. At one year in . 1 At two years in 1 Total, e g tº e © * ge * tº gº . 158 Treatment.—The first step in the treatment, if the child is nursed by the mother, is to remove it from the infected parent and substitute a healthy wet-nurse; great attention being paid to bathing and fresh air. Then the administration of such medicines as are indicated, must be carefully attended to. Of these, the preparations of mercury will generally be found most ad- vantageous, and of these, according to my own experience, the corrosive sublimate or bichloride is decidedly preferable. Whether it be that these compounds have a more searching action, and permeate the system more deeply than others, I am not prepared to say, but certain I am, that when other mercurials have failed in obstinate cases, these have been of decided benefit. Next to these we have kali hydriodicum, which may be given WOUNDS. 245 during alternate weeks. The preparation of the bichloride which I use is the third, that of the potash, the first. I am aware that these drugs are considered antidotal to each other, and are considered “incompatible,” according to pharmacologists; but in the treatment of the varieties of syphilis many distinguished surgeons have found from experience that the two agents may be combined with excellent results. It is a common practice nowadays (I cannot say whether it be entirely scientific or no) to mix a few grains either of the protoiodide or the deutoiodide of mercury with iodide of potash and Sarsaparilla, and use the same in syphilitic affections. The iodide of iron (ferri iodidum) is a valuable medicine in the syphilitic cachexia of children, and is particularly adapted to those forms of the dis- ease where there is a constant tendency to indigestion and diarrhoea; it may be given in alternation with other medicines. Nitric acid, phytolacca, sanguinaria, thuja, iris versicolor, and other medicines are called for. In the majority of instances, however, it will be found that when the symptoms can be traced to hereditary syphilis, the preparations of mercury and potash are best adapted to the cases. CHAPTER XIV. WoUNDS: DEFINITION — CLASSIFICATION — DANGER OF-DRESSINGs For—SUTUREs — STRAPS–ANTISEPTIC TREATMENT—METHODS OF HEALING—INCISED–PUNCTURED– CONTUSED–LACERATED–PoisonED GUNSHOT. - WoUNDs are solutions of continuity in any texture of the body, or divi- sions of the tissues caused by mechanical violence, and weapons of every variety, and are produced in innumerable ways. For convenience of de- Scription, however, they are divided into six general classes, this classifi- cation being based upon the appearance or general characteristics of the wound, and upon the agent or material which produced it. We have, 1st, Incised; 2d, Punctured; 3d, Contused; 4th, Lacerated; 5th, Poisoned; 6th, Gunshot wounds. There are also superficial and deep wounds, these terms explaining themselves. Wounds are also named according to the part of the body in which they occur, as wounds of the head, face, chest, abdomen, and extremities. Wounds in the direction of the long axis of a muscle or limb are called longitudinal, those passing directly across, diagonal or trans- werse wounds; the latter class generally gape much more than the former, which fact should be remembered in making incisions in surgical operations. Wounds are also divided into penetrating and non-penetrating, or those en- tering joints or the cavities of the body, and those which enter but a short distance from the surface; the former are again subdivided into wounds with injury of the organs—or viscera contained in the cavity—and those without injury to the viscera. There are also flap wounds, found most fre- quently about the scalp, or made by sharp cutting instruments in other parts of the body. The flap is connected to the body by a neck of tissue, called “the bridge;” if the bridge be very narrow, and the flap very large, the probabilities are it will perish, because the only means of nourishment is through this pedicle. After a time, however, adhesions form other con- nections with the main surface of the body, and the circulation is thus re- established. By wounds with loss of substance, we understand those in which masses of tissue are entirely cut away. These are the general definitions, and will answer sufficiently for the purposes of this work. The Healing of Wounds depends not only upon their proper treatment, but 246 A SYSTEM OF SURGERY, also upon the constitution or condition of the person at the time the injury is received. The more depraved or broken down the constitution, the longer will it take to repair the wound, and vice versa. These solutions of conti- nuity occurring in persons who are ill-fed, who are improperly clothed, or are uncleanly in their habits, who live in crowded and badly-ventilated apartments, heal with much difficulty, as do also those found in scrofulous or syphilitic individuals. Danger.—The danger attendant upon a wound depends upon its extent, and the physiological importance of the organs involved. Wounds of the heart, aorta, or medulla oblongata, produce almost instantaneous death, while Quite severe lacerations of the extremities often recover rapidly. Penetrating wounds are critical, their danger being increased by injury inflicted on the lung, liver, stomach, intestines, kidneys, or bladder, in which case they are often rapidly fatal. Wounds of the brain or spinal cord rarely heal. Divi- sion of large nervous trunks produce paralysis of the parts supplied by them, and punctured wounds of the hands and feet frequently produce tetanus. The danger of poisoned wounds depends principally upon the virulence and amount of poison introduced into the system ; in very many instances their prognosis is bad. Dressings.-There are various appliances to facilitate the healing of wounds. These consist mainly in sutures, various kinds of adhesive plaster and bandages, the object of all being to maintain the parts as nearly as pos- sible in apposition, and to give support to the mutilated structures. Sutures.—There are several varieties of suture, viz., the continued, the inter- rupted, the twisted, the quilled, and the india-rubber; these are most constantly in use; the “clamp-suture” of Sims, the “button suture" of Bozeman and the “plastic suture” of Professor Pancoast are sometimes employed by those who are adepts in the use of the varied instruments with which they are made. - The substances employed for sutures are either the ordinary saddler's silk, or a more costly article manufactured in England for surgeons’ use, and coming to the market either in skeins or wound upon spools; it is a most excellent fabric, and is called “patent ligature silk;” it does not kink or curl, and is remarkably strong and pliant. (See pages 38 and 39.) The description of the needles which I now generally employ is found upon page 40 of this volume, and the needle-holder on page 35. I desire, however, here to call especial attention to the newer form of needle and needle-holder invented by Hagedorn. Dr. Hagedorn's Needleš-The advantages claimed for these new needles, which are graded from 1 to 19 (see Fig. 102), are: 1. Being curved on the edge, they are more resistant, and the point fol- lows without deviation, the intended direction of the puncture. 2. The eye, perforating the flat side, can be made larger and tapering at the terminal end; in consequence of which, even a stout double thread will pass without difficulty through the puncture, an advantage which no sur- geon will fail to appreciate. - - 3. The needle, owing to its equal thickness, can be firmly and safely taken hold of at any point, whereby its direction will be much facilitated. 4. The cutting-edge being on the convex side, cannot be injured or blunted by the needle-holder, and may be easily resharpened by the surgeon himself. 5. The incision made by the needle is at a right angle to the edge of the wound, similar to a button-hole. The two edges of the stitch-wound, on tying the suture, are drawn into close apposition, whereby their union is favored. (Fig. 103.) - 6. The flat needles cause less injury, which is of great importance, espe- cially in sutures of nerves and tendons. SUTURES. 247 Hagedorn's needle-holder differs from the usual kind. It is so construc- ted that it is made to hold the needle at the flat side; its jaws open and close parallel to each other, and every size of needle, of whatsoever curve, is held with equal firmness. The breaking of a needle is rendered impos- sible, even when the strongest pressure is applied. In using it, the needle- holder is held in such a position that the little finger is near the ratchet, ready for releasing its hold by slightly pressing against it. Attention must be paid that the needle is placed in the longest diameter of the jaw with the inner curve close to the stem of the fixed rod. Only when the needle has been grasped in this manner will its perfectly firm position be secured. Tiemann & Co. have constructed a needle-holder, a combination of Hage- dorn's and the Russian needle-holder, combining the advantages of both. In wounds of considerable extent we may employ both suture and adhe- sive plaster. In making an interrupted suture, the stitches should be placed Fig. 102. : FIG. 103. a, b, Wound of Old Needles. c, d, Wound of New Needles. Dr. Hagedorn's Needles. not more than half an inch apart, and in some particular cases at a less dis- tance; they should be inserted at regular intervals, and great care should be taken to have the edges of the wound so adapted that there shall be no puckering. One lip of the wound should be seized with the fingers of the left hand, or a pair of forceps, whichever the operator finds the more con- venient; the needle, threaded with silk or silver wire, is then passed from without inwards through the centre of the tissue; the other lip is then seized, and the needle passed from within outwards, inserting it at the same depth, and passing it out at the same distance from the edge or lip of the 248 A SYSTEM OF SURGERY. Wound as it was passed in on the opposite side. A space of two to six lines from the margin of the cut will generally be found sufficient to hold the Suture. In threading a needle with wire, care should be taken to have the wire lodge in the grooves running back from the eye; the end should be pressed tightly down behind the end of the needle, and twisted about the long end of the ligature. This may appear a trivial matter, but the accomplished Surgeon does not so regard these apparent trifles. Many surgeons of the present day make the metallic stitches in the following manner, which was, I believe, first introduced by T. Addis Emmet, of New York: An ordinary sized needle is threaded by passing the two free ends of a loop of silk through the eye. The extremities are then tied firmly, leaving the loop free; upon this loop is placed the wire, which is simply bent over it. By FIG. 104. gºssºs ... 2 …sºs introducing the needle, thus armed, it will be readily seen that the flexi- bility of the silk will allow a considerable degree of manipulation with the needle, which could not otherwise be accomplished without twisting or FIG. 105. --- ============FF E=== == ŽZZZZZ Tiemann & Co.'s Modification of Hagedorn's Needle-Holder. knotting the wire. After the metallic threads have been introduced, they may be seized with a pair of strong straight pliers and twisted, and the extremities cut off. : - º (on next page) shows the wire supported and in process of being twisted. - Fig. 107 (on next page) is a silver wire carrier, which works with a spring and a slide. After the introduction of the wire some surgeons prefer to tie it in a square knot, and to cut the ends short off. The twisted or figure-of-eight Suture, is made by introducing pins or needles through the lips of the wound, and twisting over them, in the figure-of-eight form, silk, thread or cotton. The pin should be placed in the pin or needle forceps, and introduced about one-eighth to one-quarter of an inch from the margin of the wound; care must be taken to pierce the tissue at least to the middle of its thickness. When the point is seen emerging from the raw surface, it is made to enter the opposite lip of the wound, and SUTURES. 249 brought out on the surface at the same distance from the margin as it was entered on the opposite side. After the introduction of several pins, the FIG, 106. FIG. 107. -TV / G.I.A.A4&-co. FIG. 108. FIG. 109. | FIG. 110. t º 250 A SYSTEM OF SURGERY. silk is to be applied by placing its centre part over the first pin, and making two or three turns in the shape of a figure-of-eight; the ligature is then Carried to the next pin, and the same process gone through. The cut (Fig. 108) gives a good idea of the interrupted and (Fig. 109) the twisted suture. . . In tying either the silk, the thread, or the wire, the knot should never be placed over the line of approximation, but to one or the other side. The ends of the pins are then cut off with the pliers, and if there is a tendency to laceration from pressure, small pieces of wax may be placed upon the extremities of the pins, or a small strip of adhesive plaster be laid under them. The latter is the plan which I usually adopt. As a rule, the pins should not be allowed to remain more than three days, as sufficient adhe- sion has generally taken place in that period of time. To remove the suture the thread must be carefully snipped on both sides of the pins, and lifted away; one extremity of the pin is then grasped by a forceps, rotated slightly, and withdrawn. The continued suture, or that known as the glover's suture, is made by pass- ing the needle, properly threaded, diagonally from one lip of the wound to the other, making, as it is called, the over and under stitch. The india-rubber suture (Fig. 110) was introduced by Washington L. Atlee, of Philadelphia. It consists of small sections of gum-elastic tubing, which are stretched over the pins, as seen in the FIG. 111. figure. This suture may answer well in some cases, but is liable from its elasticity to cut into the tissues. The quilled suture (Fig. 111) is merely an in- terrupted suture, with the extremities of the thread tied over pieces of quill or bougie, which are laid parallel with the lips of the wound. It is especially applicable to lacerated wounds, where the parts will not bear the trac- tion of single threads. Gauze and Collodion.”—This method of draw- ing together the lips of wounds, especially where there is much laceration, was first suggested by Dr. Paul B. Goddard, of Philadelphia, and has been extensively used in the Pennsylvania Hospital. I have employed it with good re- sults. The method of application is as follows: Having prepared strips of gauze, or tarlatan, or bobbinet, of the requisite width, one end of the strap is placed upon one side of the wound on healthy texture. Over this collodion is painted, care being taken that none of this substance touches the wounded part. By the rapid evaporation of the ether the solu- tion soon dries, and in so doing fixes itself and the fabric securely to the integument. The surgeon then draws the gauze over the wound, the edges of which are nicely adapted, and fastens the other end of the gauze on the opposite side in the same manner. This method of securing wounds has, besides the firmness with which it brings the parts together, the additional advantage of allowing the free application of any medicated substance to the wound without disturbing the dressing, and the surgeon can observe at any moment the progress of the case. The Dry Suture in closing long wounds, is recommended by Dr. John H. Packard.* He uses strips of Seabury & Johnson's porous plaster, two * Medical Record, February 1st, 1879, No. 430. ADHESIVE PLASTER—HEALING OF WOUNDS. 251 and a half inches wide and the length of the wound. These are applied on each side of the incision and then the sides laced together, using the holes in the porous plaster. - Adhesive Plaster.—There are several kinds of adhesive plaster. We have the old-fashioned adhesive, composed of resin, lead, and a little soap ; Isinglass, Robbins's, Behrle's, Surgeon’s, etc. There are other varieties, composed of resin, lead, litharge, and turpentine, in various proportions, said to possess advantages, but they are generally rather irritating to sensi- tive skins. The india-rubber plaster and that variety known as Mead's has already been mentioned in the article on dressings in the first chapter of this volume. - - Cutting the Plaster.—The plaster, whichever kind is used, should be cut into strips sufficiently wide for the purpose, generally from one-quarter to half an inch in width, and in the direction of the long fibres of the cloth : if it be divided transversely it is very liable to stretch and allow the wound to gape. To apply adhesive straps, that is if the old-fashioned plaster is used, the free or unspread surface of the cloth must be laid on the outside of a smooth tin vessel, filled with hot water, until the adhesive surface is sufficiently sticky; it should then be carefully and evenly laid upon the part, sufficient traction being used to bring the cut surfaces in apposition. The traction or tenseness of each strap must be graduated in such a manner that an even support is given to the part, and to do this properly requires considerable experience. In the removal of straps, or even in changing them, there should be no haste; so long as they are fulfilling the purpose for which they were applied they should be allowed to remain, and when taken off, considerable care is necessary to prevent tearing the edges of the wound apart. One extremity of the strap should be carefully raised and drawn towards the edges of the wound. As soon as it has been raised to this point, the other extremity must be dealt with in like manner. In wounds of the Scalp or parts covered with hair, the razor should be used, and the surface rendered perfectly smooth. Collodion.—This substance is also used with advantage in small wounds, or it may even be applied after the use of sutures or straps. When there is a tendency to haemorrhage, the styptic colloid of Richardson is of good service, the tannin acting as a styptic, while the collodion forms an impervious covering to the wound. It is necessary to mention here, that some surgeons have objected to the use of these preparations of ether, on the ground that they cause too great contraction or shrinkage of the tissues. For my own part, however, I have not observed that untoward results have followed their application. - * ealing of Wounds.-For a more accurate description of this process the student may refer to Part II., Chapter IV., a brief recapitulation being only necessary here. - There are several methods which nature adopts in healing wounds: the first of these is what is termed immediate union, or that method in which the parts are brought into immediate contact and the continuity of the ves- sels restored, there being no inflammatory action or no deposit of lymph. This, however, is rarely the case, although there may be instances in which it can occur. The scabbing process may be called nature's mode of healing wounds. We often see the process in animals when they receive slight wounds: the blood, dirt, and other materials which collect on the outside form a thick scab, ex- cluding the air; when the scab falls off the wound beneath is healed. This process takes place, however, only in slight wounds, where there is little or no suppuration. Dr. Hewson imitates this process in his earth treatment, 252 A SYSTEM OF SURGERY. and I must confess I have seen wonderful results from this application in recent wounds and burns. Healing by first intention, as it is called, is the desideratum to be ob- tained in all varieties of recent wounds. This is the manner in which incised wounds generally heal, and takes place by the adhesive inflamma- tory process, if the edges are well coaptated, and there are no constitutional Causes to operate against the healing process. The changes that occur are chiefly in the so-called connective tissue, composed of cells and intercellular substance. The cells multiply and form themselves in numbers about the divided tissues. These gradually form themselves into “scar tissue,” by first becoming spindle-shaped, then infiltrating the intercellular substance, and finally, the cells become changed into connective-tissue corpuscles. These latter are flattened and in a measure disappear, leaving their nuclei. This tissue gradually contracts until the scar is compact. There is a considerable difference of opinion regarding the action of the capillaries in this pro- cess, Billroth assuming that these minute radicals occupy a secondary im- portance, the changes being made by the cells themselves, while Cohnheim regards the capillaries as the main factors, as through them are exuded the white corpuscles. : However this may be, we find after a time that circulation through the tissue is again re-established. In the present state of pathology it is quite impossible to state with any degree of certainty, what power the nerves of the part play in the reparative process. Wounds with loss of substance, such as contused and lacerated wounds, cannot be expected to heal per pri- mam intentionem, because the vitality of the bruised tissue is destroyed to such a degree that it can never again regain the normal standard. It dies and must be thrown off, and replaced by granulation-tissue, which consti- tutes the process adopted by nature to restore lost substance. All wounds in which there is loss of substance, or contusion sufficient to destroy the vitality of a part, must result in sloughing, and therefore the lost tissue must be supplied or replaced, which is accomplished by the process of granu- lation. It is as follows: . Small red granules or points are seen at the bottom and sides of the wound, and increase rapidly in number, inosculate with one another, and fill up the cavity from the bottom and sides towards the surface. Healthy granulations are not very sensitive; are of a bright-red color, and ordinarily do not bleed easily; sometimes, however, they become sensitive, and bleed from the slightest touch, or they may become flabby, pale in color, and very luxuriant in growth ; these are, of course, deviations from the normal or healthy process, and require treatment. In a healthy granulation there is a single vessel and within each are ar- ranged nuclei parallel to the sides of the vessel, or in some cases transversely. The granulations must be well supplied with blood, by means of which their many transformations are accomplished. When the granulations have reached the surface, around the margins of the wound or sore, the epi- dermis grows towards the centre, exhibiting a white line around the border of the cavity to be repaired. In this manner the reproductive material will partake of the nature of the part to be reproduced : bone in bone, muscle in muscle, nerve in nerve. (Wide Part II., Chapter IV.) - Incised Wounds are inflicted with sharp cutting instruments, and are gen- erally considered the simplest of all the varieties previously mentioned, but the latter feature must depend to a certain extent on the parts that are in- jured. The most troublesome symptom is haemorrhage, and this aside, there is but slight danger connected with them,-fibres have been simply divided, they have suffered no contusion or laceration, and consequently they are less likely to inflame severely, or to suppurate or slough. TREATMENT OF INCISED WOUNDS. 253 Simple incised wounds pour out more blood than the contused or lacer- ated, although in the latter, much more important blood vessels may be injured, but their coats not being divided entirely or fairly, they recede, owing to the size of the instrument by which the wound is produced, or to their inherent elasticity or contractility. If the haemorrhage be arterial, the blood has a florid, bright-red color, and if vessels of any magnitude are severed, it spouts in jets; if the blood be venous, it is a dark-red or purplish, and flows gradually. This variety of injury may heal by the first intention, but there are fre- Quently causes that operate to prevent such a desirable result. Among these may be the inability to coaptate the wound, or the effusion of blood between the margins of the cut, which may interfere with the healing process in several ways: first, by acting as a foreign body; secondly, by decomposing and furnishing a further source of irritation. Again, contusions of the wound-flaps may produce death of certain parts of the wound, or foreign bodies, as sand and dirt, etc., remaining in the cut may prevent the process of healing. Thus we see that there are a number of causes besides the con- stitutional Ones, which may operate against the speedy closure of incised wounds. It may not be amiss here to ask the question, how do wounds heal by first intention ? What is the modus operandi of the process? When a wound is first united, either by the interrupted suture or otherwise, its edges may at first appear pale from the pressure produced by pins or su- tures, or they often assume a purplish hue, owing to an obstruction to the return of the venous blood. Sometimes within a few hours, or at most within a day, local reaction is established, the edges of the wound become red, it pains slightly, swells to a certain extent, and feels warmer to the touch, though in reality the temperature is but little increased. These symptoms indicate the presence of inflammation, which may be termed traumatic inflammation, or the adhesive inflammatory process. So long as this inflammation remains, so to speak, normal, it does not extend far from the wound, does not increase in severity after the first twenty-four hours, and begins to subside from the third to the fifth day. If all goes well, at the end of the fifth or sixth day, the infiltrated or exuded plasma will have become totally firm, the edges of the wound will be found quite solid, even firmer than the surrounding tissues. This induration, sooner or later, disappears. If the wound be now cleansed, the new cicatrix will be seen as a red stripe along the track of the original wound; indeed, it is slightly elevated. In course of time it loses its redness and hardness, and finally becomes white and soft, even whiter than the surrounding skin. Treatment.—In the treatment of incised wounds, the surgeon should endeavor to accomplish three objects, viz.: 1st. Arrest the haemorrhage. 2d. Remove all extraneous matter from the wound. 3d. Coaptate the edges in the manner most favorable for their union. Arterial haemorrhage is most effectually checked by the application of a ligature to the ends of the vessels (it is frequently necessary in the treat- ment of incised wounds to ligate both extremities): when the bleeding is slight, it may be arrested either by compressions or twisting the divided ends of the artery.* After the first and most important object has been effected, attention must be directed to the second consideration, “removal of all extraneous matter.” The wound should be carefully examined, and all such substances, which by their presence would prove a source of irritation (glass, dirt, clots, etc.), should be gently removed, as it is impossible for the wound to heal by the first intention if such be allowed to remain. * See Chapter on Arresting Haemorrhage. 254 A SYSTEM OF SURGERY. Haemorrhage having been stanched, and the wound cleansed, the third consideration, coaptation, is to be thought of. In former days it was deemed advisable to effect the union immediately and completely, but the expe- rience of modern surgery teaches the expediency of moderate delay and in- completeness. - If the external wound be put together while oozing blood continues, even though slightly, especially if the part be covered with lint and bandages, adhesion is necessarily thwarted on account of the oozing blood, which, being unable to escape, accumulating, forms a coagulum between the lips of the wound, and this, acting as any other extraneous body, prevents the Ull].1OIl. All attempts at closure should, therefore, be delayed for a time, in wounds of moderate extent, and in those of large dimensions the approximation of the edges should be incomplete. In cases where the wound is not exten- sive, a few moments’ delay suffices; and when the cut surfaces present a glazed appearance, they should be nicely adapted, and retained either by straps or sutures. If the oozing from the lips of the wound continue for some time, and if a considerable amount of blood is thus discharged, the local application of a saturated solution of tannin and alum, of the liquor ferri persulph., of the dry Monsel's powder, or the perchloride of iron, or the ether spray, or the xylostyptic ether of Richardson, will generally arrest it; the best dressing, however, I have found to be the prepared styptic cotton of Ende, as men- tioned in the chapter on hamorrhage. In connection with this, arnica, crocus, diadema, creasote, or phosphorus, should be internally administered. If the patient's strength appears to be failing very rapidly, the countenance becomes deadly pale, or assumes a livid appearance, china off should be prescribed, and the dose repeated every ten or fifteen minutes, until the symptoms commence to disappear. After the bleeding has entirely ceased, adhesive plaster and position are frequently sufficient to complete the cure; this method, if practicable, is much preferable to any other for promoting union; but there are cases in which the wound is so situated, or so extensive, as not to admit of the ap- plication of adhesive straps, and when such is the case, recourse must be had to sutures. Those most commonly employed are the interrupted, or twisted, as already noted in the prefatory remarks on wounds. For wounds that are slight, M. Vidal introduced small spring forceps, which at their extremities are provided with hooks, sufficiently sharp to hold the integument, without transfixing or laceration (Fig. 112, serra- fines); when they have been allowed to remain from ten to Fig.112. fourteen hours, the wound may have sufficiently healed to permit their removal, after which all other means required for retention are unnecessary. When strapping is deemed sufficient to produce adhesion, the part should be placed in the position that relaxes the fibres of those muscles which, if remaining tense, would tend to retard - union. The surrounding skin should then be perfectly freed from Serrafines, moisture, and if there be any hair upon the part, it should be carefully shaved. If we expect to use the water-dressings, such as solutions of calendula, or arnica, the old-fashioned adhesive plaster is to be preferred; if not, the Isinglass plaster, or Robbin's adhesive, or the Surgeon adhesive plaster should be used. The straps should be long, and extend some distance from the wound, in order that they may supply the place of the bandage, in supporting the surrounding parts. Spaces should be left between the straps to allow the escape of the serous discharge that passes off during the process of adhesion. PUNCTURED WOUNDS. - 255 Alcohol has been highly recommended by Dr. Dolbeau as a dressing for wounds. He applies to the surfaces and fills the cavities with charpie Saturated with alcohol, and covers the dressing with a gutta percha envel- ope. This application at first gives considerable pain, but in time the parts appear to become insensible to the action of the spirit. I have never had occasion to use the dressing, and, therefore, can say nothing in its favor. * * - The application of dry earth is also a good dressing to wounds, and may be used advantageously either to the recently cut surfaces or to suppurating wounds. 2. If metallic sutures have been employed together with the plaster, they should be allowed to remain uncovered, in order that they may be easily removed when their aid is no longer essential. The sooner they can be dis- pensed with, the more rapid will be the adhesion. Animal sutures are absorbed. . . . After the wound has been dressed, the patient should be placed in bed, all stimulating diet should be prohibited, and all causes of excitement be, if possible, removed; arnica should then be administered internally. If the patient be robust, and there is a tendency to fever or delirium, acon. or belladonna may be employed. According to my own experience the tinc- ture of hypericum in water is the best medicine to allay pain. a . For more complete instructions for dressing wounds, the student may refer to Chapter XIV., and also to Chapter I. - After surgical operations, acon. has been very highly recommended. Dr. Wurtzler writes: “After amputations, extirpations, and other surgical opera- tions, I have invariably derived the most important service from the em- ployment of aconitum. In most instances a complete cessation of pain took place three hours after its administration; traumatic fever never supervened, and the patients almost always fell into a placid and refreshing slumber; but rarely was it found necessary to have recourse to opium, and that only when startings from sleep took place from local or general con- vulsive jerkings or twitchings.” Punctured Wounds are inflicted by sharp and narrow instruments, as needles, pins, thorns, nails, splinters, etc., which bruise and tear as well as cut. They are, when slight, attended with little danger, but when of any considerable extent the injury is always serious. Much also depends upon the constitution of the patient and the situation of the wounded part. A superficial wound along the integument, and not involving the textures. beneath it, is of trivial importance; but when the direction is from the surface internally, there is always some danger to be apprehended, either from the injury inflicted upon some internal organ, or from inflammation occurring in the deep part of the wound, inducing the formation of matter, which being confined, infiltration of the surrounding textures is likely to supervene, giving rise to much constitutional and local disturbance. Large collections of matter have formed beneath the fasciae, giving rise to exces- sive pain, and even permanent contraction or extension of the limbs, by uniting the muscles or their cellular texture together. - •. Dr. Gibson mentions a case of a young man whose forearm was covered with sinuses, from which matter could be pressed in every direction. The fingers were permanently contracted, and consequently useless. The dis- ease arose from a very trivial wound inflicted by a needle fixed in the end of an arrow. - • The lymphatics often swell from punctured wounds. A wound in the foot may produce a sympathetic bubo, or a wound in the hand may give rise to inflammation and swelling of the axillary glands. If a punctured wound is made with a clean sharp instrument, and does 256. A SYSTEM OF SURGERY. not penetrate the viscera, the wound may be regarded more favorably than when a rough, rusty or dirty weapon has inflicted the injury; therefore the surgeon should, if possible, inquire and examine the instrument before a définite prognosis is given. There is, generally, slight haemorrhage from punctured wounds, because the parts soon begin to swell, and the blood clots over the mouth of the vessels, there being but small space for exit. Treatment.—It was formerly the custom among surgeons to endeavor, by immediately dilating punctured wounds, to convert them into incised, and treat them as that variety of injury; but this cruel practice is fast becoming obsolete, although dilatation may be necessary under peculiar circum- stances, viz.: If a portion of the weapon that inflicted the wound be im- bedded in the injured textures, its removal requires that incisions be made to permit the introduction of instruments used in extraction. If an artery be punctured, it must be ligated, and this requires a certain degree of dila- tation. Or, again, when by the formation of matter infiltration of the sur- rounding tissues is threatened, free incisions must be employed. But in many cases of punctured wounds, after ascertaining that there is no extraneous substance present, by the use of isinglass plaster, and by placing the part at rest and in the proper position, union by the first inten- tion takes place, and the wound in a short time heals. If, however, inflam- mation appear and suppuration threaten, hepar, mercurius, or silicea should be administered. If the local inflammation is excessive, cham., bell., or rhus will prove serviceable ; but by the judicious and early exhibition of arnica or aconite the above symptoms may be prevented. Nit. acid and cicuta vir. have been recommended in the treatment of this variety of wounds. Ledwm is said to be one of the most serviceable medicines in punctured wounds and affections attendant upon them. The characteristic symptom for its exhibition is coldness during the fever. M. Teste remarks: “Ledum is for wounds inflicted with sharp instruments, what arnica is for contusions.” The above writer mentions instances in which this medicine was produc- tive of most beneficial results. - “1st. In several whitlows caused by the pricks of a needle. “2d. Violent bite of a water rat. - “3d. In a serious wound inflicted upon a young lady who fell with an embroidery needle in her hand, which pierced through and through. No haemorrhage occurred, but I observed the intense cold which accompanies and characterizes ledum fever.”” If, as a consequence of punctured wounds, tetanus supervene, acon, arn., angust., and cicuta may be employed.t Contused Wounds.-In every contusion there must be a certain degree of injury inflicted upon the parts beneath, though the integument from its elasticity may remain unbroken. r Ecchymosis, in the generality of instances, occurs from the rupture of smaller bloodvessels, their contents being poured into the surrounding cellular tissue. If larger vessels have been torn, danger is to be appre- hended from the extensive infiltration of blood, giving rise to inflammation, suppuration, and gangrene. If, together with the contusion, the integument is broken, the injury is then termed a lacerated wound. Such wounds, when first inflicted, give rise to little pain, because the nerves of the part have suffered from the concus- sion; but after a time, when the part has to a certain extent recovered its nervous power, the pain increases in proportion to the inflammation that is established. : The degree of violence of contused wounds is in proportion to the velocity * Teste, Mat. Med., p. 77. f See Chapter on Tetanus. LACERATED WOUNDS. 257 with which the contusing weapon is carried against the parts, and the resistance of the textures to which it is applied. If the parts yield, the shock is diminished, and consequently the injury is less considerable. Treatment.—In simple bruises, or in the most violent contusions, pro- vided there is no abrasion of the integument, the remedy is arnica, admin- istered internally, applied as a lotion externally, or both. The extraordinary virtues of this “panacea lapsorum ” is not only appre- ciated by the whole medical profession, but as a domestic medicine its excellent qualities are fully understood, and the frequency with which it is employed with success, bears testimony to its usefulness in all manner of bruises. - As an external application, the tincture should be diluted according to the sensitiveness of the skin of the patient, but in the generality of cases one part of the pure tincture to ten or twelve parts of water will be suffi- cient. If ecchymosis be present to any extent, the internal administration of arnica or sulph. ac. will generally suffice. If, however, by the use of the diluted arnica there be any aggravation of pain, or if any of the pathogenetic effects of the drug are manifested, calendula officinalis must be employed. Helianthus and symphytum have also been recommended. If contused wounds be slight, and the vitality of the affected part not much impaired, union by the first intention should at least be attempted, inasmuch as partial agglutination may prevent deformity and other ill consequences; but if the injury be of any considerable extent, adhesion is impossible, for the bruising is such that the texture is immediately deprived of life, or its vitality is so much diminished that death is inevitable. In all cases sutures should be dispensed with, and antiseptic adhesive straps employed to retain the edges of the wound as nearly in situ as possi- ble. Rest and perfect relaxation of the muscles of the part are indispensable. When the ligaments or tendons are implicated, rhus tox., as adapted particularly to contusions of such tissues, is preferable to arnica as an external application, and should also be administered internally. If gangrene threaten, china off should be immediately prescribed, but if the wounded part assume a bluish tint, and the patient's strength sink rapidly, arsen. or carb. veg. must be administered. When there has been considerable loss of substance in contused wounds, the parts can only heal by granulation, and if there be present any dead or dying tissue, it must first slough away. When such is the case, the patient must be kept at rest, and hepar or mercurius sol. be administered to aid nature in her efforts to cast off the slough, and when this has been effected, calendula, silicea, or sulphur may be administered to forward the granulations and complete the cure. If bone or periosteum has been affected by the injury, mez., phos. ac., or ruta should be employed; the latter is especially serviceable when the wound has involved the tarsal or metacarpal joints. - In all injuries where there is great contusion, arnica should be immedi- ately administered internally, and if high fever and delirium supervene, it may be alternated with acon., bell., hyos., or stram., according to the indications for each medicine. If the fever assume a lower grade, and typhoid symptoms are present, rhus, ars. or carb. veg. must be employed agreeably to the presenting symptoms. Lacerated Wounds.-A wound is said to be lacerated when its edges present a torn and ragged appearance. In this variety of injury there is generally but little haemorrhage, and it is this circumstance that frequently leads inexperienced practitioners to establish a false prognosis regarding the termination of the case, but the 17 258 - A SYSTEM OF SURGERY. experienced surgeon does not allow himself to be deceived by the absence of haemorrhage; on the contrary, in proportion as there is little bleeding, the violence that the fibres and vessels have received is estimated. Whole limbs have frequently been torn from the body without the occurrence of profuse hamorrhage. In La Mott's Traité des Accouchements can be found an interesting account of an injury of this kind that happened to a lad, who, while playing near the wheel of a mill, entangled his arm and forearm in the machinery. The limb was violently torn away from the shoulder-joint, but the haemorrhage was so trivial that it was stopped with a little lint, and the boy very soon recovered. The indisposition to haemorrhage manifested by lacerated wounds is owing to the following circumstances: The orifices of the bleeding vessels, from the laceration, become drawn together, or, as it were, puckered ; conse- quently the stream of blood is diminished in volume; they also retract to a greater degree than when they have been evenly divided; the sheaths of the 'vessels are drawn, at the lacerated extremity, to a point, which also tends to retard the flow of blood, and the arterial coats being divided at different times contract separately, the internal and middle being the first that are separated. These circumstances, as will be perceived, tend greatly to arrest the haemorrhage which otherwise would necessarily occur. Any irregular body, driven with violence, may produce a lacerated wound. It may also be caused by falling from a height upon uneven surfaces; but machinery, when in full motion, produces, perhaps, the most fearful and disastrous lacerations. . There are cases of this description recorded by Carmichael, Morand, Cheselden, and also in many of the medical and surgical journals, that are highly interesting, as denoting from what frightful laceration the system may ultimately recover. Complete union by the first intention is impossible in lacerated wounds; inflammation and suppuration are certain, and the dead tissues must be thrown off in the form of a slough, and if this be large, severe constitu- tional symptoms are likely to supervene; but this is not the only difficulty which has to be encountered; gangrene often spreads rapidly in the sur- rounding textures, thus increasing the danger to both life and limb ; or tetanus may threaten with its alarming symptoms. Treatment.—The first attention of the surgeon when called upon to treat a lacerated wound, must be directed to the removal of all extraneous bodies, and if it be present, arresting hamorrhage. It sometimes happens that dirt or sand are begrimed in the wound, and this is particularly the case when the injury has been occasioned by the patient falling from a height upon uneven ground and loose stones. After all such foreign matter has been extracted and the wound cleansed carefully, the most important blood- vessels that have been implicated must be searched for and ligated, and a dose of arnica administered internally. It is advisable never immediately to cut away any of the lacerated soft parts, because it frequently happens that some portion of them may heal by adhesion, thus leaving a less amount of surface to be repaired by the reproductive process (granulation and cicatrization). Adhesive straps should then be loosely applied, and in such a manner that a free exit be allowed for the matter. Calendula officinalis, prepared as before directed, should be applied to the part, and also administered inter- nally in the usual form, as it is known to prevent, in many instances, that prolonged suppuration that so frequently occurs in extensive lacerations, and also exercises a powerful influence over granulation and cicatrization. If, however, the expectation of the practitioner be disappointed and suppu- ration is excessive, calcium sulphide 1–10 should be substituted. POISONED WOUNDS—INSECT WOUNDS. 259 If the patient is restless, uneasy, and excited by the least emotion, and the local pain is severe, cham. will prove serviceable; or, if together with the pain there is high fever and delirium, acon. or bell. should be resorted to, the latter, particularly, if the patient is of a robust habit of body. Either of the above may be alternated with armica or calendula. If the patient become extremely weak, with thirst, hot dry skin, and gangrene threatens, ars, must be substituted ; or, if the symptoms correspond, carbo veg., china, or lach. are to be employed. While the ulceration and sloughing are progressing, the wound must be narrowly watched, as there is danger of haemorrhage ensuing. Tetanus may also be present, the proper medicines for which will be found in another portion of this work. (See Tetanus.) - In some cases, however, notwithstanding the best-directed efforts in both constitutional and local treatment, gangrene appears to be spreading rapidly; in such, the question of amputation must be seriously considered. Poisoned Wounds are characterized by the presence of some poisonous material, which is itself the principal source of danger, the wound being generally a mere puncture or scratch. The prognosis in such injuries must depend upon the extent of the wound and the virulence of the poison in- troduced into the system. - The nervous system is reacted upon by the virus which is received into the blood; and the great nervous centres suffer in proportion as the poison is introduced either remote or near them. In some instances it would seem that the nervous system is immediately affected, as death has been known to follow the bites of the more venomous serpents in a very short period of time. In the majority of instances, however, in poisoned wounds, some time intervenes between the introduction of the poison and the symptoms indicating its presence in the system. - By the term zymosis, is understood a process of fermentation, which is supposed to take place in the circulating fluid after the introduction of virus, whereby the whole system becomes contaminated, and most alarming symp- toms present themselves. Some poisons after being introduced into the system have a period of in- cubation, then develop their characteristic mark in the shape of pustule or ulcer, and from this the entire system becomes inoculated. This process is called the double zymotic process. Insect Wounds.-Among insects, the bee, wasp, hornet, and yellow jacket, inflict a slight wound, and infuse into it poison contained in a bladder situ- ated at the base of the sting. The virus flows from the vesicle through the sting at the instant this passes into the flesh. Such wounds are, in this country,” generally trivial, and their effects pass off in a short time; but sometimes they are productive of intense pain and violent inflammation. * Insects are the curse of tropical climates. The bête rouge lays the foundation of a tremen- dous ulcer. In a moment you are covered with ticks. Chigoes bury themselves in your flesh, and hatch a large colony of young chigoes in a few hours (p. 404). They will not live together, but every chigo sets up a separate ulcer, and has his own private portion of pus. Flies get entry into your mouth, into your eyes, into your nose; you eat flies, drink flies, and breathe flies. Lizards, cockroaches, and snakes get into the bed; ants eat up the books; scorpions sting you on the foot. Everything bites, stings, or bruises. Every second of your existence you are wounded by some piece of animal life that nobody has ever seen before, except Swammerdam and Meriam. An insect with eleven legs is swimming in your teacup, a nondescript with nine wings is struggling in the small beer, or a caterpillar with several dozen eyes in his belly is hastening over bread and butter. All nature is alive, and seems to be getting all her entomological hosts to eat you up as you are standing, out of your coat, waistcoat, and breeches. Such are the tropics. All this reconciles us to our dews, fogs, vapors, and drizzle, to our apothecaries rushing about with gargles and tinctures, to our old British constitutional coughs and swelled faces.—Sid. Smith's Works, vol. ii., p. 147. 260 A SYSTEM OF SURGERY. The virus of the hornet or of the yellow jacket is more highly acrimonious than that of the common bee, and there are instances on record in which both human beings and inferior animals have lost their lives from wounds inflicted by these insects. Dr. Gibson records a case of a female who died in fifteen minutes after having been stung by a yellow wasp. Another case is also mentioned by the same author, of a young woman who lost her life from swallowing a bee inclosed in a piece of honeycomb. The mosquito, certain varieties of spider, and some species of fly, inflict severe and oftentimes dangerous wounds. In unhealthy constitutions, or in individuals whose skin is very susceptible to inflammation, the sting of the mosquito will degenerate into a troublesome sore. Dr. Dorsey *men- tions a case where gangrene and death supervened from a bite of this insect. The patient was previously enjoying good health. There is also recorded by Dr. Mease, in the Domestic Encyclopædia, an instance in which the sting inflicted by a spider was productive of fatal results. The tarantula, a species of spider that is found in South America, Mexico, and in Europe, particularly in the neighborhood of Naples, inflicts a sting which has been pronounced by some authors to be exceedingly severe, while others deny that ill consequences of any severity result from the virus injected into the system. The scorpion is an insect whose sting in warm climates is so severe that death frequently ensues. It attains its largest growth in Persia, India, and Africa, where it is termed the scorpio afer. The reservoir that contains the poison is situated near its tail, and is ejected from two small orifices on each side of the tip of the sting. The symptoms produced in animals after they have been bitten, are swelling, convulsions, retching, vomiting, and death Soon Supervenes. The appearances presented when individuals have been bitten by the scorpion, are related by Mr. Allan to be similar to those produced by the stings of bees, but much more aggravated.i. - Wounds of Venomous Snakes.—The two species of American serpents that are the most venomous, are the copperhead and rattlesnake. Of the latter there are ten species. The oldest naturalists mentioned but eight, but the two others, crotalus cumanesis and the crotalus loºflingii, were discovered by Humboldt and Bonpland. All are poisonous, but those whose virus is most malignant are the crotalus horridus, miliarius, and durissus. The poison of the rattlesnake is of a yellow color, tinged slightly with green; during the extreme heat, particularly in the procreating season, it becomes of much darker hue. Mr. Catesby $ informs us that the Indians, who in their constant wander- ings in the woods are liable to be bitten by snakes, know immediately if the wound will prove fatal. If it be on any part at a distance from the large bloodvessels, or where circulation is not vigorous, they at once apply their remedies; but if any artery or vein of considerable magnitude is involved, they quietly resign themselves to their fate. Sir Everard Home, in some observations on the poisons of the black- spotted snake of St. Lucia, the cobra de capello, and the rattlesnake, remarks: “The effects of the bite of a snake vary according to the intensity of the poison. When the poison is very active, the local irritation is so sudden and so violent, and its effects on the general system are so great, that death soon takes place. When the body is afterward inspected, the only alteration of structure met with, is in the parts close to the bite, where the cellular * Elements of Surgery, vol. i., p. 68. # Allan's System of Pathological and Operative Surgery, vol. i., p. 370. † Gibson's Practice of Surgery, vol. i., p. 108. - ź Preface to Natural History of Carolina. WOUNDS BY RABID ANIMAILS. - 261 membrane is completely destroyed, and the neighboring muscles very con- siderably inflamed. When the poison is less intense, the shock to the gen- eral system does not prove fatal. It brings on a slight degree of delirium, and the pain in the part bitten is very severe. In about half an hour swell- ing takes place from an effusion of serum in the cellular membrane, which continues to increase, with greater or less rapidity, for about twelve hours, extending, during that period, into the neighborhood of the bite. The blood ceases to flow in the small vessels of the swollen parts; the skin over them becomes quite cold; the action of the heart is so weak that the pulse is scarcely perceptible, and the stomach is so irritable that nothing is retained by it. In about sixty hours these symptoms go off; inflammation and sup- puration take place in the injured parts; and when the abscess formed is very great it proves fatal. When the bite has been in the finger, that part has immediately mortified. When death has taken place, under such cir- cumstances, the absorbent vessels and their glands have undergone no change similar to the effects of morbid poison, nor has any part lost its natural appearance, except those immediately connected with the abscess. In those patients who recover with difficulty from the bite, the symptoms produced by it go off more readily and more completely than those pro- duced by a morbid poison which has been received into the system.” The viper is a serpent whose bite is exceedingly venomous. It is the virus of the lance-headed viper (trigonocephalus lachesis) with which the members of our school are so familiar by the labor, research, and the self- sacrificing investigations of Dr. Hering. This poison has somewhat the appearance of saliva, but it is less tenacious. It readily forms into drops and falls without threading. It is slightly greenish in color, and when exposed to the air concretes into a dry yellow mass.f Wounds by Rabid Animals.-The bite of rabid animals produces, in many instances, that disease termed rabies canina, or hydrophobia, although this affection does not necessarily follow ; for it has been certainly ascertained that out of numerous persons bitten by dogs, undoubtedly mad, few have sustained material injury. The first symptoms of hydrophobia generally manifest themselves between the seventh and fortieth day; but there are cases recorded of the virus re- maining latent in the system for months and years. The wound is often slight and heals readily, and may never again re-open, but sometimes at the onset of the disease, it inflames, becomes painful, breaks open afresh, assuming a livid and spongy appearance, and Secreting an ichorous humor. The patient complains of pain extending from the wound or cicatrix along the nerves. The part bitten feels numb, becomes stiff and immovable, or it may be convulsively moved. . The patient is troubled with excessive apprehension, the countenance in- dicates great anxiety, or the features may assume a melancholy expression. The sleep is restless and uneasy, interrupted by frequent startings, or there is complete sleeplessness. There are also present drawing pains in the nape of the neck, burning in the fauces and stomach, sensitiveness to draughts of air, with vertigo, nausea, and vomiting of green bile. Constant urging to urinate, the urine passing in drops, or an irresistible desire for copulation, are symptoms that are not unfrequently encountered. In some cases vesi- cles appear under the tongue, which are said by some to be pathognomonic of the disease. When the convulsive stage sets in there is that frightful aversion to liquids which characterizes this disease, and from which it derives its name. * Case of a man who died in consequence of the bite of a rattlesnake. + Jahr's Pharmacopoeia and Posology, p. 221. : In a letter published in the Lancet the following remarks occur: “Drinking water is now no criterion by which we can judge of the existence or not of rabies. The name of hy- 262 A SYSTEM OF SURGERY. Although the patient is tormented with violent thirst, even the thought of fluid at once excites most painful and distressing symptoms. If the attempt be made to swallow a few drops of water, the throat and chest become con- stricted, and the most violent suffocative convulsions of the facial, thoracic, and abdominal muscles ensue. The convulsions are excited by the most trivial incidents. The movement of a curtain, contact, etc., give rise to Spasm. There is also often present another very distressing symptom, -the collection of thick, ropy, viscid phlegm, adhering with such tenacity to the throat that it is extremely difficult and often impossible to eject it. Dr. Marcet, in the Medico-Chirurgical Transactions, records a case of this disease in which the phlegm was thrown off with such extreme torture that the patient exclaimed, “O do something for me! I would suffer myself to be º to pieces ! I cannot raise the phlegm ; it sticks to me like bird- lime ! - Finally, tetanic or epileptic convulsions take place, and the appearance presented by the sufferer during these spasms is most horrible and appall- ing. The face expresses intense anguish and despair; the eyes are pro- truded, bloodshot, and roll wildly in their sockets; the delirium is furious, during which muscular strength increases to such a degree that the patient is with difficulty controlled. He howls, bites, and spits, or endeavors to tear himself to pieces. This attack continues about fifteen minutes, and subsides for a short period, leaving a state of complete exhaustion. It is during such intervals that consciousness is sometimes present, and often it happens when a slight gleam of reason returns, that the patient warns his attendants to what danger his rage may expose them, or prays them in earnest tones to terminate his sufferings. Sometimes vomiting occurs, Men may be attacked with priapism, and women with furor uterinus. The beats of the pulse are small, irregular, and very frequent, about 130 to 150 per minute, with temperature at 105°. As the disease progresses, the paroxysms increase in frequency and vio- lence, and death ensues in from two to eight days, generally from exhaustion (apoplexia nervosa), or the patient may die, Suffocated, in convulsions. These are the symptoms that occur in most cases of hydrophobia; but there are modifications in this as well as in other diseases. In some instances, the patient may be able to swallow some liquids, and not water; or the symp- toms may only appear during a paroxysm; or they may be purely nervous. This disease is said to originate and develop itself spontaneously among the canine or feline race. The virus can be transmitted to men and to all warm-blooded animals. Youatt has noticed the disease in the horse. Several severe cases of this horrible disease have been brought to my notice, one in particular deserving some attention. A man had a pet dog, which regularly slept in the same bed with his master. The dog was seized with rabies and died; shortly after the man was also attacked with hydro- phobia, and died, no wound being detected upon his person. This is a singular but undoubted case. In another instance, a mad dog had been killed upon the steps of a public institution; shortly after a man, in a state of intoxication, fell upon the same step, striking his head violently on the spot where the dog had been killed. In a short time symptoms of hydro- phobia manifested themselves, and the patient died in all the agonies of the disease. Rabies in the dog is said to be of two varieties. “The first is characterized by augmented activity of the sensorial and locomotive functions, continued and drophobia is now universally allowed to be incorrect, there being no dread of water itself, but of the horrible spasms which the attempt to swallow liquids induces. Even this is not so constant an attendant on the disease as it was formerly supposed to be. There are many well-marked cases of rabies without either a horror of fluids or difficulty of swallowing.” WOUNDS BY RABID ANIMALS. 263 peculiar barking, and a strong disposition to bite. The affection commences with some alteration in the peculiar habits and disposition of the animal, who, as the case may be, is more tractable, more irritable, more lively, or more sluggish than usual; or these several conditions may alternate in one and the same animal. An early symptom consists in the inclination to lick, or carry in the mouth, various inedible substances, especially such as are cold. The animal after a time gets restless; snaps in the air, as if at flies; frequently leaves the house, but soon returns; and is obedient and seems attached to its master. According to Blaine, constipation constantly exists. There is usually complete loss of appetite ; but the animal seems to suffer from thirst, drinking eagerly, until, as indeed usually occurs, the mouth and tongue become swollen. The eyes are red, and become dull, haggard, and half-closed, the skin of the forehead being also wrinkled, which gives the animal a peculiar aspect. The nose, tongue, and throat now usually become swollen, and the coat becomes rough and staring. According to Hertwig, the mouth is generally very dry ; but Blaine has con- stantly observed a flow of thin saliva. After some time the gait becomes unsteady and staggering, and finally the extremities are paralyzed. The tail, in this form of the disease, is not drawn between the legs; and the head is carried erect, the nose being pointed upwards. A disposition to bite sooner or later, invariably occurs. It is not, however, permanent, but recurs periodically. It is directed against both inanimate and animate ob- jects—most especially against the cat—less so towards other animals, and least of all towards man. When the animal bites, he does not previously bark, or fly at the object of his attack, but approaches in a quiet or even friendly manner, and makes a sudden snap. “The second form of the disease is distinguished by inactivity and depression. There is no disposition to bite—probably from the lower jaw being paralyzed—nor is there any indication for change of place mani- fested. The first symptoms are unusual quietness and apparent depression of spirits. The voice is peculiarly altered, as it is in the foregoing variety; but there is much less disposition to bark. The mouth is open, the lower jaw hangs as if paralyzed, and is raised only under the influence of strong excitement. There is a constant flow of saliva from the mouth. The animal either does not drink at all, or does so with difficulty, but manifests no fear of water; and, on the contrary, willingly immerses the nose in that fluid. The tongue is almost constantly protruding from the mouth.” The anatomical changes that are noticed in the bodies of those persons who have died from hydrophobia are as follows: The subject decays rapidly; the blood is dark, fluid, and quickly imbibed by the system. The veins are engorged, air is frequently found in the larger vessels, and emphy- sema develops itself rapidly. The whole surface of the body is blue-red; the epidermis is very dry; all the muscles are dark red, and, like the ten- dons, they are rigid and tight. * . $ Fleming'ſ refers to some curious experiments in relation to hydrophobia . and sexual excitement. . “A cross-bred spaniel, 53 months old, had never left its mother, never went out and was quiet. When the mother became in rut, the young dog refused food and became agitated, and was excited by the odor. After a sleep it flew savagely at the attendant and was removed. On the fifth day it died from rabies, all the time refusing food.” - Another case of what Fleming calls spontaneous rabies occurred under similar conditions: “In a box adjoining a kennel of the male, was placed * British and Foreign Medical Review, No. xxv., p. 50. f The Medical Record, July 6, 1878, No. 400. 264 A SYSTEM OF SURGERY. a female in rut, the effluvia from which caused the most ardent veneric ex- citation. After fifteen days the animal went furiously mad. Similar results have often occurred.” The introduction of morbific matter into the system is sometimes productive of the worst results. One of the most deleterious poisons seems to be engendered in the body during the puerperal disease, and when by any accident there has been inoculation with this virus, results the most fatal have followed. Anatomists, or those engaged in macerating or making preparations, have suffered severely from accidental wounds inflicted by the instruments they were using. Violent inflammation frequently follows such casualties; the axillary glands inflame and suppurate; the whole limb is painful; ab- scesses form, and gangrene and death may result. Many examples of such cases are on record. Treatment of Poisoned Wounds.-The bites of the mosquito and other insects, which are common in our climate, are often quite painful, and cause considerable annoyance. However, a lotion composed of a weak solution of armica tincture, if applied to the bitten part, eases almost imme- diately the pain and itching. Camphor and lemon juice,” as external applications, are also highly recommended for this purpose. Dr. Gibson writes: † “The aqua ammoniae applied to a part stung by bees, I have known to act like a charm.” The internal administration of ledum is also recommended by M. Teste. He says: “Against mosquito bites, a single teaspoonful of a tumblerful of water in which a few globules of the 15th dilution of ledum has been dissolved, quieted completely in a few minutes —I might even say a few seconds—the itching caused by the bite.” This I quote, though I can scarcely credit the miraculous, and would recommend the application to the part of common laundry soap as much more certain and efficient to allay the itching. If, after the sting of any insect, the part becomes swollen, tense, hot, with erysipelatous blush, bella. should be administered, and if fever super- vene, acon. may be used in alternation. Arnica is also an important rem- edy, and should be used, both internally and as an outward application, when the swelling assumes a bluish cast, and there is a bruised sensation around the part. If the pain is stinging, and there is itching, and a thin discharge from the wound, creas. should be administered. This medicine has also been recommended as a lotion, composed of about ten drops of the tincture to a pint of water. - The following medicines have also been found very serviceable; the indi- cations for their use will generally be shown in the constitutional symptoms that present themselves: Ant. crud., calad., lach., merc., Seneg., sep. In Morocco, where the scorpion is very common, most families keep a bottle of olive oil in which the bodies of several of these reptiles have been infused, and when bitten, apply it to the wound, and with reputed success. A ligature is also generally placed above the wounded part, to interrupt the progress of the poison, and the wound is afterwards scarified. “In Tunis, when any person is stung by a scorpion,” says Mr. Jackson,S “ or bit by any venomous reptile, they immediately scarify the part with a knife, and rub in olive oil as quickly as possible, which arrests the progress of the venom. If oil is not applied in a few minutes, death is inevitable, particu- larly from the sting of a scorpion. Those of the kingdom of Tunis are the most venomous in the world.” According to the same author, the coolies, * Laurie's Homoeopathic Practice of Physic, p. 541. # Institutes and Practice of Surgery, p. 119. † Materia Medica, p. 77. Ž Jackson’s Reflections on the Commerce of the Mediterranean. TREATMENT OF POISONED WOUNDS. 265 or porters who work in the oil stores, have their bodies constantly saturated with oil, and on this account not only never suffer in the slightest degree from the bites of scorpions, and other reptiles which creep over them at night, as they sleep on the ground, but there is not a single instance known of one of these people ever having taken the plague, although the disease frequently rages in Tunis in the most frightful manner. Dr. Hammond, of New York, has called the attention of the profession to Bibron's solution in antidoting the poison of the rattlesnake. The formula for its production is: B. Bromine, & te i.e. * * tº e g te g * . 3W. Hydrag. bichlor., . Q e g * * & e e ... gr. j. Potass. iodidi, . e e o tº iº © e e * . gr. iv. M. ft. Sol. S. Ten drops every twenty to sixty minutes, in accordance with the violence of the symptoms. Dr. Hammond has used this preparation with success. The use of olive oil has been highly extolled by many writers as a remedy for the bites of poisonous serpents. Dr. Miller,” of South Carolina, relates the case of a man who was bitten in the sole of the foot by a very large rattlesnake. Although very little time elapsed before he reached the patient, his head and face were prodigiously swelled, and the latter black. “His tongue was enlarged and out of his mouth ; his eyes as if starting from their sockets; his senses gone, and every appearance of immediate Suffocation.” Two tablespoonfuls of olive oil were immediately got down, but with great difficulty. The effect was almost instantaneous; in thirty minutes it oper- ated freely by the mouth and bowels, and in two hours the patient could articulate, and soon after recovered. The quantity of oil taken internally and applied to the wound did not exceed eight spoonfuls. In the course of twelve years Dr. Miller has met with several similar cases in which the oil has proved equally successful. The application of dry heat has also been highly lauded for the neutraliza- tion of the virus inflicted by serpents. In the western parts of our country, where rattlesnakes abound, and persons frequently are bitten, the treatment consists in forcing the patient to swallow from a pint to a quart of some alcoholic stimulant—generally common whiskey. Although this method of treatment may appear novel and strange, still the effects produced are recorded as most wonderful. In the iron regions of Missouri, among the mountains, the rattlesnake is fre- Quently found, and the inhabitants, although they fear the reptile, are destitute of that dread which generally connects itself in our minds regard- ing the crotalus; this probably arises from the belief that their remedy is infallible. Case.—A boy was chasing a squirrel in the locality above mentioned, when the animal, as the child supposed, ran into a hollow tree. The boy immediately thrust his arm into the opening, and was bitten by a large rattlesnake. The hand and arm soon after commenced swelling, and the glands in the axilla had become somewhat enlarged, when medical assist- ance was procured. Common whiskey was immediately administered by the half tumblerful, until the child must have swallowed nearly a pint and a half. The stimulus did not appear to produce any exhilarating effect, but drowsiness came on and the patient slept for some time; on awaking, though the arm was still considerably swollen and painful, it was more natural in color. From this time improvement continued; and the patient ultimately recovered. The author witnessed this case. * New York Medical Repository, vol. ii., p. 242. 266 - A SYSTEM OF SURGERY. The late Professor Brainerd, of Chicago, extolled very highly the follow- ing treatment in snakebites: Saturate the parts with a solution composed of five grains of iodine and fifteen grains of iodide of potassium in a fluid ounce of distilled water, and paint the limb with the tincture of iodine; at i. same time administering five grains of the iodide of potash every five OUITS. Dr. Perkins, in the Galveston (Texas) Medical Journal, states that the im- mediate application of a coal of fire is a specific treatment for the bite of the rattlesnake. In the western parts of Missouri a very popular remedy for the bites of all venomous serpents is a plant vulgarly called “the snake weed,” the “snake infallible,” or “rattlesnake master.” In the Western Homoeopathic Observer an interesting account of it can be found. It belongs to the class Pedicularis Canadense, or lousewort. Professor Halfour, in the Pacific Medical and Surgical Journal, gives some very interesting cases treated by the injection of liquor ammoniae into the veins. Two drachms of a solution of this medicine were employed. He gives some remarkable cases, from which we select the following: A robust man, aged twenty-three years, was bitten in the palm of the right hand. The part was immediately excised. Arriving at Dr. Rae's soon after, he employed suction and cauterization, and no symptoms of poisoning appearing sent the man home. In three hours, drowsiness, nausea, numbness of right arm, intolerance of light, and oppression in the chest, came on, and increased so rapidly, that it became difficult for the man to ride alone. Upon arriving again at Dr. Rae's the stupor was so great that shouting would scarcely elicit monosyllables in answer. The surface was cool and clammy, breathing quiet and slow, pulse feeble and intermittent, pupils widely dilated and scarcely responding to the stimulus of light. Twelve minims of liquor ammoniae fortior with two drachms of warm water were injected into the median cephalic vein. Within a minute the man moved himself in his chair, and in ten minutes had so recovered as to walk out in the open air unassisted. He resumed work the next day. Dr. Rae wrote that he had had no faith in the treatment, but adopted it because there was nothing else to do. He could scarcely believe his eyes in regard to the result, which seemed incredible, though nevertheless true. In some concluding remarks Professor Halfour speaks of the great value of ammonia injections in the depression resulting from the inhala- tion of large quantities of chloroform, also in opium poisoning and in cholera. It appears, however, from some further experiments that the treatment by injection of ammonia is not always free from danger, and has to be very carefully conducted. The best method of practice, however, if the surgeon is present when the bite is inflicted, or is called immediately after, is the free excision of the part. The indications for treatment are to prevent absorption of the virus, and obtain its expulsion from the body. Therefore, a ligature must be thrown immediately around the limb, in order to obstruct return of venous blood, and if the part be favorably situated, free excision be instantly prac- ticed; if the latter is impracticable, incision should be made and the flow of blood caused by every means. Suction by the mouth is also exceedingly beneficial after either operation, and should never be neglected. The suc- tion must be continued long and repeated often. It is of the greatest im- portance to ascertain whether the snake that has inflicted the wound is venomous or not. Dr. Hering writes, “All venomous snakes have in the upper jaw but two teeth, very long and large. All snakes that have two rows of teeth above and below are not venomous. After the bite of a venom- ous snake, a cutting and sometimes a burning pain is experienced. Im- TREATMENT OF HYDROPHOBIA. 267 mediately after sucking the wound, rub into it fine kitchen salt until the part is saturated with it ; or, if that cannot be obtained, gunpowder, ashes of tobacco, or wood-ashes may be used as a substitute. The patient should be kept as quiet as possible; the greater the motion or anxiety, the worse will be the consequences.” - If there be vomiting, giddiness, or fainting, and blue spots make their appearance, ars, or carbo veg. should be administered. The former of these medicines has been used with considerable success by the old-school physi- cians. Dr. Gibson* writes, “As an internal medicine arsenic has been lately found more decidedly beneficial than any other.” Mr. Irelandi has recorded five cases, in all of which the most violent symptoms produced by the bite of the coluber carinatus, a poisonous serpent very common on the island of St. Lucia, were speedily arrested, and cures finally effected, by the use of this medicine. The supposed efficacy of the Tanjore pill, a medicine very commonly employed in India against the bites of serpents, the chief ingredient of which is arsenic, first led Mr. Ireland to employ Fowler's mineral solution. He gave it to the extent of two drops every half hour, and repeated for four hours, with the best effects. Severe vomiting and purging followed the exhibition of the medicine, and the patients were soon after relieved. The administration of the above-mentioned medicine in smaller doses, would probably prove more serviceable, and save the patient an immense amount of additional suffering. A person bitten by a dog, under suspicious circumstances, writes Mr. Miller, “is usually much alarmed, and applies for relief without delay. The first business of the surgeon is to inquire into the history of the acci- dent; the disposition of the dog; its apparent condition at the time; whether loose or chained; whether provoked or not. For it may happen that the animal was not to blame, having either been provoked to assault, or having inflicted the bite with the idea of discharging a supposed duty on an aggressor. Such a wound is not supposed to contain any virus.” - If there be any reasonable grounds for doubt, concerning the state of the animal, at the time when the bite was inflicted, the treatment should be conducted as though the person had been inoculated with the virus. The best method is immediate and free excision of the parts, and at the same time, if there be any presenting symptoms, those medicines best adapted to them should be administered. If there was unquestionable and unde- niable authority concerning the efficacy of homoeopathic treatment of hydrophobia, it would undoubtedly be wrong to subject the patient to an operation, and although the cases recorded, particularly those by Mr. Leadam and Mr. Ramsbotham, have the appearance of genuine hydrophobia, and are evidences of the powerful action of several drugs in this affection; still the disease is so terrible in its nature, that the surgeon has indeed necessity for being doubly armed against it, for if excision fail, he has medicines at his command, the symptoms of which are very nearly allied to those mani- fested by hydrophobic patients. Moreover, the poison is an extraneous matter introduced into the system, and surely the conscientious surgeon may be justified in using mechanical means for its removal. My friend, Dr. T. G. Comstock, of St. Louis, has reported a case of undoubted hydro- phobia, which was permanently cured. He was called on May 14th, 1852, and the patient was discharged at the end of the month. The medicines were chiefly : rhus tox., bella., hyoscyamus, and lachesis. But let it be * Gibson's Surgery, vol. i., p. 123. # Medico-Chirurgical Transactions, vol. ii., p. 394. † Philadelphia Journal of Homoeopathy, 1852–53, p. 315; also Medical News Letter, St. Louis. : - - 268 A SYSTEM OF SURGERY. remembered, that if some time has elapsed between the infliction of the bite and the application of the patient for relief, excision of the part will prove of no avail, and immediate recourse must be had to medicines, the chief of which are belladonna, hyoscyamus, lachesis, stramonium, and cantharides. - Drs. Hartlaub and Trinks recommend cantharides as a preventive of hydrophobia. Although much reliance cannot be placed on the many popular remedies for this dreaded malady, it would seem proper to mention one which has a very great reputation in certain localities, which is the elecampane. Many persons are said to have been cured by it. The directions for its use are as follows, as given by Mr. Fry: The patient is to be kept free from excitement of every sort, especially from that caused by the visits of sympathizing friends. The medicine is to be prepared by taking one ounce of elecampane root, powdered, one tablespoonful of madder, and one quart of new milk, and boiling them all together, slowly (in a water-bath, if possible), until reduced to a pint. The dose is one wineglassful once a day for three days; then intermit three days, then repeat and intermit again, and again repeat. That is, nine wineglass- fuls are taken in all, and there are three intermissions. In support of the efficacy of this treatment it is stated that thirty years ago Mr. Reed and Daniel Mershon were bitten at Germantown by a rabid dog; that Mr. Reed was treated by an eminent physician and died of hydrophobia, while Mershon, under this treatment, never suffered at all. A young man and a young woman, under similar treatment, recovered from the dreadful disease about twenty years since. In 1858, a policeman, so far gone with hydrophobia as to have to be held in the carriage, in which he was driven through Germantown to Mr. Fry’s residence, was also treated with entire success. A number of additional cases are quoted, in all of which the remedy described is claimed to have effected complete cures. Nitrate of Amyl.—Dr. W. S. Forbes” has been making successful experi- ments on the use of Nitrate of Amyl in cases of hydrophobia, and states: In each case the first applications of the amyl relieved the patient of that dreadful feeling of impending dissolution, a striking feature in this malady. It calmed them, but did not stay the advance of death. In the two cases of which the Dr. Speaks, the sufferings preceding the last paroxysm were relieved. The pulse fell, the sense of choking vanished, the breathing became regular, the function of swallowing was restored, and sleep obtained. In both cases death took place while the patient was in spasms, which came on every fifteen minutes. There was total inability to use fluids, the men- tion of which would produce spasms. . After giving a grain of morphia without effect, 24 drops of the nitrate of amyl were administered by inhala- tion, when the patient complained of numbness in the extremities, and said if the room were quiet she could sleep. When she awoke after four hours and a half, the spasms began again and continued to her death. No post- mortem was permitted. The application of the amyl in the second case had much the same effect as in the first—this, like the former patient, went also into convulsions, and died. No post-mortem. PASTEUR's METHOD OF TREATING HYDROPHOBIA. Inoculation.—As this portion of the work is passing through the press, the treatment of hydrophobia by inoculation as produced by M. Pasteur, is exciting the attention of the medical profession throughout the world. It is known that M. Pasteur alleges that he has discovered a cure for hydro- * The American Journal of the Med. Sciences, April, 1878, No. cl., New Series. PASTEUR's INOCULATIONS FOR HYDROPHOBIA. 269 phobia by perfecting a method of inoculation by which human beings can be rendered unimpressionable to the virus of rabies canina. This treat- ment is based on the discovery, that one attack of hydrophobia in the dog protects against another, and from analogy Pasteur claims that by such method human beings may be so protected. It may be well in this place to state the method by which Pasteur prepares the virus. A portion of the spinal cord of a mad dog is injected into a rabbit. It is said that after the space of fifteen days the rabbit perishes with all the symptoms of hydro- phobia. A part ºthe cord of this dead rabbit is prepared and a second rabbit inoculated. This animal dies in a shorter space, or, in other words, with a shorter incubation than the first. A part of the cord of the second rabbit is prepared and injected into a third, and this process is continued until no less than sixty rabbits have been inoculated. It is said by this process that after such inoculation, the period of incubation shortens and the virus becomes more powerful. Portions of these diseased cords from the whole series of the sixty rabbits are placed in bottles of dried air, which somewhat weakens the poison. M. Pasteur claims, that by taking a person bitten by a mad dog and inoculating that person with a less virulent virus, and gradually increas- ing the number of injections, each of an increasing strength, such a person will be protected. All this may be very well, but as yet no tangible proof has been exhibited that the process cures hydrophobia. The fact that a person bitten by a dog undoubtedly mad, after going through a series of inoculations by Pasteur, succumbs to the disease, necessarily raises a doubt in the minds of the profession in reference to the efficacy of the treatment. - The children who were taken from Newark to be inoculated by Pasteur, and were said to have been bitten by a mad dog, and who thus far have developed no symptoms of hydrophobia, can in no way be adduced as authentic proof of the reliability of Pasteur's method, from the simple fact that there is no proof that the dog was afflicted with rabies. The seven other dogs which were bitten, and which were taken care of, and care- fully watched by the authorities at Newark, have, up to the present date, presented no symptoms of hydrophobia ; therefore, although Pasteur’s method may prevent the recurrence of rabies in the dog, there is no proof that it can cure hydrophobia in the human being. “In a late meeting of the Academy of Medicine at France, after a thorough explanation by M. Pasteur, M. Jules Guererin placed on record the following protests: “1. That M. Pasteur made his inoculations with the virus of an artificial rabies, there being no proof that his rabbits really had the genuine disease. “2. The person on whom M. Pasteur had experimented was not a proper one, since his patient had been treated with carbolic acid, and since the bites of rabid dogs are not always followed by hydrophobia. - “3. M. Pasteur had only found a preventive for rabies in the remedy declared.” This method of course will take time for its thorough devel- opment. There is a species of hydrophobia, not arising from the inoculation of virus, but proceeding from some violent mental emotion; the disease is termed symptomatic hydrophobia. Fear and imagination, after a bite from a perfectly healthy animal, may give rise to symptoms that very nearly resemble those of the genuine affection. Sometimes very serious trouble is occasioned by large doses of bella., canth., or mercury, the drug disease assuming as it were the form of a medicinal hydrophobia. The treatment Of º affections is generally simple, when their cause is correctly ascer- tained. 270 - A SYSTEM OF SURGERY. When putrid animal matter has been received into the system by means of wounds, as in dissection, there should be a ligature worn for a time, and suction by the mouth be immediately resorted to, after which, collodion should be applied over the wounded surface; if the wound after a time presents rather a bluish appearance with swelling, china off. Or arsenicum should be given; if mortification or abscess ensue, the treatment has already been mentioned. - - Gunshot Wounds.-Before entering into the consideration of the wounds occasioned by firearms, it will be necessary to make a few remarks upon the general principles of firing and the motion of projectiles, for it may often be of service to the surgeon, in his endeavors to discover the course of a ball or a bullet, and to determine other questions of import in gunshot injuries. There are three imaginary lines upon which the general principles of firing are grounded. These are: - & 1st. The line of fire or projection. 2d. The line of metal or aim. 3d. The line of trajectory, or flight of the bullet. By the first is understood the primary direction of the centre of the bullet, or the axis of the barrel, indefinitely prolonged, indicating the course the ball would take if it were subject alone to the explosive force of the powder. - The line of aim, or the line of metal, is an imaginary line drawn from the centre of the back sight and the top of the front one, directly to the object of aim. By the third, or line of trajectory, is meant the flight of the bullet, and is the curve described by the missile from the barrel of the gun to the object of aim. It must be obvious that so long as the bullet is passing along the barrel of the gun, the line of fire and that of trajectory are the same; but the moment the bullet leaves the muzzle, the trajectory leaves the line of fire, and the divergence becomes greater and greater as the bullet passes through the air. FIG. 113. Zºº -Z" This may be illustrated by the cut, Fig. 113. A to D is the line of fire; A to C is the line of aim ; A to B is the line of trajectory. The course of a bullet is urged downwards by several forces, as inertia, friction, gravity, and its rotation, the latter being occasioned by the grooves or the twists in the barrel of the gun. These points are useful in ascertaining the velocity and revolution of balls. In order to find the velocity and rotation of a bullet, divide the velocity in feet by the number of feet in which one com- plete turn is made by the bullet. Thus: “The initial velocity (that of the bullet as it leaves the muzzle) of the Enfield rifle being twelve hundred and sixty-five and one-tenth feet per second, and the turn (rotation) one in six and a half feet, the initial velocity of rotation of the bullet fired from the En- field, is one hundred and ninety-four and six-tenths revolutions per second.” The bullet, therefore, as it leaves the gun, must be under the action of three separate and distinct forces—that of the gunpowder exploding, that of gravity, and that of resistance of the atmosphere—and it is discovered that in the first second it falls sixteen feet; at the end of the second second GUNSHOT WOUNDS. 271 it will have fallen sixty-four feet; and at the end of the third second, one hundred and forty-four feet. It is from a knowledge of these facts, and many more, that the science of gunnery teaches accuracy of aiming. Robins says “he found that when a twenty-four pound shot was impelled by its usual charge of powder, the opposition of the air was equivalent to at least four hundred pounds weight, which retarded the motion of the bullet so powerfully, that it did not range one fifth part of what it would have done if the resistance of the air had been prevented.” With a knowledge of the power obtained by rotation given to bullets by the shape of the barrel, and the uncertainty of smooth-bore guns, very many remarkable improvements in the construction of firearms and cartridges have been adopted; certain grooves have been constructed, and certain twists made in the - FIG. 114. barrels, which make the guns of to-day a marvel of inge- nuity, accuracy, and execution. Among many of these Ameri- can guns we have “Wesson’s improved American rifle;” “Colt's,” which is in high favor in the service; “Sharp's,” the “Maynard,” the “Burnside,” the “Spencer,” the “Ballard,” the “Peabody,” “Reming- ton's,” “Cochran's,” and many others, which are mostly breech-loaders, and using coni- cal balls. And among the Euro- pean the “Needle-gun,” in- | = ||. º- | E ill E g tº-e ||| º * ------ • | |ºf= º - t | ſº & º FE º tº-- *|| | w ſº º |||}} #Ej - | º Whitworth Ball for needle- Wesson Large ball for yented by Herr von Dreyse; bullet. gun, 451 grs. Slug, 28 to Spencer the “Chassepot breech-loader,” pound. breech-loader. the “Snider-Enfield rifle,” the “Cornish breech-loader,” and the “Grenade rifle;” in the latter the ball is hollow, and is filled with two and a half grains of powder; it explodes when it strikes with great certainty, and sends its fragments three feet in every direction. It is reputed to do as much damage as three or four ordinary balls, and to create the utmost dismay. Some experiments have been made to show the relative number of shots that may be made by some of these remarkable guns. FIG. 115. Spencer—A little less than § {!" Peabody—Fourteen and two hundredths per minute. Ballard–Fifteen per min- li i. º º d ſ |. º twelve shots per minute. º tº: #: ute. º iſi; iſſiſſi; º º e ºil lift # tº: Berdan—Sixteen and four º # ºilº fºllº #|| , , i. | tº ſº." . . hundredths per minute. The “Mitrailleuse” is an- º > ---------- -- - - - -º other most powerful weapon, A. B JD . ; serious devas- A, U. S. round #;"; § Yºlº ; §: B, 8.TIOI]. g Springfield rifled musket-ball, calibre 58, weight 500 grs.; on and dismay *śAus; The “Chassepot rifle” can ºffiji wºrs. be fired, the men taking aim, e e about eight or ten shots per minute, and fourteen without shouldering the gun. . 272 * ' . A SYSTEM OF SURGERY. Great improvements have also been introduced in the manufacture of the balls, most of which are conical in shape, with hollow bases. Fig. 114 shows the shape of the different missiles of various guns; and Fig. 115, taken from the Surgeon-General's Circular, shows the round and conical bullets now much used in the army of the United States. - - - Of the varieties of gunshot wounds, none are more terrible in their effects than those that are produced by the peculiar bullet invented by M. Etienne Minie, of Paris. These terrible implements of war are cylindro-conical in shape, with a hollow base, and they cover every requisition, viz.: 1st. When the explosion of the powder takes place, they fill exactly the bore of the gun. 2d. When projected they proceed with a rotary motion. 3d. They are so formed as to present as little resist- ance as possible to the air. 4th. The forward portion of the ball is solid, to cut through whatever opposes its progress. The Minie bullet is for rifles, and is made of lead; the base of the ball is nearly the diameter of the rifle, and is hollowed out. The effect of the powder when firing is to expand the thin portion of lead around the recess at the base of the ball, making it fit tightly the grooves of the rifle. With these advantages the missile may be projected to immense distances with unerring precision, and the effects are truly terrible; bones are ground almost to powder, muscles, ligaments, and tendons torn away, and the parts otherwise so mutilated, that loss of life, certainly of limb, is almost an inevitable consequence. None but those who have had occasion to witness the effects produced upon the body by these missiles, projected from the appropriate gun, can have any idea of the horrible laceration that ensues. The wound is often from four to eight times as large as the diameter of the base of the ball, and the lacera- tion SO terrible that mortification almost inevitably results. Quite a number of men wounded at the Camp Jackson affray were brought to the Good Samaritan Hospital at St. Louis immediately after the skirmish, which was one of the first of our late war. I watched these cases, and made careful dissections of the limbs after amputation. In one case the ball passed directly through the inferior maxillary bone, cutting loose the pala- tine and glossi muscles, fearfully smashing the bone and forcing the tongue from the mouth. This man could neither speak nor swallow for some weeks, but finally recovered. In another case, the ball entered about the middle of the forearm, coursed down on the Surface of the radius, and emerged at the wrist-joint. Although every possible attempt was made to save the arm, untoward symptoms presented, and amputation at the upper third of the forearm was necessary, and was performed by the surgeon to the hospital. The muscles on the anterior face of the forearm were soft, but not much out of place or tume- fied; but those (particularly the deep layer) on the posterior aspect were decayed, black, and filled with extravasation ; the radius was shivered into about ten or twenty pieces, the medullary matter being thrown out into the surrounding textures; the ulna was not broken, except the styloid process, which was torn away, the semilunar bone of the carpus was divided, the os pisiforme separated from the joint, and the head of the os magnum driven forward and split open. With such a wound as this, mortification was a result to be expected. In the third case amputation was resorted to above the knee-joint. In this instance, the extravasation was very remarkable, the fluid being ex- tremely dark and very offensive. Here the fibula was only slightly touched; but the tibia was broken near the knee-joint, and split longitudinally for two-thirds its length, very many small fragments of bone being imbedded in the tissues. The fetor from the wound was intense, and the laceration of the soft parts, along the whole track of the ball, severe and remarkable. GUNSHOT WOUNDS. - 273 In the fourth case, a wound was inflicted immediately below the knee- joint, smashing the fibula, and tearing the structures to a considerable degree. The course of the ball was under the gastrocnemius and through the soleus. Every effort was adopted to save the leg of this man, a cap- tain in the service. An attempt was made to resect the fibula; upon cutting down, however, upon the bone, it was found that the external lateral ligament of the joint had literally been destroyed, that the head of the fibula was gone, and that in its place there existed a black, gritty mass of decayed muscle, bone, and ligament. All hope of Saving the limb was therefore abandoned, the patient still kept on the table and under the influ- ence of chloroform, and the limb amputated above the knee-joint at about the middle third of the femur. It is worthy of observation, that on the morning of the operation, pain was complained of in the popliteal space. On examining the limb after amputation, the tibio-fibular articulation was found to be involved; and upon inserting the scalpel through the transverse ligaments, a large amount of fetid fluid, containing flocculi of a cheesy character, issued from the joint. Upon inspection, marks of disease were found upon the left condyle of the femur, sufficient evidence that a serious, if not fatal disease of that most complicated joint, the knee, was about being established, and that amputation was necessarily the only resource left to preserve life. * Such is a brief account of effects produced by the Minie ball upon the organism. The preceding cuts will give an idea of the different shapes of the balls and cartridges. Fig. A, the Whitworth bullet. Fig. B, the ball of the needle-gun, weighing 451 grains. Fig. C, the slug of the Wesson cavalry carbine, twenty-eight to the pound. Fig. D, represents the cartridge (full size) for Spencer's army and navy rifles. Cannon-balls inflict sometimes the most severe injuries, carrying away an entire limb, or severely bruising the parts without breaking the integu- ment. - The total number of gunshot injuries in times of war is appalling to the civilian. In the British army during the Crimean war there were 12,094 wounded and 2755 killed, making a total of 14,849. In the French army in the Crimea there were 39,868 wounded, 8250 killed, or a total of 48,118. In our own war the reports from about three-fourths of the regiments, for the year ending June 30th, 1863, were 55,974 gunshot wounds, and according to the circular No. 6, from which these figures are taken, “the battle-field list of wounded for the years 1864–65 include 114,000 names.” Such is the sacrifice of life and limb in war. The following figures, taken also from the Surgeon-General’s circular, as corrected from the register on September 30th, 1865, shows the classification g wounds and injuries and results during the civil war in the United States: Of gunshot fractures and injuries of the cranium there were 1108; of gun- shot fractures of the bones of the face, 1579; gunshot fractures of spine, not involving chest or abdomen, 187; gunshot fractures of ribs, 180; of pelvis, 397; of scapula and clavicle, 389; of the humerus, 2408; of the radius and ulna, 785; of the carpus and metacarpus, 790; of the femur, 1957; patella and knee-joint, 1220; tibia and fibula, 1056; tarsus and metatarsus, 629; gunshot penetrating wounds of the chest, 2303; of abdominal viscera, 565; scalp wounds, 3942; flesh wounds of face, 2588; of the neck, 1329; of the thoracic parietes, 4759; of the back, 5195; of the abdominal parietes, 2181; of the genito-urinary organs, 468; of the upper extremities, 21,248; of the lower extremities, 25,152; wounds of arteries, 44; wounds of the veins, 3; of nerves, 76: Sabre wounds, 106; bayonet wounds, 143.” Simple fractures 18 274 A SYSTEM OF SURGERY, and miscellaneous wounds and injuries, 2883; tetanus, 363; of secondary haemorrhage, 1035; pyamia, 754; making a total of 87,822. The following is the classification of the surgical operations: Amputation of finger, . . & & e & e • * * . 1849 & 4 of wrist-joint, . tº e e tº gº º . . 46 {{ of forearm, . . º e e e e o º . 992 64 of elbow-joint, . e e o te e e º e 19 {{ of arm, . te º * e º e º e Q . 2706 Amputation of shoulder-joint, . o • * & © º g . 437 & 4 of toes, . º º & e ſº º & o & . 802 {{ of foot (partial), . o tº e & e e . . 160 {{ of ankle-joint, . º e - tº e º . . 73 {{ of leg, . . . . º e tº º & © . . . .3014 {{ of knee-joint, . o © tº & e . . . 132 {{ of thigh, tº º e e º e & e º . 2984 {{ of hip-joint, . . e e - e e ºs . . 21 Excision of head of humerus, . e e º * º º º . 575 {{ of elbow, . © & o e ſº * tº * © . 315 & 4 of wrist, . © º º G tº tº tº & tº º 34 4 & of ankle, . o e e e º º e • * * º 22 {{ in continuity of upper extremity (shafts, humerus, radius, ulna, radius and ulna), e • e º e ſº º . 695 {{ of shafts of tibia and fibula (tibia, fibula, tibia and fibula), . 220 {{ of knee, . • * . e e º o e e º e 11 { { of shaft of femur, e º e o e e e e º 68 {{ of head of femur, . e o © e e e o . 32 {{ of bones of face or wrist, . º * tº tº e $ . 101 Trephining, . tº e ºs © e - tº º • # e. . 221 Ligation of arteries, . tº º & e º e e º e . 404 Extraction of foreign bodies, . º e G tº e e º . 726 Operations for surgical diseases, . e . . . sº º . 443 Operations not classified, e {-, tº o ſº º • , e. ſº 23 Gunshot injuries partake more or less of the nature of contused and lacer- ated wounds, and are often accompanied by extreme danger, the patient being either immediately or remotely destroyed; or there may exist exten- sive mutilations, giving rise to abscesses, sinuses, or diseased bones, which are frequently extremely tedious and difficult to heal. Indeed, the after- life of the patient may be fraught with such intense suffering that the approach of death is hailed with joy as the only relief. The kind and ex- tent of the injury must depend upon the form and size of the instrument inflict- ing the wound, upon the velocity with which it is carried, and a variety of other circumstances. - A ball moving with great rapidity and striking the body, enters readily, and pursues its course generally in a straight line, either passing through the part or lodging at a greater or less depth. .On the contrary, a ball which moves slowly enters with difficulty, and instead of following a direct line, is diverted by the slightest obstacle, always taking an angular course. Owing to this circumstance, it often happens that a bullet strikes some part of the body and apparently passes through, but upon examination it will be found that it has taken a circuitous route, or traversed the head between the bone and the scalp, or passed entirely around the abdomen or neck. When such is the case the superficial track is marked by a discolored line, sometimes slightly emphysematous. Other instances there are in which the ball strikes an extremity, runs beneath the integument or among the muscles, and is lodged many inches—or even two or three feet—beyond the point at which it entered.* - - * In one instance, which occurred in a soldier with his arm extended, in the act of endeav- oring to climb up a scaling ladder, a ball, which entered about the centre of the humerus, GUNSHOT WOUNDS. 275 The aperture made by the bullet's entrance is small, and with margins inverted; often it appears of much less dimensions than the foreign body which has passed through it, and sometimes it may even simulate the in- cised character. In such cases the ball has come from some distance, and has struck with considerable force and velocity; the aperture, consequently, is made with comparatively little bruising or tearing, and the elastic tex- tures close upon its track. The aperture of exit, on the contrary, has its margins ragged and everted; and is of larger dimensions than that which marks the entrance. There has lately been some discussion concerning the size of the wound of entrance and that of exit. The French surgeons, and particularly M. Roux, of Paris, contend that in gunshot wounds, it frequently happens that the aperture of entrance is larger than the opening made by the ball as it passes from the body. When the injury has been inflicted at a short distance, the aperture of entrance is comparatively large, has no smoothness in its edges, and is obviously of a lacerated character; then, too, portions of the wadding are usually impacted in some part of the track, and the surface may be marked by the grains of powder. There are many instances in which there are not two openings. In such cases, the ball, after having entered, lodges under the integument, in the muscle, or in a bone. Extraneous substances may be carried before a bullet—such as buttons, coins, keys, etc. These always produce irritation in proportion to the irregular shape of the foreign matter. In other cases, portions of clothing may be driven before the ball, and be imbedded deeply in the wound. When such is the case, it frequently hap- pens that when the cloth is removed, the bullet is discharged with it. Balls have been buried and never been found. They become, in such in- stances, inclosed in a cyst, or surrounded by bony formation, the patient experiencing little or no inconvenience from them ; or they may change their position and traverse the body, giving rise to pain, long suppuration, haemorrhage, convulsions, or paralysis. Dr. Franklin records a very interesting case, “in which a bullet was driven into the upper part of the thigh ; all efforts for its removal were unavailing. The wound healed, and the patient attended to his ordinary duties as if nothing had happened, when suddenly (four years after the injury) he was attacked with loss of motion in the leg. Having placed himself under the care of a surgeon, and getting no better at the end of five weeks, the case was submitted to my care. Upon examination I discovered the cause of the difficulty, and learning the position when struck, examined carefully the inner and upper part of the thigh, where I felt the ball lying in contact with the crural nerve. The ball was removed, the patient improved in strength, and in a short time fully recovered the use of his limb, and up to this time enjoys uninterrupted health.” Again, balls by striking forcibly the edge of a sharp bone, may be divided, each portion of the bullet taking for itself a separate route. “It is no uncommon thing,” writes Mr. Thompson, “for a ball in striking against the sharp edge of a bone, to be split into two pieces, each of which takes a separate direction. Sometimes it happens that one of the pieces remains in the place which it struck, while the other continues its course through the body. Of a ball split by the edge of the patella, I have known passed along the limb, and over the posterior part of the thorax, coursed among the abdomi- nal muscles, dipped deep through the glutei, and presented in the forepart of the opposite. thigh, about midway down.—Hennen's Principles of Military Surgery, p. 34. * Science and Art of Surgery, vol. i., p. 676. * f See Thompson's Reports of Obs. in Military Hospitals in Belgium. 276 A SYSTEM OF SURGERY. one-half pass through at the moment of the injury, and the other remain in the joint for months, without its presence there being suspected. In the same manner I have known a ball divided by striking against the spine of the Scapula, and one portion of it pass directly through the chest, from the point of impulse, while the other moved along the integuments till it reached the elbow-joint. But the most frequent examples of the division of bullets, which we had occasion to see, were those which were produced by balls striking against the spherical surface of the cranium. It sometimes happens that one portion of the ball enters the cranium, while the other either re- mains without, or passes over its external surface. Not infrequently, in injuries of the cranium, the balls are lodged between its two tables, in some instances much flattened and altered in their shape, and in other instances without their form being changed.” The course which bullets take is at all times uncertain, for very slight obstacles cause a retroversion from the rectilinear direction. A shot may rebound from the water, and a button or a handkerchief has been the means of preserving life. “Although,” says M. Chevalier, “in many cases a mathe- matical explanation of the course of a ball cannot be given, this arises entirely from the want of data, the laws of matter being fixed and immu- table. But when the data are known, as, for instance, the velocity and direc- tion of the shot, the position of the patient, or of the wounded part at the time of the accident, and the structure of the parts penetrated, a much more probable conjecture of the course of the ball may generally be formed than if these circumstances had not been regarded.” Dr. Franklin, during his service in the army, saw many remarkable “evidences of the strange and anomalous course of balls in various parts of the body. In one case the bullet passed over more than two-thirds of the circuit of the neck, and was cut out just beneath the skin. “In another, a ball entered at the crest of the ilium, passed downward parallel with the thigh, and emerged just above the knee-joint.” The opening by which the ball has made its exit is frequently very near the aperture of its entrance. Indeed, there are cases on record in which the aperture of exit and that of entrance were the same. Dr. Hennen mentions an instance in which a ball entered the pomum. Adami, and, after running completely around the neck, was found in the very orifice at which it entered. Gunshot wounds, partaking of the nature of contused and lacerated wounds, seldonn i. profusely externally, and for the same reason; but often, though the bleeding is not manifest, a fatal haemorrhage may be taking place internally. Secondary hamorrhage is also of frequent occur- rence in this variety of wound, from the detachment of the slough, etc. But it must also be remembered, that though immediately after the injury the bleeding may be but slight, in a short time the haemorrhage may become profuse, and particularly if the wound be inflicted in vascular parts, like the face and neck, and this may occur even though the larger branches of the artery may not be opened. When a large artery is only partially divided, the bleeding is more pro- fuse and dangerous than when the vessel is completely severed; and in such cases the haemorrhage often continues until the patient expires. Mr. Guthrie i mentions three cases in which life was lost from wounds of the carotid, femoral, and humeral arteries, no means having been adopted to arrest the haemorrhage. Shock-There is a peculiar shock which attends upon gunshot wounds— * Science and Art of Surgery, p. 675. f On Gunshot Wounds, p. 8. GUNSEIOT WOUNDS. 277 an extraordinary perturbation or agitation, which the bravest are not able to resist. This, however, is not invariably present; “for,” says Dr. Hennen,* “the effects of a gunshot wound differ so materially in different men, and the appearances are so various, according to the nature of the part wounded and the greater or lesser force with which it has been struck, that no inva- riable train of symptoms can be laid down as its necessary concomitants. If a musket or pistol ball has struck a fleshy part, without injuring any material bloodvessel, we see a hole about the size of, or smaller, than the bullet itself, with a more or less discolored lip, forced inwards; and if it has passed through the parts, we find an everted edge, and a more ragged and larger orifice at the point of its exit. The hamorrhage is in this case very slight and the pain inconsiderable, insomuch that, in many instances, the wounded man is not aware of his having received any injury. If, how- ever, the ball has torn a large vessel or nerve, the ha-morrhage will generally be profuse, or the pain of the wound severe, and the power of the part lost. Some men will have a limb carried off or shattered to pieces by a cannon- ball without exhibiting the slightest symptoms of mental or corporeal agitation ; nay, even without being conscious of the occurrence; and when they are, they will coolly argue on the probable result of the injury; while a deadly paleness, instant vomiting, profuse perspiration, and universal tremor, will seize another on the receipt of a slight flesh wound. This tremor, which has been so much talked of, and which, to an inexperienced eye, is really terrifying, is soon relieved by a mouthful of wine or spirits; but, above all, by the tenderness and sympathizing manner of the surgeon, and his assurance of the patient's safety.” A rather peculiar case representing the fatality of shock present in gun- shot wounds was related to me at the time of its occurrence by Dr. Comstock. The gentleman, a patient of Dr. C., was serving at Camp Jackson near St. Louis, when the United States troops demanded surrender. A slight skirmish ensued, and the gentleman received a wound on the anterior face of the inferior third of the thigh, shattering the bone. Dr. Comstock not being at hand, a physician was called who prescribed a large dose of morphia, and sent for a surgeon to amputate the limb. In the meantime Dr. Comstock arrived and found the patient just expiring, no reaction having followed the shock. - Surgeons at the present day deny the existence of the so-termed wind contusion, or the effects produced by the wind of a ball; and explain the injuries heretofore attributed to it, as produced by spent balls, which have really struck, yet with so little quickness of force as to merely bruise, with- out inflicting an open wound. The nerves also suffer to a great extent in gunshot wounds, especially those of the extremities. Even after the wound has healed, there may be very distressing sensations around and in the cicatrix, which pains are ºnly aggravated in damp cloudy weather, or from cool moist easterly WIIl(IS. The progress of cure in gunshot wounds is often extremely tedious, from the numerous accidents that are likely to ensue. Excess of inflammation, erysipelas, abscess after abscess, excessive suppuration, sloughing, gan- grene, non-union of fracture, caries, necrosis, hectic, and tetanus, are some Of º untoward events that may occur to prevent the healing of a gunshot WOULI) Ol. As “deduced conclusions,” from considerable experience in gunshot wounds, I have condensed from the concise and practical work of P. L. Appia some most pointed observations on gunshot wounds. They are a * Principles of Military Surgery, p. 33. 278 A SYSTEM OF SURGERY. résumé of what I have written in the preceding pages, and are inserted here chiefly for the use of the student and young practitioners. Delusions.—I. It is wrong as a precautionary measure, to lay open a wound under the impression that it changes the gunshot wound into one of a simple character. - II. There are no such things as wind contusions. Heavy projectiles, espe- cially balls, can produce deep and serious injuries of the soft parts, and even to bones, without necessarily breaking the skin, and these undeniable facts were accounted for by the extreme pressure which the air in front of the projectile underwent. But one need not be a natural philosopher to see that air is too delicate and elastic a medium not to separate on either side of a convex and limited surface, like that of a bullet, rather than undergo extreme compression from it. - III. Internal injuries, in former times, would have been attributed to the wind of the ball. - { Dr. Quesnoy saw an engineer officer who had his forearm broken without any external symptoms of injury. At Alma they took into the ambulance a soldier whose forearm was in its interior a mere mass of pulp, though his skin was unhurt. Shock-I. The general shock to the system is not a constant symptom in gunshot wounds. II. In general, pain is a late symptom of a gunshot wound. Illustrations.—In the Crimean war, men with their upper and lower jaws crushed, were known to walk from the trench to the ambulance. One of these men, from whose pharynx some fragments of bone were removed. although unable to speak, could write what he wished with a steady hand. At Alma, men whose limbs hung by a mere shred of skin, were in full enjoyment of all their senses. Varieties of Gunshot Wounds.-I. Wounds from firearms are of infinite variety, according to the velocity of the projectile, its bulk, shape, and direction with regard to the body, and also the numberless changes of posture which the latter may assume at the very moment when the accident OCCUll’S. II. The relative frequency with which the different parts of the body are struck by the bullet may be seen by the following table: Cases. Cases. Legs, . g e tº ... 100 Knee-joint, e e e . 54 Thigh, . e { } & . 97 Foot, . ſº tº o * . 29 Face, e § tº º . 61 Elbow-joint, . tº ſe . 22 Arm, & * . G © , 60 Neck, e e {. e . 22 Hand, . te tº e . 57 Genitals, . e e ſº . 18 Chest, . & º * . 53 Ankle-joint, . ſº tº . 15 Abdomen, • - . . 52 Shoulder, . e º e . 13 Shoulder, & * º . 42 Hip, . te { } sº e ... 6 Skull, . e g e . 3 Vertebra, . ſº tº tº . 10 Forearm, © © * . 36 Wrist, ę e • te ... 2 Total, o tº e . 786 III. It has generally been remarked that the orifice of entrance is smaller than that of exit, its margins more sharply cut than the latter, which is usually smaller and with everted edges. In the Parisian hospitals, where in 1848 hundreds of wounded were collected, I sought often to establish this difference, but I did not find it so well marked as has been usually described. IV. According to the velocity of the projectile, a wound presents either: a. A simple bruise without laceration of the skin. b. A wound with a GUNSHOT WOUNDS, 279 single orifice. c. A wound with a double orifice. d. When it has carried off a limb. - V. A cylindro-conical ball produces a terrible shock, and splits and tears the bone. This comminution of the bone has no parallel in former Surgical annals. - . - VI. The most serious consequences of wounds from conical balls depend on three causes: 1. The conical ball is never turned by a hard or elastic body, but passes straight through it. 2. It may, nevertheless, in its course through the body change its longitudinal position, so that it strikes the organs with its long axis, causing very considerable damage. 3. It is probable, from the pointed shape of the conical ball, that it causes less actual loss of substance, but at the same time more lateral separation of tissue from its wedge-like form. VII. The surgical experiences of the Crimean war have been rather dis- couraging, as regards the resources of art for preserving limbs which have Sustained comminuted fractures. - * * - Foreign Bodies.—I. The foreign bodies which complicate and aggravate gunshot wounds are: 1. The destroyed tissues. 2. Bone splinters. 3. The ball º 4. Pieces of clothing, woollen, or other objects encountered by the ball. . II. External injury may be insignificant, compared to the internal de- struction of parts, and from external examination one might be led to under- estimate the mischief which has occurred within, and from a superficial view entertain hope of a cure, which turns out detrimental to the patient, and from which one is only warned by repeated disappointments. III. The velocity of a ball influences the extent of its injuries to a bone, and it is generally thought that these effects are less in inverse proportion to its velocity. IV. The character and shape of a ball are influenced by its encounter with hard substances. Illustrations.—Laroche relates a curious case of one of his relations, who had twenty Napoleons in his pocket, which, struck by a ball, were driven into his belly. In the Crimea, fragments of a shell were found lodged in the abdominal parietes, in the thigh, and in the leg. The following is a list of some of the foreign bodies found in thirty-one cases, in the Revolution of 1848: Cases. Small bits of ball, . * tº tº • e ge tº o © & . 5 Small shot, º © * e * e e e e ſº e * * Pieces of wadding, Pieces of shoe, te © Pieces of cloth and shirt, Wadding and tow, . Worsted, e © Bundle of hair, Many hogs' bristles, Pieces of cast iron, & Small pieces of wood, . e Copper ornament from shako, & © ſº © o tº Nail, © º e • tº tº * o tº * e $ With reference to the alterations in the form of the bullet some very curious cases are mentioned. 1. A ball split on the edge of the petrous bone. 2. A ball split in two by the crest of the tibia, which broke the latter, and half remained in the periosteum. 3. A ball divided by the orbital arch into two parts, the larger of which lodged behind the eye at the bottom of the orbit. 280 A SYSTEM OF SURGERY. 4. A ball split in three parts by the orbital arch. * 5. Division into three parts by the edge of the clavicle. 6. A ball shot into the skull of a subject, which spread out on the internal table of the skull like a piece of tin. - 7. A ball divided into two parts upon the femur. 8. In another soldier, a bullet which had struck the great trochanter, was divided into three separate pieces. 9. The oddest example is related by M. Servier. In Algeria a ball broke into five fragments on a rock, five or six paces from a grenadier; the first fragment struck and broke the right ankle, two others pierced further down; the fourth wounded his right thigh, and the fifth lodged in the skin on the back of the hand. Torrey relates the case of an artilleryman who was struck by a ball in the right thigh. The femur was broken; as for the ball, it pierced the thickness of flesh, turned around the bone, and ended near the anus, by dipping into the hollow of the thigh. When he was brought to the ambu- lance, neither he nor his surgeon suspected the presence of a foreign body; the patient was even of the opinion that the same ball had passed on and struck another bombardier. It was only when performing amputation that Torrey discovered a ball five pounds in weight. Dupuytren relates, that a ball, nine pounds in weight, was so completely concealed in a patient's thigh, that the surgeon did not at first discover its presence. On the morrow after the taking of the Mamelon Vert, a soldier applied at the ambulance, said to be wounded in his left thigh ; about its middle was found a small circular aperture, like that of a round ball. Not a wound of exit. On examination they could feel an obscure swelling in the popli- teal space, but otherwise there was no swelling, redness, or special amount of pain. A large incision enabled them to discover and extract an enor- mous shot, which had run around the limb without breaking it. Twisting Course of the Ball.—I. A ball may enter at one part of the body, and pass out at another, leaving two apertures apparently quite independent of each other. - - II. Two apertures may be found opposite to each other, including between them in the straight line, which must unite them, organs important to life, which, if the ball had touched, must have inevitably been followed by death. Whence one naturally concludes that the ball must have passed around these organs. . - III. The wandering course of a ball cannot, in the majority of instances, be known by the condition of the wounds. IV. Spitting of blood is not a pathognomonic sign of penetrating wounds of the lung, simple contusions and superficial wounds being complicated With it. - V. One is forced to admit very often, that there has been a deviation in the course of the ball, in cases when the patient's progress has been too favorable to allow the belief that the ball has traversed any vital organ, and so to suppose that it penetrated in a direct line, when the severity of the symptoms seems more in proportion to the importance of the organs iniured. *ations—Rong mentions a case of simple perforation of the right shoulder, with no trace of fracture, but, nevertheless, a line drawn between the two apertures passed straight through the head of the humerus. Hennen declared he saw a case, in which the ball entered near the thyroid cartilage, and which, after going around the neck, returned to the same point at which it had entered, and was extracted at that spot. A soldier was struck at the moment he extended his arm to mount a ladder. The ball entered the GUNSHOT WOUNDS. 281 middle of the humerus, passed along the limb above the posterior aspect of the thorax, opened for itself a passage in the abdominal muscles, pierced those of the buttock, and passed again upwards to the anterior aspect of the opposite thigh. Diagnosis.-I. In order to determine the treatment of a wound, it is neces- sary to know its depth and direction. This cannot always be accomplished by drawing a direct line between the apertures. - II. It is necessary in such cases to assume that the wounded man was in a particular position, which he sometimes remembers, and can assist in diagnosis by telling the surgeon. III. The inferior extremities being, during action, less frequently approxi- mated to the trunk, never present the same complications as the arms. There are but few cases where the ball has broken both thighs, or even both legs. IV. It is useless and wrong even to have an inclination to determine with the probe the depth of a wound of the splanchnic cavities. This practice, which some surgeons delight in, to enhance the apparent importance of their own func- tions, should be especially repudiated. V. In examining wounded limbs, the probe becomes an invaluable guide, en- abling us to ascertain the presence of splinters, etc., and should be used as early as possible. º, VI. The introduction of the finger, or especially of the probe, is always a painful operation, so it is well to perform it when the limb is still numbed by the shock of injury. Illustrations.—In one case, at St. Louis, the ball had traversed the left biceps muscle, then had penetrated the chest by the axilla, and had gone out again by the left lumbar region. To understand the course of the ball one must imagine the body much bent forward and the left arm extended to the utmost. A ball entered in the upper third of the right arm and went out just above the nipple. If the arm is hanging, the straight lines uniting these two wounds to the body would in a manner seem to indicate four skin wounds. But as there were only two, we must imagine that the arm was stretched out when struck. Surgical Prognosis.-I. Wounds of the heart, of the lungs, and the brain,” will generally be fatal when they reach the centre of the organ, as the base of the brain, the root of the lung. As to the heart, however, although a wound of it appears incompatible with life, yet cases are upon record to the contrary. II. The spinal marrow cannot be wounded without causing death, whether from its importance to life, or from the extensive Osseous injuries which of necessity accompany it. III. Penetrating wounds of the abdomen are almost always fatal, owing to the impossibility of retaining the edges of the wounded intestine in a suitable position for cicatrization. IV. Wounds of the liver can recover with a hepatic fistula. V. Lacerations of the bladder are almost always followed by fatal results from urinary infiltration. VI. Fracture of Bones.—The prognosis depends upon several causes; upon the degree of splintering, the rapidity with which new bone is thrown out, and the extent of suppuration. Fractures of the skull owe their unfavorable prognosis, independently of the extent of injury, to the inflammation which * In the American Journal of the Medical Sciences, for July, 1879, page 146, will be found an interesting case of gunshot wound of the brain, in which the ball passed through both hemispheres, and was retained in the cranial cavity. Recovery, with the persistence of all the cerebral faculties, resulted. The case is reported by Dr. P. F. Harvey, U. S. A. 282 A SYSTEM OF SURGERY. they set up, often slowly and insidiously, from without inward, through the thickness of the cranium to the cerebral mass. VII. Wounds of the pelvis admit a much more favorable prognosis than fractures of the long bones. Treatment.—Gunshot wounds are, to a certain extent, amenable to the rules of treatment that have been mentioned as applicable to contused and lacerated wounds. The symptoms of shock must be treated according to the indications laid down in the Chapter upon “The Nervous System after Operations and Injuries.” The suppression of haemorrhage (vide chapter on that subject), and the re- moval of the foreign body, should be attended to immediately. If blood be poured out copiously the vessel must be ligated, even though incisions be necessary. As soon as the haemorrhage has ceased it is of much impor- tance to ascertain if foreign substances have lodged in the wound. If the opening be large enough to admit the finger, it may be inserted; or if the wound be small, or if the finger be too short to reach the bottom, a probe must be used. The best of the kind is the long gunshot probe (Fig. 116), which, from its length, is preferable to the ordinary instruments carried in the pocket case. It should be ten or twelve inches in length, and should be much thicker than usual. Dr. Gross is a great advocate of this large probe, and I believe has one constructed which bears his name. The probe with which the celebrated Nélaton discovered the ball in Gari- baldi’s wound was tipped with porcelain, in order to detect the presence of the metallic body. - The electric bullet probe consists of a steel probe connected at one extremity with an electric chain; when the other end comes in contact with the metallic substance the chain announces the fact. Staff surgeon Nemperdick, at Berlin, succeeded, at the first trial of the instrument, in detecting a bullet lodged in the bones of the foot, which had eluded observation for six weeks. It is well, however, before commencing any operation to administer to the patient acon. and arnica in alternation; or if there is excessive prostra- tion, china may be employed, as such treatment may tend to expedite the disappearance of the shock and relieve pain. The patient should then be placed as nearly as possible in the position that he occupied at the time the wound was received, and the probe passed along the wound gently, but with determination. If from any circumstance the surgeon has reason to believe that extraneous matter is imbedded any- where in the track of the ball, probing should be instituted as soon as practicable after the infliction of the injury. If this operation be delayed for a time, the lips of the wound close, the whole track becomes so swollen and painful that it is not only frequently impossible to ascertain the direc- tion the foreign body has taken, but the operation, slight as it may appear, causes intense suffering. But immediately after the wound has been in- flicted, the probe carried, through the recently made passage, glides along with comparative ease to the bottom of the wound, where it may encounter the foreign body, which may, if practicable, be withdrawn by the forceps, or removed by a counter-opening made just over it. In every case, however, in which the ball is not easily discoverable, all examinations should be aban- doned, and the extraneous body allowed to remain in its situation until its locality is better known. , Mr. Hunter disapproved of making counter- openings, excepting when the integuments under which the ball was lodged were so contused that sloughing was inevitable; in such cases the parts might be considered as already dead, and an opening might be made for TREATMENT OF GUNSEIOT WOUNDS. 283 extraction, but it is the more modern practice to cut down upon the foreign body and extract it, if it is not too deeply imbedded. In wounds of the abdomen, probing should only be instituted to ascer- tain the track of the ball in the parietes; any further search in the cavity of FIG. I.16, FIU. 117. FIG, 118. F'IG. I.19. | §: l R i g| i i C American bullet forceps. Bullet scoop. the abdomen would be extremely dangerous, and productive of no good to the patient or surgeon. 284 - A SYSTEM OF SURGERY. Guthrie mentions that he has cut out a number of bullets that were more than an inch below the surface. However, the surgeon should always be guided by the locality and texture of the wounded part; if the ball be deep and firmly impacted, it is preferable to wait for the relaxation of the tex- tures that occurs during suppuration, before attempting its removal, as at that time the foreign body itself, in obedience to the general law, has begun to seek the surface. It should always be remembered, as has been before stated, that a ball may be inclosed in a cyst, or surrounded by bony forma- tion, and remain for years in such a condition that the patient experiences little or no uneasiness from its presence. $ For extracting the ball, many bullet forceps have been made, some of them very much more highly thought of than others. The cut, Fig. 117, represents an excellent one, made by Messrs. Tiemann & Co., of this city. It was used abroad during the late French war, and was much lauded, receiving the name of the “American bullet forceps.” The instrument, however, known as Weisse's (Fig. 118), is better adapted to the seizure of the ball than any other, it can readily be introduced into the track of the bullet, and the claws are so sharp that they “take hold " of the offending mass at once. I have used this instrument for other than bullet wounds with great satisfaction. Sometimes a scoop (Fig. 119) is very useful in removing the ball. § When a bone has been struck, or even grazed, very careful examination is necessary—assisted by incision, if need be—in order to ascertain if splin- tering has occurred. Late experience in Paris seems to have shown, that unless all bruised and splintered fragments are thoroughly removed at the time, these portions become necrosed, and serious consequences by inflammation and suppuration are likely to ensue. The remainder of the treatment should be conducted on the same plan as that noticed under contused and lacerated wounds. If the wound has been inflicted in a vascular part, and there is consider- able oozing of blood from the smaller vessels, the medicines that will frequently subdue such haemorrhage, if arnica has not proved efficacious, are crocus, phosphorus, or diadema, the latter being recommended “for haemorrhage from every orifice of the body, for violent bleeding from wounds;” or perhaps Sabina may prove useful, provided the remaining symptoms correspond. * . If there is a contusion caused by a spent ball, armica is the specific. After the extraction of the foreign matter, not only to mitigate suffering, but also to prevent exhausting suppuration, calendula must be prescribed. Or if the patient complain during the suppurative process of boring pain in the head, particularly in the forehead, whizzing and throbbing in the ears, chilliness, particularly of the extremities, hepar will be the best medicine. If the fever be high, with delirium, acon. and bell. in alternation ; or one of the above with some other medicine, may be employed. If the fever exacerbate at night, and also the other symptoms, and if suppuration proceed slowly, mercurius should be given. - Creasote may be employed if the discharge from the wound is thin and sanious, or consists of decomposed blood, and the patient is debilitated. Nit. acid should also be administered in somewhat similar cases. Silicea is also another predominant medicine, and should be exhibited, if the wound is very difficult to heal, and the suppuration very profuse; if the inflammation has a tendency to spread, and there are drawing pains in the limbs; also, when the patient is constantly chilly, with insufferable thirst and frequent flushes of heat in the head. Sulphur must be employed when the patient complains of frequent inter- DISSECTION WOUNDS. 285 nal chilliness, or there may be spasmodic jerkings through the limb; when the pains in the wound are aggravated by change of weather, and the patient sleepless and very restless; also for profuse suppuration and unhealthy pus. This medicine is also very well adapted to promote granulation and cicatrization, as is also silicea, or according to Thorer, calendula off. There are also other medicines that may be valuable in the treatment of gunshot wounds, but the practitioner must in all cases select the medicine the symptoms of which correspond to the most of those that are experienced by the patient, always, however, bearing in mind the pathological condition of the part, as it is an index to the genus of the remedies from which the appropriate medicine must be selected. - If gangrene threaten, or to prevent the spreading of such disease, the best medicines are ars., carb. veg., china off., lachesis or crotalus. Very frequently, the first care of the surgeon is to determine whether to amputate the limb, or to endeavor to save the part. Of course, whenever there is a reasonable hope that the wound may be healed without the per- formance of a painful operation, it is the duty of the surgeon to endeavor to produce such favorable result. There are cases, however, when ampu- tation is absolutely necessary. Tooth Wounds.-The wounds that are inflicted by the teeth of men and of the inferior animals are always serious. The popular impression prevails that because the animal or man is not rabid from disease the wounds in- flicted by the teeth are not serious. This is a great error. I have seen many of these wounds, and have noticed that those inflicted by man are generally more troublesome to manage and produce more serious constitutional disturbance than those of dogs or cats. In every instance save one that came to my notice, where the wounds were on the fingers, amputation was necessary; and in the one exception the recovery was lingering. Parts of the ear and nose are sometimes bitten off in those horrible encoun- ters of man, when he becomes more beastly than the brute, and death has § known to result in some cases from the bites of these “rabid" human elngs. - An accidental blow upon a tooth at times is followed by inflammation, erysipelas, and sloughing. In the treatment of these wounds, a first object of attention is to thoroughly cleanse them. They should be washed with soap and water, and then bathed with a solution of carbolic acid; if they should begin to inflame, and symptoms of erysipelas develop, acon., apis, bell, rhus, lachesis, can- tharides, or crotalus may be given. If there is a disposition to ulceration, the ointment of the carbonate or oxide of zinc will be productive of satis- factory results. Sometimes a solution of the carbonate of potash tends much to relieve the pain and soothe the part. Arsenicum and china and veratrum relieve; phytolacca and carbo veg. may also be called for according to the symptoms. If there be evidences of the formation of pus, the sooner it is evacuated the better. Other symptoms may require treatment according to directions already pointed out in the management of the various kinds of wounds. Dissection Wounds.-Under this head may be included those wounds which infect the body by the presence of poison received into the system (generally by accidental inoculation), while dissecting the cadaver, or oper- ating for malignant tumors. Students of anatomy, in the dissecting-room, frequently scratch or cut their fingers, yet considering the number thus engaged, unfortunate results are not frequent ; occasionally, however, most melancholy or even fatal consequences occur. 286 - A SYSTEM OF SURGERY. In some individuals there is greater susceptibility to the action of virus from the dead body than in others, and, moreover, this susceptibility varies at different times in the same individuals. I have known a student who, during one winter, from careless handling of the scalpel, pricked and cut his fingers without being injured, while during the second session, he was made so severely ill by receiving a scratch in the dissecting-room, that he had to abandon his studies and return home, where he remained several months before recovering. - * The poisonous virus of dead bodies has its period of incubation, which period varies in different individuals, from three to ten days. A vesicle first appears containing a limpid fluid, which gradually degenerates into a pustule, which opens, leaving an unhealthy sore beneath. At other times the hand inflames, the skin is hot, tense, and shining, the pain very severe, the axillary glands enlarged; the arm becomes stiff and painful during motion, and, if examined, streaks of a reddish hue are visible, extending upwards. . There is a high degree of constitutional disturbance; fever, deli- rium, jactitations, and prostration; entire loss of appetite; coma may super- vene, and death take place. w - In other instances suppuration takes place beneath the thecae and apo- neuroses, giving rise to excruciating pain. If the matter is not evacuated caries of the bone may result. Again, the ulceration may become phleg- monous, and gangrene require speedy amputation. Erysipelas also may appear in some cases, thus complicating the case and increasing the suffer- ings of the patient. My friend Dr. Jernigen, during the winter of 1872, while demonstrating the triangles of the neck to the class, in a subject very much decayed, be- came inoculated with the virus from the body, and for months suffered in- tensely from thecitis in the palm of his hand and the index and middle finger. He finally recovered with a stiffened joint. In this case the consti- tutional symptoms were well marked and of a typhoid nature, and the aspect of the hand so serious that at one time it was feared that amputation might be necessary. - Persons dying of puerperal fever, septicæmia, cancer, malignant pustule, and that class of ailments, at an autopsy should always be carefully dis- sected, as the poison from such bodies is always more virulent than from other subjects. What the poison is which generates in the human body after death is unknown; like the vaccine, the syphilitic, the hydrophobic, it eludes the search of the chemist and microscopist. Most severe wounds and dangerous symptoms are also induced from the introduction into the body of matter from cancers, suppurating Sores, and abscesses. I recently attended a boy who died from septicaemia and synovitis, occa- sioned by poisoning of the rhus radicans, which I believe he ate. The bandages from his ankle were changed frequently by his mother, uncle, and other attendants. Shortly after his death his mother began to suffer from a small vesicle on the knuckle of the index finger of her left hand. This went through the usual stages of inflammation, the arm was much swollen, the axillary glands enlarged, fever and prostration followed, suppurationi took place beneath the tendon of the extensor indicis, and the matter was evacuated. The uncle of the boy also suffered from several similar evidences of the poison. The person who washed the dressings, which were many and frequently changed, likewise had several pustules on the finger, and two others of the household, who had nursed the lad and handled the band- ages, had several places on their fingers cauterized to prevent further exten- Sion of the poison. EQUINIA—GLANDERS–FARCY. 287 The surgeon in operating for malignant carcinoma should always be on his guard, as instances are upon record where disastrous effects have speedily followed inoculation from such virus. . Treatment.—There are some prophylactic means which should be ob- served to prevent inoculation while dissecting or making post-mortem ex- aminations, one of the best of which is to anoint the hands freely with olive oil, vaseline, beef or mutton tallow. Olive oil is considered in many coun- tries a preventive of the unpleasant symptoms arising from the stings of venomous insects, and that it has such power is well known. It is so readily obtained that it can always be employed. The practice of using gloves during dissections is scarcely to be coun- tenanced, although gloves of india-rubber gauze are now manufactured for the purpose. A favorite custom of students when they have either pricked or cut them- selves, is immediately to wipe off the spot with a wet towel, suck out the poison, and then cauterize the injured place with the nitrate of silver, or some prefer to place upon the wound a piece of tobacco. These means are really productive of good results. Dr. Gross prefers the acid nitrate of mer- cury as a caustic, and Dr. Comstock speaks highly of the hamamelis as a local application. I believe the best caustic is the actual cautery, which may be applied Secundum artem, by the iron, or in a more homely manner with a lighted cigar, the latter being generally more easily obtainable than the former. If, however, the patient is not seen until the formation of a vesicle or pus- tule, it may be immediately opened, and a poultice of linseed applied, and carbolic acid given in the second dilution, fifteen or twenty drops in half a glassful of water, of which a tablespoonful should be taken every two hours. For the nervousness and sleeplessness which follow, the bromide of potash is the best medicine, not only as a sedative, but from its action in the various forms of toxaemia. Other medicines are those which are men- tioned in the treatment of erysipelas, gangrene or poisoned wounds. In the case of Dr. Jernigen, after the parts had been well opened, there was not the slightest disposition to heal, the hand remained swollen, and the tendons very rigid. Dr. Liebold, with whom I saw the patient in con- ºn. applied to the hand, red precipitate ointment with the very best result. For the further and more precise treatment of septica-mia and pyamia, the student is referred to Chapters VI. and XV., where the different materials and medicines for local and constitutional treatment are described. Equinia—Glanders—Farcy.—This horrible disease was formerly con- founded with malignant pustule, but further researches have proved their distinctness. It received the name equinia from Elliotson, on account } its being transmitted from the horse. It is denominated by some arcy. - It is occasioned in man by the introduction into his system of a specific animal poison derived from the horse, the ass, or the mule. * Glanders has a period of incubation of from three to eight days, and is ‘divided into the acute and chronic varieties. When the zymosis begins to be apparent, a rigor generally announces the contamination of the system. There is severe aching in the bones, fever and delirium, accompanied with profuse and offensive sweats and discharges. During this period the inocu- lated part becomes painful, red, and swollen, the lymphatics and glands are inflamed and enlarged, and abscesses form in the joints and cellular tissue. The face becomes shining and livid, and the very characteristic viscid and offensive discharge from the nostrils appears. Pustules form, or 288 A SYSTEM OF SURGERY. in some instances, blackish bullae on the face and on the body, which soon assume a gangrenous appearance, coma and subsultus tendinum supervene, and the body sinks into death, overpowered by the poison. In the chronic variety of the disease the symptoms, though they do not follow with such alarming rapidity, yet are almost as fatal. The nasal discharge is profuse and accompanied with considerable tumefaction of the nose and eyes. The pustules, both on the integument and Schneiderian membrane, Soon degen- erate into foul and ill-conditioned ulcers, the ulcerative process extending along the mucous lining of the pharynx, larynx, and lungs; these symp- toms may not appear to progress rapidly, when an unexpected aggravation takes place and the patient is rapidly carried off, or great exhaustion with excessive perspiration may terminate life. The duration of the disease is from ten to twenty days. Glanders in the horse can either arise spontaneously or be transmitted by inoculation. About forty years ago the fact of its transmission to man was undoubtedly proven. Though the disease per se requires for its devel- opment inoculation with the virus, yet the miasm arising from the disease may produce in man symptoms of malignant and fatal fever. The horse, the mule, and the ass, are all liable to the disease, and it is probable that the zebra, jaghatai, quagga, and other solipeds are also susceptible to the poison, while it is asserted that ruminating and carnivorous animals are not affected by it. - If a horse be inoculated with the virus either from man or from another animal of the equine species, the symptoms of glanders will be produced in from three to four days. Treatment.—The treatment of this malignant disease is not satisfactory. In some of the veterinary manuals, the only direction given is to destroy the animal at once, to prevent further infection. Mr. Moore, however, has suggested that kali bichromicum is a medicine of great power in the disease, and I can see no reason why, if it is beneficial to the animal, it should not be so to man. Mercurius, lachesis, and arsenicum are adapted to certain symptoms of the affection. The sixth volume of the North American Jour- mal of Homoeopathy contains an article on glanderine and farcine, in which the writer strongly urges the use of these animal poisons in diseases of peculiarly malignant type, and, perhaps, under certain circumstances, they may be serviceable in true glanders. In the treatment of glanders, great attention must be paid to cleanliness, diet, ventilation, and disinfec- tion. Maggots in Wounds.-In spite of the utmost cleanliness, maggots some- times appear in wounds and among the dressings. They are especially found in wounds which have not received proper attention as to cleansing and changing of dressing, and in those where there is a large amount of suppuration combined with heat. In some cases it appears impossible to assign a cause for them, while in others their presence may be readily accounted for. When they are once noticed they multiply with most singular rapidity and give considerable trouble. In cases of resection, especially of the knee-joint, where suppura- tion is profuse and the pus liable to gravitate around the limb and be sub- jected there to the heat of the body, maggots are often found. In compound and comminuted fractures we sometimes find them. In civil practice these maggots in wounds are the exception; indeed, of late years they are not even found in hospitals, excepting in occasional cases, the antiseptic treatment having completely abolished them. The treatment is very simple and very effective. Remove entirely all the soiled dressings, that is, all that can be spared, and cut away others; with AMPUTATION IN WOUNDS. 289 ** a good syringe or douche, send a stream of water into the wound and thoroughly cleanse the part. Wipe now all the wound and dry the parts well with “marine-lint’ (oakum). With a Richardson's local anaesthesia apparatus, spray on the parts a solution of carbolic acid and water in pro- portion to ten drops of C. A. to water one ounce. This having been done, apply clean dressings, and over these a cloth saturated with the carbolic acid. This treatment with me leaves nothing to be desired. The dressings should be changed twice a day for two days; after that period, once in twenty-four hours. Question of Amputation in Wounds.-This is a subject of the greatest im- portance to the surgeon as well as to the patient, and one in which there are so many arguments pro and con, that a conscientious practitioner is often placed in a most unenviable position. I have experienced such feelings as these. Perhaps there is a severe lacerated wound occasioned by a railroad or steamboat accident, the bones are broken, and part of the flesh is pulpy and must die. It is impossible to ascertain the exact amount of injury done, although there is an appearance of traumatic gangrene. Under- standing the power of conservative surgery, and the action of medicine, the great desire of the surgeon, as well as of the patient, is to save the limb, and the preference should be given always to conservatism. Sometimes cases which appear desperate are cured, perhaps with a stiff joint and some deformity. If, however, gangrene threaten to extend, the medicines and treatment appear to be of no avail, and the constitution suffers, the knife must be at once resorted to. There are other cases in which the experienced surgeon can see in a moment that there is no hope to resuscitate the member; then amputation must be immediate. When masses of substance are carried away, when large arteries and veins are implicated, when the cavities of large joints are opened, when tendons, ligaments, and bones are severely crushed, then a primary amputation should be performed. On the other hand, if the attempt be made to save the limb, and that effort appears unsuccessful, then, after a fair trial, not allowing the patient to suffer too greatly from the irritation produced upon his system, a secondary amputation must be made. - In gunshot wounds, there has been much discussion as to primary and secondary amputation. In military practice, the majority of surgeons are in favor of primary or immediate operation. Dr. Franklin is of opinion that the operation should be performed during the shock. He says, “Whenever I could get access to the wounded during a battle, my judgment was always to operate immediately, using the time of shock, or nature's anaesthesia, as the most opportune period, without reference to the reaction upon which so much stress is laid in surgical works.” He says, farther, “that when he has waited for reaction, the patients have not gotten on nearly so well as those who were subject to the knife earlier.” Other surgeons prefer the period of systemic repose between the subsi- dence of shock and excessive reaction. These questions, however, should be settled in the mind of every military surgeon, and I have no doubt that many circumstances would influence the performance of amputation in either case. Primary amputation may then be considered to mean: ampu- tation performed during the presence of shock, or between the subsidence of shock and establishment of reaction. What is now understood by sec- ondary amputation ? It means, in some instances, to defer the operation, though the surgeon may be convinced that it will have to be performed, in order to allow a better state of the constitution, to give greater hopes of * Science and Art of Surgery, vol. ii., p. 719. 19 The following table, from page 31 of the Surgeon-General's Circular, eachibits the results of 2003 terminated cases of Gunshot Fracture of the Femur, or of Gunshot Wounds of Knee-joint, out of 3106 cases that have been entered upon the record: Amputation. Excisions. Conservative Measures. +3 P. ,- Cls # g; #5 g | #5 5 | E º ă. § 3. É. 5 3. É. O & : (D ÉÉ, to (D .#. tºj co 3. }* E | 3 § ## : § ## 3 § | # 3 E" 3 E 2. H 3 5 Q. -3 3 5 3. º # | 3 || 3 || 5 | g; ; ; ; ; ; g; | 3 || 3 || 5 || 3 | # Gunshot fractures of femur implicating hip-joint.... 82 0 2 0 100. 2 10 1 || 83.33 0 | 68 14 100. 97 Gunshot fractures of upper-third......................... 387 8 24 11 75. 7 18 6 72 93 || 237 | 199 || 71.81 603 Gunshot fractures of middle-third........................ 346 || 42 || 51 47 || 54.83 2 || 13 10 | 86.66 || 106 || 132 || 148 || 55.46 551 Gunshot fractures of lower-third......................... 418 131 || 112 || 117 | 46.09 || 1 1 0 || 50. 72 | 101 | 137 58.38| 672 Gunshot wounds of knee-joint............... 'º e º º ºs e º 'º e º ºs º º 7.70 | 121 || 331 266 | 73.23 1 9 1 | 90. 50 258 146 83.76 1183 2003 || 302 || 520 441 | 63.26 || 13 || 51 18 79.68 || 321 || 796 || 644 || 71.26 || 3106 § THE VARIED METHODS OF DRESSING WOUNDS. 291 ‘success; or it may mean, when there is uncertainty in the mind of the sur- geon whether the loss of the limb is necessary, to wait and ascertain what conservative means may accomplish. In the one case the surgeon is certain amputation must be made, but hopes for a better state of the body for its performance. In the other, he is undecided whether he can save the limb or not, and awaits the development of symptoms. This has given rise to considerable confusion. We may, however, say that a secondary amputa- tion is one in which, from any cause, the operation is delayed. In 1689 cases of gunshot fractures of the humerus, the complete records of which have been obtained, amputation or excision was practiced in 996, and conservative treatment adopted in 693, with a rate of mortality of 21 per cent. in the former and 30 per cent. in the latter. In gunshot fractures of the humerus, the tables of statistics in the late war were rather in favor of operation than against conservative measures. The unsuccessful nature of the treatment of gunshot fractures of the femur has given rise to the opinion of some surgeons, that when the acci- dent occurs, amputation should be immediately resorted to. This, however, is not the proper method to pursue in all cases, because instances are upon record wherein fractures of the femur from gunshot injuries have united, and the cure been complete. (Wide table on page 290.) The primary operation so far gives the best results, and should be adopted when there is no hope of rescuing the limb. A secondary amputation should be performed when the hope of saving the limb, which dictated the delay, is deferred and weakened by the untoward progress of the case. The surgeon, however, should bear in mind one fact, that no matter how decided the local injury may be in calling for amputation, the operation should not be performed unless there is a reasonable hope of success; and that secondary amputation is generally called for in cases of prolonged sup- puration, hectic, non-union of broken bones, gangrene, sloughing, caries, and necrosis. CHAPTER XV.* THE WARIED METHODS OF DRESSING WOUNDS.f As it becomes the daily duty of a surgeon to apply dressings to wounds and Sores, it is also his duty to understand a variety of methods by which cicatrization may be attained, so that in case one method does not pro- duce the desired results, some other may be resorted to. In many cases, however, the healing process will go on without hindrance under the use of almost any emollient application, therefore the principal object to have in view is to give the wound a covering, and so protect it from external influences; thus frequently the method adopted for this protection is unim- portant. In the case of superficial incised wounds, the tendency, in good consti- tutions, is to primary union. Still, even in these cases, foreign bodies should be looked for, as they often have forced into them either hairs, gravel, glass, or some portions of the clothing, or even some articles neither * This chapter has been written by Dr. John H. Thompson, Lecturer on Minor Surgery in the New York Homoeopathic Medical College. f In the preparation of this chapter, I have availed myself of Prof. Gosselin's lectures on the dressings for wounds, and the excellent articles on the subject of the antiseptic treatment of wounds, by A. C. Girard, M.D., and R. F. Weir, M.D.—J. H. T. 292 A SYSTEM OF SURGERY. visible nor capable of detection by the touch. All of these should be care- fully removed, either by washing, suction, or the forceps, before applying any dressing. - Unfortunately, however, wounds do not always present this simple char- acter. It then becomes necessary to apply some method which will bring about the most favorable results; union by first intention, if possible, if not, to favor cicatrization by granulation. • In order that this most desirable result (primary union) may be attained, the wound should be clean, without having been severely contused, and without loss of much substance. If only a short time has elapsed since its infliction, the edges may be brought together and maintained in proper apposition either by some kind of suture, or the application of strips of plaster, with the addition of a light bandage; the parts should always be placed in an uncon- strained position and kept immovable; this latter is essential to primary Ullſ]IOIl. Should it be impossible to obtain union except by second intention or granulation, either on account of a severe contusion or suppuration having already become established, or in the case of gunshot wounds, which are Quite certain to suppurate, it then becomes important to inquire which is the proper method to dress these different varieties of wounds. In all cases great attention must be given to the progress of the general symptoms, and those dressings selected which afford the best protection, and at the same time have a tendency to reduce the process of inflammation. Thus, for local application, poultices, water-dressing, simple cerate, cold cream, etc., may be used. Poultices, when required, should be used warm. - Water may be applied either warm or cold, and often the feelings of the patient will be the best guide, although water as hot as can be well borne will generally reduce an inflammation more effectually than cold. When cold water is applied, the compress which holds the water should be covered with a piece of oiled silk, or thin india-rubber or impervious paper may be used, to prevent evaporation. Another excellent method is that of irrigation, or the application of a continuous stream of water upon an inflamed part. - Thus in a few words are described some of the antiphlogistic methods which are of much benefit during the inflammatory period of those wounds which are destined to suppurate. All dressings should fulfil two important indications,—not to produce pain, and not to convey subjects of contagion to the wound. . . There are many salves and other articles for local application under the use of which, if the general constitution is good and the hygienic conditions favorable, the wound will heal. When, however, the granulations become too exuberant and rise above the surface, the application of nitrate of silver as a caustic, or powdered sulphate of copper, will generally reduce the sore to a more healthy condition. When, on the other hand, it becomes pale and anaemic, often with lardaceous spots, the pus transformed into a serous discharge, the reparative process has ceased, and stimulation becomes requi- site. In addition to general treatment and hygienic measures, the appli- cation of an ointment of balsam of Peru may be made, or the sulphate of copper applied in solution, or the pure pulverized, and allowed to remain on until its caustic effect becomes apparent. An electric battery may be made of a thin plate of silver and another of zinc, connected with a copper wire, the silver being applied to the sore, and the zinc over a healthy part. Care must be taken to change the locality of the zinc frequently, or another sore will be produced. THE WARIED METHODS OF DFESSING WOUNDS. 293 Enough, perhaps, has been said concerning superficial wounds. Atten- tion must now be given to a more important subject. I mean deep and more extensive wounds, and those which are connected with Osseous struc- tures, whether consequent upon an operation or traumatism. In the case of narrow deep wounds which compound a fracture, all the means at com- mand should be resorted to in order to obtain primary union of the integu- ment, and such an adjustment of the deeper parts that they may become united in the most speedy manner. This treatment would rarely be suc- cessful in the case of an amputation of a limb, or a gaping wound, the result of an operation for the removal of a large tumor; therefore it becomes necessary to be familiar with several methods of dressing, so that in the event of a failure in any stage of the method of dressing which may be adopted, some other may at once be substituted: for no matter how highly lauded each variety of dressing may be by its author or adherents, each may be followed by failure in some case or other, either on account of its being misunderstood by the surgeon, or a want of adaptability to the Ca,Se. Open Method.—The first method to which attention is called is the open treatment of wounds. It was first introduced to notice in the early part of this century by Kern, a Vienna surgeon, whose name is sometimes attached to this method. It was revived in 1856, in Germany, by Bartscher and Vezin. It consists simply in leaving the wound just as it is after the opera- tion and the arrest of haemorrhage, with a simple dressing of cloths wet with water, without sutures, strapping, or anything of the kind, until granulation takes place; the sides of the wound are then adjusted and brought together with straps of plaster or bandages, so that the union is always that of second intention. The advantages claimed for the open treatment are as follows: 1. The dressings do not cause undue pressure. 2. Danger of conveying contagion to the wound by impure applications is avoided. 3. As adhesion to primary union is abundant from the first, as many ligatures as are desirable may be applied to thoroughly avoid secondary haºmorrhage. - 4. The wound may be inspected at any time by simply removing the cloth covering it. z 5. There are no foul emanations from dressings to vitiate the surrounding atmosphere. - - 6. There is but slight danger of the retention of pus. 7. Irritation of the wound by changing the position, and making the ex- ternal applications, is avoided. - - 8. Less material is required for the dressings. - These advantages should certainly be a recommendation for this method when frequent observation is to be made by the surgeon; also for the in- struction of students in the wards of a hospital, and for practice in war when materials are scarce. There are, however, two considerations against the open method; one is the renunciation of healing by primary union, and the somewhat more frequent occurrence of erysipelas. This may be somewhat avoided by due regard to sanitary protection. And if in a particular case the sur- . ºy expect union by first intention, some other method may be Selected. Occlusive and Compressive Dressing.—This second method of dressing wounds with wadding was originated in France by Dr. Alphonse Guérin, and used by him at St. Martin’s Hospital in 1870, where it became quite successful and gained excellent results. I will now explain the method 294, . A SYSTEM OF SURGERY. of its application. Take for instance an amputation; the operation having been performed and the ligatures applied, the bleeding having ceased, and . the wound thoroughly cleansed and dried; a large bundle of new wadding must then be prepared by having it heated in an oven to as high a tem- perature as possible. The wound should then be filled with this warm Wadding, and secured in position by layers extending up on the limb sev- eral inches above the site of the operation. A sufficient quantity of the Wadding should be applied to make the limb about three times as large as the other. The whole dressing is to be retained by an ordinary roller bandage, which should exert considerable pressure; this of course must be applied with great care. The dressing should remain on from twenty to twenty-five days. At the end of this time it should be removed and a similar one put on. It is gene- rally necessary to reapply it two or three times. - The inflammation which supervenes is but slight, and frequently the pa- tient wººp and rest as well as before the operation, as the pain is usually very slight. Upon renewing the first dressing the cotton will be matted together and as the wound is exposed a small amount of thick, creamlike, laudable pus will be found. The wound itself is usually of a healthy reddish color covered with granulations. The principle upon which this dressing is applied is the complete exclu- sion of atmospheric germs. First the cotton is made as hot as possible to destroy any germs which it may have contained when procured; it is then applied in thick masses, and bound on tightly with a bandage. It might be º: that this dressing would be impervious to germs, but vibriones have been found in the pus under this dressing on the twenty-fifth day; still they did not appear to interfere with a favorable result, as the wound afterward healed well. Without either embracing or discarding the germ theory, this will often be found to be an excellent dressing, though like all others it will sometimes fail, even under the most favorable circumstances. - Alcohol Dressings.-Professor Nélaton was the first to make recognition of this agent as a dressing for wounds, the discovery of which was the result of investigations for some method to obviate the dangers of pyamia. Quite a number of distinguished surgeons have since used it, and some very favor- able results have been obtained. The wound should be dressed with a compress of lint, which is saturated with about ninety per cent. alcohol. The effects are quite remarkable in many cases, though of course not absolutely certain in all. The period at which its inefficiency is most apparent is during suppuration, when it ap- pears to delay the formation of a definite cicatrix. The most markedly beneficial effects are that during its use it prevents the symptoms of inflammation; there is no redness, swelling, or heat, and the pain is of a very moderate nature. The wound does not become putrid in any of its parts, and constitutionally the patient has but slight febrile reaction. , - Bordeaux Dressing, so called by the professor of clinical surgery in that city, Dr. Azam, who in 1874 described his method for the reunion of wounds after amputation, which he claimed would cure the patient as certainly as the occlusive method just described, and in a much shorter space of time, the former taking from fifty to sixty days, while the method of Dr. Azam occupied for the same purpose only from ten to twenty-five days. This is certainly an important point, and worthy of our earnest attention. - After the operation has been performed, and all haemorrhage controlled LISTER'S ANTISEPTIC METHOD. 295. in the usual manner, a good-sized drainage-tube is laid in the deep portion of the wound and fastened to the limb. The bases of the flaps are then united with quilled sutures of fine silver wire, as many as are necessary to hold the wound firmly, each from one and a half to two inches from the edges of the flaps. The edges of the wound are then held together with the figure-of-8 suture or harelip pins, supported by strips of charpie dipped in collodion. The limb is then wrapped in wadding, except where the drainage-tubes emerge, the ends of which are covered with charpie to absorb the discharge. - The harelip pins may be removed on the second or third day, and the deep sutures may be loosened then, or a day or two later. The dressings should be renewed as in ordinary cases, and cicatrization will usually be perfect in from ten to twenty-five days. Under Dr. Azam's care an ampu- tation of the leg healed in eleven days, and one of the thigh in ten days. There are, therefore, three important points to be observed in the applica- tion of this method. 1st. A drainage-tube at the bottom of the wound, through which the blood and serum run out. 2d. The deep sutures which are to hold in contact that portion of the WOUIIACI. ** 3d. The superficial sutures for the approximation of the margins of the WOUII) Ol. - These latter had been used by the English surgeons towards the end of the last century. Dr. Langier had proposed and applied the deep suture twenty years before for the same purpose. The drainage system had also been used by Drs. Broca, Fochier, and Courty previous to its adoption by Dr. Azam, but he is entitled to the credit of having united the three methods of drainage, deep, and superficial sutures, and originating a method which, on account of its success, is certainly entitled to much respect. The manner in which a wound heals by this method is as follows: The margins and deeper parts unite by first intention. The inflammation which is developed in the site occupied by the drainage-tube is quite mod- erate, granulation becomes established upon the surface of the cavity, and unites the muscular to the Osseous structures, generally after quite a limited amount of suppuration, and with a good chance of freedom from serious complications. In 202 amputations, 63 of which were of the lower limbs, there were but 12 fatal cases. Lister's Antiseptic Method.—This method was introduced by Prof. Joseph Lister, and first used by him in his hospital in Glasgow in 1868. Since that time he has made some alterations and improvements, and still further changes may be made in the course of time. It is only lately that attention has been given practically in this country to the teachings of Prof. Lister in regard to antiseptic surgery. - Much interest was elicited by his appearance at the International Medical Congress in Philadelphia, in 1876, when he gave practical demonstration of his treatment. Also from the fact that highly satisfactory results have been obtained in the practice of many German surgeons with large hospital prac- tice, it has come to be used by many of our surgeons. - There are some reasons, perhaps, why American surgeons, who have the credit of eagerly adopting all improvements, have not earlier tested this mode of treating wounds. One reason given is that it is “too much trouble,” another that “other modes of treatment give good results.” To these two objections Prof. Lister answers, “that the trouble is more imaginary than real, and is one of the necessary results of a want of proper 296 A SYSTEM OF SURGERY. apparatus and appliances, together with inexperience as to their use, etc.” To the second objection he grants “that they give good results but not the best ...}} Still another objection might be given, namely, that it was declaring one’s self in favor of the germ theory.f Thus Lister's definition of the antiseptic system is, “the dealing with Surgical cases in such a way as to prevent the introduction of putrefactive influences into wounds.”$ However, “Thompson, Weitzelbaum, and others have stated that they found living bacteria in the carbolic solutions as used by Lister, and Lin- hart, Fischer, Ranke, Schüller, and Volkmann, who, in several hundred observations, have found bacteria in the discharges of wounds that had been most carefully and satisfactorily treated by the antiseptic method. “It was noticed, however, that the presence or absence of these bacteria (and such were only considered as present when chain bacteria were found), did not influence the progress of the wounds, and Fisher gives the opinion, in which many of his countrymen join, that the object of the dressing is not so much to keep the germs away as to keep the secretions in such a condition as to be as unfavorable as possible to the development of bacte- ria, and thus prevent decomposition taking place.”|| - Mr. Lister says in reply to the observations above quoted: “The statement that cell-forms have been found beneath antiseptic dressings must be re- ceived with caution. I have recently met a gentleman who was with Ranke in Halle when he found, as he supposed, these organisms beneath antiseptic coverings, and when this gentleman pointed out to me the bacteria, which he called putrefactive, I at once recognized them as of the non-putrefactive variety, and the gentleman was forced to admit that they differed from those found in decomposing masses. “The germ theory of putrefaction is the foundation of the whole system of antiseptic surgery, and if this theory is a fact, it is a fact of facts that the antiseptic system means the exclusion of all putrefactive organisms.”[ It is desirable therefore that in the interests of science all possible knowl- edge may be brought to bear upon the pathological and physiological changes in connection with it. Be this as it may, we cannot afford to wait until it is fully explained, but must acknowledge that the antiseptic method is one full of marked success. On this point the voice of those who have successfully used it is unanimous. Hagedorn, of Magdeburg, says that in every failure the surgeon himself is to blame, and not the method, and Lindpainter, representing the expe- rience of Munich with nearly a thousand cases treated antiseptically, states that it must be considered a precept that the minutest directions must be followed, and that he who does not get the results desired must certainly have made some mistake.** We must constantly bear in mind that the principal object of this method * Trans. International Medical Congress. # Ibid. † The following is an excellent and concise explanation of the germ theory as given by R. F. Weir, M.D., in the N. Y. Journ. of Med., December, 1877. That in the dust of the atmosphere, and in matter with which it is in contact, there are germs of minute organisms, which under favorable circumstances induce putrefaction in fluids and solids capable of that change, in the same manner as the yeast plant occasions alcoholic fermentation in a sacchar- ine solution; that putrefaction is not occasioned by the chemical action of oxygen or other gas, but by the fermentative agencies of these organisms; that the vitality or potency of the germs can be destroyed by heat or by various chemical substances which in surgery are called ‘antiseptics.” % Trans. International Medical Congress, Philadelphia, 1876, p. 536. - | Antiseptic Treatment of Wounds and its Results.--Weir. Lister, Trans. International Medical Congress, p. 538, * Weir, LISTER’s ANTISEPTIC METHOD. 297 is to prevent the entrance of germs into wounds, to destroy them if already there, and to guard against the accumulations of wound secretions. In order to accomplish this, Mr. Lister has instituted a method of treatment, upon which he has on different occasions made some improvements, by which he proposes to prevent the injurious effect of these germs upon wounds. The various articles and the manner in which they are to be used will now be taken carefully into consideration. 1st. A solution of carbolic acid crystals in water in the proportion of 1 to 20. This is used to carefully cleanse the surface before operations or the neighborhood of wounds, to disinfect the hands of the surgeon and his assis- tants, to wash out septic wounds, inject into compound fractures, and clean drainage-tubes. A basin of the solution of this strength should contain all the instruments which are to be used in the operation. “A solution of this strength is also required for the spray when a steam atomizeris used.” 2d. A solution of carbolic acid crystals in water in the proportion of 1 to 40 “for the sponges during the course of an operation,” to wet the “loose layer of gauze, and for the lotion when changing the dressings.”f 3d. A Steam Spray Apparatus.-In order to prevent the entrance of living germs during an operation or dressing, a spray of the solution of carbolic acid in water is used directly and constantly upon the parts. Some instrument which throws a large is: and finely divided spray should #"; be used. A Steam atomizer (Fig. ii. 120) is indispensable on account dºmiţ of the necessity of keeping up an iº-tº uninterrupted application of the spray; for one worked by hand would become too fatiguing. A boiler containing 20 to 24 ounces will give a spray for about two hours. It is said that atomizing the solution renders it weaker, so that some use a 1 to 30 solution, which, when in the form of a spray, will be about 1 to 40. It is often necessary to be pro- vided with two apparatuses, so that if for any reason one should cease working, the other will be at hand, Fig. 121 represents the atomizer of Dr. Weir. 4th. The Protective is ordinary oiled silk, coated with copal var- nish to render it impermeable to - Hºmº carbolic acid, which gutta-percha Hank's Atomizer. is not; it is then covered with a thin coating of dextrin, 1 part; starch, 2 parts; and carbolic acid solution, 1 to 20, 16 parts. After this last application the disinfecting solution will h ...; Letter from Prof. Lister to J. L. Little, M.D., of New York, in Hosp. Gaz., May 9th, 1878. - f Although Mr. Lister and many of his followers have discarded the spray, yet, as there are still some in the profession who employ it, I have thought best to allow the directions for generating it to remain in this edition, although in my own practice I now never employ it; substituting therefor a carbolic vapor from a large kettle containing a boiling solution 1 to 40 carbolic acid water. 298 A SYSTEM OF SURGERY. the better adhere to the protective. It should always be immersed in a 1 to 40 solution previous to being used after an operation. The object of the protective is to prevent the irritating effect of the carbolic acid contained in the antiseptic gauze to the part operated upon. The protective should slightly overlap the wound. 5th. Antiseptic Gauze.—This is made of a coarse-meshed, unstarched cotton cloth, which in Scotland is called “mull,” but here is called dairy or cheese cloth. This was selected by Mr. Lister on account of the facility with which the secretions are absorbed by it. Mosquito-netting has also been put to the same purpose after a careful preparation. - The mode of preparation is to heat the cloth for several hours beyond 212°, it is then sprinkled with a hot mixture, composed of carbolic acid, 1 part; resin, 5 parts; paraffin, 7 parts. The cloth is then submitted to FIG. 121. Weir's Atomizer, pressure so that the mixture will be equally distributed through it. The resin is excellent to hold the carbolic acid, and prevents its too speedy evaporation, and the paraffin prevents it from being sticky. In using the gauze, it should be wet with the carbolized solution, 1 to 40, folded in eight thicknesses, placed next above the protective, and slightly overlapping it. Between the seventh and eighth layers from the skin, should be inserted a piece of mackintosh. Dr. W. T. Bull has recommended, that thymol should be used instead of carbolic acid, principally on account of its being less irritating; but one solution is required, and that is, thymol, 1 part; alcohol, 10 parts; glycerin, 20 parts; water, 1000 parts. The gauze is also prepared with it as follows: thymol, 16 parts; resin, 50 parts; spermaceti,500 parts. In using this gauze “the protective "oiled silk may be omitted; the other minutiae are the same. 6th. Mackintosh is common rubber cloth ; this prevents the secretions from coming immediately to the surface, so that the whole dressing is saturated with the discharge, which is thus kept in contact with the antiseptic. This should be cut an inch smaller than the gauze, so that when the se- cretions come to its outer layers they may be detected while they are still in-the antiseptic gauze. It is not necessary to have a new piece of mackintosh at each dressing but it may be washed off with carbolized water and used again, but it should be held up to the light each time, so as to detect any holes or im- perfections. LISTER’s ANTISEPTIC METHOD. 299 7th. Drainage-tubes are small tubes of soft rubber, made of different sizes. They should have several openings on the sides to facilitate the egress of the secretions from the parts which they are intended to drain. Two small ones will be better to use than one large one, as they will not cause the wound to gape so much. Each pocket or angle of the wound should have its drainage-tube, and it should extend down to the bone; they should be cut off on a level with the skin, either square or bevelling, and sewed with a piece of silk drawn through the end, which should be fastened externally with a piece of plaster, so that the tubing may not be lost by slipping into the wound. Several strands of catgut may be used for drainage instead of the rubber tube; these can be withdrawn one or two at time, if desirable, as the wound closes. A small bundle of horse-hairs is the latest article used for drainage by Prof. Lister.” (See page 43.) 8th. Catgut, as used for ligatures and deep sutures, is one of the principal articles in antiseptic dressings. The edges of wounds approximated by this substance heal readily; the catgut becomes absorbed without producing any irritation. It is prepared by putting it in a mixture of carbolic acid, made liquid by one-tenth its weight of water, to which is added five parts of olive oil. The catgut should be kept separate from the watery part of the mixture, and this is best done by placing some marbles or pebbles in the bottle and laying a piece of glass on them ; this will raise the catgut above the water; they should remain in this manner two months without being disturbed. At the meeting of the International Medical Congress, held in 1876, Mr. Lister announced that he had made more satisfactory ligatures by a mixture of carbolic acid, glycerin, chromic acid, spirits of wine, and water; the exact formula has not yet, however, been made known. 9th. Antiseptic Silk.-The catgut is used for ligatures and the deep sutures, but as it does not retain its firmness long enough for superficial sutures, silk antiseptically prepared is preferable. It may be prepared by immersing the silk for an hour in a mixture of hot beeswax, 10 parts; car- bolic acid crystals, 1 part. It should then be drawn through a cloth to tºº the superabundant wax. It may then be kept in a well-stoppered Ottle. 10th. The Sponges used in Lister dressings, whether during the operation or for the absorption of secretions, should be thoroughly beaten, then washed in warm distilled water, and kept covered in a jar filled with a carbolized solution 1–20 until needed. After being used they may be washed out in a solution and replaced in the vessel. In this manner they can be used re- peatedly. In addition to small sponges used during the operation, it is well to have some larger ones, which may be applied to wounds the first day after the operation, to absorb the secretions, which are made copious by the application of the spray. - 11th. Carbolized Olive Oil, 1 to 20, is used to oil catheters and other in- ºntº ; or the fingers, when necessary to introduce them within the Ody. It is also useful where a direct and continued application of the antisep- tic is required to the wound, as, for instance, in cases of caries, or where it would not be possible to apply the gauze dressing; also in order to avoid i. of the irritating and caustic effects of the spray upon the operator's a]]CiS. 12th. Liq. Zinci Chlor, 1 part mixed with 12 parts of water, may be used in cases of compound fracture, or in any case where a wound has been ex- posed to atmospheric influences, or where a wound which has been dressed * Medical News and Library, February, 1878. 300 A SYSTEM OF SURGERY. antiseptically has become septic, it may then be rendered aseptic by being washed out with this solution; but great care is necessary in its use, and it is generally a more successful way to scrape out sinuses or caries in bones before applying this article. - The writer has purposely omitted mentioning the varied preparations of boracic and salicylic acids, as used by Prof. Lister, in order not to unneces- Sarily extend the limits of this chapter. After all of the articles above described have been made ready, if there be any hair on the part to be operated upon, it should be cleanly shaved off. The skin should then be washed with soap and warm water with a brush. The anaesthetic may then be administered, and, when complete, the spray should be directed upon the part. The surgeon's and assistants’ hands are now to be thoroughly immersed in the 1 to 20 solution, and a final washing given to the skin. The instruments, having been immersed in a basin of the same solution, should be carefully wiped and returned to it after being used. . The blood is wiped away with the prepared sponges, which are ready in another basin of the solution, and after being thoroughly squeezed should be put in the basin again. Care must be taken by the operator and the assistant who has charge of the spray apparatus not to allow any one's hands to come between the cone of spray and the wound. The bleeding vessels are secured in the usual manner, and tied with the antiseptic catgut ligatures, and both ends cut off close. A piece of gauze should be lying in carbolized water, so that in case the atomizer for any reason ceases to work, it would be ready to throw over the wound until the spray could be resumed, and for this reason it is always well to have two instruments at hand. After the operation is completed, the tourniquet or Esmarch's bandage, whichever has been used, may be removed. There is generally some ha-mor- rhage, owing to the fact that the spray prevents the formation of clots. All bleeding must be stopped, the wound carefully washed out with the 1 to 40 solution, the drainage-tubes may then be put in their places and secured as before directed, and the sutures introduced; the deep with carbolized cat- gut, the superficial with the antiseptic silk. The wound is then to be covered with a piece of the protective which has been lying in the carbolic solution of 1 to 40, and this covered with a single layer of gauze, wet in the same solution ; this should be a little larger than the protective, so as to overlap it on all sides; if much depression exists, as after the removal of a tumor, one of the large sponges which has been pre- pared may be placed between the protective and loose layer of gauze. The spray may now be dispensed with. The eight layers of gauze are then to be applied, either wet or dry, as may be desired, remembering to insert between the seventh and outer layers, a piece of mackintosh, with the rubber side down, cut one inch smaller on all sides than the gauze. The whole of this dressing is to be retained with bandages made of strips of the gauze. When the wound is large, or the discharges are likely to be excessive, a thicker dressing may be put on. . The first dressing should generally be removed not later than twenty-four hours, sooner than that if the discharge appears anywhere on the surface; but Mr. Lister says that when the oiled silk protective is used, “a wound need not be opened for a week;” however, when there is an oozing at any part, undue pain, or an increase in the patient's temperature, the dressings should at once be removed, always under the spray, which should be care- fully directed towards the parts until the wound is covered again. “If the protective is unchanged in color, the wound is certainly aseptic ; if it is not, LISTER’s ANTISEPTIC METHOD. 301 it will show dark-brownish spots, the result of the action of the liberated sulphur upon the lead in the oiled silk. This only holds good of incised wounds. In contused wounds the changes of color are met with, even though the wound is doing well.” (R. F. Weir, op. cit.) Whenever the protective is discolored, the wound must be treated like a septic wound, either with the carbolized solution or the chloride of zinc. If the wound has remained aseptic, washing it is to be carefully abstained from, and the drainage-tubes not removed until the third or fourth day, unless one becomes choked up, when it should be carefully taken out and washed with the 1 to 20 solution, and replaced according to the granulation of the wound; the surrounding parts may be gently cleansed with a sponge. The feelings of the patient and the staining of the dressing are good indi- cations of the necessity for making changes, but the best is the temperature of the body. When this is normal and the protective unspotted, we may be certain that our dressings are correctly applied, that the wound is doing well, and needs no interference. When the patient shows an increase of temperature over the preceding examination, it becomes positively necessary to remove the dressings and examine the wound, when it will be found that the drainage-tubes have either become clogged, or else that they have not perfectly drained the wound, and the introduction of another tube, or washing the wound out with the carbolic solution, by means of a syringe, will correct the septic condition, and the relief will be shown by a fall in the temperature. Prof. Lister keeps the drainage up until the wound is nearly if not quite healed, shortening them as often as is necessary. In reapplying the dressing everything had better be changed. The piece of mackintosh may be used again, after having been thoroughly washed in a carbolic solution of 1 to 20. - For wounds to which this method is to be applied, and which have ex- isted for some time before coming under observation, such as compound fractures and lacerated wounds, the procedure must be somewhat different from that already described. If it is a compound fracture, the external parts must be thoroughly cleansed, and the wound explored under the spray, the loose fragments of the bone removed, and the cavity syringed out with the carbolized solution 1 to 20, or, as Mr. Lister has lately used, carbolic acid, 1 part to 5 of alcohol, thrown into the wound with a syringe. Drainage-tubes are then inserted up to ends of the bone and the bottom of the wound; after this the protective and other dressings are to be applied as usual. In all cases the spray is to be continued until the parts have been covered by the protective. For wounds which have been brought to the surgeon in a suppurating condition, or those which “have failed to remain aseptic,” it is necessary to resort to another procedure, and that is the appli- cation of the solution of chloride of zinc, as already deseribed. However, when wounds treated from the first by this method have become septic, the experience of those who have used this method extensively, goes to show that there has been some error in making the dressing. The presence of pus is not decisive of the failure of this method; but the odor that arises from it, also the brownish spots on the protective, indicate that a septic action has taken place, for dressings which remain aseptic are always without any odor. The antiseptic treatment does not always pre- vent the formation of pus, though it may be desired, and Mr. Lister himself does not regard putrefaction as the only cause of suppuration. The results which have been obtained by this method of dressing wounds is a matter of the deepest interest to surgeons, and much has been written on the subject. The views of Prof. Lister are not confined to his pupils 302 A systEM OF SURGERY. alone, but are embraced by men of high standing as surgeons, like Volk- mann, Thiersch, Locin, Nusbaum, and many others. Its advantages, therefore, are sufficiently vouched for to render it the duty of every one having the charge of surgical cases to give it a careful trial, especially in hospital practice. CHAPTER XVI. A CONCISE REVIEW OF THE ANTISEPTIC SURGERY OF * THE PRESENT. HAVING gone over the varied methods of dressings in the last chapter, and having considered the subject of antiseptics in the chapter upon “Disinfec- tion and Antiseptics,” and having also occasion to allude to them in both the chapter on “Minor Surgery '' and the “Ligation of Arteries,” as well as in the manner of “dressing wounds,” and in view also of the many changes in opinions and practice in regard to antiseptic surgery, it would appear eminently proper that a chapter bearing the above title should be inserted in this place. With the varied discussions relative to the germ-theory and the labors of Pasteur, Schwan, Schroeder, Dusch, Roberts, Drysdale, Koch, Spina, Peter, and many others, this chapter has nothing to do, nor will its author undertake to detail the many very careful and prolonged experiments that have been made to ascertain the true nature of the micro-organisms that inhabit the atmosphere (whose presence yet causes and has heretofore de- veloped such disastrous effects during the treatment of wounds), only in so far as the opinions of the distinguished authors bear upon the question which forms the subject of this chapter. In the outset, then, we draw a distinct line of demarcation, between what is known as “antiseptic surgery” and “aseptic surgery;” the former being the treatment of all wounds by the best methods of preventing putrefaction and the consequent infectious diseases, the surgeon employing any of the so- called antiseptics in any way most in accordance with his opinion; while the latter (the “ aseptic method”), will be considered as synonymous with “Listerism,” the sheet-anchor of which is carbolic acid, and main-stay, “com- lete occlusion of the wound.” This portion of the subject, with its details, }. been fully considered in the last chapter. - - The majority of surgeons at present, I think, are of the opinion that most, if not entirely all germs come from without, either by the means of instruments, the hands of the operator, or by floating from the surrounding atmosphere, and that if these be perfectly excluded many complications will be avoided, perfect disinfection of the whole wounded surface and the complete exclusion of air being the two main conditions upon which the aseptic treatment rests. There are three parties, however, at present in dispute regarding the theory of both the antiseptic and aseptic methods, and although all appear to agree that the introduction of the aseptic (Listerian) method, has been productive of a vast amount of good, the one side are disposed to believe that these results are obtained by simply care and cleanliness, while another attributes them to the distinctive power that carbolic acid has upon bac- teria, spores, micro-organisms, and germs of all kinds, while again a third are of the opinion that the acid itself has some peculiar inherent power over the varied processes of repair. There is, however, another point which is claimed by true antiseptic sur- THE THEORETICAL ASEPTIC METHOD. - 303 gery, which exists in the fact that a really true antiseptic not only should exclude all septic ferments from the wound, but should be capable (as Dr. Chein says *) of rendering inert the causes of putrefaction. Let us first, then, consider the aseptic method as briefly as possible. That the entire surgical world is indebted to Mr. Lister for the antiseptic method of treating wounds, there can exist no doubt, and that, following his ex- ample and his teaching, most minute carefulness and perfect cleanliness have succeeded carelessness and filth, especially in hospital practice, is also well authenticated. That the results he has obtained in the treatment of wounds under his care, are remarkable when compared to the older method, is true, The practical value of his teaching in Saving human life and pre- venting an immense amount of human suffering, is a fact which cannot be gainsayed. While, therefore, I think the majority of the profession at the present day are willing and ready to accord to the aseptic method a vast practical improvement in its results, yet there is a wide difference of opinion regarding what I may term “Theoretical Listerism.” The first main proposition in this system is the perfect and complete acceptance of the germ-theory of putrefaction, viz., that bacteria floating in the dust of the atmosphere not only infect the wounded surfaces, but enter into the tissues, deeply poison the whole mass of blood, and produce rap- idly those infectious diseases known as septic; that these micro-organisms are the only sources of putrefaction, and that carbolic acid is the substance par excellence which is to be relied upon as most potent in preventing the entrance of these destructive bacteria, and offering obstacles more or less complete, to the fermentations which these particles would otherwise occa- sion. This, in a word, is the theoretical Listerism, practioal Listerism being the preparation of no less than twenty-one articles, which, as Mr. Chein in the Encyclopædia of Surgery says, will be necessary for each dressing. Many of the articles mentioned are in the plural, which in themselves cumber very materially the room, and require a long time for their preparation, and considerable expense for procuration. ‘. The Theoretical Aseptic Method.—It is in this, as I have already said, that a wide discrepancy of opinion prevails, for while no one at the present day can deny the germ-theory of certain diseases (and it appears from very recent experiments that additional evidence can be adduced in its favor), yet many do deny that germs are the sole agents of putrefaction. I may here by way of parenthesis remark that one of the best received and most carefully pre- pared works on the germ-theory of disease has issued from the pen of my esteemed friend, Dr. Drysdale, of Liverpool, for a long number of years one of the editors of the veteran British Journal of Homoeopathy. The question now is, are there no other influences than the presence of germs to account for the obstreperous deportment of wounds, and does this bad behavior always arise (as Mr. Lister and his followers strictly contend), solely from the presence of bacteria? • - In the present status of antiseptic surgery, it can be shown without doubt that these very bacteria, instead of being in all cases hurtful, are indeed beneficial, and while they may be in many instances the essential agents in fermentations, decompositions and putrefactions, at the same time they may be important factors in the maintenance of health. A large proportion of our food is prepared by saprophytes. To bacteria we are indebted for butter, cheese, vinegar, and even bread, wines, beers, and spirituous liquors. In fact, the tremendous influence of these organ- isms in consuming the waste thrown off from the animal and vegetable kingdom is indeed astounding; were it not for these, the débris would not * Chein, Antiseptic Surgery, p. 13. 304 A SYSTEM OF SURGERY. be consumed, and would accumulate as a tremendous load upon the earth. Animals would be overburdened by their own excrement, and plants die for want of nutriment. Therefore, looking at the germ theory in this light, there is reason to doubt theoretical Listerism. Again, certain varieties of bacteria, under peculiar circumstances, are absolutely of service in the process of repair. At the present time, there are many renowned surgeons who, Ithink, would give testimony in favor of such a Statement. Dr. William Hunt, senior surgeon to the Pennsylvania Hospital, thus speaks: “Having noticed wounds healing kindly under masses of maggots, I reflected that they were scavengers, eating only dead materials, and so con- verting harming matter into harmless living substance. We have to get rid of them, it is true, because they will persist in getting into wrong places, and so give an infinite amount of trouble. To my mind,” further says Dr. Hunt, and he italicizes the words, “there is no positive proof as yet of the or- ganisms being specific and primary in their operation,” and further on he says, and backs up his opinions by no less authorities than Formad and Dr. Joseph Leidy, “No micro-necrosis, no micro-maggots; that is food mostly in the shape of necrotic products precedes the advent of the micro-organisms; however these may originate, whether animal or vegetable, and in disease these necrotic products, first, plus the micro-organisms, second; play havoc with their environment.” Formad says, “The presence of bacilli (so far as our present research goes) is secondary, and appears to condition the complete destruction of the tissue already diseased and infested by them, and this destruction is in direct proportion to the quantity of the organisms which thus regulate the prognosis.” - According to this view of the theory, bacteria are useful in some instances and hurtful in others, and a still more singular fact has been noted by Kocher, who says, “In different forms of inflammation different forms of organisms come into action, and the different changes in a wound cannot be laid to the same coco-bacteria.” And again, our friend, Dr. Drysdale, also has proved that there is a specific parasite for almost every human tissue. Therefore, to account for every variety of septic poisoning by the presence of micro-organisms cannot at the present be tenable. This may be proven by the fact that the most minute attention to all the details of Listerism does not completely exclude bacteria, for they have been found in the best dressed and healthiest wounds, even, I believe, in carbolized cat- gut ligature; they have also been discovered in wounds proceeding rapidly to adhesion. “Billroth and Ehrlich, after careful experiments, declare that no difference is discoverable in the putrefaction of blood drawn directl from an artery and sealed up under spray and that taken without . protection.” Besides, if mere bacteria acted as a pyaemic poison as self- producing and in the minimum dose, like the poison of rabies, syphilis, and small-pox, nobody could survive the smallest cut or abrasion, and vaccina- tion and subcutaneous injection would be certain death.* As Dr. Hunt also says, if these organisms are specific and primary, “I do not compre- hend how any of us are alive.” Dr. Bryant also writes in his latest work, “I am no convert as yet to the theory on which it (Listerism) is based, nor to the great value of the special practice based upon it, neither is it yet proved. It is much to be regretted, that the originator of the system should not have listened to the repeated requests of surgeons to publish the results of his practice as a whole, since it can be by such alone that the value of the method is to be estimated.”f And again, Markoe, of our country, in a valuable paper on “Through —adº * Drysdale, Protoplasm, p. 45. f Bryant, Practice of Surgery, p. 792. THE THEORETICAL ASEPTIC METHOD, 305 Drainage in the Treatment of Wounds,” says that, though he is a firm be- liever in many of the most important doctrines connected with the germ theory, he certainly is of opinion that there are very many other causes which may excite “the ill-behavior of wounds.” Dr. Lawson Taiti writes: “The basis of Lister's theory of putrefaction by means of bacteria had long ago been proved beyond dispute as regards dead matter. But Mr. Lister assumed for living matter the same sequence of events as in the case of the dead.” Again, it has been proven that symptoms in appearance, progress, dura- tion, and results exactly similar to septica-mia, have been produced by in- troducing fibrin ferment into the blood in considerable quantities, that º and ptyalin produced similar symptoms, and from these facts Dr. . T. Bellfield, in his valuable Cartwright Lecture,i states positively that recent experiments have demonstrated “that the aetiology of the growth of clinical and anatomical appearances, known as septicæmia, is by no means restricted to putrid infection.” & These references are sufficient to show that there are wide differences of opinion regarding the theoretical aseptic or Listerism methods; let us look to §. which concerns us more closely, viz., the practical results of the method. Those at all conversant with surgical literature must acknowledge that Mr. Lister has roused the medical and surgical world to the proper application of thorough disinfection and perfect cleanliness, and by his praiseworthy and persevering efforts has wrought a complete revolution in the treatment of wounded and abraded surfaces. The most skeptical as to the theory are compelled to acknowledge the beneficial results of the practice, and I think I may say, that in private or in hospital routine work at the present day, any surgeon would appear derelict in his duty did he not employ some variety of the antiseptic method. The details of Listerism, however, as I have already stated, are cumber- Some and trying, both to the patient and to the time of the surgeon, and therefore many of the minutiae, which at one time were deemed essential, are now omitted altogether, or applied in a very modified form, with most excellent results. Notably is this the case in the application of the spray, which has been not only abolished by many, but by some is deemed abso- lutely hurtful. s Lister, himself, has modified his opinion with regard to the strength of his carbolic acid solutions, using first a spray of 1 to 100, and now 1 to 20; for sponges, a solution of 1 to 40, and it is stated by Delacroix that 10 per cent. of carbolic acid is required to destroy bacteric life. He says:$ “It would not at all break my heart if I were told that I should never be allowed to use the spray again in my life, and I am satisfied I could, by other means, get equally the same results.” He also goes on to express himself very much in favor of corrosive sublimate dissolved in glycerine, which prepara- tion, he thinks, has never been mentioned before, and which he considers “a new fact in chemistry.” It may be said, therefore, that as there are means of causing putrefaction other than the bacteria floating in the dust of the atmosphere, and as (as already has been stated) different inflamma- tions are attended by different forms of bacteria, and as the resistant power of bacteria is not always the same (that of the reproductive spores being much greater than fully developed bacterial products), and as also Dr. * American Journal of the Medical Sciences, April, 1880, p. 309. # Loc. cit., July, 1882, p. 267. f Medical Record, March 3d, 1883, p. 227. ź British Medical Journal, February 23d, 1884. 20 306 A SYSTEM OF SURGERY. Weir writes, “it must be admitted by the most devoted advocates of the Listerian system, that the dressings applied with the strictest attention not infrequently fail in arresting the progress of putrefaction,”—that the good results so widely acknowledged, must be explained by other than the Lis- terian theory. Again, Kocher, Volkman's assistant, is of opinion that the Same antiseptic measures cannot be used in the treatment of all varieties of wounds,” and the same surgeon after fully admitting that many wounds heal well by the carbolic acid treatment, says: “I have seen colleagues who tena- ciously hold to the spray with all the attributes which hold to the Lister- Volkman technique, have here and there the most grave cases of infection after complicated operations;” and as Drs. Hunt and Formad have stated that in many instances the micrococci seem to be increased in the proportion to the necrosis of the tissue; may it not be a fact that carbolic acid (as indeed do many medicinal substances) has a peculiar action upon certain forms of bacterial life, in the one case causing the total annihilation of the organisms, in another but partially affecting them, while perhaps in a third variety they resist the action altogether ? In other words, a specific action of carbolic acid is found in one class of cases, and, perhaps, these are in the majority, while in another, it is of no avail. In looking over Mr. Chein's work on Antiseptic Surgery, and comparing Mr. Lister's own statistics, it will be found that the best and most surprising results were obtained by Mr. Lister in his method of treating diseases of the joints. Why, then, as different micro-organisms belong to different inflam- mations and tissues, may not carbolic acid be particularly applicable to those affecting the synovial tissues of joints? Again, there are other thoughtful men, who, believing, in a measure, as I do myself, in the bacterial agency in the production of putrefaction, see in the good results that are often observed from the use of carbolic acid, something more than the mere destruction of bacilli, and give a large share of the efficiency of the drug to its action upon the tissues themselves. Dr. Markoet says, “My attention once directed to this point, I think I have verified this power which I claim carbolic acid possesses, of modifying vital action in many striking instances. I have watched many commencing surface inflammations rapidly diminish and disappear under carbolic dress- ing, when no exclusion of germs was attempted. I have seen wounds of all kinds and degrees of severity go through their stages of repair without a trace of inflammatory complication, and even when inflammatory complications had not been prevented. I have seen the morbid actions which threatened infinite mischief, so modified and controlled by carbolic acid constantly applied as to be practically robbed of their usual power to inflict damage.” It is needless here to note the opinions of Ollier, Tillaux, Weir, Beal, and others, but I may say that these views have been for the past six years entertained by myself, indeed, since the perusal of a pamphlet by John Dougall, M.D., of Glasgow. I immediately endeavored to look for some other power in carbolic acid in the treatment of wounds besides its virtues as a mere germicide. In his paper, Mr. Dougall says, “If, as is alleged, germs are the source of putrefaction, then the strongest preventives must be the best antiseptics, and vice versa. Now, as seen in the table, carbolic acid occupies a very mediocre place, . . . . . and although unable to formulate the change that takes place, when it unites in large proportion with organic bodies, for which it has a strong affinity, still the result of such change certainly is the formation of a compound capable of resisting the attacks of * Volkman's Klinische Vortage, November, 1882. f American Journal of the Medical Sciences, April, 1880, p. 314. f The Relative Power of various substances in Preventing the Generation of Animalculae, or the Development of their Germs, with Special Reference to the Germ Theory of Putrefaction. ANTISEPTIC METHOD. 307 oxygen, of water, and consequently of germs. In other words, a compound is formed which is proof against putrefactive tendencies.” If, now, we take also into consideration the valuable experiments of Prudden,* which appear to show that strong solutions of carbolic acid cause immediate cessation of amoeboid motion and death of the cells, and that very dilute solutions may cause a temporary cessation of the movement, and not the death of the white blood-corpuscles, it would appear that the physio- logical action of carbolic acid may have a great deal to do with the results which have been obtained by its use in the treatment of wounds. It would be interesting to enter upon the details of “carbolic acid poisoning,” but want of space forbids. - - Antiseptic Method.—Having now given sufficient consideration to the aseptic method, the second division of the subject, viz., “The Present Status of Antiseptics,” claims serious attention. Here at once a wide field opens to the student, and a cursory glance at medical literature for the past three or four years will show beyond cavil, that the universal antiseptic has not yet been discovered, nor will such a panacea lapsorum, in my mind, ever be revealed. I have no doubt, however, that the time will come when a more thorough understanding of the actions of the so-called antiseptics will be arrived at, and that the surgeon may then be enabled to select certain drugs or certain chemicals which, beside having antiseptic properties, may be peculiarly adapted to the process of repair as taking place in the different structures of the human body. I think it may be affirmed at the present that while the aseptic or Listerian method, or certainly portions of it, which were formerly deemed essential, are gradually being done away with, yet that antiseptic treatment is being more thoroughly investigated. This may be judged even by a cursory review of the treatment of wounds in hospitals as well as in private prac- tice. The spray, I think, is almost abolished in the majority of hospitals, and many antiseptics, other than carbolic acid, are employed by surgeons in all parts of the world. It is well known that Mr. Savory, senior surgeon to St. Bartholomew’s, the largest of the London hospitals, rejects the antiseptic treatment and relies upon cleanliness alone, and very ably has defended his position, although Mr. Chein, in his work, states that the Savory treatment was in some degree antiseptic. - Mr. Lawson Tait, as has already been mentioned, is no advocate for the antiseptic method in ovariotomy, and we find, so late as May of this year, 1886, a most surprising record, viz., one hundred and thirty-nine consecu- tive cases of ovariotomy performed in a year without any Listerian details, without a single death. Mr. Tait states that he would stuff his pads with germs properly prepared. His increased success he attributes to the im- proved methods of operating, to his more extended experience, and espe- cially the complete abandonment of the use of carbolic acid or any other disinfect- ant, and the establishment of hospital discipline and hygiene on the best known principles. Bantock, also of the Samaritan Hospital, operates without spray. Dr. Keith,S it is well known, spoke his mind in the surgical section of the London Congress when he said, that after having a succession of eighty successful cases, he had five deaths in the next twenty-five cases, two of which were from carbolic poisoning, one from septicaemia, and two from acute nephritis. He had abandoned the spray in all operations, and in * American Journal of the Medical Sciences, January, 1881, p. 96. f British Medical Journal, May 15th, 1886. † Medical Record, March 10th, 1883. & Lancet, August 13th, 1881. 308 A SYSTEM OF SURGERY. the last twenty-seven ovariotomies without any antiseptic treatment, he had lost but one patient. • . - Holmes, at St. George's Hospital, discards the use of antiseptics except in disease in the joints. . Hutchison, at the London Hospital, also works without Listerism. In the hospitals in New York they are constantly investigating substances with a view of ascertaining their antiseptic properties, the spray being in very many of the institutions entirely abolished, and even by some con- sidered as being pernicious. Sands, Stimson, Markoe, Weir, and many other surgeons are, in the hospitals to which they are attached, constantly experimenting with the newer dressings, some of which as bearing upon this subject will be mentioned shortly. In Bellevue Hospital the dressing is as follows, as communicated to me by my former pupil, Dr. Fuller, late house surgeon in that institution : He writes me: “The form of dressing now in use in our wards is one introduced by Dr. Langé, and is practically the antiseptic dressing that is being used in Germany almost entirely. The wound dressing, however, is only one element in the treat- ment of the case, the secret is absolute cleanliness and antisepsis. Say the case is one of amputation, or excision of a joint, the parts are first washed with soap and water, with ether, if necessary, and the hair shaved off. Then towels wet with an antiseptic solution, generally #6 carbolic acid, are spread around the limbs so that the operator's hands or the instruments may not touch the parts unnecessarily. Instead of a spray the wound is frequently irrigated with a solution of corrosive sublimate, four grains to the pint of water, the instruments are absolutely clean, and are lying, when not in use, in a solution of ſº carbolic acid. The hands of those engaged in the operation are wet with the same. For ligatures we use carbolized catgut or fine carbolized silk. We keep it in pots, wound on spools. In an amputation we use absorbable drains of decalcified bone, in other cases, rubber tubes. After the final washing, the wound is sprinkled with iodo- form and protected by rubber tissue, which is placed over the sutured mar- gins of the wound, and the outside dressing is then applied, it may be peat, borated cotton, or gauze. Peat is the best absorbent, but is expensive. We generally dress within thirty-six hours. When the oozing of blood and serum will have ceased, the tubes are then removed or not, according to circumstances. This dressing must be made under the same precautions as the operation, irrigation, guards, etc. The second dressing may remain on a week or longer. If the discharge comes through the outside dressing, the partis to be dusted with iodoform, or an extra amount of cotton or gauze applied. The only indication for the removal of the entire dressing is a higher temperature. With this dressing we have treated in the last two months over a dozen excisions of joints, half a dozen osteotomies, excisions of tumors, compound fractures, etc., without a bad result, and with a re- markably low range of temperatures. In all the wards we do not treat anti- septically, but there have been no results to equal these I speak of. Dr. Weir tried full Lister dressing with good results; Dr. Keys also. Dr. Wood used the open method entirely. Dr. Langé employs the one I have just mentioned.” In a somewhat late periodical,” Dr. Henry C. Simes, assistant surgeon to the Episcopal Hospital, thus writes of the general treatment of wounds in the Philadelphia hospitals. He says that Listerism is far from being accepted, and thus continues: “In this city (Philadelphia.) I know of no hospital in which its surgeons have fully and thoroughly carried out the details necessary to give their treatment the name of antiseptic, that is to say, that they have not * Medical News, Philadelphia, June 13th, 1880. IODOFORM. 309 attended to the minute directions, and in many cases the principal features have been omitted;” and then further states, that in the same hospital, when antiseptically treated cases were compared with those not subjected to the method, the results of the former were much more satisfactory. - From these facts, selected from an immense amount of material, it may be judged that antiseptic surgery, as we now regard it, is being more thoroughly investigated and improved, while the details of Listerism are being gradu- ally abolished. The constant search for new antiseptics in the treatment of wounded sur- faces, may be regarded as indicative of the fact that there are none which have as yet proved entirely satisfactory, and, as much has been written and many experiments made during the past three years in regard to new sub- stances said to be antiseptic in their nature, I therefore shall give the most important, with as much detail as the limits of the work allow. odoform.—Iodoform must take the precedence, not only because it has been very much used by many distinguished surgeons, but because the results obtained have been very surprising. In fact, I recollect reading not very long since, that Billroth had stated that the reason that he had not published his cases treated with iodoform, was that the results he had ob- tained were so very surprising that he feared they would not be credited. Iodoform contains about 96 per cent. of iodine, and when decomposition is going on, the iodine is evolved, which, by actual experiment, has been proved to be one of the best disinfectants. * After the wound has been cleansed, the powder of iodoform may be dusted over the part, and covered with a piece of protective. This substance is very useful in regions of the body where carbolic acid could not !. applied, as in cancers of the rectum, tumors of the tongue and mouth. . Billroth made twelve consecutive amputations of the tongue, and treated the wound with iodoform without a fatal result. Dr. Sands,” of New York, mentions cases of strangulated herniae, trephining for fracture of the skull, colotomy, enterotomy, castration, ligature of the external carotid, peri-nephritic abscess, enucleation of suppurating inguinal glands, excisions of the breast, and amputations, all of which made prompt recovery, treated with iodoform. Among the German surgeons, especially Esmarch, Billroth, and Langen- beck, the use of this drug has produced surprising results—out of thirty- four resections, thirty-two were cured with a dressing once applied and allowed to remain thirty-five days. Billroth's method of applying iodoform is to powder the wound thickly with the substance, or, in some instances, to fill it; surround this with a piece of cotton wool or iodoform gauze, then a water-tight dressing is put on and held in position by a bandage. From a paper entitled “The Use of Iodoform in the London Hospitals”f we read that it is a favorite dressing in almost every institution. It must, how- ever, be borne in mind that iodoform is highly poisonous, although the iodine is taken up slowly; indeed Koenig, of Göttingen, has published a special warning on this subject, and, therefore, the dressing ought not to be allowed to remain for over five days, and then for a time some other anti- septic should be employed. - . The symptoms of iodoform poisoning chiefly show themselves in intoxi- cation of varying degree and intensity, and often in mental derangement. It can be detected in the urine by adding starch and nitric acid and shak- ing well, when the blue color will appear. The lethal dose for a guinea pig * Medical Record, March 25th, 1882. f Medical Record, April 15th, 1882. 310 A SYSTEM OF SURGERY. is three grains, in rabbits forty-five grains, in the dog one drachm, and in man according to his susceptibility to the drug. - Bichloride of Mercury in dilute form is employed, especially by some of the metropolitan surgeons. I have used it in amputations, resections, and the iºnoval of tumors with excellent, and in some instances surprising resultS. Delacroix dilutes one part with 2525 of water, and Dr. Weir and Sands in about gºom, but of this Weir says, bacteric life is found under such dressings, and therefore, following the experience of Kümmel and Schede, of Hamburg, he uses it stronger and with a uniformity of good unknown to Listerism. In preparing this dressing, the Sponges, compresses, etc., are wet with solution No. 1 (as it is called), consisting of 8 grains to the pint. The liga- tures are made of silk dipped for two hours in a solution of 8 grains to the pint, and catgut immersed in 8 grains to the pint of water for 12 hours, then rolled on bobbins and kept in an alcoholic solution of 20 grains to the pint. The gauze is prepared by immersion in a solution of 20 grains to the pint of alcohol with 3iss of glycerine. It is to this variety of dress- ing that I give the preference over all others. I think by this time (July 27th, 1886) I have tested it sufficiently in surgical practice to warrant the assertion that so far it is superior to all other substances. - It has been found by Koch that the anthrax spores, the most resistant of all varieties, are completely destroyed by moistening the parts with one to five thousand of water, and if immersed for a longer period, a solution of one to twenty thousand parts is sufficient for their destruction. Turf-As Dittle discovered the elastic ligature by accident, so Neuber, a few years ago, recorded the case of a man brought to his clinic who had sus- tained a wound and fractures of both forearms, ten days before : a comrade had surrounded the wound with a turf mould, and upon its removal the cut surfaces were found healing beautifully. It has since been discovered that the dust resulting from the sawing of the turf into moulds, possesses a very great affinity for ammonia, carbonate of ammonia, and odors gen- erally; and in the infantry barracks at Brunswick, the turf mould is used to disinfect privies, etc. This dust, besides being a great disinfectant, possesses wonderful absorb- ent properties, taking wip nine times its weight of water. A great many ex- periments have been tried regarding its efficiency as an antiseptic dressing with satisfactory results. The turf mould is used as follows: Bags are made of two sizes, 12 and 24 centimetres square. The turf dust is placed in these, the smaller one having besides 2% per cent. of iodoform. This is laid on the wound, which has also been disinfected; over this the larger bag is laid, the mould of which is saturated with a five per cent. Solution of car- bolic acid. + . Its absorbent powers, its cheapness—a pennyworth being sufficient for a dressing—and its antiseptic virtues, render it an excellent dressing in those countries where the mould is readily obtained, and so much has been said of its efficiency that it is now being used by surgeons in this city, and I am informed with excellent results. The Peroxide of Hydrogen.—The Peroxide of Hydrogen has received great eulogiums from many and varied quarters, and C. T. Kingsett, of London, made a report of a series of experiments with the material in 1876. In 1878, Güttman and Fraenkel, in Germany, and Baldy, Best, and Regnard, in France, made many demonstrations of the value of the material, and under the name of “Eau oxygene” it has been widely used. It is employed as spray, as a washing for wounds, ulcers, etc., and is devoid of all odor. Kingsett has lately announced a preparation called “Sanitas oil,” which he NAPHTHALIN–CALENDULA OFFICINALIS. 311 claims to be an organic peroxide, which will continually yield peroxide of hydrogen to water, on being placed in contact there with. If laid on sur- faces it is said to keep them in a completely antiseptic atmosphere. There are a great many other of the so-called disinfectants and antiseptics, among which may be mentioned boracic and Salicylic acids; eucalyptus oil, by Bassini;* resorcin, which belongs to the phenol group, and has been noticed especially with reference to its substitution for carbolic acid;i Naphthalin—which according to Fischer, of Strasbourg, f is superior to carbolic acid; and Submitrate of Bismuth, which Kocker § claims as a new and better anti- septic than any yet discovered. He discards drainage tubes and closes the wound its entire extent by suture. During the operation the parts are sprinkled with water holding bismuth in solution. The wound is then closed by suture and the line of incision covered with bismuth paste. Then the dressings wet with bismuth water are applied. As the sutures are removed, bismuth is again applied; this method is called healing by second adhesion, but there have been also some drawbacks to this substance when applied to extensive abraded surfaces; if bismuth in powder was largely employed, it was found to produce diarrhoea, ne- phritis, stomatitis, and other disturbances; it was then employed in a solution of 10 per cent., and sprinkled on the parts with great benefit. The astringency of bismuth is said also to add to its effective healing OWerS. p Oxidized Oil of Turpentine.—This is announced || as a valuable antiseptic. It is prepared by passing air for a long time through the ordinary oil of turpentine. Mr. Lister was said to be experimenting with the substance, but as no report has as yet been given, it is reasonable to suppose that the results were not as satisfactory as Mr. C. T. Kingsett had anticipated. Chloral Hydrate.—This substance has also been used in Russia, with benefit, as an antiseptic, especially in the treatment of ulcers and open wounds. Dmitrieff demonstrated in St. Petersburg that an equal quantity of a one per cent. solution of chloral hydrate destroyed in twenty minutes all mobility of the bacteria in a putrefying infusion of flesh. Calendula Officinalis.-While on this subject I must say, as far as I have observed by actual results in the treatment of wounded surfaces—for I have never given any microscopical trial to ascertain its value as a germi- cide—that the calendula officinalis has given me equal, if not better results than carbolic acid, and while I acknowledge the fact, that since the “bac- teria craze,” and the “carbolic excitement,” I have yielded to the popular cry and used carbolic acid in different proportions and in different solu- tions, yet I am convinced, that, other things being equal, calendula, from its peculiar action on suppurating surfaces, is a medicine that sooner or later must receive the attention which its virtues deserve. I am quite sure of the following facts, that in the past five years, when I have been employing carbolic acid preparations upon wounded surfaces that have not appeared to be progressing as favorably as I thought they should, I have substituted calendula with surprising results. In many cases of breast amputations and large wounds, I have employed merely cleanliness * Medical News, February, 1881. f American Journal of the Medical Sciences, January, 1883. † Glasgow Medical Journal, November, 1882. & Volkman's Klinische Wortage, No. 224, 1882. | Lancet, 1881, p. 971. 312 A SYSTEM OF SURGERY. and the solution of calendula, one per cent. to four of water, with a most Satisfactory termination of the cases. Dr. Charles M. Thomas” speaks well of calendula, but after some experi- ments he writes: “I find that, casteris paribus, wounds treated with it follow a more favorable course than under non-medicated dressings, but in com- parison with corrosive sublimate, iodine, iodoform or even carbolic acid, the results are decidedly inferior.” But a sufficient number of these substances have been enumerated to show, as I have already stated, that as yet all of them have some disadvan- tages. It is my belief, as already stated, that there must reside in any ap- plication adapted to a wounded surface, something besides its germ-killing properties, which after all is merely mechanical. I am justified in assert- ing that because a substance is really a germicide, it is no reason that it is a perfect vulnerary. There must reside in the drug a power to act upon the leucocytes, to either hasten their amoeboid motion to the cut surfaces of the capillaries, which are endeavoring to repair waste, or to retard this very migration, and by so retarding, prevent the dying of the leucocytes, which in the majority of instances means their conversion into pus. Comparative Results.-In conclusion, it is most important to look at the results of antiseptics in surgery—and this also must be briefly considered, although on this point, viz., the welfare of humanity, the whole subject must rest. - First, I will note MacEwen's cases, because they were treated in Glasgow, where Mr. Lister began his investigations and treatment; and second, be- cause the experiments were made under the preconceived idea that hygienic treatment was all-sufficient in the treatment of wounds. In the years 1875, 1876, 1877, 1878 (four years), there were 1706 cases treated by the aseptic method, of which fifty died, giving a mortality of 2.93 per cent. During the same period, in the same number of wards, Dr. Morton treated 1884 cases without aseptic precautions, and of these 110, or 5.84 per cent., died. After Mr. Lister went to Edinburgh, from the end of 1871 to the middle of 1877, a period of about five and a half years, he treated aseptically 533 cases, of which 29 cases died. Mr. Spence, during the same time (five and a half years), was operating in the same hospital, using no very decided treatment—sometimes water dressing, sometimes boracic lint, and some- times none whatever. In the 328 cases operated upon there were 58 deaths, showing again a large percentage in favor of the antiseptics. Again, if we turn to Mr. Lister's figures, after he had changed his resi- dence from Edinburgh to London, where, in King's College Hospital, from November, 1877, till November, 1880, a period of three years, he performed 207 operations, of which 14 died, a fair estimate of his success may be ar- rived at. As these last were performed by Mr. Lister after he had studied and improved upon his method for a period of thirteen years and in three hospitals, the results as bearing upon the present status of antiseptic sur- gery, are of the utmost importance, and therefore it may be well to mention the character and kind of operations performed. Thus: There were three amputations of the hip-joint for disease, with one death. There were four amputations of the thigh for disease, of which three died. There were two amputations of the forearm, no death. There were sixteen excisions of the mamma, with two deaths. There were thirty-one operations upon healthy bones for deformity; no deaths. There were eight abscesses, with one death. There were four cases of strangulated hernia, with three deaths. There were three operations for the radical cure of hernia; no death. There * American Homoeopathist, June, 1886. COMPARATIVE RESULTS. 313 were three cases of acute necrosis, and one death. There were twenty-three large abscesses; no death. Two cases of empyema, ; no death. There were also cases of nerve stretching, castration, varicocele, and tumor. e From a careful examination of these cases, it will at once be seen that in the same hospitals, with the ordinary run of cases, with the same surround- ings, and in the same atmosphere, the percentage in aseptic treatment is almost double in its favor. This fact cannot be gainsaid, but we must now consider whether the aseptic method, Listerian in theory and practice— the carbolic-acid treatment in its minute details—gives better results than the ordinary antiseptic methods as employed without the Listerian minutiae by the majority of the profession at the present day. This is difficult to accomplish, and the best way for me to place the subject properly is to give the statistics of the Hahnemann Hospital. These figures I have copied from the case book, and extend over a period from September, 1878, to June, 1883, being four and three-fourths years. - Among these were 17 amputations of the breast, and 1 death. There were 15 amputations, 1 of the thigh, 5 of the leg, 3 Syme’s, 2 Pirogoff’s, 1 Chopart's, 3 fingers, with 1 death. There were 3 excisions of the rectum for cancer, with 1 death. There were 2 cases rectotomy, no death. There were 9 re- sections—tibia, 3; ankle joint, 1 ; elbow, 1; wrist, 1 ; coccyx, 1; ribs, 2—with no death. There were 11 ovariotomies, with 4 deaths. There were 17 abscesses, some of very large size, and no deaths. There was 1 case of empyema, and 1 death. Laceration of the perinaeum 22, with no death. External urethrotomy 11, with 1 death. There were 2 cases of internal urethrotomy, no death. There were 9 cases of lipoma, some of large size, no death. There was 1 fistula of the thorax, 1 vesico-vaginal fistula, 1 recto- vaginal fistula, 1 perineal fistula. There were 2 cases of Battey's operation, no death; 2 cases cystocele, no death. There were 9 rhinoplastic operations, 1 death. There were 3 cases of supra-pubic lithotomy, 1 death. There were 5 cases of lithotrity, no death. Removal of superior maxillary 2 cases, no death. There was 1 extirpation of the uterus, 1 death. There were 56 cases of laceration of the cervix, no death. Besides these were 10 cases of hernia, 16 cases of fistula in ano. Varicocele, tracheotomy 1 each, and others, making a sum total of 201 operations performed in the Hahnemann by the visiting surgeons, with the loss of 11 cases. There is no absolute Listerism prac- ticed at the hospital, but antiseptics are used in the shape of carbolic acid solutions, carbolized instruments, and calendula, balsam of Peru, the bichloride of mercury, or any other antiseptic used that the operator may deem proper. One feature in the dressing is the marine lint, which I regard as an agent of the greatest value. The parts to be operated upon are washed with carbolized solution, the floor of the operating room is scrubbed, and the “ovariotomy room also ventilated and disinfected after each operation.” The instruments are first laid in carbolized oil overnight, and then in shallow pans containing carbolic acid. An assistant is at hand to imme- diately wash an instrument which has been laid aside and replace it in the pan. Sponges are immersed either in a solution of corrosive sublimate, 1 to 2500, or in carbolic solution 1 to 60. The wounds are closed with silver sutures carbolized. The silk is rendered aseptic and catgut is often em- ployed. Salicylated India rubber plaster is the only kind used in the house, and after it has brought the edges of the wound in contact, a wad of marine lint is laid over the entire wound, spreading some distance around it; over this the protective gauze, and again over that a bandage is placed. These dressings are not touched until some indication for their removal is noticed, and often remain in position for days together. It will be seen, therefore, that our statistics without the minutiae are even better than those of Mr. Lister. 314 A SYSTEM OF SURGERY. If, now, we compare all these statistics, we can formulate the present status of antiseptic surgery: - Operator and Location of Hospital. Cases. Deaths. Per cent. GLAsgow. McEwen, 5 years.................................... • - - - - - - - - - - - 1,706 50 2.93 Aseptic Treatment. , , Same Hospital. - Morton, 5 years................................................... 1,884 110 5.84 Non-aseptic Treatment. - EDINBURGH. " ; Lister, 53 years................................................... 553 29 5.2 Aseptic Treatment. Same Hospital. Spence, 53 years.................................................. 328 58 17.7 Non-antiseptic. LONDON. Lister, 3 years......................... ...------------------------ 207 14 6.76 Aseptic Treatment. NEW YORK. Hahnemann Hospital, 4 years................................ 201 11 5.47 It will be found that in most hospitals the aseptic treatment, viz., Listerism, is abolished or greatly modified, and that the anti-septic treat- ment will probably give as good results as the a-septic, especially with proper hygienic surroundings. - In conclusion I will state here that all appliances for antiseptic dressings, whether prepared with carbolic acid, with salicylic acid, with the bichloride of mercury, with iodoform, or with iodine, are most carefully manufactured by Mr. C. Am Ende, of Hoboken. I have used these in both hospital and private practice and have been always satisfied with their efficacy. As the proof-sheets of this portion of my work are passing through the press, I find that Prof. Lister appears to have become somewhat dissatisfied with carbolic acid, and now uses a double mercurial salt, called salaem- broth. It is formed by the sublimation of a mixture of the perchloride of mercury and chloride of ammonium. All the dressings, gauze, wool, lint, bandages, etc., are prepared with a solution of this substance 1–100. After the dressing is applied, it is covered with aniline blue 1 to 10,000. When- ever an alkaline discharge comes in contact with the blue, the color changes to red, thus immediately indicating the presence of pus and the points from which it comes.” * Medical Record, July 17th, 1886. THE MEANS AND INSTRUMENTS FOR ARRESTING HAEMORRHAGE. 315 CHAPTER XVII. H AE MO R. R. H. A. G. E. THE MEANS AND INSTRUMENTS FOR ARRESTING HAEMORRHAGE–DEFINITION.—HAEMO- PHILIA—HAEMOSTATICS, NATURAL AND ARTIFICIAL–INTERNAL MEDICATION.—STYP- TICs—FLEXION.—CoMPRESSION.—PERCUTANEOUS LIGATION.—ACUPRESSURE—VARIOUS INSTRUMENTs—LIGATURE–ESMARCH's METHOD–DITTEL's ELASTIC LIGATURE. THE means and instruments with which to arrest hamorrhage constitute a topic of grave import to the physician as well as the surgeon, because in the panic which generally accompanies every case of haemorrhage, and of the uncertain and inopportune times at which bleeding may occur, the nearest medical man is summoned, whether he profess surgery as a specialty or otherwise. The most fearless and bold operators have more or less dread of those great losses of blood which may either immediately or secondarily prove fatal to the patient; indeed, in the majority of operations, it is “the bleed- ing” which is most feared. The fact that in a few moments the life of a human being may pass away with the crimson tide which bursts from an open vessel, causes such occurrence to be regarded with much apprehension, and, added to this, the heart-sickening scene presented by a person dying from loss of blood, the horror-stricken faces of bystanders, and the disorder and confusion which are often present on such occasions, have taught us to regard hamorrhage always with certain feelings of anxiety. The appear- ances presented by a person “bleeding to death '' are appalling. The ashy paleness of the face, the pinched nose, the blanched and drawn lips, the icy brow, the clammy skin, the intense nausea, and that hazy vacancy that gradually steals over the eye, together with the absolute depression of all those forces which render us cognizant of the great world without, indicate too plainly that vitality is giving place to death ; that the wonderful life- giving current is rapidly being withdrawn from the organism which it nourished, and that light and life are soon to be extinct. It is not, therefore, surprising, that those men who are supposed to be familiar with the means which will save life when it is threatened from loss of blood, should be regarded with feelings almost akin to reverence, and it is in these times that all the self-possession, knowledge, skill, and mechanical tact of the operator will be called into requisition. Such was the confidence placed in the skill of Ambrose Paré in arresting haºmorrhage, that he is said to have infused new life into the French army by his appearance in the midst of a sanguinary contest. I have in my possession a treatise on surgery written a century and a half ago by Samuel Sharp, a pupil of the renowned Cheselden, and sur- geon to Guy's Hospital.” On page 221 he has the following paragraph : “There are in armies a great many instances of gunshot wounds of the arm near the Scapula, but the apprehension of losing patients on the spot by haemorrhage has deterred surgeons from undertaking amputation.” Fabricius ad Aquapendente appears to have had such horror of haemorrhage that he recommended all incisions for amputation to be made in mortified, and therefore, bloodless structures. O'Halloran, speaking of amputation of the leg, alludes to the “bleeding” as the most troublesome and alarming symptom, * A Treatise on the Operations of Surgery, with a Description and Representation of the Instruments Used in Performing Them, etc., by Samuel Sharp, Surgeon to Guy’s Hospital, London. 316 A SYSTEM OF SURGERY. that and most reproachful to the surgeon, “the haemorrhage often proving jatal to the patient.” Professor Thompson, the preceptor of the distinguished Simpson, thus speaks: “The suppression of haemorrhage and the reunion of divided surfaces are, in every wound and in every operation, the first and ultimate objects of the surgeon’s attention.” It is unnecessary to multiply quotations to establish facts that are so universally acknowledged, and although by some of the newer means for arresting haemorrhage the occur- rence is deprived of some of its terrors, yet it still remains in every opera- tion to demand the serious attention of the surgeon. Definition.—By the term hamorrhage is understood the escape of blood from bloodvessels. If this discharge takes place from open surfaces or from organs communicating with the atmosphere, the simple word “haemorrhage” is used. When it occurs within the cavities of the body, we have “internal haemorrhage.” When the discharge of blood is not very great and remains beneath the surface, “extravasation ” is produced. When the blood flows freely and in streams, or is profuse in quantity, we use the term “active haemorrhage;” “passive" being applied to slow and irregular discharges gen- erally emanating from the capillary vessels. When the blood flows “per Saltum ” and is bright red, we recognize the characteristics of “arterial haem- orrhage,” and when it is of darker color and a more continuous flow, the haemorrhage is said to be “venous.” Let me here, however, remark that an arterial haemorrhage may occur, in which the blood does not flow “in jets.” I have seen this in amputations where a vessel—perhaps of the third calibre —has contracted behind muscular or tendinous substances, and in instances in which a longitudinal incision has been made in the coats of an artery; in the latter instance a portion of the blood passing through the tube, the remaining portion issuing through the opening in the coats. In such cases, which are always more or less embarrassing, the color of the blood, and a knowledge of the anatomical relations of the parts must chiefly be our guide. Sometimes also there may be an apparent pulsation or “jetting ” to the stream flowing from a good-sized vein, owing to its proximity to a large or pulsating tumor or arterial trunk. Again, surgeons denominate “primary hamorrhage” as that occurring during the performance of an operation ; “intermediary hamorrhage,” so I believe designated by Butcher, as that which takes place within a few hours after operative procedure, either from the relaxation of tissues or the increased power of the circulation as reaction is taking place; and “secondary hamor- rhage” that which results from the separation of ligatures, or the removal of pins or dressings, which have been used to prevent the primary flow of blood. Haemorrhages, even extravasations, are always looked upon with appre- hension. The gradual flow of blood into the meshes of a tissue is serious, If it take place within the globe of the eye, it may cause disorganization of the entire ball. If within the cardiac structures, imminent peril results; if within the brain, coma and death may supervene; while the dangers from active, arterial, or venous hæmorrhage are well known to every one. Haemorrhagic Diathesis—Haemophilia.-It may be well here to remark that some persons are much more prone to hamorrhage than others, and a circumstance still more peculiar is found in the fact that the so-termed “haemorrhagic diathesis” appears in many instances to be hereditary or con- genital. In the medical periodicals and text-books, many interesting cases may be found, furnishing abundant testimony of the fact. Those who are afflicted with this peculiar and distressing constitutional defect are called “bleeders,” and in such (whether it be a weakness of the capillary vessels, or a loss of their contractile power, or a diminished quan- tity of plastic material in the blood, or other unknown circumstance), a very slight and trivial cause, even a pin-scratch, may give rise to a dangerous or HAEMOSTATICS. 317 fatal loss of blood. The diathesis generally is found among the male sex, and in the earlier years of life, the tendency disappearing toward adult age. When it is acquired it is usually among the poorer classes, who are poorly fed, with lack of light, pure water, exercise, and fresh air. There are in this affection many symptoms that are analogous to scorbutus, the blood being thin and defibrinated, and the hamorrhage taking place often without any assignable cause. Often it occurs beneath the integument, giving rise to dark purple spots, or those of a slightly reddish hue. I have known an almost fatal haemorrhage occur from the gums of a patient without any as- signable cause. Children have perished from loss of blood consequent upon lancing the gums, dividing the “fraenum linguae,” excising the tonsils, extract- ing a tooth, and other minor operations. Some very remarkable cases in which several in one family have been afflicted with the haemorrhagic diathesis” are upon record. I have lately seen an interesting case in consultation with Dr. Swan, of New York, in which the infant bled profusely from the soles of the feet, the palms of the hand, the umbilicus, and the back. The complexion was very sallow, and though the child when born was apparently plump, it took no nourishment, and died in a few days. Haemostatics.—The object of the surgeon is to ascertain the proper means and instruments for preventing or arresting hamorrhage, occurring either during or after surgical operations; or that resulting from injury, or acci- dent, or constitutional diathesis. * - This is termed ha-mostatics, and is divided into two departments, natu- ral (A.) and artificial (B.). - * (A.) Natural Haemostatics.--To the student of physiology and pathology, the active part that nature, even unaided, takes upon herself to repair injury and preserve vitality is well known. With a wonderful and silent power she keeps guard over her children in every emergency, driving out the innovator; healing broken bones; repairing tissue; manufacturing flesh; gluing together wounds; and in haemorrhage strenuously working to save her own from death. On this last point, viz., the method in which natural haemostatics arrest bleeding, experimental pathology has revealed much in the last few years. As long ago as 1731 Petit wrote and published several treatises on this subject, giving from actual experiment the manner in which “the two clots” are formed by nature to arrest ham- orrhage. The inside clot he called “bouchon,” the outside “couvercle.” In 1736 Morand, besides allowing the formation of clots as proposed by Petit, advanced the idea that besides this, very important changes took place in the coats of the artery itself. It is rather remarkable that some years after- wards Sir John Bell denied this proposition. In 1763 Kirkland made an additional step by showing that besides the two clots and the arterial con- tractions, syncope or swooning lessened or arrested temporarily the discharge of blood, allowing time for clots to form and organize, or for mechanical interference, and finally, Dr. I. F. D. Jones, who has given us the best treatise on the subject, has informed the surgical world (which it is very important for us to bear in mind for the proper understanding of the ratio- male of certain methods now employed in arresting hamorrhage) that for the permanent arrest of bleeding, “an effusion of coagulating lymph within its (the artery’s) canal, between its tunics, and in the cellular substances surrounding it,” is necessary, and does take place. Here are then four im- portant means employed in natural haemostatics, and if we call to mind the * Gross's Elements of Path. Anat., pp. 203, 204. Gross's Surgery, vol. i., “Haemorrhagic Diathesis.” Braithwaite's Retrospect, No. 24, p. 199. Druitt's Modern Surgery, p. 305. # A Treatise on the Process Employed by Nature in Suppressing the Haemorrhage from Divided or Punctured Arteries, and on the Ligature, by I. F. D. Jones, M.D. * 318 A SYSTEM OF SURGERY. method pursued by nature in repairing fractures;–the internal and external callus, “the temporary” and “permanent,” and the removal thereafter of that which is unnecessary, a wonderful similarity in the two processes will be found to exist. Let us suppose that an artery of some magnitude is cut across; almost immediate y both divided ends retract within the sheath, and by virtue of the elasticity of their coats, contract upon themselves, thus diminishing the calibre of the vessel and necessarily diminishing the stream. The sheath, however, not being nearly so elastic as the arterial tunics, re- tracts but little, thus leaving a species of cylinder around the vessel to be filled with coagula, which takes place from filaments of fibrin being adhe- rent to its walls; and this is increased by the increased plasticity of the blood as it flows. Wide Fig. 122, which shows the plan of natural haemo- statics in a cut artery; a is the divided extremity of the arterial tube ren- FIG. 122. - FIG, 123. dered conical by contraction; b, the arterial sheath vacated by the retracted artery, and occupied by coagulated blood; c, the coagulum, projecting from the orifice of the sheath. The more slowly the blood asses through the vessel, the more opportunity is of ered toward the formaton of the internal coagulum, which forms within the vessel in a long and thin clot, FIG. 124. -Q and if syncope have supervened, the conditions will be much more favorable to the “couvercle.” “In the mean S time," says Jones, “the cut surface of the artery in- flames; the vasa vasorum pour out lymph, which is revented from escaping by the º coagulum.” his lymph fills up the extremity of the artery; is situ- ated between the external and internal coagula of blood; is somewhat intermingled with them, or adheres to them or is firmly united all around to the internal coat of the artery. Fig. 123 (after Jones) shows also the 1. 2 lan of natural haemostatics; a is the external coagu- um, incorporated with the coagulum of the sheath, b. The internal coagulum is also seen resting upon the external and extending to c, the first collateral branch. These are the processes which we find in natural haemostatics, and the more we examine them, the more will the HAEMOSTATICS. 319 beauty of the process be appreciated. After haemorrhage is suppressed, the artery at its extremity and sometimes up to its first anastomosing branch, becomes converted into a ligamentous cord, and the clots are removed by absorption. Fig. 124 shows: 1. Plan of retracted artery after section; a, the conical, contracted, and retracted arterial tube; b, the arterial sheath left vacant. 2. Plan of retracted artery after laceration; a, the retracted middle and internal coats of the artery; b, the external coat ; c, the twisted sheath. (B.) Artificial Haemostatics.-Internal Medication.—Among those haem- orrhages belonging to surgery, besides those occurring from accidental causes and the surgeon's knife, are epistaxis and bleedings from the blad- der and the rectum, and even these, in the majority of instances, fall within the province of the physician, in the same manner as haemopty- sis, metrorrhagia, hæmatemesis, and post-partum ha-morrhage. I shall therefore speak of internal medication, so far as it has power to arrest haemor- rhage (surgically so-called), and must confess, that it is a very difficult matter to lay especial stress on any medicinal means whatsoever, as in almost every case of haemorrhage, some local application is made simultaneously with the internal treatment, or, indeed, if a medicated substance is not laid over the bleeding surface, it is covered or bound up with bandages, or cloth, or lint, or cotton, or some other substance, to favor the formation of the clots. When vessels of any magnitude bleed, I would unhesitatingly regard it, not only the height of folly, but an unpardonable dereliction of duty, to rely exclusively on the internal administration of medicine, under the con- viction that the bleeding will be arrested. Yet I have been told, though I scarcely credit the fact, that there are physicians who, having a case of arterial haemorrhage, would neither cover the wound with a bandage, nor ligate a vessel, nor apply a styptic. s In passive haemorrhage there can be no doubt that medicines are capable of exercising a beneficial effect. In oozings after large operations, I have frequently witnessed their excellent results. I do not propose to record in this place what is found in the manuals for haemorrhage, or I would write that for haemorrhage in general (?) we have asaf, cocc., copaiba, iod., and crocus. Haemorrhages from “various parts,” canth. and phosph. Haemorrhages “from a newly opened wound,” opium. Excessive haemor- rhage, antimonium crud., and much of the like. My object is merely to mention those remedies which, internally administered, have a beneficial effect in certain forms of haemorrhage. Of these secale cornutum in half drachm doses of the fluid extract repeated every hour or two is perhaps the most satisfactory, and next, gallic acid in five or ten grain doses. Cinnamon, iron, opium and lead are also effective. - Hamamelis will arrest a venous hæmorrhage, proceeding from varicose veins, and haemorrhage from the mouth and gums, and from haemorrhoids. Dr. Cushing has seen it suppress hamorrhage after extracting a tooth. Dr. Preston has with it cured haemorrhage from the bowels. Veratrum viride is one of the best medicines for hamorrhages. A case is recorded of its successful use in secondary hamorrhage after amputation.* Nitric acid, given internally, will arrest a secondary hamorrhage from the lower part of the rectum, after the removal of haemorrhoidal tumors. Monsel's styptic, from 20 to 30 drops in half a glass of water, a table- Spoonful every half hour, will arrest an oozing from the medullary canal after a resection of the humerus. I was led to its use in surgery by some remarks by Dr. Malcolm McFarland. Erigeron I have administered with success in haemorrhage from the bladder, after operations for vesico-vaginal fistulae, rupture of the perinaeum, etc. For operations about the lower por- tions of the rectum, crocus and carbo veg, are excellent medicines. So far * Medical Record, November 1st, 1872. 320 A SYSTEM OF SURGERY. as my own knowledge goes, with the exception of arsenicum and china, in those cases where there is great prostration of the vital power, and the blood is thin and defibrinated, I can speak of no other internal medicines. The alnus rubra, apocynum cann., erechthites hieracifolius and iris, or diadema, are laid down as possessing power over haemorrhage. This is a portion of the field of surgery that presents a wider scope than perhaps any other, and, no doubt, will in future be more thoroughly cultivated, but as I have before mentioned, the fact that many mechanical agents, from the simple roller bandage to the most complicated styptic compounds, are generally employed, will always embarrass the attempt to assign the proper sphere to internal medication. Styptics.-Before proceeding immediately to mention those articles which may be considered the most efficient as styptics, I would have the fact borne in mind that the exposure of the bleeding surface to the atmosphere will arrest quite a profuse haemorrhage. Mr. Skey, years ago, taught this fact:* “A Surgeon who has the least fear of haemorrhage loses the least blood; a small wound may be tortured by styptics, and by compresses, and other unprofit- able agents, until it becomes the fruitful source of protracted hamorrhage. Masses of lint are piled up in heaps upon the wound, pressure is main- tained until all the parties are exhausted, but still the haemorrhage returns and continues by reason of the irritation caused by these very agents and nothing more. Under these circumstances, which I have frequently borne witness to, all dressings should be removed, and the wound should be opened and exposed to the air by its edges being drawn widely asunder and the bleeding apparently encouraged; its surface sponged freely with cold water, the coagula wiped away, and in this condition it may fearlessly be left to bleed; the cessation of the haemorrhage by such means is often immediate.” I have known quite a number of cases where such treatment has proved beneficial, and have laid down a rule, that in every operation where a band- age is not absolutely necessary to support the parts, it should be done away with. For the past five years, after amputation, or the removal of tumors, I have not permitted the application of the dressings until all bleeding had ceased, the parts being merely covered by a light cloth, and thus many untoward symptoms have been prevented. A bandage often keeps up venous congestion, thereby producing troublesome oozing. Cold.—The application of cold, either by means of ice-water, or of ice pounded in bladders and applied to the part, or ice-water used with a syringe upon the bleeding vessel, as employed by Agnew in ruptured peri- naeum, or the ether spray of Professor Richardson, or the rhigolene of Dr. Bigelow, all have excellent styptic effects, and with the exception of the latter are so devoid of all odor and so easily applied that they are always desirable except in those cases where the haemorrhage is active. Alum may be applied either in powder or in solution, and possesses power- ful astringent properties. It is efficient in its action, and when combined with tannin exercises powerful control over the bleeding surfaces. Equal parts of sulphate of alumina and tannic acid I always keep ready for emergency. An excellent formula for a solution combining the two is that of Monsel : R. Acidi tannici, . e G e e © e e º c ... gr8. X. Aluminae sulph., . Bj. Aquae rosae, * . #iss. M. ft. sol. A Combination of Tannin and the Elixir of Vitriol has been known to arrest a very profuse arterial haemorrhage from the tonsils. This is easily ob- * British and Foreign Medico-Chirurgical Review, 1851, p. 290. STYPTICS. 321 tained, and though I have never applied it, yet it must be a powerful as- tringent. - Rhatany.—By digesting rhatany with sulphuric acid a brown extractis ob- tained, which has been highly lauded by Mr. Tessier,” of Lyons, as one of the best ha-mostatics. Oil of Turpentine.—The properties of this substance brought it into gen- eral use some seventy years ago, and it is occasionally used at present, but there are so many other agents of superior efficacy, that it has fallen into §. general disuse. It was highly lauded and recommended by Mr. Onge. Matico.—Dr. Jeffries, of Liverpool, is said to have introduced this sub- stance as a haemostatic to the profession, in 1843. It has been given inter- nally, and applied locally. A decoction is made of one-half ounce of the matico to a pint of water, although Dr. Hunter Lane recommends that an ounce of the substance be used to a pint of boiling water. Sulphate of Copper-This substance has been employed for centuries to arrest bleeding; it was formerly pounded and placed in “little linen clouts,” thus forming the well-known “button of vitriol,” and applied. It has often been mixed with tannin. - Perchloride of Iron.—The coagulable properties of the varied preparations of iron render them superior in arresting haemorrhage. I have used the perchloride in very many cases with success, although of late years I have preferred the persulphate. Persulphate of Iron may be used in the form of the liquor ferripersulphatis, or in powder. It is the well-known “Monsel's styptic,” and is decidedly one of the most efficient we possess. I could cite many cases wherein its efficacy has been proven. There is a precaution, however, which should be employed in using many of these styptics, and that is, knowing their liability to produce unsightly stains on whatever articles of cotton or linen they touch, care should be taken to use only “old rags,” as they are termed, or some cheap substitute. I have known many quite valuable articles of clothing, as well as bed and other linen, completely spoiled by these prepa- rations carelessly applied. Collodion, by its contractile power, and by the cold produced by evapora- tion, is often efficient. I have arrested a severe and prolonged haemorrhage from leech-bites, by dipping pieces of lint into collodion and placing them over the bleeding surface, over this applying a piece of cardboard, and then freely pouring collodion over the part. Styptic Colloid.—This substance, which was introduced by Mr. Richardson, consists of ether saturated entirely with tannin and a collodial substance, either gun-cotton or xylodine. When such is applied, the natural heat of the body evaporates the ether, leaving the tannin and cotton applied to the raw surface.f. I can speak well of the efficacy of this agent, having used it very frequently and with good results. hū. of Iron and Cotton.—Dr. Ehrle describes a simple preparation of cotton which he has found of great service in surgical operations followed by great effusion of blood. American cotton of the best quality is cleansed by boiling it for an hour in a weak solution of soda (about 4 per cent.) then repeatedly washed in cold water and dried. By this process it will be perfectly disinfected and adapted to more ready absorption. After this, it should be steeped once or twice, according to the degree of strength required, in liquid chloride of iron, diluted with one-third water, pressed, and thor- oughly dried in the air—neither in the sun nor by the fire—then lightly pulled * Medical Record, vol. ii., p. 393. f Wide Braithwaite's Retrospect, July, 1867. 21 322 A SYSTEM OF SURGERY. , out. The cotton so prepared will be of a yellowish-brown color. It must be kept very dry, as it is affected by the damp. Lint may be similarly treated, but the fine texture of the cotton renders it preferable. When placed on a fresh wound, it causes a moderate contraction of the tissue, and gradually coagulates the blood in and beyond the injured veins, thus closing the Source of the effusion. This property of the chloride of iron is increased by the dryness of the cotton, and the extended surface offered for the development of its chemical action. - C. Am. Ende, of New York, prepares “a styptic cotton,” and also an article which is called haemostatic cotton, somewhat after the formula of Ehrle. This I have used with success and can highly recommend. Benzoic Acid and Alum.—Probably the most energetic styptic known is the following: B. Benzoic acid, dº * sº gº tº * > ge tº 1 part. Sulphate of alumina and potash, aā . iº tº º © . 3 parts. Ergotim of Bonjean, . * e e tº e ſº tº . 3 parts. Water, . . . . . . . . . . . . . 24 parts. The whole is to be boiled for half an hour in a porcelain vessel, with constant stirring, replacing the evaporated with boiling water. It must then be evaporated to the consistence of an extract, which is of a chocolate- brown color, strongly astringent taste, and having an odor of ergotin. Together with this the following formula is to be taken internally : Benzoic acid, . tº tº º tº & ſº º tº tº © ... gr. j. Pulv. alum, - Ergotin, aa . e tº ºn ſe te & tº tº wº ſº . gr. ij. Ft. mass, et div. in pil. no. xvi. S. One pill to be taken every two hours. There are many other substances which are possessed of astringent prop- erties. Thus the famous styptic of Broussard was composed of the agaric of the oak, while, as remedies against hamorrhage, the felt of a hat, cob- webs, nut galls, and the preparations of zinc and mercury have long been known and applied. Hypodermic Medication.—A very valuable agent in the arrest of haem- orrhage, especially from the internal organs, is the hypodermic injection of secale cornutum. I use Squibb's fluid extract, and inject ten minims under the skin. In some instances I have seen most decided effects from its use. Dr. Hammond has reported the cure of several pulsating tumors of small size by the injection of ergot. These, however, are alluded to in another ortion of this volume. The Actual Cautery.—The old surgeons applied almost universally the red- hot iron to arrest bleeding after surgical operations. I have seen depicted in a well-preserved copy of the Armamentarium Chirurgicum, of Scultetus, published in Frankfort in 1666, the various methods of its barbarous applica- tion. Melted lead, melted copper, boiling oil, and boiling oil of turpentine were also used for the same purpose. The severity of this mode of arresting haemorrhage, combined withits unsuccessful results (secondary bleeding gene- rally following the separation of the eschar), led to its disuse, and Ambrose Paré, three centuries and a quarter ago, in 1564, proposed that surgeons “should cast aside all hot irons and cauteries, and apply the ligature and the tourniãuet.” Yet this advice was slowly followed, and Paré was assailed by the surgeons of his time “for daring to introduce the ligature, * A very interesting account of the methods employed by Paré in arresting hemorrhage can be found in Simpson's work on Acupressure. FORCED FLEXION. 323 and condemn, as they said, a method so highly commended and approved by all the ancients, teaching in opposition to that, without any authority, without knowledge, without experience, without good sense, some new method of his own of tying arteries and veins.” It took nearly two hundred years to introduce into general practice the process of ligating arteries, and now, having been adopted, it will take probably as long before the newer methods will be looked upon as sufficiently reliable to be generally accepted. So has it ever been in the history of medicine. The fact is lamentable, but nevertheless true. In certain operations, however, in which there is much oozing, it is necessary, even at the present day, to have recourse to the heated iron. It can only be justifiable when the bleeding vessel is beyond the reach of the ligature. According to Bransby Cooper, no surgeon should ever undertake to remove the whole of the upper jaw without being provided with a variety of actual cauteries. He recommends an iron rod, working in a sheath, to prevent - the surrounding structures from FIG. 125. being injured. I have on sev- immer-Y eral occasions been obliged to ... • G, TIEMA WWe•CO, – use this method of arresting ºr **) bleeding, once in the removal of the entire superior maxillary - Sion, is generally used to restrain haem- R. | orrhage during the performance of sur- * º gical operations, and there is no appara- tus that can compare with the fingers and S.S’S ** l $ º thumbs of a competent assistant. (Fig. $ s 127.) The old-fashioned tourniquet, vide § s Fig. 128 (next page), consisting of a strap § s § to encircle the limb, a pad to place over § º the vessel, and a screw to tighten the \ #. Sº band, is very efficient, and is used to the i º present day in operations that take but § a short time for their performance. It Digital Compression. was introduced by Morrel in 1674, and & is applied for amputation, it is modified by Petit. Before the tourniquet i well to elevate the limb, and having it held in that position by an assistant, # * The Amer. Journ. of the Med. Sciences, April, 1878. No. CL., New Series. 326 A SYSTEM OF SURGERY. the surgeon, beginning at the extremity, with both hands encircling the limb makes friction steadily and firmly towards the trunk, thus saving much venous hamorrhage. - Various tourniquets have been used at different times; those of Signorini, Malan, Skey, and others. In the United States army, during the late war, an ingenious tourniquet was used for temporarily suppressing arterial haem- orrhage, while allowing the venous circulation to continue unrestrained. FIG. 129. Petit's Tourniquet. Signorini's Tourniquet. It consists merely of pads with flanges, the latter holding off the straps which keep the compresses in their place. In some of the regiments every FIG. 130. FIG. 131. wº-sº avºi Skey's Compressor. Pancoast's Tourniquet. soldier was supplied with one, and was taught the method of its applica- tion, with what result, however, I am unable to say. Fig. 129 represents Signorini's tourniquet. Fig. 130 shows the compres- sor of Professor Skey. Fig. 131 represents Pancoast's tourniquet for the compression of a single artery. - Dr. Arthur E. Spohn,” of Texas, has devised what he denominates the rubber-ring tourniquet, Fig 132, which, from the remarks upon it, would seem to be a very effective and an easily applied method of arresting hamorrhage. * Richmond and Louisville Journal, November, 1876. TORSION. 327 This tourniquet is made for the arm and leg, and is applied by rolling it up the extremity. The doctor states that he has “resected the shoulder joint three times successfully, without the least haemorrhage,” and also amputated the thigh “without losing any blood during the operation.” Torsion.—The torsion or twisting of arte- ries to arrest bleeding was mentioned by Galen, and I believe was reintroduced by Amussat, Thierry, and Velpeau, but gradually fell again into disrepute, excepting in those cases where the haemorrhage proceeded from vessels of the fourth class. After the intro- duction of the acupressure needle by Simpson (over fifteen years ago), torsion again came into vogue, and has met with the highest favor among surgeons. The method usually recommended is as follows: Seize the vessel with the ordinary artery forceps, taking especial care that it only is embraced within the jaws of the instrument. Then draw forward the artery, and with a pair of forceps, with roughened and narrow blades, take hold of it transversely, or at right angles with the vessel; press down the blades of FIG. 132. FIG. 133. Torsion of an Artery. this pair of forceps firmly, in order to lacerate the internal and middle coats of the vessel, and then twist the artery with the artery-forceps several times around itself, and the operation is completed. Fig. 133. In a paper read before the Clinical Society, of London, Mr. Cooper Forster states that after losing two cases from ha-morrhage after acupressure, he had employed torsion alone in several cases of amputation, in excision of the knee, elbow, and hip, and forty other operations, with complete success. He pre- fers torsion to acupressure on account of the reduplication of the middle and internal coats of the artery, thereby affording a mechanical impedi- ment, which increases daily, while acupressure only forms pressure above the pin. Dr. Bryant states that he has not employed the ligature in ampu- tations since January, 1868, and has had no cases of secondary hamorrhage” —of 300 cases of amputation, 110 were of thigh, and torsion practiced on the femoral. This is most remarkable success, and Mr. Callender, f in a lecture upon the subject, thus writes: “There is no record, where the oper- ation has been properly practiced, of any sloughing of the twisted end, or of any abscess along the track of the vessel; and whilst the presence of a foreign body in the wound is avoided, the patient escapes the anxiety which the prospect of the removal of the ligature entails. And to add one other (and this is a strong argument in favor of torsion), it is free from all risk of that secondary bleeding, which is sometimes associated with the * Medical Times, October 15th, 1870, p. 22. f Lancet, March 21st, 1874. 328 A SYSTEM OF SURGERY. Separation of the ligature.” It would appear also, that torsion is applicable to the larger vessels, while the smaller are more secure when tied with the ligature. Poland has successfully applied torsion to the femoral artery six times, to the brachial twice, and to numerous smaller vessels. Durham has used it for the femoral four times, to the brachial twice, and to many arteries of minor calibre. Dr. Addinell Hewson devised an instrument called the “torsion forceps,” which does away with the necessity of using two hands in the operation of torsion, and which exhibits considerable in- genuity. M. Tillaux* arrives at the following conclusions: 1. Torsion is applicable to all arteries, and particularly to the larger ones. 2. A single pair of forceps is sufficient, and not two pairs, as employed in England and else- where. 3. The artery should be seized obliquely, and not longitudinally, and in such manner that the three coats in their entire breadth should be included in the grip. 4. The torsion or twisting of the artery should then be practiced until the portion seized becomes detached. 5. It is unneces- sary to adopt measures to limit the extent of the torsion, as practiced by Amussat and the English surgeons, as the operation limits itself either to the parts seized, or one or two centimeters above it. 6. Torsion is applica- ble to atheromatous or inflamed arteries, as well as to arteries in a healthy condition. 7. Torsion favors union by the first intention, owing to the ab- sence of a foreign body, as in the case of ligatures. 8. Like the ligature, torsion prevents primary hamorrhage. 9. Torsion acts more effectually than the ordinary ligature in preventing secondary hamorrhage. M. Til- laux asserts that ever since he began to employ torsion, in 1871, he has never had a single case of primary or secondary hamorrhage, and yet he has practiced it in about a hundred capital operations. Dr. Wheeler has introduced an instrument for the torsion of arteries some- what similar to that of Hewson, Fig. 134, which I have successfully employed. FIG. 134. WY v.A.V.V. V K M \, \, \, \ y \ * A s --- º º lºss F.------ * :=== Wheeler's Torsion Forceps. Ecraseur.—In this connection it may be well to mention the écraseur of Chassaignac, which prevents haemorrhage by twisting the mouths of the FIG. 135. IECra.Seur. vessels, as the chain, worked slowly by the screw, passes over the part being cut away (Fig. 135). From considerable experience in the use of the écraseur * British Medical Journal, 1872. ACUPRESSURE, 329 in very many operations, I can speak of its efficacy. In haemorrhoids, am- putation of the tongue, through the pedicle of ovarian tumors, to divide the stalks of uterine tumors, and in other operations, I have used it with com- plete success. The main desideratum in the application of the écraseur is the formation of a pedicle. In flat tumors this can be accomplished by passing below the surface, and especially beyond the diseased mass, large needles, beneath which needles a strong ligature is drawn somewhat tightly; this makes an excellent pedicle, and the chain may be passed around this and slowly worked. In some instances an incision through the integument greatly facilitates the operation. If there be much substance to be removed an excellent method of application is as follows: A trocar, with a canula of sufficient calibre to admit the passage of the chain, is passed beneath the parts to be removed, and a small elastic bougie, having been tied to the end of the chain, is pushed through the canula and made to emerge at the point desired. In some instances it may be necessary to have two of these canulae and trocars, one passing at right angles to the other. The chain and FIG. 136. screw should always be well oiled, and the instrument should be worked slowly, especially in very vascular growths, indeed, a minute to a link is allowed by Some operators. This rule is a good one, and should be fol- lowed by young practitioners. Instead of working with a chain, wire is sometimes used. Fig. 136 represents Smith's modification of the wire écraseur. From my own experience I much prefer the chain to the wire, because the latter is very liable to break. - The late Dr. Nott, of New York, devised what he termed a rectilinear écraseur, which he stated was less likely to be followed by secondary haemorrhage than when the instrument of Chassaignac was used. It is not claimed that it severs the tissues entirely, as does the écraseur, but crushes them to a pulp; a ligature is placed around the pedicle, and the parts may then be cut off. The écraseur has, of course, as have all similar instruments, the cases adapted for its use, and though it will never be selected to amputate the thigh, it will always be found useful in certain vascular parts where opera- tion is required. Acupressure.—If Professor Simpson had done nothing else to immortalize his name, the introduction of acupressure into the domain of surgery would have been entirely sufficient. This simple and safe method of arresting ham- orrhage will be more universally adopted when a more thorough trial of its merits has been instituted by surgeons. On December 9th, 1859, Professor Simpson read before the Royal Society of Edinburgh, a paper entitled “Acu- pressure, an Excellent Method of Arresting Surgical Haemorrhage and Accel- erating the Healing of Wounds;” and he subsequently published a most exhaustive treatise of the same subject,” in which all the advantages claimed * Acupressure, a New Method of Arresting Surgical Haemorrhage and of Accelerating the Healing of Wounds, by J. Y. Simpson, M.D., F.R.C.S., etc. Edinburgh, Adam and Charles Black, p. 571. 330 A SYSTEM OF SURGERY, for the method are carefully considered, and compared with other means for Controlling haemorrhage. It will be some time no doubt before acupressure will become generally adopted. It is very difficult to overcome precon- ceived opinions, and especially our actual experience. We know from facts, that in operations of all magnitudes the vessels have been secured by anti- Septic ligatures, and that hundreds of thousands of patients have made ex- cellent recoveries after hamorrhage has been restrained in this manner, and therefore the apparent insecurity of acupressure has, no doubt, pre- Vented many from applying it. For the same reason the ancients rejected the ligature of Paré. But when we contemplate the rationale of acupressure we will be convinced of its efficacy. The process which takes place in the artery after the introduction of acupressure needles is somewhat similar to that noticed in natural haemostatics. The needle presses together the walls of the artery, acting as does the external coagulum; the blood then stagnates in the vessel up to the nearest anastomosing branch, forming the internal coagulum. The lymph is exuded between the pin and the “couvercle,” and the vessel is closed. The needles are bayonet-pointed, vary in length from two to five inches; they should have cutting edges and firm round glass heads to facilitate their introduction through the tissues. The other instruments are needles of Various lengths, threaded with iron wire. These needles or pins may be used several times. Those which I have been in the habit of using I pro- cured in Edinburgh from the cutler who made them under Professor Simp- Son's express direction. There are several methods of using acupressure, as described by Professor Simpson, and one introduced by Joseph C. Hutchison, M.D., of Brooklyn, N.Y., which he terms “The Brooklyn method.” In his elaborate paper on this subject Dr. Hutchison has done much to introduce the subject to the American profession, and his statistics are very valuable.* Drs. Pirrie and Keith have also introduced their methods, making in all eight forms of acupressure, Professor Simpson at first describing but three. 1st Method.—The pin is pushed through from the cutaneous surface of the flap, it is then passed sufficiently close to the artery to press together its walls, and the point brought out again on the surface; or, as Professor Simpson remarks, in the same manner as we pin the stalk of a flower in the lapel of a coat. - 2d Method.—Take a needle, threaded with iron or silver wire, to render its withdrawal easy, and having raised up the flap, catch up sufficient tissue with the point to make the needle firmly hold, and then bring out the body of the needle close to the vessel and imbed its point again in the tissue, in the same manner as the tailors “run a thread.” 3d Method.—Pass the needle behind the vessel, and having thrown a loop of iron wire around its point, bring the same (the wire) in front of the artery and twist it around the needle. 4th Method.-This is similar to the third, with the exception that a pin is used from the cutaneous surface of the flap, rather than the needle on the internal face. 5th Method.—This is known as the “Aberdeen Twist,” which is performed as follows: The pin or needle is inserted on one side of the bleeding vessel, and its point made to emerge from the tissue a few lines from the artery. The head is then made to rotate either a quarter or half a circle, and the point pressed close to the artery as it is passed into the tissue beyond. 6th Method.—A loop of wire and a pin are the instruments necessary. “The pin is inserted into the tissues on one side of the artery and close to * The Merritt H. Cash Prize Essay, “A Practical Treatise on Acupressure, by Joseph C. Hutchison, M.D.” Transactions of New York State Medical Society, 1869, p. 86. ACUPRESSURE, 331 its mouth, and is carried transversely to the vessel through the tissues of the opposite side; an end of the wire is held in each hand and the loop thrown over the point of the pin, and the ends, brought back on each side of the artery, are crossed behind the body of the pin, and are drawn in opposite directions, sufficiently tight to close the vessel; the ends are then brought up on each side, and the wire is fixed by a half twist around the pin's head.” 7th Method.—This is very similar to the second, with this difference; the pin is entered at the cutaneous surface of the flap, and brought out again in front of the artery, thereby compressing it against the bone; it is then entered again on the cutaneous surface on the other side, and buried #. the tissues sufficiently to hold it securely, bringing the point out on the 8,10. §h Method, is that known as the Brooklyn method, and is especially ser- viceable in closing arteries in their continuity. The artery is first exposed by the usual dissection, then a loop of wire is laid in the wound parallel with the artery. The pin is entered in the integument, and brought out be- neath the vessel, the loop of wire is then passed over the point of the pin, which is then pressed into the skin on the other side, and the ends of the wire secured by half a turn around the pin. - The pins may be removed in a very short time, indeed, to those employ- ing acupressure, it requires quite an amount of moral courage to remove the pins or needles according to the directions laid down. I have with- drawn a needle from the femoral in 38 hours, and from the brachial in 24 hours, and have removed the pins from the facial on several occasions immediately after excising the lower jaw. An instance is upon record where a boy removed the pin from the femoral in four hours after its application without any hamorrhage. In a case of extirpation of the mamma, Coghill removed the apparatus in two hours after the operation. No bleeding resulted.* In October, 1867, my friend, Dr. Comstock, applied acupressure to the arteries of the leg in a secondary amputation (the primary being Chopart's, and was performed by myself during my term of service), in which the haemorrhage was arrested, and the pins removed in forty-eight hours. The cure was perfect, and the wound healed by the first intention,i Dr. Simp- Son thus sums up the comparison between the ligature and acupressure. LIGATURE. ACUPRESSURE. 1. Requires isolation, and consequently 1. Requires none. Some detachment of the end of the vessel from its vital organic connec- tion. - 2. Produces direct mechanical injury, bruis- 2. Produces none. ing and lacerating the two internal coats of the artery. 3. Produces strangulation of the external 3. Produces none. COat. - 4. Leads on inevitably to ulceration or 4. Produces none. molecular destruction of the external coat of the constricted part. 5. Causes mortification of the artery at the 5. Produces none. tied point, and usually below it. 6. Produces, consequently, as many sites of 6. Produces none. ulceration and suppuration, and as many dead decomposing sloughs in each wound as there are arteries liga- tured in the wound. * Wide Simpson on Acupressure, and Hutchison, p. 87. f Transactions of the American Institute of Homoeopathy, 1868, p. 74. 332 A SYSTEM OF SURGERY. IIGATURE. ACUPRESSURE. 7. If organic, as of silk or hemp, it imbibes 7. Requires only impervious metallic animal fluids, which speedily decom- needles or threads, which are inca- pose and irritate the surrounding pable of imbibing animal fluids. living structures. - 8. Requires to produce the three highest 8. Requires to produce inflammation up to stages of inflammation at each liga- the stage of adhesion only. tured point, viz., ulceration, suppura- tion, and mortification. 9. Is not removable, except by slow ulcera- 9. Is removable in an hour or two, or, in tion and sloughing of the ligatured one, two, or three days, at the will of vessel, and requires a period of from the operator. four or five to twenty days or more for its separation. * 10. Stops only the artery tied. - 10. Stops generally both artery and vein. 11. Stops only one artery. 11. May close two or more smaller arteries by means of a single needle. 12. Generally requires two persons for its 12. Requires only one person. application. 13. Is sometimes followed by secondary haem- 13. Is seldom followed by secondary haemor- orrhage, as an effect of sloughing and rhage from ulceration or from slough- - ulceration. ing, as it produces none. 14. Sometimes fails altogether, in cases of re- 14. Has succeeded under such circumstances curring secondary haemorrhage. where the ligature has failed. 15. Sometimes cannot be applied until the 15. Does not necessarily require the exposure surgeon first exposes the bleeding e of the vessel, and therefore often pre- vessel by dissection with the knife, as vents the necessity for antecedent dis- in vessels retracted in amputations, in section by the knife. wounds of the wrist, etc. 16. Prevents, as a foreign body, adhesion of 16. Is early withdrawn, and is hence far less the sides and lips of the wound by opposed to primary union. first intention, in the course of its track, as long as it remains. 17. Is apt, as an irritant body, to disturb and 17. Is early withdrawn, and has no irritant upset the process of primary adhe- effect. sion in its vicinity. 18. Unavoidably creates within the depths 18. Does not create nor apply any danger- of the wound, pus, sloughs, and putrid ous putrefying materials to the fresh materials, which are locked up and absorbing surface of the wound. applied to the imbibing or absorbing cut surfaces of the wound. 19. Places the wound, therefore, in a very 19. Places the wound locally in far healthier dangerous local hygienic condition. hygienic conditions. 20. Is not unfrequently followed by surgical 20. Is much less likely to be followed by fever, from its leading to the formation surgical fever, because it does not lead and absorption of septic matters from to the formation of septic matter, and the surface of the wound. closes the veins as well as the arteries. 21. For these various reasons it makes pri- 21. For these reasons it makes complete mary union rarer, healing slower, primary union more frequent, healing and hectic or surgical fever more fre- quicker, and hectic or surgical fever quent. less common. It will be seen that the advantages claimed for acupressure are chiefly the absence of foreign substances in the wound, of inflammation and sup- puration, and although since the introduction of antiseptic animal ligatures the dangers of septicaemia are very much reduced, yet the presence of a thoroughly carbolized pin is preferable in a wound to any variety of liga- ture. I would strongly recommend this method of arresting hamorrhage. I have found acupressure also very useful, as a means not only of arrest- ing haemorrhage, but of preventing its occurrence. I do not hesitate to say that the pins applied before operation will prevent haemorrhage in many instances, and that the pressure temporarily excited on the veins and nerves of the part give rise to slight if any inconvenience. This method, however, has also many opposers, among whom are Dr. G. M. Humphrey, surgeon to the Addenbrook's Hospital, Mr. I. Cooper Forster, ACUPRESSURE. 333 whose experiments with “torsion” we have already mentioned, Dr. Lee, Dr. Callender, and others. Out of nine cases, in which Mr. Forster applied acupressure, there were four deaths; one from secondary hamorrhage and pyaemia, one from the latter cause, one from the former, and one from pleuro- pneumonia, following gangrene of the stump. Dr. Callender,” late assist- ant surgeon at St. Bartholomew's Hospital, in speaking of Prof. Simpson's success with acupressure says: “He resorted to it in the case of a breast which had been removed in the Hôtel Dieu. Eight needles were employed, and there was no haemorrhage after their removal, but the edges of the wound became erysipelatous, rigors followed, and the patient died in five days after the operation.” Of his own experience he says, “that he ampu- tated the breast of an aged woman for scirrhus; the bleeding was stopped by means of four needles, which were removed thirty-six hours after the operation, but the wound presented an sº blush, with some dusky discoloration, and beginning rapidly to distend with products of decompo- sition, had to be speedily opened. Its entire surface was in a state of gan- FIG. 137, FIG, 138. First method, after Pirrie. Torsoclusion.—PIRRIE. Circumclusion. 1. Introduction of pin, 2. The torsion. grene, and the woman, sinking with symptoms of blood poison, died six days after the operation.” These facts are introduced here, that the impar- tial may judge of the merits of this method of arresting hamorrhage, although it appears to me, that most of the cases cited are scarcely fair FIG. 139. Retroclusion. samples on which to test the merits of acupressure. Dr. Addinell Hewson,t of the Pennsylvania Hospital, is an advocate of the method. * A Report on the Progress of Surgery, by E. A. Clark, M.D., p. 24. † Wide Pennsylvania Hospital Reports, p.127. 334 A SYSTEM OF SURGERY. It has been proposed by Professor W. Pirrie, a great advocate of acupres- Sure, that three methods only should be adopted, and Sir James Simpson, before his death, agreed to the proposition, and named the three methods: circumclusion (Fig. 137), torsoclusion (Fig. 138), and retroclusion (Fig. 139). In the first, the pin is passed behind the artery, and an elastic wire looped . the point and twisted around the pin, thus, the pin is behind, the wire in front. Torsoclusion has already been described as the “Aberdeen method.” In retroclusion, the pin passes behind the artery, after its point is made to describe the greater part of a semicircle.* Several modified forms of acupressure have been adopted by surgeons, but it is impossible to mention them in this chapter. A very ingenious one, however, is that devised by R. Clement Lucas, Esq., late house surgeon to Guy’s Hospital. Dr. Oscar H. Allisi has devised acupressure forceps of several sizes for the arrest of haemorrhage, which I have used with advantage. They are readily FIG. 140. FIG. 141. §§ss.sº gº Allis's Acupressure Forceps. applied, and answer admirably for the purpose intended. Fig. 140 repre- sents the instrument open. The needle is to thrust underneath the vessels, and the blunt blade closing over the bleeding surface stops the hamorrhage. Fig. 141 represents the instrument straight, and shut. There are larger sizes, to be used where more tissue is to be embraced between the blades. Wyeth’s haemostatic forceps is also used to take up a large quantity of bleeding tissue, and by the catch at the handles is serviceable in many FIG. 142. Wyeth's Haemostatic Forceps. ways. I have employed it often as a clamp before putting the ligature upon tissues, or to arrest an extensive hamorrhage while an operation was being completed. Fig. 142 represents the forceps. * Braithwaite, January, 1872, p. 137. # Medical News, Philadelphia, September 1st, 1883. . ARTERY CONSTRICTOR. 335 Percutaneous Ligation.—Ledran, in 1720, was the first to mention this method of securing arteries, and in 1856, Professor Middledropf, of Breslau, revived it.* It is becoming quite a favorite method of arresting haemorrhage, especially from the palmar arch. In recent numbers of the medical periodicals I have ob- served several cases of its successful application. It con- sists in casting a ligature around the artery near its divi- sion, or in the continuity of the vessel, by means of a curved needle, threaded with silk, or silver or iron wire, which is made to pierce the integument, is carried beneath the vessel, including in its course more or less of the soft parts, and made to emerge, in the integument, on the opposite'side, at a point equidistant from its point of en- trance. A compress is placed between the extremities of the ligature, which are then tied. The entrance of the needle should be made from one-third to one and a half inches from the artery. The ligature may be allowed to remain from three to seven days. This is easily accom- plished and is safe, no danger being apprehended from any particular source. It is indeed a species of acupressure. Other Methods.--Speir's Artery Constrictor. — At a meet- ing of the New York State Medical Society, held in Al- bany, the Merrit H. Cash prize was awarded to S. Fleet Speir, M.D., for his essay on “A New Method of Arresting Surgical Haemorrhage by the Artery Constrictor,” etc. Having myself witnessed the application of this instru- ment in several cases, with complete success, and having applied it to the common carotid in its continuity, I have great confidence in its power to arrest arterial haemorrhage. “It consists,” says Dr. Speir, “of a flattened metal tube, six inches (more or less) in length, open at both ends, with a sliding steel tongue running its entire length, and having a vise arrangement at its upper extremity, by which it can be made to protrude from or retract within the tube or sheath. The lower end of the tongue is hook- shaped so as to be adapted to the artery to be constricted. It is so shaped, that having grasped an artery it can be made to contract upon it by means of the vise at the upper end, which forces it within the sheath. The hook of the tongue is so shaped and grooved as to form only a com- pressing surface, by which means the artery, when acted upon by the force of the wise, is compelled to assume the form of the curve of the tongue, and the artery is con- stricted in such a way that its internal and middle coats FIG. 143. Speir's Artery Con- strictor. give way, but the external coat is preserved intact. The severed internal and middle coats contract, retract, and curl upon themselves, and are drawn down into the artery in the form of a plug by the continued pressure of the grooved tongue as it passes on into the sheath.” (Fig. 143.) The experi- ments made by Dr. Speir with this remarkable instrument are quite con- clusive. For instance, it was applied at two points to the carotid of a horse in the continuity of the vessel; the artery was then divided between the points d'appui, no hamorrhage followed. The horse was then thrown down, * Report on the Progress of Surgery, by Professor E. A. Clark, p. 33. f Medical Record, April 1st, p. 49. * 336 A SYSTEM OF SURGERY. but the ends of the vessel remained closed. Experiments were also made upon dead arteries, upon living dogs and sheep, upon the femoral, profunda, and other arteries, with remarkable success. Dr. Speir claims for his instru- ment its efficiency, its safety, its ease of application ; that no internal clot is necessary on account of the invagination of the middle and inner coats of the vessel; that no foreign substance is left in the wound; that the risk of pyaemia or phlebitis is very much lessened ; and that it is applicable to any artery when the external coat is intact. This method of arresting hamor- rhage deserves the strictest attention of the surgeon, and fair and impartial trials should be made with it before it is either too highly lauded or too severely condemned. I am very favorably impressed with what I have seen of its action, and shall take every opportunity to give it a fair trial. Stearns' Artery Clamp.–Dr. C. W. Stearns, of New York, has also intro- duced to the profession an instrument for arresting haemorrhage, especially from deep-seated arteries. It consists of a slender pair of forceps grooved in the beak; the clamp consists of perfectly annealed iron wire somewhat in the shape of a horseshoe. At the other extremity of the forceps is an arrangement by which the clamps may be removed. The loop of wire is fitted upon the groove in the beak, thrust around the artery, and “a dead pinch " made.* There is no elasticity to the wire, and it “sets” immediately over the coat of the vessel. After a number of days the wire is removed, as above mentioned, by a simple contrivance arranged in the handles of the forceps. • º, Metallic Snare, and other Methods.-The late Professor Nathan R. Smith, of Baltimore, devised what he termed his “Metallic Snare for Arresting Haemorrhage.”f It consists of an annealed iron wire, and a silver tube. The ends of the wire are slipped around the vessel, and then passed through the tube, so that the flow of blood is instantaneously arrested. The wire must cut its way out before it can be removed, which is rather a drawback to its application. Mr. John Dix, of Hull, and Mr. Teale, have also tried what they consider a modified form of acupressure. The artery is to be isolated, the wire passed around it, the ends being brought out through the surrounding in- tegument, and fastened over a needle or probe. Dr. Sands, of New York, reported to the Pathological Society, in October, 1867, a case where this. method was tried upon the femoral, but the patient died shortly after. Dr. Aitken, of Michigan, has written a paper, S on what he terms “Compound Acupressure,” in which two needles are used, the vessel being compressed between them, and Dr. Van Gieson, of Greenpoint, New York, has a very ingenious contrivance for arterial compression by “a sectional ligature,” more especially designed for the treatment of aneurism, Ligature.—Having mentioned the numerous methods for arresting sur- gical haemorrhage, which have been proposed at different periods, we come last to the ligature. Its consideration has been postponed in order to show that the ideas introduced by many have been entertained by others in the profession in times gone by. For instance, Scarpa employed a flat ligature to arrest haemorrhage, and placed between the ends of the same a species of compress, because he asserted that it was not necessary that inflammation should be established to obliterate the artery, all that was required being an approximation of the sides of the vessel. Jones, * American Medical Times, November 16th, 1861. + New York Medical Gazette, vol. i., October 19th, 1867. f Lancet, January 5th, 1867; Medical Gazette, December 30th, 1865. ź American Journal of the Medical Sciences, July, 1865. | Medical and Surgical Reporter, February, 1868. LIGATURE. 337 in 1806, affirmed that Scarpa's opinion in this regard was entirely errone- ous, and that it was very essential that organizable matter should be thrown around and into the vessel, to permanently restrain the flow of blood, and that therefore a round ligature must be applied to divide the internal and middle coats of the artery. After a time, “the temporary liga- ture" was introduced, which was much after the manner of what has been Said of percutaneous ligation. Then there was introduced “the sudden obliteration,” by rupturing the internal and middle coats of the artery at short distances from each other, thus establishing several points where co- agulable lymph would be effused, to check the flow of blood immediately, and M. Travers, in his experiments upon horses, found that a ligature kept upon the carotid for the space of six, two, or even one hour, generally effected a permanent obliteration of the vessel. In 1817 he applied a liga- ture to the brachial artery, and removed it in fifty hours without any ham- orrhage, and M. Robert put a ligature upon the femoral of a sailor, left it twenty-four hours, and then removed it, curing him of an aneurism in twelve days. All these experiments show that the idea of closing arteries by constriction was thought of by these surgeons, and it is a possible fact that a ligature may be removed in a few hours after its application, and that allowing it to remain longer sets up an inflammatory action, which termi- nates in suppuration, and thus produces the very result the surgeon en- deavors to avoid, viz., secondary hamorrhage. If the thread could be removed at the proper time, viz., when there has been a sufficient effusion of fibrog enous material, would not the haemorrhage be arrested almost as effectually as by the acupressure pins of Simpson ? - Dechamps invented an “artery compressor,” in which a ligature behind the vessel, and a metallic plate in front of it, arrested bleeding, and in Vel- FIG 144. peau's Surgery there is detailed, as “a new method,” the same pro- ceeding, with a needle threaded with wire, and a loop of the same material, as already described as Simpson's third method of acupressure. The ligatures most generally in vogue at the present day are those of silk, silver, iron, and flax, with the animal - ligature, which we shall notice below. To ligate a vessel, its extremity must be seized with the artery forceps (Fig. 144), drawn forward, and the ligature placed around it, and tied by the surgeon's knot, or the ordinary reef-knot (Fig. 145). It is not at all neces- sary, to put much strain, upon the ligature; S all that is required is to draw it firmly around the vessel. : Sometimes, especially in small vessels, it is better to use the ordinary tenaculum (vide Fig. 146), and a portion of structure may be taken up with the hook, although the artery should be as clear as possible from the surrounding substance. When we are ligating an artery in its continuity, after the vessel has been exposed, the ligature must be passed beneath by FIG. 145. 22 338 A SYSTEM OF SURGERY. an aneurism-needle (vide Fig. 147), which is a blunt tenaculum, with an eye near its point. Fig. 148 represents a double tenaculum used at Bellevue Hospital; it is very useful in securing retracted vessels. For different artery forceps, See page 36. If the ligature be of silk, it must be well waxed, and that article known as braided silk is preferable. Dr. Philip Syng FIG. 146. FIG. 147. Physick, known as the Father of American Surgery, had the strongest objection to silken threads, and much preferred those of flax or bobbin, he being of opinion that the silk was much more likely to slip. It was this distinguished surgeon who introduced the animal ligature,” and this form of thread has been largely used. He used catgut, although the fibrous tissue of the deer is much preferred by some surgeons. It must be dried and twisted into a firm round thread smooth and regular on the surface, non-elastic, and sufficiently strong to resist the trac- tion made upon it by the surgeon. The ends of this variety of ligature can be cut off short, and the wound closed over them. One objection, however, may be found in the fact that these ligatures do not always determine the degree of inflammation necessary to the obliteration of the artery. Antiseptic Ligature.—Professor Lister, to whom the profession is so largely indebted for the various methods of applying car- bolic acid, speaks in terms of unqualified praise of the animal ligature when it is steeped in a solution of carbolic acid. He uses catgut, Saturated or steeped in the following preparation: | Carbolic acid, . e & º g g g . 1 part. Olive oil, . © * © e e g e . 5 parts. Water, tº & & º {º * e tº . 3 parts. He says also:f “When we apply a ligature of animal tissue antiseptically upon an artery, we virtually surround it with a ring of horny tissue, and strengthen the vessel where we ob- struct it.” He also highly recommends what are termed anti- septic ligatures, which are composed of silk steeped for a length of time in a saturated watery solution of carbolic acid. He ex- perimented with this ligature upon the carotid of a horse, dress- ing the wound with a solution of carbolic acid and olive oil, one part of the former to four of the latter. The wound healed by the first intention, and after the death of the animal, which oc- curred from causes in no way connected with the operation, the vessel was entirely closed, and the ligature was found imbedded in a fibrous structure, with no appearance whatever of any irritation. * Wide Memoir of the Life of Philip Syng Physick, by Randolph, p. 84. † London Lancet, April, 1869. ESMARCH's METHOD OF ARTIFICIAL ISCHAEMIA. 339 On this subject, Dr. Eben Watson reports that in all the cases of ampu- tation under his charge at the Glasgow Royal Infirmary, he used ligatures of Mr. Lister's prepared catgut. “I cut them,” he says, “short off at the knot and closed the stump over them. Never in any one case have I been able to detect the ligatures in the discharge; I mean the early sero-San- guineous discharge which flows for a few hours after amputation. I may say that none of the stumps suppurated, except very slightly and super- ficially. I ought also to state that there was no instance of secondary ham- orrhage in all these cases of amputation. I have, therefore, great pleasure in recording my sense of the value of this reintroduction of organic ligatures into surgery, for which we are indebted to Mr. Lister.” At present there is a good deal of discussion among surgeons regarding the use of the antiseptic ligature, but the testimony of most of them is in its favor. I have used it in many ways, and upon the largest vessels; have applied it to the pedicles of ovarian tumors, and in amputations, resections, removal of all kinds of tumors, and have not had a single accident of any kind occur. I am strongly in favor of this method of securing arteries. l There are a few rules which it is well to observe in the application of the igature: * 1. Draw the vessel forward sufficiently to give a good space for the thread to be passed around the artery. - * ... • 2. If operating for aneurism, do not place the thread on a trunk near a good-sized branch. - 3. Be particular not to draw upon the thread too tightly, or the external Coat may be endangered. 4. Be certain that the knot does not slip, the reef-knot being the best for this purpose. 5. Do not draw upon the ligature to see if it is separating, but allow it to come away of itself, the period of time differing in different subjects. According to reliable statistics, it is found that the longer period of time it takes for a ligature to separate, the less danger is there of haemorrhage. The application of wire, either of silver, iron, or platinum, was strongly advocated by both Physick and Dieffenbach, although the systematic intro- duction of silver sutures into the domain of surgery is claimed by Dr. Sims, of New York. The varied methods of using wire have been already noted in the different apparatuses employed for arresting haemorrhage—as Simp- son's acupressure, Stearns’ clamp, Nathan R. Smith's snare, Van Gieson's sectional ligature, and others. For further information regarding the ligature the student is referred to the chapter on MINOR SURGERY, article “Ligature Threads,” p. 38. Esmarch's Method of Artificial Ischaemia.-If we include in the meaning of the word “operation,” as applied to surgery, the entire process of cut- ting, ligation of vessels, and dressing of wounds, it cannot be said that Es- march's method is “bloodless.” During the cutting and tying there is no blood, at least a very little lost; but after the upper band has been removed there is often a plentiful supply. - Several surgeons have claimed priority for this method, more especially Silvestri, of Vicenza; Esmarch, therefore, being called the “promoter,” and not the discoverer of the bloodless method. Stromeyer, Langenbeck, and many others, have also had similar ideas. This, however, is of little prac- tical importance; the truth is that Esmarch utilized the bandage, and brought it before the profession, as Morton did the ether anaesthesia, and to them the profession at large are indebted. * Wide article by R. F. Weir, M.D., Med. Rec, vol. ix, p. 60. 340 A SYSTEM OF SURGERY. As is well known, the apparatus consists of two rubber bands, one broader than the other, which may be applied in the following manner: Elevate the limb, and if there be suppurating sinuses, place over them small wads of prepared oakum, and over these pads put on a roller ban- dage, beginning at the toes or the fingers, as the case may be. Then take the broad bandage, which was formerly made of elastic webbing, but now of pure gum, and beginning at the distal extremity of the limb, put it on tightly, being sure to keep the bandage on the stretch while the turns are being made. A moderate amount of force is all that is required, and the bandage should be slowly put on to give the blood time to recede. After a point sufficiently far above the site of operation has been reached, this ban- dage may be turned two or three times around the limb, and secured by FIG. 149. Esmarch's Bandage applied, fastened with hooks. passing the extremity under the last turn. This being done two or three times, does away with the upper band. However, if the upper band (which is generally india-rubber tubing, either round or flattened) is to be applied, it is put on over the upper turns of the first, and secured by the hooks and chain at the end (vide Fig. 149); or what is better, especially if the band is round, an instrument figured in the cut, which I have found very valu- able in many instances, simply because all slipping is prevented. The original instrument is described in Esmarch's prize essay on military surgery, and was introduced to my notice by Mr. Tiemann. The tubing being drawn out, of course becomes thin- ner, and is then pressed into the slit on the top of the cylinder (Fig. 150); both ends are to be put in, and then the pres- sure withdrawn. The tubing coming back to its original size, of course becomes firmly fixed.* After this, beginning at the distal end of the extremity, or in other words at the point where the bandage was started, the Clamp for Esmarch's Bandage. india-rubber and the cotton roller are re- moved, showing the limb blanched, pale, with modified sensibility, and at a temperature lower than normal. If we place the ear upon the chest when the bandage is being applied, * According to Dr. Robert Weir (Medical Record, February 10th, 1878), who gives a wood-cut of this instrument, Langenbeck has also devised a clamp somewhat like an ovarian clamp, for similar purposes. ESMARCH's METHOD of ARTIFICIAL ISCHEMIA. 341 there is at once perceived an increase in the action of the heart, which has been supposed to arise from the diminution of the normal difference between the pressure of arterial and venous blood; that is, the blood being pressed up first into the veins, produces increased action of the right heart. The same result, viz., increase in the heart's action, takes place when the bandage is being removed. This, no doubt, is occasioned by the reverse condition, viz., the removal of arterial pressure, and the overaction of the left heart. - Dr. Gamgee has made several experiments regarding the effects of this pressure on the general circulation.” He found that when the blood was driven from one leg, there was a short increase in the frequency of the heart-beats; when both legs were subjected to the pressure the same results followed. He found also, that the blood first left the veins, then the arteries, and finally the lymphatics, and was of opinion, that compressing the limbs would send no more blood into the veins than into the arteries, and as the lymph would have a tendency to swell, the venous pressure, the venous blood, and the lymph would be greater in amount than the blood sent into the arteries; but the controlling influence of the valves of the veins would prevent the general increase of pressure. There can be no doubt of the great efficacy of this bandage in restraining haºmorrhage, and par excellence is it of service in all operations for bone dis- ease. None but those who have cut down through the very vascular struc- tures which often cover diseased bone, or those who have been groping about sinuses or through incisions to find dead bone, know the comfort of seeing what is being done. The general voice of the entire profession is in favor of this method, although several objections have been found to it. I exsected a shoulder and had paralysis of the arm follow from pressure; motion returned in three months. I removed a large sequestrum from the femur, and had a similar result, the patient recovering in one month. These two untoward circumstances are all that I have personally been cognizant of, and I have used the bandage a great many times. Dr. Weir, in the Medical Record, publishes a case of paralysis of the hand and forearm, caused by the bandage, and refers to three cases reported by Langenbecki where similar results followed. A similar accident is men- tioned as occurring in the Roosevelt Hospital; and Dr. Stephen SmithS re- cords a case of fatal cellulitis following the use of the bandage. A point here worthy of note is, that the elastic webbing is unsafe. When new, it acts well, but after it has been used a few times, the cotton becomes weak, the elastic becomes brittle, and it breaks readily. This has happened to me twice. The plain rubber is best, and has the great advantage of being kept clean. The bloodstains on the webbing and other soiling, which are unavoidable, soon render it unfit for use. Capillary hamorrhage, said to arise from paralysis of the coats of the vessels from pressure, has also been remarked. The little bleeding that I have observed, generally is soon arrested by exposing the surface to air or the application of ice. Dr. Kupper, of Elberfield, points out, as a serious disadvantage of Es- march's bandage, the free and prolonged bleeding from many small arterial branches, thus compelling the surgeon to tie two or three times the number of vessels that he need have tied had not Esmarch's apparatus been used. * American Journal of Medical Sciences, January, 1877, p. 230. # May, 1874. f Medical Times and Gazette, January, 1874. ź Medical Record, 1874, p. 592; Archives Clinical Surgery, vol. ii., p. 75. | Monthly Abstract of Medical Science, Feb., 1877; London Medical Record, Dec. 15th, 1876; Deutsche Medicinische Wochenschrift, No. 43, 1876. 342 A SYSTEM OF SURGERY. This hamorrhage he attributes to a paralysis of the arterial muscular tissue produced by the pressure of the bandage, and proposes as a remedy, which he has successfully used, the application of a strong induced current, one pole being placed in direct contact with the divided vessels and nerves, the other at Some distance from the seat of operation. On the immediate capillary hamorrhage produced through Esmarch's method, Dr. Nicaire” states that he is able to immediately control it, after the removal of Esmarch's bandage after operations, by applying over the surface of the wound a large sponge dipped in a solution of carbolic acid (1 to 50), and firmly retaining it in that position until the tegumentary redness disappears. Eight or ten minutes will generally suffice. Dr. Henry B. Sandst has given a résumé of 143 cases, in which this band- age has been employed in New York city. In all these cases it was success- ful, the cases of sloughing and secondary hamorrhage and paralysis being attributed to the bandage being inaproperly applied. He suggests also that this bandage would be of great service in cases of coºf fractures at- tended with free haemorrhage, and that it should always be in the hands of the ambulance surgeon, as life might be saved thereby. It has been suggested also that this bandage be applied in cases of ex- treme prostration from hamorrhage. It is estimated that if all the ex- tremities were bandaged an addition of twenty-five per cent. of circulating medium could be added to the body. - With reference to throwing back into the circulation impure or decom- posing products, a good deal of diversity of opinion exists. I have never seen any bad results, and Mr. Holmes considers the idea as wholly theoreti- cal. Yet there are cases upon record that certainly justify prudence on the part of the surgeon in this regard. It may be proper here to give a few remarks of Prof. Esmarch on his experience with the bandage, and how it should be applied for amputations at the hip and shoulder.S - “I have never observed any disadvantages. Especially paralysis was never witnessed as a consequence of the constriction. Where paralysis fol- lowed, it might have been caused by drawing too tight the india-rubber tube. I always perform bandaging and constriction myself, as assistants are constantly trying to overdo the thing. Nor is every kind of india-rub- ber tubing available. The heavy stiff tubes of gray vulcanized rubber are not to be used, and I prefer the brown, non-vulcanized, tubes, or those pre- pared from red rubber or rubber bandages. It does not need such powerful constriction to prevent perfectly the afflux of arterial blood. Especially the first turn need not to be made too tight, as every consequent round enhances the action considerably. “Several surgeons observed gangrene of the flaps after amputations, and ascribed it to the artificial bloodlessness (Guy’s Hospital); and as I never observed it, I suppose that gangrene had more to do with the formation of the flaps or with the after-treatment. “In some cases local anaesthesia is produced in consequence of the local ischaemia and the compression of the nerves, and thus the operation is less painful. We therefore always apply this procedure in small operations on the fingers and toes, in incisions of panaritia, in the extraction of ingrowing toe-nails, exarticulation of phalanges, etc. Stokes|| relates a case where * Monthly Abstract of Medical Science, March, 1877; Gaz. Medicale de Paris, No. 34, 76 f Medical Record, vol. x., p. 79. † See Medical Record, vol. ix., 132. 3 Wien. Med. Wochenschrift, 1874. | Dublin Medical Press, 1874, p. 248. ESMARCH's METHOD OF ARTIFICIAL ISCHAEMIA. 343 he extirpated an epithelioma on the back of the head during ischaemia, where the patient did not feel the operation. Anaesthesia usually sets in after the ischaemia has lasted several minutes, but we can produce it very Quickly with Richardson's etherization, as the congelation occurs far more rapidly when the arteries fail to carry more heat with the blood. Even a rain douche of ice-water deprives quickly an ischaemic finger of all sensibility. * “Artificial bloodlessness renders easy a thorough examination of morbid §: especially bones and joints. I examined many a joint and bone efore the operation, as if it were on the dissecting-table, and only then decided whether resection or amputation was indicated. I could recognize the tuberculous nodules in the degenerated synovial membranes, and in the scrofulous osseous granulations on the living body, and repeatedly cut pieces out of tumors and examined them microscopically, in order to decide on the mode of operation. “In order to master, in operations of the shoulder joint, the afflux of blood through the axillary artery, we have only to carry a rubber tube FIG. 151. FIG. 152. º: § : à & * : & Bloodless Method of Operating for Disarticulation at the Shoulder Joint. under the axilla, draw it tight above the shoulder, and keep it in that ten- sion by a strong hand, which supports itself on the clavicula (Fig. 151), or we hold both ends tight by a clamp, for instance, like that one used for the fixation of the pedicle in ovariotomy (Fig. 152.) I formerly made a spica humeri with the tube, and carried it over the chest and back to the other axilla, but this is not advisable, as the tension of the tube prevents respira- tion too much. “In high amputation of the thigh, the tube is carried strongly around the leg once or twice close to the groin, the ends are crossed above the inguinal region, carried around the posterior surface of the pelvis, and finally closed 344 A SYSTEM of SURGERY. with a chain on the anterior surface of the lower abdominal region (Fig. 153). Or a closely-rolled linen bandage may be used as a compressor to the arteria iliaca externa, close above the ligamentum Pouparti, and firmly pressed upon the artery by several spica-rounds of a strong rubber band- FIG. 153. Bloodless Method of Operating with Elastic Ligature for High Amputation of the Thigh. age. Only in exarticulations and resections these bandages would obstruct the field of operation; hence we prefer in such cases to compress the aorta in the umbilical region, using a compress or roller, made of a bandage eight meters (27 feet) long and 6 centimeters (a little over two inches) broad. We roll it firmly around the centre of a piece of wood, a foot long, and of the thickness of a thumb, by which the compress is held in its place. This compress is applied closely under the navel, and pressed firmly against the vertebrae by rounds of a rubber bandage about two inches broad, carried five or six times around the body (Fig. 154). Thus the arterial afflux FIG. 154, º º 2% º Compressio through the aorta can be perfectly arrested, if we only use the precaution of emptying the bowels by purgatives and injections. In other cases it may be more to the point, to use a pedunculated compress, which can be pressed more deeply into the abdomen. The handle (made of steel) of my compressor (palotte) is perforated with a large hole, through which the rubber bandage can be easily carried. Should any surgeon be afraid of this abdominal constriction, he can carry the rubber bandage around the operat- ing table (Brani), or fasten it to a fenestrated splint put horizontally under the back of the patient.” DITTEL’s EIASTIC LIGATURE. 345 Dr. Gibb" relates a most successful amputation of the hip-joint where this method was practiced. Dr. Erskine Mason, of New York, reports simi- lar cases.i. The use of this bandage in the treatment and the production of anaesthe- sia are noted elsewhere. Dittel's Elastic Ligature.—This method of performing operations should be mentioned in this place, because it is for the most part bloodless. The singular way in which Prof. Dittel was led to investigate the subject is well known,i and the results which have been obtained are various. I have removed a fibroid of the knee with the elastic thread, but some time was required for the sloughing, and the odor was very disagreeable. In fistula in ano, of the very worst varieties, I have had excellent success, and have used it in over fifty cases. Of these, several did not do well—I mean did not granulate rapidly, and in one instance four months elapsed before the wound closed; this, however, is often seen after the knife opera- tions for this disease. The method I used is as follows: The ligatures are of different sizes, made of solid india-rubber, and they must be freshly made, or otherwise they be- come very brittle, as I have found to my cost. If a fistula is to be cut through, I pass the director into the fistula, and having threaded a probe with the ligature (which must be done by putting it on the stretch, to make its calibre smaller, and then drawing it through the eye of the probe), I introduce it (the probe or needle) upon the groove of the director, and draw it through the internal opening of the fistula. The director is then removed. Having then at hand a small, round, leaden circlet, about the diameter of a small bullet, I pass the two free ends of the ligature into the circle of lead, which I then grasp in the jaws of a forceps held in my right hand; taking in my left hand the two free extremities of the ligature I put them thoroughly on the stretch, and slide the ring of lead close up to the integ- ument; then by forcibly closing the jaws of the forceps, I clamp the liga- ture. This is a more secure method than tying, because in some instances I have found the elasticity of the india-rubber untie the knot. If the leaden rings cannot be obtained, a perforated shot will answer, or the ligature ends may be secured by tying them with a piece of silk. Prof. Dittel has gone so far as to apply the “elastic thread " not only to the removal of tumors, but also for the ligation of large arteries. Sir Henry Thompson has since introduced this method into England, and has removed a cysto-sarcomatous tumor of the right breast by it. The tumor was pend- ulous, the mamma shrivelled, and the growth the size of an orange, with a fungoid ulcer on its summit. The proceeding was as follows: A large navus needle was threaded with a tubular elastic ligature, and then passed through the base of the tumor. The elastic was then divided, the needle laid aside, and the ligatures tied on either side of the tumor. There was not much pain, and the operation was successful. Elastic thread is also useful for other purposes in the practice of sur- gery. . I have lately employed it in the withdrawal of ligatures which are tardy in separating. It not unfrequently happens in a wound healing with rapidity, as after removal of the breast, that granulation-tissue appears to overlap the ligature, and thus causes it to remain for a length of time after the vessel to which it has been applied is obliterated. Again, in wounds where tendinous or nervous filaments may have been accidentally included * Lancet, January 31st, 1874. f Archives of Clinical Surgery, vol. i., p. 74, 1876–77. † London Medical Record, December 3d, 1873, or Braithwaite, July, 1874, p. 108. 346 A SYSTEM OF SURGERY. within the loop, the thread is long in separating; in such cases the elastic is 8, SUICCéSS. It may be applied as follows: Take one of the thin sections of india-rubber tubing, which are now in general use, and sold by the box at the stationers. Tie the free end of the “dilatory" ligature to one side of this section, slip the upper end over a piece of bougie, and fix the latter, by means of adhe- sive straps, at a point sufficiently far from the wound to put the elastic ring on the stretch. The constant traction thus effected removes the ligature in a short time without pain. CHAPTER XVIII. TRANSFUSION. HISTORY-USEs—APPARATUS—TRANSFUSION OF BLooD; of MILK ; of SALINE AND OTHER SUBSTANCEs. THE operation of transfusion of blood from one organism to another is very ancient and is shrouded in mythological conjecture. According to classical writers, Medea withdrew the blood from the veins of Æson, and by filling them with the juices of herbs restored to him the vigor and sprightli- ness of youth. Pope Innocent the VIIIth is said to have been killed by the operation of transfusion. In experiments of transmitting the blood of animals through the veins of one another it was supposed that if blood was taken from an animal of different species, the operation was fatal to the recipient, but if one of the same species supplied the blood to another of its kind, the operation was harmless. As has been since demonstrated in cases of human beings, this rule does not invariably apply. The blood of sheep can be transfused in cases of severe hamorrhage with beneficial results. It is said that the circumstance that led finally to the transfusion of blood, was the statement made by Sir Christopher Wren, that he could construct an apparatus by which he could convey fluids into the blood during life. - To Denys and Emmerett, of Paris, belong undoubtedly the credit of hav- ing first performed the operation on the human being with success. In 1666 or thereabouts, Denys operated on a maniac and relieved him; a repetition, however, in another case, resulted fatally. The operation seems to have been perfected by Lower, about the year 1667, who used the method of conveying the blood directly from the artery of a healthy person to the vein of a patient, allowing the force of the circulation to be the propelling OWer. p The discovery at the time was regarded by some as a new era in the art of healing. The first experiments, however, unluckily resulted fatally, and excited so much alarm that in France, transfusion was prohibited by an act of the legislature, and soon fell into disuse. In 1826 Dr. Blundell revived the operation and practiced both the medi- ate and immediate methods, as they are called. The second was that em- ployed most successfully by letting the blood pass by its own gravity from the vein of one person to that of another, but finding this method unsatis- factory, he used a “propella,” but still used venous blood—in this differing from Dr. Lower. TRANSFUSION OF BLOOD. 347 From time to time the operation has been revived, and is now coming more into use. So far the results have been unsatisfactory, mainly for two reasons—First, none but moribund persons have been selected for testing it, and the patients are unable to overcome the symptoms of shock, which are more or less constant accompaniments of the operation; and secondly, there is danger of clots being introduced into the circulation, causing embo- lism, and also of the introduction of air into the veins, thus causing death probably by obstruction of the capillary circulation of the lungs, and rapid collapse. - The operation is especially adapted to those anaemic conditions caused by constant and prolonged losses of blood,” exhausting suppuration, and varied Zymotic processes which take place in the system from the absorption of poisons of any kind (septicaemia, pyamia, ichorrhaemia). In diseases in which there is a destruction of fibrin or degeneration of tissues, transfusion also may be practiced, or in cases of starvation arising from disease. A very interesting case of this kind, in which the patient was dying from actual starvation from gastro-intestinal catarrh, is placed upon record by Dr. S. A. Mason.f The patient was a widow, aged forty-five. She was pulseless, wandering in her mind, and with five respirations a minute, when the doctor first saw her. An apparatus was improvised for the occasion and from six to eight ounces injected with success. Transfusion consists in abstracting blood from a healthy individual, de- fibrinating the fluid, and injecting the same into the veins of the patient. This is known as “mediate’’ or “indirect transfusion,” while “immediate’” and “direct transfusion ” is that in which the blood flows in a continuous stream from the arm of a healthy person into the circulation of the patient. There have been many instruments devised for this purpose, but a very good method, which I have employed with complete success in several cases, is as follows: .- - Having placed a band around the arm, just above the elbow, in order to obstruct venous return, a fold of skin is then pinched up over the median basilic, or median cephalic vein, and with a fine sharp-pointed bistoury the integument is divided from within outward, the back of the knife being placed toward the vein; the skin is then dissected carefully from the vessel, which should be exposed for about an inch and a half. Two ligatures should now be placed under the vein, one at the upper end and the other at the lower angle of the wound, but not tied. The next step is to see that the syringe works well, and has a clean nozzle. A silver syringe, holding an ounce and a half, is best. The nozzle may have an aperture about one- eighth of an inch in diameter, must be movable, and fitted with a stop-cock. Have then ready a basin of hot water, and a bowl, which must be placed in the hot water in the basin; bring the arm of the healthy person, from whom the blood is to be extracted, over the bowl, and perform ordinary venesection. After having allowed several ounces to pass into the bowl, the blood must be thoroughly “whipped ” with an egg-beater or a bundle of twigs to defibrinate it. While this latter act is being performed by an assistant, the operator will tie in a single knot the ligatures, which are al- ready beneath the vein, and raising up the vein, make a longitudinal in- cision therein, only of sufficient length to admit the end of the nozzle of the syringe, fitted with the stop-cock. Before entering the nozzle it must be * In typhoid fever, Medical Press and Circular, November 30th, 1884. # Medical Record, 1880, vol. i., p. 215. - * † The first operation for transfusion of blood made by the author was on November 15th, 1869. Wide Western Homoeopathic Observer, vol. vii., page 152. 348 A SYSTEM OF SURGERY. warmed, and be filled even with its end with the defibrinated blood, in order that no air be introduced into the vein. The nozzle now must be carefully placed in the incision made in the vein, and its end insinuated gradually along until it passes the upper ligature, which then must be tied over it. The syringe then must be filled with blood from the basin, its end fitted into the nozzle fixed in the vein, the stop-cock turned, and the piston gradually pressed home. This part of the operation must be conducted with care, and the piston pressed slowly down, to allow the blood gradu- ally to enter the venous system ; if the blood be forced in too rapidly, the patient will experience a sense of faintness, and the heart, in endeavoring to accommodate itself to the additional quantity of fluid introduced into the circulation, will begin to act irregularly, and serious consequences may ensue. The operation of transfusion is not a very difficult one, but requires careful and nice dissection and much time. The instruments should all be very clean, and several assistants are required to perform the varied steps of the process. The wound, after the nozzle of the syringe is withdrawn, should be immediately closed with the thumb, the ligatures removed from the vein, and a stitch or two taken in the integument. Dr. Garrigues, of New York, has invented a simple and ingenious ap- paratus for mediate transfusion. It is represented in Fig. 155, and the following are the directions accompanying the instrument: Draw eight or ten ounces of blood from a healthy person into a clean vessel, whilst it is accumulating whip it with a silver fork, a stick of wood or a bunch of straw, then strain it through a piece of cleanly washed linen into a vessel placed within another containing warm water (about 105° F.). Warm the syringe, put the suction end A into the blood, compress the bulb, and when it flows through the canula, turn the stopcock C. - Having bared the patient's arm, raise a fold of skin over a vein at the bend of the elbow, divide it and pass a probe or thread under the vein thus brought into view. This is now held with a pair of forceps or tenaculum and an in- cision made with a lancet or pair of fine-pointed scissors, carefully avoiding wounding its posterior wall. Now introduce the canula D, open the stop- cock and inject slowly. The bulb contains about three fluid drachms, but by moderate compres- sion about two only are expelled. In most cases it suffices to inject from four to six ounces. If resistance not due to external pressure be felt, or dyspnoea, or any other untoward symptom appear, the operation has to be interrupted or ended. Dress the wound as after phlebotomy. After use, the instrument must be thoroughly cleansed, which is best done by separating all the parts and washing them in warm water. For immediate or direct transfusion, the engraving will give a most accurate description of the operation. It represents the apparatus of Aveling. (Fig. 156.) TRANSFUSION OF BILOOD. 349 Dr. Roussel” has also invented an apparatus for the performance of direct transfusion from vein to vein. Its object, he says, is to prevent coagulation of the blood that is drawn, and thus to do away with the necessity of defibrination. The instrument is made of hardened pure caoutchouc, which has no effect on the blood. It consists of a tube with a syringe in its course, to serve as an aspirator FIG. 156. Canula B is for the vein of the giver. C is placed into the vein of the patient. The tube and bulbs should then be filled with warm water, or, what is preferable, a solution used by Mr. Little, composed of 60 grains of sodium chloride, 6 grains of potassium chloride, 3 grains soda phosphate, 20 grains soda carbo- nate, and 20 ounces of water. The tubes are now adjusted to the canulae and the blood allowed to flow into the apparatus. The canula being steadied by an assistant, the tube is to be nipped tightly between the fingers, close to the giver's or efferent end, and then the bulb marked 1 is to be compressed, and the blood of course forced on towards the receiver. While this bulb is still held compressed, the tube at the giver's side is to be relaxed, and that portion of it between the bulbs is to be nipped; bulb 1 is relaxed, and No. 2 gompressed and held; then the tube at the receiver's side is to be seized and held to prevent regurgitation, and the whole apparatus allowed to refill. The same operation to be repeated till suffi: çient blood is transfused. As suggested by Dr. Aveling, a few drops of ammonia solution may be injected into the bulbs now and then, by a fine-pointed hypodermic syringe, in order to more effectuall prevent coagulation. It will be found that considerable force is necessary in sending blood or other fluids into the veins. . This we discovered while doing transfusion twice in a case after haemorrhage from gunshot injury, and we have also found it in our experiments on the lower animals. It is a fact that we have not seen noted in connection with transfusion, and one well worth remembering. In order to use the apparatus as a mediate transfuser, the vessel marked A in the cut receives the blood, the tube is to be applied, and the instrument used as before directed. If the blood is not defibri- : Strained, three or four drops of ammonia solution to each ounce are added, in order to avoid COagulation. of the blood from the supplying vein, and the alternate compression and ex- pansion of which, allows a flow of blood to ensue; the bulb is inwardly Smooth, holding ten grams, so the blood is easily measured. The appa- ratus being filled with water, the vein is opened, and the contents of the cyl- inder and tube pumped out, the water being expelled through the free end till the blood flows from it, the stopcock is turned, and the blood (with the few drops of water left in the canula now in use—that, namely, which is in- serted into the vein of the patient) is injected into the patient's arm. With- out drawings it is impossible to give clearly an idea of the apparatus. The conditions are: 1. That the blood of the giver and receiver be of the same animal species, and from the same organic source, from man to man, and vein to vein. 2. That it be pure in its chemical and physiological conditions. 3. That the ability to regulate and inject the proper quantum be present. 4. That the connection between the giving and receiving veins be by a * Medical Times and Gazette, November 18th, 1876. 350 A SYSTEM OF SURGERY. direct channel free from air; and that the giver's vein be opened under Water. In fifty-two cases in which the operation has been performed, including acute anaemia after childbirth, haemorrhage, and exhaustion-after suppura- tion, malignant fevers, septicæmia, etc., benefit always resulted; not a case of accident or fatal result followed. B. E. Fryer,” surgeon, United States army, has modified the apparatus of Aveling. It has been noted by me in all my cases of transfusion that, as a rule, for the first few hours, the patients seem to improve, and that frequently after that, without apparent cause, syncope and death result. This peculiarity has been noted by others, especially in cases of haemorrhage after typhoid fever,i and by Dr. T. G. Morton, who relates this case. The man (aged forty) had been in a comatose condition, and in order to relieve the system of the poison, a large quantity of blood was drawn from him before transfusing. Eight ounces of defibrinated blood were then thrown into the saphena vein on the right foot. The pulse rose, the respi- rations increased in number after the operation, and the patient began to grow steadily better, when, five hours after the fresh blood had been in- tººd. his heart suddenly ceased beating, and he died without a WOI’Ol. In none of my cases did I perceive the chill which is mentioned by M. Roussel, but in all of them there was quickened respiration and increased cardiac action, with a sensation of tightness at the praecordium. This chill is said, however, to be a favorable symptom as indicating reaction of the system. The quantity of blood may vary from five to ten ounces (150 to 300 grams). An important item also for the surgeon’s consideration is the quality of the blood injected. - Transfusion of Milk.-I have only performed this operation three times; in one instance the patient died, though it must be stated that she was in extremis before the operation was performed. As milk resembles chyle in a great degree, it was thought that by in- jecting it into the circulation, the same effect would be produced as if blood were employed. Chyle is fat, suspended in its finely divided condition, and milk is also fat in an emulsified form, and as chyle enters into the circulation at the Sub- clavian vein without bad effects, it is fair to presume that milk may be used to supply nutrition in certain conditions. It certainly is very highly recom- mended. Dr. Hodder, of Toronto, in 1850, I think it was, treated several cases of cholera by this method, and in 1873 Dr. Howe, of this city, per- formed the operation, using goat’s milk—the patient died three days after the second injection. Dr. Thomas repeated the operation with success some years after. The results of some experiments on dogs were reported by Dr. Howe in the Medical Record, in which nine animals were bled to a condition of syn- cope. Seven of them were then injected with milk and died, while two were left to themselves and recovered entirely. The Doctor thinks the cause of death in these cases was due to the quantity of milk that was injected; while Dr. Thomas thinks the fault was in the impurity of the substance used. A series of researches has been made by N. Wulfsbergș on animals, with * Medical Record, April 15th, 1874. # Medical Press and Circular, November 30th, 1881. † The Medical Record, March 15th, 1879, No. 436. ź Am. Journal of the Medical Sciences, April, 1879, No. cliv. PERITONEAL TRANSFUSION OF BLOOD. 351 regard to the effects of intravenous injection of milk, recommended by some as a means of preserving life in haemorrhage and other forms of anaemia. After injecting about 250 grams, and examining the blood, it was found that the white corpuscles increased in number, having taken up (in fact, eaten) the milk spheres. It was found impossible to maintain the life of animals by subcutaneous injections of fresh milk, as they became atrophic. The injection of milk caused the sounds of the heart, which previously were in- audible, to become clear and distinct. I believe that the general conviction in the minds of surgeons is, that not much reliance can be placed upon the intravenous injection of milk. If, however, it has to be done, it is an all-important consideration that milk just drawn from the cow or goat be used, and that the fluid be kept warm. In my injections at the Ward's Island Hospital, I employed a simple fountain syringe with an Aveling's tube, keeping the bag in hot water and using the thermometer frequently. Dr. McDonnell” reports a successful intravenous injection of milk, in which ten ounces were injected. Peritoneal Transfusion of Blood.—Strange as it may appear at first sight, it has been proved by actual experiments made, notably by Ponfick, Kaczorowski, Bizzozero, Golgi, and others, that defibrinated blood may be allowed to flow into the abdominal cavity, not only without disastrous con- sequences, but that the serous surface will absorb the haemoglobin, and thus become instrumental in saving life, when threatened from anaemia, or from profuse hamorrhages. The advantages claimed for the method are: first the simplicity of the operation, the absence of danger, and the very suc- cessful results that have thus far followed the method. The apparatus for peritoneal transfusion consists of a curved trocar to be thrust into the linea alba, an india-rubber tube which is to be attached to the can- ula, º a funnel through which the blood—thoroughly defibrinated—is poured. In the first of the cases recorded by Professor Ponfick, the quantity of blood used was 250 grams (38.82); in the second case, 350 grams (312.35); and in the third case, 220 grams (3 7.70). The average quantity is said to be, by our measure, about one pound and a third. These three patients recovered without any alarming symptoms, slight fever and pain only being noticed after the injection. In Kaczorowski’s cases, five in number, the improvement was marked immediately, and there was no unpleasant symp- tom whatsoever. - After many experiments upon rabbits, the following conclusions have been noted: 1st. That in less than twenty minutes after the injection, there was a progressive increase in the relative quantity of red blood-corpuscles. 2d. The increased quantity of the haemoglobin was in the direct ratio of the injected blood, but the increase never reached over fifty-seven per cent. of the haemoglobin of the giver's blood. 3d. That the increased richness in the blood continued for several weeks together; and 4th, that healthy animals showed an increase in the blood corpuscles, as well as the alſ).32IIllC. This method of transfusion I have never yet employed, but I should not hesitate to put it into practice in any case in which I thought it might be of service. Transfusion of Saline Substances.—Acting upon the suggestion, that death in severe cases of haemorrhage was caused less from the loss of the red blood corpuscles than from the sudden emptying of the arteries—an idea * Medical Record, March 29th, 1879. 352 A SYSTEM OF SURGERY. first promulgated by Goltz, Swhartz experimented upon animals and found that, when in an apparently lifeless condition from loss of blood, they could be restored to life by the injection of alkaline saline solutions, and declared that a similar procedure would be productive of good in patients similarly reduced. The method has been tried with success in some cases. Bischoff’s gives a remarkable cure. The patient was a woman who was delivered with forceps of a dead child weighing 3450 grams (3 121.69). The placenta was deliv- ered with the hands, and a quantity of blood, weighing 1490 grams (3 52.56), was lost. Collapse followed, with pulselessness at times; at others, the beats numbering 156 to the minute. The ordinary remedies appearing to produce no good effect, the left radial artery was exposed, divided, and the cardiac extremity tied. Into the peripheral end of the vessel a small canula was inserted, and 1250 grams (344,09) of a saline solution were allowed to pass into the circulation by means of an india-rubber tube, one end of which was fixed to the canula, the other end being attached to a glass funnel, both of which had been thoroughly carbolized. The preparation was a sixteenth per cent. Solution of common salt (chlo- ride of sodium) mixed with a couple of drops of the liquor potassae. It took exactly an hour to complete the injection. No unpleasant effect fol- lowed, but, on the contrary, the patient rallied during the operation, the pulse falling to 122 beats per minute, and the patient made a complete re- covery. Bischoff is of opinion that the operation should not be attempted in cases of acute anaemia from diseases of the spleen, and that the quantity of injection should be 500 grams (3 17.64). - The hydrated oxide of sodium is said to be the preferable substance for rendering the injection alkaline. CHAPTER XIX. AMPUTATIONS. DEFINITION.—QUESTION OF AMPUTATION.—INSTRUMENTs—METHODS—MoRTALITY AFTER. THE term amputation in surgery signifies the “cutting off” of a portion of the body; and though it is generally restricted to the removal of either the upper or lower extremities, or portions of them, it is employed also to designate other operations, thus: “annputation of the breast,” “of the penis,” “of the tongue,” and other parts. By a disarticulation is to be understood the removal of a limb at its articular surfaces, which operation is also desig- nated “an amputation in contiguity.” When amputations are made through the shafts of bones, “in continuity” is the expression used. When two of the extremities are removed at the same time, “double amputation” is made; and when it becomes necessary to remove a limb a second time, it is said to be “re-amputated.” The question as to when an amputation is to be performed must remain * Correspondenzblatt fuer Schweizer AErtz, December 1st, 1881, quoted by the Medical Record, 1882, vol. i., p. 209. COMPOUND FRACTURES. - 353 an open one for the consideration of the surgeon in each particular case. In some instances, it would appear that the only opportunity the patient may have for the preservation of life, rests in immediate amputation. In severe accidents, where there is crushing, and the hamorrhage cannot be arrested, such a course is the only one to be pursued. In other cases, twenty-four or forty-eight hours may be allowed, to enable the patient to recover from the shock, but not to postpone the operation till the occur- rence of that inflammation, which the surgeon apprehends from the extent of the injury will surely follow. This amputation, the “intermediate,” is of such danger that it should, if possible, not be practiced at all, or only in extreme cases. The Secondary amputations are often followed by suc- cess, especially when performed after the full process of suppuration has set in. For further particulars, the reader may consult the chapters on “Gan- grene,” and “Wounds.” So long as the destructive effects of injuries and diseases of the extremities cannot, in every instance, be prevented by the employment of other means, a necessity for amputation must continue to exist, and the sacrificing of a branch, as it were, thereby making use of the only rational means for main- taining the integrity of the trunk, frequently becomes indispensable. It is, however, the imperative duty of the surgeon never to have re- course to this serious, and sometimes fatal operation, without a per- fectly clear and fully substantial conviction of its necessity. It should always be regarded as the last expedient to which the surgeon should resort, justi- fiable only when farther attempt to save the injured or diseased part would be fraught with danger to the life of the patient. With this conviction, it is evident that a precise knowledge of such cases as demand amputation, as also of those where it should be dispensed with, and the exact periods at which its performance is most conducive to the welfare of the patient, are considerations demanding marked attention. The various conditions demanding a performance of this operation are as follows: Compound fractures, extensive contused and lacerated wounds, gangrene and mortification, gunshot injuries, diseases of the joints, exos- tosis and necrosis, haemorrhage, etc. Compound Fractures.—The necessity for amputation in injuries of this nature does not depend entirely upon the seriousness of the accident, but also, in a measure, upon other circumstances: as the condition of the patient, his mode of life, the facilities for ventilation, etc. If, however, a compound fracture occur in which the soft parts have been extensively in- volved, and the bones have been so seriously injured that perfect quietude and constant attention are unable to afford any chance of recovery, am- putation should be performed. On the contrary, when the soft parts have been less extensively injured, and the bones have been broken in such a manner that they can readily be readjusted and maintained in their proper position; or if but one bone be involved in the injury, amputation is deemed both unnecessary and inhuman. Accompanying circumstances, however, are to be considered in concluding for or against amputation.* * The circumstances adverse to a favorable prognosis in cases of compound fracture, are thus detailed by Professor Miller: “Comminution of the bone, or fracture at several points; extension of the fracture into an important articulation; an open state of the joints; much bruising and laceration of the soft parts, rendering extensive sloughing inevitable, with a risk of gangrene involving the whole limb, and with a certainty of extensive and tedious sup- puration following separation of the sloughs; laceration of a large artery, as evinced either by haemorrhage or by rapid formation of a large bloody swelling; old age; and enfeeblement of the frame by disease, by privation, by intemperate habits,” etc.—Principles of Surgery, . 717. p 23 354 & A SYSTEM OF SURGERY. In compound fractures, as Mr. Pott” pointed out, there are three distinct periods when it is deemed proper to perform amputation. The first of these is immediately, or soon as practicable after the receipt of the injury. The second, when the bones remain for a great length of time without manifesting any disposition to unite, and the discharge from the wound has continued so long and is so excessive that the patient's strength fails, together with the supervening of general symptoms foreboding dissolution. And third, when mortification has so completely involved the soft parts of the inferior portion of the limb, quite down to the bone, that upon separation of the diseased portions, the bone or bones are left bare in the interspace. The first and second of these are matters requiring serious consideration. The last demands scarcely any. A disposition to mortification is often evinced when fracture occurs in the middle of a bone; but much more frequently when any of the larger joints are involved; and in many of the above-mentioned instances a de- cision favorable or adverse to amputation is really a determination for or against the patient's life. If, after judicious treatment throughout every stage, by the united efforts of medicine and surgery, the sore, instead of granulating kindly and con- tracting daily, does not diminish in size, has a tawny, spongy surface, dis- charges a large quantity of thin sanies; the fractured ends of the bones, instead of tending to exfoliate or unite, remain as perfectly loose and unu- nited as at first, whilst the patient is deprived of sleep and appetite, becomes greatly weakened, hectic fever, with a quick, small, hard pulse and profuse sweat, contributing at the same time to bring him to the brink of the grave, notwithstanding all efforts to the contrary; under these circumstances, if amputation be not performed, what else can rescue the patient from de- struction ? Extensive Contused and Lacerated Wounds.--These form the second class of general cases requiring amputation; though when not in conjunction with fracture, they seldom render the operation necessary. But if a limb is extensively lacerated and contused, and its principal blood vessels are injured to so great an extent that a continuance of the circulation cannot reasonably be expected, an immediate removal of the affected limb is recom- mended, even though no bone is involved in the injury; and as all efforts of the surgeon to preserve a limb so seriously injured generally prove unavailing, and such wounds are more disposed to assume a gangrenous condition than any others, the sooner the operation is performed the more favorable will be the prognosis. In the preceding varieties of injuries, although amputation may not always be necessary in the first instance, yet it may become so subsequently. Sometimes mortification rapidly takes place, either in consequence of the extreme violence of the injury, or, consecutively, from greatly excited action going on in parts whose powers of resistance have been much impaired; or profuse suppuration, with its consequences and accompanying conditions, ensues, which the system is unable to resist; in these instances amputation should be resorted to. Gangrene and Mortification.—Gangrene is another cause, which, when ad- vanced in a certain degree, renders amputation indispensable. At page 143 I have given some remarks on this subject, which is further elucidated by Mr. Fergusson. - It sometimes happens that gangrene appears So extensive in either the upper or lower extremities, or that mortification has committed such ravages * Remarks on the Necessity, etc., of Amputation in Certain Cases.—Surgical Works, vol. iii., London, 1808. DISEASES OF THE JOINTS. 355 as to preclude the hope of saving the limb, or even the life of the patient if such a source of irritation is allowed to remain. The surgeon will seldom be performing his duty if, in this instance, he leaves the case to the efforts of nature so entirely as in partial slough; for although experience proves that a portion of the hand, foot, forearm, or leg, may drop off, or that either member may be separated at its articulation with the trunk by the process of molecular death, it is equally certain that the work is done in a tedious, painful, and unsatisfactory manner, months sometimes elapsing ere the parts are entirely separated; and when at length this has been accomplished, months more may pass ere cicatrization takes place. There cannot be a doubt that the surgeon is justified in many of these cases, in performing amputation; and the only difficulty is to determine the proper period for such a procedure.* - Practitioners have entertained very opposite opinions concerning the time when the operation should be performed. Some declare that whenever the disorder presents itself, especially if it be the result of external violence, amputation should immediately be performed, as soon as the disease has commenced, and while it is in the spreading state. Mr. Pott says that he has often seen the experiment of amputating a limb in which gangrene had begun to show itself tried, but never saw success follow, and it invariably hastened the patient's death.i. - The operation, however, may be postponed too long, and it is sometimes advisable to amputate to prevent gangrene; thus when a limb has been much injured by mechanical or chemical means—in the case of severe com- pound fracture or burn—and it is apparent that mortification must ensue, involving the whole thickness of the limb, of an acute character, tending to spread, and from the first accompanied by the most formidable constitu- tional symptoms, amputation is to be performed above the injured point as Soon as the primary shock has passed away, and the system rallied so far as to afford sufficient tolerance of the operation. In injuries of this nature, when gangrene has set in, delay, with the object of waiting for the spontaneous line of separation, will be in vain. The gangrene spreads upwards and upwards, with a diffused and streaky mar- gin ; typhoid symptoms grow more and more intense; the trunk is reached, rendering operative interference hopeless; or long ere this, the system has sunk and the patient perished. The only hope of escape is by early ampu- tation; it is a slender chance, but it is the only one, and to it the sufferer is entitled. - When gangrene is an attendant upon one particular cause, as cold; the line of disjunction is to be awaited, and as soon as it has become evident that this is fairly formed, the surgeon should resort to amputation, which may be performed either at the point of separation of the dead from the living textures, or at a distance above, according as the circumstances of the case may demand. . . Diseases of the Joints.-Scrofulous diseases of the joints involving the bones, with morbid alteration of the structure of the adjacent ligaments and cartilages, so extensive that resection cannot be resorted to, is another con- dition in which amputation may become an absolute necessity. An un- pleasant circumstance attending these affections is that the majority of subjects are young children, incapable of determining for themselves. All efforts at cure sometimes prove unavailing, and operation is the only resort. - It is a highly important fact that amputation in these instances is attended * Fergusson's System of Practical Surgery, p. 108. f Surgical Works, vol. iii. * f See Question of Amputation in Gunshot Wounds. 356 A SYSTEM OF SURGERY. with a greater degree of success when the disease has considerably advanced than when undertaken at an earlier period. This is particularly fortunate, as it affords ample opportunity for the administration of those medicines that have been mentioned, and thus, perhaps, the necessity for the opera- tion may be obviated. Bony tumors, under certain circumstances, sometimes occasion a necessity for amputation; but when they merely produce deformity without pain or ſ|- : ti; FIG. 157. a F. Dis 2 : z Ç º O C i. | | inconvenience from the pressure which they exert on neighboring parts, the performance of an op- eration for their removal is not advisable, for, as Boyer has ob- served,” in a great number of in- stances, the local affection is much less to be dreaded than the means used for its removal. When, however, the tumor be- comes hurtful to the health, and its situation permits of a ready removal, this may be done with- out an entire division of the part on which it is situated; but fre- quently its base is so extensively and deeply seated as to preclude the possibility of a removal by this method. If, in this case, it is situated on the extremities, and has become insupportable on account of its weight, ampu- tation should be performed in preference to any operation hav- ing in view the saving of the limb. Another affection of the os- seous system which sometimes demands the performance of am- putation is necrosis—or the death of the whole, or a very consider- able portion of the bones of the extremities. The performance of this oper- ation in these cases, however, is the exception, not the rule. It may happen that in acute ne- crosis in the young subject, vio- lent inflammatory action is fol- lowed by severe irritative fever, which latter is quickly succeeded by a formidable hectic that must evidently be relieved at all haz- ards, by a removal of its cause; Or, in more chronic cases, a like summary procedure may be required at a more distant date, after weeks and even months have elapsed, when the separation of the sequestrum is * Treatise on Surgical Diseases, vol. ii. AMPUTATION INSTRUMENTS. 357 far advanced, but not yet complete, after the system has long resisted the exhausting burden of irritation and discharge, but when, nevertheless, it has evidently become unequal to a prolongation of the contest. On the one hand the surgeon must beware of sacrificing life in endeavoring to save a limb, and, on the other, must be equally careful not to sacrifice a limb in FIG. 158, 2 s. Iſ O "|iº. º º E = <-E Fºº & E.: Egº-º-º: endeavoring to succor life not yet actually endangered; and, in connection with this subject, it is important to remember that necrosis is not always so extensive as outward appearances would lead one to suppose. Before an amputation is commenced, the parts should be carefully washed with carbolized water, and turned towards the light, and the oper- . should so place himself that the limb to be removed falls to his right S1Clé. Instruments.—The instruments used, besides those already mentioned in the chapter on minor surgery, are chiefly knives, of different lengths, sharp- FIG. 159. ºrieMANN ºtb sº-I. IITIſ pointed, rounded, or double-edged (catlings). Fig. 157 shows the different forms of amputating knives. Saw8.—Fig. 158 shows an amputating saw ; Fig. 159, metacarpal saw ; Fig. 160, Hey’s saw. Bone forceps, to remove any projections of bone spiculae which remain after the use of the saw, is shown by Fig. 161. FIG. 160. FIG. 161. -āºm DENNºwaii: = Retractors (Figs. 162 and 163), or split cloths to draw back the soft tissues after they are divided with the knife, are made either with a single or double split, as follows: Take a piece of muslin, a yard in length and ten inches in width; fold it upon itself, to mark its middle point, then slit one-half lengthwise into two parts, or into three. The former is used in amputations 358 A SYSTEM OF SURGERY. where but a single bone is to be divided, the latter where two bones are to be sawn through, the middle tail of the retractor passing between the bones. - FIG. 162. ::::::::::: *::::::::::::::::::::::::::::::::: jºss-ºº-ºº: :::::::::::::::::::::::::::::::: º::::::::::::::::: º::::::::::::::::::::::::::: ** *** : e º * º: sº :::::: #: *** **** *:::::::::::::: ##########: & & sºrººººººººººº-ºº: - ***** º tºº. - *** Pºsº. ************** lºssºs sººººººº -----assºsºsºsºsºsºsºsºsº: $º º :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: sº º : :::::::::::::::::::::: sº. * :::::::::::::: ######### ;:::: ºº::::: * sº tº::::::::::::::::::: ::::::::::::: º º sº ##### tºº-º-º-º: *ººge :::::: se 3:::::::::::::::::::: º ečº e ***********************sºsºsºgas - gº :::::::::::: º: # :::::::: º :::::::::::::::::::: :::::::::::::::::::: ##################5 ::::::::::::: ########## *º-ººrºº 3: º ::::::::::::::::::::: --- #:::::::::::::::::::::::: w it:::::::::: ---º-º: - gº g :::::::::: - wº ºº::::::::::::::::::: -- **º-sºº :::::: - - ######################################## tº: **********agº §::::::::::::::::::::: s sº > *** ################### **** **** *º-ººººººººº. *** ******** ºn d gºes-º-º-º: tº:::: ** tº gº :::::::::::::::::: :::::::::::::: ::::::::::: :::::::::::::::::::::::::::::: sº ::::::::::::::::::::::::::::::: ***@sº ***º-º-º-º: º & - *****-ā * ****** ****** ::::::: #################: * - ::::::::::::::#: :::::::::::::::: ::::::: #. - ::::::::::::::: - ########### :::::::::::: ::::::::: ::::::::::: :::::::::: Linen Retractors for One bone. for two bones. Methods,--There are two principal methods of amputation, one being denominated the circular, in which the integument is divided with a circular cut around the limb (Fig. 164), and then dissected and turned up like the FIG. 164. Circular incision. cuff of a coat-sleeve, after which the muscular and other tissues are severed to the bone, the knife being held nearly at right angles with the shaft. The METHODS OF AMPUTATION. 359 other, the “flap amputation,” consists in passing the knife through the integument above and below the bone (Fig. 165), and cutting outwards, forming sufficient covering to make a good stump. It is not always easy to determine exactly which method is best adapted to the case, especially in severe accidents, when much tissue is lacerated. Often a combination of both the circular and flap operation is necessary. In civil practice the circular variety is generally performed at the middle of the forearm and leg, while the flap is resorted to in the arm and thigh. In the lower portion FIG. 165. & * . . . . ſº *º $g * … tº anº * t s º tº . * ſº. tº § "h. "º d | Nºjº ºf .2° ſº º ſ |. ; : * Making flap by transfixion. of the thigh, however, I have known the circular give as satisfactory, if not better results than the flap, because in the former there is not nearly the tendency to retraction of the flaps, which will often ensue when the ends of so many powerful muscles are divided. Amputation by a Long and Short Rectangular Flap (Teale's Amputation).- The advantages claimed by Mr. Teale for this method of amputation are: Avoidance of tension, a better stump for the accommodation of an artificial limb, a soft and pliable covering for the ends of the bone, the non-disturb- ance of the plastic process, and a favorable outlet for the discharge. In this operation the long rectangular flap is perfectly quadrangular in shape, and is of sufficient length to fall readily over the end of the bone, and is made of parts devoid of important bloodvessels and nerves; the short one contains these structures, and is made about one-fourth the length of the other. Mr. Teale, in his work,” gives some statistics of his method, which are very favorable. The directions for the operation will be found in the special amputations to which it is applicable. Carden's or the Mixed Method.—This amputation, as its name implies, is partially circular and partially flap. It was devised by Young, and revived and systematized by Carden. The flaps are formed from the integument and fat, are oval and dissected up; the circular portion of this operation is then made by dividing the muscular tissue down to the bone. This ampu- tation is a valuable one, and it is very applicable to forearm, leg, and knee. * Amputation by a Long and Short Rectangular Flap, by Thomas P. Teale, F.L.S., F.R.C.S., London. 360 A SYSTEM OF SURGERY. In order to prevent any confusion of terms, it may be stated here, that the circular method receives the name of the tegumentary, and that where the skin flaps are made oval, instead of being circular, the name of oval tegu- ºnentary is applied to the operation. The flap operation is also called the Tmusculo-tegumentary, and embraces the skin and muscular tissue. It was the introduction of this method (flap) that at one time caused so much discus- Sion among the surgeons of England. The partisans of the flap, which num- bered among its most zealous upholders Sir John Bell, were denominated “flappers,” while those still continuing to uphold the circular operation, fore- most among whom was Sir Benjamin Bell, were called the “anti-flappers.” The musculo-tegumentary method was very much in vogue before the days of anaesthesia, on account of the rapidity with which it could be executed by skilful men. Time was of vast importance to the sufferer undergoing the terrible ordeal of an amputation, and therefore for quite a long period the flap method was preferred. Since the days of the safe abolition of pain in surgical operations, many modifications designed for shaping the soft parts covering the bone have been adopted, among which are those of Teale and Carden just mentioned. A modification of the circular and flap amputations I have adopted in both the arm and the thigh, which, though it takes a little more time, is to my mind the most satisfactory of any of the operations. is Combined Circular and Flap.–In this method the tegumentary flaps are oval. The surgeon marking with his eye the point at which the bone is to be sawn; with a large scalpel or small catling makes an anterior skin flap with the convexity downward, and then dissects off the skin and cellular tissue for about an inch and a half, and turns up the flap. An exactly similar cut is made on the posterior surface of the limb, and the posterior skin flap is turned back for the same distance. Taking then a catling, he enters it by transfixion, at the angle on the limb at which the tegumentary flaps begin, and passes it over the anterior face of the bone, and brings out the point where the two flaps on the other side begin ; then cutting outward the edge of the knife is brought out at the point of the junction of the skin and muscular tissue. A similar cut by transfixion is made on the posterior surface of the limb. The retractor is then put on, and the periosteum is divided about two inches below the point where the separation of the bone is to be effected, and that membrane is to be carefully peeled off and turned back. The bone is then sawn through and the spiculae removed as in all other amputations. It will be seen that by this method we have three flaps to be adjusted: first, that of the periosteum, which must be carefully brought over the ends of the bone; second, the muscular flaps are to be adjusted and sewn with antiseptic ligatures; and third, the integumental coverings are brought over and stitched together. At each angle of the union a decalcified bone tube should be inserted. Mortality.—To show the mortality after amputation I have arranged a few statistics from the reports of the Bellevue Hospital, New York; the Pennsylvania Hospital, Philadelphia; and St. Thomas's Hospital, London. Table of Amputations in Bellevue Hospital, from 1864 to March, 1869, com- piled by F. J. Metcalf, M.D., Acting Junior Assistant. . The number of cases is said to represent but about one-sixth or one-eighth of those operated upon. The classification is that adopted by the Surgeon-General of the United States Army.* Total number of amputations and reamputations, fifty-five. * Bellevue and Charity Hospital Reports, 1870. MORTALITY AFTER AMPUTATION. - 361 Cases. Cured. Died. Amputations, . • • © & c © º . 52 26 26 Reamputations, © tº º tº e e e ... 3 1 2 Immediate or primary, . º • * o e . 37 20 17 Intermediate, . º º º o & e e ... 3 3 Secondary, . . © e - © º º . 12 5 7 52 25 27 Reamputations, . . . . . . . . 3 1 2 Making a total of . 28 27 Ether was used in 43 cases, 22 being cured, and 21 died; chloroform in 9 cases, of which 5 were cured, and 4 died; nitrous oxide, 1 died; bichl. methylene, 1 died; no anaesthetic, 1 cured. AMPUTATIONS IN CONTINUITY. Cases. Cured. Died. Forearm, . e º o © © e e ... 4 3 1 Arm, . & º o e º º te e . 11 5 6 Leg, . . . . . . . . . . 19 10 9 Thigh, . . . . . . . . . 7 3 4 AMPUTATIONS IN CONTIGUITY. - - Cases. Cured. D ied. Wrist, e º 1 1 0 Elbow, tº gº 1 1. 0 Enee, tº ſº e e 8 3 5 Hip, . © 1 0 1 REAMPUTATIONS. - Cases. Cured. Died. Leg, . . © e tº e © e . . 1 1 0 Thigh, . . . . . . . . . 2 1 l This latter is a mortality of nearly 50 per cent. AMPUTATIONS FROM JANUARY, 1872, To JUNE, 1873. Number of amputations, excluding those of the fingers and toes, . . 58 Recoveries, . © º º e tº tº tº o º Q . . 30 Deaths, . º º © . 28 Causes of death, ; : . 4 from shock. 2 “ secondary hamorrhage. 1 “ tetanus. 11 pygemia. 1 “ hospital gangrene. 8 “ exhaustion. 1 “ osteomyelitis. Hand, 5 amputations; 2 recovered, 3 died. Forearm, 4 amputations; 3 recovered, 1 died. Arm, including shoulder-joint, 11 amputations; 6 re- covered, 5 died. Thigh, 3 amputations; 1 recovered, 2 died. Leg, includ- ing knee-joint, 28 amputations; 15 recovered, 13 died. Foot, 8 amputations; 4 recovered, 4 died. 9 amputations for disease, 49 for injury. In one case º forearms were amputated. In two cases both legs. In two cases both €6t. - 362 A SYSTEM OF SURGERY. Amputations at the Pennsylvania Hospital.—Dr. George W. Norrisº gives an elaborate and very carefully prepared table of the amputations per- formed in that charity, from January, 1850, to January, 1860. There were 228 amputations made, and of these 173 were cured and 55 died. They were as follows: Thigh, 43; leg, 70; foot, 8; shoulder-joint, 6; arm, 38; forearm, 52; wrist-joint, 8; elbow-joint, 1; hand, 2. Cases. Cured. Died. Primary (within 24 hours), . tº e tº . 146 119 27 Secondary, e tº º º tº º tº . 42 27 15 Forty were for the cure of chronic diseases, of which 27 were successful and 13 died. Twenty-five were done at the joints, with two deaths and 23 cures. Cases. cured. Died. Upper extremity, . tº º & o tº ... 107 94 13 Lower extremity, . e º g o © . 121 85 36 Dr. Norris then makes a summary of the whole number of amputations performed within a period of thirty years, as follows: There were 428 amputations performed upon 424 patients during the thirty years from 1830 until 1860. 321 of these were cured, and 103 died. . Cases. Died. Primary, . tº tº tº º e ſº © * e . 261 54 Secondary, * tº tº e tº * * e e . 83 31 For chronic diseases, is tº © g e * tº . 84 18 Upper extremity, . © tº g e c e ſº . 194 21 Lower extremity, . tº e e e tº & º . 234 74 Joints, . e tº gº º © § tº tº • . 46 6 - Cases. Cured. Died. Age—under 20 years, e Ç ſº i.e. * . 118 108 10 between 20 and 30 years, tº * © . 133 101 32 &&. 30 “ 40 “ . e e & . 87 60 27 & 40 “ 50 “ . e * tº . 62 40 22 £6 50 “ upwards, . 3 * & . 21 16 5 Amputations at St. Thomas’ Hospital, from 1862–69. 1862, 1863. 1864. 1865, 1866. 1867. 1868. 1869. Limb Amputations. of - | (a | – | of | – | of gº of rºº I am tº 3 || 5 || 3 || 5 || 3 || 5 || 3 || 5 || 3 || 5 || 3 || 5 || 3 || 5 || 3 | E Thigh......................... 10 || 5 || 7 || 3 || 7 || 4 || 6 || 2 || 7 5 || 2 | 1 1 Leg............................ 1 4 5 || 4 || 4 || 3 || 3 2 || 1 || 1 6 || 1 Arm........................... 2 3 || 2 || 2 || 1 || 3 || 1 || 1 Forearm ..................... 5 3 || 1 4 || 1 1 4 During the eight years that the hospital has been at Surrey Gardens, Music Hall, there have been 111 amputations, with a mortality of 36; for the first four years, 57 cases and 24 deaths; for the last four years, 54 cases and * Pennsylvania Hospital Reports, 1868, p. 164. MORTALITY AFTER AMPUTATION. 363 12 deaths, or about half the mortality of the preceding period. The use of carbolic acid, and care being taken to exclude all sufferers from foul Suppu- rating sores, may to a certain extent account for the improvement. Frederick Churchill, M.D., has analyzed these cases, and separated those which were primary, secondary, and for disease. The mortality will be found to vary considerably. For 1861–63, and 1866–69, the amputations were tabulated under these three headings, and during these seven years there were 41 primary amputations with 10 deaths; 16 secondary amputa- tions and 8 deaths; and 39 amputations for disease with 7 deaths, i.e., Primary amputations, tº e º º º ſº tº . 1 death in 4.1 Secondary {{ e 1 “ 2. 1 {{ 5.5 For disease, “ The late Sir James Y. Simpson furnished statistics showing that out of 2089 limb amputations, “in large and metropolitan British hospitals,” there were 855 deaths, or a mortality of one in 2.4, and out of 2098 limb ampu- tations “in patients operated on in single or isolated rooms in British country practice,” there was a mortality of 226, or 1 death in 9.2 cases. That such a result does not tally with the experience of the surgeons at St. Thomas’s Hospital is evident from the table above quoted. Mr. Callender published statistics of limb amputations at St. Bartholomew's Hospital, by which it appears that the mortality is greatly influenced by the class of cases under treatment. That whereas, the average death-rate, after all amputations, at St. Bartholomew's Hospital, is 1 in 3.6, the mortality of country cases in the same hospital, under similar circumstances, is one in 5.8, showing that other things must be taken into consideration in comparing the death-rate of hospitals with that in private country practice. The statistical tables of St. George's Hospital, London, for the year 1867– 1868, which were at the hospital, and examined, give the following results: 54 amputations, 27 recoveries; 32 for disease; 11 deaths from pyaºmia; most of them of the thigh, leg, and foot. The following four tables are taken from Agnew's Surgery as being most complete, reliable, and recent. Table of Amputations for all Causes at all Periods; showing also the Average Mortality for Different Amputations, and also for Amputations of all kinds. - - Seat. NO. Of Cases. Cured. Deaths. Death Rate. Hand.................................... 62 56 6 9.67 Wrist joint............................. 115 112 3 2.60 Forearm................................ 1,313 1,120 193 14.69 Elbow-joint........................... 30 28 2 6.66 Arm.…................................ 2,867 2,190 677 23.61 Shoulder............................... 298 178 120 40.13 Foot..................................... 159 130 29 18.23 Anklejoint............................ 150 126 24 16.00 Leg..…................................. 4,337 3,018 1,319 30.41 Knee-joint............................. 215 119 96 44.65 Thigh................................... 3,947 2,018 1,929 48.87 Hipjoint............................... 836 305 531 63.51 Double............ “.................. 37 15 22 59.45 Aggregate.................. 14,366 9,415 4,951 34.46 364 A SYSTEM OF SURGERY. 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Bellevue and Charity Hospital..................... 55 19 34.54 Birmingham Hospital................................. 33 8 24.24 Boston City Hospital................................... 366 145 39.61 Edinburgh Royal Infirmary......................... 26 11 42.30 Guy’s Hospital............ ‘e e e º O & e a s e e s m e º sº e e º e e e s e º e e º e a 581 206 35.45 Hotel Dieu de Rouen................................. 47 9 19.15 Leeds General Infirmary............................. 189 45 23.80 London Hospital....................................... 132 73 55.31 London and Provincial Hospitals (thigh and leg) 680 205 32.06 Massachusetts General Hospital.................... 784 193 24.61 Pennsylvania Hospital................................ 712 197 27.66 Radcliffe Infirmary (Oxford)........................ 46 5 10.86 St. Bartholomew's Hospital.......................... 97 14 14.43 St. George's Hospital.................................. 180 74 41.11 St. Thomas's Hospital,................................ 181 61 33.64 Various places in England........................... 135 25 19.25 Total........................................... 4,204 1,290 30.68 (b) MoRTALITY OF ALL AMPUTATIONs. Boston City Hospital.................................. 135 56 41.44 Glasgow Royal Infirmary............................ 1,973 672 34.10 Guy's Hospital...... * * * * * * * * * * s e e s e º e º 'º e s e a e e a e s a e a e e º e 735 253 34.42 Paris Hospitals............................. * * * * * * * * * * * * * 1,144 522 45.60 Pennsylvania Hospital................................ 902 230 25.49 St. Bartholomew's Hospital.......................... 358 74 20.67 St. George's Hospital................................. 226 92 40.70 Total........................................... 5,473 1,899 34.69 CHAPTER XX. SPECIAL AMPUTATIONS. AMPUTATION OF THE LOWER EXTREMITIES. 1. Amputation at the Hip-Joint.—According to the report of the Surgeon- General of the U. S. Army; Kerr, of Northampton, in 1774, was the first surgeon who performed this formidable operation, although in 1748, La- croix, of Orleans, completed the exarticulation of the limb at the coxo- femoral joint, which sphacelus, from ergotism, had already almost removed. . Since then, the operation has been performed many times. In civil sur- gery, out of forty-seven cases, there were sixteen recoveries, and in America, in twenty-four examples of amputation, fifteen successful results are pub- lished. The report reads thus: “Of one hundred and eleven amputations 366 A SYSTEM OF SURGERY. at the hip-joint in civil practice here recorded, forty-six succeeded, and sixty-five ended fatally.” During the late civil war there were fifty-three amputations performed at the hip, thirty-four of which were done in the service of the United States, and nineteen in the Confederate armies. These cases, which have been tabulated and arranged with great care by Dr. Otis, are classified into primary, of which there were nineteen; the in- termediate numbered eighteen, the secondary nine, and the reamputations seven. In the first the mortality was very large, being 94.73 per cent. The case of Dr. Shippen is said to be the only perfectly authentic one of 72 on record, of recovery after primary amputation at the hip; of the second classification all terminated fatally; of the third there were two recoveries; in the fourth, four were successful, making the mortality rate 42.85. In performing the operation six assistants are necessary; to one must be given the charge of the anaesthetic, a second hands the required instruments, a third and the most experienced takes charge of the limb, making the requi- site movements at the proper time; a fourth controls the bleeding, with the aortic compressor, and with his finger compresses the femoral artery as it passes over the brim of the pelvis; a fifth attends to the sponging, and the sixth takes care of the sound limb, carrying it away from the body, at the same time holding the scrotum aside with a towel, as represented in Fig. 166. The common iliac artery may be compressed by carefully introduc- ing a straightwooden rod with a bul- bous end into the rectum for about nine inches—the length of the rod being about twenty-two inches. Slight elevation or depression of the handle, when once the instru- ment is brought to bear on the vessel, will be sufficient to stop or to allow the flow of blood. This method was successfully tried by Mr. A. Pierce Gould.” Or the ham- orrhage may be controlled by the abdominal tourniquet of Pancoast. Before the latter is applied, the en- tire limb from the toes up should be encased with an elastic bandage to a point where it will notinterfere with - the formation of the flaps, thus forc- Anatomy of the Hipjoint with position of the ing the blood out of the extremity. knife in forming anterior flap. The abdominal tourniquet is then screwed down. Wide also page 344. The operation which appears the most simple, is that of Mr. Bryant,f who says: “The best flaps appear to be the external and internal. The patient being brought to the edge of the table, with the tuberosities of the ischium in view, Lister's valuable abdominal tourniquet is to be adjusted, and, when the patient is under chloroform and everything is prepared, screwed up. The surgeon should then make the external skin flap by means * The Medical Record, March 8th, 1879, No. 435. # Practice of Surgery, p. 953. AMPUTATION AT THE HIP-JOINT. 367 of a semicircular incision, starting from the tuberosity of the ischium, downwards and outwards, one hand's breadth below the great trochanter, then upwards and forwards to the centre of the groin on the outer side of the femoral vessels, and this should then be reflected upwards above the trochanter so as to expose it and allow the joint to be opened and disarticu- lation to be completed, the limb being forcibly adducted by an assistant to facilitate this step. In doing this no vessels of any importance are opened while the most difficult part of the operation is completed. “The inner flap now remains to be made, and this is readily done by transfixing the thigh on the inner side, inserting the knife (twelve inches long) in the anterior wound, passing it backwards close to the inner side of the neck of the femur, and bringing it out near the tuberosity of the ischium where the external incision was commenced, and then cutting out through the soft parts, including all the abductors, etc. . In doing this, all the pel- vic muscles are separated at one clean sweep from the thigh-bone, and a few touches of the knife complete the amputation. Should there be much fear of loss of blood, the common femoral artery may be ligatured in the wound before the second flap is made, or it may be divided and twisted. The vessels are then to be secured in the way the surgeon proposes, and the parts brought together, the two flaps usually forming an excellent covering to the pelvic cup ; the wound is a vertical one, and therefore good for drain- age, and a good scar results.” Lateral Flap Operation.—A line one inch in length should be drawn downwards from the anterior superior spinous process of the ilium ; from the lower extremity of this line, a second, half an inch in length, should be drawn inward to mark the head of the bone. The surgeon then, standing on the outer side of the limb, enters a straight single-edged amputating knife, with a blade twelve to fourteen inches in length, on the inner end of the last line, and passes it perpendicularly down to the head of the femur. The handle of the instrument must now be slightly inclined towards the pubis, and the blade pushed on the outer side of the cervix femoris. The assistant in charge of the limb now raises the femur and slightly abducts it. The surgeon grasps with his left hand the soft parts, and brings the point out a little below the tuberosity of the ischium, about an inch from the anus. The great trochanter then must be cleared as the blade of the knife cuts out the flap from seven to eight inches long. The assistant now puts the capsular ligament upon the stretch, which must be divided with the point of the knife, and the head of the bone is then disarticulated. Passing the knife then close to the head of the femur, ment passes close to the bone, the thumb of the assistant should follow it, and immediately compress the artery. The anterior and posterior flap operation is performed as follows: The patient having been prepared as before, and the requisite number of assistants at hand, the surgeon flexes the leg slightly, rotates the thigh in- ward, and introduces the point of the knife just above and posterior to the trochanter major, and carries the blade across the front of the thighbone, entering, if possible, the capsule of the joint in its passage, and bringing out the point in the perineal fold, in front of the tuberosity of the ischium (Fig. 166). The knife then is made to cut out the anterior flap, six to eightinches in length. The vessels may now, if it is expedient, be secured, and without loss of time the operator proceeds to the formation of the posterior flap as follows: The femur must be drawn downwards, in order to stretch the orbicular ligament of the articulation, which must be divided with the point of the knife, inserted behind the head of the bone (Fig. 167), and guided by the bone cuts out the posterior flap somewhat shorter than the anterior. 368 A SYSTEM OF SURGERY. Dr. Hamilton makes a somewhat different line of incision, to prevent the point of the knife entering the belly or wounding the iliac artery and vein,” and directs that the point be introduced “one inch in front of the trochanter major, the edge of the knife being directed downwards in the line of the axis of the limb. From this point the knife is made to pene- FIG. 167. Amputation of Hip-joint—making the posterior flap. trate transversely, and with a slight inclination backward, so as to strike the head of the femur in its upper half, and near the upper margin of the acetabulum.” The handle of the knife must then be carried toward the head of the patient and the point, cutting the capsule, must be thrust in front of the neck, and made to emerge below the tuber ischii. As the flap is cut out, assistants follow with their fingers in order to arrest the bleeding. The thigh must then be forcibly abducted and carried backward, and the articulation opened (provided it has not been done by the manoeuvre just mentioned) with a large scalpel, and the round ligament cut. The centre of the blade is then passed above the head of the bone, and the knife brought out at the gluteal fold. The operation of Dr. Van Buren f consists in making the anterior flap by transfixion; the flap is drawn upward by the assistant, and “the surgeon, partially kneeling, carries the knife beneath the thigh to its inner side, as in a circular amputation, and placing its heel in the integument at the internal angle of the wound, sweeps it firmly across through the tissues on the back part of the thigh, cutting with a slightly sawing motion down to the bone, and joining the two extremities of the first incision. The long knife is then immediately relinquished, and with a large straight scalpel, the femur being forcibly abducted, the capsule of the joint is laid open as near as possible to the acetabulum, the round ligament divided with the rotator muscles in- serted into the trochanter, and the fossa at its base, the assistant regulating the limb, so as to keep these parts successively on the stretch, and the operation is completed.’ In all the above performances the great danger is always that of haemor- rhage; since, however, the introduction of the aortic tourniquet the danger has been much lessened. Compression on the abdominal aorta has been ascribed to Lister, although it properly belongs to Professor Pancoast, of Philadelphia. The tourniquet of Mr. Richard Davies, which is described * The Principles and Practice of Surgery, p. 378. f Trans. New York Academy of Medicine, vol. i. AMPUTATION OF THE THIGH. 369 by him as a lever, which introduced into the rectum can be made to com- press the iliac artery, was introduced in 1878. Dr. C. B. Keetley,” in a valuable article upon disarticulation at the hip- joint, after detailing several methods, draws admirable conclusions. In his fourth, he says, “that, if in a case of disarticulation of the hip-joint the operation be divided into two parts done on separate days, so that the patient has time to recover from the shock of one before the other is in- flicted on him, he will be more likely to survive than if the total shock is given at one operation.” He advises, according to this plan, that the trochanteric part of the femur with the head of the bone shall be first excised, and that after the patient has recovered from the shock, say forty-eight hours, the thigh should be amputated near the conjunction of the shaft with the epiphysis. - - In some instances the oval method of amputation may be made and the bone excised afterwards; in others the femoral artery and vein may be ligated in Scarpa's space before beginning the amputation. . . . Amputation of the Thigh.--This operation is generally performed at th lower, middle, or upper third of the thigh, and may be either the circular, the flap, or the rectangular flap of Mr. Teale, or a combination of the two. The selection of the method of forming the flaps is a subject for serious consideration. The ordinary flap amputation is the most readily performed, and immediately after the operation the stump appears well covered with muscular tissue; but experience has taught me, and I believe others also, that this muscular covering, especially at the lower third of the thigh, gradually and steadily retracts, and that after a year or more nothing re- mains but a covering of skin; and even this, in many instances, likewise retracts, exposing the end of the bone, which may finally become necrosed. The arguments in behalf of the flap amputation are: that its rapidity of execution renders it much less painful and prolonged; that soft parts can be readily furnished to form an excellent muscular covering for the stump, and that, the different textures being allowed to remain in connection with- out dissection, there is much more likelihood of rapid union. But these reasons in its favor are counterbalanced by others, among which are: shock from the rapidity of the operation; that there is a greater extent of surface exposed, and that the contraction of muscles, even after the most carefully conducted operation, often leaves what is called a conical stump. There- fore, the numerous powerful muscles of the thigh, which are divided at their extremities in the ordinary flap operation, at the lower third, would tend to the formation of the undesirable conical stump. These reasons seem to be sufficiently forcible to determine in favor of the circular opera- tion at the lower third of the thigh. Moreover, the nearer we operate to the neck of the femur, the more likelihood will there be of a good stump by the flap procedure. When the lower or middle third is selected, a tourniquet must be applied high up in Scarpa's space, but when the operation has to be performed at the upper third, an assistant must compress the artery where it passes over the brim of the pelvis. This is readily done by grasping the greater tro- chanter with the fingers, and pressing the thumb firmly upon the artery; upon this the thumb of the other hand may be firmly pressed and the artery kept under complete control, Esmarch's bandage may also be used. Sometimes the condition of the limb will admit of no choice, and the place for operating will then be where flaps can most readily be secured. A double circular operation may be practiced at any part of the thigh with success. The military surgeon frequently finds the tissues entirely destroyed * Annals of Surgery, vol. ii., 1886, p. 473. 24 370. . A SYSTEM OF SURGERY. upon one side; under such circumstances the covering of the bone must be obtained from the opposite side. . Lateral Flaps.--The thigh may be removed by a lateral flap operation in the following manner, which is especially applicable to the lower third : The exterior or outer flap is first made by entering the point of the knife at the middle of the thigh, about three inches above the patella, carrying it close around the bone and bringing it out through the centre of the ham, and cutting downwards and outwards. The point of the knife is again entered at the upper angle of the incision, and carried around the bone on its inner side, and made to cut out a flap of similar dimensions to that first formed. By keeping the knife close to the bone the danger of splitting or prick- ing the femoral artery is avoided. The bone then must be well cleared and sawn off at about four and a half inches above its articular surface. At the middle and upper third of the thigh, if flaps are determined upon, the anterior and posterior flap are preferable. + Anterior and Posterior Flaps.--In the majority of cases the anterior is the flap first made. The surgeon, standing on the outside of the limb, raises with his left hand all the structures from the bone, and enters the point of the knife about the site where the division of the bone is contemplated (Fig. 168). This flap must be cut out and held back by an assistant, or as is FIG, 168. * \\n" W. i preferred by some surgeons, the flap may be made from without inwards. The soft parts are then drawn down on the posterior side, and the knife entered at about the same point at which it passed to make the anterior flap. Then the knife is allowed to cut itself out, making the posterior flap. The two-tailed retractor is then placed around the bone, which is evenly divided with the saw. The spiculae of bone are then carefully removed with the bone pliers, the vessels secured either by acupressure or ligature, and the wound closed with silver sutures and the collodion and gauze dress- ing. If, however, the patient is much emaciated it is very difficult to pro- cure a good cushion from the anterior flap; in such instances it is better to follow another course and make the posterior flap first by transfixion, and the other by cutting from without inwards. When the muscular tissue is much mutilated an excellent stump can be made by a long square anterior flap, and then with one stroke of the knife cutting through the soft parts on the back of the thigh, obliquely from below upward; thus the anterior flap, when laid down, will form the cushion at the end of the stump. Dr. Child, of Mobile, Alabama, suggests a single oblique flap opera- tion, the division of the soft parts being made by cutting from without in- AMPUTATION THROUGH THE CONDYLES. 371 ward on the anterior face of the femur, and after having transfixed the tissues on the posterior surface of the bone, cutting downward and backward. Combination Method.—The method that I prefer in amputating any por- tion of the shaft of the femur from below the trochanter to the base of the condyles is the mixed method, which is fully described in the preceding chapter under the head of “Methods.” . No one after performing this opera- tion several times would, I think, provided there were integument sufficient to form the flaps, resort to any other. - The Rectangular Flap of Mr. Teale.—In his work “On Amputation, by a Long and Short Rectangular Flap,” Mr. Teale speaks of the imperfections of many stumps after the usual methods of amputation, and remarks that in the stumps formed after the circular and transfixion methods, it is ex- tremely rare to find a soft movable mass of tissue over the ends of the bone; secondly, that with very few exceptions, the cicatrix is adherent to the ends of the bone, and that, in addition to this, such stumps are generally unable to bear pressure on their extremities. To remedy all this he proposes the operation named above, and which will be described below. It has been regarded with a good deal of favor by some distinguished surgeons, and makes a most excellent stump for the application of a patent limb. In this operation the long flap folds over the ends (Fig. 169) of the bone, and is, in the majority of instances, devoid of important bloodvessels and nerves, while both are found in the short flap. Mr. Teale says: “The size FIG. 169. of the long flap is determined by the circumference of the limb at the place º of amputation, its length and its breadth ~Vº being each equal to half its circumfer- º ence. The long flap is, therefore, a \\\\\"." º square, and is long enough to all easily over the end of the bone. § | The short flap, containing the chief \ , […wº gºi vessels and nerves, is in length, one- Nº. º # * fourth of the other.” - º six In the thigh amputation, the circum- -- # ºt-2. ference must be measured at the point Stump after Teale's Amputation. where the bone is to be sawn; if this be eighteen inches, then the long flap must be nine inches long, and nine inches broad, and it is recommended that these measurements be accurately made, and the lines traced withink, or other substance, upon the limb. The length of the short flap will be one-quarter of nine, or two and one-quarter inches in length and breadth. In the commencement of the operation, the lateral incisions are to be made through the integument only. The transverse incision joining these two cuts is to be made down to the femur. The flap must then be made, by cutting the fleshy structures from below upwards, close to the bone. The posterior flap must be made with one sweep of the knife down to the bone; the soft structures being afterward carefully separated from the perios- teum. The vessels may then be secured, and the flaps united. Amputation through the Condyles known as Stokes’.-This method of am- putation is now receiving much attention from surgeons, and has many points of interest. When the femur is sawn through at the condyles, the medullary canal—the largest in the body—is not opened; there is not a compact structure of bone to be removed, and the soft or cancellated struc- ture opened is more rapidly reproduced than the hard ivory texture of the shaft. Professor Fergusson has recorded several interesting cases of this successful amputation. Mr. Jessup, of Leeds, and others, also speak highly 372 A SYSTEM OF SURGERY. of it. In this operation, the incision is commenced about two inches above One condyle, and carried around the knee in a semicircular incision, with its convexity downward, about an inch below the tubercle of the tibia, and extended upward to a point on the opposite condyle, to correspond with the commencement of the incision. The ligamentum patellae is then cut off, the flap turned up, and a thin slice of the patella sawed off. The posterior integumental flap, one-third the length of the anterior, is then made. The joint is then opened and the condyles sawn through. The sliced patella in the anterior flap is then brought in apposition to the sawn femur and the wound dressed. The special advantages of this amputation are described as being the fol- lowing: 1. The resulting stump is more useful, as pressure can be borne on its extremity. 2. There is a diminished liability to tubular sequestra. 3. The operation is less hazardous to the patient than amputation of the thigh, its situation being more distant from the trunk. 4. It is accompanied by less shock. 5. There is less tendency to the occurrence of suppuration. 6. In the posterior surface of the anterior flap, which is lined with a natural synovial membrane, no vessels or nerves are included. 7. The preserved portion of the patella acts as an Osseous curtain, covering the cut surface of the femur, and has not yet been known to slough away. 8. The attach- ment of the tendon of the quadriceps extensor muscle to the patella gives an increased power of extending the thigh in progression, and renders the formation of a conical stump impossible. 9. The vessels are divided at right angles to their continuity, and not obliquely, as in all flap operations, thus being less exposed to inflammatory action from the extent of the wounds. The operation known as Gritti's is similar to the one just detailed, but in reality is not a very new amputation, it having been performed in this country many years ago. - Circular Method.—In performing this operation a medium-sized, or rather a small amputating knife, with a sharp point, should be used. The sur- geon stands on the outside of the limb, which having been raised, he places his arm underneath the thigh and touches the heel of the knife at a point on the anterior aspect of the limb, and with a single sweep around the thigh divides the integument and superficial fascia; the parts are then to be drawn backward by an assistant, or a free dissection of the skin from the muscles may be necessary for two or three inches; then with the arm and hand placed in the same position as that when the first incision was made, he di- vides all the parts down to the bone; a retractor, or the hands of an expert assistant, may be used to retract and hold the flap, while the bone is sawn through. The arteries are secured and the flaps adjusted according to gen- eral principles. Amputation at the Knee-joint.—The advantages claimed for this somewhat popular operation, are thus stated by Dr. Markoe, of New York, who has arrived at his conclusions from careful observation of fourteen cases: “1. The grand advantage of this operation is the useful character of the stump that results, strongly contrasting with the uselessness of the stump left after amputation of the thigh, and enabling the patient to wear an arti- ficial limb with comfort and advantage. 2. The seat of operation is farther removed from the trunk, and the constitutional shock is probably, there- fore, less. 3. The section at the knee-joint is less extensive than that of amputation higher up, no parts being divided but the integuments, and, although a large surface is exposed, a great portion of it, the femoral carti- lage, is a healthy, not a wounded surface. 4. No muscular interspaces are exposed by the knife excepting those of the heads of the gastrocnemius, which are of small extent and depth. There is, therefore, less chance of any AMPUTATION AT THE KNEE-JOINT. 373 inflammation that may attack the stump travelling upwards and forming burrowing abscesses, amidst the soft areolar tissue filling such interspaces. The section of tendons that takes place in this operation is rarely followed by any other than reparative inflammation. 5. Fewer ligatures are re- quired, and the orifices of the divided arteries lie close together in the centre of the popliteal space. By following Blandin's Fº". therefore, of making a small opening through the integument, of which alone the poste- rior flap consists, we are enabled to bring all the threads out of the stump by a short and direct route, in the most depending position, and thus the space between the flaps and condyles, where we are most anxious to pro- cure adhesive inflammation, is not fretted into suppuration by the presence of the ligatures crossing it, to be brought out between the lips of the wound. 6. The muscular attachments concerned in the movements of the limb are not divided. Those which are severed are merely for the movements of the leg, all the muscles proper to the thigh being left untouched. The result is that the patient is able to move the stump with astonishing freedom and facility. 7. Another advantage directly resulting from this is that there is no muscular retraction after the healing of the wound. Dr. S. Smith has made a comparison of this operation, and that of amputation at the thigh, and finds that in European practice, of 28 cases of amputation at the knee, 12 died and 16 recovered. There have been 18 American cases, with 13 recoveries and 5 deaths; making in all 46 cases and 17 deaths. The pro- portion of deaths in European practice has been, therefore, 43, in America 28, and together 37 per cent. Of 987 cases of amputation at the thigh, col- lected by Phillips, 435 died; and in 68 American cases, collected by Dr. Markoe, there were 29 deaths, being an average mortality of about 43% per cent., and making a difference of 64 per cent. in favor of amputation at the knee-joint.” FIG. 171. In amputation at the knee it must be remembered that it requires more integument to cover the broad surface of the condyles than to protect merely the shaft of the femur, and therefore, it is well to make the anterior flap long, and the posterior flap short (Fig. 170 shows lines of incision), although 374 A SYSTEM OF SURGERY. circumstances may demand that the posterior be the long, and the anterior the short flap. If we desire to make the former operation it must be done as follows: the leg should be bent at a right angle with the thigh, the sur- geon takes a large and strong scalpel, and, beginning at the posterior surface of either condyle, makes a semicircular incision, extending about an inch and a half or two inches below the tubercle of the tibia; the flap is then raised and the joint opened; the ligaments of the articulation are divided, and the knife, kept close to the posterior surface of the tibia, is made to cut itself out with a short flap (Fig. 171). When it is necessary to make the posterior flap the long one, the leg is placed in a horizontal rather than the flexed position; the incision is made as before, with the difference that in- stead of extending some distance below the tubercle of the tibia, it passes just above that prominence; the ligamentum patellae is then cut through, and the leg flexed as for resection of this joint, then an amputating knife is thrust behind the bones, and a flap of six to eight inches is cut away from the posterior surface of the limb. Carden's, or the Mixed Amputation at the Knee.—“The operation consists in reflecting a rounded or semi-oval flap of skin and fat from the front of the joint (knee), dividing 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 integument to fall over it. The operation is simple. The operator, standing on the right side of the limb, seizes it be- tween his left forefinger and thumb at the spot selected for the base of the flap, and enters the point of the knife close to his finger, bringing it round through skin and fat below the patella to the spot pressed by his thumb; then turning the edge downwards at a right angle with the line of the limb, he passes it through to the spot where it first entered, cutting outwards through everything behind the bone. The flap is then reflected, and the remainder of the soft parts divided straight down to the bone; the muscles are then slightly cleared upwards and the saw is ap- plied. Or the limb being held as before, the hand and knife may be brought round under the limb, as in the circular operation, and the blade entered near the thumb and drawn round to the opposite side, when the ham may be cut across by turning the edge of the knife upwards, and the operation completed as before. In am- putating through the condyles, the patella is drawn down by flexing the knee to a right angle before dividing the soft parts in front of the bone; or, if that be inconvenient, the patella may be reflected downwards.” Circular Method.—In the performance of this operation, the leg must be fully extended, and a circular incision made around the upper por- tion of the leg about three inches or a little more below the patella. This cuff of integument must ** **º be dissected up, to facilitate which, the flap * may be divided at each side by a small longitu- dinal cut. The joint is then to be flexed and the *; ºne (ºr ligament cut off just below the knee-cap, and the anterior part of the capsule, together with the lateral ligaments, divided as closely as possible to the condyles of the femur, thus leaving the semilunar cartilage as much as possible undis- FIG. 172. AMPUTATION OF THE LEG-FLAP, OPERATION. 375 turbed. The joint then must be more flexed, and the crucial ligaments divided also close to the femur. The leg must now be brought into almost a straight position, and the soft parts divided with one sweep of the knife (Fig. 172). The patella may be now removed if necessary, and the edges of the wound approximated according to directions already given. . The removal of the patella, in my opinion, is rarely called for. I have never as yet had reason to remove it excepting on one occasion, and then I found that not only was its careful cutting out a matter of some time, a nicety of dissection, but the flap sloughed afterward. If the upper flap should show any tendency to retraction, an extension with a weight of four É. ºpounds may be applied to the stump, until the cicatrix is firmly OI’IſléCl. Amputation of the Leg.—Flap Operation.—This is a very favorite operation with many surgeons, although I am, from the satisfactory results obtained in my own cases, very partial to the circular, especially in the lower third. The operator, standing on the outer side of the right leg, or the inner side of the left, introduces a knife behind both bones, cutting downward and for- ward, making a flap four or five inches in length, from the posterior muscles of the leg. He may then relinquish the catling, and with a strong scalpel join the points where the posterior flap begins with a similar incision, hav- ing its convexity downwards. This integumental anterior flap is then dis- sected up and the bone sawn through, dividing the fibula first and removing the spine of the tibia to prevent its afterward cutting through the flap. f i. Fergusson's method, which is illustrated in Fig. 173, is described as O11OWS : , , . • - - He first places the heel of the knife on the side of the leg farthest from him, and draws it across the front of the limb, cutting a semilunar flap of skin; when its point has arrived at the opposite side, it is at once made to transfix the limb–this stage of the operation is represented in the figure— and then the flap is cut as above directed. When transfixing the right limb, the surgeon must take great care not to get his knife between the two bones. When the operation is performed high up, the popliteal artery will be divided, instead of the two tibials. The tibia, however, should never FIG. 173. be sawn higher than its tuberosity, or the joint will be laid open. The am- putation may be performed near the ankle in the same manner. If low down, the tendo Achillis will require to be shortened after the flap is made. The flap is to be brought forwards and confined by a stitch or two, the line of junction being, of course, horizontal. - - - . 376 A SYSTEM OF SURGERY. Circular Method.—The patient having been brought to the edge of the table, an assistant supports the ankle, while a second draws back the in- tegument and steadies the knee; the surgeon (on the inner side if the right leg is to be removed, and vice versa) places his arm beneath the leg and brings the heel of the amputating knife in contact with the integument near the spine of the tibia; with a circular motion he divides the skin and fascia around the leg. This can be conveniently done with the small catling, the use of which renders a change of instruments unnecessary in the after stages of the operation. The integument is then dissected up and turned back, and the tissues divided down to the bones. The catling is then passed be- tween the bones to divide the interosseous ligaments and muscles. When this is thoroughly done, the three-tailed retractor is to be used, the middle “tail” being passed between the bones, and the flesh well drawn back. The knife is now laid aside, the saw applied, and the bones sawn through. If any spiculae remain, they must be removed with the bone-pliers, and the flaps are then adjusted with silver wire sutures. The integuments, when put together, should make a perpendicular line of junction. Teale's Amputation.—In removal of the leg by this method, the point selected should be at the junction of the lower and middle third of the leg. The measurements are made according to the same rule as for amputation of the thigh. Two lateral incisions, through the skin only, are to be made, the transverse one being carried through all the structures down to the bone. The long flap is then dissected up, keeping close to the periosteum. The short flap, by a direct cut through all the structures down to the bones, is made and dissected upwards, the bones are sawn, and the flaps placed in apposition as before mentioned. - In the mixed method the skin flaps should be lateral, and should be made of sufficient length to fall readily over the ends of the bones. The circular incision should be made about an inch below the point of union of the skin and muscular tissue, making thus a better stump. Amputation at the Ankle-joint.—Syme's Operation.—This operation is by no means new. Sedellier is said to have first performed it, and by referring FIG. 174. - FIG. 175. FIG. 176. ; º • * }; * •; tº& - tº- ; s: - tº . a sz, a . * 3 * . w a sº. •: - s: :: - - -- - §§ ... .º *::: ** e: - ** § • * - º - w - *, *: º - - cº *RS *: s & = 'º sº -S & & º sº •rs • re. - - - º º *: --> *~~ - sº * 3: •º ºr a : w º tºº º º & 3 - wº : ºn tº * sº. º º º º - t º to Velpeau it will be seen that it was held in repute by many French sur- geons. Mr. Syme, of Edinburgh, systematized the operation, and it has AMPUTATION AT THE ANKLE-JOINT. 377 since gone by his name, and to him is due the credit of removing the ob- jections: first, of scantiness of flap, which he has practically demonstrated can be taken from the heel; and secondly, the exposure of larger articulat- ing surfaces, which are lessened by the removal of the malleoli and the cartilages. The latter plan was first practiced by M. Baudens. The results of this operation are not always satisfactory. The operation is performed as follows: The patient is subjected to the influence of an anaesthetic, and the arteries compressed by assistants, or Esmarch's bandage applied. The foot then being held at a right angle, the point of the knife should be introduced directly below and a little posterior to the external malleolus (Fig. 174 a), and then cutting down to the bone, is to be carried under the sole of the foot (Fig. 175 b–c) to a point on the inner side, directly opposite its place of entrance. The incision is then con- tinued to the front of the ankle-joint till it reaches the incision already made. (Fig. 176 a-d.) The lower flap must then be detached, which requires an accurate dissection, and is somewhat tedious, the knife being kept close to the bone. After the os calcis is completely denuded, the tendo Achillis must FIG. 177. FIG. 178. FIG. 177-The bone sawn through after Symes's operation. Fig. 178—Heel-flap seen from the interior. be severed. The next movement is to open the joint in front, which is done by applying the knife to each side of the astragalus, dividing the lateral liga- ments and liberating the joint, during which procedure it is advantageous to depress the foot. The malleoli are then to be exposed by careful dissec- tion, and their articular projections sawn off, taking care to remove the cartilages with them. (Fig. 177.) The anterior tibial, the external and internal plantar arteries, and smaller twigs require ligation. Fig. 178 shows the appearance of the flap after the removal of the bone. The flaps are then brought together and secured by metallic sutures. The objections which are urged against this operation are that, in some cases, the large 378 - A SYSTEM OF SURGERY. band of muscular fibres acting upon the tendo Achillis, no longer antago- nized by the anterior and plantar muscles, would draw the stump upwards and backwards, and destroy or remove the line of cicatrix, which would º to the ground. Mr. Syme met these objections by expressing his elief that the cut extremities on the forepart of the foot would speedily acquire new attachments and act as extensors. Experience shows such to be the fact. " In this operation there is also a tendency to sloughing of the lower flap, and, therefore, a flap may be made of more than sufficient length to come into close apposition. This has been proved to be of great advantage. Amputation at the Ankle-joint by a Lateral Plantar Flap.–This operation is performed as follows: Having extended the leg, mark a point on the dorsum of the foot equidistant from each malleolus. With a small sharp- pointed amputating knife pierce the tissues down to the bone at the site above mentioned, and cutting steadily carry the knife outside of the joint, a very little below the malleolus of the fibula, and finish the incision at the insertion of the tendo Achillis. Enter the knife again at this point, namely, at the extreme projection of the heel, and, making an acute angle, bring it downwards º forwards to the sole, and then mounting over the dorsum of the foot, it divides the tendon of the tibialis anticus, and reaches the point where the first incision commenced. The foot must now be strongly everted and the joint being opened, the inferior flap is dissected off the heel. The tendons of the calf muscles must now be divided, and the foot turned out of its socket. By a careful dissection the internal adherent flap is dis- . off and the foot removed. The after treatment is the same as before Stated. - Pirogoff's Operation (Osteo-Plastic).-This amputation thus differs from that of Mr. Syme: in that of Pirogoff the posterior portion of the calca- Fig. 179. FIG. 180. Pirogoff's amputation (sawing After the division of the bones the os calcis). in Pirogoff's operation. neum is allowed to remain in the heel-flap, and its advantages are a longer limb and a more perfect stump. The incisions are made in the same manner as those directed for a Syme’s amputation, but the heel-flap is not dissected up. The lateral ligaments are divided, and the foot disarticulated in front; the os calcis can then be CHOPART's AMPUTATION THROUGH THE TARsus. 379 seen behind the astragalus (Fig. 179), when the former is to be sawn through in the line of the heel; the foot is then removed, and the ends of the tibia and fibula are sawn off. Fig. 180 shows the lines of the division of the bones in Pirogoff's operation. Watson and Pirrie performed the latter por- tion of the operation without previous disarticulation. Pirogoff's operation, as modified and amply tested by Professor Hayfelder, of Prussia, in the Prusso-Austrian war of 1866, seems to be highly merito- rious. The modification is performed as follows:* “Make a curved in- cision, which, commencing above the posterior edge of the internal malle- olus, passes along the dorsal surface of the foot and terminates at the outer malleolus. After this incision (which divides only the skin), and the preliminary separation of the incised parts, the subjacent tissues are com- pletely cut through down to the bone, and the epiphyses of the two bones of the leg are removed by the saw. The soft parts covering the os calcis are next divided, and the bone sawn in the same direction. The sawn sur- faces of the bones of the leg and of the os calcis are easily brought in contact, which is impossible by the unmodified procedure even after section of the tendo Achillis.” Chopart's Amputation through the Tarsus is as follows: The foot must be held, as for the operation just described, and the position of the articulation FIG. 181. ascertained by the same guiding marks. The thumb of the left hand should rest upon the external extremity of the joint, and the index finger on the tuberosity of the scaphoid. A semilunar incision is then made, with its convexity downward around the dorsum of the foot, about half an inch beyond the line of the articulation. (Fig. 181, a-b.) The flap may then be raised about an inch, and the tendons divided down to the bone. The fibrous bands connecting the astragalus and the scaphoid bones are then to be carefully and completely divided in order to facilitate the opening of * Half-Yearly Abstract of the Medical Sciences, January, 1869. 380 A SYSTEM OF SURGERY. the joint, which is effected by entering the point of the knife from above, recollecting that the edge of the scaphoid overlaps the astragalus. The articulation being opened, pass the flat of the blade behind the bones, and cut the flap from the sole of the foot as seen in Fig. 182. Fig. 183 represents the disarticulated bones. - Subastragaloid Amputation.—This operation removes all that Chopart's amputation effects, and with it the os calcis also. Malgaigne described the operation in 1846. The dorsal flap is made in the same manner as directed FIG. 183. Disarticulation through the tarsus (Chopart). above in the performance of Chopart's ; the heel-flap after the manner of Syme. The knife is then entered between the scaphoid and astragalus, the joint opened, and the foot removed by disarticulating the os calcis from the astragalus. Hancock has made a modification of this operation, by removing only the forepart of the heel-bone, leaving its tuberosity to be turned up in the flap. The under surface of the astragalus is “freshened ’’ by the removal of a slice of bone, thus making an osteo-plastic operation. This operation is rarely called for. Amputation through the Tarso-metatarsal Articulation (Lisfranc's).-In the removal of the forward portion of the foot, no matter which operation be selected, a knowledge of the anatomy is absolutely essential. The tarso- metatarsal joint is formed posteriorly by four bones, viz., the internal, middle, and external cuneiform, and the cuboid bone; anteriorly by the articular surfaces of the metatarsal bones. The outline of this joint is very irregular, but the following directions will assist the operator: Grasp the dorsum of the foot with the palm of the left hand and extend it. With the finger of the right hand on the inner side of the foot, trace the inner border of the first metatarsal bone backward until a prominence is detected. One or two lines anterior to this point is the commencement of the articula- tion internally. On the outer side follow the border (external) of the fifth metatarsal bone, until its proximal extremity is recognized by the protu- berance at the end of the bone. The outside of the articulation lies im- mediately behind it. The operation is performed as follows. Find the outer and inner margins of the joint as directed, and, holding the foot as seen in Fig. 184, make a semilunar incision, with its convexity downward across the dorsum of the foot, about half an inch anterior to the line of the articulation. (Fig. 184 a-b.) This incision must extend to the bones, and the flap raised with the point of the knife. The dorsal ligaments are divided on a line with the joint, and the articulation of the head of the second metatarsal bone opened by carrying the point of the knife between the internal cunei- form and the head of the first metatarsal bone (vide Fig. 185). When this has been accomplished, pressure downward with the left hand will separate the articular surfaces and the metatarsus; the remaining attachments must AMPUTATION OF THE TOES. 381 be divided, and the knife is then passed beneath the heads of these bones, and a flap cut out from the sole of the foot. FIG. 181. Amputation of the Toes.—Amputation of the great toe is performed as follows: The surgeon, having satisfactorily ascertained the point of articulation be- tween the metatarsal and phalangeal bones, enters the knife on the dorsum of the foot, about an inch behind the articulation, and carries it around the inside of the toe to the centre of the space between the toes. A second FIG. 187. incision is then made, beginning at the point of entrance of the first, and is brought around the other side of the toe to meet the extremity of the first cut (vide Fig. 186). The soft parts are then dissected up, and the bone disarticulated, or the head of the metatarsal bone is exposed and sawn off, which latter is preferable, as the removal of this large protrusion will yield a much better stump, and allow the patient to wear a boot without much inconvenience. In some cases the toes, especially the second and third, may have to be removed at the second joint, which I have found to be necessary in consequence of contraction of the flexor tendons, causing great inconvenience in walking or dancing. Should their removal be demanded, an anterior and posterior flap can be made, and the bones divided with the 382 . A SYSTEM OF SURGERY. pliers, just behind the articular surface of the phalanges, as also may be seen in Fig. 186. Two or more toes may have to be removed together, the character of the stump being represented in Fig. 187. In general, however, in disarticulation of a single toe, it is the better practice to remove it at the metatarsal joint, as the small size of the phalanges, and their comparative unimportance, render the preservation of parts of far less moment than those of the hand. - ,” - Disarticulation of all the Toes.—The surgeon, seated before the patient, takes in his left hand all the toes, and with a strong scalpel makes a semicircular incision in front of the metatarso-phalangeal articulation, from the border of the fifth to that of the first metatarsal bone. The point of the knife, FIG. 189. Amputation of the metatarsus (sawing). which should be narrow-bladed and sharp, is introduced into the joints of each toe successively, and the ligaments divided; the knife is then carried behind the phalanges, and the flap cut out on the plantar surfaces (Fig. 188), or the saw may be applied as seen in Fig. 189, and the heads of all the bones removed. AMPUTATION OF THE UPPER ExTREMITIES. Amputation at the Shoulderjoint.—There are many methods proposed for removal of the shoulder. An excellent one consists in making the flaps from the outer and inner aspect of the joint. The position of the patient, the application of the Esmarch, and the lines of the flap are well shown (Fig.190). The operation is thus performed: Supposing the left arm is about to be disarticulated, the head of the humerus must be depressed as far as possible, by raising the arm at right angles with the body, and the knife entered at the posterior border of the deltoid, and in front of the ten- dons of the lattisimus dorsi and teres major muscles, and brought out below and in front of the clavicle, and made to cut its way outward around the head of the humerus. This flap will be mostly composed of the deltoid muscle, which must be held aside, and the head of the bone can then readily be detached from the glenoid cavity. The bone must then be turned upon its longitudinal axis, and thrust outwardly and upwardly (Fig. 191). The operator then carries the knife behind it, and grazing the humerus cuts out the internal flap, by carrying the instrument downward and for- ward (see Fig. 191). If the right shoulder requires removal, the first incision should be made by entering the knife at the infra-clavicular triangle, and bringing it AMPUTATION AT THE SHOULDER-JOINT. 383 out at the posterior margin of the deltoid, thus reversing the method as described for the left shoulder. As the inferior flap is cut, compression is made by the assistants on the great vessels contained in it. . The method of Larrey, or that known as the oval shoulder-joint amputa- tion, is done as follows: The surgeon first enters the knife at the edge of the acromion process, and makes a vertical incision to a point about an inch below the head of the arm-bone, Two long oval incisions are then made, one on the anterior and another on the posterior surface of the shoulder, extending from the centre of the short vertical cut already men- tioned, through the tissues composing the anterior and posterior walls of 384 A SYSTEM OF SURGERY. the axillary space. The next step is to draw downward the humerus, to stretch the ligament and open the joint from the top, and disarticulate the head of the bone from the glenoid cavity, and finish then, by joining the extremities of the oval cuts already FIG, 191. made, by division of the soft parts in the axilla. The lastincision severs the artery, which must be immediately secured. A somewhat similar opera- tion may be performed by making the flaps by transfixion, and not from without inwards. - Amputation of the Arm.–In ampu- tation of the arm, the patient having been placed under anaesthetic influ- ence, a tourniquet, or Esmarch's band- age, applied, and the arm placed at right angles from the body and held by an assistant, the operator then, if the flap operation is selected, grasps the skin and all the tissues, and, raising them from the bone, enters the knife in the middle of the arm, grazes the posterior face of the humerus with its point and brings it out on the inner side. He then cuts a flap of several inches, according to the circumstances of the case. The anterior flap is then made in the same manner, the FIG. 192. Amputation by Muscular Flaps. Langenbeck's Method. retractor applied, and the bone sawn through ; or the flaps may be made according to Langenbeck's method, from without inward (Fig. 192). If the circular method be preferred, the arm is drawn from the body at right angles, and the surgeon, standing on either side of the limb, passes his arm underneath the arm of the patient, enters the heel of the ampu- tating knife on the uppersurface, and draws it steadily around the arm, divid- ing only integument and fascia. The flap is then dissected and turned up, and the muscular tissue divided down to the bone (Fig. 193); the two- AMPUTATION OF THE FOREARM. 385 tailed retractor is then applied, and the bone sawn through. Teale's or Car- den's operation may also be performed if the operator prefer. FIG, 193. Division of the Muscle at the Edge of the Turned-up Cuff. Amputation of the Forearm.—When it is necessary to remove the forearm, the arm should be held securely by two assistants, one of whom steadies the elbow, the other grasps the wrist. The circular or flap method may be selected according to the circumstances of the case, although casteris paribus I prefer the circular. If the right forearm requires removal, the surgeon stands on the outer side of the limb; if the left, he places himself on the inner side. The integument and fas- cia should be divided with a single sweep of the knife, taking care to commence the incision with the heel of the instrument (Fig. 194). The integument must then be dissected and turned back; the soft parts are then divided down to the bone, and with a narrow knife the interosseous muscles also cleared from the bone; a “three-tailed” retractor is then ap- plied, the centrepiece, or tongue, being drawn through between the bones. The saw is now applied carefully, and in this instance both bones should be divided at the same time. The ves- sels, sometimes two, more frequently three, are to be secured, the flap turned down, and properly adjusted. FIG. 194. Position of Knife in Circular Amputation of Forearm. The flap operation is performed in the following manner. An assistant compresses the brachial artery, or applies Esmarch's bandage, and ex- tends the limb in a position between supination and promation. The sur- geon then may transfix the flaps with a small amputating knife, or may cut 25 386 A SYSTEM OF SURGERY. from without inward, forming an anterior or posterior flap. The interos- seous muscles are separated, and the bones sawn through as before. Teale's Method.-In the forearm the long flap must be taken from the dorsal aspect, and, as in all like amputations, it is recommended that the lines of incision be traced on the limb. In this amputation, in marking out the long flap, a longitudinal line is drawn over the radius so as to leave the radial vessels in the short flap. At a distance equal to half the cir- cumference of the limb, another line, parallel with the former, is drawn along the ulna. These are then joined at their lower ends by a transverse line equal in length to half the circumference of the forearm. The short flap is marked by a transverse line on the palmar aspect, one-fourth the length of the long one. The operator, in forming the long flap, makes the two longitudinal incisions merely through the integuments, but the trans- verse one is carried directly down to the bones. The short flap is made by a transverse incision down to the bones, care being taken to separate the parts upwards close to the periosteum. FIG. 195. Making Anterior Flap-Amputation at Amputation at Wrist. Opening Joint from Elbow. Dorsal Surface. According to Mr. Bryant, amputation of the forearm should always be a “mired" one; he says: “two well-cut and fairly long skin-flaps, and a clean circular section of the muscles are far preferable to the flap operation, and yield a good stump.” Amputation at the Elbow-joint-This operation is usually performed by a long anterior and short posterior flap. The forearm should be slighly flexed upon the arm, and the knife entered in front of the joint close to the bone, and brought out by cutting upwards and forwards in order to make a sufficient flap of the muscular tissue. The operator stands on the inner side of the right arm and the outer side of the left. A transverse incision is then made behind the joint, the extremities of which cut should meet the beginning of the first cut, or at the base of the flap. The external lateral ligament must then be divided, and the joint opened between the external condyle of the humerus and the head of the radius; the internal lateral lig- AMPUTATION AT THE WRIST-JOINT, 387 ament must then be severed, and the olecranon process of the ulna sawn through below the point of insertion of the triceps, a portion of the process being left in the stump, which is to be treated on general principles. It is sometimes thought advisable to make the posterior flap first, which may be done by an incision carried around the posterior aspect of the joint, its line being a little below the head of the radius, which can be detected by pronat- ing and supinating the hand; this flap is to be dissected up as high as the upper border of the olecranon process, as seen in the figure. The forearm must then be flexed, and the joint entered above the olecranon, and carried through the joint and made to cut itself out on the anterior face of the limb. In Fig. 195 the position of the parts and knife are represented. An anterior and posterior flap of skin and fat may also be made and the bone disarticulated ; then with a circular sweep of the knife the remaining muscles are to be divided. - Amputation at the Wrist joint.—The circular method of amputating at the radio-carpal articulation is as follows: An assistant should draw back the integument, and hold the arm firmly with both his hands, making pressure with his thumbs on the brachial artery. The surgeon then makes a circular incision, from an inch to an inch and a half below the styloid process of the radius, through the skin and superficial fascia, down to the tendons; the flap must then be carefully dissected up to a point above the line of FIG. 197. S § § Ş § ºº S § § §§ \ £º * º à º w § es § 2. %& S * 2-’ º §). hº * . sº- ºr § S$ N N. \ §§ \ § § §§ . º º-s, : . . . . . . - %tiº Metacarpo-Phalangeal Amputation of all the Fingers. articulation, which flap must be reflected. A second circular incision must then be carried through the tendons, and the joint opened from its dorsal to its palmar aspect. There are several important points to be considered in performing this amputation. First, that the two styloid processes are marks by which to distinguish the line of articulation, and that the styloid process of the radius projects lower than that of the ulna, consequently the joint is more accessible at that point; second, that the first fold of the skin on the pal- mar surface of the wrist, reckoning from the arm toward the palm, almost covers the joint. Recollecting these important bearings, and entering the joint from the dorsal surface, and on the ulnar side, the facility of opening the articulation will be increased, and the operator be much less likely to enter the knife between the rows of carpal bones, a mistake which might otherwise easily occur. Fig. 196 represents amputation at the radio-carpal articulation; the joint 388 A SYSTEM OF SURGERY. is opened upon the back of the hand, and the skin and cellular tissue re- flected back. Amputation of the Fingers.-There are different methods proposed for the removal of the fingers, but the size and direction of the flaps must be in accordance (adhering to the general rule for all amputations) with the amount of integument left to cover the bone. Metacarpo-phalangeal Amputation of the Fingers.--All the fingers may have to be removed at once, in consequence of mill, railroad, or machinery casualties; or from gangrene, frostbite, or embolism. The best method for these operations is for the surgeon to take the fingers to be removed, prone, in his own hand, and have a good assistant steady the wrist and draw aside the thumb. A semilunar incision is then made with a strong Scalpel, extending from the outside to the inside of the hand, a little in ad- Vance of the joints; the fascia and integument must then be dissected up, and the extensor tendons be divided. The fingers, still held firmly, are then flexed at a right angle, the lateral and other ligaments divided, and each joint fully and carefully opened; a small-sized narrow-bladed cat- ling, its flat being placed close to the phalanges, is made to cut itself out on the palm of the hand, forming a sufficient flap. (Fig. 197.) - Disarticulation of the Last Four Metacarpal Bones Preserving the Thumb.- The incision in this amputation is peculiar and must be made with care. The surgeon begins his cutting on the palm of the hand at the web of FIG. 198. FIG. 199. . . . FIG. 200. *ſº w º s > R & . F iſ a ; : i\; e º *-* * ** --3. e j . |; § * | l ; w | & { y | ſ # , ; ; ; s \ , ; ; Palmar incision. Dorsal incision. Line of union. Disarticulation of the Last Four Metacarpal Bones. the thumb and carries it with a convexity forward to the base of the fifth metatarsal bone (Fig. 198). The dorsal incision also must begin at the web of the thumb, is carried upward toward the wrist as far as the upper third of the second metacarpal bone and then is carried over the hand, as seen in Fig. 199, to meet the line of the palmar cut. These flaps must then be carefully dissected back beyond the carpo-metacarpal joints, which are to be opened with great care, keeping the knife close to the bone, especial watchfulness being maintained when opening the finger-joint at the trape- zium, otherwise its connection with the thumb may be opened. The pos- session of the thumb is of the greatest possible advantage to the patient. Fig. 200 shows the line of cicatrix after the operation. AMPUTATION OF THE INDEX FINGER. 389 Amputation through the Metacarpus.-If it be necessary to amputate through the metacarpus, a double flap is made, one on the anterior, the other on the posterior face of the joint, and the bones exposed. Then a five-tailed re- tractor is placed between the fingers to protect the tendons, and the saw may be evenly applied to the whole. As a general rule, when a single finger is to be amputated, it is not necessary to ligate the arteries; the surgeon may remove clots, wait awhile, making slight lateral pressure, and then dress the parts with cold dilute calendula. Amputation of a Finger.—To remove a finger is a very simple perform- ance. A flap anteriorly and posteriorly (vide Fig. 201) is made, the flaps held aside with the finger and thumb of the left hand, and the bone forceps applied just behind the protuberant extremities of the phalanges or metacarpal bones. If it is deemed advisable to disarticulate, after the superior flap is made, the finger may be flexed, the joint entered, and after having divided the tendons the inferior flap is made. - Amputation of the Index Finger.—The important office subserved by the index and ring fingers, has given rise to the question among surgeons, whether it is more advisable to save as much of the palmar phalanx as possible to give the patient a more useful stump, or to remove the entire phalanx and a portion of the meta- carpal bone, thereby making a much more seemly stump. It is better, as a rule, in all the fingers except the index, that the extremity or head of the metacarpal bone should be taken away, otherwise it leaves a projection which is oftentimes much in the way, and is liable to be struck or injured. This is accomplished by making a V-shaped incision, the apex looking toward the wrist, and having reached the bone, with a pair of strong bone pliers, held at right angles with the hand, the metacarpal bone is divided close behind the head. In removal of the index finger much depends upon the judgment of the surgeon. He must determine as to “usefulness” or “appearance.” If the applicant is a laborer, depending upon manual exertion for Support, as much FIG. 201. Amputation of a Finger. FIG. 202. as possible of the finger should be saved, but if it be a person in the upper ranks of life, who might be horrified at an unseemly finger, then operate in a manner to leave the least possible deformity. As a general rule, a better stump is made by removing the bone in its continuity than at the joint, on account of the rounded and protuberant extremity of the articulation pre- senting a knobby appearance after the parts have healed. When the little finger is to be removed, in conjunction with the metacarpal bone (an opera- tion which, as yet, I have never been called upon to perform), a somewhat oval incision is necessary. Enter the knife at the junction of the metacarpal bones with the wrist, bring the incision upward around the back of the hand, and terminate it on the palmar surface. This may be continued 390 - A SYSTEM OF SURGERY. around the finger, down its outside, to the point of beginning. The tendons are carefully divided and disarticulation effected as in other cases. - Amputation at Carp0-metacarpal Articulation of the Thumb.-The same rule is followed with the thumb (vide Fig. 202), beginning at about half an inch in front of the styloid process of the radius, carry the incision around the thumb, and back again to the point of entrance. Divide the extensor tendons from behind, and by flexing the thumb the disarticulation is easy. In this operation two or three small arteries may require torsion. Treatment. After Amputation.—The management of the stump is of great import, and differs materially at the present from that practiced a few years ago. It was the custom, after having secured the flaps, to strap the stump closely, then to apply a wad of charpie or lint; over this the “Maltese cross,” and then to envelop the limb with a roller bandage, thus doing everything to cause retention of the effete fluids, and keep the parts hot and feverish. It has been my custom, in all the varieties of amputation, to dispense with this pernicious treatment. In every amputation, after the bleeding has been arrested, the entire surface of the stump should be FIG. 203. . Dressing of an Amputation Stump with Carbolized Strips of Gauze and Bandages. thoroughly irrigated with a hot solution of calendula, one to six, and all the clots carefully picked out. Antiseptic (decalcified bone if possible) drain- age tubes should be inserted down to the bone on each side of the wound, and to prevent the drainage tubes from slipping back as they are being ab- sorbed, I am in the habit of piercing them with a moderate sized safety pin. The surgeon should then call for hot water containing calendula one to four, corrosive sublimate gºrg, or carbolic acid Tłº, and thoroughly inject the parts through the drainage tubes, pressing out the solution, and continuing to use the injection until the water runs clear. Then the dry dressings are applied as follows: Along the whole line of the incision a narrow strip of protective made of gossamer india-rubber cloth, clean and disinfected, is to be laid. Then strips of salicylated india-rubber plaster A, A, in Fig. 203, are applied as seen in the engraving. Over this an anti- septic bandage is (not too tightly) wound, and upon this several layers of antiseptic cotton (that prepared in sheets and enclosed in antiseptic gauze NEURALGIA OF THE STUMP. 391 —as manufactured by C. Am Ende—is best) are placed. Finally, a bit of antiseptic oiled silk, held in position with an antiseptic bandage—loosely applied—and kept in position with safety pins will complete the dressing. This method, if conducted with the requisite care and cleanliness, need not be removed for several weeks. If, however, the dressing become soiled, or there is odor detected from the wound, the outside layers should be care- fully removed and the soiled portions taken away, or if necessary the entire toilette be gone over. Lister's and other methods, especially the “open '' (so much practiced by Dr. James R. Wood) and the “dry,” are so fully described in Chapters XV. and XVI., that space forbids any repetition in this place. Neuralgia of the Stump.–This is a most distressing affection, and often is very intractable. It may arise from a bulbous affection of the nerves, or their adherence to the cicatrix, which subjects them to constant and con- tinued pressure; this latter cause, however, is not always present, the pain arising from irritation of the spinal cord. The symptoms generally appear in paroxysms, are almost unendurable during the night, with spasm and twitching of the stump, which not unfrequently terminate in muscular contraction, causing the bone to protrude. The sensations vary in different individuals, and at different times in the same individual. A successful treatment depends upon an exact correspondence between the symptoms of the medicine and the sensations experienced. Such similarity may be found in the Materia Medica, which contains remedies wherewith to miti- gate or entirely subdue the sufferings of the patient. To this storehouse the surgeon must resort, and with patience and pre- cision select his weapon. .” Perhaps among the primary influential impulses which homoeopathy received was the successful treatment by Hahnemann of the distinguished cavalry chief at the battle of Waterloo, the Marquis of Anglesey, who underwent amputation of the leg in consequence of a wound inflicted by a cannon-shot. Neuralgia of a torturing kind followed, and the fruitless efforts of many physicians induced this renowned nobleman to solicit the advice of Hahnemann, then practicing in Paris. The private physician of the marquis (Dr. Dunsford) became a convert to the homoeopathic doctrine after having witnessed the salutary effects of the medicines which Hahne- mann administered. The medicines I have found most serviceable, are acon., bell., ignatia, cuprum, veratrum, hellebor., and spigelia, according to the presenting symptoms, which must be looked for in the Codex. But I desire here to invite attention to a medicine which was brought to my notice by Dr. Shelton, of Jersey City, and accidentally came to his knowledge after the following manner: He had amputated the thigh of a man, and the wound had almost entirely healed by the first intention, when most intense neuralgia of the stump followed. The doctor prescribed all the medicines that appeared indicated, with little or no relief. I saw the patient in con- Sultation with him, but nothing we tried was of permanent service. After both high and low potencies had been given without benefit, the patient became desperate. Extract of hyos., zinc. valer., codeia, chloroform, and chloral were administered. An ointment of bell. and opium was rubbed into the stump. The muriate of ammonia, in half-drachm doses, produced for a time decided effect; a repetition of the same medicine was of no avail whatever. Hypericum and cannabis in tincture, and the higher potencies, were equally unavailing. The following is the record for September 5th : “The patient picked up a scrap of printed paper with which to light a cigar. Before doing so, he whiled away a few moments in looking it over. It was in French, and, rather strange to say, his eye met a little paragraph on raw onion in neuralgia. He resolved to try it. He ate a whole one at 392 A SYSTEM OF SURGERY. bedtime. All pain immediately ceased, and he slept quietly that night, He continued to do so nightly until the 23d, with entire relief, when the onion was omitted for two nights, to see what the result would be. The pain returned. “Sept. 25th.-Allium cepa” was given for two days, without any effect. Ten-drop doses of the tincture were taken for two days, when all pain ceased from that date to the present—8th of November.” - Retraction of Flaps.-Perhaps this accident occurs to the young surgeon more frequently than any other, at least it did so in my own practice. The axiom to spare the skin and never the bone, is a good one—as a rule too much bone cannot be taken off. The retractors should draw the soft parts well up on the bone, and the surgeon with his hands should push upward the muscular tissue around the bone as far as he can get it before he applies the saw. In the flap operation, retraction of the flaps is more likely to occur than in the circular or mixed methods, on account of the large amount of muscular tissue, which forms the greater portion of the flaps. Sometimes, notwithstanding the utmost care, this untoward accident occurs. If, therefore, the surgeon, on the second or third day, feels that the bone is nearing the line of the incision, he should immediately apply ex- tension to the stump-a large strap of adhesive plaster extending along each side of the stump for nine inches, with “a traverse” at its distal end for fastening the cord, should be put on, and kept securely in position by a roller bandage. The cord should be made to play over a pulley at the foot of the bed, and a weight of four or five pounds be attached. This will greatly overcome the retraction, and prevent the formation of a conical Stump. Conical Stump. —This disagreeable complication is caused by the retraction of, or insufficient flaps, or from sloughing, either of which allows a portion of the end of the bone to show itself; after a time however this end becomes covered with granulation tissue, and, finally, partially cicatrizes, leaving a conical shaped stump of low vitality, often disposed to ulcerate from slight irritation, and always of great annoyance to the patient. There is no remedy for such a condition but re-amputation, which must be a complete division of the skin, muscle, and bone, together with the excision of all cicatricial tissue; this is often more difficult to accomplish than the primary amputa- tion. CHAPTER XXI. PLASTIC SURGERY. ANTIQUITY OF-GENERAL Consider ATIONs—VARIED METHODS OF TRANSPLANTING FLAPs. THERE is no branch of surgical science that demands more inquiry, and that is so often both satisfactory and unsatisfactory in its results, as that of plastic surgery. Autoplastic and other varieties of plastic surgery signify methods of reconstruction of parts that are deficient. These may be either congenital defects or the products of accident or disease. Sir Spencer Wells gives this definition of plastic surgery: “It is,” he says, “that de- partment of operative surgery, which has for its end the reparation or ºfton of some lost, defective, mutilated, or deformed part of the ody. PLASTIC SURGERY. 393 It is said that Celsus and Galen were acquainted with this method of restoration of parts; but it is generally conceded that the father of “plastics,” was Gasparo Tagliacozzi or Taliacotius, who lived in the sixteenth century, was professor of surgery and anatomy at Bologna, and who was supposed to be a necromancer, on account of his being able to restore parts which were lost; to fit on a nose if it were gone, to put on a prepuce if it had been destroyed by a chancre, etc. In the olden times plastic surgery was mostly limited to the integu- mentary surfaces, but recent operations, termed the osteoplastic, have given such favorable results, that they will necessarily come under the head of “ plastics' in surgery. The skin-grafting of ulcers, transplantation of flesh and tissue, either with or without pedicles, the operations for hare-lip, cleft palate, lacerated cervix and perinaeum, operations upon the eyelids and urethra, all belong to this interesting field. The Osteoplastic operations on the maxillary bones, Pirogoff’s amputation, amputation through the condyles of the femur, with attachment of patella, and the recent operative measures for removing tumors of the antrum and naso-pharyngeal polypi, as well as various operations for deformities of the lower extremities, render the domain of plastics a wide one indeed. The great points to be remembered in performing such operations are: 1st. The general condition of the patient. 2d. To completely arrest the haemorrhage before closure of the wound. 3d. To obtain union by the first intention. All patients about to be subjected to plastic operations, should be allowed to remain in bed for several days. Abernethy remarks, that he found that patients who had been confined in bed for a length of time, underwent operations better than those who had not been so rested, and I am disposed to agree with him. A bath should be given daily, and all food prohibited which would tend to cause dyspeptic symptoms. Cheerful apartments, attentive nurses, good ventilation, and proper diet are essential in all opera- tions, and especially in the more delicate ones of which we treat. During this period the iodide of potassium should be given twice a day, about three grains at a dose in six tablespoonfuls of water. - A peculiar fact which I have noticed, especially in the treatment of ulcers, is, that the grafts do better, and are not so likely to abort, when the patient has been using silew for a week or two previous to the operation. In syph- ilitic patients silicea has no effect, but I am positive the iodide of potash has, particularly when administered in tangible quantities as above. The best method of arresting hamorrhage in the operation, if it be pos- sible, is by torsion. Speir's artery constrictor will often serve the purpose, as will the acupressure pin, well applied. After the bleeding has stopped, every clot should be washed away, and oozing allowed to cease. The sutures to be used are those of silver wire, carbolized catgut or whole tendon, or the iron-dyed silk. (Wide page 38.) In closing the wound, such sutures must be used as will in the least degree obstruct the circulation of the flaps. These, perhaps, are the bar sutures with the perforated shot, or the ordinary quilled sutures. The needles should be round, slightly curved at the point, and without cutting edge. In making the flaps, much time and discrimination must be used, and many patient measurements taken, especially if the flap is to be twisted or bent upon a pedicle. It has been recommended by some surgeons that the dimensions of the flap should be taken on card-paper, or gutta-percha; but I can recommend a better article in parchment which has been wetted. It is very pliable, and will twist upon itself as easily as the integument; it is Semitransparent, and being laid over the part to be closed, the boun- daries can be clearly defined and traced. It is especially serviceable in the 394 A SYSTEM OF SURGERY. many manipulations which are often necessary, because it does not tear. I have used this substance for a number of years, and have reason to speak Well of it, for the purposes mentioned. In repairing parts of the body wanting, either from arrest of development, or from the ravages of disease or accident, the surgeon should bear in mind the fact that he cannot expect to have a result equal to nature, and he, be it patient or surgeon, who anticipates such a result, will certainly be disap- pointed. “Nature ever triumphs over art, and here is the boundary between what is God-like and what is human.” Another item to be"remembered, is the shrinkage of the flap, which almost invariably occurs, and which should be in a measure anticipated by always dissecting off a flap which will be somewhat larger than the exact size of the wound. - Gangrene which may result from a defective supply of blood, either from too much constriction of the pedicle, or the pressure of the sutures, together with the presence of the so-called nodular tissue, which must be cut away entirely if we expect a good union—are often the causes of failure. The simplest plastic operation is skin-grafting in ulcers. It is a method which, according to Jobert, was known long ago in India. The grafts were taken from the nates, having been previously slightly bruised to increase vascu- larity. This method, however, failed frequently, probably from the bruising process to which the parts were subjected. t There is no doubting the fact, that portions of the body have been entirely . tº and, having been speedily replaced, have united themselves per- ectly. - Dr. Prince” mentions the case of a man, who, having cut off two of his fingers, replaced them, and then consulted a surgeon; he, for the sake of greater security, applied additional dressings to them. The fingers united firmly, but their ends became gangrenous, in consequence of the tight strapping which had been employed. Professor Evet cites the case of a woman who had the whole of the soft parts of her nose bitten off in a fight with a man. Three hours after she was seen by the surgeon, who insisted upon searching for the lost olfactory. After a considerable time the missing member was found, “contracted and covered with filth.” It was thoroughly cleansed, adjusted, and reapplied. In thirty-seven days it was firmly united, but had assumed a bluish hue. A solution of nitrate of silver was applied to the tip, and in five days it had resumed its natural color. - Brown-Séquard, in 1850, grafted the tail of a cat on a cock's comb with SUICCéSS. On one occasion I replaced the end of a finger which had been severed by an accident, and held it in situ by straps and bandages. Not the slightest attempt at union resulted. In a second case my efforts were followed b success. I do not propose to occupy any space with the simple methods of the skin-grafting process, which can be found at page 136. It is generally attributed to M. Reverdin, who, in 1870, published a paper on “Epidermic Grafting.” In Holmes's System of Surgery the following paragraph occurs, written by Holmes while surgeon to St. Bartholomew's. Speaking of the “transplantation of skin,” he says: “the ingenuity and merit of the invention, which is due to M. Reverdin, of Paris, the readiness of adoption, which is due to Mr. Pollock, and the great success which has followed the numerous trials now made in every direction, warrant the conclusion that the proceeding is one of the most striking and successful in * Plastie Surgery. f Remarkable Cases in Surgery. PLASTIC SURGERY. 395 modern surgery.” I can claim for this country priority for this operation, as I can for excision of the jaw, by Deaderick, of Tennessee, and of ovari- , otomy by McDowell, of Kentucky. In a report of the Dispensary of the Geneva Medical College, 1847, can be found the record of the case of a boy whose leg had been stripped of integument eight years before, and the wound not having healed, Dr. F. H. Hamilton proposed the transplanting of a piece of sound integument, in the centre of the ulcer, to which, how- ever, the patient did not consent. On January the 21st, 1854, Professor Hamilton made his first operation in the case of one Horace Driscoll, at the Buffalo Hospital of the Sisters of Charity. The ulcer was large, and the healthy integument was taken from the opposite leg. In ninety days cicatrization was complete. On the 24th of June, 1854, Dr. Hamilton read a paper before the Buffalo Medical Association, on “Old Ulcers Treated by Anaplasty,” which gives to him the priority of claim in this department. His views and some interesting remarks on skin-grafting are detailed by him in his work.” * The classification of the different methods of performing plastic opera- tions is—first, when the flaps are taken from the same person. This is known as autoplasty. When the term heteroplasty is used, it is understood that the supply comes from another; and when other substances, sponge, etc., are used, the term prothesis is used. The varied methods of performing plastic operations are as follows: I. Sliding in a direct line. II. Sliding in a curved line. III. Jumping. (Indian method.) IV. Inversion or eversion. V. Taliacotian. (The part obtained from a distance.) VI. Grafting. (Already considered.) As I have already remarked, no rules can be laid down for plastic opera- tions. Every case is so different that each requires a careful consideration, as to the number and character of the operations to be performed. Some- times the result is so satisfactory that the surgeon is more than gratified with it; while at others so unsatisfactory, that both the surgeon and the patient become discouraged from frequent disappointments. As a rule, however, it may be said that the sliding method, having pre- viously cut under the edges of the flaps, and the torsion method, are the two which are the most practical and give the best results. In the proper places, hare-lip, rhinoplasty, cheiloplasty, osteoplasty, and other plastic operations are fully described, to detail which in this place would be merely repetition. —” * Principles and Practice of Surgery, by F. H. Hamilton, A.M., M.D., LL.D., p. 42. PA R T III. SURGERY OF SPECIAL REGIONS AND TISSUES. CHAPTER XXII. DISEASES AND INJURIES OF THE SRIN AND CELLULAR TISSUE. ERYSIPELAS–PoisonING witH RHUs—FURUNCLE, BoIL–ANTHRAx, CARBUNCLE – EFFECTS OF COLD, PERNIo—BURNS AND SCALDs–CICATRICEs—PARONYCHIA, WHIT- LOW-LUPUS—ELEPHANTIASIS ARABUM–MALIGNANT PUSTULE—INTERNAL MALIG- NANT PUSTULE—VERRUCAE, WARTs—BED-SoREs—INGROWING TOE NAIL–ONYCHIA —SUBUNGUAL ExoSTOSIS-PERFORATING ULCER OF THE FOOT. Erysipelas.-In a work upon general surgery, only a description of those diseases of the skin which fall within the province of the surgeon can be mentioned; the varied and multiform affections, with their classification and treatment, which belong to Dermatology, must be sought for in works upon that specialty,+a department indeed of medicine which, within the last few years, has assumed vast importance. Erysipelas is an inflammatory affection, accompanied with fever, which, together with drowsiness, is generally present a few days before the attack, the latter symptom disappearing when the disease is fully established. The inflammation is generally confined to the epidermis, which becomes hot, red, and swollen, and sometimes covered with blisters (erysipelas bullo- Sum), or vesicular erysipelas, but in very violent cases the deeper-seated tissues are affected, and the disease is termed phlegmonous erysipelas, or the cellulo-cutaneous. Every part of the body is liable to be attacked, although the face, legs, and feet are most frequently affected. Erysipelas does not often attack persons before the age of puberty; it is a disease of advanced life, and is more frequently encountered among fe- males than males, particularly those of a sanguine, irritable temperament. In some individuals there appears to exist a predisposition to the disease. In other instances it returns periodically, attacking the patient once or twice a year, and sometimes oftener, thereby greatly exhausting strength. Erysipelas is occasioned by the several causes that are liable to excite in- flammation, such as injuries of all kinds, the external application of acrid substances to the skin, exposure to cold, obstructed perspirations, suppressed evacuations, etc., etc. The disease also appears to be, under certain circum- stances, epidemic, caused by a peculiar state of the atmosphere, and this is frequently the case in crowded ships or in hospitals. . In slight cases, when the extremities are attacked, this disease makes its appearance with roughness, pain, heat, and redness of the skin, which be- comes pale when the finger is pressed upon it, but immediately returns to its former color when the pressure is removed. There also prevails a slight febrile disposition, and the patient is rather hot and thirsty. If the attack be mild, these symptoms will continue for a day or two, when the surface of ERYSIPELAS. 397 the affected part assumes a yellowish tinge; the cuticle may separate in small scales, and the patient experience no further inconvenience ; but if the attack be severe, and the symptoms of high inflammation be present, there will be intense throbbing pain in the head, pain in the back, great heat, thirst, and restlessness; the affected parts will swell, the pulse become frequent, and either hard and tense, or it may be small and rebounding; the temperature often rises abruptly, as is seen in the accompanying cut, Fig. 204. About the fourth day a num- ber of small vesicles make their appear- FIG. 204. ance, containing a limpid, or in some d cases a yellowish fluid. In unfavorable cases these blisters have sometimes de- generated into obstinate ulcers, which assume a gangrenous character. This, however, does not happen frequently, for though the surface of the skin and the bullae may assume a bluish, or even a blackish tinge, yet such appearances generally disappear, together with the other symptoms of the complaint. The appearance of these vesicles is not always present in an attack of erysipe- las, and when they do show themselves, the period of their eruption is very uncertain. - The trunk is also attacked with erysipelas, but less frequently than the extremities; but infants in a few days after birth may be affected in this manner, the genital organs being generally involved. When erysipelas attacks the face, the premonitory manifestations are chilliness, succeeded by heat, thirst, restlessness, glistening eyes, coated tongue, redness of the cheeks and other febrile symptoms, with a tempera- ture of 104° to 105°; there is drowsiness, or a tendency to coma and delirium, and the pulse is very frequent and full. At the end of two or three days, a scarlet redness appears on some parts of the face, which may extend to the scalp, and then gradually down the neck, leaving tumefaction in every part occupied by the redness. When the swelling and redness have continued for a time, blisters, varying in size and contain- ing a thin, colorless, and sometimes acrid liquor, appear on the face, which becomes turgid and swollen, and the eyelids are sometimes swelled to such a degree that the patient for a time is deprived of sight. The fever some- times becomes less when the inflammation is established, but in the major- ity of cases it increases as the latter extends, and, unless checked by the appropriate means, may continue for the space of eight or ten days. If such is the case, the coma and delirium increase greatly, and the patient may be destroyed between the seventh and eleventh day. If the attack be mild, the inflammatory symptoms subside gradually, and the disease ter- minates in a few days. In ordinary practice, erysipelas cannot be said to be contagious; but in hospitals, or where many persons are crowded together in a small space, with poor ventilation, the character of the disease assumes a far different type. It sometimes causes the surgeon great apprehension, especially for the wel- fare of other patients suffering from wounds. I well recollect my conster- nation when, after having performed a resection of the elbow-joint at the hospital, on going through the wards I found a case of erysipelas in a little girl in one of the lower rooms. Although every precaution was used, on the next day symptoms of the disease developed themselves in a boy from whom I had removed half of the inferior maxillary bone about ten days "… = *- : * ~ * * * * : * ~ * W. - : T : . . . . . . . . . . . . . Heat-line in Erysipelas. 398 A SYSTEM OF SURGERY. previous. The patient from whom the elbow-joint had been exsected died about the twelfth day. In the case of the little girl I administered bella- donna every two hours, and in a few days she was able to undergo the oper- ation of removal of the limb. - With reference to “hospital erysipelas,” Mr. T. Holmes,” in his admir- able work on surgery, thus writes: “I cannot but protest against the assumption involved in the terms ‘hospital erysipelas’ and “hospital diseases” as descriptive of the complica- tions of wounds. Such complications are met with, it is true, most com- monly in hospitals, for the simple reason that wounds are also met with most commonly there; but they occur very frequently in private practice, even under the most favorable circumstances, and they have never really been proved to be relatively more frequent in good hospitals than in private practice, in similar cases. There is much need for us all to do our best to improve in every way the air, the treatment, the dressing, and all the other circumstances of the wounded in our hospitals, and thereby, doubtless, the prevalence of these complications will be lessened; but it is a sad error to impair the reputation and thus diminish the usefulness of our hospitals by reckless aspersions on their salubrity.” Erysipelas of the face is more dangerous than when other portions of the body are attacked, because there is a tendency of the inflammation to attack the brain. The prognosis is unfavorable if the fever assumes a malignant type, or when there is threatened metastasis to internal noble organs. These are generally indicated by a persistently high temperature. Treatment.—The medicines that are most serviceable in erysipelas are acon., apis mel., bell., bry., euphorb., puls., rhus t, sulph., canth. Rhus tox is the principal medicine for vesicular erysipelas; it is also in- dicated in erysipelas where there is excessive oedema, or where there is a tendency to metastasis of the disease to the brain; rhus radicans has been very highly extolled for facial erysipelas, as have been also graphites and hepar, but of course there must be corresponding symptoms to indicate their use. - - According to Reissig, nux vom. is well adapted to this disease when it attacks the knees or feet, when there is intense pain and bright-red swelling. If there be a tendency to metastasis to the brain, cuprum acet. is an ex- tremely valuable medicine, as the author has had opportunity of witness- ing. Dr. Schmid, of Vienna, also corroborates this statement. Belladonna and rhus tox. are adapted to many forms of this disease, even to that found in hospitals, in which it partakes of the phlegmonous charac- ter, and therefore the former remedy would perhaps be preferable. If the disease assume a gangrenous form, the vesicles become dark and blackish, with prostration, dry skin, frequent but easily quenchable thirst, arsen. should be administered, or perhaps carbo veg. may also be indicated in erysipelas gangrenosum, particularly if there be night and morning sweats, excessive prostration, and disposition to typhoid symptoms. Rhus should also be remembered, and administered if suitable for such a condition. If there be a disposition to ulceration, sulph., hepar, graph., silic., are important medicines.t I have never witnessed satisfactory results from the use of local applica- tions in the treatment of erysipelas. It is very fashionable (and fashiona- ble folly too), to apply poultices or mercurial ointment, or the acetate of * A Treatise on Surgery, its Principles and Practice, 1876, p. 70. f There have been many interesting cases of erysipelas reported in the homoeopathic peri- odicals. One of the best can be found in the British Journal of Homoeopathy, vol. vi., p. 532. - BOIL, FURUNCULUS. .399 lead in solution, or to pencil the parts with tincture of iodine and nitrate of silver. These are worse than useless. The medicines are so marked in their action in the disease, and so extremely efficacious, that all outside applications positively retard recovery. If there be much itching towards the close of the affection, rye flour dusted over the part is quite sufficient to allay it, and even this symptom is often quickly relieved by hepar Sulph., or sulphur. Poisoning with Rhus tox. —It is well known that certain individuals are very susceptible to the poisoning of rhus toxicodendron, and other varieties of the poison oak. What causes this peculiar idiosyncrasy, it is difficult to Say; certain, however, it is, that while some persons (even members of one family) may handle the plant with impunity, others are so easily affected by it, that simply passing in a neighborhood where the poison oak is grow- ing, produces a peculiar inflammatory action upon the skin, resembling very closely the vesicular variety of erysipelas, and causing much incon- venience and pain. The affection thus produced is called by some rhus dermatitis. The period of incubation varies from a few hours to a couple of days, but in the cases that have come under my observation—which have not been few—four or five hours generally is a sufficient period to develop the eruption. The hands and face are most frequently affected, although if other portions of the body have been exposed, as is the case in persons about to swim or bathe, the arms and genital organs may suffer. At this present writing I have a lady under my care whose left ear and side of the face are covered with the vesicles peculiar to the poisoning. The symptoms begin with a slight efflorescence and considerable itching, which in a short time are accompanied by Oedema, which is often great, es- pecially about the face. Small vesicles then appear, which are filled with serum. If the inflammation has covered a large extent of surface, there may be some febrile exacerbations, but, as a rule, fever is absent. The vesi- cles either rupture themselves, or gradually shrink and dry away, leaving, as in erysipelas, a slight dry scale. Treatment.—According to the old law “isdem, iisdem, curantur,” which law is in some parts of the country mistaken for the homoeopathic formula, rhus toxicodendron, in small doses, is the remedy for this disorder; and I have found this medicine, in the second and third dilutions, administered internally, a very reliable method of treating the affection. Sometimes I have given sulphur, and at other times bella., and on one or two occasions, the rhus radicans was of the most marked service. Either of these medi- cines, selected according to the judgment of the practitioner, will be found efficacious in arresting the disease. I do not think much of the fashiona- ble carbolic acid lotions, but prefer the juice of the sanguinaria canadensis, or if this cannot be obtained, the tincture, diluted one-half with water (or in some cases pure) painted over the parts. The fluid extract of the grindelia robusta, two drachms to a pint of water, makes an excellent application. Sometimes I have also used the ordinary saleratus, and again borax: one drachm to half a pint of water, as an application to the inflamed surfaces. Cloths wrung out in either of the solutions may be used, as the judgment of the practitioner may direct. Boil, Furunculus.-A boil is a prominent, hard, red, and circumscribed tumor, very often extremely painful, and though terminating in suppura- tion, the process by which the pus is formed is frequently of long duration. The inflammation is of the sthenic type, affecting the skin and areolar tissue; the latter becoming disorganized, constitutes what is termed the core of the boil. A common furuncle differs from a carbuncle, because the latter is as- thenic, not only constitutionally, but locally, the life of the patient being 400 A SYSTEM OF SURGERY. often endangered by the disease; whilea boil is sthenic in itself, is gener- ally developed in robust and plethoric temperaments, and is in most in- stances free from fever or any constitutional disturbance. The cases in which fever may be expected, are those in which the tumor is large, and situated on a sensitive part, or when a number of these swellings appear at the same time in different places. A carbuncle contains no single core, but has several openings for the exit of sloughs. As Suppuration progresses in a boil, the apex of the cone becomes yellowish, and surrounding this, the hardness of the swelling disappears, though still the base is firm and unyielding. The pus is superficial, the slough or core being at the base. According to Richerand, the origin of boils depends upon a disordered state of the gastric organs; this is frequently the predisposing, while the exciting cause may be a prick, a scratch, or some other slight irritation. Constitutional irregularity, however, is, in very many instances, sufficient in itself to produce this variety of inflammation. Boils may appear in any part of the cellular tissue, and are mostly found among young plethoric individuals, or in those persons who are given to high living and suffer from dyspepsia. Some individuals appear to be par- ticularly liable to the formation of furuncle, and the hips and buttocks are frequently the seat of the disease ; it is in this locality that they are ex- tremely vexatious, as the afflicted mortal can neither sit with comfort nor Walk without pain, which is occasioned when the muscles are rendered tense, and, moreover, the individual is constantly kept in a ferment of anxiety and suffering, consequent upon the frequent blows that are invariably, unac- countably and inadvertently inflicted upon the tender and painful tumor. A boil, after suppuration is complete, bursts at its apex, and the purulent Secretion is discharged, after which the pain, heat, and swelling subside; but unless the slough is also extracted, the part may remain in a subacute inflammatory condition, the disorganized tissue acting as any other me- chanical irritant. At certain periods of evolution of the system, a number of boils are apt to make their appearance in the same individual. Treatment.—At the climacteric, during teething, or about pubescence, the surgeon is often called to treat a succession of these disagreeable visitors. A systematic constitutional treatment must then be adopted; the medi- cines being chiefly hepar, kali hydriodicum, and sulphur. The homoe- opathic treatment of boils is very efficacious; indeed, the careful practi- tioner can frequently administer prophylactic medicines to those in whom there is a tendency to this variety of inflammation, thereby saving the patient from great inconvenience and a considerable amount of pain. In the treatment of furuncle a poultice is very often necessary. The heat and moisture of an unmedicated fomentation produces often great relief. Such means, however, I have not always found essential. There is naturally existing in the minds of the older portion of the community, whether physicians or laymen, a favorable predisposition in regard to the application of a poultice. Those who have been born, bred, and habituated to the application of such means for almost every variety of local inflam- mation, cannot, without some hesitation, resign the adjuvants; but experi- ence teaches,that patients can be cured as speedily, and in some instances more radically, of such inflammation, by homoeopathic medicines, than by purging the patient with drastics, “touching the liver” by means of mer- cury, and enveloping the tumor with a poultice of mush, oatmeal, flaxseed, or slippery elm. - The medicines that are most applicable in the treatment of boils are: arm., bell., calc., hep., lyc., phos., sulph., or alum., antim. C., led., merc., mur. ac., nit. ac., nux vom., Sep., thuj. ANTHRAX, CARBUNCLE. 401 To eradicate the disposition to boils, the medicines are: calc., lyc., nux Vom., phos., and sulph. If suppuration progress slowly, merc. will hasten the formation of pus. When there are stinging pains in the boil, the medicine is nux wom. When there is troublesome itching, carb. veg. or thuja, the latter particu- larly when the redness extends to some distance around. If the pain is lancinating, calc. carb. If the pain is stinging when the boil is touched, lyc. If this be present during motion, mur. ac. If burning, colocynth. If there is burning pain, extending to some distance around, antim. crud. Dr. Gallupe, of Bangor, has seen good results follow the exhibition of crotalus horridus in furuncle. There are also many other remedies mentioned for boils appearing on different parts of the body, but it is probable that if the above symptoms are present, the medicines will relieve without regard to locality. However, the student is referred to the Symptomen Codex, to ascertain the particular ºn of the boil, if the treatment above recommended has been unsuc- cessful. . - Berberis vulgaris is an excellent medicine to hasten suppuration in boils, and by its proper administration has removed the predisposition to them. In the British Journal of Homoeopathy, for July 1st, 1861, p. 499, is de- scribed the lotion (so highly lauded by Rademacher) of the solution of cal- Carea muriatica. This I have used topically for boils, but think it better adapted to anthrax. - Dr. Dudgeon has witnessed the beneficial effects of the solution. The prescription is as follows: B. Calc, mur., . . . . . . . . . . . . 3iij. Aquae purae, tº tº tº cº e © e tº § iij. M. * Kallenbach, Sr., of Utrecht, has given an excellent paper on the subject. In Hale's New Remedies, asclepias, erigeron, gnaph., nymph., phyto., and Sanguin., have all been proved to be beneficial; and hamamelis, iris ver, : stillingia would, by provings, seem to be indicated as efficient reme- 16S. . - Anthrax, Carbuncle.—A carbuncle is, in some respects, analogous to a furuncle, though the former is much more dangerous, the inflammation being more extensive and gangrenous in character. This inflammatory swelling must not, however, be confounded with the charbon, or malignant pustule, of which something will be said further on. The tumor is deep-seated, hard, and circumscribed, and rapidly advances, becoming livid, and attended with severe burning or lancinating pain. The inflammation, as has been before stated, is of the asthenic type, and attacks the skin and subjacent areolar tissue. As the inflammatory process progresses, the tumor becomes soft, of a purple hue, and spongy; suppuration, ulceration, and sloughing of the cel- lular tissue supervene, and numerous small apertures form in the skin, through which a thin sanious pus is discharged, together with the disinte- grated areolar tissue. This condition is one of the most important diag- nostic signs between anthrax and common boil, for in the latter, however large, there is but a single opening. The usual situation of carbuncle is the back, from the nape of the neck to the pelvis, though any portion of the body may be attacked. The size varies from that of a chestnut to that of the palm of the hand, the con- 26 402 A SYSTEM OF SURGERY, TOE ） » +→ -- TE 2 ~ ~ ~~ ----Eſ= |-！5 ºg º £ ğ.2 ± -º?-- g º ? £5） E = "№ §§§ = = = TĒ º = º ºg E „º （ſ. 5 =E= un 35 º ~~' += ',_'， → ∞， +） º ：） ---- .22 ）, º ± − × 3.-5. § > ！ o 5 -- 25 E 2 № 5.5 | ž， š Ž ž $ € £ § € £ § 53 S? ? º º INJURIES AND DISEASES OF THE WEINS. 479 three inches downward on a line which, if continued, would reach the middle of the instep; the aponeurosis and fascia should be dissected up as already mentioned; then, with the finger or handle of the scalpel, sepa- rate the extensor muscles from the tibialis anticus; the artery then comes in view with the anterior tibial vein on its inner side, and can be secured. * In the lower part of the leg the operation for ligation may be performed at several points. This incision is made along the course of the artery as indicated by the line which has already been mentioned. The integument, fascia, and aponeurosis are divided, and the fibres of the extensor longus pollicis are exposed. This muscle must be separated from the surrounding tissues and drawn with retractors to the side; when the artery is found beneath it. On the internal side of the vessel is the anterior tibial vein. The ligature should be passed from the inside toward the outer side. Ligature of the Dorsalis Pedis.--Anatomy.—Same plate (Fig. 233) repre- sents the dorsalis pedis emerging from the leg to the ankle. The artery, with the ligature underneath, is distinctly seen; internal to which is the tendon of the extensor longus pollicis; externally, the tibialis anticus nerve is found; external to which are the fibres of the extensor brevis digitorum pedis. Operation.—An incision should be made two inches in length, in a line carried from the middle of the instep to the first interosseous space. The integument is dissected up for a little distance; then the incision is carried down in succession between the tendons of the first two toes and until the deep fascia is reached; this is divided upon a director, and the artery is exposed at its internal side, having the tendon of the extensor longus pollicis internally, and externally the anterior tibial nerve. CHAPTER XXVI. INJURIES AND DISEASES OF THE WEINS. THROMBOSIS-THROMBALLOSIS-COAGULATION IN VEINS-THROMBUs–PHLEBITIS- VARIx—ENTRANCE OF AIR-WoUNDS—PHLEBOLITHES. BY these terms are understood those manifestations and changes which occur from coagulation of the blood within the veins, and by some within the arteries also. Virchow” proposes to drop entirely the old terms phlebitis and arteritis, and substitute the word thrombosis, “inasmuch,” he says, “as the affection essentially consists in a real coagulation of blood, at a certain fixed point.” There has been a good deal of confusion of terms in both diseases of arteries and veins, and to prevent future misunderstanding in this volume, thrombosis will signify the coagulation of blood in veins, and embolism the formation of clots in arteries. Thrombosis occurs, in some instances, from the spontaneous coagulation of blood fibrin, or by the formation of clots after injuries, while the method of repair is being carried on, or from slow and imperfect circulation, occa- sioned either by unwholesome food, pressure of tumors, or defective nutri- tion. The clots may increase either in the direction of the current of the blood or against it, and when they commence forming, a true phlebitis may also set in, thereby assisting the clot deposit. After the coagulum has ex- isted for a time, it slowly contracts upon itself, and is retained in its posi- * Cellular Pathology, p. 233. 480 A SYSTEM OF SURGERY. tion by the firm fibrinous processes which attach themselves to the vein- Wall; it may be more closely fastened to one side than the other, and the blood may thus regain a passage by flowing between the clot and the wall of the vein. When the thrombus is so large as to entirely arrest the circulation and terminates in obliteration of the vein, there of course follows great Oedema, which is of remarkable paleness, and is called “the white leg.” To this there is often a state of inflammation superadded, softening and disinte- gration of the fibrin, and a puriform substance is generated. This sub- stance was formerly supposed to be pure pus, whereas later investigators prove it to be puriform. When thrombosis affects a limb, the constitutional disturbance at first is not very severe; the face feels hot and dry, with considerable stiffness; the surface veins are found hard and corded, and when the inflammation is established its usual symptoms appear. If with these symptoms there is an injury or bruise, the diagnosis will be sufficiently clear. The prognosis of thrombosis depends upon the size of the vessel affected and the magnitude of the clot; when both are large, nutrition is much in- terfered with, and if portions of the clot separate and are carried into the circulation, symptoms of pyaemia may supervene. Treatment.—In the first stages of this disease, aconite is the appropriate medicine, and must be given often and in fair doses to produce a percepti- ble effect. When the symptoms are further advanced and evidences of suppuration appear, then hepar sulph., mercurius, cham., lycop., and sulph., are appropriate medicines. When the oedema begins, an elastic bandage or stocking must be employed and perfect rest enjoined. In the treatment of this affection there is yet much uncertainty, its true pathology having been so recently recognized, which, together with the rarity of its occur- rence, has permitted but little therapeutical experience. I should select rhus radicans, lachesis, or hepar sulph. in addition to those medicines mentioned above. Phlebitis.-Inflammation of the Veins.—Phlebitis may be either acute or chronic ; the former may terminate fatally if not arrested; the latter is not dangerous, and generally affects varicose veins of the lower extremities. In acute phlebitis the countenance of the patient expresses anxiety and de- pression of spirits, there are repeated rigors, dry, brown, or blackish tongue, cadaverous skin, great prostration, pulse rapid and weak, muttering deli- rium, and vomiting of bile. - Consecutive abscess is said to be a characteristic termination of acute phle- bitis; excessive pain may be experienced in any of the joints, which is rapidly succeeded by a copious formation of pus; purulent formations may, after this, collect in other parts of the body, especially in the lungs and liver. Many of the symptoms formerly attributed to phlebitis are now known to originate from thrombosis; in fact the ordinary suppurative phlebitis, says Mr. Holmes, “is nothing more than a diffused phlegmonous inflammation, and should be reclassed with disorders of that character.”* Treatment.—The treatment of acute phlebitis is somewhat difficult, which, in many instances, is owing to the disjointed character of the homoeopathic Materia Medica. However, for the presenting symptoms, particularly in the first stages of the affection, when the fever is high, with a quick, full pulse, dry, furred tongue, etc., aconite should be employed. If after a time the brain appears to participate in the disease, belladonna * Holmes, System of Surgery, vol. iii., p. 302. VARIX—TREATMENT, 481 is indicated; but the medicine that is best adapted to inflammation of the veins is pulsatilla, which may be employed after aconite or belladonna, in the first stages of the inflammatory process; but when the tongue becomes dry, brown, and cracked, when the patient is much prostrated, with burn- ing thirst, and hot, dry skin, arsenicum is distinctly required. Carbo veg. may be prescribed for a somewhat similar group of symptoms, and perhaps would be a preferable medicine, when the action of the arterial system has been almost entirely overpowered, and venous congestion is indicated by a blue tinge of the skin over the whole surface of the body, attended with anguish about the heart, and icy coldness of the surface. e If suppuration threaten, or if it have actually occurred, and the amount of purulent secretion is considerable, silicea should be administered, or the case may strongly call for hepar, merc. Sol., or sulphur. For chronic phlebitis, besides the medicines just mentioned, arn., cham., lyc., nux vom., spig., or zincum, may be demanded. Hamamelis is one of the most suitable medicines for the chronic form of phlebitis, which together with pulsatilla and lachesis, are more to be relied upon than any other medicines. The last named was efficient in the hands of Mr. Ayerst. Lachesis.”—Dr. Dunham relates the following: “I have three times been called to cases of chronic ulcer of the lower extremities, probably of syph- ilitic origin, in which the discharge had ceased, the extremities became Oedematous, and a hard slightly red swelling, extending up along the course of the principal veins, together with great and sudden prostration of strength, low muttering delirium, and typhoid symptoms, gave good reason for sup- posing that general phlebitis had occurred. In these cases a careful study of the symptoms induced me to give lachesis; the effect was all that could be desired, the patients rallying promptly, and all the symptoms of phlebitis speedily disappearing.” Varix.-The term varix designates an hypertrophied condition of the veins, in which they are divided into irregular pouches, in consequence of not being able to sustain the reflex column of blood. In other cases the walls of the veins become thinner than usual, or may be unequal to their dilatation. Deepseated as well as superficial veins are frequently rendered varicose by undue muscular action, by interruption of the circulation from ligatures, by the pressure of tumors, and by the gravid uterus. The veins of the upper extremities are rarely affected with hypertrophy, while those of the lower, especially the Saphenae and their branches, are very liable to the disease. In the commencement, numerous small circumscribed swell- ings are observed, but after a time the venous trunks and branches appear enlarged throughout their whole extent; sometimes they are knotted or doubled upon each other, and these gyrations are particularly conspicuous in the neighborhood of the valves. An enlargement of the veins may continue for a considerable period without giving much inconvenience to the patient; but in the generality of cases, after the veins have attained any magnitude, a sense of soreness, weight, fulness, and fatigue of the limb are experienced. "The feet are cold and the veins become more prominent, corded, and swollen, particularly after exercise, or when standing. Sometimes the thin walls give way and profuse hamorrhage results. After these varicose enlargements have con- tinued for a time, the parts are deprived of their vitality, there is an obstruction of the absorbents, and the varicose wicer is produced (vide page 133). Treatment.—The opinion was long entertained that any attempt to * American Homoeopathic Review, vol. iv. 31 482 A SYSTEM OF SURGERY. operate upon veins was a rash procedure and fraught with extreme peril. Experience, however, has shown that in many cases this appre- hension is unfounded, and I am satisfied, from my own experience in operations for varicose veins in different portions of the body, that, with a moderate amount of care, untoward symptoms will not occur. . There are different methods of obliterating varix. Those which I have found most ºnd successful are with the caustic paste and by the subcutaneous method. The first is effected as follows: Prepare equal parts of caustic potash and quick-lime. Mix them together with sufficient alcohol to make a paste, and then, with a glass .. apply the mixture to the vein. After having allowed it to remain for a few minutes, wash off the eschar with vinegar, and wait for the separation of the slough. If sufficient caustic has not been used, a second or third application may be necessary. Sometimes as the dead portions separate, quite a haemorrhage follows, which, how- ever, is readily checked. This process I have repeatedly resorted to with success, as I have also the following: Place beneath the vein, about three inches apart, two hare-lip pins, twist over each of them a piece of silver wire, then introduce a narrow tenotome flatwise beneath the vessel, turn the sharp edge outward and divide the vein, taking care not to bring the edge prough the integument. After a few days the pins are to be re- IOC)VéOl. Sir Benjamin Brodie thus writes: “For this operation I have generally employed a narrow, sharp-pointed bistoury, slightly curved, with its cutting edge on the convex side. Having then ascertained the precise situation of the veins or cluster of veins from which the distress of the patient appears principally to arise, I introduce the point of the bistoury through the skin on one side of the varix, and pass it on between the skin and the vein with one of the flat surfaces turned forwards, and the other backwards, until it reaches the opposite side. I then turn the cutting edge of the bistoury backwards, and, in withdrawing the instrument, the division of the varix is effected. The patient experiences pain, which is occasionally severe, but which subsides in the course of a short time. There is always hamor- rhage, which will be often profuse if neglected, but which is readily stopped by ºrate pressure, made by means of a compress and bandage correctly applied. . Pº Cartwright and also Mr. Mayo apply over the course of the distended vessel potassa cum calce, which causes sufficient inflammation to produce coagulation of the blood and occlusion of the vein. Velpeau advocates the twisted suture alone. Davit passed needles through the veins at right angles with transverse needles previously introduced beneath the vessels. Others apply the galvano-puncture, and others again the injection of the perchloride of iron. An excellent method may be found in having a pin constructed after the fashion of an ordinary diaper pin used in dressing infants; pass the sharp point behind the vein and bring down and catch upon its point the clasp, having laid a piece of linen over the integument to prevent too much abra- S1OI). In the treatment of superficial varices, Cazin, referring to these cases and the avoidance of phlebitis or pyamia, recommends the following procedure: An incision, three centimetres long, is made parallel to the vein, and at a distance of one centimetre from it. At the two extremities of this incision two others are made transversely towards the vein, and reaching to it. This flap is dissected up and the vein is isolated by a blunt instrument. The flap is next passed beneath the vein and replaced in its original position EXCISION OF THE WEINS–ENTHANCE OF AIR. 483 and fastened, the vein remaining thoroughly isolated without any ligature having been used. - Great advantage may be derived from allowing the patient to encase the limb in an elastic stocking, which is constructed especially for the treat- ment of varicose veins; this should be constantly worn, and at the same time medicines should be internally administered, which are chiefly agaric., ars., particularly when the veins are of a livid color, and attended with severe burning pains; bell., when erysipelatous inflammation surrounds the varices; carbo veg., graph., lyc., puls.; the latter is perhaps the most efficacious medicine when there is considerable inflammation, excessive pain and swelling, and when the limb assumes a livid hue; arnica is a valuable medicine in the treatment of this affection; it is particularly use- ful when the patient is obliged to maintain an erect posture for a length of time, or when the veins have become diseased in consequence of wounds or blows; very beneficial results have been obtained by the exhibition of arnica and pulsatilla in alternation, a dose every night. Hamamelis virginiana has been highly recommended by Dr. Okie, of Providence, in the treatment of this affection. It has been used with beneficial effect both as an external application and as an internal medicine, and has done me good service in several cases. Excision of the Weins.—Excision of the vein in varix may be performed in º ways. Dr. Fry + has formulated his method in the following WOrCIS : “1. Excise through several small incisions not more than two inches in length, leaving one large piece, as by so doing the vein is included at seve- ral points. “2. Mark the site of the intended incisions before applying the bandage, as the position of the varix becomes identified with the limb when it is rendered bloodless. - “3. Apply the Esmarch bandage carefully to thoroughly empty the bloodvessels, or the wound becoming full of blood, there will be considerable difficulty in dissecting out the vein and very troublesome haemorrhage may OCCUIT. {{ i Ligate the vein at its upper end and dissect it out from above down- WarCIS. “5. Remove as little as possible of the tissues surrounding the vein, but if it is unavoidable take away the deeper tissues which are well supplied With blood. - “6. Apply the dressing and bandage to the limb before removing the tourniquet; by this means hamorrhage is avoided, and primary union en- couraged. “7. Above all be careful to employ antiseptic measures during the opera- tion and in subsequent dressings.” Entrance of Air.—The entrance of air into veins is an untoward acci- dent, and has occurred many times in the practice of distinguished sur- geons. The accident is so immediately followed by alarming, if not fatal consequences, that it must always be regarded as a serious complica- tion. The symptoms which indicate the presence of air in the veins are the sudden and peculiar gurgling noise, similar to that heard when pouring a fluid from a bottle, with sudden prostration, rapid collapse, and death. The air probably passes into the lungs, and there arrests the circulation of both systems, and complete stoppage of respiration takes lace. p Prof. Hamilton details an interesting case of this kind (in which, however, * British Medical Journal, September 5th, 1885. 484 ge A SYSTEM OF SURGERY. his patient was saved) in his chapter on Enlarged Lymphatic Glands of the Neck. The following are supposed to be the conditions which predis- pose to the entrance of air into the veins: “Incision of a large vein in the vicinity of the heart, and especially in the lower anterior portion of the neck, where these vessels experience a reflex pulsation. Canalization of a vein, in consequence of a thickening of its coats from morbid deposits, or in consequence of fibrinous infiltrations into the adjacent tissues, or owing to its being more or less imbedded in a solid tumor, either of which circum- stances converts the vessel into a rigid incollapsing attachment of the outer wall of the vein to the base of the tumor, so that in lifting the latter the two walls of the vein become drawn asunder and collapse is prevented, when the blood escapes. Traction made upon the outer wall of the vein by the forceps, or by tension of the overlying structures, or a deep inspiration º the moment of dividing the vessel may accomplish the same re- Sult. - It is only necessary carefully to read the above causes of this serious accident to prevent its occurrence, and if it should transpire, arrest of haem- orrhage by immediate compression and rapid artificial respiration are all that can be done. - Wounds of the Weins.—The veins are frequently wounded during the per- formance of operations, but the haemorrhage can generally be arrested by properly applied pressure; in Some instances, however (though the pro- ceeding, if possible, should be avoided), ligatures become absolutely neces- S3,I’W. º such instances, the threads may be applied at both ends, and as a gen- eral rule, without danger. If possible, however, the ordinary acupressure pins, if introduced beneath the vein, and allowed to remain for a few hours, will prove efficacious and safe. Phlebolithes.—Loose calculi are sometimes found in veins, to which the term phlebolithes is given; these peculiar formations are found growing to the inner coats of the vein, are oval in shape, and attached by a narrow pedicle. There are many conjectures concerning their formation, the most plausible being that they are the transformations of inspissated coagula. They appear to move from place to place in the circulation, the pedicle having broken from its attachment to the inner coat by the force of the stream of blood. They are composed almost entirely of protein material and phosphate of lime. (Wide Thrombosis.) CHAPTER XXVII. DISEASES OF THE CAPILLARIES. ERECTILE TUMoRs—NAEVI—TELANGIECTASIS. THE erectile tumor of arteries occurs most frequently in the submucous and subcutaneous cellular tissue about the head, face, and neck; but may also exist in nearly every part of the body, and has even been found in bones. It is soft, compressible, of a slightly higher temperature than sur- rounding parts, pulsates synchronously with the beats of the heart, and has a peculiar bruit, which is sometimes loud and harsh, at other times soft and cooing. This peculiar bruit, the distance of the tumor from any large * Hamilton's Principles and Practice of Surgery, p. 189. TREATMENT OF NAEVUS. 485 artery, and its less forcible pulsation, will serve to distinguish it from aneu- rism. It varies in color according to situation; when deeply imbedded in Subcellular tissue, the tumor presents a bluish appearance, but when situ- ated on the surface it is generally of a vivid scarlet. Capillary navi are flat, slightly elevated, and of a red or purplish hue; they are usually small, and occur most frequently on the head, face, neck, and arms. The contained blood may be arterial or venous, or a mixture of the two. - As a general rule, these growths do not attain a size much larger than an egg. Fig. 234, taken from a photograph, represents a case of my own, in which the growth had attained the size of half an ordinary melon, and for which I FIG. 234. ligated the common carotid below the omo- - " … hyoid, after failure by other means. At first the tumor diminished one-half, remained sta- tionary for a time, and then disappeared. In an interesting paper by Dr. George H. Hub- bard, entitled “The Big Naevus,” the growth measured twelve inches in its long diameter and eight in its transverse, “and extended from the second dorsal vertebra nearly to the crest of the ilium.” * , , , , - g The tumor was ligated in mass with needles w; fl.º.º.º.º.º. #. a foot in length, armed with whip-cord; during gated below the omo-hyoid. the sloughing period it was constantly soaked with a solution of the sulphate of iron. In six weeks the man went to his work. In three months more there only remained an unhealed surface the size of half a dollar, but shortly after, an abscess formed beneath the latis- simus dorsi, which never healed, and finally caused the death of the patient. Treatment.—It may be laid down as a general rule, that the treatment of these cases must be purely surgical. When the navus consists of a simple red spot, it may be cured by vacci- nation, or by application of collodion with pressure. When situated over a bone, the tumor may be treated by compression with pads of ivory or other hard substances. External application of nitric acid, setons, and the passage of one or more silk threads soaked in some caustic solution, have also been recommended. Some surgeons prefer nitrate of silver or the actual cautery. Injections of persulphate or perchloride of iron, sulphate of º lactate of iron, matico, tannin and other astringents, may prove llSéIUll. Dr. John Pattison treats navi by injection of persulphate of iron, fol- lowed by enucleation in the mannér described under cystic tumors. Gross speaks highly of the topical application of “Vienna paste.” Sometimes Small navi may be cured by breaking up their substance subcutaneously with a cataract-needle or tenotome and applying pressure. Puncture with º needles or acupressure pins has been advised by Dr. Valentine Ott. - Dr. Hamilton has succeeded in removing superficial navi in the neighbor- hood of the eyelids, where eversion of the lid must have followed removal of the integument, by dissecting up the skin covering the navus, cutting away the subcutaneous areolar tissue, and then replacing the flap. Perhaps the best method of treating navi is by electrolysis or galvano- puncture. Many successful cases are upon record treated by these methods. * Transactions of the Medical Society of the State of New York, 1870. 486 A SYSTEM OF SURGERY. The student may refer to page 58 for a full description of the method of performing electrolysis. Division of the soft parts around the tumor is recommended by Mr. Lawrence. Fergusson treats small naevi by passing a pin beneath them, and then compressing the tumors between the pin and a loop of wire, as in the third method of acupressure. For tumors composed of dilated veins, subcutaneous incision and con- tinued bandaging is excellent. Naevi may also be treated by the following methods of ligature: 1. Pass two pins or needles beneath the naevus, at right angles with each other; then throw a ligature behind them, and tie it tightly. The pins should be introduced and brought out at least one-eighth of an inch from the margins of the tumor. 2. Dr. Barton’s method is similar to the above, with the exception that the ligature is first passed behind the pins, and then carried over the top of the tumor. 3. Pass beneath the tumor a needle threaded with a double ligature, and tie the ends so as to strangle each half of the naevus separately. - 4. Liston’s method: Pass two needles threaded with double ligatures, cut each noose and tie the contiguous ends of the ligatures. By drawing the last knot very firmly, all the other nooses are tightened and the knots dragged toward the centre. When the tumor is entirely subcutaneous, and the surgeon desires to avoid an unseemly scar, the skin may be di- . by a crucial incision and the flaps turned down before passing the IleeCII6S. 5. Erichsen’s method: Take a strong whipcord three feet in length, stained one-half black, the other half white; thread a long needle upon the FIG. 235. FIG. 236. * . aſ ''f's º iſ iſ " º, |: ſh, Nº.%. FIG. 235.-Ligature for strangulating a large naevus. The white loops are divided on one side, and the black on the other, and the corresponding ends (A A', B B') tied together. The terminal strings C C may be either tied or withdrawn, as the surgeon thinks best. FIG. 236.-Subcutaneous ligature of naivus. The upper figure shows a single ligature carried round the tumor. The lower (in which no tumor is dºñº double string carried below the centre of the base, then divided into two, A A' B B', and each of the two carried subcutaneously round half of the navus, and then tied. middle of this cord. Then commencing at about one-quarter of an inch from the end of the tumor, pass the needle several times beneath the navus. The loops should be three-quarters of an inch apart, and the last one brought out through the healthy tissue beyond the tumor. (Fig. 235.) “Thus we have double loops—one white and one black—on each side. Cut the white loops on one side and the black on the other; then tie firmly the TREATMENT OF NABVU.S. 487 white threads on one side and the black on the other,”* and the navus is effectually strangulated. 6. Fergusson’s method: “A double thread is thrust transversely beneath the centre of the tumor and divided in the middle. Next, one end of the thread is passed through the eye of a long needle (the eye near the point), and having been brought one-fourth around the circumference of the tumor, is thrust transversely through its base. Then it is to be disengaged from the eye of the needle, and the other thread to be put into the eye and to be carried back with it. Lastly, the adjoining ends of the two threads are to be tied tightly, so that each of the two threads shall include an 8-shaped portion of the tumor; after two or three days the ligatures should be tight- ened or fresh ones applied.”i 7. Mr. Curling proposed subcutaneous ligation, which may be performed in the following manner: A needle threaded with a stout ligature is passed beneath the middle of the tumor, then the needle is withdrawn and the ligature divided into two threads. “One end, being passed through the eye of the needle, is thrust into the second wound, and carried semi- circularly round under the skin and brought out at the first wound, where it is seized and held firmly whilst the needle is withdrawn. One end of the other thread, being in like manner put into the needle, is thrust in, and carried round under the skin, on the right side, and brought out as the first. The operation is completed by tying the ends very tightly, so as to Strangle the half of the base of the tumor, encircled by each respectively. The ends are to be left and fastened with plaster, so that they may be tightened if requisite and drawn out, as the base of the tumor perishes by ulceration.”f 8. Mr. Startin proposes to pass the ligatures subcutaneously, attach them to rubber rings, and make traction upon the tumor by means of tapes tied to the rings. . When the navus is not situated in the vicinity of any large artery, it may be excised by carefully dissecting it from the cellular tissue. Great care must be observed not to puncture the tumor during the operation, for this accident is always followed by profuse and obstinate hamorrhage. For large vascular naevi Dr. William Gibson, of Philadelphia, has recom- mended partial incision, which is performed in the following manner: One- half of the tumor is dissected up, the bleeding vessels secured, and lint interposed between the raw edges to prevent union; then, after a few days' interval, the operation is repeated, and the tumor completely excised. Very large navi may require three or four operations. When the tumor is inaccessible to knife or ligature it has been proposed to ligate the nutrient arteries. This is often successful when the tumor is situated in a non-vascular part, but ligation of the carotid for naevi of the head and face often fails on account of extensive collateral circulation. Amputation even is sometimes necessary in naevi of the limbs. * Gross's Surgery, vol. i., p. 787. f Druitt's Surgery, p. 315. f. Druitt's Surgery, p. 116. 488 A SYSTEM OF SURGERY. CHAPTER XXVIII. THE NERVOUS SYSTEM AFTER INJURIES AND OPERATIONS. SYMPTOMS OF SHOCK–TEMPERATURE DURING—SECONDARY SHOCK–TREATMENT— TETANUs – Wounds of THE NERVEs – NERVE STRETCHING – NERVE SUTURE— NEURALGIA. AFTER surgical operations of magnitude, when there has been a large amount of tissue removed, or excessive haemorrhage; when the patient has been a long time under anaesthetic influence; when a large quantity of fluid, either serum or pus, has escaped, or where closed cavities have been opened, there is always a greater or less degree of nervous prostration, which is denominated “shock.” The nervous system has a powerful influence over the action of the heart and vessels, and death has been known to result without any assignable cause, excepting that which can be attributed to the nervous system. I recollect an instance of this kind. I was present at the post-mortem examination of a young lady, who had been unwell for a few days, but who on the evening before her death had been enjoying the Society of her friends, and accompanied them to the street-door of her resi- dence at their departure. On retiring for the night she took, by the direc- tion of her physician, a dose of the 200th potency of rhus. In the morning she was discovered dead in her bed. The coroner was called to investigate the matter. A most thorough post-morten examination was made, every organ in the body carefully and minutely inspected, the fluid from the ven- tricles of the brain, the stomach, and bladder examined by professional chemists, but no cause whatever could be discovered for her demise. Many other similar cases are upon record. Dr. H. C. Cameron relates two inter- esting cases. He says:* “Some years ago I had occasion to make an incision in the leg of an old soldier, and as he was very bronchitic I persuaded him to dispense with chloroform. The moment the incision was made, he Screamed, gave vent to a volley of oaths, and almost immediately expired. A post-mortem revealed nothing beyond evidences of old bronchitis, and of advanced granular disease of the kidneys. I was asked to see an elderly lady with a small tumor in the groin, which was causing her no uneasiness but great anxiety. She was said to be the subject of fatty heart, prone to attacks of syncope, and with a weak and often irregular pulse. The tumor was evidently a small femoral hernia, and on trying to move it a little from side to side, it slipped with a gurgle from between my finger and thumb and passed up. I said to her, ‘Did I cause you any pain?”. She replied, “Not in the least.’ I then asked her to feel the tumor now. On discovering that it had gone, she was evidently greatly startled and surprised, no doubt pleasantly so, for it had been much in her thoughts. Almost immediately she complained of feeling faint and asked for some cold water...This was supplied, but her syncope deepened and in about ten minutes life was ex- tinct. These are examples of shock following respectively upon sudden pain and sudden mental emotion.” With a knowledge of these facts, it is evident that sudden and severe impressions upon the nervous system some- times produce such a decided action upon the circulatory apparatus that * Glasgow Medical Journal, March, 1884. SHOCK. 489 Symptoms of the gravest character, nay, death itself, may be the conse- quence. The symptoms of shock or collapse, once having been witnessed, can never be misapprehended. The lips are blanched, a deadly pallor overspreads the face, the skin is cold and clammy, drops of cold perspiration appear upon the forehead, a dull leaden hue overspreads the face, the ex- tremities are cold, the nose is pinched, sometimes the nostrils are dilated, the eye partially glazed and slightly turned in the socket, with a drooping lid. The pulse is fluttering and tremulous, and the heart is feeble, with temperature of 96° or 97°. In fact, the symptoms resemble those often seen in cholera, as the patient sinks into collapse, or in cases where fatal haemor- rhage is stealing away vitality. As reaction takes place the pulse loses its - “whirring ” beat, the motion of the heart, though feeble, becomes much more regular and a little “rounder,” and as the blood begins to flow into the larger capillaries an increased temperature and decreased pallor result, the eye becomes more natural in expression, and warmth gradually diffuses itself over the surface. With these symptoms of returning life there are generally long-drawn respirations, and the patient becomes rather restless. These symptoms may continue until the unmistakable presence of increased action shows that fever has commenced, a condition which must be as care- fully watched; for if the action is excessive, and flushed face, intense thirst, delirium, jactitation of muscles, insomnia, and other well-marked indica- tions of a high degree of nervous irritability succeed, the prognosis is unfa- vorable, and hiccough, convulsions, coma, and death may ensue. It is well, also, to bear in mind that these symptoms often vary very much in intensity and duration, and require the utmost care and watchful- ness of the surgeon. Some patients may never fully recover from the effects of a severe shock, though they may be able to perform imperfectly the usual duties of life. In an interesting essay on this subject by W. W. Wagstaffe, F. R. C. S. E., published in St. Thomas’s Hospital Reports, are several tables which show the fall of temperature in the fatal and non-fatal cases. In eighteen cases of operations, embracing ovariotomy, hip-joint operation, herniotomy, and the removal of tumors, the difference in the fall of temperature in the fatal and non-fatal cases was as follows: Non-fatal, mean fall, 0.3°; in the fatal, 3.70°. From this it is inferred that if there be no especial cause for shock before an operation, the thermometer should not fall more than 1°; and if it is more than this, an unfavorable prognosis may be anticipated in pro- portion to the downward tendency. The following table, taken from the article in question, shows the fall of temperature in certain forms of surgical injury: NOT FATAL. FATAL. ar A mean fall. A. Burns and scalds, & tº º e e tº º O.19 3.59 Severe fractures, e ſº © * * tº te 1.69 2.10 Operations (without undue haemorrhage), e & 0.39 3.09 B. Concussion of brain, . Q tº º te & 1.29 6.19 Injury to spinal cord, . . . . . . 5.60 C. Visceral injury (extravasation into peritoneum), . 3.30 3.89 D. Haemorrhage, wº & tº º e g 2.29 The employment of the thermometer is, therefore, found to be a useful adjunct in forming a prognosis, both before and after surgical operations and injuries. In some constitutions there is another condition produced by accidents and operations, which is not nearly of so acute a character as that already described, and which is termed by some surgical writers Secondary Shock. In these cases the patient appears to rally, and reaction to be somewhat 490 A SYSTEM OF SURGERY. established. There are no particular symptoms excepting, perhaps, occa- sional weakness; the pulse is moderately good and the mind active; yet the countenance becomes dejected, the skin sallow, the functions of different organs impaired, and although nature makes strenuous efforts to react, the shock has been too great for the system to withstand, and the patient ulti- mately succumbs. Different temperaments suffer in different degrees from the effects of shock; this is especially noticeable in gunshot wounds and railway acci- dents, where many individuals are affected with different degrees of col- lapse. No doubt in these cases, the suddenness of the injury, combined with a certain degree of mental excitement, assist in producing the collapse. Mental emotions, weak constitutions, debauchery, and excess of any kind, or advanced years, are all predisposing causes of shock, and must be taken carefully into the consideration of each particular case. Prof. Von Nussbaum remarks, that many deaths after injuries and opera- tions, attributed to shock, are really the result of other causes. He believes that, in cases of rapid absorption of septic peritoneal contents, death is caused by septicaemic collapse. Then there is the sudden death of old people after a day or two's satisfactory progress, death resulting from the hamorrhage caused by the operation, although its effects are not apparent until the final collapse takes place. The sudden fatality, after severe rail- way accidents and their consequent amputations, he attributes to “fat-em- bolism,” showing itself in dyspnoea, oedema of the lung, and death. Death also results from sudden and extensive cooling of the abdominal viscera, the abstraction of heat having been found by Wegner “to be a competent fatal agent.” To sum up, the conditions apt to be confounded with shock are, “septicaemia, senile anaemia, fat-embolism, in crushing of bones, and abdominal cooling.” Treatment.—The first object of attention in the treatment of shock is to ascertain the condition of the heart, and whether its 'action is altogether suspended. If it be, and there is reason to suppose the organ has for some time ceased performing its function, little can be done; but even in such cases it is well that electricity be applied, together with frictions to the ex- tremities. Artificial respiration should also be resorted to. For ordinary cases of severe shock there are homoeopathic medicines which are of great service. Of these, camphor, veratrum, arsenicum, and china are, as far as my experience goes, the best, and the surgeon will scarcely be called upon to use any others. Camphor, when demanded, should be given in one or two drop doses every ten or fifteen minutes when the body is cold and clammy, and when the shock is sudden. With the internal administration of this medicine, frictions to the extremities and warm applications are to be perseveringly tried, and if improvement does not supervene, then veratrum is the medicine par excellence. The patho- genesis of this extraordinary medicine, its great value in diseases which are liable to terminate in collapse, and its great reliability and uniformity of action, render it of signal service in these affections. It is especially called for when, in connection with other symptoms, there is nausea and vomiting. Prof. John C. Morgant adds the following medicines to the list: Capsi- cum, calamus (especially after profuse hamorrhage), cuprum, nux mos- * London Medical Record, May 15, 1877; Monthly Abstract of Medical Science, July, 877. f Franklin's Science and Art of Surgery, vol. i., p. 618; and Transactions of American Institute of Homoeopathy for 1869, p. 112. TETANUS. 491 chata, aconite, arnica, strontiana, chloroform, digitalis, nux vomica, ammo- nium-causticum, carbo vegetabilis, mercurius, natrum muriaticum and phosphorus. Stimulants.-The question arises, and it is an important one, as to the propriety of administering stimulants in the condition of which I am speaking. I have employed them often and with benefit, and again have observed that no satisfactory result followed their administration. I am, however, convinced that the habit of pouring down brandy or whiskey, ad libitum, cannot be too emphatically denounced. I am disposed to be- lieve, that, in the majority of cases, if reliance is placed in the medicines, the patients will do as well, probably better, without stimulants. If the surgeon considers it expedient to use them, brandy is the best, because more prompt. It should be given in tablespoonful doses, of a mixture of equal parts of the best cognac and water. The effects of each dose must be carefully watched, and only repeated when the effects of the preceding one are subsiding. The late Dr. John T. Hogden, of St. Louis, recommended very highly the hypodermic use of gºth to gºth of a grain of atropia in collapse. His first experiments were made in 1866 and 1867, during the cholera epidemic.” He states that within a period of twelve years he employed it in many cases of collapse; among them, in that arising from strangulation of the intestines. Dr. Weber has recommended belladonna for the same pur- poses. This medicine demands a thorough trial in cases of genuine shock as well as in those of collapse. Tetanus.--This disease is well known and is frequently the result of in- juries, and so intractable is the affection under any method of treatment, that its occurrence is always regarded by the practitioner as unfortunate in the extreme; and although the influence that homoeopathy possesses over this, as well as over many dangerous surgical diseases, modifies in some degree the danger of the affection, still, until the light of further investiga- tion be brought to bear upon it, the surgeon cannot otherwise than entertain for it a doubtful prognosis. - Tetanus is characterized by a permanent spasm of the muscles of a portion, or nearly the whole of the body, rendering it stiff and straight. When the spasm presents itself in the muscles of the neck, throat, and jaws, the term trismus or lockjaw designates such a condition. When the muscles of the back are affected, the word opisthotonos expresses the affection, while empros- thotonos denotes an exactly opposite condition; the body being bent for- wards. Pleurosthotomos is the term used when the muscles of the side of the body are affected with tetanic spasm. The disease may be either traumatic or idiopathic; the latter often arises without any assignable cause, and is usually chronic; the former, being acute, follows upon a wound, or other injury, is much more dangerous and of more frequent occurrence. The spinal system is the seat of the disease; there is an “excitable state of the spinal cord and medulla oblongata, not involving the ganglia of special sense. This may be the result of causes altogether internal, as in the idiopathic form of the disease, in which the condition exactly resembles that which may be artificially induced by the administration of strychnine, or by its application to the cord. Or it may be first occasioned by some local irritation, as that of a lacerated wound; the irritation of the injured nerve being propagated to the nervous centres, and establishing the excitable state in them. When the complaint has * St. Louis Medical and Surgical Journal, November, 1866. # Philadelphia Medical Times, February 20, 1878. 492 A SYSTEM OF SURGERY. once manifested itself, the removal of the original cause of irritation (as by the amputation of the injured limb) is seldom of service, since the slighest impressions upon almost any part of the body are sufficient to ex- cite the tetanic spasm.” The brain only becomes affected in the last stage of the disease, when the delirium and stupor supervene that are present before death. Dr. Cullen wrote: “In this disease the head is seldom affected with de- lirium or even confusion of thought, till the last stage of it, when by the repeated shocks of a violent distemper, every function of the system is greatly disordered.” The spasm, in the generality of instances, approaches in the most insidi- ous manner; if trismus is about to commence there is slight difficulty in swallowing, and the patient cannot open his mouth to the usual width, there is also hardness of the muscles about the neck and throat; the spasm increases, the mouth becomes distorted, the pulse quick and irregular, the teeth clenched, and the temporal and masseter muscles become hard and bulging; the face is distorted by the spasmodic action; the corrugatores Supercilii act upon the eyebrows and draw them into angles; the forehead is wrinkled, the nostrils dilate, and the angles of the mouth are drawn back- ward. The orbicularis oris binds the lips firmly on the teeth, which, how- ever, are now always more or less seen, and sometimes wholly disclosed. The expression is indicative of much suffering, and is quite peculiar to the disease; it may, indeed, be said, to be pathognomonic. Hitherto the only muscles that have been affected are the voluntary, but at this stage of the disease the involuntary also become attacked; the first affected is the diaphragm, and consequently breathing is performed with difficulty; the other muscles of the system soon participate, until the whole body becomes fixed and rigid. The arms are the last attacked, but the fingers may retain their motive power to the last. The bowels are consti- pated, and there is difficulty in passing urine, occasioned by the spasm of the muscles of the perinaeum and neck of the bladder. The disease is more common in hot than in temperate climates, and children and adults are more liable to be attacked than youth or aged indi- viduals. At certain seasons portions of Long Island appear especially ob- noxious to the development of the disease. It arises most frequently from wounds, etc., inflicted in tendinous parts that are well supplied with nerves, but it has been occasioned by mere bruises or blows. It also has followed an injury done to the nerves, as when torn in wounds or ligated together with an artery. - The size of the wound is of no consequence, in regard to its influence upon tetanus, as severe incised, lacerated, or contused wounds may heal without its accession, while the disease may appear from a slight puncture or mere scratch. r The duration of time between the infliction of a wound and the accession of tetanus varies. The case which illustrates the shortest period on record, between infliction and invasion, is that related by Prof. Robison, of Edin- burgh, in which a negro expired in fifteen minutes after having torn his thumb with a broken china plate.* If three weeks elapse, the patient may generally be considered safe. Treatment.—The remedies that are adapted, and those that have been most successfully used in tetanus, are acon., ang, arn., ars., bella., camph., cham., cic. vir., cupr. met., hyos., ipecac., ignat., lauro., nux vom., opium, rhus tox, secal. cor, stram., verat. - * Rees's Cyclopaedia, article Tetanus. TREATMENT OF TETANUS. 493 With reference to other treatment of this distressing malady I may remark that, throughout the medical periodicals, numerous cases are recorded as cured by the exhibition of chloral hydrate. From experience of my own, I am disposed to regard it as a valuable medicine. The case was one in which I had resected the head and upper portion of the humerus for caries, resulting from a gunshot wound of the axilla, of sixteen years’ duration. The operation was difficult, pro- longed, and bloody, on account of extensive bony adhesions to the body of the scapula. For ten days after the operation everything progressed well. On the eleventh day, a slight stiffness in the nape of the neck, with some rigidity of the temporo-maxillary articulation, indicated what was to come. Severe tetanus followed; trismus and opisthotonos, with profuse sweating resulted. The spasms were most violent in character, a draft of air, the contact of the spoon to the lips, or movement about the room, producing them. Almost all the medicines recorded above were tried without avail. Chloral hydrate, in ten-grain doses, was given, and immediate relief was experienced. This medicine, with opium, first decimal, finally cured the patient. The recovery was slow; at one time, during convalescence, the patient was covered with herpes circinatus; this disappearing, strangury resulted, and for a long time flushes, with sudden perspiration, depression of mind, and bed-sores, complicated the case, which was under continued supervision for over three months. Upon referring to current medical liter- ature, more cases are reported as successfully treated by chloral than by any other one medicine. A proving of this substance is now being made, from which more reliable data may be afforded. It may be used hypodermically in 5-grain doses. * Dr. Chapard,” in These de Paris, from a review of eighty cases of tetanus, concludes that chloral administered by enema or draught, offers the best hope of Saving the patient's life. Enemata are made by adding the solution of chloral to milk into which the yolk of an egg has been stirred. In a case that came under my observation the calabar bean was used hypodermically with amelioration of the symptoms, especially the spasms of the muscles of deglutition. The formula was: B. Alcoholic extract Calabar bean (English), . * & * ... grs. Vij. Alcohol dilute, . tº tº ſº tº e e - 3.j. M. Of this eight drops were injected every three hours. Atropia in ſo grain doses, hypodermically, is also much commended. M. Demarquay has reported two cases of traumatic tetanus treated by intramuscular injections of morphine. The hypodermic syringe was intro- º: is: into the masseters, and afterwards into any of the muscles most affected. Dr. Kella recommends curare (the arrrow-poison of the Indians, which antidotes Strychnine and removes spasms) as a remedy of great service in tetanus.f E. Brown-Séquard has written an interesting paper on the action of extract of nux vomica compared with that of the curare. A very remarkable cure of trismus is worthy of record:$ A soldier having lockjaw from a wound in the foot, was given over to die. An officer cut a * Monthly Abstract of Medical Science, May, 1877. London Med. Record, March 15th, 877 & d . # United States Journal of Homoeopathy, vol. ii., p. 547. † Journal de la Physiologie; condensed in the United States Journal of Homoeopathy, vol. i., p. 10. & Medical Independent, vol. i., No. 3. 494 A SYSTEM OF SURGERY. piece of tobacco, about three inches square, put it in a pan of boiling water, and, having thus softened it, flattened it out and placed it over the epigas- trium. In five minutes deadly pallor ensued with twitchings, and the jaws completely relaxed. Dr. Bompart* attributes the cure of a case of tetanus to four grams daily of jaborandi (powdered leaves in infusion), given from January 23d to March 3d. At the same time, clysters of eggs, broth, wine, black coffee, and the elixir alimentaire de Ducro, were administered. The jaborandi pro- duced very abundant salivation. Dr. George W. Le Cato reports a cure of traumatic tetanus, in which the symptoms developed two weeks after the accident; these lasted a little over two weeks, during which the patient, besides large doses of chloral, took “more than half a pound of bromide of potassium and nearly two ounces of calabar bean.”f Kalmia latifolia is also reported to have cured tetanus. i ºne-ni. method will be alluded to further on in this chapter. Amputation of the affected part has been employed in some cases with varying results. | Wounds of the Nerves.—The nerves are frequently wounded by cuts, stabs, and in the performance of surgical operations: but they, after a time, are repaired by intervening tissue, through which the nerve-power appears to be conducted. If a nerve is merely pricked, the symptoms for a moment are quite severe; the sensation is sharp and darting, with tingling and numbness below the part injured. With rest, however, these symptoms generally pass away. If a nerve be entirely divided, there is loss of motion and of sensation in the part which it supplies, with coldness and paleness of *: surface, and if the nerve-force is not restored, permanent paralysis results. In the subcutaneous division of tendons a nerve is sometimes divided, as happened to me lately while operating for anchylosis of the knee. In divid- ing the tendon of the biceps the peroneal nerve, which lies in close prox- imity, was cut through. This was followed by immediate paralysis of the abductors and extensors of the foot, which continued for two months, after which motion was entirely regained. Sometimes after a division of nerve- substance, especially if the gap be wide between the severed ends, the parts connect by an enlarged or button-like formation of the extremities; these are excessively painful and occasion great suffering; in such cases a redi- vision has been necessary, and indeed a reamputation may be the only means of relief. Prof. Willard Parker, of New York, has described a condition of the ner- vous system which he calls concussion of the nerves. The first symptoms after the injury are paralysis, then reaction, followed by inflammation, and the patient is left weak or miserable for a considerable time. Treatment.—For an injured nerve rest is essential; the part should be elevated and enveloped in cotton-wool or batting. Twice during the day, frictions made with towels, dipped in a mixture of Salt and whiskey, should be used; and if symptoms of reaction do not appear, a current of electricity ..ºly Abstract of Medical Science, June, 1876; London Medical Record, April 15th, 1876. f Medical News, November 25th, 1882. f Dr. Paul Vogt (Monthly Abstract of Medical Science, March, 1877), in a case of trau- matic tetanus supervening upon an injury to the right hand, and in which there was tender- ness of the brachial plexus, completely and immediately cured the patient, although he had opisthotonos and clonic spasms, by exposing the plexus at the anterior border of the trape- zius, vigorously pulling the nerves centripetally and centrifugally, and freely dividing nerve- sheaths, which were red. NERVE STRETCHING. 495 should be passed through the part. If this treatment does not relieve, in ordinary cases, a few doses of aconite will be serviceable. If after puncture of a nerve there should be swelling, together with sprained sensation of the joints, accompanied with excruciating pains, hypericum is very useful. Other medicines are: moschus, ignatia, camphor, veratrum alb., Strychnia, calabar bean, tabacum, hyoscyamus, Secale, and zinc. Nerve Stretching.—The first experiments in nerve stretching were made by Harless and Haber, in 1858, and in 1864 Valentin arrived at the follow- ing conclusions, which were more recently verified by Paul Vogt : That nerve stretching, in a moderate degree, lengthens the primitive fasciculi of the nerve trunks, and by decreasing their calibre, frees them in a greater or less degree from the pressure exerted upon them by their sheaths, and that the microscope, even after quite extensive stretching, does not discover anything abnormal, excepting that, at certain points, the nerve substance appears to be separated from the neurilemma. According to further experiments, the fact is apparently proven that “the excitability of a nerve trunk, and the reflex excitability of the parts supplied with it, are lowered by prolonged stretching.” Various experiments were made to answer the following postulates; First. Does the forcible extension of a nerve trunk act especially on the central ganglion or organ 2 Second. Does the stretching, instead of affecting the origin of the nerve, produce changes in the organ supplied by its terminal (peripheral) extremi- ties 2 * Third. Is the power of a nerve, thus treated, altered as a conductor of sensibility ? - With regard to the first point, it has been found that the central organ is not materially affected by stretching; to prove this, the sciatic nerve of a goat was laid bare at its junction with the spinal cord, and also between the tuber ischii and the great trochanter; at the latter point, the trunk was stretched to such a degree, that the nerve ruptured, but no change could be noted to take place at its spinal connection. The reverse of this, however, took place when the direction of the force was altered. Two openings were made on the arm, one just above the wrist, three centimetres square, on the flexor surface of the forearm, and the median nerve exposed. A second opening was made at the brachial plexus, and the nerve also exposed at that point; traction was then made upon it in the latter locality, and at once the nerve at the wrist opening could be seen to move considerably from its position. In other words, the centripetal stretching produces a mate- rial effect on the peripheral termination of the trunk. With reference to the last point, as to whether the power of the nerve as a conductor of Sensibility is altered by stretching; after various experiments the following conclusions were noted, viz., that the nerve is only elastic and stretchable within certain limits, that the limits of normal elasticity corre- spond with the physiological limits of the motion of the human body, and that any attempts to stretch the nerve beyond these limits are followed by a rupture in its continuity. In the second of my reported cases,” it will be noted that the lady was always better when the sciatic nerve was put fully upon the stretch, almost to its extreme physiological limits, viz., when she was on horseback, with her knee over the pommel of the saddle, in a state of flexion and abduction; the leg, also, in this position being flexed on the thigh, and muscular power exerted to hold the body firmly in the saddle during the movements of the horse. From these facts, it would appear that nerve stretching carried beyond the ordinary elasticity of the nerve, to a * Pamphlet on Nerve Stretching. 496 A SYSTEM OF SURGERY. degree sufficient to separate the continuity of the primitive fasciculi, is at º one point in the rationale of the cure, or at all events in the relief of the pain. - With reference to the amount of stretching required, the following were the results of interesting experiments reported by Vogt:* 1. That slight stretching (once) of the trunk of the sciatica in decapitated frogs increased the reflex irritability of the respective extremity. . . 2. That a second stretching, following shortly upon the first, reduces the irritability. 3. That a third stretching, following the second, reduces the irritability far below the normal standard, though mechanical stimuli may still act. 4. That the centripetal fibres of the sciatic cannot be exposed to prolonged and forcible stretching without losing, partially or fully, their function. From these, he lays down the axiom that “every severe stretching of a nerve trunk reduces its irritability and its reflex power, in the region sup- plied by it; or, in other words, the mechanical irritation of stretching changes the mechanism of nervous activity.” The following is the list of published cases in which the operation of nerve stretching has been performed, as given by Dr. Paul Vogt,i in his work on the subject: 1. Billroth (operation performed in 1869, published in 1872): Laying bare the sciatic nerve and examining it with the finger. Nothing abnormal was detected. The spasm of the leg, for which the operation had been undertaken, completely ceased within three months after the operation. 2. Von Nussbaum (operation 1872): Laying bare and stretching the brachial plexus, on account of an intense neuralgia, with spasmodic con- tractions, and loss of sensation of the muscles of the arm. This operation was completely successful. - 3. Gärtner (1872): Laying bare and stretching the brachial plexus, for a paralysis of thirty-four years’ standing. The arm was greatly wasted and the fingers contracted. - 4. Patruban (1872): Laying bare and stretching of the sciatic nerve for sciatica. Great amelioration. 5. Vogt (1874): Laying bare and stretching of the ulnar nerve for paral- ysis, in consequence of adhesions of the nerve. Cured. 6. Von Nussbaum (1875): Laying bare and stretching of the tibial and peroneal nerves in a case of reflex epilepsy. Complete cure. 7. Callender (1875): Laying bare and stretching of the median nerve in the stump of a forearm, on account of neuralgia. Cured. 8. Von Nussbaum (1876): Laying bare and stretching the sciatic and crural nerves of both sides, for central disease. Paralysis of lower extremi- ties with clonic spasms, following on a fall eleven years ago. Spasm en- tirely cured. - 9. Vogt (1876): Laying bare and stretching the brachial plexus intraumatic tetanus following extensive injury to the hand. Cured. 10. Kocher (1876): Laying bare and stretching of the tibial nerve for traumatic tetanus. 11. Petersen (1876): Laying bare and stretching of the tibial nerve for neuralgia. 12. Vogt (1876): Laying bare and stretching of the inferior dental for neuralgia. Cured. * Die Nerven-Dehnung, als operation in der chirurgischen praxis. Leipzig, Vogel., 1877. # An abstract of the work can be found in the Monthly Abstract of Medical Science, November, 1877. . NERVE STRETCHING. 497 Besides these, Dr. Vogt gives three other operations of his own, each per- formed for tetanus, and in two of the three cases the patients recovered. The following may be cited to show the philosophy of the operation. The case was one of traumatic tetanus, following injury to the hand. The patient was a man sixty-three years old, in whom tetanus had devel- oped about two weeks after his receiving a severe lacerated wound of the right hand. In spite of local treatment and large doses of opiates, violent opisthotonos set in, with tonic rigidity of the back and lower extremities, with intercurrent clonic spasms. The wound had not thor- oughly healed, but neither this nor any part of the arm or forearm was abnormally sensitive, while pressure over the region of the brachial plexus caused pain and a return of the tonic contractions of the muscles of the neck. Other treatment having been of no avail, and the cicatrix of the wound being in the vicinity of the median and radial nerves, it was decided to divide the cicatrix, detach the edges of the wound, excise these two nerves, and also stretch the brachial plexus. After the operation at the seat of the wound had been performed, the brachial plexus was exposed through a longitudinal cut at the anterior border of the trapezius, about two inches above the clavicle. The loops of the plexus were then raised upon the finger, drawn out, and thoroughly stretched in both directions. In the operation, the nerve sheaths, which were found to be quite red, were freely divided. The wound was dressed with salicylicated jute, a drainage-tube having been used to provide for free discharge. A short and violent attack of vomiting took place on the next day, but the recovery from the tetanic condition was immediate and complete. There was free use of the jaws, tongue, and throat, and neither the mobility nor the sensibility of the arm appeared to be appreciably affected. In about two weeks the patient went out completely cured. In addition to the foregoing cases, I have found the following ones. Mr. John Chiene" records two cases of stretching the sciatic which are somewhat remarkable, in that the patients, immediately after the procedure, retained complete motor power. The first operation was performed on the 19th of April; the next day the pain had entirely disappeared. The patient was discharged on May 11th, 1877. In the second case, the nerve was stretched on the 23d of April; the nerve substance appeared fatty, and its course was covered by a plexus of large and tortuous veins. In attempting to raise the limb from the table, it stretched to such a degree that the operator Sup- posed he had torn it. On the following day both sensation and motion were not affected, and the patient, as in the first case, expressed himself as not having been so comfortable for months. By the 10th of May he was cured. In my cases of sciatic stretching, motion was at first much impaired and only gradually restored; the pains were often intense, but not of the neuralgic character, and lasted for several days. In the Lancet,f another case of sciatica is reported, which was treated by Dr. Macfarlane, of Kilmarnock, with success, by stretching the nerve. . In this case the nerve was thoroughly extended, although the leg was not raised from the table. After eight months, there had been no return of the pain. Duplayſ reported two cases of nerve stretching, in one of which the nerves thus treated were the median and the radial, the disease being paralysis; a cure rapidly followed. The second case—a man aged twenty-six, who had been wounded at the wrist, where a small tumor appeared, which was excessively painful. * Practitioner, June, 1877. # Medical Record, December, 1878. † London Medical Record, January 15th, 1879. 32 498 A SYSTEM OF SURGERY. The nerve was fully stretched, the tumor soon disappeared, the muscles regained their contractility, and the pain ceased. Dr. William C. Cox” reports the two cases alluded to as operated upon by Thomas G. Morton, M.D., of Philadelphia. The first case was one of neuralgia of the shoulder and arm, arising from an accidental wound, made by the sharp points of a pair of scissors entering the outer side of the right wrist. . The patient was just convalescing from an attack of typhoid fever, and, although the wound had healed within two weeks, the pain in the forearm extended to the elbow and shoulder, and resisted all means used to procure relief. The accident occurred on February 11th, 1877, and on May 7th the operation was performed. The stretching was done by the fore- finger, and the wound closed with silver sutures. The record, to which I desire to call special attention, because the symptoms are those which I have noted in three cases now reported, and which it is important to know, with reference to prognosis, thus continues: “The pain in the arm, after the effects of the ether had passed off, was intense, notwithstanding large doses of morphia, used hypodermically. A few days later an abscess formed in the upper part of the wound, which discharged through the opening near the wrist. For several weeks a feeling of numbness continued in the little and ring fingers and upon the outside of the hand, but gradually these symptoms disappeared. . . . . . In a month the pain had ceased; sewing and writing Still produced an ache, which was participated in by the whole arm and shoulder.f. This gradually diminished; but as the patient was of a rheu- matic temperament, it may have been aggravated by that condition.” In the second case, the most intense neuralgia afflicted the leg and foot, arising from a fall upon the buttocks from a scaffold twenty-five feet from the ground, the patient striking upon a stone pavement. After ten days of insensibility he partially recovered, with difficulty in articulation. From this he gradually convalesced, but paralysis of both legs followed. After five months the patient was able to get about on crutches, but without motion or sensation in the left leg. Shortly after, he had an attack of acute articular rheumatism, which was followed by excruciating pain on the outside of the foot. For this, Dr. Casselberry, of Hazelton, excised a portion of the plantar nerves, which gave relief for seven years. In 1874 the pains returned, and on June 12th, 1877, Dr. Morton stretched the sciatic, in the middle of the posterior surface of the thigh. The limb was lifted twice from the bed by the nerve. The patient returned home on the second day after the operation, but was not relieved. The pains continued so severe that neurectomy was performed on the external popliteal nerve, which gave relief. I have detailed these earlier cases of nerve-stretching that the student may have an idea of the first history of the operation, which now has become so popular that the record of the cases would occupy more space than could be allotted to the subject. In the third volume of Agnew's Surgery the most complete table can be found. From these cases we learn : that immediately after severe stretching, there may be not only loss of power and sensitiveness, but also excruciating pain and twitchings; that after twenty-four to thirty-six hours, we may reason- ably hope the severity of the suffering will be materially diminished, and that it generally will disappear; that tingling burning pain, and often swelling, remain for some time, and are especially noticed during motion, and that these symptoms pass gradually away; that when we have reason to believe that the neuralgic pains are returning, from the peculiar character of the sufferings, which are easily recognized by the patient and often * American Journal of the Medical Sciences, vol. lxxv., page 150. f These italics are made use of here to note that time is often required to complete the cure after these operations. NERVE SUTURE. 499 described as “the old pain,” a thorough manipulation of the parts (if prac- ticable) in all directions, putting the nerve to the utmost stretch of its physiological limits, may assist the cure, in preventing the formation of new adhesions. I have performed nerve stretching many times and on different nerves with varied success. Some of my cases have been published elsewhere,” and others have not been recorded. The reader may refer to the published cases, if he desire further information on the subject. The methods of performing nerve stretching must vary, of course, according to the position of the nerve to be stretched. As a rule, those incisions made for the ligation of arteries, and described in the chapter upon that subject, will be the same as those necessary for finding the great nerves. When the diseased nerve is found, a blunt hook must be insinuated gently beneath it, until the little finger or, in the sciatic, one or even two fingers be gotten under it, then it is gently drawn out until quite a loop is made. The stretching is discontinued and the wound closed. The whole operation must be done antiseptically. For more explicit directions regarding the * nerve, the student may refer to Vogt's pamphleti or to Agnew's article. It must be remembered that nerve stretching is not without its dangers, and that death has been known to result from the operation. Socin, Langen- beck, Billroth, Berger, and Benedict have been unfortunate in this re- Spect, and the cause of death in all the cases has been attributed to shock conveyed to the medulla oblongata from too violent stretching. Vomiting, singultus, cyanosis, emesis, and paralysis of the bowels were the symptoms that preceded death.Ş Nerve Suture.—The sewing together of divided nerves has been, like many other so-called recent operations, considered and even practiced by the older surgeons. Guy de Chauliac and Lanfranc are said, if not to have done it, to have advised it, and Dupuytren is said to have performed it. The question arising in the surgeon's mind is in the selection of the cases suitable for the operation. When we remember how beautifully nature, after a part has been seriously wounded, restores it to its usefulness, both in motion and sensibility, there can be no doubt that in by far the majority of cases of wounds, the parts after having been carefully adjusted should be left to themselves. The symptoms, however, that indicate the non-union of nervous trunks and filaments are generally soon made manifest, and are pain, anaesthesia of the part, and trophic changes materially affecting nutrition ; these often are noticed before the wound is completely cicatrized. The first symptom, in by far the greater number of instances, is neuralgia, the pain radiating in directions corresponding with the course of the nervous filaments. It is said by some authors that the suffering is more acute when the nerve is contused than when it is completely divided. Accompanying the pain there is a burning, sticking sensation, often also associated with redness and Sometimes with itching. The anaesthesia which, of course, begins upon the complete severance of a trunk, is at first confined to a spot surrounding the point of division, but soon the insensibility extends to a considerable dis- tance, and by reflex action may even be noted in remote parts; this is as- * Nerve Stretching, with a Short History of the Operation, with Illustrated Cases. Boston, 1879. Otis Clapp and Sons. Also New England Medical Gazette, 1879. Also The American Journal of Electrology and Neurology, July, 1879. + Die Nerven Dehnung als Operation in der Chirurgischen Praxis. von Paul Vogt. Leipzig, 1877. Also Traite des Sections Nerveuses par M. Leitrévant. Paris, 1873. f Agnew's Surgery, vol. iii., p. 727. 3 British Medical Journal, January 7th, 1882. 500 A systEM OF SURGERY. sociated with motor paralysis, and in bad cases, by spasmodic action of the parts supplied by the nerves. The trophic changes also soon become apparent in the defective nutrition and are made manifest in a variety of ways. These metamorphoses are frequently, and indeed generally, shown in the dermatous tissues. The skin assumes a slight redness, becomes glossy, somewhat hard, and resem- bles that seen in pernio. Often vesicles appear, sometimes bullae, the nails, according to Mitchell, become “turtle shelled,” the sweat glands are inter- . with in their function, and finally the body wastes and the mind SUlfferS. t * such cases as these, it is certainly necessary that the nerve be su- Ul]"60l. If a nerve be united when the first dressing is made to a wound, the term primary suture is used; when some time has elapsed, either with or without complete cicatrization of the wound, the nerve is united by Secondary Suture. Dr. T. Gluck,” referring to his experiences on animals regarding the path- ology of divided nerves, is of opinion that when a nerve is divided the first evident change is that the sheath retracts, and the myelin spreads over the cut surface, while blood is effused into the ends of the nerve and wound. The nerves and muscles degenerate, the limb wastes, and the animals die about the fifth month—this has been found in experiments on the sciatic in the fowl, as the result of division. When a piece of nerve is excised, and the ends brought together by sutures, the process is less simple and less rapid in its course; microscopically, the two ends are hardly to be distin- guished ; each presents thrombosis in the minute vessels, and a somewhat wavy appearance of the nerve-tubes. In the young granulation-tissue be-, tween the ends of the nerves, about the fifth day, peculiar fusiform cells appear, dark, granular, and looking like the ganglion-cells of the nerve- centres. What becomes of the catgut ligature during this process? It is apparently absorbed—in eighty hours the section shows deep excavations in the thread, which increase in size the next few days, and in about a week all traces of the catgut have disappeared. An early restoration to function in divided nerves has been doubted by pathologists, and the theory of a collateral path has seemed a more probable explanation, than that of a restoration of function through the injured part; it is difficult, indeed, to exclude the possibility of such an explanation in the experiments on animals if the recovery of power in the muscles at first paralyzed is taken as the indication of the recovery of functional power in the divided nerve. How the function of a part is restored, after section, or even when united by nature, has been a matter of discussion ever since the time of Sir Charles Bell, and as yet pathologists have arrived at no very definite conclusion in the matter. However, it is now a pretty well established fact, that primary suture of nerve trunks should always be done; indeed, Mr. H. E. Clark says: f “It should be as much a rule of practice to bring together the cut ends of a divided nerve, as to stitch the wound in the muscles and skin.” Experiments of Vulpian and Brown-Séquard have tended much to the arrival of this conclusion. Secondary Nerve Suture was considered as a very doubtful procedure until recently, but the satisfactory results obtained by those surgeons, who had the temerity to perform the operation, has in a great measure changed the tide of public opinion. In some cases complete restoration of function has * The Monthly Abstract of Medical Science, July, 1878, vol. v., No. 7. f Glasgow Medical Journal, October, 1883. - NEURALGIA. 501 been effected after an absence of many months, indeed Tillaux reports one after eighteen years. The average time, however, for the establishment of sensibility is from six months to one year; that for the reproduction of motion being a longer time, on account of the paralysis of the muscles which is always more or less present. The operation itself is not difficult, but delicate; it requires a thorough knowledge of the anatomy of the part. The young surgeon before he essays it should, if possible, make a careful dissection upon the cadaver, and must bear in mind that in looking for the divided or injured nerve in the living, he may find it altered somewhat in character, thickened and bulbous, therefore the incision should be made three or four inches long and the trunk of the nerve be exposed above and below the site of injury; it should then be carefully raised from its bed and traction made upon it, until the two extremities are nearly approximated and the suture (always of gut) should be passed through the neurilemma and the nerve substance and then secured with a knot; two stitches or even three (if the nerve be large) will generally be sufficient. If there be a considerable sepa- ration between the divided extremities of the nerve, it may with gradual traction be drawn together, even to the distance of an inch. In no case has tetanus been known to result from this somewhat serious interference with nerve trunks, and of thirty-three cases collected by Weis- senstein, sixty per cent. were completely cured—of the balance, there were imperfect accounts given of three; in six, there was little or no change; and sensibility alone returned to four. This makes an excellent showing, and demands a trial of the operation whenever the symptoms already noted are present from injuries to the nerves. Neuralgia is a Greek term, compounded of Newpov, a nerve, and ałros, pain; a generic term for a number of certain diseases, distinguished by very acute pain, following the course of a nerve through its trunk and ramifications. . The principal neuralgias are known as: 1. Ischias nervosa digitalis; in this variety the pain extends from where the nerve passes under the inner condyle, to the back of the hand and to its cubital edge. 2. Neuralgia den- talis, odontalgia nervosa. 3. Neuralgia facial, neuralgia faciéi, trismus dolorificus, tic douloureux, dolor faciei, prosopalgia, dolor faciei Fother- gilli. 4. Neuralgia femoro-poplitæa, sciatica, coxalgia, neuralgia ischiadica, ischias nervosa; this latter is characterized by pain following the great sci- atic nerve, from the ischiatic notch to the ham, and along the posterior sur- face of the leg to the sole of the foot. 5. Ischias nervosa antica; the pain in this variety commences in the groin, extends along the forepart of the thigh, and passes down on the inner side of the leg to the inner ankle and back of the foot. Neuralgia also attacks the liver, uterus, vagina, spleen, the plantar nerves, the heart, and other parts of the body. These affections are obstinate in character and are the most painful of all diseases. Some nerves are more disposed to the disease than others, especially the three grand divisions of the fifth, and the facial portion of the seventh pair, although this has been denied upon the supposed discoveries of Sir Charles Bell and Shaw. «» The pains vary in character, though always violent in the extreme, Oc- curring either suddenly or gradually, with numbness, itching, heat, or preceded by numbness or coldness. Neuralgic pains at times resemble electric sparks passing through the nerves. When the neuralgic attack is at its acme, the part feels as though burning needles were thrust into it; after a while the intensity of the pain diminishes and is followed by numbness, or great sensibility of the part to touch, or sometimes a feeling as though it had received a blow. When the affected part feels cold, no actual diminution of temperature is ascertained, nor is there any evidence 502 A SYSTEM OF SURGERY. of inflammation or congestion; muscles to which the affected nerves pass are sometimes agitated with slight contractions, not reaching to that degree, however, to which the term of spasm could be applied. These contractions, continuing, produce involuntary twitchings, called by the French tics, whence the term tic douloureux. When the nerves affected supply glandular or- gans, morbid and increased secretions take place. The severity of the pain may irritate the vascular system to increased action, which does not, how- ever, indicate inflammation. Affected organs decrease in bulk, and are ob- served to become paler. In long-continued cases of great severity, the system severely suffers. A neuralgic affection may continue from days to years. When pains in a nerve are produced by pressure upon it, as for instance by a tumor, with }. removal of which the neuralgia disappears, such neuralgias are termed (LLS6. - Prosopalgia, or tic douloureux, is most apt to attack females, one attack predisposing to others. Neuralgias attack neither very young nor old per- Sons; the period of life most obnoxious to the disease is between the thir- tieth and the sixtieth years. Exciting causes are moist, cold winds, the slightest exposure to either being sufficient to bring on a very severe attack. The causes, however, are generally obscure; mechanical injuries are included among the number. When the predisposition to the disease is strong, the attacks are induced by the slightest corporeal or mental disturbance. Ma- laria has been assigned as a cause, the periodical character of the affection strengthening such an opinion. Sometimes great regularity is observed in the returns of the paroxysms, the type being quotidian ; this periodicity generally takes place in recent cases; when the affection becomes chronic, the intervals between the attacks are of very different duration. The Superficial or subcutaneous nerves are those frequently attacked, and this is explained by the fact of their greater exposure. The shades and varie- ties of pain experienced in this disease, it would be impossible to enu- merate. Among them, however, of a prominent kind, are tearing, tugging, darting, piercing, plunging, dragging, jerking, sharp, sudden, pricking, lan- cinating, burning, cutting, lacerating, stabbing; sometimes radiating through the entire ramifications of a nerve, at others passing along a few of its branches only. The pains also extend in different directions; outwards, inwards, backwards, upwards, or downwards. The pains are, at times, also gnawing, pressing, heavy, dull, obtuse, boring, like the pressure of a dull instrument. Sometimes, as has already been noticed, the attacks come on suddenly; at others, they are preceded by rigors, heat, perspiration, and an abundant secretion of clear, pale urine. During the paroxysms the surrounding parts are very sensitive to touch, and a characteristic circumstance in many cases is that the slightest touch will produce agony, while firmer pressure not only occasions less pain, but will sometimes afford much relief; at times much soreness is left after the paroxysm, and in general the bloodvessels in the vicinity of the affected part are swollen. Sometimes the paroxysm is composed of a series of transitory shocks of darting pain, with short intervals of respite from suffering. In general, . much pain is felt during the entire paroxysm, with frequent darting pains, so severe as to produce loss of consciousness or delirium. A paroxysm may continue a few minutes, or may last for days, weeks, or even months, with only at times a few seconds' relief from pain. The intervals between the attacks may be of hours, weeks, or months’ continuance. In recent cases there is a complete intermission of pain; in chronic cases the patient always feels some uneasiness. - Dissection affords no assistance in the elucidation of the pathology. In- DISEASES OF THE LYMPHATICS. 503 flamed conditions of the nervous tissues, either of the nerve itself, or a thickening of the neurilemma, the fine transparent membrane which en- velops the nerves, when found, are only effects of the disease. Its cause has been supposed to be an inflammation of the periosteum of the bones, over which the affected nerves are distributed. Morbid alterations will not explain the periodical nature of the affection. The short, quick paroxysms, the absence of all signs of inflammation or swelling; the pain following the course of the nerves; the periodicity of the affection ; its diminishing rather than increasing from firm pressure, are diagnostic signs of sufficient pre- cision to prevent its being confounded with other affections. The disease seldom terminates fatally ; it has been alleged that apoplexy and insanity have followed it, but such results are certainly very unusual, and Dr. Quinn suggests them as the effects of the treatment rather than of the disease. Neuralgias, when acute, although more violent, are more easily cured than when chronic. Neuralgias have been noticed when epidemic fevers prevail, and also as attacking more individuals at cer- tain seasons. The disease most frequently attacks the face—prosopalgia, tic douloureux, neuralgia facialis, dolor faciei—the pains following the course of the different branches of nerves of one side of the face; for both sides of the face to be attacked at the same time is a very unusual occur- rence, if indeed it ever takes place; the pains, however, after subsiding in one side may attack the other, and this often happens. If the supraorbital branch be affected, the pains are felt in the supraorbital foramen, from which they shoot to the eyebrows and eyelids. . - Treatment.—A great variety of medicines have been employed in the treatment of the varied forms of neuralgia. Among these are: aconite, bel- ladonna, China, arsenic, calc. carb., Veratrum, colocynthis, spigelia, meze- reum, stannum, lycopodium, phosphorus, staphisagria, platina, rhus t., bryonia, conium, digitalis, aurum, verbascum, Sepia, cannabis, ignatia, nux vomica, pulsatilla, chamomilla, and many others. The names of these medicines are given that their proper pathogeneses may be studied. Neurotomy and Neurectomy.—When remedial measures have failed neu- rotomy is to be remembered; it consists in making a subcutaneous punc- ture, or a small incision transversly across the immediate track of the nerve, down to the bone; or neurectomy may be preferred in which the surgeon by a careful and minute dissection exposes the trunk of the nerve and cuts away a portion of it, from half to an inch in length. Dr. Carnochan, of New York, had made some remarkable dissections and removal of nerves for this disease. CHAPTER XXIX. DISEASES OF THE LYMPPHATICS. LYMPHANGITIS-ANGEIoDEUCITIs—ADENITIs—NEOPLASMs—LYMPHADENOMA— LYMPHOMA. THE various diseases of the lymphatic system are not as a rule idiopathic, being rather secondary to some other disorder. The pathology also of these affections is not well understood, although it is an established fact that in- flammation, suppuration, calcification, and finally obliteration of the coats of the vessels, and even of the thoracic duct, occasionally occur. 504 A SYSTEM OF SURGERY. Lymphangitis is generally occasioned by poisonous substances, which may have their points of origin either on the surface or within the body, being taken up and circulating through the lymphatic vessels. . It frequently follows certain varieties of punctured wounds, as in such, Septic matters are not so liable to be washed away by the blood, the discharges and the dress- ings, as in the more open varieties of wounds. The disease also may arise from the presence of cold abscesses, from diseases of the connective tissue about the uterus, especially in puerperal women. - The symptoms belonging to this disease have in part been mentioned in the Chapter upon Poisoned Wounds. The first manifestation usually noticed is a severe rigor, followed by fever, thirst, and restlessness, then the appearance of faint red lines, following the course of the vessels which either take a direct course, or appear to anastomose with each other. At the focus of the disease there is much swelling, on account of the accumulation of lymph, which cannot be removed by the enlarged vessels. The pain varies in severity, according to the number of the vessels involved and their depth; the deeper the duct from the surface the more severe the pain. Some of the diagnostic marks between lymphangitis and inflammation of the veins con- sist in the facts that the red lines alluded to are much larger and more tender in phlebitis; that they run in the direction of the lymphatics and not of the lº in lymphangitis, and that the area of tenderness is much less in the atter. +. Another diagnostic point is that, as Mr. Holmes” says: “The inflammation ceases at the nearest gland. This is a fact abundantly exemplified both in the simple and in the specific inflammation of the absorbents. The known situa- tions of the superficial glands are those toward which inflamed absorbents may be traced, and at which their inflammation culminates to the highest degree of severity, and is almost invariably extinguished. The gland appears to arrest the free progress of the acrid lymph, itself becoming inflamed.” During this time there is continuous fever, the pulse beating 130, and a temperature sometimes as high as 104°, but rarely higher. I have mostly found it range from 102° to 103°, and keep pretty much at these figures through the extent of the disease. The corresponding glands are always more or less affected (adenitis); they become hard, painful, and enlarged, and finally, as already noted, may suppurate. The inflammatory process often extends into the surrounding connective tissue, which may also sup- purate, or this process may take place in the vessels themselves. If this latter result is to be favorable, the diseased lymphatics are but partially obliterated, and the glands gradually resume their normal condi- tion, though it is not by any means uncommon for them to remain Oedema- tous for a long period of time after the original disease has passed away. If, however, the ºpº continues, the symptoms of a more dangerous disease are developed. From the obstructed lymph return, the parts be- come permanently Oedematous, and Sclerosis and hypertrophy of the con- nective tissue results, and here and there are found indurated tumors of transformed tissue. It is considered by some that elephantiasis is the result of lymphangitis. . When the ducts are completely plugged by diseased lymph, occasioned by the inflammatory process, we have a thrombosis of the lymphatics. This form of the disease is often met with in the uterus, and is due in the majority of instances to some injury to the inner surface of the organ; the lymphatics are found filled with viscid, purulent, or dark- colored matter. When the thoracic duct is the seat of the inflammation, which fortunately is a rare occurrence, especially in the idiopathic form, the most grave complications are to be expected. It appears that this duct is * System of Surgery, vol. iii., p. 331. LYMPHADENOMA. 505 not prone either to thrombosis or stenosis, for in three hundred post-mor- tem examinations, made by Andral, the duct was found perfectly normal in two hundred and ninety-five. The symptoms, as observed by Worms, ap- i. to be: rigors, very high fever, rapid rise in temperature, swelling of the eft arm, with intense agony extending down to the fingers, pyaºmia, jaun- dice, and death. Neoplasms.-In cancer and tuberculosis, the glands and lymphatics be- come sooner or later involved; degenerate cells, cancer-juice, and other debris are soon taken up by the vessels and are carried on in the lymph- ducts, until they either adhere to the coats of the tubes themselves or are stopped short at a gland, whereat indeed many such accumulations may be present. Here the seeds are sown that soon take root and develop neo- plasms of different formations. Neoplasms also, may originate in the lym- phatic system, at least such is the assertion of Klebs, Rindfleisch, and others. One thing, however, is certain, that the glands themselves often become chronically indurated, and the disease known as lymphoma or lymphadenoma, is a variety of adenitis accompanied with lymphangitis. Lymphadenoma, Lymphoma, Lympho-sarcoma, are terms used to designate a peculiar hypertrophy of the lymphatic glands, which has been so accu- rately described by Dr. Hodgkin, in the Medico-Chirurgical Transactions, for 1832, that it is now named “Hodgkin’s DISEASE.” Wilks calls the disease lymphatic anaemia, Cassy, general hypertrophy of the lymphatic glands, and Wunderlich, multiple lymph adenoma. The cervical glands are those most generally affected, but the axillary are also not unfrequently attacked, as may be other of the glandular tissues. The disease does not depend on zymotic influences, and bears in many respects a resemblance to phthisis. In some cases it may be caused by traumatism. The glands gradually en- large, with their connective tissue, and these appearances may result from a bruise or a strain, or may appear without any appreciable cause. A small swelling may be the first indication of the disease. Acute pain, neuralgic in character, accompanies the growth, or may appear in the locality before the tumor is noticed. The tumor at first appears movable, but grows rapidly without seriously inconveniencing the patient. A peculiar and frequent accompaniment of the disease is leucocythaemia, the white blood-corpuscles being always in excess, and often in enormous quantities. There is also the usual bruit de Souffle which accompanies the condition. A single gland may be thus affected, or, as is more frequently the case, several become seats of the disorder, and finally tumors in the lungs, liver, and cellular tissue are developed. Lymphadenoma is not always accompanied by leucocythae- mia, as is noted by Mr. Haward, and offers a better opportunity for treat- ment when uncomplicated. M. Jaccoud concludes, that this disease is occasioned by a twofold condition of the blood. In the one the red globules are much reduced; in the other, this condition coexists with a vast increase in the leucocytes. According to this view the anatomical constitution is different in each variety. He is of opinion that in the latter cases, viz., where there is a great increase in the amount of the white blood-corpuscles, the new growth is altogether expended in the cellular elements, but when both conditions noted above are combined, the capsule of the glands and the connective tissue are much thickened. At present, operative interference º ºly considered justifiable, as most of the cases reported have proved atal. Mr. Warrington Hawardi presented at the Clinical Society of London the following interesting case of lymphadenoma. “The patient, a child of * Wide Medical Times and Gazette, January 27th, 1877. # Medical Times and Gazette, December 25th, 1875. Reported also in the Monthly Abstract of Medical Science. 506 A SYSTEM OF SURGERY. four years, had on the left side of the neck an immense mass of enlarged glands, extending from the ear above to the clavicle below, and from the spine behind to the trachea in front. The glands were elastic, and mode- rately firm and not adherent to the skin. There was no evidence of dis- ease in any other part of the body, and the number of the white globules in the blood was not increased. There was a family history of phthisis on the mother's side. The child was pale and rather thin; the growth was of a year's duration, and commenced soon after an attack of small-pox. As the disease of the glands appeared to be confined to those visible in the neck, it was determined to remove these, in the hope that the general in- fection might thus be prevented or delayed. As the removal of the disease involved the dissection of the whole of one side of the neck, it was effected in two operations. At the first, the affected glands were removed from the anterior triangle of the neck; at the second, from the posterior triangle. The child recovered well from the operation, and soon gained flesh and color to a remarkable extent. Subsequently, however, the disease returned in the upper part of the left anterior triangle of the neck, and tumors after- wards appeared in the axilla and groin. The child died, pale and emaci- ated, and post-mortem adenoid growths were found in the abdominal vis- cera in addition to the enlargement of the glands. No recurrence occurred in the posterior triangle of the neck, and it was thought that possibly some diseased glands might have been left in the upper part of the anterior tri- angle, where the growth first reappeared.” - M. Trelat (in the Lancet, April 14th, 1877)* mentions two cases of removal of lymphadenomata, attended in each case with similar growths in other parts of the body. In both these cases there was a recurrence of the growth and a fatal issue, and lymphomatous growths were found in the vertebrae, sternum, spleen, and liver. It is held that there are forms of lymphade- noma which are malignant, and others which are not, but the definite his- tological criteria for determining between the two varieties is not pointed out. The conclusion drawn from these cases is that the removal of these tumors is not advisable when there is any suspicion of visceral implication. Lymphatic Fistula.-In some cases of lymphangitis, a fistula forms and opens upon some portion of the body, from which the secretion is poured out. Such may also result from a wound, or it may arise from a varicose condition of the lymphatic vessels. It is said that elephantiasis of the ex- tremities is a frequent accompaniment of these fistulae, and that their most frequent site is the groin and the scrotum. Treatment.—In the treatment of lymphangitis, the first indication, if the disorder is of local origin, is to remove, if possible, the exciting cause. The application of the cautery, chloride of zinc, or lunar caustic to the wound, the constant application of poultices, in the admixture of which antiseptics have been freely used, and withal, great attention to cleanliness and fresh air, are important items. The system must then be nourished with appropriate diet and judicious stimulation. I say judicious, because it is much the custom in such cases to pour into the stomach all kinds of drinks, at all kinds of unreasonable hours, without regard to the condition of the patient, or the digestive apparatus. There are some individuals who bear with favorable results an incredible amount of stimulants, and there are others with whom even small quantities will disagree. These cases must be duly discriminated. Internally, either the second decimal dilution of nitric acid, or the first decimal dilution of carbolic acid, prepared with glycerin, or arsenicum in the third trituration, will be found the ºpropri. ate medicine. China, lachesis, or carbo vegetabilis may be indicated. * American Journal of the Medical Sciences, July, 1877, page 256. INJURIES AND DISEASES OF THE BONES. 507 In the idiopathic variety (by which I mean those cases occurring without appreciable local causes), aconite and belladonna in the earlier stages, and mercurius iodatus or soluble mercury may be of service. When there is chronic enlargement of the glands, calc. carb., conium, baryta carb., or sulph., should be remembered. When the tendency to oedema is great, the two medicines which in the majority of cases will produce the best results are arsenic and apis mel. I believe that these remedial agents will often shorten the duration of the disease. Latterly I have used, with a great deal of success, arsenic in doses of 5% of a grain three times a day, or the liquor potas. arsen., three drops after meals, in conjunction with kali hydriod., and the application of mineral earth made into a paste and worn night and day. Professor Busch,” of Bonn, has treated, with great success, certain cases of lympho-sarcomata, by what are known as Kern's cataplasmata. After speaking of the unsuccessful treatment of these growths by the or- dinary surgical procedures he was induced to use the cataplasmata which are composed of one part of mustard flour and five parts of black soap, the whole being applied in a gauze bag over the tumor four or five hours. Very often a severe irritation of the skin is produced almost amounting to an erysipelas. Phosphorus, the carbonates and phosphates of lime, with ferrum iod. or ferrum met, with the occasional use, as symptoms may indicate, of lyco- podium and silicea, may prove successful. Dr. Lilienthal has suggested to . the use of hecla lava in this disease, especially where there is cervical adenitis. For lymphatic fistula little can be done: care with reference to position, the judicious application of straps, the careful application of an astringent or caustic lotion to the parts, with internal medication as the symptoms may present, is all that can be done in such cases. CHAPTER XXX. INJURIES AND DISEASES OF THE BONES. PERIOSTITIS – OSTEITIS, SUPPURATION AND SCLEROSIs — OstEO-MYELITIs — CARIES — SCROFULA AND SYPHILIS IN BONE–NECRosis—MoILITIES Ossium AND RACHITIs— FRAGILITAS OSSIUM-ATROPHY OF BONE–TUMoRs, INNOCENT AND MALIGNANT. INFLAMMATORY action effects changes in the osseous as well as in other parts of animal structure. . The bones pass through the different stages of inflammation, suppuration, ulceration, and death; and are subject to peculiar deviations from healthy formation, owing to their chemical composition. To effect a cure of diseases of the bones, the causes upon which such affections depend must be removed; a want of such knowledge often in- duces the most distinguished surgeons to employ severe methods of treat- ment, which rather aggravate these affections than produce a beneficial effect. By the administration of proper medicines the constitution of the patient can be improved, and the disease more successfully treated. The * Medical Record, September 15th, 1883. 508 A SYSTEM OF SURGERY. dilution of the medicine and the repetition of the dose are of paramount importance. Experience teaches that the exhibition of dynamization, to the 6th, is more speedily followed by beneficial effects than when the crude drugs are employed; the system by the latter being excited to a reac- tion prejudicial to favorable results, whilst the too frequent repetition of medicines often disturbs their curative action, and thereby retards re- covery. I have for years used with surprising efficacy medicines triturated to the 30th potency, by Dr. Henry M. Smith, of this city, and have been much gratified by their action, especially in bone diseases. “We are often at a loss to determine,” writes Dr. Jeanes,” “which of the remedies that are indicated by the morbid condition, or its particular de- yelopment, as caries, hyperostosis, etc., is the appropriate remedy for the individual case. The circumstances which can guide in the choice of the remedy, are the temperament, the disposition, the character of antecedent diseases, and the treatment to which they have been subjected, and the nature of the exciting cause of the existing disease of the bone. The symp- toms which indicate the remedies are those of the disease of the bone, viz., the appearances, the pains, and other manifestations which accompany it, and the symptoms which affect the whole system, or particular parts of it, other than those immediately implicated by the disease of the bone. But most of the latter, which may be termed the general symptoms, namely, hectic, loss of appetite, emaciation, debility, etc., are often merely the result of the local irritation.” It is also of some importance for the practitioner to become acquainted with the manner in which any antecedent disease may have been treated, as all such circumstances tend to aid in the selection of appropriate reme- dial agents. Periostitis.-Periosteum is the name given to the strong white fibrous membrane that closely envelops bones, excepting such of them as are covered with cartilage. This membrane is connected externally to adjacent cellular substance, and therefore indirectly with muscular tissue; the inner surface adheres closely to the bone by means of short strong fibres, which enter the numberless foramina on the surface of the ossific structure. Although fibrous tissues are not as liable to be attacked by inflammation as other textures of the body, still, when such abnormal action is found, the sufferings of the patient are often exceedingly severe; and if the inflam- matory process be considerable or acute, it is seldom limited to the tissue originally affected, but extends to all the surrounding parts. Great pain is the usual attendant upon this disease, whether acute or chronic, and when in the former variety, if the inflammation has extended to the bone, the sufferings of the patient are excruciating. This increase of suffering may be readily accounted for, if we remember that the inflam- matory process progresses with greater rapidity in tissues which are secon- darily involved, consequently there is an increased amount of exudation, j, being confined by the external membrane, tends greatly to aggravate the pain. #. swelling in periostitis is small compared to the violence of the in- flammatory action; this may also be explained in the same manner alluded to when speaking of the unusual degree of pain that is present in the dis- ease, viz., the confinement of the exudation. All the symptoms are aggra- wated at night. - The constitutional symptoms are well marked in periostitis. If the dis- ease be acute there is a high degree of inflammatory fever; if chronic, the * Homoeopathic Practice of Medicine. PERIOSTITIS. 509 system is gradually undermined by the continued loss of sleep, caused by the severe nocturnal sufferings. Emaciation, loss of appetite and spirits, and hectic, often supervene, rendering the patient extremely miserable. In the acute form of the affection the membrane is softer and loosened from its connection with the subjacent bone; in the chronic variety it be- comes more dense, and adheres with unnatural firmness. When inflammation does not become fully established, or, in other words, if active congestion be only present, fibrin is exuded, and the swelling is termed a node, which, when arising from syphilis, is denominated the venereal, when complicated with the results of large doses of mercury, the mercurial, or the two causes may be combined, giving rise to the mercurio- syphilitic node. If inflammation proceed a step further, and the bone becomes involved, a purulent formation (abscess in the bone) is the result, which, not being able to approach the surface, from the strength and non-ulcerative property of the periosteum, extends laterally, denuding the bone of its membrane. The same process may be present in ossific structure, as has been here- tofore related concerning inflammation occurring in other textures; the inflammatory process having established suppuration, gradual molecular disintegration (ulceration) of the bone may ensue, and if this be not re- strained, necrosis may take place. Sometimes, in the acute form of the disease, these terminations may be- come apparent in a short time after inflammation has developed itself; if chronic, weeks and months may elapse before caries or necrosis is estab- lished, but the patient will exhibit unmistakable signs of severe constitu- tional irritation. There is a variety of periostitis, known as secondary, in which the mem- brane has not been primarily affected, but has become so from contagious sympathy, the bone, or spinal marrow, being primarily the seat of the inflammatory action. In this disease the symptoms are even more severe than in the ordinary variety, and the constitution is more profoundly affected. Some of the differential marks of diagnosis between periostitis and endo- stitis (ostitis) are thus clearly pointed out by Mr. Bryant:* “In periostitis, when suppuration is about to take place, external evidence will appear in the form of increased swelling, tenderness, and redness of the skin ; oadema of the tissues covering in the node and fluctuation will be present. In endostitis terminating in abscess there will be a great aggrava- tion of all local pain, with constitutional disturbance, and often rigors; oadema of the soft parts over the bone and external evidence of inflamma- tion will rarely appear, and then only when the abscess is making its way through the periosteum externally (vide Abscess in Bone). “When periostitis ends in necrosis it is only of the shell of bone beneath the inflamed node (peripheral necrosis). When endostitis ends in necrosis it is usually of a greater or less mass occupying the centre of the bone (cen- tral necrosis); sometimes the whole shaft or articular extremity dies. “In periosteal necrosis the dead bone rests exposed, and when covered in it is by soft parts alone, no new bone surrounding it. “In endosteal necrosis the dead bone or sequestrum is more or less com- pletely surrounded by new bone—a new periosteal formation. When this is incomplete, it is a fair proof that the periosteum has been involved. “In necrosis of a long bone the result of periostitis, and endostitis by ex- tension, the hope of a new bone being formed is a forlorn one; whilst in the necrosis of endostitis there is every hope of a complete restoration of the * Practice of Surgery, 806. 510 A SYSTEM OF SURGERY. bone taking place, through its periosteal covering, on the removal of the dead portion or sequestrum. “In the necrosis of the skull, which is always periosteal, no new bone is formed, the bone-forming membrane, the periosteum, having been destroyed. When following an injury to the skull it is preceded by ‘puffy tumor of Pott.’ In syphilis it follows a suppurating node.” Treatment.—The medicines that are of service in periostitis are aur., calc., carb. an:, caust, kali c., lyc., merc., mez., nit. ac., ruta, rhododen., staphis, and sulph., or croc., fluor, ac., magnes, c., natr. mur., petrol., pulsat., silic. Staphisagria and sulph. have also symptoms that may be present in peri- Ostitis, but for the precise indications of these, as well as the other medicines . mentioned, the student must refer to the repertory and symptomen COOléx. By the administration of some of these medicines the disease may be arrested before the inflammatory process has reached the suppurative stage; at all events, many of the most distressing symptoms of the patient certainly will be alleviated, thus rendering him comparatively comfortable. But when pus has formed and collected beneath the periosteum, the matter must be evacuated, and that as speedily as possible, or caries and necrosis may be the result of delay. If the operation of dividing the peri- osteum be performed, as soon as the surgeon has satisfactory reason to be- lieve that matter is present, simple ulceration only may have taken place, and as soon as the pressure occasioned by the pus is removed, the repro- ductive process will in all probability complete the cure in a short time. But although this practice is eminently beneficial in acute abscess of the bone, it must never be employed unless the signs of suppuration are suffi- ciently obvious to render it certain that pus is accumulating rapidly and in quantity between bone and periosteum. Cod-liver, oil (ol.jec. ase.) has been employed by many practitioners with excellent results, when there exists a scrofulous taint. M. Duplay,” in a discourse on the Treatment of Diffuse Phlegmonous Periostitis, offers the following interesting case: - A boy, aged 16 years, had suffered from abscess in one of the phalangeal joints of the middle finger. Subsequently periostitis exposed nearly the whole shaft of the tibia. It was determined to resect the shaft of this bone superiosteally, instead of amputating. A free incision was made, the periosteum where it was ad- herent was easily detached, a chain saw was passed around the bone at the upper limit of the disease (as was believed) and the bone sawn through op- posite the tubercle of the tibia; the diseased shaft was then extracted with but little blood lost. . But the portion of the shaft which had been left, kept up suppuration, and it became necessary to remove it also, the two together measuring nearly nine inches. The patient recovered perfectly and with a thoroughly useful leg. M. Duplay dwells chiefly in his remarks on this case, to the advantages of resection as contrasted with amputation; and in this he seems to meet with no opposition. This interesting case shows conclusively the success that may attend the attempt to save the patient's life without amputation in such instances. About a year since, a boy, aged 14, was brought to me with his right arm in a sling and entirely useless. From the elbow to the wrist the tumefaction was very great, and several large openings with everted edges proclaimed serious bone disease beneath. I determined to amputate the arm, and it was only after the urgent appeal of the father that I consented to * London Medical Record, February 15th, 1876. INFLAMMATION OF BONE–OSTITIS. 511 make the endeavor to save it. Upon cutting down upon the bone, I found it so much diseased that I determined to resect the whole of it. I therefore removed the entire ulna embracing the olecranon at the elbow and the styloid at the wrist, saving the periosteum. It was beautiful to see the new spiculae of bone projecting from the interior of the periosteum, as it was lifted away, and to observe how rapidly the boy gained in health after the removal of the bone. I also found it necessary to take away the head of the radius and the external condvle of the humerus. Inflammation of Bone—0stitis.-In the early stages of inflammation of bone, it is difficult to diagnose whether the abnormal action is affecting the periosteum, the bone, or the medulla; after a time, however, the uniformity of the swelling will indicate that the bone-substance is diseased, thus dif- fering from the enlargement which has just been described under the head of periostitis. Dr. Markoe” classifies the different varieties of the inflam- matory process as affecting the osseous system, first, as those attended with organization of exuded products; second, those in which the exuda- tion ends in suppuration; third, ulceration or caries; and fourth, necrosis. It has been maintained by some authors that the true bone-cells are never primarily affected, the first accession of the disease being in the marrow. There are not, however, sufficient grounds for this belief, for although the bones, especially in their compact structure, are not very largely supplied with bloodvessels, yet there is certainly sufficient blood to carry on nutri- tion, and in some, the nutrient arteries are of considerable size. From these facts there is no reason why inflammation should not attack the bones, although, perhaps, not as frequently as other structures of the body. The cancellated structure is of course more obnoxious to inflammation than the compact. Ostitis may be acute or chronic, and the disease may begin in the marrow and extend to the bone, or vice versa. The acute variety is not so frequently met with as the chronic, and, in the majority of instances, I think we find that ostitis partakes more of the subacute variety of the inflamma- tory process. The symptoms of the disease resemble much those of periostitis; the pains are severe, sometimes excruciating, and are, in the majority of in- stances, worse at night, They are boring, throbbing, and burning. The patient will complain of the peculiar “deepseated " nature of his suffer- ings. Movement aggravates the pain, and atmospheric changes are pecu- liarly noted. In fair, bright wº the sufferings are less, but the patient can predict a change to dampness and rain, by a peculiar increase of suffer- ing, before any evidences of an approaching storm are apparent. It will be readily understood that a short season of such severe pain may induce constitutional symptoms. Fever, especially at night, is present; exhaustion, loss of appetite, fretfulness, emaciation, and hectic often supervene, espe- cially when the sufferings have been prolonged. Important structural changes also take place in the bones affected with inflammation. The Haversian canals enlarge in the same manner as the bloodvessels in other tissues; there is an increase in the density of the bone, and often also of the periosteum; thus having a close resemblance to the hardness and increased size of the soft parts in the earlier stages of inflammatory action. As the dis- ease progresses the density gives place to a more softened structure, although the parts still are enlarged and laminated. The bony structure, in part, may disappear, leaving pores throughout the surface, and the bone-cells are filled with a sero-sanguinolent fluid. Thus the enlargement which takes place in ostitis may be occasioned first by an increase of density, and tººd, by softening from metamorphosis of the structural elements of the OIle. * A Treatise on Diseases of the Bones, by Thomas D. Markoe, New York, 1872, p. 19. 512 - A SYSTEM OF SURGERY. Many constitutional causes give rise to inflammation of bone, as syph- ilis, scrofula, scurvy, rheumatism, gout, or mercurial poisoning, as well as those injuries which are known to produce the disease. Exposures to damp weather or to cold are very often exciting causes of the affection. Resolution may occur in ostitis as well as in other tissues affected by in- flammation; and when such result obtains, the bone generally remains en- larged, if not permanently, certainly for a considerable time. Treatment.—The medicines which have been found most serviceable in this disease are asaf, bell, calc., calc, phosph., merc., mez., nit. acid, phosph. acid, staphis., sulph., kali hydriod., symphytum. Suppuration and Sclerosis in Bone.—If the inflammatory process has not been arrested, the next step is the gradual softening of structure and the formation of pus. In speaking of abscess (page 115) the acute or circum- scribed, and the diffuse variety as occurring in the soft parts, are men- tioned. The formations of pus are similar in the osseous system; a true abscess often forms in bone, as well as purulent infiltration. According to Dr. Markoe, the abscess (properly so called, not including purulent formations of caries and necrosis) may occur in three situations: “1. In the cancellous structure. 2. In the medulla. 3. Between the periosteum and the bone.” Wherever the abscess forms, the pains are those of inflammation united with the constitutional manifestations indicative of the formation of pus in other parts of the body. The pains are agonizing, worse at night, and sometimes of an intermittent character, the patient being at times compara- tively free from suffering. The integument covering the diseased bone is very sensitive to the touch, is Oedematous, and pits upon pressure. The constitutional symptoms are severe, and hectic fever is not an uncommon OCCurrence. In many instances it is difficult to diagnose true abscess in bone from other inflammations, but the deepseated character of the pain, the chronic nature of the suffering, the aggravation of the symptoms at night, and the previous history of the case, must be the guides in these cases. In some instances, however, after the pus has been imperfectly evacuated, the inflammation continues, though not so acute, and the pus burrows here and there, forming sinuses, which are difficult to FIG. 237. heal, and are often followed by disastrous conse- quences to the bony structure in the vicinity. This disease is termed the chronic sinuous abscess; or, when the patient is of better constitution, the inflam- matory products within the bone become partially organized, and the bone expands, developing the disease known as Sclerosis in bone. Treatment.—The medicines which have been mentioned in the preceding section must be em- ployed for the inflammation, and hepar, merc., sili- cea, and sulphur be used according to symptoms. But when the pus is formed, the sooner it is evacu- ated the better. This may be done as follows: A semicircular flap is raised over the swelling, and the periosteum carefully raised with an instrument made for the purpose. A trephine (Fig. 237) is then applied, the pin pushed down, and the bone sawn through. If the matter is reached, it will generally exude ; if not, the surgeon must try again. In some instances several openings may be necessary. If there is but a small collection of pus, an instrument devised by the late Dr. Charles A. Pope, of St. Louis, and shown in Fig. 238, may be OSTEO-MYELITIS. 513 used. In other cases again there may be such an amount of deposit, and that so hard and firm, that a trephine with an auger-handle, but with a small cutting crown, will be the most serviceable instrument. FIG. 238. 7A/4///-C0 Osteo-myelitis-There is a peculiar inflammation of the cancellated or medullary structure of bone almost exclusively of traumatic origin, and occurring in crowded hospitals, or in ill-ventilated apartments, which has received the name of “osteo-myelitis.” It must not, however, be under- FIG. 239. FIG. 240. FIG. 241. - - ſºn ...]". ºn- º A. | T |"Tº Fig. 239-Osteo-myelitis of the femur.—From a drawing in the Museum of St. George's Hospital. Fig.240.-Inflammation of the femoral vein from the same case. Fig. 241-Upper portion of humerus amputated for necrosis after osteo-myelitis. The necrosis does not extend into the tuberosities, neck, or head of the bone, which, however, are expanded by inflammation (osteo-porosis).-After Longmore, in Med.-Chir. Trans., vol. xlviii.-(Hoi MEs.) stood that the marrow and medullary canal are alone affected; the abnormal action also extends to the compact structure and the periosteal surface of the bone. Dr. Lidell, who has given considerable attention to this pecu- liar variety of ostitis, especially in connection with military surgery, makes several divisions of the disease: first, carnification; second, suppuration; 33 514 A SYSTEM OF SURGERY. third, mortification of the medullary matter. The disease also may be acute or chronic, diffused or circumscribed. When a patient is about to be attacked with the disease, a chill is gener- ally the precursor, which is followed by fever and most severe and agoniz- ing pains, much aggravated at night, especially by the warmth of the bed. The pain is very peculiar; the patient knows that it is in the bone; it is deepseated, and so violent that the sensation is that of the bones being broken off. Together with these symptoms, oedema of the parts, with sen- Sitiveness, ensue; the swelling at first is circumscribed, which latter fact is of especial import in the diagnosis of the affection. The fever, after a few days, assumes a typhoid type; the system appears to be profoundly affected; delirium supervenes, of a low muttering character; there is great prostra- tion and profuse nightsweats. While the constitution is showing such marked signs of disturbance, the wound also changes its appearance, the discharges become unhealthy, are either ichorous, sanious, or flocculent. In some cases there may be a great diminution in the quantity, granula- tions which had been healthy become bluish or fungoid, the process of granulation is arrested, and there appears to be a tendency to sloughing and gangrene. Suppuration then follows; the whole bone-tissue becomes involved. Figs. 239, 240, and 241 show the extent to which the bones and even the blood vessels become affected. Very often symptoms of severe septi- Caemia are present. During the latter process the marrow becomes softened, oozes from the bone, mixed with a thin ill-looking pus, and accompanied with severe constitutional symptoms. According to Prof. Busch, the changes which take place in the medulla present all degrees of variation, from simple hyperamia of the fatty marrow to complete transformation of the same into red (lymphoid) marrow. The changes are not, however, equally intense in all the bones, being most marked in the humerus and femur; the tibia, radius, and ulna present more resistance to the morbid process. In the portions of bone removed for ex- amination, no blood vessels are found, though nucleated red blood-corpuscles can be seen in small numbers. In one case some of the nuclei of white cells were distinctly colored by hematine. The microscopical appearances were similar to those in cases of leucocythaemia. Idiopathic Symmetrical Osteo-myelitis.-There are certain cases of osteo- myelitis which are very acute in their character, and present no traumatism or other local assignable cause in their history. The epiphyses or the ex- tremities of the bones are likely to be affected, and from thence the entire shaft may become involved. The disease, being “symmetrical,” and affect- ing several joints at once with Oedema, sensitiveness, and redness, and being accompanied by fever, is likely to be mistaken for acute rheumatism. A case of this variety of osteo-myelitis is recorded by Dr. Charles Carey.” Treatment.—In the outset of the treatment of this malady arnica is a medicine which, internally administered, will often produce excellent re- sults. The medicines are chiefly phosphoric acid, staphis., lachesis, arsen., merc. corr. Sub., kali iod., aurum, nit. acid. Arsenicum should be given when the symptoms are of a very low grade; when there is much restlessness, thirst, and delirium; when symptoms of pyaemia or ichorrhaemia present, and the pus is sanious and offensive, with blueness of surface, coldness of skin, and thirst. Nit. acid may be employed in cases in which mercury has been previously administered in large doses, and when the Osseous system appears to suffer * Med. Record, vol. xiii., p. 109. CARIES-ULCERATION OF BONE. 515 much from a thorough impregnation of this drug; also when there is present a syphilitic dyscrasia. Merc. corr. sub.-The bichloride of mercury acts better in this form of bone disease than any other mercurial with which I am acquainted. It is especially indicated for bone-pains with swelling and tenseness of the parts, when the disease runs a very rapid course, and when there exists no pre- vious mercurial taint in the system. Other medicines are calc., sulph., silic, graph., iod., lycop., kali bich., phosph., baryta carb., and mang. With regard to local treatment, which is sometimes necessary to allay severe sufferings, cold applications are very efficacious. When pus has formed it must be evacuated by the trephine, and free incisions into the surrounding structures are often necessary to relieve tension and evacuate fluids. As a last resort amputation may have to be performed, and even this affords no guarantee that the existing state of the system will not pre- dispose to an outbreak of the disorder in the stump. Caries—Ulceration of Bone.—The term caries is used to denote a peculiar ulceration of bone in which reparation is rarely effected by nature, and is with difficulty obtained by the most skilfully applied artificial means; or, according to Mr. Miller,” a breach of continuity of bone of altogether a pe- culiar kind; of itself very difficult to cure, yet not in any degree partaking of truly malignant action. On this subject Dr. Markoe writes: “Without attempting, therefore, to define caries, I will content myself with describing it as a disease of the cancellous structure of bone, characterized by a chronic or subacute inflam- mation terminating in suppuration, which is partly infiltrated and partly collected into abscesses, the cavities of which abscesses, after they have dis- charged their contents, have a tendency to ulceration, whereby sometimes extensive destruction of bone-tissue results.”f Every portion of the Osseous system is liable to be attacked with caries; but it has been observed that those bones that partake most of the cancel- lated structure are more frequently the seat of the disease than those of a more firm and compact conformation; thus the vertebrae, the bones of the carpus and tarsus, the sternum, and the extremities of the long bones, are the most frequent sites of this disease. For similar reasons the ossific struc- ture in young persons is more subject to it than those of advanced years. Surgeons of the olden time confounded caries with necrosis, the latter being termed by them dry caries; others have considered it the same as necrosis. These suppositions appear the more strange when we consider that caries was described by Galen as being somewhat analogous to ulcer- ation of the soft parts.j. It has been previously remarked that ossific matter, when attacked by in- flammation, becomes acutely sensitive, hence, in the commencement of this disease, in which the inflammatory process is always present, the patient suffers considerable pain; so great, in the generality of instances, as to prevent the enjoyment of repose for weeks and months together. The affected part is considerably swollen, but the enlargement is seldom so gen- eral or so great as is present in the diseased condition of the ligaments and other apparatus of the joints, although affections of the bursae, ligaments, or synovial membrane, may in time extend to the adjacent bones, and breach of continuity be the consequence. In caries, the affected portion appears neither to possess vital action * Principles of Surgery, p. 435. # A Treatise on Diseases of the Bones, by Thomas M. Markoe, M.D., New York, p. 94. † See Cooper's Surgical Dictionary, vol. i., p. 820. 516 . A SYSTEM OF SURGERY. enough to enable it to repair the solution of continuity, nor is the diseased mass sufficiently deprived of vitality to be thrown off by the surrounding tissues. When the affected parts have remained a considerable time in this inactive state, the surrounding vessels become somewhat excited, and the surface of the bone in the vicinity is studded with small points of new Osseous formation; these new deposits, however, are not limited to the affected bone, but may be traced to those with which it is articulated. The soft, parts surrounding the diseased mass are commonly more or less thickened and rendered exceedingly dense by effusion of lymph into the cellular tissue, which sometimes becomes of a cartilaginous hardness. As the ulceration proceeds, a cavity forms in the bone, with soft, spongy mar- gins, with an unequal bottom, deep at one portion and completely shallow in another (vide Fig. 242); the substance of the bone may crumble easily, or the part may be covered with pale and unhealthy granulations; often a loose, fungous growth sprouts from the interstices formed on the surface of the diseased bone, bleeding readily at the slightest touch; from the decaying structure also a thin, fetid, and corrosive ichor is discharged, in many in- |####, # , ºff ºff g y f º & * º ; - { |||ſ , t :: *, ºf f : tº Afºg Tºº ºl A. *i; }; ºf ºn A 'ſº … . . . . . * || || || ||Nº|| | | º º º t * , t 8 ºf ºr ºf º j º º # *f; fiftſ/ ...; ſº ºff, #!"ºft # $ * & % | *º- fift ſº ºff!}}} *: sm: º, g, º f : * > . . . . . . 4°:3 ####1 *:::::crºſſº: *: * ſºs Caries of the lower extremity of Humerus after resection. Author's collection. A, showing commencement of ulceration. stances through a sinus which has been formed in the soft parts; these symptoms, however, as well as the tendency in the accompanying ulcer or sinus to produce large fungous granulations, are more constantly met with in necrosis than caries, for the latter disease has been known to exist for a considerable length of time unattended with any outward sore, abscess, or SIIlllS. A superficial caries may be ascertained without much difficulty, and when the affected bone is deepseated it may be discovered by the use of the probe; for if the disease exist, the surgeon can often readily detect the in- equalities of surface, and, owing to the spongy character of the diseased part, the instrument can readily be made to penetrate the substance of the bone; in some instances, however, when there exist the unhealthy granu- SYPHILIS IN BONE, 517 lations already mentioned, a moderate degree of force is required ; the latter fact, if remembered, may prevent in some instances an incorrect diagnosis. There are some bones which may be diseased, and which from their situ- ation, do not admit of the use of a probe; in such cases the diagnosis may be more difficult; however, if a fistula, from which a fetid, corrosive, and dark-colored matter is discharged, be found leading directly from the sur- face of a bone, and if the surrounding part be at the same time turgid and indurated, there is every reason to suppose the existence of caries. “If a person,” wrote Boyer,” “affected with certain constitutional dis- ease, feels deepseated or acute pains in any of his bones, and if the pained part swell and become the seat of an abscess, from which a purulent matter of a bad quality flows, there is reason to believe that the bone affected with pain is carious. Inert abscesses are attended with nearly the same symp- toms, with this difference, that they are not preceded by pain. Caries oc- casioned by syphilis affects most commonly the tibia, os frontis, ossa nasi, Ossa palati, and sternum. Whenever, therefore, any of these bones become carious, whilst the person labors under syphilis, there is just ground for concluding that the caries is a symptom of the venereal affection.” Caries may be divided into three varieties, simple, Scrofulous, and tubercu- lar. The simple form is such as has been described, the scrofulous variety is dependent on a constitution affected with scrofula, and in tubercular, * disease is accompanied by deposit of tubercle in the loose texture of the OIl€. The causes of caries are various. It may arise from disease of the soft parts—ulcers, etc.—having extended to the bone, or constitutional taint may be the remote, and recent injury the proximate cause, but probably the disease most frequently arises from scrofula, syphilis, or abuse of mercury. Scrofula in Bone—Scrofulous Ulceration of Bones.—As will be imagined, this condition is characterized by the deposition of tubercular matter, or of a very low grade of inflammatory action. In the earlier stages the bone becomes soft, and an oily material is found deposited in its substance. At a later period a soft worm-eaten and foully-smelling ulceration is discovered. After a period the entire periosteum is destroyed or thickened. The can- celli and the lacunae are filled with an exudation. Dr. Blacki finds that there is in tuberculous bone always fatty degeneration; that the lime salts are diminished and the soluble salts are increased. The peculiar appear- ance of a whitish, Oedematous, indolent swelling, characteristic of scrofula, is found around the ulcer. There is not much pain nor much swelling. When the bone is examined, pits or round holes, with sharp edges, and filled with a cheesy deposit, are found. These peculiar pits are regarded as char- acteristic. Syphilis in Bone.—When the bones are affected with the tertiary forms of syphilis, the appearances presented at first are those of a node which has already been described. If the disease is not arrested in this stage, the ulceration attacks the bones in one of the two varieties of syphilitic ulcera- tion, viz., the annular ulcer or the tubercular ulcer. In the former there is a round depression, generally found in the cranium, with a groove around the margins like a trench, which marks the outset of the ulcerating process, while in the latter form, a syphilitic tubercle first appears, which finally ulcerates, and penetrates deeply into the bone; indeed, in Some instances, the entire thickness of the bone may be eaten through. * See the Lectures of Boyer upon Diseases of the Bones, arranged by Richerand, trans- lated by Farrell, and edited by Joseph Hartshorne, M.D., p. 167. f Pathology of Tuberculous Bone, p. 32. 518 A SYSTEM OF SURGERY. Treatment.—Much vigilance should be exercised with a view to prevent the occurrence of this morbid condition; therefore, if there be ulcers and abscesses in the soft parts which appear to have a tendency to involve the bones, they must be carefully watched and judiciously treated.* If simple Suppuration occur as a consequence of diseased periosteum, the medicines before mentioned for periostitis should be administered in accordance with the presenting symptoms. By careful watching, the formation of matter may be averted; but to accomplish such desirable result, the treatment must be commenced early. When there is merely an inflammation of the bone with slight swelling, red- ness of the integument, and extreme sensibility to touch, bryonia and pul- satilla are recommended; the latter being more adapted to the disease when it occurs in persons of a phlegmatic temperament, with mild disposition, apathy, etc.; the former deserving preference if the patient be of a dry, meagre habit, with bilious or nervous temperament. Mercurius is an im- portant medicine for ostitis as well as periostitis, and by its administration the inflammatory action occurring in the bone may be checked before other untoward symptoms present themselves. The indications for the admin- istration of this medicine, as well as others, have been mentioned in the previous chapters. If inflammation of the bone is chronic, the following medicines may be resorted to, according to the correspondence of symp- toms in each individual case: asaf, calc., phosph., phosph. ac., silic, sta- phis, and sulph. When the affection has arisen from the abuse of mercury, and the disease is accompanied with mercurial or mercurio-syphilitic symp- toms, aurum, hepar, or nitric acid may be used. If from a blow or bruise, ostitis threaten, arn., calen., ruta, or symphytum may be employed; but when there is considerable erysipelatous redness around the wounded part, bella. may be used and in some cases in alternation with arnica. My friend Dr. Holcomb says of asafoetida in this connection: “I have twice verified the value of this remedy in scrofulous caries of the bones. I used the 12th dilution. It is singular that a remedy whose principal appli- cations are for the most fugitive and sympathetic disturbances of the ner- vous system, should extend its curative power to the most deeply seated and chronic organic lesions. My opinion is that we know almost nothing about this ‘devil's dung,” as the Persians call it, and that it is well worth a thorough study.” Other medicines that have been serviceable in the treatment of caries are baryta, carb. veg., dulc., fluor. ac., lyc., mang, mez., staphis. If a patient affected with caries apply for relief, the first duty of the physician must be, if possible, to remove the causes which have either proximately, remotely, or both, given rise to the disease. The paucity of symptoms recorded in the Materia Medica belonging to caries, makes it difficult to select appropriate medicines for each case. The medicines mentioned, however, have proved beneficial, ex, w8w morbis, in the treatment of this disease. - - Mr. Pollock has recently used sulphuric acid topically, with marked suc- cess, to hasten the separation of dying or diseased bone. In his essay upon the subject he has made some important observations. He says: “I am not aware that the application of sulphuric acid in the treatment of carious bone has been previously adopted in preference to the use of the gouge, actual cautery, or caustic potash. I find no special reference made to its effects, nor any allusion to its extreme applicability or efficacy in the treatment of caries, in any of the modern treatises on bone. In the number * See Abscess, p. 113; Ulcers, p. 131. NECROSIS-DEATH OF BONE. " 519 of cases which have come under my notice both in St. George's Hospital and in private practice, in no one instance have evil consequences been known to follow the application of sulphuric acid to diseased bone in any part of the body, nor has the treatment been found a painful one when the acid has beeh used in a diluted form.” He then directs that if there be a cavity it may be packed with lint, saturated with dilute acid; or a syringe may be used charged with a solution. A very peculiar fact connected with the process is, that the dilute acid will not act on healthy bone, but limits its operation to the diseased Structure. Mr. Henry Noad, clinical clerk to Mr. Pollock, conducted the following experiments in view of the fact stated above. Ten grains each of (1) diseased, (2) dead, (3 and 4) healthy bone, both of ºil. age and of old age, were subjected for three days to the action of a mixture of sulphuric acid and water, one part in four, at the tempera- ture of 100°. The following were the results: 1. From the dead bone, 2 grains of phosphate of lime and 3.3 of carbonate of lime were dissolved in the acid. 2. From the diseased bone, 2 grains of phosphate of lime and 1.3 of carbonate of lime were dissolved. 3 and 4. In both specimens of healthy bone no action took place. In several cases this treatment has, in my hands, been successful. Necrosis—Death of Bone.—The term necrosis, which literally means destruction, is by surgeons applied to bone deprived of its vitality. It was first used in this particular sense by M. Louis, who restricted this appella- tion, however, to cases in which the whole thickness of a bone was destroyed. The ancients termed the disease “dry caries.” Between caries and necrosis, says Wiedmann, there is all that difference which exists between ulcers and gangrene, or sphacelus of the soft parts. In caries, the nutrition of the bone is impaired, and an irregular action disunites the elements of bony structure, which consequently sustains a loss of substance. In necrosis, on the contrary, the vitality and nutritive function cease altogether in certain portions of the bone, the separation of which then becomes indispensable. Bones are not as extensively supplied with bloodvessels as other textures of the body, and their natural powers are inferior to those of the softer parts; and this circumstance may serve to explain the frequent occurrence of the disease under consideration. Necrosis may appear at various periods of life, but is most commonly met with in young subjects, in whom the inflammatory action is allowed to make some progress before it is noticed or attended to. It may affect the external or internal structure of a bone, or nearly its whole thickness. An entire bone seldom dies in consequence of diseased action; and it is in rare instances that the whole thickness of any portion of it is found necrosed, although a larger proportion may be involved, Mr. Miller divides the process of necrosis into several stages: 1st. The bone or portion of bone inflames. 2d. The bone dies. 3d. The dead por- tion is separated from the living, 4th. Separation of the dead portion is complete. 5th. The dead portion is extruded. “When a portion of bone is to die,” writes Holmes,” in an admirable article, “the first phenomenon is the cessation of circulation in it. This leaves it hard, white, and sonorous when struck. It does not bleed when exposed or cut into, and is insensible. Occasionally, when the dead bone is exposed to the air, and acted on by the presence of putrid pus, its color * System of Surgery, vol. iii. p. 760. 520 *. A SYSTEM OF SURGERY. becomes nearly or quite black; large surfaces of hard, black, necrosed bone are sometimes left exposed by the sloughing of the skin over the tibia. The dead bone at first retains its connection to the bone around, as well as to the periosteum or whatever part of the nutrient membrane may belong to it; but the presence of a dead part is never long tolerated by the living tissues, and accordingly the processes which are to eliminate it soon become perceptible in both these structures. The periosteum or medullary mem- brane, as the case may be, separates from the dead bone and becomes in- flamed, a quantity of Ossific deposit (more or less, according to circum- stances) is poured out between it and the dead bone, and this deposit soon becomes converted into new bone, forming a sheath over the dead portion, by which the latter is inclosed or invaginated, as the technical term is. The dead part is now called a sequestrum, a name only properly applied to it when loose and invaginated, though often incorrectly used of any piece of the dead bone. While this sheath is being formed from the membrane coating the dead bone, changes are going on in the living bone to which it was attached. When the latter has been previously diseased, i. e., when the necrosis has been of inflammatory origin, the inflammatory deposit which surrounds the sequestrum softens, pus is formed, and a groove of ulceration is produced at the expense of the circle of inflamed bone which forms the margin of the sequestrum. If the surrounding bone has been previously healthy, the sequestrum acts as an irritant upon it, setting up first inflammation and thickening to a variable distance, and then ulcera- tion. Thus a groove is traced round the sequestrum, and the formation of the groove is accompanied by suppuration, “the pus containing much earthy matter from the disintegrated tissue, B. B. Cooper stating 23 per cent. of phosphate of lime.’” When the disease has not far advanced, there is a copious discharge of purulent matter,” and the external openings, through which the pus finds exit, are found to lead to cloacae or apertures in the new bone (the involu- crum), which encases the old; through these, the dead portions can be dis- covered by the probe. Sequestra are also sometimes cast off, the hue of which resembles that of Ossific matter which has been for some time buried in the earth. When a sequestrum is discharged, the disease may be con- sidered at its height; for Nature is throwing off the dead structure, which can no longer be of any service to the economy. Often at this period, by introducing a probe, several pieces of detached bone may be readily felt. These symptoms of necrosis, thus evident in affections of those bones that are covered with thick muscular fibre, are still more so in cases of flat superficial bones, as those of the skull; in diseases of the latter, the skin at first becomes thick, hard, and reddish; but soon ulcerates, and discharges matter of the character before mentioned. - The prognosis varies according to the situation of the bone affected, and the circumstances with which the disease may be complicated. If necrosis occurs, and is confined to a small surface of a bone, it is not very difficult to cure ; but when large portions of the Osseous system are involved, and if the introduction of instruments be required to separate the exfoliated por- tions (sequestra), the prognosis is extremely unfavorable. In cases of necrosis, in which the dead bone is entirely inclosed in that newly formed, the prognosis may vary, according to the state of the sur- rounding soft parts, the age and strength of the patient, and the form of the * “Formation of matter is occasionally the cause of necrosis. I have seen several instances in which it occurred from neglected erysipelas of the leg.”—Liston's Elements, p. 76. IDEATH OF BONE–TREATMENT. 521 new osseous substance. There is in some cases a peculiar variety of intra- Osseous necrosis without suppuration. W. M. Baker* mentions a case of intraosseous necrosis of the femur, without suppuration, for which amputation at the hip-joint was per- formed. The case presented all the characteristics of malignant tumor of the femur, even to undergoing spontaneous fracture, and the amputation was resorted to on that diagnosis. The patient recovered. On dissecting the amputated limb it was found that nearly the whole of the femur had perished, and in some parts, the dead bone was beginning to separate, but not a drop of pus was anywhere to be detected. New bone had been pro- duced, both by the periosteum and by the medullary membrane, and the dead bone was so locked in by it as to render futile an attempt to remove the disease by any other method than by amputation. This form of necrosis is held to be the last of a series of changes, of which the earlier consist of chronic ostitis with hypertrophy and sclerosis. The tumefaction of the limb may be excessive ; the fistulae numerous; the suppuration abundant; and the patient reduced by colliquative diar- rhoea and hectic; under such circumstances the danger is much greater than if the suppuration were trifling, the patient young and healthy. A favor- able termination of the disease may be anticipated, if, together with these latter conditions, the newly-formed bone is perforated by nature, that the dead portion may be readily withdrawn. The causes of necrosis may be divided into internal and external: among the latter may be classed—contusion, excessive pressure, imprudent appli- cation of caustic, f etc.; and of the former, syphilis, scrofula, or mercury, or the inhalation of the vapor from phosphorus. In persons thus constitu- tionally affected, a blow, or other external accident, may prove an exciting cause of the disease. Concerning the death of bone, and the reproduction of new ossific matter, Dr. Gibson writes: † “So far as opportunities have been afforded me of ascertaining this point, I have no hesitation to express the belief, that the periosteum is the chief agent in both processes. If from any cause the periosteum inflame, and matter is poured out between it and the bone, so as to separate one from the other, all vascular intercourse must cease—or, at least, the bone then depends exclusively for its support upon the internal periosteum and marrow; but these being inadequate to furnish the requi- site supply, a part or the whole of the bone will necessarily perish.” Violent inflammatory fever attends the excited action of the bone and periosteum, which precedes necrosis. But, after the matter has accumulated and been discharged, most of the painful symptoms subside. Frequently fresh collections of pus are generated, as each portion of the dead bone approaches the surface. When the formation of new ossific material has extended to a neighboring joint, its motion may be very much impeded, and if the limb is kept at perfect rest anchylosis may occur. Treatment.—In the treatment of this disease, Š as in caries, the great ob- ject is prevention, to be accomplished by the successful treatment of Ostitis, periostitis, caries, and of the constitutional affection (if any be present), upon which death of the bone may follow as a consequence. * American Journal of the Medical Sciences, July, 1877, p. 267. f As happened in a case of a woman, who had caustic potash applied to an exostosis on the internal side of the tibia. f Institutes and Practice of Surgery, vol. ii., p. 55. & For an interesting paper on this subject, see Quarterly Homoeopathic Journal, vol. i., p. 86; an article entitled “Case of Necrosis of the Posterior Portion of the Superior Maxil- lary Bone, and Gangrene of the Gums and Cheeks,” by J. Lloyd Martin, M.D. 522 A SYSTEM OF SURGERY. One of the principal indications is the evacuation of purulent formation, which frequently bathes the inflamed bone and detaches it from the perios- teum. Separation of the sequestrum may be hastened by the administration of medicines, which, acting beneficially upon the surrounding osseous struc- ture, tend to increase the action by which exfoliations are cast off. The affected part must be allowed to remain at rest, and all stimulating appli- cations avoided. In the first stage of the disease, if there should be severe or extensive inflammation of the soft parts, acon., bell, bry., hepar, merc., or sulph., are indicated. - Asaf, calc., phos., silic., sulph., and, according to some authorities, sym- phytum, when properly prescribed, materially lessen the tendency of parts to renewed inflammatory action, and also exert a specific action upon the Osseous system; either of these may be administered, according to the presenting symptoms, to hasten the separation of the dead from the living bone. After this is accomplished, it is the duty of the surgeon to interfere, and, by the requisite incisions and proper mode of extraction, liberate the necrosed portions of bone, which, if allowed to remain, acting as extraneous matter, irritate the parts and give rise to increased inflammation and pro- fuse suppuration. But the surgeon must ascertain that the sequestrum is entirely detached before attempting its removal. On this point Mr. Miller writes: “A common error, in practical surgery, is interference with the sequestrum before it has become loose. To lay hold of it and use violence, after exposure by incision, is certainly to induce a combination of evils. The evulsive effort often fails, and consequently the patient has been put to a grave amount of pain, unnecessarily and fruitlessly. By the violence, in- flammatory reaccession is certainly induced in and around the part origi- nally implicated. In other words, a fresh ostitis—probably both acute and extensive—is induced, and aggravation of the necrosis is most likely to follow. Also the loss of blood which attends on such attempts, whether successful or not, is invariably considerable; coming from a wound of soft parts, which are not only unusually vascular, but besides unfavorable to natural haemostatics. And the patient's state of system is generally such, in the advanced stage of necrosis, as to be altogether intolerant of a repe- tition of such haemorrhages. Therefore, on this ground alone, it is plain that the operation for removal of a sequestrum should never be undertaken, unless the surgeon be tolerably certain that his efforts will then prove suc- cessful.” In probing, the simultaneous use of two instruments is sometimes advan- tageous. One probe resting on the end of the sequestrum, a second is in- troduced through another cloaca; and by pressing with each otheralternately, looseness of the sequestrum may be made plain in circumstances otherwise extremely doubtful. If the disease arise from syphilis, or scrofula, or if from scorbutic symptoms complications appear, the medicines must be selected with the view of meeting, if possible, both the constitutional vice and the local affection; although in many cases, by removing the former, the latter will also be remedied. If the disease originate from injury, the application of arnica externally and internally will be beneficial. A man, aet. 28, fell from a tree, and seriously injured his arm by striking it against a stump; for the space of four months all motion was pre- vented; after which, though mobility in a degree returned, the limb was somewhat painful, and at times quite rigid. Two years subsequently, seve- ral fistulous openings were formed, through which fragments of bone fre- quently were discharged. Arnica relieved the pain. Silic., calc., and sulph. OPERATIVE MEASURES. 523 effected a cure. A remaining stiffness of the joints was removed by colo- cynth.* - Operative Measures.--When it becomes necessary to remove a sequestrum, FIG. 243. º.º.º.º. ºffſ is tº 1. ſ & lººr a lit.: § is . it; hº G, TIE/MA/W/V & CO Bone Chisel. ºf , ; ; ; ; ; ; especially if it be firmly covered by the involucrum, a free incision should be made down to the bone with a strong scalpel, through the tissues, the FIG. 244. Bone Hammer. point selected being out of the way of bloodvessels and nerves. It may be necessary now to enlarge the cloacae by means of the chisel (Fig. 243) and Bone Forceps for Deep Cavities. hammer (Fig. 244), and then to remove the sequestra with forceps, repre- sentations of which will be found in the Chapter upon “Resection of Bones FIG. 246. G.77&MA/V/V & CO Bone Gouge. and Joints.” . A forceps curved at the beak, in a manner seen in the cut (Fig. 245), is very useful in deep cavities, FIG, 247, IBone Graining Forceps, Dr. Markoe also has a gouge for operations in necrosis (Fig. 246), which, * See Jeanes's Homoeopathic Practice, pp. 55-57. 524 A SYSTEM OF SURGERY. he says, gives him “a very delicate corner to work with—delicacy is re- quired, and a powerful instrument where heavy cutting is to be done.” Forceps for biting or graining away bone are often serviceable, as seen in Fig. 247, and gouges, rasps, and elevators, which are contained in the ordi- nary resection cases. From a case of necrosis of the femur which he relates, M. Sédillot thinks he ought to draw the following conclusions in regard to the treatment of the periosteum during these operations:* “1st. Superiority of operations saving the relations of the periosteum with the subjacent Osseous layers. “2d. Condemnation of the methods in which the periosteum is dissected and isolated from the Osseous surfaces in contact. “3d. Failure of the attempts at regeneration of bone from the periosteum detached from the splinters in the seat of fractures. “4th. Absence of Osseous reproduction from the fringe of periosteum pre- served around amputated bones. “5th. Absence of Osseous regeneration in cases of pseudarthrosis treated by resection with preservation of a periostic sheath.” Mollities Ossium or Malacosteon and Rachitis.-Both of these affections are occasioned by a deficiency of the requisite proportion of earthy material in the bony structure, and differ only in this, that in the latter the cretaceous matter is not deposited originally, while in the former, it is absorbed after having been deposited. The difference between mollities ossium and rickets appears to be simply this: rickets is an affection of childhood, and bears a close resemblance to scrofula in the factors which produce it; it is curable, and patients are gene- rally improved by constitutional treatment. Mollities is found chiefly in adult life, and there is no scrofulous cachexia. In its obstinacy it bears a strong relationship to cancer, to which class of diseases it has been assigned by some noSologists. Softening of the bones is met with at all ages and in different degrees. It often follows dentition, measles, whooping-cough, or other infantile diseases which induce general debility; and in females it appears to be produced by the weakening effects of leucorrhoea, miscarrriages, etc. Mercury ad- ministered in inordinate quantities, also produces the disease; but by far the greater portion of cases are said to depend on scrofulosis. As in all other chronic dyscrasiae, the development of the affection is gradual; the first symptoms that are noticed being generally those of derangement of the di- gestive functions, alteration of secretion, etc.; by degrees a material change in the solids of the body takes place, particularly in the Osseous system, and the alterations of composition in the latter give birth to many functional derangements. The gastric symptoms that are noticed, as precursors of the disease, espe- cially when children are affected, are: flatulency, acidity of the stomach, distension of the abdomen, Sour eructations, and vomiting. The appetite is impaired, the patient usually desiring those articles of food which are par- ticularly indigestible; the countenance is P. and cadaverous, the urine becomes turbid and cloudy, and if subjected to chemical analysis, is found to contain a superabundance of phosphate of lime, and probably benzoic and oxalic acids. - In children (rachitis) there is much emaciation; the skin and muscles become flaccid, the face is wrinkled, distorted, and resembles that of the aged. The growth of the child is arrested, walking is difficult, and in the * See a paper prepared by Dr. Deslande, American Medical Times, November, 1861. MOLLITIES OSSIUM-TREATMENT. 525 more advanced stages altogether impracticable; the teeth become yellow, §. or streaked transversely, are at length attacked by caries, and soon all Out. During the progress of the disease the bones flatten and bend, are soft, cellular, and of a brown color, contain a dark fluid, and are very deficient in earthy matter. In many instances, this latter component of Ossific structure is almost entirely removed, the bones consisting of an extremely thin external Osseous shell, covered by thickened periosteum, and contain- ing a pulpy substance resembling fatty matter. Although this disease has been said to attack individuals of all ages, by far the greater proportion of those affected are young children. Certain rare cases, however, have been ºld. in which all the bones of the adult were softened to a very great egree. The vertebral column is particularly liable to be affected with rachitis, and the disease may be in certain instances confined to it alone. When the cervical vertebrae are attacked, the anterior part of the neck projects, the head falls backwards, and appears sunken between the shoulders. When the affection is general, the vertebral column becomes shorter, and is curved in various directions; the breast is deformed, not only in con- sequence of the curvature of the spine, but by the depression of the ribs and projection of the sternum; the bones of the pelvis fall inwards, and generally the pubis approaches the sacrum.* According to the observation of Mr. Stanley, when the tibia and fibula become affected they acquire increased breadth in the direction of the curve, losing a proportional degree of thickness in the opposite direction.f The proximate cause of softening of the bones is involved in much obscurity; various authors have endeavored to explain the origin of the affection in accordance with their own peculiar views. These conflicting Suppositions, although possessed of much interest to the curious, are of no practical value, and therefore need no comment in this place. Treatment.—In this disease great advantage is to be derived from the general treatment; the patient, if residing in the city, should, if possible, be removed to the country, where an elevated and dry situation should be chosen, nourishing diet, with a moderate quantity of wine, may be allowed, and the strictest cleanliness, with regularity of habits, should be observed. But as the poor, among whom the disease is most frequently observed, are not able to procure change of residence, the patient should be placed in a room that is well ventilated and clean, and in temperate weather be allowed to walk or sit in the sunlight. A straw or wheaten chaff mattress should be used, as it is dry and does not yield to the weight of the body; the clothing should be sufficient to prevent uncomfortableness from ex- tremes of heat and cold, and should be changed to suit the variations of temperature. . In the first stages of the disease, when gastric derangements predominate, ipecac., bry., nux and verat. are indicated, and their adminis- tration is frequently followed by beneficial results. In addition to this, appropriate splints and bandages should be applied, which will, in certain cases, if used in the earlier stages of the disease, be productive of much good. If these mechanical means be not sufficient, the child should be thoroughly etherized, and forcible means employed to re- store the parts to their natural position. If this also is not sufficient, the Surgeon must resort to subcutaneous osteotomy, for which directions are given at the end of this chapter. * Boyer on the Bones, p. 190. f Med.-Chir. Trans., vol. vii., p. 402. 526 A SYSTEM OF SURGERY. In children, when the abdomen is hard and distended, the gait unsteady and staggering, and the complexion pale, with occasional flushes of heat, bell. is particularly j. Sulph., calc., hepar, and silic. are also powerful agents in the treatment of rachitis; by their exhibition the general health improves, and the dis- ease has been known to be arrested in a short period of time. The attenua- tion of these medicines, however, is an important consideration ; the practi- tioner will fail in his endeavors if recourse be had to the crude, inasmuch as the most beneficial results are more certainly attained by the adminis- tration of the third dilution. Hartmann writes:* “I have employed with great success brucea anti- dysenterica, particularly when the feet were turned outwards and the chil- dren walked on the inner ankles.” - In another work, he further says: “According to my experience, it is in the preliminary stage that cod-liver oil will do the most good and actually effect a cure, and remove the danger of relapse, providing a proper dietetic and hygienic regimen is observed. The oil may be used internally, and at the same time rubbed on the abdomen. If no improvement should set in after using the oil a fortnight, or if the child should evince an insurmount- able repugnance to taking the medicine, as a matter of course some other remedy will have to be used.” Acid. phosph., ruta, staphis., mez., lyco, calc., and asaf may be indicated in the treatment of this disease. According to Dr. Patzack, pinus sylvestris is often of great benefit in the treatment of rickets. It may be used both externally and internally. In the Medical Record, I find an article headed “Artificial Production of Rickets and Osteomalacia,” which is well worthy of mention here. It appears that Heitzman has lately been making some experiments with lactic acid, and that selecting a number of dogs and cats, he fed them every day with a small quantity of the drug, at the same time injecting it subcu- taneously. After two weeks the epiphyses of the long bones, and the ribs at the attachment of the costal cartilages, began to enlarge, and at the same time there was diarrhoea and emaciation. These symptoms increased, and finally there was bending in the bones in a marked degree. The micro- scope revealed the same appearances as seen in the bones of persons suffering from rickets. To make the experiment still more certain, some of the animals were allowed to recover, and were treated in the same manner a second time with precisely the same results. By persevering in the use of lactic acid for four months, every appearance of osteomalacia was presented, the medullary substance possessing a great degree of vascularity, and the compact structure being much thinned. In those animals living almost exclusively on vegetable diet, there was a somewhat different result, death ensuing in from three to five months. The conclusions arrived at are: “That carnivorous animals, fed on lactic acid, first develop rickets and then Osteomalacia. Herbiverous animals, on the other hand, develop osteomalacia without previously having rickets. Finally, osteomalacia and rickets seem to be due to the same general cause, viz., an excess of lactic acid in the system.” Subcutaneous Osteotomy.-Considerable attention is now being given to this method of relieving the deformities occasioned by rachitis. Some sur- geons, as Langenbeck, perform the operation with a small auger and a straight saw. Mr. Bradleyi uses a tenotome to divide the integument, and * Chronic Diseases, vol. i., p. 63. † Diseases of Children, p. 401. † Lancet, July 21st, 1877, p. 78. FRAGILITAS OSSIUM. 527 then a very fine saw to cut through the bone; the extremities, are then placed in appropriate splints, and the wound covered with collodion. The cases which require the performance of this operation are those which have resisted the treatment by splints and bandages; as also those in which forcible 'manipulation has been tried while the patient is under anaesthetic influence. He says in conclusion: “From time to time surgeons have advocated the use of instruments, in appearance worthy of an old torture-room, to break the crooked rickety bones when they resisted the pressure of the hands; but by most, these appliances are relegated to the limbo of forgotten rubbish, and, as it seems to me, wisely, since we have in subcutaneous osteotomy an operation at once so safe and so satisfactory. And one final word on this subject. When subcutaneous osteotomy is performed for the cure of rickety legs, we need be under no apprehension about the filling up of the V-shaped interval which is necessarily left when the bones are straightened, for, as a matter of experience, this gap always does fill up with fresh bone, and thus we secure not only a strong and straight leg, but a limb not shortened, as it would of course be if we were compelled to excise a wedge-shaped piece of bone instead of simply sawing across the concavity.” M. J. Boeckel,” who has operated nine times for rachitic deformities, always with success, gives his method of treatment, as follows: “First, he tries manual reduction : if this fail, he endeavors to break them by the ordinary methods of osteoclasty; if this also fail, he cuts down to the periosteum, peels it off the bone; the bone is divided by the chisel and hammer, the saw is never used. The wound dressed after Lister's method, reduction performed when it is cicatrized. The operations were performed on patients whose ages varied from fifteen months to eight years.” The varied operations of subcutaneous osteotomy are detailed in the chapters upon deformities of joints, etc.; to them the student must refer for more specific directions. Fragilitas Ossium is a term which ought to become obsolete, as it is merely a symptom of other diseases. This condition occurs chiefly in old people whose osseous system contains an undue quantity of earthy material. Boyerſ states that a certain degree of fragilitas ossium necessarily occurs in old age, because the proportion of lime in the bones increases with age, while the organic matter decreases in the same ratio; but Mr. Wilsoni observes that they are never found so friable and fragile as to crumble like calcined bone, but, on the contrary, contain a large quantity of oil. The latter fact is also noticed by Mr. Liston, $ who gives as a definition of the disease that the bones become brittle on account of an undue proportion of earthy * are endowed with little vascularity, and are full of an oleaginous Ull Cl. In persons who have been long afflicted with cancerous disease, the bones are said to become as brittle as if they had been calcined. In inveterate syphilis, deprivation of organic material in the Osseous system has been noticed, and in those individuals who have been frequently afflicted with severe attacks of scurvy, the bones become so brittle that they are fractured from the slightest causes, Dr. Markoe, Mr. Stanley, and others have re- corded remarkable cases of this kind. The following interesting case was communicated to me by Dr. Charles A. * Journal de Méd. et de Chir., March, 1876. Abstract Med. Science, vol. iii., No. vii. + On Diseases of the Bones, p. 197. £ On the Skeleton and Diseases of the Bones, p. 258. § Elements of Surgery, p. 80. 528 A SYSTEM OF SURGERY. Church, of New York. I saw the patient with him in the Children's Hospital of the Five Points House of Industry in that city: Willie S., aged twelve, while playing with the children, sustained a trans- Verse fracture of the femur at the middle third, by being pushed, and, at the same time, struck upon the thigh by the knee of one of the other chil- dren. In December, 1869, he had a fracture of the tibia, caused by falling down. His family history I got from his mother, as follows: His only sister had her leg fractured at two different times; his oldest brother had one thigh fractured three times, the other twice; also one leg, one arm, one clavicle, and three ribs; his mother has had fractures of one leg, scapula, and three ribs; his mother's brother had fracture of one thigh three times, both legs, both arms, and one clavicle; and yet he served through the whole war in the Southern army without receiving an injury. His child has had fractures of both legs, one thigh, one arm, and one clavicle. The mother's sister had fractures of one arm and one clavicle; her father had fracture of one thigh three times and one clavicle; and all his brothers and sisters had more or less of broken bones, how many I cannot ascertain. The patient has a younger brother that has not yet had a fracture, but he has an unenviable prospect before him. The general health of the whole º, aside from this tendency to fracture, has always been remarkably good. Treatment.—This disease, particularly when occurring in the aged, is very difficult to cure. The patient should be allowed a generous diet, and pro- hibited from much muscular exertion; indeed, all circumstances likely to produce sudden action of any particular combination of muscles should be studiously avoided. The medicines that are best adapted to this affection are ruta, phosph. ac., mit. ac.; and from the effects that have been produced by symphytum, this medicinal agent should exercise much influence in this peculiar disorder. If the fragility of bone depend upon constitutional affections, syphilis, scrofula, etc., great advantage may be derived from the internal treatment of these diseases. The internal and persistent use of the phosphate of lime in the second trituration—five grains twice a day—has produced most excellent results. Churchill's hypophosphites of lime and soda I always order taken with the food, and Dr. McCready’s lacto-phosphates are also very highly spoken of Atrophy of Bone.—This is a peculiar affection, which, as a rule, is not marked with any characteristic symptoms. It may be caused by fatty de- generation, the result of the inflammatory process. The disease just men- tioned as brittleness of bone, is, no doubt, especially in the aged, a variety of atrophy. The most frequent cause, however, of the affection, is fracture occurring near or at the point of entrance of the nutrient vessels. A pecu- liar variety of this disease is the arrest of development of the epiphyses of the long bones. In such cases there generally has been some injury in- flicted upon the epiphysial cartilages. In the treatment of this disease calc. carb., symphytum, silicea, and sulph. are the very best medicines. They must be persevered in for a long time, and every attention paid to hygienic measures. º Tumors in Bone.—Tumors in bone are divided into the malignant and the non-malignant, and partake very much of the character of tumors, in other portions of the body. There is, however, great trouble often in making a correct diagnosis, and I think I may say that in some cases it is wholly impossible. Innocent Tumors—Exostosis.--Any bone in the body is liable to enlarge- ment, and in such cases we merely have an ordinary hypertrophy of bone, CANCELLATED EXOSTOSIS. 529 which can scarcely be classed as a tumor. A circumscribed exostosis is a bony tumor, which has a well defined margin and is generally formed of compact Structure. The formation of exostosis is similar to that of new bone; a plasma is exuded and becomes organized; this passes into transitional cartilage, and thence the osseous structure is gradually completed. At one time the term was made to include all growths, fleshy, osseous, and cartilaginous, but with propriety it is now limited to growth of bone from bone. Sir Astley Cooper wrote: “Exostosis has two different seats; it is either periosteal or medullary. By the periosteal exostosis I mean a deposition seated between the external surface of the bone and the internal surface of the periosteum, adhering with firmness to both surfaces; and by the medullary, is to be understood a formation of a similar kind, originating in the medul- lary membrane and cancellated structure of bone.” This description is true at the present day; the “periosteal” being the eburnous, or dense, ivory- like exostosis, and the other the common cancellated exostosis. The first is smooth, shining, and presents a polished appearance resembling ivory or pearl, is solid throughout, and appears almost destitute of those vessels by which an internal circulation is carried on. It usually appears on the flat bones, especially on the cranium, but the most frequent site of this form of the disease is the superciliary ridges.* The growth of this tumor is slow, and it is often unattended with pain. Cancellated Exostosis appears to be mere enlargement of processes of the parent bone, the cancellated tissue extending itself and forming the interior of the new bony formation, while the exterior resembles a proportionate extension of the outer lamina. This kind of exostosis seldom occurs ex- cept in the long bones of the extremities, and is most frequent in the femur at its lower part. The cancellated texture usually predominates, the external laminae being thin and delicate. Exostosis, according to Boyer, rarely proceeds from an external cause, such as contusion. In most cases it is produced by an internal disease, and principally by lues venerea or scrofula. The effects of exostosis may be divided into general and special; thus the swelling is accompanied by a sense of weight, pain is produced by the mor- bid action, and the affected part is necessarily deformed. Its particular or special effects arise from its situation; thus if an exostosis form in the orbit, the eye is expelled from its cavity, and the patient is deprived of sight. If a tumor of this nature arise from the clavicle or sternum internally, death may result by compression of the principal blood vessels. The prognosis differs according to the nature of the primary disease from which the exostosis originates, and according to the particular change in the texture of the bone. The ivory exostosis, if so situated that it does not impede the action of any organ, is said to be the least dangerous of all. Treatment.—The medicines that are best adapted to exostosis are: arm., asaf, calc. C., dulc., led., lyc., merc., mez., phosph., rhus., sep., silic., Sulph. The primary ostitis must be treated as before recommended, and if the dis- ease still progress, any of the above-mentioned medicines may be selected in accordance with the presenting symptoms. For exostosis syphilitica, aur., bell., nit. ac., and phosph. are recommended. I may here mention that I have given the Hecla lava, as recommended by Dr. Holcomb, whose attention was directed to it by J. J. Garth Wil- kinson, $ in many cases of exostosis and of caries, with the following * See McClellan's Principles and Practice of Surgery, p. 343. f Liston's Elements, p. 114. - I See Boyer on the Bones, p. 177. 3 Transactions of the American Institute of Homoeopathy, 1870, p. 249. 34 530 A. SYSTEM OF SURGERY. results: Exostosis of the wrist, of two years’ standing, in a gentleman who suffered most intensely. The medicine was taken in the sixth potency, and was continued for two months; great improvement, but not a cure, followed. In a second case, a boy with circumscribed exostosis of the ulna, was also benefited, but I lost sight of the patient. In a third case of cartilaginous tumor, approaching exostosis, no good result was obtained. In a fourth case the tibia was affected seriously, and the suffering was much relieved, and the tumor, though it did not diminish, ceased growing. In a case of caries I think I did not give the medicine a fair trial, though the patient ultimately completely recovered. Other cases gave similar results. If the bony tumor is large, and medicines do not appear to produce any beneficial effect, the surgeon may think proper to remove it by mechanical means. This may conveniently be done by the knife, Hey’s saw, and tre- phine. Sometimes a spring-saw will be found to answer a better purpose than any other instrument. Rarefying Ostitis—Osteo-Cystoma.-By these terms are understood an ex- pansion of bone from a collection of matter, which is not purulent but Serous, glairy or gelatinous. The cyst has not a pyogenic membrane, but is composed of a structure resembling that which is found in some en- Cysted tumors. Its growth is slow, but the bulk acquired may be enormous. The disease may be produced by external injury exciting inflammation, and consequently suppuration in the cancellated tissue; or the inflammatory action may be of a less acute kind, particularly in weakened and unhealthy Constitutions. As the disease progresses, the fluid accumulates, the cancelli are broken down, and the much-attenuated parietes of the bone are pressed outward. Occasionally the inflammatory action may be excited on the ex- ternal surface, from the pressure of the contained fluid ; and, when this is the case, minute nodules of Osseous matter are formed, as if nature en- deavored to strengthen the parietes, which from diseased action daily be- come thinner and more incapable of affording support. Sir Astley Cooper describes this disease as a species of exostosis; * Boyeri mentions it under Osteosarcoma; but the difference between the latter and the affection now under consideration appears to be, that in spina ventosa the discharge is uniformly fluid and of a serous character, though sometimes mixed with a cheesy matter, there is no fungus protruding after a portion of the attenu- ated bone has given way, and the tumor is not of a malignant character. There is considerable pain while suppuration is being established; but after the formation of matter the more acute suffering subsides, and in some instances there is but slight inconvenience and the tumor remains stationary. In other cases the enlargement is enormous, and the constitution of the pa- tient is very materially affected.[ Treatment.—Previous to the development of the disease, if the patient complain of weariness, heaviness, and aching in the limbs, arnica or phosph. acid may be prescribed. These medicines are also suitable, if, upon careful examination, slight swelling of the bone be detected, which is sensitive to pressure. By the exhibition of these medicines, together with mezereum, the disease may be arrested in its incipient stage, d Asaf., phosph., sulph., and silic., have also been recommended for this 1S63 Sé. Other medicines are calc., phosp., staphis., hepar, and sepia. Together with this treatment, a moderate degree of long-continued pres- * See Gibson's Institutes and Practice of Surgery, vol. ii., p. 62. f On the Bones, p. 182. † For an interesting case of osteo-cystoma of the cranium, which was skilfully and effectually removed by the late Dr. George McClellan, see McClellan's Principles and Prac- tice of Surgery, pp. 348-352. OSTEO-SARCOMA–CANCER IN BONE. 531 sure upon the part may also be resorted to. This method alone is said to have effected the cure of the disease. The best treatment is to freely open the cyst and pack the cavity with lint saturated with balsam of Peru. Should any of the large cylindrical bones be the seat of Osteo-cystoma, and after a thorough trial of remedial agents, the disease appears to be steadily advancing, amputation or resection may be performed. Osteo-sarcoma.-This term, though rather vague, is applied to that variety of tumor in which there exists an outside bony lamella with an internal fleshy or fibro-plastic substance, partaking of the nature of one or other of the varieties of sarcoma. In the commencement of this disease the bone is slightly enlarged, per- haps somewhat thickened in its outer laminae; and if a section of it be made, it is found to contain a brown fleshy substance instead of the usual cancel- lated structure. If this be placed under the microscope the cells are found to be either myeloid, spindle-shaped, or round. The Osseous portions of the tumor are in the form of spiculae, radiating outward, leaving interstices which are occupied by the sarcomatous tissue. Most frequently it is com- posed of sarcomatous substance, containing portions of cartilage. If the structures are composed of cysts, these are lined by a secreting membrane, and it is thought by some that on the perverted action of this formation, the increase as well as the peculiar structure of the disease depends. By the pressure of the new formation, the parietes of bone are forced outwards; in some cases attenuated, in others thickened by deposition of new osseous matter. To this the name “ossifying sarcoma' is given by Butlin. If the disease begin in the interior of the bone the term “central sarcoma "is given to it. As the disease advances, the bone becomes more attenuated, and in some places extremely thin, diaphanous, and somewhat flexible and elastic. From the latter condition it would appear that the part of the Osseous system affected had lost its proportion of earthy matter, and was filled with one of the varieties of sarcomatous cells. To a tumor composed chiefly of cartilage, with an admixture of bony lamella, the name osteo-chondroma, or enchondroma is given. For a full de- scription of this variety of tumor, as well as of myeloid tumors of bone, the student is referred to the Chapter on Tumors. For the usual forms of osteo-sarcoma there is nothing, in my opinion, to be done but amputation, or removal of the tumor, and too often when this is practiced, the disease is found to be of a malignant or recurrent character, and again makes its appearance. Cancer in Bone.—Sir James Paget lays down the following important rules for diagnosis, between innocent and malignant bony tumors: “1. The tumor is probably cancerous if its growth commenced before puberty, or after middle age, unless it be a cartilaginous or bony tumor on a finger or toe or near an articulation. “2. If a tumor has existed, on or in a bone, for two or more years, and is still of doubtful nature, it is probably not cancerous or recurrent, and this probability increases with the increasing duration of the tumor. “3. If a tumor, on or in a bone, has doubled, or more than doubled its size in six months, and is not inflamed, it is probably cancerous, or recur- rent; and this probability is increased if, among the usual coincidences of rapid growth, the veins over the tumor have much enlarged, or the tumor has protruded far through ulcerated openings and bleeds, and profusely dis- charges ichor. “4. If with any such tumor, not being inflamed, the lymph-glands near it are enlarged, it is probably cancerous, and still more probably if the pa- tient have lost weight and strength to amounts more than proportionate to the damage of health by pain or fever or other accident of the tumor. 532 A SYSTEM OF SURGERY. “5. A tumor on the shaft of any bone but a phalanx is rarely innocent, and so are any but cartilaginous outgrowths on the pelvis, or any but the hard bony tumors on the bones of the skull.” Of all the malignant diseases, the encephaloid is the most frequent, and presents itself as periosteal or interstitial. The periosteal is chiefly confined to the long bones, while the flat ones are generally affected with the inter- stitial form of the disease. - The following are the symptoms in the periosteal variety: The pains experienced by the patient are at first dull and deepseated, but in a short time they become more intense, the volume of the bone in- creases, though the soft parts appear yet in their natural state. The latter, however, soon become red and inflamed ; the pain becomes severe, and is lancinating in character; the system is deranged, the tumor softens, often presents a sense of distinct fluctuation, and on being freely handled, is found to crepitate in consequence of loose spiculae of bone being pressed against each other. Ultimately the integument becomes livid, or dark red, ulcerates, and allows a portion of the softened tumor to protrude in the form of a fungus. There is profuse discharge, thin and sometimes bloody; and, as may be supposed, much constitutional irritation and exhaustion. Not unfrequently during the progress of the disease, especially if it be situate in the cylindrical bones, fractures occur either from muscular contraction or external injury. This accident gives rise to serious complication, as the process of reproduction in the diseased bone is very slow, if, indeed, it is not altogether suspended, consequently the fracture does not unite, suppu- ration is increased, and the disease is, therefore, much hastened. Although after the protrusion of the fungus, the soft parts are not readily involved, the tumor may properly be pronounced malignant. At an earlier stage of progress it is confined to the tissue in which it originated by laminae of bone, but after this barrier has given way, it projects further through the aperture, and contaminates all the surrounding structures until again held in check by bony formation. Treatment.—In the commencement of this affection, several medicines may be indicated in accordance with symptoms which present themselves, among which are ars., bell., merc., mez., phosph., phosph. ac., nit. ac., Sulph. If the constitution of the patient suffers severely from the exhausting suppuration, china or hepar should be administered. If the disease has been occasioned by a blow, arnica, ruta, rhus or symphytum may be called for. From the action of thuja upon fungous formations, this medicine must be remembered, and should be prescribed if the sarcomatous formations are red and fleshy, pouring out blood profusely at the slightest touch ; if the patient is debilitated both in body and mind, and the symptoms are all aggravated towards evening or at night. The mercurial preparations are often used. Some have highly recom- mended the oxymuriate of mercury, which, according to other authors, has proved quite efficacious. The latter treatment is noticed in this place with the hope that some may be incited to experiment with the mercurial preparation just mentioned. - If medical treatment fail, which it generally does, surgeons of the present day have recourse to amputation or extirpation; the result, however, is sel- dom favorable, the disease returning with renewed vigor either in the stump or in some other portion of the body. When the cancer is interstitial it arises generally in the cancellous struc- ture, the pain being very intense, because the affection progresses rapidly, and the bone is mechanically forced open, from the continued and increas- ing pressure of the diseased mass in its interior. The characteristics which distinguish malignant from non-malignant PULSATING TUMCRS IN BONE. 533 tumors in bone, are also present, and the disease has a tendency to involve the subjacent textures. The chief indication in the treatment of these tumors is to commence early the medical treatment. Frequently, if the primary affection can be Subdued, or the constitutional symptoms successfully combated, the disease may be arrested; these ends may be accomplished by the treatment that has previously been mentioned for diseases of the periosteum and bones. The medicines that are best adapted to the medullary sarcoma are asaf, bell., calc., mez., merc., phosph., phosph. ac., silic., or sulph. For a description of myeloid tumors as affecting the bones, the reader is referred to page 168, in which case the entire superior maxillary, malar, and turbinated bones were converted into the peculiar suet-like mass of myeloid formation. Pulsating Tumors in Bone.—To this variety of bony tumor especial atten- tion should be directed, because although the diagnosis in certain cases is comparatively easy, in others it is almost impossible. Nélaton collected six cases of this disease, and named it “true aneurism of bone.” Volkmann collected four cases, Cappelletti and Landi each recording one. It is inter- esting to note, that of these twelve cases, in nine the head of the tibia was affected, the lower end of the femur in two, and the head of the humerus 1I] OIlê. In all these, pulsation was distinct, except one, in which there was a per- ceptible blowing murmur. In Dr. Carnochan's case, there was a bruit, the only one in the twelve where such a symptom was noticed. In two of the cases an aneurism of the anterior tibial artery was diagnosed.* The chief difficulty in diagnosis is to distinguish these tumors from aneurism by anastomosis, and this must be especially the case when the tumor appears in localities where such aneurisms are found, especially in the scalp. The chief points to be looked after are first, whether there be any unmistakable signs of a cancerous cachexia; second, whether the pulsation seems to be defined, or compressed by the periosteum, which offers some resistance to the throbbing. These certainly are but meagre signs upon which to base an opinion, and it is from these very facts that the diagnosis is so difficult. When the tumor lies upon a superficial bone, and is out of the track of a large artery, the diagnosis may be more readily made out. These tumors grow rapidly and the skin covering them shows enlarged superficial veins. Treatment.—If the tumor is small, it may be removed by cutting down upon it, and applying the galvano-cautery or the thermo-cautery, but as a rule the part if possible should be amputated. According to Professor Landi, who has analyzed the twelve cases already mentioned, two were cured by ligature of the main artery of the part, two ceased to pulsate, but were not removed; in three cases the ligature failed but amputation was successful; primary amputation was successful in three, and fatal in two Ca,SéS. A most interesting case of pulsating bone tumor, which was mistaken for popliteal aneurism, is recorded by Dr. Erskine Mason.f Every symptom of the latter disease was present, especially the “distinct eccentric ’’ pulsa- tion and loud and distinct bruit. The femoral was ligated in Scarpa's space, which effectually stopped all pulsation. The post-mortem revealed a sar- comatous tumor involving five inches of the femur. * London Medical Record, November 15th, 1877. f American Journal of the Medical Sciences, January, 1877, p 85. 534 A SYSTEM OF SURGERY. CHAPTER XXXI. FRACTURES: GENERAL CONSIDERATIONS IN THE TREATMENT of DIVISIONS-CAUSES- SYMPTOMs—ExAMINATION of PATIENT—MoDE of REPAIR-GENERAL TREATMENT. FLEXION OR BENDING OF THE BONEs – PSEUDo-ARTHRosis — CRACKED BONES.– SPECIAL FRACTURES IN THE WARIous REGIONs of THE BoDY. PROFESSOR GROSS, speaking of fractures, indicates the importance of a thorough understanding of the subject in the following words: “If I were called upon to testify, under oath, what branch of surgery I regarded as the most trying and the most difficult to practice successfully and creditably, I should unhesitatingly assert that it was that which relates to the present subject, and I am quite sure that every enlightened practitioner would concur with me in the justice of this opinion.” From the moment the young practitioner begins his professional life, he is liable to be called upon to treat this variety of injury, and as the first case may be one of those difficult and trying ones which baffle the skill of experienced surgeons, it is of the utmost importance that a thorough knowl- edge of the subject be imparted to the student. - Let it be borne in mind by the young surgeon that there is generally deformity after fracture; it may be so slight as to be almost unnoticeable, or it may be so great as to cause deformity the most unsightly; but certain it is that the best authorities of the present day are cautious in expressing tº: opinion in regard to perfect apposition of the fragments of broken OrléS. - On this subject, Dr. Hamilton writes: “I am frank to confess, that until I commenced these investigations, I had not any just notion of the frequency of deformities after fractures. Students will continue to go out from our hospitals with a belief that perfect union of the broken bones is the rule, and that the exceptions imply unskilful management; and if, when here- after they have themselves occasion to treat a fractured femur, the result falls short of their standard of perfect success, they, taught also by the Same instinct of self-preservation which actuated their teacher, will conceal the truth from others, or even from themselves, if possible.” I introduce these remarks, for the sake of encouragement to those beginning their sur- gical career, and will produce such cases, as we proceed with the subject, as will show that we must not expect too much in the treatment of fractures, especially if they be in the vicinity of joints, or complicated with much laceration of the soft parts. By the term fracture is understood a solution of continuity of the Osseous system, or, in other words, a separation or breakage of the bones, by various causes, both direct and indirect. Various divisions are recognized by sur- geons. Thus: & Simple Fracture.—The bone being broken at one point. Compound Fracture.—The bone being broken, and there being a wound in the soft parts communicating with the bone. Comminuted Fracture.—The bone being broken or crushed in many places. By the term compound comminuted fracture is understood the breakage of a bone into several fragments, with accompanying wounds of the soft parts. An impacted fracture is that in which one extremity or portion of the bone is wedged or driven into the other; a complete fracture is one in which there is an entire separation of the bone; an incomplete fracture signifies but a partial division of the Osseous material. Again, terms are used to designate the directions in which the separation FRACTURES-CAUSES-SYMPTOMS. 535 may occur; thus we have the transverse, longitudinal, oblique, or Serrated. Of these the second variety is most rare, and is generally occasioned by gunshot Injuries. Causes.—These are many, and are divided as usual into predisposing and exciting. Among the former we may enumerate: 1. Sex; men seeming to be more liable, although the difference in the avocations of the sexes may account for the more frequent occurrence in men than in women. 2. The season of the year; more fractures being treated in the winter than in the summer. 3. Age; old persons, from the preternatural brittleness of the bones, are especially liable to suffer from fracture, while the bones of younger persons, being supplied with more cartilaginous material, have much greater power of resistance. On the other hand, however, it must not be forgotten that in the former case, there is generally greater risk encountered from greater activity and exposure to accident. 4. The situation of the bones; the long bones of the extremities, being used naturally for locomotion and protection, are the most liable to be broken, while the small and irregular ones rarely suffer. 5. The position of the bones; the fibula is external, and is thin and slender, and is more frequently the seat of fracture than the tibia. The radius, being attached to the hand, more often suffers than the ulna, and the clavicle, from its articulations and position, is rendered very obnoxious to accident. 6. Disease; there are several diseases which render the Osseous system liable to fracture; some of these are to be classed as regular diseases of the bone, which are of a constitutional character. Among the former we have rickets, mollities, and fragilitas ossium, and among the latter syphilis, scurvy, gout, mercurialization, cancer, scrofula, etc. It is in these latter diseases that the proper exhibition of medicine may, by re- storing the healthy equilibrium and nutrition of the parts, render the patient less liable to fracture. The exciting or the efficient causes of fracture are generally external vio- lence and muscular contraction. Of these, the first is the more frequent, and can take place in either a direct or indirect manner. A man receives a blow on the leg or the arm, and the bone separates immediately at the spot where the force has been applied; another man falls upon the pavement, stretches out his arm to save himself, and though the force may be applied to the hand, the radius breaks above the wrist. Sometimes two forces may operate, one at each extremity of a bone, and it may separate in the centre, as is observed in the clavicles. Muscular contraction may cause a solution of Osseous continuity, espe- cially in persons advanced in life, and also in young persons in whom the muscular system is well developed, while the bones may be small in S1262. The late Dr. Hodgen,* of St. Louis, recorded a remarkable case of fracture of the sternum, and also fracture of the spinous processes of the vertebrae by muscular action. Symptoms.-Crepitus.-By the term crepitus is understood not only the sound which is emitted when the fractured extremities of a bone are rubbed together, but the peculiar sensation that may be felt by the surgeon during a careful examination. When this is really present it is always pathogno- monic, but it must never be forgotten that there are sometimes present in fractures what might not inaptly be termed false crepitus, by which I mean that peculiar rubbing noise that may be distinctly heard in the irritated sheaths of tendons and joints, or from the accumulation of air in the tissues. I have now in mind a case of injury of the knee-joint, caused by the fall * Medical Record, Dec. 22d, 1877. 536 A SYSTEM OF SURGERY. of a horse upon the limb of a young and athletic man, in which at first I Was led to suppose that a partial fracture of the patella must certainly exist, from the crepitus both felt and heard upon attempting to move the knee- cap. Sometimes the sound is very obscure, and the over-anxious surgeon may fancy that he can detect it when such is not in reality present; in such cases the application of the stethoscope may facilitate the diagnosis. We must also bear an important fact in mind, that a fracture may exist with- Out Crepitus. . Thus, in the so-called impacted fractures, or in those where Strong muscular contraction draws asunder the fragments, there may not be a trace of the sound, and I would have this point strongly impressed upon the mind. Preternatural Mobility.—This symptom is generally present in fractures, although in the bones of the leg and forearm, when one bone only is the seat of injury, the increased motion may be very slight, as may also be noticed in the impacted variety; but by grasping the fractured bone above the site of contusion and holding it firmly, and moving the lower portion of it in a lateral direction, an unnatural motion may be generally observed. This preternatural mobility may also be difficult to recognize, especially when the bony lesion takes place in the vicinity of a joint, and there is much contusion of the soft parts, which are torn or lacerated. Deformity.—We find deformity noticed in a great number of fractures; Sometimes it is in itself sufficient to render the diagnosis perfect. In some fractures we find—as in those of the olecranon and patella—there is a con- cavity existing between the broken extremities, in others an angularity may be observed; again, a prominence indicates the injury. In the long bones it may be asserted that the more nearly the lesion approaches the trans- verse variety, the less deformity may be expected, while the more oblique the direction of the fracture, the more will deformity exist. The pain and swelling belonging to these injuries, as a general rule, will have but little weight in establishing a diagnosis, for the reason that severe symptoms of this character, together with ecchymosis, are found in ordinary bruises and sprains. It is well for the young practitioner to remember in this connection an important fact, viz.: that because a patient may have considerable motion of a part, there is no reason that a fracture may not exist; a man with an impacted fracture of the femur has been known to walk unassisted for a considerable distance, and Velpeau has pointed out that even with a lesion of the collar bone, the arm of the affected side may be raised to the head. Taking into consideration what has already been mentioned, that crepitus, preternatural mobility, and deformity are the general symptoms upon which to depend, and in many cases these may one or all be difficult to detect; that in muscular subjects, and where the contusion or laceration of tissue is great, these symptoms may be, if present, hard to find, and that the usual presence of pain adds doubt to the appreciation of the injury, it will readily be understood what difficulties the surgeon may have to encounter. When to these we add the de- formity that frequently happens after the most judiciously managed cases, and the odium which is cast upon the surgeon by the ignorant or the malicious, or those whose cupidity for gain has smothered their feel- ings of honesty—is it remarkable that so distinguished an authority as Dr. Gross has written the words which are inserted at the beginning of this chapter ? Hºmination of the Patient.—When called to examine a patient in whom a fracture is apprehended, if there is the slightest doubt as to the diag- nosis, the best method is to place him immediately and completely under FRACTURES.–MODE OF REPAIR. 537 anaesthetic influence, and then conduct the manipulations thoroughly and as gently as possible. The sooner the examination is made the better, before much tumefaction has appeared, and before the excessive soreness, which soon is manifested. Never be in a hurry; if many demands upon your time are engaging your attention, either postpone some of them, or, if that cannot be done, the patient must be turned over to another surgeon. Another remark may also be inserted: do not be discouraged if the diag- nosis is not made clear upon the first, second, or even the third visit. There are some cases of obscure nature that the surgeon may never entirely diag- nose; and if he were candid enough to admit the fact, many are the cases that have made a fair recovery which were not entirely understood during a prolonged treatment. () Mode of Repair.—The method which nature observes in repairing lesions of the Osseous structure is beautiful, and when carefully noted may be divided into several stages; thus we have, first— * A. The period of rest, which may again be divided into— 1. The period of exudation, when inflammatory lymph is thrown out around the site of injury, which may occupy two or three days. The tis- sues during this stage are soft and somewhat succulent, and infiltrated with a fluid containing leucocytes. 2. The period of true rest, so far as the ends of the bone are concerned, which remain in a quiet condition, while nature removes the debris, clears away extravasated blood, takes away the swelling, and prepares for the second period. B. The period of uniting the fragments together. This is accomplished by the deposition of a fibrinous, gelatinous sub- stance (granulation tissue), which surrounds the extremi- ties as it were with a pad, holding them together. This substance may also be poured out, though in a lesser degree, in the medullary canal; thus giving support both externally and internally to the fractured ends of the bone. This sub- stance gradually and in different ways is transformed into the so-called provisional or intermediate callus. (Fig. 248.) This last process I shall not here minutely describe, suppos- ing that all are in a measure acquainted with osteogeny, or . the origin and growth of bone in the foetus. Method of Re- According to Mr. Paget, it may be accomplished through F. * * fibrous tissue, or by either nucleated cells or nucleated blastema, or by cartilage. Perhaps the best description of the manner in which broken bones may unite, may be found in Prof. Hamilton's excellent Treatise on Fractures. He states that fractures of the adult human bone, “whether placed end to end or overlapped, unite most naturally and most promptly either immediately or mediately, and in the same manner as the soft tis- sues unite, that is to say, without the interposition of any reparative mate- rial, or through the medium of any intermediate permanent callus; and that all deviations from these simple methods are accidental, or the result of disturbing influences.” - In whatever manner, however, ossification of callus takes place, so soon as the broken ends of the bone are surrounded and held in position by the provisional callus, then the uniting of the fractured extremities takes place through the permanent callus, which is followed by C, or that period when the provisional callus is removed by the absorbent system, by which the bone is restored to its original shape. From these remarks, we learn that the fractured ends of a bone, being brought into direct and perfect apposition, which, by the way, is very rarely . FIG. 248. 538 A SYSTEM OF SURGERY. the case, will unite without the formation of the provisional callus, or more after the fashion of union by the first intention in the soft parts, but that in the majority of instances we have first a period of rest, divided FIG. 249. into that of exudation and clearance, followed by the forma- tion of provisional or intermediate callus, both exterior and interior to the bone; after which we have the deposition of the permanent callus, and, finally, the removal of the extraneous bony deposit, which is no longer of service. These processes are more or less varied in accordance with the extent or direc- tion of the fracture, or the position of the bone. When bones are not brought into apposition, the callus is thrown around the opposing ends, or, indeed, in some instances, a com- plete bridge of bone may extend from one fragment to the other. (Fig. 249.) . General Treatment.—The indications in the treatment of fractures are: 1st. To set the bones; or, in other words, to restore the fragments as nearly as possible to their natural position. 2d. To maintain them in that position. 3d. To prevent or...allay constitutional or local disturbances. According to the old-fashioned method of treatment, a frac- ture bed, especially when bones of the lower extremities were the seat of injury, was considered an almost indispensable re- quisite. These were often very ingenious contrivances, with pulleys and joints and hinges, by means of which the patient could be raised or moved slightly without materially affecting the broken bones; but of late, with the new methods of treating fractures of the lower extremities, all that is required is a good moss or hair mattress, Covered with a sufficiency of blankets or “comfortables' to render it soft to the patient. It is really curious to look over the cumbersome contrivances called “fracture-beds,” which were used by our ancestors. The fracture-bed of Jenks, at least the plate thereof, reminds one of the curious representations in the Armamentarium Chirurgicum of Scultetus, or some of the instru- ments of torture in the Tower of London. - Let the bed be made comfortable to the patient, and let sufficient care be taken to insure this condition. Let the bones be set as soon as possi- ble after the injury; this is the rule, and if it cannot be accomplished en- tirely, bring the parts as nearly in apposition as the swelling will allow, and apply the splint, and a pad, and a roller to maintain them in such position. Callus does not form until the eighth or tenth day, and therefore, say some surgeons, there is no particular hurry in readjusting the fragments. The longer any portion of the body, or any organ or part of an organ, muscle, tendon, or bone, is allowed to remain in an abnormal position, the greater will be the irritation, both local and constitutional, and the more difficult and painful will be the manipulations. Treatment.—The apparatuses for treatment of fractures are bandages, splints, adhesive strips, and cushions or pads. In regard to fractures especially, it is absolutely required that a precise knowledge be had of the indications to be fulfilled for a satisfactory use of the means. Without the possession of such knowledge, there would be but little practical profit from an acquaintance with all the very numerous kinds of bandages and other contrivances, however ingenious or highly recom- mended, which from time to time have been introduced to the notice of the profession. By such as are curious in these matters, the older surgical writers may be examined. In the present work it is designed to invite at- tention to means now in use, selecting those only which by the most talented SPLINTS. 539 and experienced in the profession are considered best adapted to accomplish the ends desired. - Splints.--A great variety of splints have been introduced at various times to the notice of the profession, some possessing advantages over others. The essential points necessary for a good splint are lightness, firmness, facility of application, and adaptation to the parts to which they are applied. A great many substances have been used, some of which are capable of being moulded to the part, as those constructed of felt, sole-leather, binders’ board, or gutta-percha. Others are constructed of iron, iron and brass wire, or of tin, and of zinc. The most serviceable materials, and perhaps the best for the upper extremities, are wood, metal, or felt; and for the lower, those made of iron wire and narrow board, as we will show as we proceed with the subject. Those splints which are constructed of gutta-percha, sole-leather, etc., and prevent the proper exhalation from the part, become offensive; and if the fracture be of the compound variety, and there has been much Suppuration, and the pus makes its way beneath the splints, maggots #. be bred, and the patient rendered miserable from the odor and the th. Excellent splints for fractures of the upper extremities are those made of thin poplar boards which are glued upon sheep-skin, and then cut through lengthwise. These are greatly in vogue, and are so easily made, and are so handy of application, that the surgeon should always have them in readiness. A variety of splints is constructed of perforated hard rubber, which, when heated, can be moulded to the part affected. Dr. Bushrod W. FIG. 250. James, of Philadelphia, has devised a good splint for fractures of the forearm. New and very good splints have lately been introduced under the name of “Ahl's Adaptable Porous Felt Splints.” They can be obtained in sets of fifty pieces, and are adapted to every fracture in the human body. They are constructed of porous material, and both hot and cold water dressings can be applied through them. They are moulded to the limb, will remain pliable but firm, and are in many ways most desirable. Johnstone has also introduced a porous felt splint of utility and conven- 540 A SYSTEM OF SURGERY. ience. Figs. 250, 251, 252 show how admirably adapted these splints are to both the superior and inferior extremities. Carved splints sometimes answer a good purpose, although to make them fit accurately they should be prepared for each individual case. FIG. 252. i l | | | | | | | Sº, § Fº § º t- &j --- º:~ºa. *-s |i:|:s-- t#". # : i | º s &- . tº sº * * * * = a - sº * - - - -----, Dr. R. J. Levis, of Philadelphia, has devised a set of metallic splints which possess excellent qualities. They are made of copper, less than one- eightieth of an inch in thickness, are perforated for free ventilation and the exit of discharges. They do not become offensive, and can be adapted to the inequalities of surface without trouble. These splints are arranged in sets, and are made by the cutler William Snowden, of Philadelphia. Plaster of Paris Splints.--In some instances the application of plaster of Paris, or immovable dressing, is of great benefit in the treatment of frac- tures, especially in the bones of the leg. It seems that the use of this sub- stance was known in remote times, and was employed by the Arabians a century since. In 1814, Hendricks introduced it into the hospital of Gröningen, and Kyle and Dieffenbach subsequently made use of it. Prof. Pirogoff, during the Crimean campaign, used the plaster of Paris in a dif- ferent and highly satisfactory manner, and in 1854 published a monograph on “A new method of bandaging fractured limbs with linen soaked in a solution of plaster of Paris.” - - The formation and use of the plaster of Paris splint were devised by the late Dr. James L. Little, of this city (New York). He introduced it into the New York Hospital in 1861, and published the method in the flºan Medical Times of that year, from which the description below is taken. PLASTER OF PARIS SPLINTS. & 541 In 1867, Dr. Little called the attention of the American Medical Associa- tion to his method, which since that time has been almost universally adopted in certain fractures, especially those of the leg. It can, however, be applied anywhere, as it moulds and adapts itself to any part. The student must be careful not to confound the plaster of Paris bandage, now so much in vogue in the treatment of spinal deformities, and employed by some in the treatment of fractures, with the plaster of Paris splint. The former is open to the following objections: The parts shrink away from it and it becomes loose, thus losing all its supporting power. The limb cannot be properly inspected, and the bandage has to be renewed, or else pieces cut out of it to make it adapt itself to the surface, in either case a troublesome proceeding. Dr. Little has also published his method,” to which the reader is referred for accu- rate details for the application of the splint to both the upper and lower extremities. - The mode of application to the leg is as follows: “The limb is first shaven or slightly oiled; a piece of old coarse washed muslin is next se- lected, of a size that when folded about four thicknesses it is wide enough to envelop more than half of the circumference of the limb, and long enough to extend from a little below the under surface of the knee to about five inches below the heel. The solution of plaster is then to be prepared. Fine, well-dried, white plaster had better be selected, and before using, a small portion should be mixed with water in a spoon and allowed ‘to set,’ with a view of ascertaining the length of time requisite for that process. If it is over five minutes, a small quantity of common salt had better be dis- solved in the water before adding the plaster. The more salt added the sooner will the plaster “set.” If delay be necessary, the addition of a few drops of carpenter's glue or mucilage will subserve that end. Equal parts of water and plaster are the best proportions. The plaster is sprinkled in the water and gradually mixed with it. The cloth, unfolded, is immersed in the solution and well saturated; it is then to be quickly folded as before arranged and laid on a flat surface, such as a board or a table, and smoothed once or twice with the hand in order to remove any irregularities of its sur- face, and then, with the help of an assistant, applied to the posterior sur- face of the limb. The portion extending below the heel is turned up on the sole of the foot, and the sides folded over the dorsum and a fold made at the ankle on either side, and a roller bandage applied pretty firmly over all. The limb is then to be held in a proper position (extension being made if necessary by the surgeon), until the plaster becomes hard. The time required in preparing the cloth, mixing the plaster, and applying the casing to the limb, need not take more than fifteen minutes. After the plaster is firm and the bandage removed, we will have a solid plaster of Paris case, partially enveloping the limb, leaving a portion of its anterior surface exposed to view. If any swelling occur, arnica lotion can be ap- plied to the exposed surface, and we can always easily determine the rela- tion of the fractured ends. If necessary, an anterior splint, made of the same material, can be applied, and then both bound together with adhesive plaster, and, if desirable, a roller bandage over all. If the anterior splint is not used, two or three strips of adhesive plaster, one inch wide, or bands of any kind, may be applied around the casing, and will serve to hold them in position.” The advantage of plaster of Paris over the starch bandage is, that it “sets” while the surgeon moulds it to the part, whereas the starch apparatus may take several days to thoroughly dry. * Medical Record, 1873, p. 530. 542 ' A SYSTEM OF SURGERY. . The use of metallic strips as an application to the plaster of Paris splints, is highly spoken of.” I have found that they not only give additional strength to the splint, but do away with the necessity of keeping up manual extension until the splint has set. Dr. Harris, of New York city, states that by preparing it in the following manner, the weight of the dressing may be considerably diminished, thus: water, by weight, 100 parts; gypsum, 75 parts; boiled starch, clarified, 2 parts. . In the appendix to the Army Medical Report, for 1869, a plaster dressing is described by Staff-Assistant Surgeon Moffit, who states that it is used by the Bavarian Ambulance Corps. Two pieces of flannel, suited to the length of the limb, are cut sufficiently wide to overlap slightly in front. When so Fº they resemble the leg of a stocking cut vertically. One is now aid over the other, and they are stitched together from top to bottom, down the mesial line, like two sheets of note-paper stitched at the fold. They must now be spread out under the injured limb, so that the line of stitching corresponds to the back of the calf. The two inner leaves, so to speak, are now brought together over the shin, and fastened by long pins, the heads of which are bent. The leg being held firmly, an assistant mixes the plaster with about an equal bulk of water, and rapidly applies it, partly with a spoon and partly pouring over the outer surface of the flannel cover- ing the limb. The two portions of the second layer are then quickly brought over, so as to meet, and the inequalities in the distribution of the plaster are removed before it hardens, by smoothing with the hand. In about three minutes the gypsum sets, and the limb is encased in a strong rigid covering, which gives uniform pressure and support to every part. The edges of the flannel in front can now be trimmed, and the pins with- drawn from the inner layer, by seizing their bent heads. A couple of straps, or a few turns of a roller, make all secure. In order to take the apparatus off, it is only necessary to remove the straps and separate the edges of the flannel, when the two sides will fall asunder, the line of stitching behind acting as a hinge. The application takes less than ten minutes, the removal about two. Thus, from day to day if necessary, the limb can be inspected, and the splints (for they are no less) reapplied. In cases of compound fracture, an open- ing suitable to the wound may easily be made. In most cases it is desirable i. make a number of perforations with a gimlet, to prevent unnecessary eat. Starch Bandage, or the Movo-amobile Apparatus of Suetin.--To apply the starch bandage, which was introduced by Suetin, of Brussels, in 1834, the following precautions are necessary, which taken, it may be used in cases of recent fracture with great benefit. It has the advantage of being much more cleanly than the plaster of Paris splint, although it takes much longer to harden. There can be no doubt that this variety of permanent dressing may be properly applied in recent fractures, when there is no shortening of the limb to be overcome, and no painful spasms of the muscles have been excited by the irritation of the fractured bones. Having prepared some of the best starch, and having boiled and strained it either through a piece of cambric or a wire sieve, envelop the part in carded cotton, in order to cover all inequalities of surface, and over the cotton apply, not too tightly, a wet bandage. After the limb has been thus encircled, with the hands, and not with a brush, apply the starch all over the bandage, taking care to cover it thoroughly ; having done this carefully, again retrace the course of the bandage, and again apply the starch, and after performing the manipu- * Medical Record, May 1st, 1874. MEDICAL MANAGEMENT. 543 lation for the third time, allow the dressing to set for half an hour, and over the whole apply a dry bandage. It will take nearly thirty hours for this bandage to dry, but when it has become hard, it will be found to be very immovable and permanent. If it is necessary or deemed expedient that the starch apparatus be dried sooner, by placing heated plates alongside the dressing, the process will be facilitated. It is necessary on the third or fourth day to open the bandage and to ex- amine the limb, and for the division of the apparatus, Suetin devised a pair of pliers or shears which are serviceable. After the splint has been divided, it must be kept in apposition by an additional bandage. It will be seen that this apparatus is both immovable and movable, and in fact is called by Suetin himself, movo-amobile. Velpeau uses dextrin in the preparation of such a bandage, and Hamil- ton says: “For myself, I am quite as much in the habit of using wheat flour paste as either starch or dextrin, and if properly made, it dries about as quickly as starch, and is equally as firm.” f To remove this bandage a pair of Suetin's pliers may be used, or the in- strument devised by Dr. Henry for the purpose (Fig. 253). The flat blade FIG. 253. being introduced under the bandage prevents any irritation of the skin, and gives support to the instrument in the act of dividing the bandage. Fracture-cushions are made of different shapes and sizes, to correspond with the inequalities which are to be filled. They are made of unbleached muslin stuffed with horse-hair, moss, or excelsior. A form of fracture- cushion very much in vogue is made of oblong bags filled about two-thirds with bran or sawdust. These are serviceable to place alongside fractured bones, as they prevent displacement. Compresses are made of muslin or linen, and must be adapted to the parts to which they are to be applied. Adhesive straps are now employed by many distinguished surgeons, not only for fixing dressings and appliances, but for exerting extension and counter-extension. In 1830, Prof. Samuel D. Gross called attention to their use, and since that period they have been almost constantly employed. Medical Management.—So soon as a person with a fracture is brought in, it is well, as before mentioned, if possible to set the bones, and having ap- plied a loose dressing, merely sufficient to maintain the parts in apposition, to cover the whole limb with a large towel which is wetted with a strong solution of arnica, in proportion of an ounce of the tincture to one pint of water. If the swelling be very great, it is well to use the irrigator, or to 544 A SYSTEM OF SURGERY, allow a stream of cold water to fall gently upon the surrounding parts as well as upon the direct seat of injury. A dose of arnica 3d should then be given, and at the proper time, that is as soon as the swelling subsides, the permanent bandages should be applied. The medicines which are best adapted to the treatment of fractures, to hasten the formation of tardy cal- lus, are the phosphate and carbonate of lime. These are to be given in the 3d trituration, about 3 grains three times daily; the symptoms, or rather general conditions which lead to their use, are these: In children, when there is a tendency to marasmus and deficient nutrition, when the nutritive nervous system is especially disarranged, and in adults who have dyspepsia, sour stomach, and frequent gastric disturbance, or in females when the menstrual function is irregular, and there is a low grade of vitality, then the carbonate of lime is the more appropriate. The phosphate must be given when there is tendency to thoracic disease, bº disorders, cough, etc. I have known phthisis pulmonalis result in these cases by giving, after in- jury, the carbonate of lime in oft-repeated doses. Another excellent method of introducing lime into the system, and one which I have seen do good service, is by the use of that preparation known as Churchill's hypophosphites of lime and soda. A teaspoonful of this preparation may be mixed with a glassful of water, and taken during meals. An indication to either lessen the quantity administered, or to discontinue its use, is a peculiar taste of lime which remains long in the mouth, or may come on suddenly, and, after continuing for a time, disappear. I have never found either sulphur, silicea, or hepar serviceable in the treatment of frac- tures, that is, so far as assisting the formative process is concerned. I have also used symphytum after the direction of Croserio, but am not sure that good results have followed. Ruta has also been employed by Dr. Hen- riques, and I have seen excellent effects from its use. Very frequently after a severe fracture, there is a tendency to spasmodic muscular action, which is sometimes so great that there is danger of the fragments being drawn out of place. In such cases ignatia and cuprum have always proved sufficient in my hands; my friend, Dr. Willard, has seen similar good results from the exhibition of ignatia, and on one or two occasions hyoscyamus has produced quiet and sleep, when the jactitation was sufficient to give the “patient great annoyance. Chamomilla is useful when the patient faints frequently, with uneasiness about the heart, with twitching of the limbs and oppression of the chest. Other symptoms which are sometimes present, may be combated with the appropriate medicines, which may be found in the chapters on Erysipelas, Wounds, Suppuration, etc. If there are excessive pains in the bones and periosteum, mez. will be the best medicine, or phosph, acid or rhododendron may be called for. Flexion, or Bending of the Bones.—In children, or in those whose osseous systems are deficient in lime, bending of the bones is sometimes found. In the early periods of life, when there is a preponderance of cartilaginous ma- terial, the bones, especially the cranial, are soft, and can readily, without any noticeable fracture, be flexed to a considerable degree. We find this exemplified in those Indian tribes whose craniums are subjected to pressure to alter the conformation of the skull. When, however, the patients are more advanced in life, there is a partial fracture of the ossific substance which allows the bone to bend. This fracture has received the name of “green-stick fracture,” as represented in Fig. 254. Dr. Willardº reports a case in which there was bending of both radius and ulna, and after the removal of the splints, callosities appeared, showing that in this case the bending had been accompanied with a partial fracture. * Western Homoeopathic Observer, vol. vi., p. 350. NON-UNION OF BROKEN BONES, OR FALSE JOINT. 545 Some authors treat these alike, classing them as bending of the bones, cracked bones, or incomplete fracture. The symptoms are generally easily recognized. The first diagnostic symptom upon which the greatest stress is laid in fractures, viz., crepitation, is wanting, but there is curvature, pain, immobility. The treatment consists in gradually and gently restoring the bones to their situation, and keeping them in FIG. 254. position with appropriate splints and bandages, and admin- º º to the patient the third trituration of the phosphate of lime. Non-union of Broken Bones, or False Joint—Pseudo-arthro- sis.-The humerus and the femur are the bones that are said to be the most likely to be affected with false joint after fractures, although ununited fractures are discovered in other bones. Considering the number and variety of fractures which occur, this untoward accident is not frequent, and when such a result happens, it is generally occasioned by some disease of the Osseous system, or dyscrasia, or from premature use of the limb after fracture, or perhaps from want of the proper management on the part of the surgeon. Very frequently, in advanced life, the progress of ossification is tardy, indeed it is often delayed a length of time in fractures occurring in persons of intemperate habits; g if these cases are not thoroughly appreciated, and are º treated as ordinary fractures, that is, the bandages and splints removed at the ordinary time, then a false joint will be the result ; but such an unfortunate result may be prevented by the surgeon insisting that the apparatus be kept constantly on the fracture, and the appropriate medicine be perseveringly administered; ruta, Calc. carb., calc. phosph., or symphytum being appropriate. But when from whatever circumstances the fractured extremities of bones do not unite, we then have pseudo- arthrosis, or false joint. In all the long bones nutrient foramina are found, and it is re- FIG, .255. markable to observe the obliquity with which º they enter the substance of the bone. From these facts, Guéretin was led to investigate whether the peculiar course of the arteries had any influence upon the time occupied in the consolidation of fracture ; from his experiments it was discovered that if the fracture occurred below the entrance of a nu- trient artery which took its course upward, a false joint was most likely there to form, and vice versá. Dr. Norris, of Philadelphia, has classified false joints into four varieties: First, when the fractured ends are completely covered by cartilage, making the bone movable. Second, when there has been no attempt at union and the limb is wasted and shrunken. Third, in which the ends of the bone become wounded, and are covered with a cartilaginous forma- tion, the medullary canal being obliterated and the ends working the one upon the False Joint. other (Fig. 255). Fourth, when a capsular ligament has formed over the broken ends of the bone, making very nearly a true diarthrodial articulation; this last is quite rare, while the 35 546 A SYSTEM OF SURGERY. ; variety is that most commonly found. In a later work Dr. Norris In CIS . “1st. That non-union after fracture is most common in the thigh and arm. 2d. That the mortality after operations for its cure follows the same law as after amputations and other great operations on the extremities, viz.: That the danger increases with the size of the limb operated on, and the nearness of the operation to the trunk; the mortality after them being greater in the thigh and humerus than in the leg and forearm. 3d. That the failures after operations for their relief are most frequent in the humerus. 4th. Failures are not more frequent in middle-aged and elderly than in young subjects. 5th. That the seton and its modifications are safer, speedier, and more successful than resection and caustic. 6th. That incising the soft parts previous to passing the Seton augments the danger of the method, though fewer failures occur after it. 7th. That the cure by seton is not more certain by allowing it to remain for a very long period, while it exposes to accidents. 8th. That it is least successful on the femur and humerus.” I have taken the liberty of quoting these deductions in full, because they are replete with instruction. - Treatment.—There can generally be little done medically after pseudo-ar- throsis has taken place, although proper medicinal agents administered and judicious pressure being brought to bear on the uniting fragments, may, in many instances, prevent it. The pressure is made by compresses, wetted in a solution of symphytum, one part to four of water, and constantly ap- plied over the seat of accident. This unfortunate termination of fracture may in some instances be pre- vented by the internal administration of calcarea carb., or perhaps the phosphate of lime; the latter has been recommended for such conditions, but there are no indications in the meagre proving of this medicine which would lead the practitioner to have recourse to it. The former, however, is a well-known medicine, and in numerous instances has been of essen- tial service in the treatment of fractures and other injuries occurring in individuals of a weak, sickly constitution, and scrofulous diathesis. This medicine improves the tone of all the organs in the body, by giving addi- tional power to the functions of assimilation and sanguification, therefore it is a valuable assistant in the treatment of those cases of fractures in which the reproductive process appears to proceed tardily from a deficient ac- tivity. Ruta has been employed by hºmºpºliº surgeons to hasten the forma- tion of Ossific matter. Dr. Henriques,” in recording the treatment of a case of oblique fracture of the superior third of the femur below the capsule, which occurred spontaneously in an aged patient, of enfeebled and vitiated constitution, who had been liable to periodical attacks of diarrhoea and cere- bral congestion, dysuria and cough, remarks concerning the action of ruta, that it “appears to possess a decided elective affinity for the periosteum, as well as the Osseous system in general; and it was the desire to avail myself of the known specific property of rutá, that led mé to employ it as a means of promoting the process of Ossification. I have no doubt in my own mind that it had the desired effect; for if the unfavorable prognosis of the case be compared with the ultimate happy and prompt result obtained, I do not think it possible to deny that the action of this medicine contributed in some degree to the final consolidation of the fracture.” d Symphytum has also been recommended for the purpose of inducing Ossific eposit. The general health of the patient should receive attention; if the consti- * British Journal of Homoeopathy, vol. x., p. 448, a paper entitled Fractures, and their Homoeopathic Treatment. -- NON-UNION OF BROKEN BONES.–TREATMENT. 547 tution is worn out by disease, or debilitated either from hereditary taint or more proximate causes, the general tone of the system should be strengthened by the administration of the appropriate medicine; by such means the patient may be restored to perfect health, and the performance of painful operations avoided. However, if after the patient administration of medi- cines, the formation of false joint does occur, it may then be advisable to have recourse to friction of the broken surfaces; this in some instances has produced the desired effect. Before proceeding to the more heroic measures about to be detailed, it would be expedient to try the injection of a weak solution of carbolic acid into the joint, as recommended by Dr. Becker.” It must be performed once or twice during the day, the strength of the solution being increased or diminished in accordance with the symptoms. Dr. Physick's method of treatment has been successful in many instances; it consists in passing a Seton between the fractured surfaces. A seton needle is armed with a skein of silk or other material; the limb is extended to separate the fragments, and the Seton is passed between them, care being taken to avoid all large vessels and nerves. Violent inflammation follows the application of the Seton in all cases, and bony union may take place. The late Prof. Mütter performed the following operation, first introduced by Dieffenbach, to remedy pseudo-arthrosis: The fractured extremities of the bones are exposed by incision, and, by means of gimlets, perforations made on each side of the false joint; into these openings ivory pegs should be driven, and the wound dressed antiseptically. Union very frequently - tºº and absorption soon removes the extraneous matter forced into the OIléS. There are many other methods of uniting the false joint. Dr. Brainerd, of Chicago, succeeded by perforating the extremities of the bone in vari- ous directions, by an instrument which bears the name of Brainerd’s Per- forator. He uses it as follows: “In case of an oblique fracture, or of one with overlapping, the skin is perforated with the instrument at such a point as to enable it to be carried through the ends of the fragments, to FIG. 256. Brainerd's Perforator. wound their surfaces and to transfix whatever tissue may be placed between them. After having transfixed them in one direction it is withdrawn from the bone but not from the skin, its direction changed and another perfo- ration made, and this operation is repeated as often as may be required.” Dr. Brainerd has several drills, fitting into a single handle (Fig. 256). * Medical Times and Gazette, November 18th, 1876. 548 A SYSTEM OF SURGERY. Recently success has been obtained by “pounding” the extremities of the bone with a small hammer with a head of gutta-percha. Dr. Geo. F. Shrady,” of New York, has introduced an instrument com- bining saw, knife, and rasp, which he devised for operating upon the ex- tremities of the fragments in ununited fractures. The instrument is for subcutaneous work and can be used in many operations. As will be seen in Fig. 257, the instrument consists of a trocar; fenestrated canula (Fig. 1), and a staff (Fig. 2), with handle and blunt extremity. A portion of this staff at a short distance from the extremity is flattened, one edge (B) being made into a knife-blade, and the other edge (C) being pro- vided with saw-teeth. This staff (Fig. 2) is intended to replace the trocar in the canula after the latter is introduced. When in position (Fig. 3), either the saw (C) or the knife (B) edge of the shaft, according to the way the latter is turned, corresponds with the opening in the canula. The saw or knife can then be worked to and fro within the canula, by a piston-like ºnent the canula being steadied by grasping the flange (D) at its paSe. *" Another excellent mode of proceeding, and one which in the majority of instances is successful, is, after having removed the soft substance from the extremities, to pierce the ends with a common gimlet, then, after having made considerable friction between the surfaces, pass into the holes a suture of strong iron or silver wire, and draw the pieces of bone into apposition. After a number of weeks the wire is withdrawn, and reunion is found to have taken place. Dr. Smith,t of Philadelphia, objects to all the modes of treating this accident, as founded on a wrong principle. He objects particularly to the opinion that absolute rest is necessary to the cure, and that this idea is one very fruitful source of failure. His plan is to fix the limb in an iron framework, constructed with joints to allow movement of the limbs, and by straps and pads to steady, the extremities of the broken bones in a proper position. . Fixed in this apparatus, he allows the patient to use the injured limb, and he asserts that union is effected with much less consti- tutional and local disturbance than by means of the various plans of treat- ment used by practitioners, viz., violent friction, the seton, resection, Dieffen- bach’s plan, and others, while at the same time the patient is less exposed to phlebitis and other risks, he escapes the disagreeable monotony of a long confinement. This method appears to have many advantages over some * Medical Record, January 4th, 1879. f American Quarterly Journal of Medical Sciences, January, 1855. f See Ranking's Abstract, vol. xi., July, 1855. FRACTURE OF THE NASAL BONES. 549 others, but more statistics will be necessary before its actual value can be ascertained. If internal treatment be adopted with the use of the apparatus of Dr. Smith, the results doubtless would be more speedily accomplished than when the apparatus alone is used.* Resection has also been practiced, but generally it is a last resource, for it should be remembered that cutting down to the extremities of the bone and scraping or removing portions of them, at once converts the simple to a compound fracture. Cracked Bones or Incomplete Fracture.—It sometimes happens that a bone is cracked when the force applied has not been sufficient to produce an entire separation, but only adequate to break the continuity of some of its fibres, whilst others remain entire. This injury is generally found where there are two bones, as in the leg or forearm, when the uninjured one sup- ports that which is partially broken. It is probable that it occurs occa- sionally in both bones, although the accident is rare. Diagnosis.-Diagnosis is more difficult when the bone is merely cracked than when the solution of continuity is complete ; still, with care, it may be recognized. The patient is unable to use the limb without considerable pain; he has a sense of pricking about the seat of injury, and when the bone is closely examined, there may be a slight deviation from the direct line of its axis, but there is no crepitus; yet when the above signs follow a severe blow or fall upon the part, and the pain and inability to use the limb freely exist after the effects of the contusion have subsided, it is probable there is a solution of continuity in some of the fibres of the bone. In other words, the bone is cracked but not entirely broken. Treatment for the repair of this injury is the same as if the bone were broken into two fragments. It is not necessary, however, to keep the appa- ratus quite as long applied as in complete fracture. The medical manage- ment has already been given. SPECIAL FRACTURES OF THE HEAD AND FACE. Fracture of the Nasal Bones.—Fracture of the nasal bones is generally the result of direct violence, as falls and blows. The swelling, which usually is great and follows immediately after the accident, often prevents a cor- rect diagnosis. Of the site of the fracture, Prof. Hamilton thus speaks: “When the ossa nasi are struck with considerable force from before and from above, a transverse fracture occurs, usually within three to six lines of their lower and free margins, and the fragments are simply displaced backward ; or if the blow is received partially upon one side, they are dis- placed more or less laterally. This is what will happen in the great majority of cases, as I have proven by the examination of the noses of those persons who have been the subjects of this accident, and by repeated experiments upon the recent subject.” These bones heal with great rapidity. reatment.—If the surgeon be timely called, manipulation with the fingers outside and the introduction of a female silver catheter within the nares * Dr. Smith's plan has been tried in several cases with these results: Cases. Cured, Relieved. Failed, but able to walk. False joints in the femur, . e e 4 3 0 1. & Ł “ leg bones, . e e 8 7 0 1 {{ “ humerus, . iº & 2 0 2 0 Total, , . . 14 10 2 2 550 A SYSTEM OF SURGERY. will in a measure restore the bones to something near position, the nostrils may then be filled, though not too tightly, with lint ; or if there be a tendency to epistaxis, with prepared oakum, and narrow strips of plaster placed across the nose in such manner as to make the parts secure. The septum of the nose being flexible may be turned to one side or the other, and thus complicate the case. Under such circumstances the plugs may be in- troduced from the posterior nares and thereby assist in restoring the sep- tum and give support to the ossa nasi. In a case of this kind, I found great contusion about the face, and profuse hamorrhage from the nose, which was almost flattened upon the cheek. The epistaxis had continued for an hour, and the patient was much exhausted. Upon examination, the lower portion of the nasal bones (properly so called) were found broken, and by introducing a female catheter along the floor of the inferior meatus, the inferior cartilage could be felt turned to one side, and the loose frag- ments of the inferior turbinated bone on the other. It struck me at once that the haemorrhage might be arrested, the broken bones replaced and held to a certain extent in situ, by plugging the posterior nares. I had not a Bellocque's canula, and therefore substituted a well-curved male catheter, and, by the ordinary method of procedure for arresting nasal haemorrhage, plugged up the nares. By introducing at the external meatus conical plugs of lint, and keeping them well up to the septum, I had the satis- faction of seeing the nose almost restored to its normal position. It may be remarked, that erysipelas of the face set in on the second day, which was successfully combated by the usual remedies. One of the best and most recent methods of treating fracture of the nasal bones, especially when the breakage extends to the nasal process of the superior maxillary, is that introduced by Mason. The deformity is to be remedied as before noted with the catheter or sound, and by gentle manipu- lation, the bones are to be replaced. A good-sized needle is then to be passed transversely across the nose, through the line of fracture. A strong and broad piece of tape, or an india-rubber bandage, is laid over the nose and attached to the ends of the needle, which necessarily projects on either side of the nose. f Fracture of the Superior Maxillary Bones.—Fractures of the upper jaw, like breakage of the nasal bones, are caused by direct violence. The bones are broken in many directions. The displacement also is varied. The bone may be pressed downward and backward, or downward and forward, or directly downward; or be separated from its surrounding connections, or it may be complicated with fracture of the nasal and malar bones. The accident is often accompanied with symptoms of concussion, and sometimes followed by severe inflammation and facial erysipelas. Treatment.—The indications for treatment are to endeavor to mould the parts into nearly a natural state as possible by using the fingers, and allow the parts to remain quiet. If the alveolar margins are broken away, the ends may be retained in their position by wire, although this, in many in- stances, is difficult to accomplish; or a gutta-percha splint may be moulded to the bone. In the efforts to replace the fragments, the parts should be approached both within and without the mouth. The symptoms of inflam- mation and erysipelas must be combated with the usual medicines. Fracture of the Malar Bones.—This fracture is produced by direct violence, as falls, blows, or other injuries. There may be a depression of one of the fragments or there may, in rare cases, be outward displacement. In the generality of instances there is considerable injury done to the face, and the accident is followed by much swelling, which for a time may render the diagnosis very obscure. By passing the finger along the zygomatic arch, by attempted movement of the jaws, and in some cases by the projection of one FRACTURE OF THE INFERIOR MAXILLARY BONE. 551 i. the ºgment into the tendon of the temporal muscle, the diagnosis may € IOO, a Clé. Treatment.—If there is not much displacement a simple bandage is all that will be required. If, however, there is evident depression, and the movements of the temporal muscle are impaired, the effort should be made to restore the fragments by manipulation within and without the mouth. If the fracture be compound, and there is an opportunity of applying an elevator to the depressed fragments, the facility of coapta- tion will be very much increased. Some authors recommend that in a simple fracture with depression, it is justifiable to make an incision, and apply the elevator. It appears to me, that in each case the practitioner should use his own judgment, and if material injury is threatened to the temporal muscle, or, more properly, its tendon, it would be justifiable to make an incision and use the instrument. If, on the other hand, the func- tions of the mouth and jaws are not much impaired, nature may prove sufficient for the necessary restoration. Fracture of the Hyoid Bone.—This bone, from its peculiar situation, being protected by the chin, and possessing a certain degree of mobility, is not often broken. When the accident does occur, it is usually from a blow upon the neck, either by falling against some unyielding body, or from a sudden grasp of the hand or clinch of the fingers, or from the tightening of a bandage around the neck. The patient is generally made aware of the accident by a sudden sensation about the throat as though something had given way; severe pain is experienced in talking, degluti- tion, in fact all movements bringing into motion the muscles connected with the hyoid bone aggravate the suffering. Salivation and tumefaction are likewise present, and sometimes hamorrhage from the pharynx, cough, dyspnoea, and expectoration. When passing the finger along the body of the hyoid, an inequality is perceived, although in some instances the tumefaction is so great that this may not be at once distinguished ; after a time, however, the mobility of the parts can be more easily detected. Fracture of this bone or of its cornu is often accompanied with severe complications; abscesses, Oedema of the glottis, necrosis, and severe lacera- tions of the soft parts. Puncture of the adjoining tubes and other unto- ward accidents may lead to an unfavorable termination; the complications being, as a rule, of more import than the fracture. Treatment.—In ordinary cases, excepting when the complications above alluded to are present, for complete reunion of a fracture of the hyoid, from six to nine weeks are required. Reduction of the fragments should be at- tempted as soon as possible, by introducing the finger into the pharynx, and moulding the parts, bringing them as nearly as possible into their natu- ral position. There appears to be no especial rule as to the position of the head, whether it be thrown backward, forward, or sidewise. The position, according to circumstances, will vary in different cases, that one being preferable which brings the fragments most nearly in apposition. After the fragments are put in position, perfect rest must be enjoined, and the head placed in the most comfortable manner and supported. Talking or any movement of the jaws must be forbidden, and light nourishment allowed, of a liquid kind and at long intervals. If the patient should apparently suffer from want of sufficient nutrition, injections of beef tea may be given per rectum. Compresses wet with a solution of arnica and water should be constantly applied to the throat. Fracture of the Inferior Maxillary Bone,—In most instances fractures of the lower jaw occur in the body of the bone (Fig. 258), although the rami may be the seat of the injury, as may the condyles; though the latter is 552 A SYSTEM OF SURGERY. infrequent. The coronoid process, owing to its muscular covering, rarely suffers. Some surgeons deny the existence of fracture in the direct line of the symphysis, while others assert that separation of the bone does occur in a direct line in that part. It is, however, difficult to decide precisely - the course of fracture. The causes are FIG, 258. generally direct violence, as a blow, fall, º kick, etc., although a crushing force, as the passage of a wagon or car over the side of the face, will produce a fracture of the body of the bone. The symptoms, in the majority of instances, are easily recognized. The line of the inferior maxillary is broken, there is crepitation when moving the part, and often severe pain is experienced. When the bone is fractured near the middle, there is a tendency of the angles of the jaw to spread outward. . The points of the teeth have lost their regularity, and When the bone is broken at both angles, the action of the throat muscles tends to draw the central fragment downward. If the ramus be fractured, any motion of the part is exquisitely painful, and the suffering is sometimes attributed to the ear. In this variety of fracture the displacement is not so well marked as in other parts of the bone, on account of the thick, strong, and double layer of the masseter fibres, which cover this entire portion of the bone. An occurrence may also take place in fractures of the lower jaw which may give rise to Some perplexity, and perhaps may alarm the young Surgeon. I refer to hamorrhage from laceration of the inferior dental artery. . It may happen that the fragments become impacted, or driven one behind the other. Dr. Buck gives an instance in which he was obliged to dissect up the lip and use the saw before he could adjust the fracture. Sometimes, from laceration of the nerves, the soft parts become numb and insensible; and in the majority of instances there is necessarily difficulty of mastication and articulation, together with salivation and con- tusion. The prognosis in simple fracture is favorable; if the bone is broken in several places the treatment is often very unsatisfactory on account of the difficulty of keeping all the parts in proper position. Dr. Stephen Smith, of New York, reports a case in which, after careful treatment for one hundred and thirty-seven days, the bone had not united; and instances are on record where years elapsed without bony union having taken lace. p Treatment.—When called to treat a fracture of the lower jaw, the first thing to be done is to remove those teeth which the force has entirely sepa- rated from the alveoli, while those that are partially loosened should be carefully replaced in their sockets, and this must be attended to before dress- ings are applied. A great number of apparatuses, some of them extremely complicated, consisting of jack-screws, plates, wires, moulds of gutta- percha, bandages, slings, etc., have been devised for the treatment of frac- ture of the lower jaw. Many of these I shall not notice, but merely invite attention to those which are simple in construction and best suited to the object in view. Velpeau,” on this subject, writes: “Unless there are very great displace- ments, and difficulty in maintaining them reduced, I abstain from applying any “bandage.’ The pain of the injury is amply sufficient to prevent the * Welpeau's Lessons, p. 15. TREATMENT OF FIRACTURE OF THE LoweR J.A.W. 553 patient from making any injurious movements, and the consolidation is effected regularly without the patient being condemned to an immobility which is a real hardship.” The simplest contrivance is the four-tailed bandage, and many satisfac- tory cures have been made with it; and this, with the application of the pasteboard splint (Fig. 259), is frequently used by sur- - geons, especially by those residing in the country. To FIG. 259. make the four-tailed bandage, take a piece of muslin one yard and a quarter long, and tear it longitudinally at each end, to within four inches of its centre. To apply it, lay a piece of pasteboard, which has been moulded to - % the part, or the splint of Barton, on the jaw, and then, having placed the middle of the bandage upon the chin, the two upper ends are carried backward and tied on the nape of the neck, and the two lower ones carried up over the sides of the face and tied at the occiput. Sometimes a slit is made in the centre piece, through which the chin is allowed to protrude. Silver wire has also been used to keep the fragments in apposition, and Dr. T. B. Gunning, of New York, has used vulcanized india-rubber. Dr. Gibson's bandage (Fig. 260) is made by a roller an inch and a half wide, which is passed in circular turns under the jaw up the face, and over the head several times; it is then pinned at the temple and turned at right angles, encircling the back of the head and forehead by several turns; it is pinned again at the temple, and carried down the side of the face and pinned on a line with the chin; carried then at right angles, several hori- Zontal turns are made, embracing the chin and back of the neck. A strip of roller is then carried over the top of the head and pinned to the several turns, to secure the bandage from slip- plng. Dr. Rhea Barton's bandage, with the use of a pasteboard splint, is one of the simplest and best that has been recommended. It consists in a narrow roller, the initial end of which is to be placed under the occipital protuberance; the bandage is carried over the right parietal bone, obliquely across the coronal suture to the left temple, down the left side-face, under the jaw, up the right side-face, and obliquely over the coronal suture to the left ear (above it), being carried around the occipital protuberance to the right side, then passing under the ear, is carried around the chin, embracing the neck and chin by a circular turn ; it is then carried on under the occi- pital protuberance, over the right parietal bone, and again obliquely over the ºnal suture to the left temple, and continued in these turns until ex- €I]CléC1. p With each of these bandages it is necessary to have the compress or wet pasteboard well adapted to the jaw. The patient must be nourished by liquids, the teeth always leaving sufficient space for this purpose. When the position of the fracture makes it practicable, it is a good plan to bind the teeth together at the seat of fracture by passing a silk ligature or silver wire around them. This plan is quite old and sometimes may be successful. Dr. E. A. Clark, of St. Louis, invented an interdental splint of gutta-percha, which is held together with springs, and applied as follows. (Fig. 261.) The directions are in Dr. Clark's words: In order to adjust the splints properly, the springs should be compressed FIG. 260. 554 A SYSTEM OF SURGERY. by grasping the plates between the thumbs and fingers So as to insert them between the jaws, and place them in proper position upon the crowns of the teeth, then force the fragments into their proper position, when the in- ferior plate will be found to fit the jaw accurately, which it will not do until the bone is properly adjusted. After the plates and fracture are once in position, the mouth will be forced wide open by the action of the interden- tal springs. This is counteracted by a sling bandage passing beneath the jaw and over the top of the head, forcing the jaws in such proximity as to leave a sufficient space between them in front to enable the patient to take food and drink, and at the same time allow him to talk so as to be understood distinctly, while he is also enabled to expectorate without diffi- culty. The amount of space that will exist between the plates in front, will depend upon the amount of force necessary to be used by the sling bandage, and which should be just sufficient to place the fragments in their proper axis. If the force required for this purpose should be greater than the resistance of the springs in any given case, and force the plates in con- tact with each other, the springs should be removed and replaced by stronger ones. Another difficulty existing in the apparatus of Gibson and Barton is obviated in this appliance, i.e., instead of drawing the anterior fragment backwards, in which direction it is already displaced to some ex- tent in fractures of the body of the bone, the interdental springs, when compressed by the sling bandage, have a tendency to push the anterior arch forwards, while, by keeping the inferior maxilla depressed by the force of the springs, the submental muscles are in a measure relaxed, and the ten- dency to displacement downwards and backwards of the anterior fragment FIG. 261. FIG. 262. § N N S. § N \\ N N. & §WNWN (N Clark's Interdental Splint. Hamilton's Apparatus for fracture of the lower jaw. is diminished. Indeed, the principle involved in the apparatus is to sub- stitute these two plates for the jaws, the former of which being entirely under our control by means of the interdental springs, so that just as we control the splints so do we control the jaw, while, at the same time, the force exerted is operating upon the entire surface of both maxillae at the same time, thus adapting the apparatus to fractures occurring at any point of the jaw that can be reached by the material necessary to secure a cast of the fragments, regardless of the absence or irregularities of the teeth, or the character of displacement of the fracture. - FRACTURE OF THE VERTEBRAE. 555 Prof. Hamilton's sling is also often very serviceable, and is composed of a maxillary strap made of leather, which passes under the chin perpendicu- larly upward, and buckles upon the top of the head. A counter-strap is then passed around the occiput and forehead, which, above the ears (Fig. 262), is looped upon the first-mentioned strap. A second counter-strap, called “the vertical,” passes over the top of the head to the maxillary strap, which prevents the latter from dropping over the forehead. Beneath the symphysis the maxillary strap is narrow, becomes wider at the sides of the jaw, and to this, across the front of the chin, a strong piece of linen or webbing is stitched. An excellent interdental splint has been devised by Dr. Thomas Bryan Gunning, of New York. Dr. Goodwillie likewise has invented a useful splint for fracture of the lower jaw.” The most recent, however, is that of Levis. FIG. 263. Tº re-g Dr. Lewis's Metallic Splint for fracture of lower jaw. This splint forms a complete cap or covering for the entire chin and lower max- illary bones, and keeps the fractured parts in the correct position. (Fig. 263.) FRACTURES OF THE TRUNK. Fracture of the Wertebrae.—When we consider the peculiar manner in which the vertebrae are joined together, and how closely they are fitted by numerous joints to each other, the shortness of their processes, the round- ness of their bodies, the double curve of the entire column when the body is erect, and the amount of tendon and muscular fibre with which they are closely connected, a fracture would appear almost impossible. Neverthe- less, from great violence applied directly to the spinal column, or from the indirect force of a fall from a great height, these bones are at times broken. The symptoms of fracture of the vertebrae differ materially ac- cording to the portion of the column injured. Generally the most promi- nent symptom is paralysis. If the lumbar vertebrae are broken, the lower extremities suffer, and there is in most cases complete or partial paralysis of the legs, with involuntary passage of faeces and urine. Cases are recorded, however, where fracture has occurred below the second lumbar vertebra, without the power of motion being lost. * For a full description of these splints the reader is referred to Nos. xviii. and xix. of the New York Medical Journal; to a Report on the Progress of Surgery, by E. A. Clark; and to a pamphlet on Resection of the Maxillary Bones, by Dr. Goodwillie. 556 A SYSTEM OF SURGERY. If the dorsal vertebrae are broken below the origin of the brachial plexus, the superior extremities are not paralyzed, nor are the lower, but there aré abdominal and thoracic symptoms, torpid bowels, distended abdomen, and retention of urine. If the upper dorsal or lower cervical bones are injured, there is either partial or total paralysis of the upper extremities, together with the general symptoms of paralysis exhibiting themselves upon the in- testines and bladder. If the second or third cervical vertebra be injured the phrenic nerves are involved and death soon takes place. There may be crepitus, but in most cases it is absent, and displacement is often difficult to recognize. With the foregoing symptoms, and with a knowledge of the fact, that paralysis may occur from extravasation and concussion, it will readily be supposed that very often the diagnosis is difficult, and the prognosis bad. In this connection, however, one point must be borne in mind, that the spinous processes may be broken off without any material injury to other parts of the column. - Treatment.—Vertebral fracture is generally fatal; little can be done toward restoring displaced fragments, removing extravasations, or remedy- ing the paralytic symptoms, the latter being caused by mechanical pressure. Professor Hamilton, the best authority on the subject, says:* “The first and most important requisite of successful treatment in a ma- jority of these cases, is a water bed, since, without this, bedsores are almost inevitable, if life is prolonged a few weeks. I have, in a few cases of late, when the fracture was below the middle of the dorsal region, employed with advantage moderate extension by means of a pulley and weight, the exten- sion being º to the lower extremities, in the same manner as in frac- tures of the femur. In case this plan is adopted, the bandages employed to make fast the adhesive plasters must not be applied very tight, lest they should cause Oedema and excoriations of the limbs, and the weight must be light, not exceeding eight or ten pounds for an adult. In two examples also of fracture of the cervical vertebrae, my patients have experienced great relief from extension in the opposite direction, by means of straps fastened under the chin and occiput.” - Internal medication may be of considerable service in mitigating the suf- ferings of the patient. If inflammatory symptoms supervene, aconite, bella- donna, nux vomica, Strychnia, Veratrum viride, phosphorus, cuprum, ignatia, cocculus, zincum, and that class of medicines, selected according to present- ing symptoms, may be prescribed. If there be violent fever, with inability to pass urine, acon. may be ad- ministered, at the same time compresses moistened with arnica solution may be applied to the seat of fracture. If there be much urinary tenesmus, canth. alone, or in alternation with arnica, will probably relieve the patient, if not, bell., camph., hepar, puls., or 'sulph., may produce the desired effect. If these means fail, the catheter should be used. If there be a tendency of the spinal cord to take on inflammatory action acon. should be used ; it is one of the highly recommended medicines in the treatment of myelitis. When the inflammation is seated in the lumbar and sacral regions, when the adjoining abdominal organs are affected, and the alvine evacuations dif- ficult, bry. should be administered. Ars., bella., cocc., dulc., dig., ignat., nux vom., puls., and veratrum may be employed. Effusion of blood and suppuration sometimes occur in the course of the * The Principles and Practice of Surgery, New York, 1886. FRACTURE OF THE STERNUM. - 557 spinal marrow, and in its sheath, which give rise to very dangerous symp- toms. . The patient must be kept at perfect rest, in the horizontal posture, and great care taken to prevent gangrene of the nates. This may be effected by arranging pillows or air-cushions in such manner that the parts are equally supported. If the skin assume a bluish appearance, or, from the constant irritation of the parts, bedsores are present, a solution of arnica relieves the sufferings of the patient. Fracture of the Ribs.-This fracture results from being run over by heavily laden wagons, or by being crushed between cars, or being thrust forcibly against a wall. A powerful force is required to fracture a rib, especially in children, in consequence of the mobility of these bones, and their attach- ment anteriorly to elastic cartilages. The ribs which are most frequently fractured are those which give roundness to the chest; they are mainly the fifth, sixth, and seventh. The accident is generally produced by indirect violence. The bones are apt to yield about one-third, either from their posterior or anterior termination, and the fracture generally is slightly oblique. A single rib may be broken, or several may participate at the same time. In the case of an old gentleman who was caught between two cars, both in motion, at a railway station, four ribs gave way, the fourth, fifth, sixth, and seventh, the patient hearing distinctly the snap of each fracture; the clavicle also was broken. In these cases there is acute pain of a sticking character at the place of injury, painful respiration, crepitus often, especially in lean subjects, and in a majority of cases, emphysema. The patient often is conscious of the crep- itus, detecting it when he attempts to take a full inspiration. These frac- tures are not dangerous in themselves, but may become so from the irritation produced from constant friction of the fragments, which are often spiculated, against the pleura and lungs. Treatment.—The most approved treatment of fractured ribs is to envelop the body with a belt, or encircle the thorax with adhesive straps, bringing the bones as nearly as possible into apposition. To accomplish this, two Fº of antiseptic plaster should be used ; the initial end of one should e placed on the anterior face of the thorax, and the initial end of the other on the posterior surface of the chest. Having these well secured, traction should be made on the free ends, which are to cross each other as they are laid over the chest. For this purpose, gauze and collodion will answer every requisite, and will “hold" even better than the adhesive strips, possessing the advantage of allowing any application to be made to the contused surfaces. If the fragments should press into the lung- structure and so endanger the patient's life, the propriety of resection, or at least elevation of the offending piece of bone should be considered. If the lungs have been wounded, or any of the internal structures impli- cated, arnica or calendula lotions should be kept applied to the part, and either administered internally, according to the character of the wound and the symptoms manifested. If inflammation of the pleura Supervene, arnica is an excellent internal medicine; its characteristic indications are, stinging pain in the affected part, dyspnoea, short, dry cough, general internal heat with coldness of the hands and feet. Other medicines are, Sulph., Scill, bry., nux vom., or ant. tart. The costal cartilages may be fractured; the repair in such cases being by bone, not cartilage. The force required to break these elastic communi- cations of ribs and sternum is very great, and fatal results often accompany the accident from severe injury done to other organs. The treatment is the same as that for fractured ribs. Fracture of the Sternum.—When a fracture of the breast-bone takes place 558 A SYSTEM OF SURGERY. it is usually at its articulation with the ribs. The bone originally is devel- oped from six points of ossification, and is not fully solidified until adult age. This fracture is usually transverse and is occasioned by direct violence. The lower fragment rides slightly upon the upper, and by placing the pa- tient in an upright position and forcibly drawing back the shoulders and raising the arms, crepitus and mobility are detected. The accident, like fracture of the ribs, is often complicated with severe injury of the thoracic organs, and often is followed by suppuration and hectic. Treatment.—The patient must be placed in the upright position, the shoulders drawn back, and pressure made upon the over-riding fragment. When this is adjusted, or nearly so, a compress should be placed over the site of fracture, and adhesive straps applied around the chest above and below, as well as over the fracture. A figure-of-eight bandage around the shoulders, crossing over the back, will assist in maintaining the bones in position. Compresses, moistened with a solution of the tincture of armica, should be applied to the fractured part, and a dose or two of the medicine admin- istered internally. * If the fever be synochal; the pulse hard, quick, and full; the face red; excessive chilliness or heat; the pains in the chest violent, and the respira- tion oppressed and accompanied with anxiety, aconite should be given in repeated doses. If the pain in the chest is not exceedingly severe, but there are evident signs of inflammation of the lungs, if a loose cough be present, the op- pression not excessive, with constant desire to inspire, bryonia should be exhibited. When there are evident symptoms of violent pneumonia, with sticking pains in the chest excited by coughing or breathing (also pleuro-pneumonia); when the pains are violent and extend over a large surface; when a consid- erable portion of the lung is inflamed, with dyspnoea; when the cough is dry and the sputa rust-colored, phosphorus is indicated, and will probably relieve the patient in eight or twelve hours. This medicine may be given in alternation with aconite or bella., agreeably to the presenting symptoms. For further treatment of pneumonia the FIG. 264. student is referred to works on the Prac- tice of Medicine. Carious portions of the bone can be re- moved by Hey’s saw, bone-nippers, and forceps; but aid in this way should not be rendered too officiously. The trephine has been successfully ap- plied in evacuating collections of pus in the anterior mediastinum. Fracture of the Clavicle.—A fracture of the collar-bone may be caused either by direct or indirect violence, although more frequently by the latter. The exposed situation of the bone, it being the imme- Oblique Fracture near the middle third of diate support of the shoulder, renders it the Clavicle. very liable to be broken by a counter- stroke, as a fall upon the hand, or the stretching out the arm for protection when falling. If the bone were straight it would even be more obnoxious to fracture, but nature, for its Safety, gives it the shape of the italic letter f which, being a double arch, adds materially to its strength. The clavicle may be broken at its outer, its middle (Fig. 264), or its FRACTURE OF THE CLAVICLE–TREATMENT. 559 inner third. Often the diagnosis is easy, but sometimes extremely diffi- cult. When the fracture takes place at the middle third, the deformity is well marked ; the outer fragment is displaced inward and downward, occa- sioned partly by the dropping of the arm and partly from the action of the muscles which pass from the trunk to the shoulder, drawing upward the inner fragment. The shoulder is flattened; the patient supports the injured side with the hand of the sound side applied to the elbow. The integument is stretched tightly over the protruding end of the bone; crepitus can be produced by raising and rotating the shoulder; indeed, the whole appearance of the patient proclaims “fracture of the clavicle.” It has been stated that the shortening and deformity which exist, even after the best managed cases of this fracture, are greater than those of any other bone, excepting, perhaps, the femur. Fracture of the Acromial Extremity of the Clavicle.—If the bone be broken between the coraco-clavicular ligaments, there is seldom any displacement, only *ight alteration in the direction of the bone, its convexity being in- CreaSéOl. Treatment.—Numerous appliances have been introduced from time to time for the treatment of this injury, some of which are cumbrous and difficult of application, while others have the advantage of simplicity and effectiveness. Dessault's apparatus, with its three rollers and anterior and posterior triangles, has fallen entirely into disuse. Most of the more recent appliances partake, more or less, of the principles of Fox's apparatus. FIG. 265. FIG. 266. ..mil/ ar t arºv ſº/ º * \\\\\". G.77E/MAWW & Co. \\ Fox's Apparatus. Lewis's Apparatus for Broken Clavicle. This latter contrivance is in use in the Pennsylvania Hospital, and proves extremely satisfactory. It consists of a padded ring, with buckles attached, which fits over the sound shoulder; and of a wedge-shaped pad, which fits into the axilla of the injured side. From the top of this pad pieces of web- bing are fastened, one of which is to be passed anteriorly over the chest and buckled to the ring over the sound arm ; the other to be passed over the posterior wall of the thorax and fitted to the posterior portion of the ring; a sling made of stout linen or other material, in length about two-thirds of the forearm, and in depth sufficient to cover it completely, is then applied to the elbow and secured tightly to the ring (Fig. 265). The hand must be supported by a bandage as seen in the cuts. - The following is the very ingenious apparatus of Dr. Levis. It consists of a pad for the axilla, a shoulder strap, and a sling, and is adjusted in the 560 A SYSTEM OF SURGERY. following manner: The arm is passed through the opening above the pad, the wide band is thrown across the opposite shoulder, the elbow placed in the sling, and the long strap attached to the back of the sling and brought round in front. The extra buckle noticed in the figure at the front of the wide band comes into use when the apparatus is applied to the opposite shoulder. The apparatus is seen in Fig. 266. Many surgeons are opposed to the pad in the axilla, believing that it makes too much pressure upon the great vessels and nerves; and there is no doubt that serious conse- quences have followed its application. To dispense with using the pad, patients willing to submit to the irksomeness of the method, have been placed upon the back, with the head low and with a hair pillow between the shoulders, until the fracture is united, the use of any apparatus being unnecessary. In hospital practice this plan is often ineffectual, because the patients become dissatisfied, supposing that nothing is being done for them. The following is a case in point: H. R., aged forty, applied for admission into the Good Samaritan Hospital. Upon examination I discovered a fracture of the clavicle at the middle and sternal third. Upon inquiry I ascertained that he had been in another hospital for ten days. Upon further questioning he informed me that he had obtained his discharge because they did nothing for him, but “put him in an uncomfortable bed.” I fixed upon his shoulders the yoke which comes with Day's patent splints, taking care that the extremities of the splint projected a considerable distance beyond the shoulder (far enough to prevent his turning in bed), and placed him in the recumbent position. He became satisfied, endured considerable pain, and made a fair recovery with the bone shortened a quarter of an inch. - - Another simple method for fulfilling the indications of upward, outward, and backward, is by placing a folded towel in the axilla of the injured side, and passing a figure-of-eight bandage around from shoulder to shoulder; or a padded belt may be placed around each shoulder and drawn together by a strap on the back. - A dressing of adhesive plaster, as practiced in Bellevue Hospital, was first suggested by a surgeon residing in Western New York. Dr. Lewis A. Sayre gives an excellent description of it.* “The dressing is prepared by cutting from strong adhesive plaster—that spread on canton flannel or jean is preferable—two strips, from four to six inches in width, and one-half longer than the circumference of the chest. These are to be applied as follows: Begin by fixing the end of one strap upon the inside of the arm of the in- jured side, opposite the insertion of the deltoid ; carry the strap across the belly of the biceps and around the back of the arm, bringing the arm well back. Continue the strap horizontally across the back and around under the nipples to the back (Fig. 267). In fixing the end to the arm, care must be taken not to begin too far back, lest the arm be girded and the circulation arrested. Into the axilla a pad of proper size is to be placed, and the elbow pressed to the side, which carries the shoulder well outward. The hand should then be carried high upon the sound shoulder, and the elbow supported at the desired point, while the second strap is applied as follows: Begin in front of the sound shoulder, and carry the strap over the shoulder diagonally down and across the back, so that its upper edge shall cross the injured arm near the junction of the middle and lower thirds. The plaster is then moulded to the back of the arm and elbow, and dorsal and ulnar surfaces of the forearm, and finally drawn firmly over the back of the hand, overlapping the other end of the plaster on the top of the shoulder (Fig. * Bellevue and Charity Hospital Reports, 1870, p. 131. FRACTURES OF THE SCAPULA. 561 268). It is well to fasten the ends together by a pin, which prevents the possibility of slipping. At the elbow the plaster should be made to fit accurately by cutting nicks in the end and lapping them.” There are Several other means for the treatment of fractured clavicle, and as has been FIG. 267. FIG. 268. * & | * ...co §: s * : § G.TIEMANN & Cº. Sayre's Dressing for Fractured Clavicle. Sayre's Pºg, Front View. irst Strap. - Both Straps. already mentioned most of them are constructed upon principles similar to that of Fox. - - Morgan's Apparatus for Fracture of the Clavicle is made wholly of sus- pender webbing, 1% inch wide, with the usual axillary pad as the fulcrum of the extending force upon the elbow and clavicle of the injured side. Buckles are adjusted at the joints of the apparatus, two small ones for the narrow straps suspending the pad, a larger one at their converging point on the acromion, to receive the uppermost back strap (Fig. 269); four more of the larger buckles at the four corners of the sling; and, if desired, the use of other buckles may be resorted to, to render the triangle of counter-extension at the sound shoulder adjustable to patients of different sizes. This triangle is obliquely “spherical,” its longest side passing over the shoulder, its shortest at right angles with the spine of the scapula, its third across the side of the chest, just below the axillary folds, avoiding all con- tagt with these sensitive points. The angle thus formed in front sustains a bifurcated strap, each end of which fits into one of the buckles of the sling; posteriorly the other two angles support the remaining three straps, going respectively to the pad and to the back corners, upper and lower, of the sling; the balance of all being thus perfected. An old coat will afford the best ground on which to figure this system of straps. The sling itself is of open work, for ventilation, of two longitudinal, and more numerous transverse pieces, the former beginning and ending at the wrist. Linen may be interposed everywhere, if desired, for cleanliness and comfort, between the webbing and the skin. (Fig. 270.) . . Fractures of the Scapula.-Fractures of the shoulder-blade, especially in the vicinity of the surface articulating with the humerus, are very difficult to diagnose. There is generally so much injury to the soft parts, that the movements necessary to establish diagnosis are with difficulty performed. In fact, a mere blow upon the deltoid may so impair motion, and give rise 36 562 A SYSTEM OF SURGERY. to so much swelling, that the parts may assume an appearance similar to that of a severe injury of the joint itself. Fracture of the acromion and neck of the scapula, dislocation of the humerus downwards, fracture of the neck and head of the humerus, -all have many of their symptoms in common, and all require careful manipu- FIG. 269. & “. Nº sº, sº • Sº º, ºr SNOWDBN, O Morgan's Clavicle Apparatus. Front view. lation, thorough anatomical knowledge, and an acquaintance with the signs which may be diagnostic of each. + Let me illustrate this by a case or two which occurred in my practice, and which caused me considerable anxiety. - Case I.-A man aged forty-five was driving a loaded wagon which came in contact with a street car. By the violence of the concussion he was thrown upon the pavement, striking on the right shoulder. He was very severely bruised, and being picked up by passers-by, was carried to the office of a neighboring physician. The medical man diagnosed a disloca- tion of the humerus into the axilla, and called assistance for the reduction. Several men were brought in, and after a time the arm was said to be replaced, and the patient was sent to his home. He was placed in bed, and shortly after a severe chill resulted, followed by high fever. The arm still remained powerless at the side, and other physicians were sum- moned. He gradually improved in his general condition, but his arm still hung helpless; his friends consulted many medical gentlemen, with as many FRACTURES OF THE SCAPULA. - 563 different opinions. I saw the patient in consultation. His case presented the following symptoms: There was a prominence over the point of the acromion, but the shoulder was otherwise round. There was a slight de- pression toward the extremity of the spine of the scapula. The arm could be moved in different directions without much pain, and the hand could, FIG, 270. SNOWDEN, PHILA. Morgan's Clavicle Apparatus. Back view. with difficulty, be placed upon the opposite shoulder. There was some swelling in the axilla, and I thought that I could detect the head of the bone in that situation. Six or eight weeks had elapsed since the accident, and I was quite at a loss for a correct diagnosis. I could not agree with those surgeons who had declared that a downward dislocation existed, nor could I satisfy myself as to the exact nature of the accident. I placed the arm in a sling and supported it well at the elbow, and extended a spiral bandage around the chest. Shortly after, I saw him the second time, and found him not much improved. A few days after this a relapse of fever occurred, and he died in about a fortnight. A post- mortem examination, besides revealing multiple abscesses in the liver, which I am convinced were caused by the severe contusion, showed about three-quarters of an inch of the acromion process fixed firmly to the head of the humerus, and a slightly ligamentous growth extending from the broken extremity of the spine of the scapula to the acromion process. The case was one of great interest to me. I am sure I may assert that fractures 564 A SYSTEM OF SURGERY. of the acromion, especially when there is but little displacement, are very difficult to diagnose. Case II-A young lady was thrown violently from a carriage, and struck upon her right shoulder. She was carried to a physician, who stated that nothing but a contusion existed. The arm was powerless, and the pain Severe. After a period of some weeks she was seen by her own medical adviser, with whom I saw her in consultation. The head of the bone was in the axilla and to be felt. It moved with the humerus, there was the double inclined plane formed by the muscles of the arm, and I was disposed to regard the case as one of an unreduced dislocation. There was, however, considerable motion of the part. By manipulation and rotation, I brought the parts in apposition, and having them held there, applied a bandage. The shoulder looked well after the dressing was applied, but in two days the patient returned with the arm in the same position as formerly. There was a depression below the acromion, quite well marked. The head of the hu- merus was again in the axilla. The arm could be moved in various direc- tions without much pain, and with but slight difficulty the hand could be placed upon the opposite shoulder. When the arm was raised at the elbow, the shoulder appeared much more natural, but the deformity re- turned when upward pressure was relaxed. The diagnosis was a fracture of the neck of the scapula. A wedge-shaped pad was placed in the axilla, the arm secured to the thorax, and a sling used to elevate the elbow. In both of these cases I could not detect any crepitus, and for this reason I record them. In the latter case, it will be remembered that four weeks had intervened between the accident and the examination, and in the former at least two months. I mention these cases because they are both instructive in several particulars. Case III.-A gentleman of forty fell down through a hatchway a distance of over thirty feet. He did not recollect exactly the posture he assumed as he fell, and must have lain for a considerable time, stunned by the severity of the blow. When I saw him, about four hours after the injury, there was immense tumefaction of the shoulder. No depression could be felt under the acromion process. I could not feel the head of the humerus within the socket, nor within the axilla; accurate measurement showed no appreciable alteration in the limb ; yet, by fixing the shoulder and rotating the arm, crepitus was detected. The elbow could be placed at the side, and could, with much pain, be moved backward and forward. The fracture was no doubt one of the intracapsular variety of the head of the humerus. A simple sling and a narrow oblong axillary pad were all that was required. A good recovery resulted. I will now proceed to speak more in detail of the accidents occurring to the shoulder-blade. These injuries cannot be too carefully studied by the surgeon. They give the greatest anxiety to the most experienced, and often present really insurmountable difficulties in diagnosis. - A fracture of the Scapula may occur in the body, as well as at the neck or processes of the bone. It is, in the majority of instances, the result of direct and great violence. Oftentimes there is so much tumefaction that the diag- nosis, especially in muscular or corpulent subjects, is very difficult. In examining a patient where such fracture is supposed to exist, the first course to be pursued by the surgeon is to trace with his finger the whole contour of the bone. He should then manipulate, or endeavor to move its body, both above and below the spine, and finally should press gently along the entire course of the spine itself, a fracture of which is more easily recog- nized than that of the body of the bone. The forearm should be laid across the posterior wall of the thorax, when there is reason to suspect a fracture of the infraspinatus fossa. The diag- FRACTURE OF THE ACROMION PROCESS. 565 nosis is also rendered more difficult by the absence of crepitus. This may result from the wide separation of the fragments, or from their closely riding one upon the other. Though in fracture of the blade, there is difficulty of motion in the shoulder, yet we must bear in mind that contusion may produce this symptom, especially if the muscles be severely bruised. The most general site of fracture of the body of the bone is below the spine, and it is generally broken FIG. 271. transversely. The scapula may also be incom- pletely fractured, of which Prof. Hamilton records an example. Treatment.—A great variety of bandages have been devised for the treatment of this fracture. The simplest of these is probably the best, and this con- sists of a bandage and sling, having at the same time the elbow carried a little backward. The arm should be allowed to hang by the side of the tho- rax, and then bandaged to the body, with the elbow in the position above named; the forearm should be supported by a sling. Fracture o º: Coracoid Process.-This portion of the bone is not very liable to be broken, and dis- tinguished surgeons have not, during an extended practice, met with it, although there are many well-authenticated cases upon record which prove beyond doubt that such an accident may occur. As a general rule, however, there is more or less complication in these accidents. A case came under my observation in which a man, having fallen from a height and upon the right shoulder, broke off the cora- coid process. The fracture was not recognized for some eight or ten days on account of the amount of swelling. If the fracture is complete and the coraco-clavicular ligament is ruptured, the combined action of the coraco-brachialis, the pectoralis major, and the long head of the biceps, tends to drag down the fractured end of the bone. To fulfil properly the indications in the treatment of this fracture, it will be necessary to fix the body of the scapula by frequent turns of the roller, or by long and broad bands of adhesive plaster well applied. The elbow must then be drawn forwards upon the anterior portion of the thorax, and the forearm placed in a sling. Fracture of the Acromion Process.-This lesion is of rare occurrence, and if there be no displacement, it will be next to impossible to obtain a clear diag- nosis. The best method of proceeding is to pass the finger along the spine to the process, where the fracture may be felt. Perhaps crepitus may be detected, or the line of the spine may be broken, and the depression behind the acromion will point to the diagnosis. (Fig. 271.) The following may be found useful as diagnostic signs: FRACTURE OF THE ACROMION. DISLoCATION OF HUMERUs INTO THE AxILLA. Limb movable. Limb almost fixed. Hand can be placed upon opposite The reverse. shoulder. Deformity remedied by lifting the Arm cannot be lifted to its place. shoulder and by raising the - elbow. Deformity recurs upon relaxing the Deformity the same; cannot be removed by upward pressure. upward pressure. Crepitus may be detected. No crepitus. Depression found by tracing spine No depression. toward the acromion. 566 A SYSTEM OF SURGERY. The apparatus for fractured clavicle, carefully and firmly applied, will generally be found sufficient for fractures occurring behind the acromio-cla- vicular articulation; whereas, if the break FIG. 272. is found to be anterior, the patient must be * laid upon his back, and the arm fixed nearly at a right angle with his body, thereby relaxing the deltoid, and lifting the fractured extremity to its place. Fracture of the Neck of the Scapula.— This accident does not frequently hap- pen. The symptoms which indicate it are more positive than those belonging to the breakage of the processes, which have just been described, and which have many indications in common with downward dis- location of the humerus. The inexperi- enced may mistake the fracture for the dis- location. I have a case in mind, where a man of sixty was placed under the influ- ence of chloroform, and three stout Irish- men were ordered to pull upon his arm. This great pain was unnecessary, for there was no dislocation, but a fracture of the neck of the bone. More than one suit for * malpractice has been instituted, and dam- ages recovered for a mistake made by the surgeon in diagnosing a dislo- cation downward of the shoulder, when there was actually a fracture of the neck of the bone. In both we have the head of the humerus in the axilla; in both we have a depression under the acromion process, the same loss of motion, the same flatness of the shoulder, and the same numbness and pain in the arm. The chief diagnostic signs are: First, the parts may, with moderate facility, be restored to their normal position, but as soon as the sustaining force is removed, the deformity reappears. Secondly, crepitus may be felt, by having an assistant fix the body of the scapula; then the surgeon, raising the arm upwards with his right hand and manipulating the shoulder with his left, will feel the grating of the fractured extremities. It may be well also to remember that the flatness of the shoulder may assist in diagnosing this injury from fracture of the head of the humerus, and that in the latter, the limb is shortened. The treatment is quite simple. Replace the humerus in its normal posi- tion; keep it there by the sling and pad used in fracture of the collar-bone. Then fix the scapula by a bandage passed around the chest and over the shoulder, or by broad adhesive strips. Dr. C. H. Van Tagen” reports a case of fracture of the neck of the scapula treated by means of the third bandage of Dessault, with Fox’s ring and sling, which made a good recovery. In Fig. 272, an apparatus for fracture of the neck of the scapula is seen (without the sling) which will be readily understood. - FRACTURES OF THE PELVIC BONES. Fractures of the 0s Innominatum.—Fractures of the pelvis are generally occasioned by great violence. Indeed, when we consider the formation and position of the bones composing this portion of the human skeleton, it * United States Medical and Surgical Journal, vol. ii., p. 51. FRACTURES OF THE OS INNOMINATUM. - 567 would seem that nothing but great force could cause a solution in their con- tinuity; yet, in my researches upon this subject, I find a case recorded by Cappelletti, in which the ascending branch of the ischium and descending branch of the pubis were broken by muscular contraction. The patient, fifty-four years old, had jumped from a carriage (the horses having run away), with one leg in the greatest possible degree of abduction.* Mr. Handcockt reports an interesting case of fracture of the descending ramus of the pubis. The patient fell from a height of about fourteen feet, and presented the usual symptoms of shock; the following symptoms then resulted, which will give a fair résumé of what may be found in such cases: “On the tenth day, the patient got out of bed for the first time since the accident, and endeavored to dress himself; but although entirely free from pain in the buttocks, he was unable to raise his left foot from the ground ; and, in attempting to do so, he said he felt something move in the perinaeum. Crepitus was felt close to, but rather higher than the junction of the ramus of the ischium and pubis on the left side. The shape and position of the limb were natural. There was exact correspondence of the length of the limb with its fellow; the leg resting on the bed in its straight position could not be raised beyond about an inch, and then only with great pain, neither could it be abducted beyond a certain distance (twenty-three inches measured from heel to heel). When the patient lay straight in his bed, he could bend his knee, and afterwards approximate the thigh to his body, the foot being in this way entirely raised from the bed. He could not assume the sitting posture without supporting himself on his hands. For ten days the patient always referred his suffering to the left nates and the lower parts of his back, and never to the seat of fracture, but this may be attributed to the bruising of his buttock having been so severe.” There was not the slightest injury to the urethra and bladder. Mr. Handcock states that, in examining a patient for this accident, the limb should be abducted to put the adductor and gracilis muscles upon the stretch, and the thigh afterwards rotated upon its axis; as when rotation and circumduction were employed, whilst the limb was adducted, no crepitus was felt, but after previous abduction, crepitus was distinct. This remarkable case, which presents many points to be remembered, recovered without a single untoward symptom, the complete use of the ex- tremity being regained. As will hereafter be stated regarding dislocation of the pelvis, fractures are not necessarily fatal, the danger being as a rule in proportion as the viscera are implicated. Hamilton reports several cases of comminuted fracture of the pelvis which it is unnecessary to quote here, as the work is accessible to all. He is of opinion that there is not much displacement, and if any occur, it is in the upper fragment, which is carried slightly inward, although he admits that occasionally it is displaced upward, outward, or downward. He also quotes from the New York Journal of Medicine, a case reported by Lente, in which a dislocation and fracture of the alae of the pelvis on the same side were recognized; the patient died, and “the autopsy disclosed what had not been suspected during life, viz., that the left ilium was broken horizontally about its middle, and vertically through the crest, and also that there was a fracture extending through the sacro-iliac synchondrosis, accompanied with considerable comminution of the articular surfaces. It was also found that a portion of the small intestine was ruptured, and probably by one of the sharp fragments of the broken pelvis.” The anterior superior spinous process of the ilium is also sometimes * Ranking's Half-Yearly Abstract of the Medical Sciences, 1848, p. 83. f London Lancet, May 23d, 1846. 568 A SYSTEM OF SURGERY. broken. The fragments are generally displaced downwards, and motion and Crepitus are distinct. In such cases the patient must be laid upon the back, and the limbs drawn upwards to relax the muscles attached to the process, and a bandage applied. The latter, however, is not absolutely necessary, as cases are recorded wherein a good result was obtained by keeping the patient in the position alluded to. Sir Astley Cooper says:* “I have known of three instances of fracture of the os innominatum recover; two of these were fractures of the ilium, and the nature of the accident was easily detected by the crepitus, which was perceived upon moving the crest of the ilia; the third was a fracture of the junction of the ramus of theischium and pubis. In the first two, a circular roller was applied upon the pelvis, and the patient freely bled; but in the latter no bandage was employed.” Mr. Sanford gives the details of a frac- ture passing through the body of the pubis on the left side, and through the ramus of the left ischium. The patient was aged thirty years, and the acci- dent had been produced by her body being pressed by the wheel of a cart against a lamp-post. This case is too lengthy to quote in this place. The symptoms were crepitus and mobility, easily recognized by placing the pa- tient on the face, one hand on the back of the right ilium, and the other on the pubis of the same side; the posterior spine of the ilium projected up- wards; a vaginal examination revealed the pubis passing inward into the cavity of the pelvis; there was also some extravasation of blood, vomiting, cold feet, severe pain, great thirst; pulse 90 and small; the right leg was shorter than the left, with numbness of that side. She lived about three weeks; the autopsy revealed what I have already stated. In such cases the extension treatment is the appropriate one, and it ap- pears to me that an excellent apparatus would be the wire-gauze splint of Hamilton, applied with appropriate pads, with an additional band in front. * It very often happens, as will be seen from the cases mentioned, that frac- tures of the pelvis are comminuted; the pubis and ischium may be fractured, or a distinct portion of bone may be severed; these, if they do not unite, must be exsected. Fractures of the Acetabulum.—This injury is more difficult to diagnose than any other affecting the pelvis. In this remark I should exclude the breaking off of the rim or lip of the cotyloid cavity, which often hap- pens in the ordinary dislocations of the femur, more especially that on the dorsum ilii. In such cases, crepitus is present when the reduction is being effected, and there is a great tendency for the head of the bone to slip from its socket when the extending force is withdrawn. In such cases permanent extension and a circular pelvic bandage generally suffice. The difficulty of obtaining a correct diagnosis when fracture of the ace- tabulum takes place is great, because the symptoms may simulate closely those belonging to dislocation or fracture of the neck of the femur; and although Mr. Travers assertsi that “very acute pain produced by pressure upon the projecting space of the os pubis, and the inability of the patient to maintain the erect posture immediately after the infliction of a blow or fall which produces the mischief,” diagnosticate fissures or cracks in the ace- tabulum, yet there are some other symptoms that must be considered when the fractures are more extensive, especially when by sheer force the head of the femur has been driven through the cotyloid cavity. It is well known that there is a junction of the ilium, ischium, and pubis within the acetabulum, and cases are recorded by Earle, and Cooper and Travers, where the bones separated at their anatomical junction. When, * Cooper and Traver's Surgical Essays, Phila., 1821, p. 39. f Holmes's System of Surgery, vol. ii., p. 713. FRACTURES OF THE ACETABULUM. 569 however, the thigh-bone is driven through the acetabulum, the symptoms are very liable to be confounded with fracture of the cervix femoris, as well as dislocation of the thigh-bone. Mr. Earle” gives four cases which closely simulated fracture, there being eversion of the foot and loss of prominence of the trochanter; the diagnosis being chiefly made out by the fact that the limb could be drawn outward to a considerable degree without suffering, which cannot be effected without much pain if the bone is broken. Another case, however, is recordedi in which the affected limb was two inches shorter than the other. Sir Astley Cooper, in the essays already quoted, relates a case that “was admitted to Saint Thomas's Hospital, having the appearance of a disloca- tion backward. The patient lived four days. On examination, the frac- ture was found passing through the acetabulum, dividing the bone into three ; and the head of the thigh-bone was deeply sunken in the cavity of the pelvis. Mr. William M. Tyer gives three cases of a similar injury, two of which were mistaken for fractures of the neck of the femur, and the third for dis- location. It is a curious fact that, in the majority of cases of this variety of fracture, the cervix femoris has been found entire, although I find the record of one case, by Dr. George W. Gibb,i in which not only was the acetabulum extensively fractured, but there was an intracapsular fracture of the neck of the femur. He also gives another interesting case of com- minuted fracture of the pelvis, from which he draws such pertinent deduc- tions that I quote them entire. He says of his case: “1st. There were the symptoms of fracture of the cervix femoris, when that lesion was not present, as eversion of the foot, shortening, crepitus, etc., and great nicety was required in forming a correct diagnosis. “2d. The shortened member could not be drawn down to an equal length with its fellow of the opposite side, neither could it be inverted, and motion in almost any direction gave great pain. “3d. None of the pelvic viscera were injured, although the catheter had occasionally to be used, and blood was passed at stool. - “4th. The fracture had become perfectly united, and the patient was on the eve of discharge, whan another cause produced death. “5th. The sequence showing the union of the bones, bent in an irregular manner; the formation of a ligamentous acetabulum, with the wise provision of nature in the total absence of any new deposit within the articulation which might have interfered with the function of the joint.” From what I have already written, and as has already been mentioned, from a careful inquiry and research, it has been found that the neck of the thigh-bone is rarely fractured in these injuries; that in the majority of instances, if the limb is turned outward, the trochanter having lost its prominence, with shortening, and severe pain when moving the limb in any direction, we may be tolerably sure of fracture of the acetabulum. If the foot is inverted, and the head of the femur cannot be discovered in either of the positions it is known to assume in the various forms of dislo- cation, the fact must be remembered, that often the posterior lip of the acetabulum is broken, and the femur may be dislocated. The presence, however, of the head of the bone on the dorsum will readily diagnosticate the luxation. - From the record of these cases, it appears that the treatment in most cases of fracture of the innominata, consists, if possible, in reduction of the * Medico-Chirurgical Transactions, vol. xix. f Cyclopædia of Anatomy and Surgery. . : Ranking's Half-Yearly Abstract of the Medical Sciences, 1849. 570 A SYSTEM OF SURGERY. bones by proper manipulation, for which no especial rules can be laid down, each case being left to the judgment of the surgeon, and proper extension applied. . Even the latter is not always necessary, as good recoveries have been made by perfect rest and the body bandage. It is a question in my mind, whether the in section of the perinaeum Would not be a proper step to pursue in cases of rupture of the bladder, when the surgeon is called shortly after the accident, as such measures have lately been resorted to with good results in perforation of that viscus by disease. FRACTURES OF THE UPPER EXTREMITY. Fracture of the Humerus.-The humerus may be broken in a number of places, either in the shaft or extremities of the bone—the head, the surgical and anatomical neck, the greater tubercle, the condyles, either one or both, are all liable to the accident; and this bone serving such an important part in the usual avocations of life, it behooves us to study carefully both the nature and treatment of those fractures to which it is liable, and to under- stand especially the relations of the soft parts to the osseous structure, par- ticularly the insertion of the deltoid. The supra- and infraspinatus and the teres minor are attached to the greater tubercle; the subscapularis to the lesser tubercle; the triceps behind, and the brachialis anticus and the biceps in front, all give certain direction to the displacements which occur in frac- tures in different portions of the bone. There is sometimes a variety of that form of paralysis known as “wrist- drop,” which may result from injury to the musculo-spiral nerve, or one of its branches, in fracture of the shaft of the humerus, or in fracture of the condyle; then the hand falls into a state of pronation and flexion. In the college clinic such a case presented, in which the condyle had been broken off, partial paralysis resulting. We may begin by considering that variety of fracture which is perhaps the most simple, viz., fracture of the shaft of the bone. This accident occurs generally about its centre, and, as a rule, it is found more frequently at the lower than at the upper half. It is, in the majority of instances, oblique, and the displacement takes place in different directions accord- ing to the seat of the fracture, and may, in extent, be from a half to three- quarters of an inch. Crepitus is usually well marked, the deformity ap- º: except in transverse fractures, and the indications of treatment are SITY110162. ºtment—Extension must be made to bring the bones into apposition, and a carved splint, or one of felt or leather, or binder's board, moulded to extend two-thirds of the distance around the arm, be placed on the out- side of the arm and should extend to below the elbow; this splint must be carefully applied while extension is being kept up by assistants. A second short splint then may be set on the inside of the arm, and both secured by a well applied roller. The forearm is then to be placed in a sling, but without support at the elbow, as the weight of the arm will have a tendency to keep the fragments in apposition. In this variety of fracture the leather and wooden splints are found very efficacious. The metallic splint of Lewis also can be used, and will give satisfaction. In my own practice I use generally the long outside splint, and apply to the inside of the humerus a light wooden or pasteboard one, which I inclose with the same bandage, and place the forearm in the ordi- nary sling. At times, when there is a strong disposition of the bones to lap over each other, Prof. Hamilton lets the forearm hang, thus promoting more prolonged and powerful extension, and he relates cases where such treat- ment was followed by excellent results. FRACTURE OF THE HUMERUS. 571 Fracture at the Base of the Condyles.—These fractures generally are occa- sioned by indirect violence, as a blow or fall upon the elbow, although cases are recorded where they have been the effect of a direct blow upon the humerus, immediately at the base of the condyles. The direction of the fracture in the majority of instances is oblique and upward and backward. Difficulty of diagnosis is experienced in distinguishing the accident from a backward dislocation of the radius and ulna, and from complications which may be connected with the fracture. The first duty of the surgeon is to endeavor to discover if there be crepitus, which usually will be found, by slowly and cautiously extending the arm, by which motion the fractured ends of the bone can be again brought into contact. Preternatural mobility cannot be relied upon if the fracture is not ascertained for some time after the accident, and for two reasons: first, because very often the end of the upper fragment may project into the elbow joint; and secondly, from the stretching and bruising of the anterior muscles they become very rigid, in fact as hard as in dislocation. There is shortening of the bone, which, however, may be counteracted by extension, but the deformity returns when the traction is discontinued. There is a large prominence on the pos- terior and lower half of the bone, and the hand and forearm are in a state of pronation. Treatment.—An excellent method of treating this fracture is by means of rectangular side-splints, as advised by Dr. Physick (Fig. 273), which may FIG. 273. FIG. 274. º º \º Q--- sº.º. ºº' ºr “º, º 'º - . Sºśs- sº ...sº Physick's Elbow Splints, Hamilton's Elbow Splint. be made of binder's board, felt, or leather, or by Johnston's splint, or the well-known carved posterior splint. During the period of healing, the dress- ing should be removed once a week, the fragments steadied, and passive movements made, to prevent anchylosis of the elbow, to which this fracture has a strong tendency. The roller should first be applied, from the arm to the shoulder, then the elbow bent, at its proper angle, and the splints applied. The metallic splint of Levis is provided with hinges, and allows passive motion, without much interference with the dressings. In two cases which I recently had under treatment, I obtained satisfactory results 572 A SYSTEM OF SURGERY. from a rectangular posterior splint of sole-leather moulded to the arm and well padded. One of the best splints for this accident is that of Prof. Hamilton as FIG. 275. Fracture of the Ana- tomical Neck of the Hu- merus. (Intra-capsular.) seen in Fig. 274. It consists of gutta-percha, moulded to fit the shoulder, arm, and forearm; this must be well padded, placed upon the limb and secured by the roller. Fractures of the Head and Anatomical Neck of the Hu- merus.-These fractures are generally caused by balls and other missiles, which, entering the joint, complicate the injury, either by fracturing the head of the bone or lacerating the soft parts. Direct force applied to the shoulder may also produce the injury. This fracture may be intra- (Fig. 275) or extracapsular; if the former, bony union rarely takes place, and resection of the head of the bone may sooner or later be required. The dis- placement differs; sometimes the head of the bone is impacted in the cancellated structure, or there may be very little displacement, or the upper fragment may be turned on its axis; and cases are recorded where it has been turned completely around. If the fracture be in- tracapsular, undue violence must be avoided in en- deavors to detect crepitus, and the arm and forearm be well supported in a sling. Fractures through the tubercles are generally occasioned by forces similar to those producing fractures of the head and anatomical neck of the humerus. There usually is not much dis- placement, because the muscles covering these portions of the bone act over - FIG. 276. | * * à A à ſº Q. | | | | a large surface, and equally on all the frag- ments. There may be impaction, or the head of the bone may be forced downward into the axilla. Treatment.—This fracture should be treated with a simple sling if there is not much dis- placement. If, however, there should be any moving of the fragments, the apparatus used for fractures of the surgical neck may be em- ployed. - Fractures of the Surgical Neck.-There is displacement in the majority of these frac- tures, and the accidentis one of not infrequent occurrence; the direction of the displacement is toward the coracoid process. There may be, but not necessarily, impaction. Several kinds of treatment have been adopted, but the best is the outside splint with a shoulder support. Prof. E. A. Clark devised an excellent appa- ratus for the treatment of this fracture. It consists of two strips of adhesive plaster three inches in width, applied to the internal and external surfaces of the arm, as high up as the upper and middle third of the humerus. The strips are bound to the arm by a collar bandage, and at their lower end beneath the point of the elbow is fixed a cord to which a sand-bag is attached, weighing from three to four pounds. This sand-bag is attached close to the point of the elbow, and when the patient wishes to walk, the cord to which it is FRACTURE OF THE RADIUS. 573 Suspended is knotted in order to make it shorter. When he lies in bed the cord is loosed and carried beneath the bedclothing over a small pulley placed at the foot of the bed, and in this way an equal extension is kept up, whether the patient be either in the upright or recumbent posture. The dressing is seen in Fig. 276. Fig. 277 represents the appliance of Mr. Richardson for fracture of the upper portion of the humerus, whether through the anatomical or the surgical neck, or through the tubercles. The lower fragment having been drawn down, the upper one is maintained in its position by an axil- lary pad. The outside splint is of sufficient length to reach from the acro- mion midway to the elbow, and is held in position by adhesive straps. The body splint, which tightly fits the side of the thorax, and is attached to the arm splint, is kept in position by adhesive straps passing around the thorax. FIG. 277. - - FIG. 278. Apparatus for Fracture of the Surgical Welch's Shoulder Neck of the Humerus. Splint. The arm is then brought to the side of the chest, and secured by several turns of the bandage, and the hand placed in a sling. Probably as efficient splints as can be found alſº those of Welch (Fig. 278), Ahl, Johnston or Levis, which are readily applied. FRACTURE OF THE FOREA.R.M. Fracture of the Radius—Neck.-A fracture of the neck of the radius is very rare, indeed its occurrence has been denied by many distinguished sur- geons. Cabinets, however, possess some specimens, though few, of uncom- plicated fracture of the cervix of the bone; and Prof. Hamilton says of it, while alluding to the single specimen in the Mütter collection, “While, therefore, the presence of what may appear to be the rational diagnostic signs has compelled me to record one case as an uncomplicated fracture of the neck of the radius, and two others as fractures at this point accompa- nied with a fracture of the humerus, or a dislocation of the ulna, I am pre- pared to admit that some doubt remains in my own mind as to whether, in either case, the fact was clearly ascertained, nor do I think, speaking only of the simple fracture, that it will ever be safe to declare positively that we have before us this accident, lest, as has happened many times before, in the final appeal to that court whose judgment waits until after death, our decisions should be reversed.” The difficulty in making a correct diagnosis consists chiefly in the absence 574 A SYSTEM OF SURGERY. of crepitus, owing to the dense mass of muscular fibre which covers this portion of the bone, and from the lower fragment being drawn away by the powerful action of the biceps, the displacement being thus rendered greater by extending the forearm. - Treatment.—It is very essential in this variety of fracture to flex the fore- arm upon the arm, and to apply the dorsal splints, with an anterior one of binder's board well secured with a roller bandage, or to use the apparatus devised for the fractures of the olecranon by Dr. E. A. Clark, and which is described when treating of that variety of lesion. Fracture of the Shaft.—Before proceeding to detail these accidents, the origin and insertion of the pronators of the forearm should be carefully studied, as by such knowledge the direction of the displacement of the fragments may be understood. If the bone is broken below the attachment of the biceps and above the insertion of the pronator radii teres, of course the counterbalancing action of this and the quadratus is lost, and the biceps continuing its action on the upper fragment completely supinates it. If the break occurs below the insertion of the upper pronator, this muscle, aided by the biceps, draws the upper fragment forward, while the quadratus has a tendency to force the lower fragment toward the ulna, thus making con- siderable displacement. This teaches the surgeon the importance of supi- nating the hand, when bringing the bone into apposition, otherwise if it remain in a state of pronation, though it may be accurately adjusted, the line of the axis of the bone will be lost, and though there may be no apparent deformity, the power of Supination is destroyed. reatment.—Supinate the hand as much as possible, and having applied the roller, place a splint on the anterior and posterior face of the forearm, and adjust the arm in a sling. Some surgeons prefer keeping the arm in a state of semipronation, which, if the fracture is far down, answers well. The plaster-of-Paris splint also can be advantageously used. Colles's Fracture.—We next are to consider a fracture at the lower ex- tremity of the radius, first described by Colles. This fracture has received FIG. 279, ſliii. W. |#. § Fracture of Radius near lower end. the attention of many surgeons, and requires such care in diagnosis and treatment, and is so often accompanied with deformity, that it demands all the attention of the practitioner. By the term Colles's fracture is understood a fracture of the lower ex- tremity of the radius, from one-half to three-fourths of an inch above its carpal surface, with displacement of the lower fragment backward; it is generally transverse, although it may be from above downwards and inward. It is, in the majority of instances, caused by a fall upon the palm of the hand, though a force applied to the dorsum may produce it. The head of the ulna points to the inner border of the carpus, and there is much de- formity as well as displacement. (Fig. 279.) The hand takes an outward direction, stretching to a degree the internal lateral ligament, producing often the most excruciating pain. It is also called the “silver fork” fracture. It must be remembered that in a true Colles's fracture the articula- COLLES’s FRACTURE. 575 º the radius with the carpus remains intact, and that the ulna is not I'O Ken. There is another fracture which takes place in the vicinity of the wrist- joint, called Barton’s fracture, first described by Dr. J. Rhea Barton, of Philadelphia.” It is of rare occurrence, and its peculiarity is that the frac- ture separates either entirely or in part the posterior margin of the articular surface of the radius. This accident is so infrequent that many surgeons have supposed it to be merely a modification of the fracture described by Colles. In all these fractures in the vicinity of the wrist-joint, the junior or inexperienced must be prepared to meet more or less deformity, stiffness of the joint and fingers, and considerable hard and tense swelling, which may remain for months and even for years. This rigidity is caused by the effusion of plastic lymph beneath the annular ligament and along the sheaths of the numerous tendons which traverse the part, as well as spurious anchylosis, which in greater or lesser degree follows in the majority of cases. With refer- ence to this latter deformity I insert the testimony of experienced surgeons. Dr. Mott wrote: “Fractures of the radius within two inches of the wrist, when treated by the most eminent surgeons, are very difficult to manage so as to avoid all deformity; indeed, more or less deformity may occur under the treatment of the most eminent surgeons, and more or less imperfection in the motion of the wrist or radius is very apt to follow for a longer or shorter time. Even when the fracture is well cured, an anterior prominence at the wrist or near it will sometimes result from swelling of the soft parts.” Another says: “As the above opinion of Professor Mott coincides with my own observations both in Europe and this city, as well as with many of our most distinguished surgical authorities, I venture to hope that it may assist in removing some of the groundless and ill-merited aspersions which are occasionally thrown upon the members of our profession by the ignorant or designing.” Treatment.—A great variety of apparatuses have been invented and used by surgeons for the treatment of fractures in the vicinity of the wrist, all resembling more or less the “pistol-shaped splint.” . It must be remem- bered that the great object in view is the raising of the lower fragment Bond's Splint. to its place, and maintaining it in apposition with the upper. Sometimes this may be accomplished by a palmar and dorsal splint applied to the fore- arm, the hand being allowed to drop, and by its weight falling to the ulnar side of the forearm, may preserve the bones in apposition. Some forcibly flex the hand upon the wrist and keep it there. Welpeau renounced, in his later years, all bandages which were complex, and used a simple contrivance, the idea of which he stated he received from a Danish surgeon. He says: “At first I obtain immediately the required position by very strongly flexing the hand upon the forearm at a right angle. The extensor tendons thus constitute a pulley to push back the fragments. The limb is then fixed in this situation ; a dry roller and a * Philadelphia Medical Examiner, 1838. * Velpeau's Lessons, p. 27. 576 A SYSTEM OF SURGERY. graduated compress upon the back of the forearm and the hand; a splint of moistened pasteboard which moulds itself perfectly, and a dextrine ban- dage maintains the whole.” The splint I formerly used, and with a good deal of success, was that of Dr. Bond, of Philadelphia (Fig. 280). It can be made by any one having a moderate degree of ingenuity, and is simple and will prove satisfactory. With a little care a properly cut shingle or the side of a cigar box, suitably padded, will make an excellent pistol splint. Hamilton’s splint (Fig. 281) is made from a wooden shingle, and should extend from half an inch below the bend of the elbow to the metacarpo- phalangeal articulation. The splint should FIG. 281. be well padded, and applied on the palmar 777mmuniſm/m/ſ, surface of the arm. Dr. Lewis's Splint. In the treatment of fracture of the lower end of the radius it is g - * , , , essential that proper allowance be made for Hamilton'sspºracture of the the curvature of the anterior or palmar sur- . & face of this part of the bone. This is insured in this splint, which follows correctly the radial curvature; and the fix- ing of the thenar and hypothenar eminences of the hand in their moulded beds, maintains the splint immovably in its correct position with reference to the radial curve. To the neglect of complete primary reduction of the displacement of the lower fragment, and to inefficient restoration and retention of the normal radial curve, are due the frequent unfortunate sequences of this fracture. No dorsal splint is needed, but a small pad will, in most cases, be required over the dorsal surface of the lower fragment. For retention of the splint an ordinary bandage, two inches and a half to three inches wide, is all that is necessary. FIG. - 282, Dr. Lewis's Metallic Splint for Fracture at the lower end of the Radius. This splint has the merit of being applicable to all cases of fracture of the lower end of the radius, and also to many other injuries involving the forearm and wrist. (Fig. 282.) Professor Moore, in an interesting paper on Colles's fracture, gives a dressing so simple and efficacious as entitles it to notice. . He observes that in Colles's fracture especially, there is a luxation to encounter, as well as a fracture, and that the former must be reduced before the latter. He says:* * Wide Transactions of the Medical Society of the State of New York, 1870, p. 238. TREATMENT OF COLLES’s FRACTURE. 577 “The patient may be etherized or not. An assistant holding the forearm of the patient, the surgeon grasps his hand, the right with the right, and wice versa. With the other hand placed under the forearm above the frac- ture, he is enabled to bring the thumb over the back of the ulna, the fingers wrapping around the radius. Traction is first made by extension, then drawing the hand laterally to the radial side, then backward, next keeping it held backward, and while making extension, it is swung toward the ulnar side, bending well laterally, when the extension of the hand is changed for flexion, thus describing nearly a semicircle in circumduction. The position of the hand grasping the forearm undergoes constant change, as it is the antagonist of the other hand in everything but the extension. As the back- ward position of the hand, when it is carried to the extreme ulnar side, is changed to flexion of the hand, the thumb of the surgeon rolls around the border of the ulna, and is below when the manoeuvre is complete. The test of reduction is to be found by the presence of the head of the ulna on the radial side of the ulnar extensor. • “The head of the ulna rests mediately, through the triangular fibro-car- tilage, on the cuneiform bone, and is restrained from going backward by the annular ligament, holding on each side the tendons of the extensor minimi digiti, and the extensor carpi ulnaris, thus making a concavity correspond- ing in form to a socket. When it is pressed into this socket, and the hand flexed so that the head is supported by the wrist, the position of the hand is also restored in its relation to the radius. As a result of the displacement of the ulna, the ulnar extensor is carried from its place above the styloid process to the opposite side of the ulna in an extreme displacement, but sometimes remains above its centre. To disentangle the styloid and swing the tendon of the ulnar extensor over into its place, is the purpose of the manoeuvre. The hand is drawn toward the radius to pull off (by stretch- ing) the annular ligament. The backward motion, accompanied with ex- tension, renders the ulnar extensor tense, which serves to draw the annular ligament backward. This is effected by pressing the thumb upon the ulna. The circumduction carries the tendon over the side. Its character as a luxation is still further shown by the fact that the restoration is often accompanied by a snap, both tangible and audible. If restored, the reten- tion is effected by a compress and bandage of adhesive plaster. When the manoeuvre described has been completed, the hand is flexed, and the thumb of the surgeon rests on the under side of the ulna. Its head appears on the back of the wrist, and corresponds with the opposite arm in every respect, except the swelling from blood effusion. As in the treatment of any other luxation, the effort should not be abandoned until the deformity is removed and the ulnar extensor in its place—a fact that can be determined at once. The dressing I propose is intended to hold the head of the ulna up in its fascial socket, by bringing the weight of the hand to bear upon the ulna to retain it home.... If the thumb of the surgeon is kept under the ulna after reduction, it will be found that the weight of the hand is sufficient to keep it in place. As a substitute for the thumb I placed along the ulna, from the pisiform bone upward, a cylindrical compress about two inches in length, and about half an inch in thickness—in fact, a single-headed roller. This is placed against the ulna, resting also on its radial border against the tendon of the flexor carpi ulnaris. A band of adhesive plaster of the same width is wrapped firmly around the wrist and over the compress, extending downward to the extreme point of the radius, thus grasping the bones neatly and tightly. . The ordinary rule of loose dressing on the first visit to a frac- ture is one that I distinctly reject. I propose to bring all the parts into close relation. The patient is allowed to cut the bandages along the back of the wrist in about six hours, if the swelling and pain seem to demand it. 37 578 - A SYSTEM OF SURGERY. But I find it is not often done. The thickness of the compress raises the adhesive plaster so far from the anterior surface of the forearm that stran- gulation of the vessels does not take place. Moreover, the compress yields a little, and thus diminishes the pressure. A narrow sling passing under the compress, so as to bring the hand's weight to bear upon the ulna, com- pletes the dressing.” - I cannot close this subject, without allusion to a paper which has ap- peared on the subject of wrist-joint injuries,” and which certainly, so far as the explanation of the various appearances resulting from Colles's frac- ture and the great simplicity of the treatment recommended, is the most rational that has yet been offered to the profession. Dr. Pilcher claims, and I think proves, that in the majority of cases it is the severe sprain that always occurs in Colles's fracture that demands the chief atten- tion in the treatment. He explains the manner in which the fracture takes place, as well as the resulting deformity, with accuracy. Owing to the firmness of the articulation between the carpus and the metacarpus they virtually act as one bone, joined to another (the radius) by strong anterior and posterior ligamentous attachments. By forcible extension of the hand backward, of course the ligaments posteriorly are put upon the stretch, while the anterior are somewhat relaxed, by which the end of the radius slips forward as far as that relaxation will allow. If the force be continued in the same direction the bone gives way above the liga- ments, thus making the fracture. He says, “The lower fragment of the radius is now virtually a part of the carpus, with which it moves and by which it is carried backwards. At its inner border it is still tied to the ulna by the triangular fibro-cartilage and by the radio-ulnar ligaments; at its outer border, being less restrained, the fragment has been displaced to a greater extent than at its inner, as the result of which, a decided inclination to the radial side has been impressed upon the entire hand and wrist. The upper fragment driven downward and forward has become entangled in the lower, near its palmar margin. The impaction is but slight, and disentan- glement is easy when the attempts are properly made. The lower fragment is a broad thin shell of bone. If the upper fragment is driven into it with much force, its comminution is inevitable. That this sometimes occurs, post-mortem examinations have repeatedly demonstrated.” He then goes on to show that the periosteum on the lower and back part of the radius is very thick, and strengthened by fibres from the posterior ligaments of the wrist, and that this periosteum is not torn but stripped up from the back of the upper fragment, in accordance with the amount of displacement of the lower fragment. He says further : “When the radius has given way, and the force of extension is no longer arrested by the insertion of the anterior ligament into its broad margin, this force is felt strongly by that portion of the liga- ment which is inserted into the ulna; the whole hand with the lower radial fragment is caused to move backward and outward as in supination. The styloid process of the ulna becomes approximated to the radius upon the back of the wrist, while the rounded head of the ulna is brought to project strongly upon the front and inside of the wrist. In this position the parts are firmly held, all rotation in either direction being prevented as long as the backward displacement of the lower radial fragment remains unre- duced.” This peculiar appearance, which I own has often puzzled me, and I have never been able to understand, nor have I ever had it satisfactorily explained, is said by Dr. Pilcher to consist in the action of a strong fasciculus * Reason vs. Tradition in the Treatment of Certain Injuries of the Wrist-joint. By #. Pilcher, M.D. Proceedings of the Medical Society of the County of Kings, March, 1878. FRACTURES OF THE ULNA. 579 of the anterior ligament passing from the front of the cuneiform bone upward and inward to the ulnar side, to be inserted into the anterior border of the styloid process of the ulna. By the backward displacement of the carpus this is put upon the stretch, and limits all rotation until relaxed. The points in treatment to be deduced by these anatomical peculiarities are these: First, that always in Colles's fracture there is a severe strain, the treatment of which is of paramount importance. Second, that the mere breaking of the radius transversely entails no permanent disability. Third, that it is the sprain from which those untoward results occur which I have already detailed when speaking of this injury. The fracture of course must be first reduced, which is often difficult, but can be accomplished thus: “By simply bending the hand and wrist back- ward, approximating the position in which the parts were when the dis- placement took place, the tense periosteum is relaxed. Slight extension now in the line of the forearm is sufficient to disentangle the rough surfaces of the fragments from each other. Moderate pressure upon the dorsum of the lower fragment causes it to fall into line. The weight of the hand is now sufficient to secure perfect apposition of the fragments; the periosteum again envelops closely the whole length of the radius; the tense inner fasciculus of the anterior ligament is completely relaxed ; the radio-ulnar movements are free ; the head of the ulna has ceased to project as if sub- luxated.” Therefore we see, for fractures without displacement, that if the wrist is supported in the prone position, and the hand allowed to hang, and appropriate straps applied, a good result may be antici- - pated. When there is displacement, the fracture may be re- duced as above directed, and the application of a broad and strong strip of adhesive plaster, two inches wide, around the lower ends of the radius and ulna, sometimes assisted by a compress applied along the inner border of that bone, is all that is required. This is the treatment which appears rational in every par- ticular, and certainly the best theoretically. I have not tried the method, but shall as soon as an opportunity offers, and the members of the profession must thank Dr. Pilcher for his information concerning the “untorn aponeurotic dorsal peri- Osteal strip, and the inner oblique fasciculus of the anterior ligament” in fractures of the radius, as they have awarded their praises to Dr. Bigelow for his explanation of the action of the ilio-femoral ligament and the obturator internus muscle in coxo-femoral dislocations. Fractures of the Ulna.-Any part of this bone may be frac- tured, the accident being generally occasioned by direct vio- lence. The displacement sometimes is not very well marked, but if the injury be near the centre of the bone, the tendency of the inferior fragment is toward the interosseous space (Fig. 283) owing to the action of the pronator quadratus muscle, while the firm articulation of the superior fragment with the Fracture of humerus will prevent that portion from being thrown inward. the Úina. The bone lying superficially beneath the integument on the inner side of the arm, the deformity and crepitus will readily be detected. A fracture of the ulna is often complicated with other injury, especially dislocation of the head of the radius forward. This necessarily increases the deformity and shortens the forearm from one-half an inch to an inch. Treatment.—Make extension with the hand supinated, and press with the finger and thumb the broken fragments to their places, and apply dorsal and palmar splints well padded. If the tendency of the lower frag- 580 A SYSTEM OF SURGERY. ment be towards the interosseous space, the fingers must be passed along the border of the radius and the parts separated, and a graduated com- press applied on the integument, over which the roller is to be turned, and the splints used as before. If the head of the radius be dislocated, the arm must be flexed to relax the biceps, and counter-extension made by holding firmly the condyles of the humerus, while the head of the bone is pushed into its place. Fracture of the Coronoid Process.—This fracture is exceedingly rare, and the cases that are cited of it are all more or less amenable to criticism. Its symptoms are displacement of the ulna backward, its process felt on the anterior face of the elbow-joint, and if broken off it may be drawn up- ward by the action of the anterior brachial muscle. When extension is made with the forearm the resemblance to luxation disappears, to return, however, when the traction is no longer applied. Another important symptom would be, that the olecranon, prominent when the arm was in an extended position, would resume its natural shape when the forearm was flexed (Fig. 284). The treatment would be to flex the arm at a right angle, and retain it with angular splints from eight to ten days, then to allow a little motion to pre- vent anchylosis, and the splint reapplied. . Fracture of the Olecranon.—Fractures of the olecranon process are, in most instances, occasioned by falls or blows upon the posterior surface of the elbow-joint, or, though rarely, by the powerful contraction of the triceps. The direction of the fracture is generally transverse, although sometimes oblique. It is scarcely necessary to observe that the only direction of the superior fragment is upward, owing to the action of the three-headed muscle which is inserted into the process. * The symptoms are, first, a depression on the posterior surface of the joint; inability to straighten the arm and the absence of crepitus, although some- times this may be produced by extending the arm FIG. 284. and forcing downward the upper fragment upon º the lower. This is more readily effected when the patient is thoroughly under anaesthetic influence. The fragments sometimes unite with ligament, sometimes with Ossific matter. Considerable discrepancy of opinion exists as ſº/ to the position the arm should maintain during tººlſ the treatment of this fracture, some insisting upon º (.9% flexion or semiflexion, while others are emphati- [...] Sº Af. cally in favor of extreme extension. Velpeau as- | w serts positively that “it is not in the least neces- the olecranon is free and analogous to the patella in very many animals, without impairing the movements of the limb, and that the only possi- ble harm that can result is an inability to extend the arm completely; he considers nothing more necessary for its treatment than the application of a figure-of-eight bandage. Notwithstanding such distinguished authority, I think too little impor- tance is attached to the olecranon process. It is true that the actions of some animals, having a species of movable olecranon, are not impaired, but the movements are those of extension and flexion only. The motions of the human arm require the olecranon to be fixed. Treatment.—In treating this fracture complete extension should be made, and as a general rule it is better to relax the triceps, and then to bring the parts in apposition with the usual apparatus. The figure-of-eight bandage § ſ - sary to obtain a union of the fragments,” because | FRACTURE OF THE OLECRANON. 581 simply applied to draw the fragments in apposition has been employed with success. The apparatus of Sir Astley Cooper, with transverse bands and lateral tapes, is also successfully used. Several folds of the roller are placed securely above the elbow, and a similar number below it. Two lateral tapes are then passed beneath these and drawn tightly together; above this a straight carved splint or one of felt, leather, or pasteboard is applied. A plaster of Paris bandage may be substituted for the roller. Professor Hamilton's method is as follows: “The surgeon will prepare extemporaneously always, for no single pattern will fit two arms, a splint from a long and sound wooden shingle, or from any piece of light thin board. This must be long enough to reach from near the wrist-joint to within three or four inches of the shoulder, and of a width equal to the widest part of the limb. Its width must be uniform throughout, except that at a point, corresponding to a point three inches or thereabouts below the top of the olecranon process, there shall be a notch in each side, or a slight narrowing of the splint. One surface of the splint is now to be thickly padded with hair, or cotton batting, so as to fill all the inequalities of the arm, forearm, and elbow, and the whole covered neatly with a piece of cotton cloth, stitched together on the back of the splint. Thus prepared, it is to be laid upon the palmar surface of the limb, and a roller is to be applied, commencing at the hand and covering the splint by successive circular turns until the notch is reached, from which point the roller is to pass upward and backward behind the olecranon process, and down again FIG, 285. * “--- - º “º SSS S$S § to the same point on the opposite side of the splint. After making a second oblique turn above the olecranon, to render it more secure, the roller may begin gradually to descend, each turn being less oblique, and passing through the same notch, until the whole of the back of the elbow-joint is covered. This completes the adjustment of the fragments, and it only remains to carry the roller again upwards by circular turns, until the whole arm is covered as high as the top of the splint.” The following is a minute description of Prof. E. A. Clark's apparatus, given by himself, he having allowed me the use of the drawing (Fig. 285): The apparatus above represented consists of a band of ordinary sole leather, about two inches in width, and of sufficient length to surround the arm, lined with cloth or chamois, and well padded with cotton or hair. In order to give the band additional firmness, and also to secure it around the arm, a strip of common harness leather is stitched upon the outside, to one end of which two small buckles are attached, while the other end, which ex- tends about three inches beyond the band, is split or cut into two straps to correspond with and fasten into the buckles. The band is fastened around the arm above the fractured process, and may be drawn to any degree of 582 A SYSTEM OF SURGERY. tightness necessary to bring the broken fragment down when traction is made upon it. The same band may be used on either arm, and may be adapted to an arm of any size. On the outer side of this band, and one inch apart—one on each side of the olecranon—are two buckles or staples, which should be two inches in length and three-fourths of an inch in width, and clinched on the inside of the leather band, from which they project at a right angle. These buckles or staples also have three bars across them, with two tongues made to turn either way. - In applying this apparatus the arm should be fixed at an angle of forty- five degrees, and a common pasteboard splint bent at that angle placed upon its anterior surface. The leather band is then buckled over this Splint, just above the fragment of the olecranon, and the entire forearm is covered with a bandage to hold the anterior splint firm to the arm, and thus prevent any movement of the elbow-joint, which, if allowed, would be con- stantly modifying the force exerted upon the fracture. A common buck- skin glove is then placed upon the hand, to the anterior and posterior surfaces of which are attached two leather straps, which are to be buckled into the staples on the band. By buckling these straps over the bars at a greater or less distance from the band, and tightening them as required, we obtain the necessary amount of leverage to turn the lower edge FIG. 286. of the band in upon the arm, and push the fractured process Q down before it. - By making traction upon these straps any degree of force may be exerted upon the band necessary to draw the broken fragment down and hold it in perfect apposition with the head of the ulna. - It may be objected to this method of treatment, that the arm is held in a flexed position, thus increasing the space between the two fragments. But the advantage of this position is ap- parent in the relaxation of the biceps, and prominence of the olecranon. e Fracture of both Bones of the Forearm.—When both bones of the forearm are broken the fracture is generally about the middle or lower part of the lower third (Fig. 286), the upper parts being so covered by muscular structure that they are more protected from injury. The solution of continuity is generally single, although Dessault treated a patient in which he found six distinct fractures. This, however, must be regarded as a very rare occurrence. The causes are gener- ally direct violence, although a counter-stroke produces the fracture, though such force generally operates upon the radius alone. bº". § The following are the symptoms: Preternatural mobility of Oth bones of & ū tº & & º “ . the roºm.” parts which are normally inflexible; crepitus, which is easily produced; a depression at the site of the fracture, or some- times, when the displacement is greater, a sharp bony projection distin- guished under the skin; more or less pain when attempting to move the part, the patient stating, if questioned closely, that quite a noise was noticed at the time of the accident; forearm bent, and the power of supination and pronation is lost. When the fracture occurs near the wrist joint, the appear- ance of the part may simulate dislocation. In fracture, the crepitus and the position of the styloid processes either above or below the joint, will reveal the true diagnosis. If there be a dislocation, by moving the hand the sty- loid processes remain in their situation; if there be a fracture they will move with the hand. Displacement in the longitudinal direction is rare, FRACTURES OF THE PHALANGES. 583 on account of the arrangement of the muscles and the interosseous ligament; but the transverse displacement is generally perceptible, the four pieces then approaching each other and diminishing if not obliterating the interosseous space. There is likewise a tendency of the fragments to ride one upon the other, causing also an angular displacement. Treatment.—In the treatment of this fracture I formerly followed, and with success, the method of Boyer, as follows: The forearm is to be bent at a right angle with the arm and hand, which must be placed in a position between pronation and supination. An assistant then takes hold of the four fingers of the hand and makes the requisite extension, while the counter-extension is kept up by another assistant, who grasps the lower por- tion of the humerus with both of his hands. The bones are thus restored to their natural situation, and the soft parts can be pushed into place. Two graduated compresses, with their apices to the interosseous space, are then placed, one on the anterior and one on the posterior surface, the depth of the compresses corresponding with the thickness of the forearm. Next, the surgeon takes a single-headed roller six yards long, and makes three or four turns over the fractured part, and descends upon the hand and up again over the forearm; two well-padded splints are applied, ante- riorly and posteriorly, and these embraced with the turns of the bandage as it descends. In ordinary cases this method will be found successful. A simpler method, however, and one which has given me satisfaction, is that in which adhesive straps are employed. Having set the fracture, take two pieces of adhesive plaster, each about seven inches wide and six or eight inches long, and roll each upon itself as tightly as possible, with the adhesive side out. These are for the compresses. Lay one on the anterior, the other on the posterior surface of the arm, over the interosseous space. Having the splints prepared, place one on the anterior, the other on the posterior surface of the forearm, and hold them in position with straps of plaster, each strap enveloping the part twice. Three strips of this kind will generally be sufficient to hold the fragments firmly. Fractures of the Hand.—Fractures of the metacarpal bones are generally easily recognized, although the swelling may be so considerable immedi- ately after the accident, that the injury will not be ascertained for a day or more. In the majority of cases, the mobility, pain, and crepitus are readily discovered; indeed, the latter symptom can be detected by the patient, even when the swelling is considerable. There is, in many cases, a tendency of the fragments to override each other, the anterior generally overlapping the posterior; in which case the surgeon, by passing his finger over the bone on the dorsum of the hand, will readily detect the inequality of surface. Treatment.—The best treatment for fracture of these bones is to apply an anterior and posterior splint (each well padded) on the dorsum and palmar surface of the hand, allowing the support to extend almost to the elbow. These splints may be secured by broad strips of plaster, or by the ordinary roller bandage, or by bands of india-rubber. Fractures of the Phalanges.—Crepitus and mobility without severe pain are the symptoms most characteristic of this accident. In some cases the displacement is so slight that the break is not at once discovered. reatment.—Extension soon replaces any displacement, and a paste- board splint, or one made of a narrow and light piece of wood, extending to the wrist, and kept in place by strips of plaster, is all that is required. If more than one finger is broken, a carved splint, in which the whole hand may rest, will be appropriate. When the carpal bones are broken, the injury inflicted is generally so severe that amputation or resection must be resorted to. If, however, hopes can be entertained of saving the joint, a splint well padded should be placed on the palmar surface of the hand 584 A SYSTEM OF SURGERY. and secured by plaster placed above and below the seat of injury. By this arrangement the parts may be carefully examined without disturb. ing the dressing. FRACTURES OF THE LOWER EXTREMITIES. Fracture of the Femur.—The femur is generally broken at the upper portion of its middle third, although its lower third, the cervix, either within or without the capsule, the trochanters or the condyles may be the seat of injury. . According to the statistics given by Prof. Hamilton,” out of one hundred and fifty-six cases treated by him, sixty-seven were of the hºle third, sixty-three of the upper third, and twenty-six of the lower third. Fracture of the Neck-This variety of fracture may occur either within or without the capsule, and the symptoms and prognosis as well as the method of union have been the subject of much discussion among surgeons. FIG. 287. FIG. 288, ſ Fracture of the Neck of the Femur. - gº External Characteris- tics of Fracture of the Neck of the Femur. Fracture within the capsule generally occurs in persons of advanced life, and is usually the result of indirect and even slight violence. The position of this portion of the bone, the greater brittleness of the osseous system in advanced life, and certain constitutional diseases have a material influence in this fracture. Sometimes it may occur from apparently trivial causes, such as tripping of the foot or a slight fall. It has been asserted by some surgeons that if it be possible to ascertain the exact direction in which the force has been applied, we can readily diagnose the locality of the sepa- ration. A fall upon the knee or the foot it is contended will cause an oblique intracapsular fracture, while, if the force be applied in front of the trochanters * Fractures and Dislocations, p. 348, FRACTURE OF THE FEMUR. 585 the break will be, though still within the capsule, of the transverse variety (Fig. 287). In fractures within the capsule, crepitus is, in the majority of instances, absent. There may be a very slight degree of immediate shorten- ing, which may be temporarily removed by moderate extension. The pain is slight during complete rest, but insupportable when movement is at- tempted. Eversion of the foot almost invariably takes place (Fig. 288), though according to some authorities, inversion has been noticed in a few cases. After a time, as the swelling subsides and the muscular action commences, there may be a sudden shortening of the limb of one to two inches, which results from the sudden rupturing or wearing out of the cervical ligament. In those cases in which, from many contingent circumstances, there may be difficulty in the diagnosis, the thigh must be carefully measured in many directions, and if it be possible the patient raised upon his sound leg for careful and accurate examination. The question as to whether these fractures unite by ligamentous or bony union it is not necessary here to discuss, but from the careful inves- tigation of the subject there appears to be no doubt that both osseous and ligamentous union occur, the former most frequently when there is a slight degree of impaction. Fracture without the Capsule.—Fracture without the capsule is almost in- variably accompanied with fracture and displacement of both trochanters, which generally are split or divided obliquely downward and forward; if, however, the fracture should be of the impacted variety, then there will not be so great a displacement of the trochanteric eminences. In these fractures the Superior fragment is denominated the acetabular, the latter the trochan- teric. The causes are very similar to those producing the variety of frac- ture last considered. The symptoms are: a considerable amount of shortening immediately upon the receipt of the injury, which may reach even two inches and a half. There is pain, lack of prominence of the trochanter, and eversion of the foot. If there be considerable difficulty in bringing the foot and leg to its natural length, then impaction may be suspected. Crepitus can be detected by rotating the bone with the fingers on the trochanter. Prof. Hamilton's differential diagnosis between fractures within and with- out the capsule is here introduced: FRACTURE WITHIN THE CAPSULE. FRACTURE WITHOUT THE CAPSULE. 1. Produced by slight violence. 1. Produced by greater violence. 2. A fall upon the foot or knee, or a trip 2. A fall upon the trochanter major. upon the carpet, etc. 3. Generally over fifty years. 3. Often under fifty years. 4. More frequent in females. 4. Relative frequency in males and females not established. 5. Pain, tenderness, and swelling less and 5. Pain, swelling, and tenderness greater deep. - and more superficial. The following measurements are to be made from the anterior superior spinous process of the ilium to the lower extremity of the malleolus ex- ternus or internus: 6. Shortening at first less than in extra- 6. Shortening at first greater, almost al- capsular fractures, and often not any. ways some. 7. Shortening, after a few days or weeks, 7. Shortening, after a few days or weeks, greater than in extracapsular frac- less than in the intracapsular—that tures. . Sometimes this takes place is, the amount of shortening changes suddenly, as when the limb is moved but little, if at all; if the impaction or the patient steps upon it. continues, not at all; if it does not continue, it may shorten more. 586 - A SYSTEM OF SURGERY. FRACTURE WITHIN THE CAPSULE. 8. Measuring from the top of the trochan- ter to the inner condyle, or to the malleolus internus, the femur is not shortened. 9. More mobility of the limb at the joint. 10. Trochanter major moves upon a longer radius. 11. If the patient recovers the use of the limb, it is not restored under three or four months. 12. No enlargement or apparent expansion of the trochanter major, after recovery, from deposit of bony callus. 13. Progressive wasting of the limb for many months after recovery. FRACTURE WITHOUT THE CAPSULE. 8. Measuring from the top of the trochan- ter to the inner condyle, or to the malleous internus, the femur may be found a little shortened. 9. Less mobility. 10. Trochanter major moves upon a shorte radius. o 11. If the patient recovers the use of the limb, restored in six or eight weeks. 12. Enlargement or irregular expansion of the trochanter, which may be felt sometimes distinctly through the skin and muscles. . 13. The limb preserves its natural strength and size. 14. Excessive halting, accompanied with a peculiar motion of the pelvis, such as is exhibited in persons who walk with an artificial limb. 14. Slight halt. Motion of the hip natural. Treatment.—About the same as that for intracapsular fracture. Wide the end of this chapter. Impacted Fracture of the Neck of the Femur.—In this variety of fracture, in many instances, the lower end of the upper fragment is forced into the upper extremity of the lower fragment, and generally at the point of union between the cervix and the diaphysis of the bone. In other cases the upper end of the lower fragment is forced into the cancellated tissue of the lower end of the upper portion of the bone. In this variety of fracture the patient may be able to bear weight upon the injured side; there is no crepitus, but there is shortening and eversion of the knee and leg, though the latter is not so well marked as in the non-impacted variety of extra- capsular fracture. Occasionally instead of eversion, there may be inversion of the foot. Dr. J. W. Conklin+ records a case, in which the latter symptom was very well marked. The injured limb may also be rotated, abducted, or flexed, although with pain, but great force is necessary to bring the heels to a level, and in some cases such a position is impossible. There is also considerable alteration at the site of the trochanter major, which is drawn upward and out of a line parallel to that of the opposite side. It must be borne in mind by the student that there are often injuries, especially falls upon the hip, which simulate fracture of the neck of the femur, and which it may be at first almost impossible to correctly diag- nose. The fact that there may be little immediate shortening of the leg in the intracapsular fracture, and that impacted fractures present no crepi- tation, are the chief sources of uncertainty. An elderly person falls upon the hip, he finds himself unable to move, and is carried to his home, placed upon his bed, and the surgeon is summoned. There is almost total inability to move, the slightest attempt giving rise to severe pain; the foot is everted, the leg may be of the natural length, but more frequently is apparently shorter. No crepitus can be found, and by placing the patient upon the back, the heel of the injured limb may be brought down to a level with that of the sound one. The pain is not always experienced at the site of injury, but along the internal portion of the thigh, and the heel cannot be lifted from the bed. In these cases there is great difficulty in diagnosis, and frequent careful examinations and measurements are necessary before a positive opinion can be reached. In cases of sprain the * Medical News, November 25th, 1882. FRACTURE OF THE NECK OF THE FEMUR. 587 shortening is apparent, not real; in intracapsular fractures, the shortening will sooner or later appear. In sprain, the foot is not so completely everted, and there is more muscular power, which increases as the violence of the injury subsides. In such cases, time, watchfulness, careful measurements, the history of the accident, and all minutiae in connection with it must be taken into consideration before a certain diagnosis can be made out. From a knowledge of these facts I here insert thirty “ deduced conclusions" relative to fractures of the neck of the femur, taken from the excellent work of Dr. Robert William Smith, of Dublin. This gentleman has con- densed, in a manner remarkable for a judicious conciseness, all the infor- mation appertaining to this subject contained in one hundred and twelve pages of his work on Fractures, and the analysis is well worthy a careful consideration. 1. “A slight degree of shortening, removable by a moderate extension of the limb, indicates fracture within the capsule. - 2. “The amount of immediate shortening, when the fracture is within the capsule, varies from a quarter of an inch to an inch. 3. “The degree of shortening, when the fracture is within the capsule, varies chiefly according to the extent of laceration of the cervical ligament. 4. “It waries according as the fracture is impacted or otherwise. 5. “In some cases of intracapsular fractures, the injury is not imme- diately followed by shortening of the limb. 6. “This is generally to be ascribed to the integrity of the cervical ligament. 7. “In such cases shortening may occur suddenly at a period more or less remote from the receipt of the injury. - 8. “This sudden shortening of the #. is in general to be ascribed to the accidental laceration of the cervical ligament, previously entire, and is indicative of a fracture within the capsule. 9. “The deposition of callus around the fragments is not necessary for the union of the intracapsular fracture. 10. “When Osseous consolidation occurs in the intracapsular fracture, it is effected by a direct union of the broken surfaces, which are confronted to one another. 11. “The osseous union of the intracapsular fracture is most likely to occur when the fracture is of the variety termed “impacted.” º 12. “In the intracapsular fracture, the mode of impaction is different from that which obtains in the extracapsular. 13. “The degree of shortening when the fracture is external to the cap- sule, and does not remain impacted, varies from one inch to two inches and a half. 14. “When a great degree of shortening occurs immediately after the re- ceipt ; the injury, we usually find a comminuted fracture external to the C8, OSUllé. ſº “The extracapsular fracture is accompanied by fracture with displace- ment of one or both trochanters. 16. “The extracapsular impacted fracture is accompanied by fracture without displacement of one or both trochanters. 17. “In such cases the fracture of the trochanters unites more readily than that of the neck of the bone. 18. “The degree of shortening in the extracapsular impacted fracture va- ries from a quarter of an inch to an inch and a half. 19. “The exuberant growths of bone met with in these cases have been erroneously considered to be merely for the purpose of supporting the ace- tabulum and neck of the femur. 20. “The final cause of their formation is the union of the fracture through the posterior intertrochanteric space. 588 A SYSTEM OF SURGERY. 21. “The difficulty of producing crepitus and of restoring the limb to its normal length are the chief diagnostic signs of impacted fracture. 22. “The position of the foot is influenced principally by the obliquity of the fracture and the relative position of the fragments. 23. “Inversion of the foot may occur in any of the varieties of fracture of the neck of the femur. 24. “When the foot is inverted, we usually find that either a portion or #. whole of the extremity of the lower is placed in front of the superior agment. 25. “In cases of comminuted extracapsular fractures, with fracture and displacement of the trochanters, the foot will generally remain in whatever position it is accidentally placed; it may be turned either inwards or out- wards, or there may be inversion at one time and eversion at another. 26. “Severe contusion of the hip-joint, causing paralysis of the muscles which surround the articulation, is liable to be confounded with fracture of the neck of the femur. 27. “Severe contusion of the hip-joint may be followed at a remote period by shortening of the limb and eversion of the foot. 28. “The presence of chronic rheumatic arthritis may not only lead us to suppose that a fracture exists when the bone is entire, but also when there is no doubt as to the existence of fracture, may render the diagnosis difficult as to the seat of the injury with respect to the capsule. 29. “Severe contusions of the hip-joint, previously the seat of chronic rheumatic arthritis, and the impacted fracture of the neck of the femur, are the two cases most likely to be confounded with each other. 30. “Each particular symptom of fracture of the neck of the femur, sepa- rately considered, must be looked upon as equivocal ; the union of all, can alone lead to the formation of a correct opinion as to the nature and seat of the injury.” Prof. J. S. Wright,” both from measurements upon the living person and the cadaver, whose soft parts had been removed by dissection, has found that only one person out of every five has lower limbs of the same length, and that this difference in length varies from one-eighth of an inch to one inch. It is, therefore, useless to expect to obtain limbs of the same length after every case of fracture of the femur. Whatever treatment may be adopted, certain cases will inevitably show a shortening of one inch; and he affirms, that excessive efforts to bring down the injured limb to an equal- ity with the uninjured, are calculated to do harm, since the strong fascia of the thigh offers great resistance. . Dr. Hamilton appears to place but little reliance in these measurements, and says, f “This cannot be so, for in nine out of every ten cases of fracture of the femur, we do get actual shortening, and how would this happen so constantly, if the fracture had occurred in the longer limb?” Fracture of the Shaft of the Femur.—When the upper third of the bone is the seat of injury, the fracture is mostly oblique, and the symptoms so ap- arent as to lead to little doubt in the diagnosis. The limb is shortened #. two to three inches, and its superior portion exhibits a convexity of surface with a concavity on the internal side of the limb. This is caused by the overlapping of the lower extremity of the upper fragment over the lower. This displacement forward, as will readily be seen, will be caused by the action of the internal iliac and large psoas muscle, and by that of the pectineus and the short head of the biceps, while the external rotators twist the fragment outward, and the lower fragment is drawn upward by the flexors, and outward by the tensor vaginae, vastus, and glutei. * Archives of Clinical Surgery, February, 1877. f Archives of Clinical Surgery, November, 1877. FRACTURE OF THE SHAFT OF THE FEMUR. 589 Fractures at the Middle of the Shaft.—This accident is, according to most surgeons, of rare occurrence, although I have treated patients with fractures nearly at the centre of the bone. The direction of the fracture is oblique, and the upper fragment projects over the lower; there is eversion of the foot, shortening of the limb, and an unevenness of surface at the site of fracture, which is readily detected both by sight and manipulation. Crepitus is distinct and is more pronounced by extension. In fracture of the lower third, especially if the accident has happened some time before the surgeon is called, and the bone is broken near the joint, the tumefaction may be so great, especially around the knee, that difficulty may be experienced in making a diagnosis. In this fracture there is over- lapping of the ends of the bone, though when broken in the immediate vicinity of the condyles, the fragments do not “ride'' upon each other to such an extent as when the fracture is higher up. In some instances complications ensue from the fragments penetrating the joint, thus giv- ing rise to additional serious symptoms. The fractures in this portion of the femur are oblique, the upper fragment overlapping the lower. In other instances the lower extremity of the upper fragment has been known to push the patella upon the tibia, thereby producing the appearance of a dis- location. There is shortening, eversion of the foot, and angularity of the limb, which will suffice to diagnose the accident. Treatment.—Very many splints, bandages, and apparatuses have been devised for fractures of the femur. I do not propose a detail of these many contrivances, the greater number of which have been thrown aside and the remainder will soon be consigned to a like oblivion. The greatly simplified means now used relieve the patient of the inconvenience, pain, and discom- fort of the cumbersome and complicated contrivances of the past. In treating fractures of the femur most surgeons of the present day pre- fer the straight position of the extremity with extension, to the double inclined plane, which at one time was very much in vogue, and as most of the ap- paratus now employed is equally adapted to fractures of the shaft, as well as of the neck of the bone, I have thought fit first to detail the symptoms of each fracture, and afterwards, in due order, give a description of the means to be used. This plan will save unnecessary repetition. It is proper to remark in this place that some surgeons prefer both positions in treating fractures of the femur, being guided in the selection of the position by the locality of the fracture. If the separation be below the trochanter minor, the upper fragment is tilted forward and upward by the action of the psoas muscle; if the fracture occur at the lower third, then the heads of the gas- trocnemius draw the lower fragment downward and backward, and in either case, it is argued, that extension in a straight line will not produce the desired effect. This reasoning is plausible, but I am persuaded, from some experience in the management of these fractures, that properly ap- plied extension with weight and pulley, or by suspension, or both, will effect, in the majority of cases, results equal if not superior to any other methods. I am disposed to believe that each surgeon, having become thoroughly acquainted with the application and results obtained by his favorite method of treatment, is loath to change his apparatus, and continues experimenting and arranging his particular device, until it not only becomes better adapted for the purposes to which it is applied, but the surgeon himself be- comes more perfect in his method of using it. However this may be, I think with these two truly “American methods” all the cases of fracture of the thigh may be successfully treated. It is well known that in Buck's original apparatus, as seen in Fig. 289, there was a perimeal band to effect 590 A SYSTEM OF SURGERY. 23| à à à | s 1 º º º counter-extension. That “instrument of torture,”* as Dr Van Buren calls it, is done away with by the elevation of the foot of the bed, and the old and terrific and almost invariable accompaniment of a fracture of the thigh or leg, viz., “a sore heel,” is also avoided by the elevation of the foot in the anterior Splint, and by extension in the straight method. The following is the manner of preparation and application of the straight extension method, as laid down by its great advocate, Dr. F. H. Hamilton.f I quºte his own words: ‘Saw from a half-inch board a strip four inches in breadth, and of such length that when made fast to the foot of the bedstead, it shall rise four inches above the toes of the patient as he lies supine upon the bed. “Construct a long slot in the upper portion of this strip intended to re- ceive the pulley. FIG. 289, É/ Nº arº - . . . T Lºg : º: agº:#fº : - -º-º- :- -º É à É É :- º- :- ºr----_*- 2 = Lºr: : s Fº== == }_e= ====== "—-- ~~~ --~. = -->==== ...~-- ~~~... → • | - - - G.7/EMA/VN & →== Buck’s Extension Method. “Make holes with a gimlet from side to side through the strip, traversing the slot, the holes being about three-quarters of an inch apart. These holes are intended to receive a large wire, which will serve as an axis upon which the pulley will turn. In case a metallic pulley cannot be obtained, a spool will serve the purpose. - “This piece of board, thus constructed, is to be fastened upright to the foot of the bed. “In order to complete the apparatus for extension there will be required a small rope four feet long, a bag of sufficient size to hold twenty-two pounds of sand or of small shot, and a piece of thin board four inches long, and three and a half inches wide, to traverse the sole of the foot and prevent the adhesive plaster bands from pressing upon the malleoli. This traverse must be perforated in the centre to receive the cord, in the end of which a knot is to be made, which will prevent its being drawn through. Half a pound of cotton batting, cotton or woollen rollers, four feet of strong adhe- sive plaster, and two small blocks or bricks to place under the footposts of the bedstead will also be required. * Is there an American Method of treating Fractures of the Thigh 2—Medical Record, N. Y., March 30th, 1878. f Principles and Practice of Surgery, p. 296. TREATMENT OF FEACTURES OF THE FEMUR. 591 “The adhesive plaster extending band will be composed of one single piece, which, for adults, must generally be about four feet in length, and three and a half inches in breadth; but as it approaches the middle, it should widen to about six inches, so that when the traverse is placed upon the middle of the band, the margins of the band may be folded over the sides of the traverse. The rope, having been knotted at one end, is now passed through the hole in the traverse, and while an assistant steadies the foot, the extending band is applied to each side of the leg as high as the knee, the traverse touching the sole of the foot. If the straps are found to be longer than the leg, the ends may be left and folded down upon the roller after the first turns are applied. The application of the roller intended to hold the bands in place will be commenced at the ankle, but first the instep and the back of the leg above the heel must be well covered with cotton bat- ting, and if the patient is verythin it is well to cover the whole length of the spine of the tibia in the same manner. The roller may now be applied over the bands as high as the knee, and the superfluous ends of the bands being doubled down, it may be made to return a short distance towards the foot. “Passing the rope over the pulley, and attaching the weight, extension will be made. The pulley ought to be one or two inches higher than the middle of the sole of the foot, so as to lift the heel gently from the bed. The amount of weight to be employed, or which the patient can endure, will vary somewhat. - “I have found the maximum to be about twenty-two pounds, and gener- ally patients will not endure for any length of time, over twenty pounds. “To render it more certain that the patient will not be drawn towards the foot of the bed by the continuous extension, the foot-posts must be lifted about three or four inches by blocks or a couple of bricks.” To secure coaptation and support the fragments, four splints, made of sole leather and covered with woollen cloth, must be applied to the circumference of the limb. These splints should not quite touch at their margins. The inside and outside splints ought to be long enough to embrace the condyles, and the posterior splint should be wider than either of the others, and extend from the tuber ischii to a point below the knee. The whole is to be secured in place by four or six strips of bandage, and knotted over the front splint and stitched fast to the covers of the side splints to prevent displacement. To obviate the tendency to eversion which exists in nearly all fractures of the femur, a long side-splint, four inches wide, and extending from near the axilla to beyond the foot, must be laid outside of the limb, supported on the side next to the limb and body by a long sack filled with cotton batting. From the lower end of this splint a foot-piece should project six or eight inches outward, the more effectually to prevent eversion. The whole is to be secured to the leg, thigh, and body by separate bands of cotton cloth. Perhaps it is because I have had more experience with the anterior splint of the late Dr. Nathan R. Smith and the improved splint of Prof. Hodgen, of St. Louis, that I am partial to their use. In my hands more comfort has been given to the patient and better results obtained by them than by straight extension. Mr. Bryant, of Guy’s, prefers the suspension method, and it is used in the Greenwich Hospital in preference to others. In this city (New York) the modification of Buck’s method is the one which is preferred, being used in all the larger hospitals and public charities. The following is the manner of applying the anterior splint of Dr. N. R. Smith : - The fracture having been adjusted, the splint is so bent that the upper angle may come up on the abdomen to the anterior superior spinous pro- cess of the ilium; the lower end is also bent to a convenient angle, to lie 592 A SYSTEM OF SURGERY. over the dorsum of the foot. A roller bandage is then applied to the limb, an assistant keeping the fractured ends of the bone in apposition. A layer of cotton batting should then be placed over the crease in the groin, over the knee, and over the anterior face of the ankle-joint. The splint is then laid on the anterior portion of the leg, and fixed thereto by another bandage, FIG. 290. SS's §§§S . . * : E M A - N & U 0. Smith’s Anterior Splint. which must be long enough to extend from the toes to the groin, and thence several times around the body. Over this a thick coating of starch must be applied. The upper hook must be placed nearly over the seat of fracture, the lower one about the middle of the leg; the cords are then attached and fixed to a pulley, which may be screwed to a frame extending over the bed, or to the ceiling. See Fig. 290, FIG. 291. Hodgen's Splint. The differences between the splint just described and that of Dr. Hodgen are as follows: In the latter, the point of suspension is at an angle from the TREATMENT OF FRACTURES OF THE FEMUR. 593 seat of fracture, making thus additional counter-extension by the body. It is not an anterior but a lateral splint. Pieces of muslin are pinned or sewed from side to side of the bars, to make a “cradle” for the fractured bone thus leaving the anterior face of the limb, if necessary, exposed to view, and allowing (by the removal of any of the slips) a wound or ulcer to be ex- amined or dressed without disturbing the fracture. I have used this splint many times with most satisfactory results. Fig. 291 gives a correct idea of it when applied. The following is a description of a modification of Hodgen's splint by the late Dr. Clark. The measurements are accurate, so that a splint may be constructed from them. Dr. Clark reports six cases of fracture of the femur treated by this splint without shortening or deformity. I can also add my testimony as to its efficacy in many cases. The arch should be turned of iron bars (Fig. 292), one-eighth of an inch in thickness and half an inch in width. The top of the arch, H, should stand eighteen inches from the surface of the bed, while the width of the frame at the bottom, L, should be fifteen inches, and its length, K, twenty- FIG. 292. $s sº \{\ /š /* \; ſº t º º \\\ S. S. º Sº N § N ** , & º Nºel - šº WSNSºiſſº Rºssº 㺠Vºž 3 : J & º § Nºw WNWS \\ ſº º - gºs Clark's Splint. four inches. The two arches are braced upon each other by the two slender bars, FF, at either side, and the rail at the top upon which the pulley, P, glides. This rail, to prevent bending, should be made of steel, three-eighths of an inch in width and one-fourth of an inch in thickness, with its broad diameter placed in the vertical position, and fixed with a thumb-screw at one end, so that the rail may be withdrawn to apply the pulley. It will be observed that the arch at the proximal end is cut away at the inner side below where it joins the lateral bar, F, the object of which is to allow the patient to use the other limb more freely. The splint of Dr. Hodgen, upon which the limb is mounted, consists of iron rods, A A, one-fourth of an inch in thickness, placed parallel on both sides of the limb, extending its whole length and transversely across the bottom of the foot, much after the manner of Smith's anterior splint. The limb is then adjusted in the splint by placing it in position, and pinning strips of bandage, N N, four or five inches in width, over the bars on either side, constituting the floor of the splint, upon which the limb is allowed to 38 594 A SYSTEM OF SURGERY. rest in the suspended position; adding, however, as will be seen in the diagram, R, a sheet of pasteboard five inches in width, extending from the nates to the knee upon the posterior surface of the thigh, thus giving a more equable support to the limb at the point of fracture. These bars upon which the limb is supported, are prevented approaching too near to each other or to the limb, by an iron bow, E, holding them in position at their upper extremities. The attachment for extension is by means of the adhesive strips, M, extending to near the knee and passing around the foot-piece, I, to which is attached a small bracket, B, which hooks over the lower end of the main splint. Then the limb is suspended by the four hooks, D D, which are attached to thimbles that slide back and forth upon the bars, and are fixed at the desired point by means of thumb-screws in their outer sides. The limb now being suspended, the extension is made by means of the cord, C, attached to the hook in the pulley at S, passing forward between the cords playing over the pulley at O, to drop over the pulley, G, fixed in the slender post at the foot of the bed, and then attached to a sand-bag of sufficient weight to make the necessary amount of exten- sion. The weight ordinarily required for an adult will be from 10 to 15 pounds. . Now with the limb completely adjusted in the apparatus, the axis of the femur may be changed to any line, by sliding the thimbles nearest the foot, forward or back, which will elevate or depress the leg, and in doing so will produce just the opposite effect in the position of the thigh. Or again, the same can be accomplished by sliding the thimbles at the thigh back or forth. Or the axis of the femur may be still more conveniently adjusted by gliding the pulley, P, back or forth upon the suspension rail, which, as will be seen by a glance at the diagram, if the pulley be drawn towards the body, will have the effect of elevating the thigh and depressing the foot, and vice versa. Then by means of the lateral movement in the pulleys, S, O, the patient is enabled to rotate the limb sufficiently to allow him to lie upon his side if he desires, or if it become necessary. The only counter-extension required with this dressing is the weight of the body, which is quite sufficient in all cases; for even though the patient should gradually slip down in bed, the extension is constantly the same until his foot reaches the post at the foot of the bed, when, without any assistance, he can draw himself up in bed again, the whole apparatus connected with the limb coming back with the pulley, P, upon the suspension rail, when the body is drawn upwards. Dr. H. L. Hodge, of Philadelphia, invented a means of extension and counter-extension which has been introduced into the Pennsylvania Hos- pital, and which is said to pro- duce very satisfactory results. It consists (Fig. 293) of an or- dinary Dessault's splint, to the upper extremity of which is made fast an iron bar, so bent that it passes over the shoulder, and its hooked extremity comes --~~~~" - in a line with the axis of the ------T fractured limb. A broad strip - w of plaster is laid along the chest and abdomen, as seen in Fig. 294, a loop left over the shoulder; it is then carried down the back to the nates. A block is fixed in the loop, and to this a cord is attached, which is tied firmly to the iron hook. To make the counter-extension strap more secure transverse bands are placed around the chest. Among the useful additions to surgery is a splint for dressing com- FIG. 293. TREATMENT OF FFACTURES OF THE FEMUR. 595 . º fractures of the femur, invented by Dr. E. A. Munger, of Water- ville, N.Y. The advantages claimed for this splint are; 1st, cheapness; 2d, dura- bility; 3d, simplicity; 4th, facility for dressing the wound; 5th, ease of FIG. 294. { - --- i iſ t 2: Sº making extension; 6th, ease and certainty of regulating the amount of ex- tension. These are illustrated by a description of the splint itself. Take an ordinary straight splint, such as is described in Liston’s Sur- gery, and fit it to the injured limb as if for application. Then divide FIG, 295. Munger's Splint. it at the point of fracture, and remove an inch or an inch and a half from each section of the splint at the point sawn asunder. To the outer edges of the upper or body portion of the splint, A (Fig. 295), screw two iron rods, F, F, three-eighths of an inch in diameter, and a foot or more FIG. 296. Munger's Splint Applied. in length. These rods slide into grooves, G. G, in the lower section, B, which are covered with tin to prevent displacement of the bandages. At the up- per end of the lower segment is attached an iron brace, G, through the head of which runs a screw, E, ten or twelve inches in length. The end of this screw strikes against a corresponding brace, D, attached to the upper seg- ment; by turning this screw the two portions of the splint are forced apart. 596 A SYSTEM OF SURGERY. By this means extension is made and kept up to any desired degree. The iron parts of this splint, as described, can be made in a short time and at trifling cost by any blacksmith, and if well made will last a lifetime. These irons can be easily removed from one splint and applied to another, either long or short, as the case may require. Application.—Each section, when made according to the foregoing plan, should be well padded, and the whole is then applied to the limb in the same manner as an ordinary Liston's splint, with rollers and perineal band, excepting only that the space between the sections is not to be covered by the roller, but with a light dressing separate from the rest. By this means a wound may be examined and cleansed as often as necessary without dis- turbing any other portion of the apparatus. It is obvious that with this Splint, properly applied, extension may be made with great ease. Placing his thumb and finger upon the head of the screw, the surgeon, with a few turns, easily forces the limb to its natural length. This is done without his being troubled or annoyed, or the limb endangered by the rude efforts of bungling, inefficient, or inexperienced assistants. The straight splint of Mr. Liston (Fig. 297), which was used and recom- FIG. 297. º intº 24 - - -, alſº - - fºliº. N º * * , d |||ſ ſº º N d | * ~ :--> * : -; —iºſ | gº....W. Wilſº - Liston's Splint. mended by Cooper and Fergusson, and has been variously modified by many of the patent splint makers, consists of a narrow board about a hand’s-breadth in width, and extends from a short distance below the axilla to several inches below the foot; at its upper extremity are holes, through which º are passed to fix it securely to the body, together with a peri- neal band, and at the lower extremity it is notched to receive the extending bandages. This splint was modified by Day, who appended a foot-board, which could be graded to the proper length for each subject, and was divided in its middle, to render it more portable. - Dr. Physick, of Philadelphia, altered the long splint of Dessault and had it extended from the axilla to the foot, using also an inside splint, keeping up the extension at the perinaeum. After the splints have been made comfortable for the patient—no matter what kind are used—they should be allowed to remain four or five weeks without being touched, being constantly watched and the bandages kept Snugly applied. At the end of the fifth week, the apparatus should be carefully removed, the leg washed and rubbed with alcohol, or arnica, and water, double the quantity of water being used to that of either of the other ingredients; the Splints should then be carefully reapplied, and should not be taken off until three weeks have elapsed. Upon the removal of support the patient will have some pain, often swelling, and sometimes discoloration. During the next few weeks there should be applied a couple of paste-board splints, one anterior, and the other posterior, which should be retained in situ by either a bandage or straps made of webbing. The patient must then use crutches for several weeks, for which a cane must be substituted before he can trust himself without any support. In treating fractures of the femur a variety of apparatuses from time to time have been introduced to the profession. Very few of them can be TREATMENT OF FRACTURES OF THE FEMUR. 597 mentioned here. Fig. 298 represents an ingenious and comfortable suspen- sion devised by Dr. George F. Shrady. The iron rods, bent to sustain the limb, as seen in the figure, are fitted with clamps, which allow removal, render the suspensory apparatus easily applied to the sides of the bed, and º the additional advantage of elevating the injured limb to any required eight. FIG. 298, N § saf (º +/-, * ſºcºs #.º M N C-R fºº; Hºº-Fºs. Jºº-ºº::==#EEE WiN/ = tº =sars =ºf *\º º ºn " sº * { º iº §. º išº ºr ". hº º'ſ N →::: --->{ſſ º Wººl Fº Fºliº: d.TiEMANNºë. ::::::::" l º [. º fºr ºlºmum ºf Tulſit Uiº ſºlſ|| . wº º (s i`'`` it...ºn. sº Tººl. º º | iº Shrady's Apparatus. One of the best contrivances for treating not only fractures of the femur, but hip-joint disease in its early stages, is the fracture-bed of my friend Dr. E. J. Morgan, of Ithaca, New York. The following cut and description will show its admirable workings (Fig. 299): - A, represents the rectangular frame which supports the tilting-frame, B, by means of the rack-shaft, C, passing through it; D, represents the spring FIG. 299. ºğs; + x- s's $ff zºsº º ºn tº ſ - - - N ſº º º º º - - º - Illſlīllūīllūlīllūll #. º º 5 °. illlllllllllllllllllllllllllllſ cº E-F# Sº tº Mºil ºf autºutnut º | ºulºuſ" | | sºlºs-E. º == * || i - - ºit -- ºr--> - , - F -- º | | | | |: E º - - ==== Hº-IBFFER E. E. z º.º. - . . . . i. Fº-ºº:::= } a — Fºº Fi := . . . = F ====Elº- · · · · ·- . 1.-- --Tº: EFlº: wº- E —sº lever attached to the rack-shaft for elevating the thigh and leg planes, E. F.; G, represents the back-plane, and H, the body-plane; I represents the sound arm, that holds the lifting-frame at any angle; J, the circle-ratchet, that holds the back plane at any angle; K K, the pulleys and weights attached for effecting extension; L, the parallel rods which support the leg- 598 A SYSTEM OF SURGERY. planes; M, the thigh-bars attached to the rack-shaft pendants; N, the circular opening leading to the earth-closet: O, the earth-closet. This bed may be constructed of iron instead of wood, and fixed upon wheels, which will enable it to be moved from place to place without jar or noise, and without endangering misplacement of the broken ends of the bone. Fracture of the Patella.-A fracture of the patella is generally occasioned by the sudden action of the quadriceps, or direct violence; the separation may be either longitudinal or transverse. In either case the diagnosis is not difficult. In the former, a depression can be felt running along the bone, the chasm being diminished by lateral pressure ; in the latter, the separation of the fragments is transverse, and through the rent in the bone the synovial sac protrudes, which may in itself prevent the replacement of the fragments. This fracture is often the result of direct violence; and the sudden loss of power, sensation as though something had given way FIG. 300. ºl. t iii. W . Wilſº ºf...;3 ºr ; Levis’s modification of Malgaigne's Patella Hooks. at the time of the injury, and the effusion and pain, are sufficient to diag- nose the accident. In the last case of fracture of this bone that came under my care the separation was directly transverse, and was caused by a fall upon the knee, as the patient was stepping from a carriage. - In some cases both patellae are broken at once, and the bone is often fractured in several places. The union is, in the majority of cases, liga- mentous, although occasionally it may be bony. In some half or three- quarters of an inch of separation remains. In the starred or vertical fracture, osseous union generally results. Treatment.—In the treatment of fractured patella the chief desideratum is to prevent flexion of the knee-joint, and to keep the fragments as nearly as possible in apposition. This is well effected by a posterior splint, which should be of sufficient length to extend from the tuber ischii to the heel; this being well padded, should be applied, and a figure-of-eight bandage put on, so to envelop the patella that the fragments are drawn into appo- sition. The hooks of Malgaigne are not much used at present, although I am informed by Dr. Levis, that they still are employed in the Pennsylvania Hospital, and that he has made a useful modification of them. (Fig. 300.) TREATMENT OF FRACTURE OF THE PATELLA. 599 I have never used them. Sir Astley Cooper's method of applying a band around the thigh and drawing it down with lateral bands which pass under the foot, is not much in vogue, and is liable to many objections. Dr. W. A. Gibson* describes a ring made of iron, about three-eighths of an inch in thickness, and sufficiently large, after being padded, to embrace the patella closely. All the fragments are gathered within the ring, which is then retained in position by attaching a strap or band on either side, and fastening them around a wooden splint, laid upon the posterior surface of the leg and thigh, the splint being retained in position by a roller bandage, thus preventing any motion of the knee-joint. - The apparatus of Professor Hamilton is as follows, and is the one which in my hands has been productive of most good (vide Fig. 301). “The dressing consists of a single inclined plane, of sufficient length to support the thigh and leg, and about six inches wider than the limb at the knee. This plane rises from a horizontal floor (b) of the same length and breadth, and is supported at its distal end by an upright piece of board (c), which servés both to lift the plane and to support and steady the foot. The distal end of the inclined plane may be elevated from six to eighteen inches, according to the length of the limb and other circumstances. Upon either FIG. 301. side, about four inches below the knee, is cut a deep notch (d). The foot- piece stands at right angles with the inclined plane, and not at right angles with the horizontal floor; it may be perforated with holes for the passage of tapes or bandages to secure the foot. - “Having covered the apparatus with a thick and soft cushion (e) carefully adapted to all the irregularities of the thigh and leg, especial care being taken to fill completely the space under the knee, the whole limb is now laid upon it, and the foot secured gently to the foot-board, between which and the foot another cushion is placed, . “The body of the patient should also be flexed upon the thigh, so as the more effectually to relax the quadriceps femoris muscle. “A compress made of folded cotton cloth, wide enough to cover the whole breadth of the knee, and long enough to extend from a point four inches above the patella to the tuberosity of the tibia, and one-quarter of an inch thick, is now placed on the front of, and above the knee (h h). While an assistant presses down the upper fragment of the patella the surgeon pro- ceeds to secure it in place with bands of adhesive plaster (g). Each band * St. Louis Medical and Surgical Journal. 600 - A SYSTEM OF SURGERY. should be two or two and a half inches wide, and sufficiently long to inclose the limb and splint obliquely. The centre of the first band is laid upon the compress partly above and partly upon the upper fragment, and its extremities are brought down so as to pass through the two notches on the side of the splint, and close upon each other underneath. The second band imbricating the first, descends a little lower upon the patella, and is secured below in the same manner. The third, and soon successively until the whole extent of the compress and knee are covered, is carried more nearly at right angles around the leg and splint; the last bands passing obliquely from below the ligamentum patellae upwards and backwards. The dressing is now completed by passing a cotton roller (f) around the whole length of the limb and splint, commencing at the toes, and ending at the groin. This is applied lightly, as its object is only to support and steady the limb.” Fig. 302 represents Turner's apparatus. The thigh and leg pieces are of sheet-iron, which are fastened around the leg and thigh with §j and FIG. 302. Turner's Apparatus for Fractured Patella. straps, and united to each other by three bars, two lateral and one posterior; to the latter are joined two troughs with a double reversed screw. . By turn- ing the screw the troughs can be made to approach or separate from each other. Adhesive straps are applied around these troughs, as seen in the figure, and by turning the screw the fragments are drawn together. Dr. James L. Little, the originator of the plaster-of-Paris dressing for frac- tures, devised an application which he claims secures bony union in the patella. His method of dressing the fracture I give in his own words.” “Sometimes, when the effusion into the synovial cavity is great, I º pressure as soon as the patient is able to bear it, by means of a bandage. When the swelling has subsided, which takes from five days to a week, the following dressing is applied: a posterior splint is made of two thicknesses of bleached canton flannel, strengthened in the middle, under the knee, by two extra layers. This is made long enough to reach from a little above the ankle to above the middle of the thigh, and wide enough to cover two- * Medical News, March 29th, 1884. TREATMENT OF FEACTURE OF THE PATELLA. 601 thirds of the circumference of the limb above and below the joint, but at the joint it should only just cover the condyles of the femur. Two pieces of canton flannel, of from two and a half to three inches in width, double thickness, one long enough nearly to encircle the limb at the ankle, the other to encircle it at the upper third of the thigh, are prepared at the same time. The pieces designed for the posterior splint are then thoroughly Saturated in a mixture of plaster-of-Paris and water, taking care that the mixture is not too thick, and then smoothed out upon a board with the hand, and applied smoothly to the limb. Then the two bands are prepared in the same way and applied around the upper and lower extremities to hold it in position. A dry roller bandage is then firmly applied over all, and the plaster allowed to set. “As soon as this is accomplished the bandage is removed, and we have a firm posterior splint secured above and below by transverse bands. Two other strips of a double thickness of canton flannel an inch wide, and long enough to overlap on the posterior surface of the splint, are saturated in a fresh mixture of plaster-of-Paris, and then tightly applied above and below the FIG. 303. § s tº º A N \\ V W º & \\ º Ş. {\\\\ \ \\\\\\ §§ NYN patella, while the fragments are held in position by an assistant, in the same manner as adhesive straps are used for coaptation in this fracture. A dry roller bandage is then rapidly applied, with the figure-of-eight turns, over the strips. The surgeon then, with thumb and finger of each hand over these coaptation bands, forces the fragments into close approximation, and holds them there until the plaster has set (Fig. 1); the bandage is then removed and a fresh one applied over the whole length of the limb. The dressing is then complete. Fig. 2 shows the splint with the bandage re- moved. It is a good plan for the surgeon, before applying the coaptation bands, to see that the fragments can be easily approximated. In a number of cases I have found some difficulty in keeping the fragments in the same plane, or in preventing them from tilting, there being a tendency for one to rise above the other. This can be overcome by making pressure with the fingers over the line of fracture while waiting for the bands to harden. “This dressing differs essentially from all others, in that the fragments are adjusted by the hands of the surgeon, and the “setting' of the plaster keeps them in the exact position in which they were held.” Dr. Ed. Hornibrook* procures osseous union of the fragments in trans- verse fracture of the patella by the use of the posterior splint, immovable fixture of the lower fragment by means of adhesive straps, and coaptation * Monthly Abstract of Medical Science, January, 1877. 602 A SYSTEM OF SURGERY. of the upper to the lower fragment by traction, made by weight, pulley, and cord, after the manner of Buck's extension in fractures of the thigh. Adhesive straps, placed-lengthwise over the upper fragment, and extending up the thigh three inches, form the means of attachment to the cord. Wiring the Patella.-Of late there has been much written concerning wiring the patella, which performed with strict antiseptic precautions has been followed by fair success. The operation consists of exposing the fracture by a transverse incision, piercing the fragments with an awl, and through the holes thus made passing silver wire, turning down the ends of the wire and closing the wound. The success following some of these operations was brilliant, but occasionally very bad results and even ampu- tation and death followed the process, and therefore it must be looked upon for the present with some degree of ‘mistrust. Dr. L. A. Stimson, of New York, lately procured excellent union in a case of fractured patella, by using strong antiseptic catgut in place of the silver wire, and his example is worthy of imitation, although the surgeon must bear in mind that when these operations are made, he converts a simple into a compound fracture and exposes the cavity of a joint, which are both serious complica- tions. He must also remember that excellent recoveries have taken place even without bony union. Fracture of the Tibia.-The tibia may be fractured throughout any por- tion of its extent, although the separation is most likely to occur at the upper extremity of the lower third, or the lower extremity of the middle third, and as a general thing, the fracture is of the oblique variety, and is perhaps more generally occasioned by direct violence. The prominence of the spine of this bone and its exposed position render it very obnoxious to direct force. The external malleolus is sometimes broken by a fall upon the foot or by a twist of the ankle; the latter happens often while running, and I have in mind a case in which, after fracture of the malleolus, there was a compound dislocation of the ankle, which lasted for many months, and only recovered with a severe stiffness of the articulation, - - The fracture is not, in the majority of instances, difficult to diagnose. The line of the spine of the tibia is broken, and in most instances there can be distinctly felt and seen a sharp projection beneath the skin, which indeed often pierces it, and thus complicates the case. If the fibula re- main intact, we do not look for very much displacement, for the latter bone acts as a splint in keeping the varied muscles in position, and for the same reason we rarely have shortening of the limb, which can only occur when the fracture is high up, above the fibula, or in other complications which are rarely met with. The Treatment of fracture of the tibia is very simple. Neither extension nor counter-extension is necessary in the majority of cases; if, in the judg- ment of the surgeon, it may be serviceable to use slight extension, a pulley at the foot of the bed, over which a weight FIG. 304. of five or six pounds is hung, the other extremity of the cord being attached to a - traverse at the sole of the foot by means of \ adhesive strips, will answer the purpose; \ W- * --~ 1.-- tº--> . \ . the limb may be placed over an inclined 3,I\62. p Usually, the felt splints of Ahl, or the wire of Dr. Lewis Bauer, or the metallic r plates of Levis, answer the purpose. Dr. Gross used a tin case with a foot-piece, which was accurately adjusted to the leg, and extended up to the knee. FRACTURES OF THE FIBULA. 603 Sometimes a good old-fashioned fracture-box, well supplied with cushions (Fig. 304) or pillows, with deal-board splints, effects excellent cures. As a rule, to all these fractures, the plaster-of-Paris splint, described on page 46, is applicable, and is my favorite method. A simple dressing, and a good one, too, consists of first laying upon a firm mattress four tapes about a yard in length, over these a splint-cloth, which is nothing more than a piece of muslin reaching from the sole of the foot to a little above the knee, and about a yard and a half in width. Having adjusted the bones, place alongside the leg junk-bags, half filled with bran, and neatly adapted to the inequalities of the surface; lay side-splints flatwise on the splint-cloth, and roll them up firmly, and secure the whole with tapes. Fractures of the Fibula.-The position of this bone and its peculiarly slender formation, render it liable to fracture. Slipping, twisting, or turning the foot, stepping from a carriage, or falls, directly or indirectly, give rise to fracture of the fibula. - The most frequent site of the accident is at the lower fourth of the bone, and the fracture is generally accompanied with dislocation of the ankle, in which the foot is everted, which has been called Pott's fracture. Dr. Jernegan * reports a case of this fracture where there was inversion of the foot. I have lately seen a case, in which I could recognize no displacement. For a time I could not believe the bone was broken, until, by rotation in a certain direction, I obtained distinct crepitus. Sometimes the bone is split upward from the lower extremity, and from a careful study of the anatomy of the joint we can readily see what deformity may exist at the point where such fracture occurs. Great pain is often present, from the rupture of either the deltoid or the external lateral ligament. We generally find that the displacement of the lower fragment is inward toward the tibia. In those cases of fracture of this bone where there is inversion, the internal malleolus is generally broken, while in that already mentioned (Pott's fracture) the internal lateral ligament may remain entire. In some cases of compound fractures, implicating the ankle-joint, amputation or resection may have to be performed. A great deal of stiffness remains for a long time after this fracture, no matter how diligently the treatment has been attended to ; and in some cases, even after the lapse of years, in damp and rainy weather, pain and inconvenience are experienced. In a case in which I was summoned to testify as a medical expert, the plaintiff sued for permanent disability ten years after the accident. The treatment had been of the best, and yet a certain degree of pain and stiffness remained. Professor Hamilton men- tions an extraordinary case in which the joint remained almost immovable after twenty years. Treatment.—In fractures of the fibula above the middle, with but little eversion or inversion of the foot, the plaster-of-Paris splint (the method of its application being given in the general treatment of fracture) is an excellent apparatus, or a simple fracture-box is as good an appliance as can be made. When Pott's fracture is to be treated, the old-fashioned Dupuytren's splint is excellent, although Mr. Thomas Bryant, in his late edition, f recommends as preferable a posterior and two lateral splints. Dupuytren’s splint must extend from the condyle of the femur to two or three inches beyond the foot. Upon this a long triangular pad must be laid, the thickest portion of the triangle corresponding to a point about an inch above the internal malleolus. The bone is then set, and the splint, with the pad resting upon it, applied along the inside of the leg, which is * New England Medical Gazette, Dec., 1877, p. 541. # The Praetice of Surgery, by Thomas Bryant, F.R.C.S., London, 1884. 604 A SYSTEM OF SURGERY. secured as seen in Fig. 305, the bandages not covering the site of the frac- #: Ahl's felt splints, moulded for the purpose, are very useful in this acture. FIG. 305. *...* <& | tº- || ||| ºf Hºiſillilºſºkºs "" t '''". '''' || || lſ *!!!'s "...", * , , * * *. . . . . ." § ºffſ ºl' ſº tiſſillºw. ‘'ſ "": ºff"|| || || || lithilfºwº, sº Dupuytren's Splint. Fracture of Both Bones of the Leg.—Fractures of the tibia and fibula are of frequent occurrence, and are often both compound and comminuted. Accidents of all kinds, kicks, blows, falls, or wounds, in FIG. 306. which direct violence is applied to the leg, may result in fractures of the leg (Fig. 306). -- The bones may be broken at the same point, or one higher up than the other, and the direction may be either trans- verse or oblique, but probably that most frequently met with is the former, having its site three or four inches above the ankle. The symptoms are generally unmistakable. The super- ficial position of the spine of the tibia, the loss of power, pre- ternatural mobility, and crepitus, generally proclaim the character of the accident. In some cases, when the break has occurred in the vicinity of the ankle-joint, a doubt may arise as to the presence of a luxation, but in these cases the rela- tive normal position of the malleoli with the foot, and the facility of restoring the displacement, should give sufficient evidence of the true nature of the accident. In some cases, where the fracture has occurred in the vicinity of either the knee or the ankle-joints, anchylosis may exist for a long period of time. Treatment.—A great variety of apparatus has been intro- duced for the treatment of fractures of the leg. In some cases I have used a well applied plaster-of-Paris splint, with success. I have also used Ahl’s splints with advan- tage; and in former times the anterior splint of Professor Smith; it is so simple and so comfortable that I would ad- vise a trial of its merits. The swing of Dr. Clark I have also seen applied with good results. . A description of this I published,” by permission of Dr. E. A. Clark, and saw the splint in use in the City Hospital of St. Louis, and have employed it with excellent results. By referring to Figures 307, 308, the following description of the splint by Dr. Clark will be readily understood. The two arches, represented by the letter H at one end, are made of iron bars one-eighth of an inch in thickness, and three-fourths of an inch in width, and are continuous with the bottom pieces, K, which rest upon the bed, and measure twenty-two inches in length. The arches are also sup- ported on the sides by the two slender bars or rods, FF, while the bar supporting them at the top, upon which the pulley, P, glides, should be made flat, with the long diameter vertical, and of sufficient strength to pre- vent it bending with the weight of the leg. The width of the arches, as * Western Homoeopathic Observer. TREATMENT OF FRACTURES OF THE LEG. 605 indicated by the letter L, should be fifteen inches, and their height eighteen inches from the surface of the bed (Fig. 307). The bars, A, of the frame or portion of the apparatus in which the leg is suspended, should be about two feet in length, unless when the fracture is so close to the knee that it may be necessary to attach the adhesive straps, M, above the knee, when the bars may extend to near the perinaeum if necessary, and the cross-bar passing beneath the foot-piece, I, and upon which the foot-piece rests by means of a suitable hook or bracket, B, should be flattened, the more readily and securely to engage in the hook or bracket, and be five inches in length, so as to allow ample space for the limb to rest FIG. 307. 7. sº § tº ºut | º tº Tº +7=-z between the bars; the space between these bars at the upper end should ordinarily be about six inches. The leg is supported entirely by strips of muslin pinned over the bars on either side, rendering the apparatus more appropriate for the treatment of compound fractures, as the wound may be examined and dressed when necessary, by removing one or more of these strips, which may be replaced by new ones without disturbing the fracture. By means of the pulley at the letter P, the patient is enabled to move his limb, or even his body, forward and back, to the extent of the length of the bar upon which it glides; and by means of the cord playing over the under wheel in the same pulley, the patient is able (when the fracture is not so near the knee as to necessitate the apparatus extending above the knee), by a very slight effort, to flex or extend the knee by depressing or elevating the foot, while at the same time he can swing the leg from side to side to any extent, within the space of the arches; and by means of the cords playing through the pulleys at O O, the leg can be rotated to any extent, even to allow the patient to lie upon his side if he desires, without disturbing the fracture in the least. It will be observed in the diagrams that at the letter G there is a thimble, which can be made to slide up on the bar, by means of which—sliding this thimble forward or back and fixing it at any point, by the thumb-screw attached to the thimble—the lower end of the leg can be elevated or depressed at the will of the patient. The apparatus just described is especially designed for the treatment of compound fractures; for simple fractures a posterior splint is used (vide C, Fig. 308), constructed either of tin or felt, well adapted to the limb. Dr. Clark afterwards constructed this splint with an aperture at the extremity for the heel to project. - 606 . A SYSTEM OF SURGERY. A favorite method of treating fractures of the leg is in Pott's position. This dressing is composed of an outside splint of angular shape, as seen in Fig. 809, which should be seven inches in width, constructed of deal. board, and with a projection to accommodate the foot; this splint, well padded and with a hole with bevelled edges to accommodate the external FIG. 308. * * ſity tº ry: - w \\ \ \ſ \\\\\ 1 \\\\ . º t º \ ;" \ \\ Mºs § \\\\\\\\\\\\\\\\\\\\ t. S. - … : S. ºW º ... t malleolus, and otherwise well cushioned, should be placed on the outside of the limb, which must be flexed on the abdomen and the leg kept at a right FIG. 309. Pott's Splint. angle with the thigh ; on the inside of the leg a padded straight splint of" felt, leather, or pasteboard, extending from the ankle to the knee, is placed, FIG. 310. G.T | E N ANN & CO, NY. INTETILITENSlmmiſſilſ º - - - - 5 º' gºl §§§ E.N. jº | ºr ºf - S. rºm NE| º | * * 3. zº-EE-sº- Neill's Apparatus. and the two secured by a roller-bandage. The limb is now allowed to rest On its outer side. TREATMENT OF COMPOUND FRACTURES. 607 Fig. 310 represents Neill's apparatus for compound fractures of the leg. The illustration explains itself. In very many cases of compound fracture, extension, made with the pulley and weight, and a fracture-box constructed with hinges, that the parts may be examined and dressings applied, answer very well all the indications required. ractures of the Foot.—These accidents are not very frequent, and are generally accompanied with destruction or laceration of the soft structures, which may result in gangrene and require amputation. The toes may be injured by heavy weights, as happens to coal-heavers, quarry-men, stone- masons, and others similarly exposed; and as amputation is the advisable recourse in most of ‘such cases, the question of greatest importance for con- sideration will be with reference to the site of the operation. Unless, how- ever, the tarsus be involved in the injury, the idea of amputating the foot Ought not to be entertained: and, as a general rule, applicable here as in most other parts of the body, the smallest possible degree of mutilation ought to be inflicted consistent with the object of the operation, which is to remove such parts as are irrevocably injured, and at the same time leave a properly formed stump. In instances of fracture of the foot where there is no necessity of resorting to the knife, it is scarcely requisite to use any ap- paratus to keep the fragments in apposition; in the toes, the phalanges are so short, that, if properly adjusted at first, they will remain so, unless the patient injudiciously bears his weight upon the foot at too early a period; even in the longer metatarsal bones it is not found necessary to employ splints. The application of arnica, etc., at first, and complete rest ºp the foot for about twenty days afterwards, constitute the most important parts of the treatment. Treatment of Compound Fractures.—The management of compound frac- tures is oftentimes troublesome, and requires a great deal of care and atten- tion. In some instances the end of a bone protrudes through the wound in the soft parts and cannot be restored to its natural position; in such cases, the saw must be applied and a sufficient portion of the bone removed to allow of its reduction. In other instances, when there is a comminution of bone, the spiculae must all be carefully removed, which may require inci- sions in different directions through the soft parts. After either of these operations, the entire wound should be thoroughly washed with a solution of carbolic acid, and the parts brought as nearly in apposition as the charac- ter of the wound will allow, the object of the surgeon being to obtain union of the soft structures as soon as possible, and thus convert the compound into a simple fracture. In dressing such fractures the bandage of Scultetus should always be em- ployed next to the skin, in order that the wound may be opened and ex- amined. If the injury be to the thigh, the cradle-splint of Hodgen, or the extension apparatus of Buck, will be of service. If it be the leg, and one bone is broken, the simple fracture-box, filled with bran which has been sprinkled with carbolic acid, should be used. If both bones are broken, and extension and counter-extension are necessary, Neill's apparatus may be employed. An excellent splint is that invented by Dr. A. Hays, which can be made by taking a long side-splint, cutting out a sufficient portion opposite the site of fracture, that free access can be had for dressing and an exit for the discharge, and uniting the two portions of the splint, which are separated, by a convex iron-hoop, which must be securely fastened by screws. The hoop of iron also acts as a protection from the pressure or rubbing of the bedclothes on the affected part. - Dr. Hays remarks: “This plan I found to meet my wishes and expecta- tions very fully. The extension and counter-extension being continued, 608 A SYSTEM OF SURGERY. the dressing might be repeated as often as requisite, without in the least disturbing the position of the limb.” If inflammation and swelling supervene, the bandages must be loosened, and a lotion of arnica or calendula applied to the part; if the pain be very Severe and synochal fever be present, aconite may be prescribed, or if cere- bral symptoms develop themselves, arnica, bella., cuprum, or hyos., may be indicated; if strangury be present, acon., nux, cann., canth., or some other appropriate medicine must be resorted to. Other indications for the treatment have been already alluded to in the chapters upon Wounds and Abscesses. º The great object of the subsequent treatment is to prevent the lodgment of matter, by sponging and pressing it out carefully at each dressing, and applying compresses to prevent its accumulation, and, if necessary, to make openings for its exit. " In this state of excessive discharge, dry bran, as an absorbent, is one of the best beds the limb can be laid upon. If the patient seems likely to sink under the discharge and irritation, notwith- standing the local application of calendula, and the administration of acon., bella., China, hepar, merc., and other medicines that have been mentioned for such conditions, amputation is the last resource. For further information on this subject the student may refer to the Question of Amputation, at page 353. - CHAPTER XXXII. INJURIES AND DISEASES OF THE JOINTS. WounDS—SYNOVITIS-ARTHROPYosis—ULCERATION of THE ARTICULAR CARTILAGEs— GENUTHROTOMY-ANCHYLOSIs: FALSE AND SPURIOUs—SUBCUTANEOUs OSTEOTOMY —CHRONIC RHEUMATIC ARTHRITIS-HIP-joinT DISEASE—Loose CARTILAGES IN JOINTS—TALIPEs: VARUS—Equin Us—VALGUs—CALCANEUs—TENOTOMY-SPURIOUs TALIPES—WEAK ANKLES.–GENU VALGUM–KNoCK-KNEE–Bow-LEGs—TRIGGER- FINGER–HYSTERICAL Joints— Gona LGIA — DISEASE OF THE SACRO-ILIAC SYN- CHONDROSIS. Wounds,--The joints are wounded from various causes—from cuts, thrusts, or by machinery. Of these wounds by far the most dangerous are those which penetrate the synovial membrane, allow the escape of synovial fluid and the admission of air into the cavity of the joint. Other accidents as the crushing and severing of articular surfaces, are treated in other portions of this chapter and in that upon fractures. All wounds in proximity to the joints are more or less serious, because sometimes even a slight puncture has been followed by most disastrous consequences. When the cavity of a joint has been opened by a wound and synovia escaped, there may at first be but little pain ; in a few hours, however, symptoms of inflammation become manifest; there is throbbing, severe pain, a tense stiff feeling of the part affected and redness; with these symptoms there are also decided in- dications of constitutional disturbance, as exhibited first by chilliness, fol- lowed by fever, thirst, anorexia, and aching pains in the bones. The dis- charge which issues from the wound loses its ordinary character; it is thin, sanious, and I have seen it of a reddish hue. At times suppuration takes place, pus is discharged, and the bones are threatened with caries; this lat- ter, however, need not always happen, inasmuch as the inflammatory pro- cess may be arrested and terminate in resolution. In many persons, especially those disposed to the disease, erysipelas makes its appearance; or, in other cases, the parts appear to be doing well SYNOWITIS. - 609 when, either gradually or suddenly, symptoms of tetanus supervene, and the patient, after undergoing the agonies of this disease, either dies or has a prolonged convalescence. Treatment.—In wounds of the joints the parts first must be thoroughly cleansed, and the lips of the wound brought as nearly as possible in appo- sition. Absolute rest for a number of days is necessary. The patient should take internally arnica, if there has been much bruising of tissues, but if there is that peculiar coldness of surface which belongs to ledum that medicine must be administered. During the first few days of the treatment, the patient must be narrowly watched, and if chilliness, stiffness of the nape of the neck, or other symp- toms of approaching tetanus supervene, the appropriate medicines must be given. The reader may refer to this subject, in the Chapter on “Injuries and Diseases of the Nervous System.” For erysipelatous inflammation, aconite, bella., rhus tox., apis, lachesis, canth., arsen., and other medicines will be required, according to the charac- teristics. If synovitis ensue, it will be known by the symptoms detailed in the next section of this chapter. Synovitis.-Inflammation of the synovial membrane may result from traumatic irritation, or other local causes, or be caused by constitutional disease. Mr. Athol A. Johnstone, the author of the essay on Diseases of the Joints, in Holmes's System of Surgery, divides synovitis into scrofulous, rheumatic, gouty, syphilitic, and pyaºmic. Briefly, however, the terms acute and chronic will suffice. - The disease commences with severe aching in the joints, together with shooting pain, sometimes extending into the sº parts. After a short period the joint enlarges, becomes of a reddish hue, is extremely sensitive to pressure, and symptoms of severe constitutional disturbance develop themselves. The fever is intense, with redness of the cheeks, glistening eyes, coated tongue, high-colored urine, and, in Some instances, derangement of the digestive functions. The swelling often advances rapidly, and is caused by effusion into the synovial cavity. If the joint be superficial, fluctuation is distinct; the inflammation may terminate in suppuration, and the formation of purulent secretion, to which the term arthropyosis is applied. In a case which I attended with Dr. Lilienthal, of New York, the symptoms were rather remarkable, the pain being chiefly confined to the rotator muscles of the thigh, the knee also exhibiting the usual symptoms, with profuse perspiration. - In the syphilitic variety of this disease, it occurs as a tertiary manifesta- tion, and the knee and elbow are the joints most frequently attacked. In chronic synovitis, the pain is not so severe and is of a dull aching character, the part is but little sensitive to pressure, and there is experienced a sensation of weakness and relaxation of the limb. The swelling appears a few days after the pain, which in cases of an indolent character may be of trifling moment. After a time, an effusion takes place within the cavity of the joint; this fluid contains but a small proportion of lymph, and coagu- lates by the application of heat. The joint is rendered useless and there is a feeling of insecurity that prevents the movement of the parts. To such, the term hydrops articuli is applied. The disease may follow local injuries, or be dependent on constitutional causes, as rheumatism, gout, syphilis, scrofula, abuse of mercury, etc. Children are seldom attacked. The knee-joint is generally the site of the affection. In such instances the patella protrudes, and there is fulness on each side of it, and also at the lower and anterior portion of the thigh. At the elbow the swelling is most marked above the olecranon; at the hip 39 610 A SYSTEM OF SURGERY. and shoulder articulations there is general swelling of the surrounding muscles. . The disease is considered serious when it arises from penetrating wounds of the joint, as in such instances the constitutional disturbance is so severe that life is brought into imminent danger. Delirium and typhoid symptoms are very unfavorable. In severe cases Suppuration within the cavity may ensue, or ulceration of cartilage and complete anchylosis result. Treatment.—The limb should be kept at rest until the violent inflamma- tory symptoms have been subdued, which may be accomplished in the first stages by the employment of aconite. This medicine is especially indi- cated by the severity of the fever, and when there are drawing and sticking pains in the affected joint, with tension, aching, and gnawing ; when the patient complains of frequent chilliness and thirst, together with prostra- tion and trembling of the limbs. I have tried many remedies in the treatment of the chronic forms of synovitis, and must give unqualified preference to the iodide of potash over all other medicines. I must say also that I have been obliged to give it in substance, from three to ten grains at a dose, three times a day; in addition to this, the diseased surfaces must be kept apart. This is accom- plished by the weight and pulley, five pounds being sufficient in most cases to effect the result. It is astonishing what relief this simple contrivance often gives, and from experience I should lay it down as a rule that this mechanical treatment should not be lost sight of in the management of either the acute or chronic forms of the disease. Dr. A. P. Williams records two cases of acute synovitis which were cured at the Homoeopathic Hospital on Ward's Island, by the internal adminis- tration of apis mel.” Aur., calc., lyc., nit. ac., phosph. ac., sulph., together with silic., have been found useful in inflammation of the synovial membrane, in consequence of effects of mercury; and bry., china, lyc., nux wom., rhus, and sulph., when the disease occurs in gouty or rheumatic individuals. Calc. carb. and sulph. have been chiefly recommended in lymphatic or scrofulous enlargements of the knee. If suppuration ensue, silic., merc., and hepar; and in cases of serous infiltration, silic. and sulph., or calc., merc., and iodum. Other medicines are helleb. (particularly in hydrops articuli), iod., natr. phosph., ruta, stront. By the use of some of these medicines motion of the joint may be restored, but if there has been much effusion of plastic material, anchylosis, either spurious or bony, generally the former, will result. In all cases when the symptoms indicate the presence of fluid within the joint, the aspirator must be used, and if pus follows its introduction, the fluid must immediately be evacuated. There need be no fear in the with- drawal of fluid from the joints by this means. I have repeatedly performed the operation, and often punctured the same joint several times, and have never known an untoward result. Dr. Dieulafoy, f in one hundred and five punctures recorded, finds but one fatal case. His directions for aspi- rating the knee-joint are as follows: “The limb is placed in extension, the joint being surrounded by a caout- chouc or linen bandage, leaving the point exposed towards which the liquid has been pressed, and where the needle has to be passed in. This place of election is the external cul-de-Sac of the synovial membrane, opposite the * New England Med. Gazette, January, 1877, p. 20. f Abstract of Medical Science, April, 1878, p. 77. TREATMENT OF SYNOWITIS. 611 upper end of the patella, and at about two centimeters exterior to this bone. The No. 2 needle, which is to be exclusively employed, only measures a mil- limeter in diameter, and when passed into the joint is to remain in a fixed position while the fluid is aspirated. All manipulation of the joint is to be avoided as causing unnecessary irritation. When the liquid has been re- FIG. 311. FIG. 312. FIG. 313. \ º | | | moved the needle is withdrawn and compression employed. The knee is surrounded by a layer of wadding, pretty firm compression being main- tained by means of a flannel or linen bandage. A roller is also to be applied to the foot and leg in order to prevent the production of oedema. Twenty- four hours afterwards the joint is examined, and if there is no or only very slight reproduction of the liquid, compression is again had recourse to ; but if the effusion has been reproduced in a notable quantity, aspiration should again be performed before reapplying the compression.” Dr. Sayre's apparatus, already described, for making extension in sprained ankle, and which, from its action, prevents the constant friction which otherwise would take place in chronic inflammation of the FIG. 314. FIG. 315. ankle-joint, is an excellent appli- 8.IlC6. For chronic inflammation of the knee, the same gentleman has also devised an ingenious apparatus. Fig. 311 represents the instrument, made of two steel collars, one being fastened above, the other below the knee; they are connected on both sides by extension rods, which are worked with a key; strong strips of adhesive plaster one inch wide are then applied longitudinally, as seen in Fig. 312, which are secured by a roller, as shown in Fig. 313, to within an inch of their extremities. The in- strument is then applied, the collars drawn sufficiently tight to be com- fortable, and the ends of the adhesive plaster wound over the collars above and below, as seen in Fig. 314. The limb is then brought down as nearly | *...*.*.*.*.*. - *.*.*** 612 A SYSTEM OF SURGERY. straight as possible, and the rods extended simultaneously, until pressure can be made on the foot without pain. A sponge is placed in the pop- liteal space, and others around the joint, and the whole kept in position by a bandage saturated with cold water. The apparatus complete is seen in Fig. 315. If this cannot be obtained, the weight and pulley, as recommended on a preceding page, may be advantageously used. & Ulceration of the Articular Cartilages.—If inflammation continue, the articular cartilages suffer, and finally molecular death occurs—the “ulcera- tion of cartilages,” of some authors. In these cases the degeneration takes place in a linear direction, and the surface of the cartilage appears to split into fibres as shown in Fig. 316. In reality, this destruction of the articu- FIG. 316. Vertical Section of Inflamed Cartilage, showing the Splitting into Fibres of its Surface. From Redfern.—HOLMES. lar cartilages is not a primary, but a secondary affection. It is caused by an extension of the inflammatory process; it may follow either acute or chronic synovitis, generally the latter. Scrofulous and syphilitic consti- tutions are especially liable to the affection. When such process goes on, the synovial membrane ulcerates and is finally converted into a thick, pulpy substance, intersected by white membranous lines. This condition has received the name of pulpy degeneration. There is much pain and stiffness, together with considerable swelling of the joint, which is elastic, but there is no fluctuation. The tumefaction presents an irregular ap- pearance, being more protuberant in one part, than in another, from the accumulation of fluid or solid matter in the directions where least resist- ance is afforded by the surrounding tissues. Pus often accumulates within the cavity of the joint, and the suppuration is accompanied with much con- stitutional disturbance; or the matter may be effused into the bursae, into the surrounding cellular tissue, or into that beneath the tendinous sheaths of the muscles in the neighborhood. After a time the capsular ligament ulcerates, the pus is evacuated, and caries of the bone is added to the al- ready alarming disease. - It has been a matter of some difference of opinion whether in this affec- tion there is enlargement of the articulating extremities of the bone. It is probable that, in the first stages of the disease, they are seldom or never affected, but as abnormal action increases, inflammation and ulceration of the osseous parts ensue. Frequently the knee is the seat of the disease; STRUMOUS SYNOVITIS. 613 and when this articulation is affected, the lymphatic glands in the groin become sympathetically enlarged. The same fact may be noticed when the Swelling occurs in the elbow-joint, in which instance the axillary glands participate. Fungoid Degeneration.—In other cases from imperfect nutrition a fungous growth makes its appearance. Dr. Ruggi,” in giving his experience on the seat of fungous synovitis of the knee-joint, remarks: That the patient seeks instinctively to diminish the contact of the bones by bending the limb. A case was mentioned, of a scrofulous old woman (age not given) in whom, after a blow, the right knee became swollen and painful, and had to be kept immovable. An amputation was performed. The disease was limited to the articulation between the femur and the patella. This case, the doctor says, demonstrates that fungus synovitis may be limited to the spot where the patella comes into contact with the condyles of the femur, and in this way may be explained the symptoms in cases where the limb is extended. There would then be two forms of synovitis of the knee, distinct in their seats and in their symptoms. When the patient has suffered for a considerable time, hectic supervenes, with its alarming train of symptoms, which are always aggravated after the opening of the abscess. Emaciation, excessive debility, loss of appetite, nightsweats, and diarrhoea are also present. In some cases, health is re- stored, and the disease abates spontaneously; in others, complete cures are effected by careful and judicious treatment. A method of restoration re- sorted to by nature is anchylosis, which may be either ligamentous or os- Seous. New bone is deposited, whereby the ulcers become, as it were, cica- trized, and the articulating extremities are joined by firm bony union. The process of Ossification is assisted by the effusion of lymph, and consequent thickening and induration of the ligamentous substance exterior to the joint. By such means the parts are retained in exact apposition, and the calcareous matter is regularly deposited, as in fractures retained in situ by the applica- tion of splints. This disease, however, may again recur, and both ligamentous and Osseous formations be destroyed by the ulcerative process. In many cases, how- ever, anchylosis remains permanent. Treatment.—Silic. is the principal medicine in the treatment, repeated every day. If it should not effect a cure, one of the following should be employed and persevered in ; ant. crud., petrol., iod., clem., or sulph. In the first stages of the disease, when there is inflammation of the syno- vial membrane, acon., bell., mez., nit. ac., phosph. ac., lyc., sulph., or calcarea should be employed. When the pulpy fungus makes its appearance, phosph., thuja, caust., or sepia may be indicated. In the event of suppuration, silic., hepar, merc., or calend., should be remembered. If the swelling is shining, white, soft and doughy, puls. is to be prescribed. In many cases iodine is useful, and may be employed in alternation with puls. When the swelling is red and very painful, bryonia would, perhaps, be more appropriate; when there is serous infiltration, ledum, calc., iodum, merc., or sulph. may be required. Excision of the joint, or amputation, may have to be resorted to in cases resisting all other treatment. Strumous Synovitis-This disease has several stages. The morbid action is continually heaping up new elements, which enlarge the joints, which, in turn, become filled with pus, in which can be found floating cells and nuclei. In the second stage the cartilages become diseased and ulcerated. In some instances, this ulceration is very rapid, in others quite slow, the * Monthly Abstract of Medical Science, November, 1876. 614 A SYSTEM OF SURGERY. latter being of the most frequent occurrence. The first appearance of this abnormal condition is a slight elevated spot, which has a yellowish tinge, and which soon becomes soft, and when examined by the microscope shows that the cartilage corpuscles have become larger and the cells greatly in- creased in number. In the quicker form of ulceration, the process is rapid and eats a hole through the cartilage, which is as cleanly cut as though with a punch. This rapid form of ulceration occurs frequently in cartilages which are subjacent to each other, and, therefore, is found espe- cially in those joints which have been allowed to remain in malposition, but whether the ulceration be rapid or slow, the result in both cases is the same. The ends of the bones are united by a soft granulated tissue, which, beginning at the outside of the bone, penetrates into it, fills the canaliculi, and obstructs the circulation in the Haversian canals. The last stage of strumous synovitis consists either in the consolidation of the granulated mass, or the complete degeneration of the ends of the bone; if the former take place, the reparatory process ensues, which is similar to cicatrization of the soft parts; if the latter, suppuration occurs and abscesses result, which open around the joint and a fungoid growth protrudes. t Chronic strumous synovitis is what formerly was designated “white swelling.” The peculiarity of the disease consists in the integuments cover- ing this strumous enlargement of the joint preserving their white appear- ance, while within the joint cavity there is a uniform pulpy swelling formed by complete degeneration of the joint itself. The treatment of this disease is, first, rest, together with which there should be a moderate exten- sion applied, the weight being but a few pounds; this must be done to separate the cartilages. The internal administration of iodine and iodide of potassium, or of some of the various forms of mercury, is often effica- cious. It is necessary sometimes that a splint be applied to secure perfect immobility of the joint. Cold applications in the acute stage are very efficacious. Chronic Contraction of the Knee from Inflammatory Action.—This disease is more common than is generally supposed, and is occasioned by a con- traction of the ligaments about the knee-joint, caused by inflammatory action. The contraction may be permanent, and if not arrested may re- sult in Osseous anchylosis. Those cases which result from the contraction of the ham-string tendons, when the internal structure of the joint has not been involved, and where fibrous bands only have formed within the joint, may be remedied by extension and an appropriate splint. But after a time, when the contraction has become chronic and inflammatory action has affected the joint, the head of the tibia is drawn backward, the condyles of the femur are thrown forward, and the ligamentum patellae is so stretched that in some cases it is partially absorbed, the patella being drawn upward or to one side. Accompanying this deformity there is ulceration of the crucial ligaments, especially the posterior, and also of the lateral ligaments. Treatment.—If simple extension, with a splint on each side of the leg, is not sufficient to reduce this dislocation, forcible means may be employed. The patient should be placed under an anaesthetic, and should lie on his face. The surgeon takes the foot of the affected side in one hand and firmly holds the leg above the knee with the other, as the leg is brought forward a slight pressure from behind will have the tendency to force the head of the bone into its position. If this does not suffice the gradual restoration by means of an appropriate splint will be necessary. Several such apparatuses have been invented, as will be seen in Fig. 319. Division of the Ham-string Tendons.—Sometimes a simple contraction of the ham-string tendons may be remedied by their subcutaneous division. ANCHYI.OSIS. e 615 The surgeon introduces the tenotome on the flat side close beneath the tendon to be divided, he then turns the cutting edge towards the skin, and with a gentle sawing motion cuts through the tendon. In performing this operation on the outer ham-string, care must be taken that the peroneal nerve is not divided (an accident which has happened to myself). This unfortunate occurrence can be avoided by keeping the flat portion of the tenotome closely against the inner edge of the biceps’ tendon and then turning the edge carefully outward. Very often after the division of the tendons, some bands of fascia may have to be divided. Extension should then be made, and very often in so doing portions of tissue will be torn away; immediately after the limb is restored it should be placed in a plaster-of-Paris splint, or in an apparatus which will keep it in a straight position, because the shortening of the posterior ligaments, which has been Occasioned by the contraction of the tendons, will not allow immediate resto- ration to a straight position. Genuthrotomy-This operation consists in making a free incision into the knee-joint and the introduction of drainage-tubes. The operation should be performed under strict antiseptic conditions. The cases that call for the operation are those of acute serous-gonitis, purulent genuthro-meningitis, Osteo-myelitis of one or both epiphyses, and in all cases where there is threatened destruction of the epiphysial cartilages. Dr. Scriba” has col- lected the reports of a dozen cases treated by this operation; seven of them were acute suppurating synovitis, four were cases of caries and tuberculosis, and one of hydrops articuli. In four of the seven there was perfect recovery, and in three the result was fatal. The four operated on for fungoid disease were fatal, and the one for hydrops successful. These statistics are not very encouraging, but are sufficient to prove the reliability of the operation in cases of simple effusion or suppuration. Anchylosis.--Anchylosis, or, as it is sometimes spelled, ankylosis, signifies, in surgical nomenclature, an affection of the joint in which motion is either partially or entirely lost. The derivation of the word, however, does not at all indicate that it should be used in such a sense, as the English word “angle " or “angular ” comes directly from the Latin uncus, which in turn takes its derivation from the Greek árzóños. According to Celsus, the term was used in ancient times to indicate a contracted joint. The loss of motion is occasioned by deposits of a fibrous or osseous char- acter, which are found either within or surrounding an articulation. We have true anchylosis when motion is entirely lost, which is generally occa- sioned by Ossific deposits, synostosis being used to designate such a condition; while false anchylosis indicates that motion is more or less impaired. Loss of motion in a joint, in certain cases, may be looked upon as a method of cure, as described by Liston.f Hunteri makes five kinds of bony anchylosis, and, though concise in description, they are very com- plete. They are as follows: 1st. From lateral attachment, where there is no joint—as the union of the tibia and fibula, of two ribs, or of two metatarsal or metacarpal bones. 2d. Bony formations in the surrounding parts. 8d. Between bone and bone, the ossific deposits taking place in the intermediate substance, as between vertebra and vertebra. 4th. By the capsular ligament. 5th. By the whole substance of the articulation.S * London Medical Record, March 15th, 1877. f Elements of Surgery, p. 60, 1837. † Lectures on the Principles of Surgery, p. 310. 3 Connor describes a remarkable case in which there was general anchylosis of all the joints; and a still more curious case is recorded of a child only twenty-three months old, whose joints were unusually stiff. 616 - A SYSTEM OF SURGERY. There is also another subdivision made by authors in reference to other circumstances—first as to position: angular or straight; or as to complica- tion: simple or compound. It has also been noticed, that whenever anchy- losis affects the amphiarthroses, synostosis is the result, but the diarthrodial joints can be affected with either spurious or true anchylosis, although bony union is more frequent in the ginglymoid, and false or spurious anchylosis in the enarthrodial. The affection may be produced by various causes, and all those which give rise to inflammations in or around joints, whether arthritic, scrofulous, traumatic, or syphilitic in character, are known to be productive of either one of the other forms of the disease. It is not my intention to enter into the great variety of adhesions that may take place in and around the various and complicated joints of the human body, but to proceed at once to detail difficulties in diagnosing the different forms of the disease. In the olden time it was considered impossible to distinguish true synostosis from false anchylosis. Mr. Bon- nett wrote: “We have no certain signs by which we can recognize bony anchylosis;” but since the introduction of chloroform, the diagnosis is made more easy. If anaesthesia had done nothing else, the assistance it gives the surgeon in this disease, alone would be sufficient to render it in- valuable. Any one who has had opportunity of examining and treating these cases, is aware that as soon as any attempt is made to “ handle '’ the limb, the patient, from the consciousness of the suffering he has already undergone, the painfulness of slight motion, the sensitiveness of the joint, and other circumstances, immediately and almost unconsciously resists; the volun- tary muscles are put upon the stretch and the limb remains fixed; the greater the effort made by the manipulator, the greater will be the exer- tion on the part of the patient to prevent the motion. What a different re- sult is obtained when the patient is fully under the influence of ether Let me here offer some rules which I have condensed from Brodhurst,” whose work on this specialty is of high merit, and whose success in the treatment of anchylosis is world-renowned : 1. Use always the greatest gentleness in handling an affected joint; let the pressure be gradual and steady. 2. As a general rule, the sensation of solidity, in bony anchylosis, is un- mistakable in grasping the limb above and below the articulation. Bony consolidation in the movable articulations is so rare, however, that an ex- amination should always be instituted after the full effect of chloroform has been obtained. 3. False anchylosis is the rule, and it is so common, that adhesions should always be held to be fibrous, until they are proved to be bony. 4. Immobility alone is not a sign of synostosis; it not unfrequently exists where the adhesions are fibrous. 5. Immobility will frequently exist until muscular action is entirely sub- dued by the anaesthetic. 6. Whenever muscles can be thrown into action so as to render the ten- dons prominent or tense about a joint, the adhesions are not bony. These rules are of great Service to the surgeon when called upon to give an opinion as to the state of a limb which has a stiffened joint, for very frequently upon his decision, in a case of the kind, the happiness of after life may depend. - Treatment.—The treatment of anchylosis may be divided into two methods, the gradual, the forcible (brisement force), and either of these ac- * Diseases of the Joints. TREATMENT OF ANCHYLOSIS. 617 companied by subcutaneous tenotomy. The gradual method is accom- plished by the different forms of apparatus as seen depicted in cuts 318 and 319, and may in many cases if comparatively recent accomplish the result. It may also be effected by the hands of the surgeon, applied with careful regularity in making passive motion. But the surgeon must not forget, that in many instances anchylosis is a method adopted by nature to cure the patient, and, therefore, must not be interfered with. If, after scrofulous synovitis, or caries, or extensive degen- eration of the articular cartilages, anchylosis result, the best thing to be done is to endeavor, while the bony or ligamentous deposits are taking place, to shape the limb in such position that it may be the most useful to the patient in its stiff position. In applying sudden force, and completing the operation at a sitting or two, the limb must be forcibly flexed and not extended; and when after the joint is comparatively loose, extension is practiced, it should be done with gradual force. It may happen in some cases, that the deformity in the flexed position is so great, that further flexion is impossible. This does not often happen, but I have seen it in several cases at the hip, and at the knee; in the former the thighs rested on the abdomen, in the latter the gastrocnemius touched the long head of the biceps. In all of these a cure was effected by extension, but it was care- fully exercised. This precaution is given, because in certain cases in which anchylosis has been of long standing, and synostosis has existed, severe and fatal accidents have followed forcible extension. The condyles of the femur, and the upper epiphysis of the tibia have been torn away, gangrene of the limb has followed from pressure on the popliteal vessels, and the artery itself has also been ruptured. This latter has happened in the hands of distinguished surgeons. Dr. Salzerº lately reports five cases, three being under the charge of Billroth, one under Nicolandoni, and one under Gussen- bauer. Gangrene took place in three of the cases, requiring amputation of the thigh, in one amputation of the hip-joint was performed. Two patients perished from septica-mia. Great caution must therefore be employed, and constant attention paid to the pulsation of the posterior tibial, and to the temperature and color of the parts while the extension is being practiced. I may also call attention to another fact, in the danger of refracturing a bone, which has been broken in the vicinity of a joint, and from which accident the original stiffness of the joint may have arisen. Such a case lately happened to me. The patient was a sea captain, aged fifty, had suffered from a fracture across the head of the tibia just below the tubercle, had recovered with a semi- flexed limb, which rather unfitted him for work. I divided the ham-string tendons with care, and, in flexing the limb, the callus gave way, and the bone, though not completely fractured, was bent. It was restored to its position, and union resulted. In spurious anchylosis, much service may be rendered by passive move- ment of the joint, together with massage, and the internal administration of graph., rhod., rhus tox., sepia, or sulph., and in some instances, cham., bry, lyc., and staphis.; very frequently by the early use of these remedial agents, together with passive movement of the joint, the disease may be cured. I must speak here of the use of Dr. Butler's electro-massage instrument in the treatment of spurious anchylosis, and in applying the proper friction with electricity, after forcible flexion has been used, and also in stiffness of the joints resulting from fractures in their vicinity. In my hands this combination of electricity and massage is more serviceable than any other. The cut will explain itself. * Weiner Medizinische Wochenschrift, Nos. 8 and 9, 1884. 618 A SYSTEM OF SURGERY. Frequent friction also, with arnicated oil, has been a favorite and satis- º adjuvant with me, one part of arnica being mixed with four parts Of Oll. - When rigidity of muscles and ligaments produces immobility of the joint, bry., rhus tox., ruta, lyc., sulph., should be employed. The patient may FIG. 317. Butler's Instrument for Electro-massage. also be placed in an anaesthetic condition, by the inhalation of ether, and the limb flexed and extended, even if considerable effort be required. In several instances I have succeeded in restoring motion to the elbow by an apparatus represented in Fig. 318. It consists of padded bands, a, FIG. 318. FIG. 319. Cº. G.T | EMANN & CO b, c, d, which are buckled around the arm, forearm, and wrist, having a steel bar on each side of the arm, with a joint at the elbow. A screw works into a cylinder on the anterior face of the arm, which regulates the amount of both flexion and extension, Fig. 319 shows a similar apparatus for the knee; it consists of metal troughs 1, 2, 3, with two lateral bars attached to the shoe, a, with a joint at the knee worked with a key, g. The knee-cap, d, fits well over the patella. The whole is held by buckles, as seen at c, d. e. f. '#'. methods may be exemplified in the following cases: A young woman, aged twenty-seven years, was brought to me with partial anchylosis of the temporo-maxillary articulation from long-continued rheu- matic inflammation. She was of a strumous habit, and the disease had existed for some considerable time. Having had under my care a case of complete anchylosis of this joint—which I reported some years since in the North American Journal of Homoeopathy—I was prepared with the necessary TREATMENT OF ANCHYLOSIs. 619 appliances, and immediately resorted to forcible extension. Having placed her fully under the influence of chloroform, I introduced the jaws of the instrument (which, when closed, resemble an iron wedge, but which are forcibly separated by means of a screw and lever) between the teeth on the affected side, and putting the instrument in motion, succeeded in opening the mouth to its fullest extent. As is usual in such cases, the adhesions gave way with a loud snap, and freedom of motion resulted. Swelling and inflammation followed, during the height of which perfect quiet of the affected parts was enjoined, the jaws being rubbed constantly with cam- phorated oil. So soon as the swelling subsided, a wedge of hickory wood was placed between the teeth during the day, thus keeping the jaws forcibly separated, but she was allowed during the night to have it removed. After two weeks of this treatment the foreign substance was dispensed with, and she was ordered to talk as much as possible—not a very difficult thing for a woman—and to chew constantly through the day portions of hard cracker. By these means motion was perſectly restored. A healthy girl of about twenty years of age, a seamstress by trade, had received a very deep burn in the palm of the left hand. During the healing process, the index, middle, and ring fingers were drawn over the palm, rendering them not only useless to her in her avocation, but a source of constant mental irritation from their unsightliness. She could not wear a glove, and generally, in the presence of company, concealed her hand from view. I placed her under the influence of chloroform and endeavored to resort to forcible extension, but the adhesions of the palmar fasciae, and the contraction of tendons, were so great, that I found it was impossible, with prudence, to straighten the fingers. I, therefore, with a tenotomy knife made subcutaneous section of the tendons, and also in two different places divided the palmar aponeurosis. Her hand was then covered, and she was told to return in a week. At her second visit I found the punc- tures healed, and, having again administered the anaesthetic, straightened the fingers with little difficulty. No apparatus was used in this case, as she was requested to constantly move the previously stiffened joints with the other hand. It is a good rule to allow all punctures to heal before resorting to extension, else, as was often the result in those cases treated by Dieffen- bach and others, a slight puncture may be converted into a severe laceration. A boy, aged about twelve years, was thrown from a horse, and fractured the superior extremity of the ulna. After three months he was brought to this city, with his arm at an obtuse angle, and with slight motion at the joint. The parts were swollen, sensitive, and painful, and therefore I re- solved upon the gradual extension plan. An instrument was applied, con- sisting of two plates of German silver united by a hinge, and both plates bent in such a manner that the superior would embrace the lower part of the humerus, and the inferior the upper part of the forearm. These were connected by a screw, by turning which the plates could be brought to any angle required. This apparatus was placed upon the arm, and the parents ordered to turn the screw in one direction in the morning, and the contrary direction at night, with strict instructions, however, that flexiom should be made first. This is also an important rule. By resorting first to flexion, the vessels of importance are not so likely to be injured as when extension is used. The case proceeded well, and the father informed me that after a couple of months perfect motion was restored. A German boy, aged about nine years, received a severe wound with an axe across the lower part of the condyles of the femur and the upper part of the tibia, involving also the patella. After the wound healed anchylosis resulted. When I saw the boy, his leg was bent at nearly a right angle; he could not move without his crutches, and his parents were in the greatest 620 A SYSTEM OF SURGERY. state of despondency regarding the deformity. I examined him very care- fully, and following the rules already enumerated, came to the conclusion that the case could be at least much benefited. Here I resolved to resort to forcible flexion, and if this proved impracticable, to divide the ten- dons and fasciae, and afterwards endeavor to restore the limb. I placed him fully under the influence of chloroform, and began to put the tendons on the stretch. When the boy was not entirely insensible the voluntary mus- cles would prevent all motion ; but as soon as the anaesthesia was complete very slight mobility was observable. As the flexion was continued, I could distinctly feel the minor adhesions giving way. I still continued the pres- sure, when suddenly, with a report so loud as to alarm the bystanders, the joint became flexible in my hands. Great sensitiveness and pain and swelling followed; symptomatic fever also was induced, which, however, was controlled by the appropriate medicines. Every day for a week the limb was moved, the patient always having to be placed under the influ- ence of chloroform. An apparatus similar to that used in fractures of the femur, to graduate extension and counter-extension, was put on the boy’s limb, and he then came under the care of other physicians of the hospital. The treatment was continued, the flexion and extension being graduated from time to time, and the boy, without his crutches, runs and plays as other children. - Dr. Reiss relates a case in which kali iod. cured spurious anchylosis. The patient had suffered considerably, and had been under the care of Lutze for a year. The least motion of any limb caused her violent pain, with complete anchylosis (spurious) of the knee and ankle-joints. The prescription was kali iod., grs. V to 3ij of water, a teaspoonful twice a day; the dose was gradually increased, and in a short time a perfect cure was effected. Subcutaneous Osteotomy for Anchylosis of the Hip-joint.—In the treatment of synostosis much may be done to relieve the patient, by an operation similar to the famous one of Dr. J. Rhea Barton, of Philadelphia; an angu- lar limb, totally useless or worse than useless, from its constantly incom- moding the patient and its great unsightliness, may be rendered useful, straight, and of comely aspect. This operation was performed by Dr. Bar- ton on the hip in 1826, and on the knee in 1838. In the one instance a crucial incision, seven inches in length and five in the horizontal direction, was made, and the bone divided transversely between the trochanters; and in the other, the excision of a wedge-shaped piece of bone above the patella with gradual flexion, succeeded in restoring usefulness to the limb. Dr. Gibson also successfully resorted to it in complete synostosis of the knee. Other surgeons have been successful in the operation. Dr. Buck” reports a case of Barton's operation which is worth perusing. A similar operation was performed by D. J. Kearney Rodgers, and Dr. Sayre modified it in 1862, f by making “a curved section of the femur above the trochanter minor, and a straight section a few lines below the first curved cut, thus removing a block of bone.” Dr. William Adams, however, has the credit of systematizing and per- fecting subcutaneous osteotomy for bony anchylosis of the hip. He says: “It occurred to me, however, that in these cases of bony anchylosis of the hip-joint, with extreme distortion, a much more simple operation might be performed by the subcutaneous division of the neck of the thigh-bone about its centre, within the capsular ligament, and on the 1st December, 1869, I performed this operation successfully.” * American Journal of the Medical Sciences, October, 1845. # Lectures on Orthopaedic Surgery, p. 423. † A New Operation for Bony Anchylosis of the Hip-joint, London, 1871, p. 9. CHRONIC RHEUMATIC ARTHRITIS. 621 Mr. Adams describes the particular varieties of anchylosis to which the operation is applicable, and finds that in rheumatic anchylosis, or in anchy- losis after pyaºmic inflammation, in which the bone is rarely diseased, or after traumatic inflammatory action involving the soft parts only, or in strumous disease of the joint itself which has been arrested at an early stage,_the operation should be performed. Where, however, caries and necrosis of the joint have resulted, and there are fistulae, with discharges of portions of bone, it is not justifiable. The operation is performed as follows: A tenotomy knife is entered a little above the top of the great trochanter, and must be carried straight down to the neck of the bone, dividing the muscles, and freely opening the capsular ligament. A small saw must then be carried down in the track of the wound, and the bone sawn through from before backward. The leg is then to be moved freely in all directions; if this cannot be accomplished, those muscles offering the most resistance should be subcutaneously divided. The rectus, the adductor longus, and the tensor vaginae femoris may have to be cut before the leg can be restored to position. So soon as this is ac- complished, the limb must be put into a straight splint and retained, or a weight and pulley may be applied. Dr. Geo. F. Shrady has introduced an excellent saw for subcutaneous osteotomy, which is seen in Fig. 320. Mr. Brodhurst.” makes an incision of one inch in length, and severs the bone by means of a saw immediately above the trochanter. He believes that the free incision is less liable to be followed by suppuration. In the FIG. 320. Shrady's Subcutaneous Saw. Clinical Society, to which he related his views, there was much difference of opinion upon the relative value of the saw and chisel, some advocating the use of the saw, and others that of the chisel. The name was thought to be a misnomer, and it was suggested that the operation should be called “val- vular,” instead of subcutaneous section.i. Chronic Rheumatic Arthritis is characterized by pain, weariness, and rigidity of the larger joints and surrounding muscles, increased by motion, relieved by warmth. The limb spontaneously and easily becomes cold; the fever and swelling are slight, and generally imperceptible. A difference of opinion exists as to the nature of this affection, some considering it a sequel of acute rheumatism, others as a distinct disease. No doubt it is often either, each case being distinguished by its own symptoms. This affection, when it attacks the hip-joint, is so peculiar and so marked that surgeons have given especial attention thereto. It has received the title of morbus coxae senilis, by Mr. Robert Smith. Mr. Benjamin Bell de- * Month. Abs. of Med. Sci., March, 1877. *f Lancet, February 3d, 1877. 622 -- A SYSTEM OF SURGERY. scribes it as an interstitial absorption of the neck of the thigh-bone. San- difort, Colles, Hamilton, and others consider it as a distinct disease. Chronic rheumatic arthritis has not so many varieties as ordinary ar- thritis. It becomes fixed in the loins, hips, and knee, but seldom in the thorax. It differs from other rheumatic affections by the absence of, or the slight degree of fever, the body preserving its natural temperature and the pulse rarely exceeding eighty beats in the minute. The joints are not much swollen, are pale, cold, stiff, and seldom perspire, and are always relieved by warmth. Some individuals are scarcely ever free from pain; others suffer only before or during damp and changeable weather. The pain is sometimes in the muscles between the joints as well as the joints themselves. - The disease continues for an indefinite period, and sometimes is incur- able. The affected joint is greatly debilitated, and resembles in some respects the condition produced by paralysis. Inveterate cases give rise to disease of the tendons, bursae, and muscles; the ligaments also become rigid and thickened, and the joints stiffen. Sometimes a jelly-like effusion is poured into the articular cavity. It affects especially the hip-joint, and in this form is more common in males than in females, and is seen more in the laboring than in the higher classes. The symptoms, when the hip is affected, are dull heavy pains extending down the thigh ; there is weakness in walking. Pressure upon the great trochanter, or forcing the head of the bone into the acetabulum, does not aggravate the pain. As the disease progresses the efforts at rotation and flexion are more and more impeded. Stooping becomes painful, the body is bent forward ; gradually, as changes take place in the joint, the limb shortens, the foot is everted, there is great lameness, and the patient has frequently to rest himself. The buttock of the affected side loses its natural prominence; gradually the gluteal fold disappears, the muscles are absorbed; there is pain back of the trochanter major. In the aggravated form of this distressing malady, the capsular ligament becomes much thickened, the ligamentum teres dis- appears, and the notch in the cotyloid cavity is converted into a foramen by the deposition of bone. The acetabulum varies much in shape, be- comes enlarged and porous, and osseous additions are made around the margin. The head of the femur no longer presents its spheroidal shape, and enlarges sometimes to a great degree, and is flattened. In some in- stances the caput falls to a right angle with the shaft. The neck of the bone is either partially or totally absorbed, and the patient, after a miser- able life, dies worn out with suffering. Cold is a common cause of chronic arthritis, even when there has not been pre-existing rheumatic trouble. Violent sprains, strains, and falls upon the trochanter are likewise causes. It may be distinguished from inflammation of the periosteum by the latter being usually seated in the long or flat bones, while chronic rheu- matic arthritis is at or about the joints. The pains of periostitis are very violent during the night, which is the reverse of chronic rheumatic ar- thritis. Treatment.—In the advanced stages of chronic rheumatic arthritis very little can be done by internal medicines. In the early stages, however, much good may be effected by the properly selected remedies; great care must be taken in selecting the medicine and its administration persevered in for a length of time. The following are among the medicines used: bry., bell., arn., cham., colch., merc. Sol., rhus tox., puls., nux, ars, sulph. - Nitric acid, calc. carb., and perhaps argentum, are valuable medicines; veratrum pains are increased by the warmth of the bed and by wet weather. HIP-JOINT DISEASE. 623 They resemble a bruise, and are lessened by walking; the part affected is weak and trembling. By the careful selection of a medicine in chronic rheumatic arthritis, in its early stages, relief is certain, and a cure probable. Hip-joint Disease, Morbus Coxarius.-There are certain indications which convey to the practitioner a knowledge of the existence of the disease com- monly and properly called “hip disease,” when it is fully established. Of the real nature of the disease there is a diversity of opinion, some consid- ering the affection as scrofulous; Mr. Johnstone” designates it “chronic or strumous inflammation of the joint.” Gross speaks of it as “tuberculosis as it affects the hip,” and Dr. C. F. Taylor, in the first chapter of his work,i after giving carefully prepared statistics of both hospital and private practice, declares the disease to be “essentially traumatic.” Sayrei entertains the opinion that the disease is more frequently local than constitutional in its Origin, and remarks, “Out of the several hundred cases that I have accurately observed, and taken the trouble to take their history, the immense majority, I may say ninety per cent., occurs in the most vigorous, wild, harem-scarem children; ” although he admits that a scrofulous child, if injured, would more likely be affected than one of a healthy constitution, which probably is the fact; scrofula, no doubt, being a predisposing cause of the malady. The disease has likewise received the name of coxalgia, which term, how- ever, should more properly be applied to the pains which are experienced during the progress of the disorder. The symptoms of hip-joint disease vary materially, especially in its early stages. Signs have been laid down for ascertaining whether the inflammation has commenced in a true synovitis (arthritis); in the head of the thigh-bone (femoral arthritis); or in the cotyloid cavity (acetabular arthritis). Wherever it may commence, the symptoms are divided into three distinct Stages. The first stage of hip-joint disease is characterized by limping; the halt is more observable in the morning, almost disappears during the day, and is absent at night. Exercise or undue exertion may increase the limp, but it often passes away after a day's rest, or is so slight as fiot to attract atten- tion. Even at this period there may be uneasiness in the knee-joint, though this symptom generally appears later in the progress of the affection. It is in this stage that more can be done by the surgeon than at any other, the main object in the treatment being rest, but, unfortunately, the patient, in the great majority of cases, is not seen by the practitioner until the second stage is developed. - The Second stage is more pronounced than the first. In it there is intense pain, which frequently is located in the knee-joint and the inner side of the thigh, or sometimes in the posterior surface of the leg. The sufferings are materially aggravated by rotation and abduction. An examination should always be carefully conducted, the child being stripped and laid flat upon a table or mattress. There then will be perceived a slight lowering of the pelvis, and some flexion of the limb ; the gluteal region somewhat flattened; and the gluteal fold sunken. There is likewise an apparent elongation of the extremity, together with abduction and eversion. Motion is much im- paired or entirely lost. The pains during this stage are often excruciating at night, the limb becomes attenuated, and severe constitutional symptoms of fever, debility, perspiration, loss of appetite, emaciation, and hectic pre- sent themselves. It is during this stage that effusion, resulting from the * Holmes's System of Surgery. - t Mechanical Treatment of Diseases of the Hip-joint. † Braithwaite's Retrospect, January, 1872, p. 110. 624 A SYSTEM OF SURGERY. previous inflammation, takes place within the capsule, and it is the hydrau- lic pressure that causes the limb to be abducted and rotated outward. This fact has been proved by injecting quicksilver within the capsule, and there retaining it; the limb in such experiments being flexed, abducted, and ro- tated outward.* The apparent elongation is also attributable to the same cause, for, says Bauer, iſ “The sole source of the symptom is the hydraulic pressure from existing intra-articular effusions. I was led to this view from the analogous position of the femur and the immobility of the joint pro- duced by experimental injection.” - In the third stage the symptoms are very different from those just noted. Pus and the effused fluids find an outlet, the muscles have not the resistance to overcome, and gradually the limb assumes a position directly opposite to that noticed in the second stage. It is rotated inward, shortened and adducted. The toes only touch the ground, the pelvis projects somewhat forward, the vertebral column approaches the opposite side, and there is great amelioration of the pains; indeed, this latter change is often so marked that hopes of improvement are entertained by those ignorant of the nature of the disease, whereas the affection is steadily advancing. During this stage the pus finds an exit on the surface, either in the neighborhood of the joint or in the groin. Great structural changes go on, in the articulation during the progress of hip-joint disease. The acetabulum enlarges, caries and necrosis of the head of the femur take place, particles of bone being mixed with the discharge. Finally the head of the bone is either entirely or partially destroyed, or is Sometimes enlarged. The acetabulum may be pushed up, presenting an appearance somewhat similar to a dislocation on the dorsum of the ilium. This latter lesion, however, is only found in those rare cases, where the shaft, with perhaps a portion of the head of the bone, becomes pushed up through a rent in the capsular ligament. The similarity of dislocation caused Rust to attribute what was formerly supposed to be a spontaneous dislocation of the head of the femur to the action of the contracted muscles. An excellent method of ascertaining the relative position of the femur to the acetabulum is given by Nélaton, and recorded by Bauer, as follows:f “In drawing a line from the anterior superior spinous process of the ilium to the tuberosity of the ischium, it passes on its way from one point to the other the apex of the large trochanter in the normal position of the femur. It crosses the trochanter more or less below the apex in dislocation.” If the patient still survive the disease, it may terminate in anchylosis, which, however, is generally spurious, sometimes being partly ligamentous and partly bony; in rare instances, a true synostosis may occur. Such a case recently came under my own observation; the disease had existed for sixteen years, the limb was short nearly seven inches, the toes inverted, and the thigh rigidly flexed and adducted. On cutting down upon this bone, the whole cavity of the acetabulum was gone, or rather there was such a complete blending of the head of the thigh-bone and the cavity, that after sawing off a triangular portion of the bone, it required great force to frac- ture the adhesion. The pain in hip-joint disease varies in its character, and is caused partly by the unyielding nature of the tissues in which the inflammatory action is present, and later from the contraction of the muscles, which involun- tarily takes place to prevent motion. I mean by this, that the very con- traction and rigidity of the muscles, which have a tendency to prevent * Wide Braithwaite's Retrospect, January, 1872, p. 109, article on the Treatment of Hip- Joint Disease, by Dr. L. A. Sayre. f Orthopaedic Surgery, p. 266. † Bauer's Orthopaedic Surgery, p. 268. HIP-JOINT DISEASE—TREATMENT. 625 concussion of the diseased joint, become factors of continuous pressure, which helps to destroy the vitality of the jºint and increases the pain. Dr. Charles F. Taylor & thus well puts it: “On the very first intimation of a diminished ability to bear pressure—which is the great obstacle to a Spontaneous arrest of any morbid process within a joint—the exigency of arresting motion to save the joint from immediate pain, causes the muscles to take on a contraction of such a rigid and permanent character as to be a condition of perpetual wounding of the parts. Their own excessive action, as well as their elasticity, constitute a continual source of severest Injury. - Treatment.—In the first stage of the disease a cure may be hoped for. The paramount object in the treatment is rest, absolute and continued for a length of time. The patient, therefore, should be placed in bed, and kept there at least a fortnight after all traces of the disease have disappeared. If the patient complain of pain in the knee, belladonna is a medicine by the administration of which, in some instances, in alternation with mer- curius, the disease may be subdued. Aconite may also be used with advantage in the commencement of the affection. If there be tension of the part, with severe pain, colocynth should be employed ; and, if there are evening exacerbations, pulsatilla is indicated. The chief medicine, however, is belladonna, which, according to Hartmann, is characteristic to the pain in the knee, though this symptom is only symptomatic of the dis- ease of the hip. - Sulph., lyc., hepar, silic, zinc., mez., phosph., phosph. ac., bry., cham., puls., staphis., and sepia, should also be remembered in the treatment of this disease. - 2. Likewise in the first stage, for the purpose of insuring entire rest, it is well to fit to the part a splint of leather, gutta percha, or wire gauze, and secure it with a bandage. Extension should also be used if there are evidences of the second stage approaching, which is best effected by the weight and pulley, as recommended for fractures of the femur; or with the anterior splint of Professor Smith, of Baltimore, which latter I have employed with advantage. If the weight and pulley be used, care must be taken not to apply greater extension than necessary—three to eight pounds being suf- ficient. In the second stage, when the pain is intense, relief may be afforded by puncturing the joint, and evacuating the fluid the pressure of which causes the pain. This, however, must be practiced with circumspection. If confinement to a recumbent position prove prejudicial to the health, a different plan of treatment must be adopted, which, thanks to the ingenuity of modern surgery, can be successfully used. The splints of Barwell, or that of Hamilton (Figs. 321,322) are excellently adapted for this purpose. A felt splint or one of sole-leather can also be em- ployed. Dr. Henry G. Davis, in 1855, conceived the idea of constructing an instrument (Fig. 323) which should allow motion at the same time that ex- tension is kept up. Many modifications have since been made, some of the apparatuses extending to the ankle, some being fastened to a shoe, as Bauer's, and some made with an iron extending some distance below the sole to pre- vent jarring the acetabulum. In the mechanical treatment of diseases of the hip-joint, American Sur- geons stand pre-eminent. The names of Davis, Taylor, Sayre, Bauer, Knight, Shaffer, and many others, are of world-wide reputation, and the acknowledgment by most foreign surgeons of the superiority of our treat- ment of this affection above all others, is both satisfactory and encouraging. Occasionally, however, we find those who, having claims of their own to * On the Mechanical Treatment of Disease of the Hip-joint, p. 13. 40 626 A SYSTEM OF SURGERY. present, and not understanding how to apply the American methods, con- demn our practices in toto. For instance, we read: “Our transatlantic brethren deserve praise for having studied diligently to improve the treatment of these joint affections, but, by ignoring in all their designs the fact that friction is a greater evil than pressure, they have devised methods of less efficacy than those previously in use.” FIG. 321. Fig. 822. FIG. 323. g - m; 3 #S: > Tº ia W.i §ge#: º?2: Our treatment is also designated as “ridiculous malpractice;” or called an “irrational method ;” or such criticism as this bestowed upon it: “The best commentary on this method is the remarkable frequency with which its principal advocate (Dr. Sayre) has had to perform excision of the joint.” These complimentary phrases are from the pen of Dr. Thomas, of Liver- pool, who has a method of his own, viz., “fixation,” to introduce. He seems to be in perfect ignorance of the inclined plane, the abduction screw of Taylor, the lateral screw of Shaffer, the platform screw of Sayre, by which “friction ” (on which he lays so much stress) is avoided. Had he paid more attention to the literature, and especially the statistics of the treatment of hip-joint disease by the gentlemen whose treatment he ridicules, he cer- tainly would have been more sparing in the use of such harsh and uncalled- for criticism. In the mechanical treatment of hip-joint disease a great deal of care must ; exercised, or the application of the extension-apparatus will do positive à,TIYl. Dr. Newton M. Shaffer, surgeon to the New York Orthopedic Dispensary, thus writes on this important subject: “If we apply extension, for instance, to a diseased hip-joint, where flexion of the thigh exists, in a line which corresponds with the long axis of the trunk, we create a lever, where the fulcrum (insertion of the flexors) lies between the power (extension) and the resistance (joint surfaces). It is for the purpose of avoiding joint pres- 'sure in this condition that the limb is placed on an inclined plane, the patient * Diseases of the Hip, Knee, and Ankle-Joints. By Hugh Owen Thomas, M.R.C.S.L., Liverpool. EIIP-JOINT DISEASE—TREATMENT. 627 being in a recumbent position. The extension is then exerted, so far as the conformation of the hip-joint will permit, directly upon the joint, and the contracted muscles yield as the cause of the contraction is modified.” This is an important point to be remembered in the commencement of the treatment of hip-disease, wherein there is much flexion and adduction. For after the splint is applied properly, the limb must be placed on an in- clined plane and raised sufficiently high to bring the lumbar vertebrae to their proper curve, and then gentle traction made by turning the elongating screw, hereafter to be described. The following is the description of Dr. C. F. Taylor's splint and its method of application, as taken from his excellent monograph on the subject: It consists of a hollow rod of steel, reaching from ankle to hip, with a foot-piece, fitting in its lower end and movable up and down, for lengthening FIG. 324. FIG. 325. FIG. 326. º \ i :zgQº% N N N § § § | t \ V and shortening, by a key, which works in a rack on the outside of the in- side bar (or top of the foot-piece). The upper end is solid and very strong, and is used, except in special cases, fastened to the pelvic band by a simple bolt at the end. The pelvic band is made of steel, sufficiently strong to support the patient's weight without yielding in the least, and is about two- thirds of the circumference of the pelvis, measured over the trochanter major. It terminates in a strap which fastens into a buckle. From two points in front to two points in the back, perineal straps, pass along the perinaeum and under the ischii. These are made of rolls of flannel, covered * Archives of Clinical Surgery, vol. ii., p. 82. 628 A. SYSTEM OF SURGERY. with kid or some non-irritating material, and terminating in pieces of leather strong enough to hold in the buckles. They should be near together in front and far apart behind. At the knee-joint there is a leather pad to steady and support the knee, which fastens to a movable cross-piece. A stout leather sole is fastened to the lower part of the foot-piece, to prevent jar in walking on the instrument. A leather strap, passing under the foot, through apertures at each end of the horizontal part of the foot-piece, turns up on each side of the ankle, and fastens the buckles in the adhesive strips (Fig. 324). The first important object is to seize the leg in such a manner as to exert against it an unyielding force. This should be done in such a way as will not interfere with the circulation, or injure the knee, by unequal strain either below or above it. In other words, the whole leg should be grasped in such a manner that the knee will be supported. It may be done as fol- lows: A strip of adhesive plaster long enough to reach from the waist to the foot, and from three to five inches wide at the upper, and about one- third that width at the lower end, is taken and cut in five tails as shown in accompanying illustration (Fig. 325). A piece from four to six inches long is cut from the centre tail and added to the lower end to strengthen it; and, if the patient be strong, one or two more similar pieces are laid on the same place, where a buckle is attached. Two similar straps are prepared, one for the inside and one for the outside of the leg, and laid against the lateral aspects of the leg, the ends with the buckles beginning about two inches above the internal and external malleoli, and the centre tails reaching the entire length of the leg and thigh, to the perinaeum inside and the trochanter on the outside. The lower strips or tails are then wound spirally around the leg to the pelvis, and afterward the other two pairs of tails, which are cut down to just above the knee, are also wound about the thigh in the same manner. When complete, the thigh is encircled with a network of strips of adhesive plaster (Fig. 326), which act equally and without pres- sure on the whole surface. The leg has about one-fourth of the attach- ments, and the thigh three-fourths, which is found to be the right proportion to protect the knee equally from compression or strain. A few turns of the roller-bandage are then made around the ankle just under the lower ends of the straps, which serve as a protection to the flesh under the buckles, and then it is continued over the straps on the whole leg, as shown in the other figures. Thus prepared, the patient is ready for the splint. The instrument should always be applied with the patient lying on his back, and great care ought to be taken that the pelvis is not inclined forward by contractions of the flexor muscles. If such should be the case, the leg should be elevated till the lumbar vertebrae come near the couch ; or, in other words, the spinal column should be made to take its normal shape by elevating the leg till it can do so. The instrument is then applied as first described. But the pelvic band ought not to embrace the pelvis tightly, but there should be room enough for the latter to move freely in it. The anterior superior spine of the ilium ought to be above the pelvic band. When all is adjusted, while the patient still lies on his back, the key should be turned to the right and the instrument elongated, when the whole leg will be gently but strongly drawn downward and the pelvis lifted up with a direct yet easy force, from which there is no escape. In any variation of position or muscular action, the direction and amount of force employed are entirely under the surgeon's control. Nor is this all. The instrument should be so adjusted that there is a little space between the foot and the foot-piece, so that in standing or walking the weight does not rest on the leg, but the whole weight of the body should rest directly on the instru- ment. The patient sits firmly upon the padded straps, which, passing under HIP-JOINT DISEASE—TREATMENT. - 629 § ischium and perinaeum, are attached to the pelvic band in front and ehind. This arrangement for supporting the patient on the instrument—besides its independent provisions for extension and counter-extension and abduc- tion—increases the length of the affected leg, when it is fully extended, about one inch. The unaffected leg should have the same amount or a little more added to its length, by means of increasing the thickness of the sole of the shoe worn on that foot. The patient can then progress com- fortably and without any danger of either lessening the traction on the muscles, pulling off the adhesive straps, or producing pressure or concussion in the joint. The foot is dressed with the shoe in the ordinary manner. The splints of Dr. Sayre are provided with a screw for abduction and rotation, and are productive of excellent results; Dr. Shaffer has invented “a lateral screw,” which allows extension in any direction, and can be made to adduct or abduct the limb as occasion may require. This screw is made for application to Dr. Taylor's splint. I have employed most of these methods of treatment, and, although they are always troublesome and require much patience on the part of both sur- geon and patient, and frequent watching that the plasters do not slip, or the pressure excoriate, or the screws pinch, or that eczema does not result, yet, on the whole, excellent results can be obtained. Of late, however, I have been in the habit of using what is now known as the physiological treatment, advanced by Dr. Joseph C. Hutchison,” which consists simply of raising the patient on the Sound leg by means of an appropriate shoe, and thus, while walking with crutches, the diseased thigh drops down by the weight of the leg, and constant and very easy extension is kept up. The doctor says, that, to secure immobility of the joint, no apparatus is neces- sary, as nature accomplishes this result very early in the course of the disease, by reflex action, aided by the voluntary efforts of the patient to secure immunity from pain. To remove the weight of the body from the limb, to the shoe of the sound limb, a steel plate, corresponding to the sole of the shoe, is attached by two or three upright rods, two FIG. 327. and a half or three inches in length, so as to raise 3. * the foot from the ground; it is the shoe ordinarily used for a shortened leg. (Fig. 327.) This and crutches constitute the apparatus. I think, from considerable experience, I can agree with Dr. Hutchison, regarding the advan- tages which the mechanical treatment here de- scribed, possesses over that commonly employed in the management of hip-joint disease. (1.) “It saves the surgeon the trouble and annoy- ance of applying and carefully watching theinstru- ments in ordinary use, to see that proper extension is kept up and undue pressure prevented, while the patient's comfort is greatly promoted by dis- pensing with adhesive plasters which irritate the skin and require removal from time to time, and also with the perineal band which is a constant source of discomfort. (2.) “The spasmodic contraction of the peri-articular muscles is overcome by the gentle, persuasive and painless (physiological) extension made by the weight of the limb for several hours each day, whilst forcible extension, either by the ordinary portative instruments, or by the weight and pulley, * American Journal of the Medical Sciences, January, 1879. Also, his work in 1880. 630 A SYSTEM OF SURGERY. irritates the muscles and stimulates them to resistance and contraction, which must be overcome by main force. (3) “Judging from experience, it is seen that the plan of managing cox- algia, herein described, will shorten its duration more decidedly than can be done by the older methods of treatment. (4.) “The apparatus (if so simple a thing deserves the name) is inexpen- sive, and can be made by an ordinary mechanic.” Dr. V. P. Gibney,” in speaking of this apparatus, says that it does not prevent deformity. The question then comes, do any of these splints, as a rule, prevent deformity entirely 2 I think not. That, indeed, in some for- tunate cases, where the patient has a good constitution and early and careful treatment has been carried out, excellent results may be obtained, I do not deny, but in the majority of instances in the treatment of the general run of hip disease, deformity cannot be prevented, and I consider the termination of the case fortunate, if the disease be cured with some shortening and a slight halt in the gait. While, therefore, we aim at the cure with a leg of equal length with the other, and a straight foot, yet if the cure of the disease is ultimately effected, even with unequal limbs and par- tial anchylosis, let us be satisfied, and let the patient be told all these con- tingencies before the treatment begins, not after the deformity is settled and the hip disease cured. If the patient's health improve, and caries of the bone still continue, excision of the head of the femur is not only practicable but proper. In cases in which I have operated, great deformity was rectified, and the pa- º ºred to health, although sometimes with considerable shortening of the leg. The fracture-bed of Dr. Morgan, of Ithaca, which can be found in the Chapter upon Fractures of the Femur, answers all the indications. Dr. Morgan has cured several cases by the extension and rest which are admir- ably secured by his apparatus. - The question of excision of the hip in morbus coxarius, is still under'con- sideration by the profession; men of large experience taking opposite sides. As yet the exact position of the operation in the domain of surgery cannot be settled. At a meeting of the New York Medical Journal Association, held in February, 1878, Dr. C. F. Taylor asserted that he could not see the advantage in the proceeding, though he was ready to perform the operation if he could be convinced of its efficacy, and considered that the argument, that the disease was arrested and life prolonged, with a more useful limb to the patient, was a mere assumption. Dr. Sayre, who is an advocate for ex- cision, and who has performed the operation over seventy times, declares that when the bone is dead, it must be cut down upon and removed. It appears to me, that with the proper internal medication, and the appropriate me- chanical appliances, most of the cases of hip disease may be cured, but on the other hand, when cases are brought to us in extremis, when a large amount of diseased bone is found, and perhaps imprisoned by the involucrum, pre- venting its removal even by the disintegrating process, I think excision should be resorted to. In the cases I have operated upon, about half were not benefited, while some have been perfectly cured. The surgeon must satisfy himself on these particulars, and resort to the operation if his judgment so dictates. The full directions for performing the operation will be found in the Chapter upon Excisions of Bones and Joints. Loose Cartilages in Joints.-These bodies vary in number, from one to twenty-seven having been found in the same joint, and in size from that of -*. w * The Hip and its Diseases, p. 338, New York and London, 1884. LOOSE CARTILAGES IN JOINTS-TREATMENT, 631. a lentil to that of a large kidney bean. Their shape is quite as variable as their bulk; sometimes they are round or oval, or they may be smooth or irregular. Those resembling in appearance ordinary cartilage, consist chiefly of albumen; while those that are of a firmer construction contain a considerable proportion of phosphate of lime. The knee-joint is their most frequent location, although they are found in other jº. The etiology of this affection is very obscure; and, although many opin- ions have been advanced, as yet little positive information concerning the origin and growth of these extraneous }. has been ascertained. How- ever, certain it is that they commence as pendulous growths upon the synovial membrane; that the capsular ligament is distended with increased accumulation of synovia; that they increase in size; and, that they more or less impede motion. They appear after swelling of a joint, occasioned by a blow or fall; or they may arise without any assignable cause. In either. case, their presence is known by the pain which is experienced by the pa- tient, and by the tumefaction of the part, which increases during rest, but subsides during moderate exercise. r. Pagetº gives credence to a sugges- tion of Mr. Teale regarding loose bodies which form in the joints, which is, that they may be sequestra: “Just as a blow on bone or tooth may induce necrosis and exfoliation without signs of destructive inflammation, so may it be with articular cartilage; and the characteristics of these cases will be, that after injury to a previously healthy joint, a loose body is formed in it, having the shape and general aspect and texture of a piece of articular car- tilage, with or without some portion of subjacent bone, and with its cartilage corpuscles arranged after the manner of articular cartilage.” This, how- ever, is a very old idea, which has been reproduced by modern surgeons. and pathologists. A century ago it was disproved by Morgagni, who, from frequent experiment, found the cartilage of the joint entire and perfectly healthy in those subjects in whose articulations these movable bodies were met with in the greatest number. It often happens that, after a time, the pedicle which connects these abnormal formations to the synovial membrane, is ruptured; and, in such cases, they pass from one part of the joint to the other, and sometimes cause excruciating pain, by becoming impacted between the articular ex- tremities of the bones. In the knee-joint, they are very liable to fix them- selves between the posterior face of the patella and the pulley-like surface of the femur. In some situations, the foreign substances can readily be detected beneath the integument; and Dessault mentions a case in which they could be seized and twisted with the fingers. Treatment.—In this affection I know of no medicine which is applica- ble, although Dr. B. L. Cleveland, of Saginaw City, Michigan, informed me that he had cured a case of this troublesome disease by the internal administration of rhus tox. The patient was a lumberman, exposed to all kinds of weather, his vocation requiring him to use violent exercise. He fell accidentally into the water, and was taken with severe pains in the joint. These existed for one year and a half, when all the symptoms of loose cartilage presented. Rhus was used for two months, and all the symptoms disappeared. The doctor saw the patient some months after and he still remained cured. The action of rhus in this case would go far to establish the suggestions of Mr. Paget, which have been recorded, and from the known efficacy of rhus in affections of the cartilage, it would seem to have especial affinity for the form of disease under consideration. I know of no other medicine. Two cases have come under my supervision, and * St. Bartholomew's Hospital Reports, 1870. 632. s A. SYSTEM OF SURGERY. these were radically cured by the operation described below. As a general rule, strictly surgical means are the only resort. Surgeons have advised to force the cartilaginous formation to a part of the capsule where it will not interfere with the motion of the joint, and there retaining it by bandages, straps, etc., to endeavor to excite adhesive inflammation; however, such result can scarcely ever be attained, and therefore the operation must be performed. The patient, however, before proceeding with any such means, should be candidly informed of the danger incurred in opening the cavity of the joint, should be told of the ratio of successfully performed oper- ations, and should be allowed to determine what course to be pursued. If he consent to the operation, it should be performed in the following manner: the strictest antiseptic precautions should be used, and the patient having been placed on a mattress, or a table, with the leg extended in such a manner that the integument of the joint may be relaxed, the surgeon should search for the foreign body, and, having found it, should bring it to the inner side of the patella, and retain it in that position. The integument immediately over it should then be drawn as tense as possible with the finger and thumb (this may be accomplished with the left hand of the surgeon, or by an assistant), and with a single incision the skin should be divided. The foreign body can then readily be pressed through the opening, and the wound immediately irrigated with the bichloride solution and closed. If there is any connection with the surrounding parts, they may be divided with scissors or a sharp-pointed knife. Forceps, fingers, or any instrument likely to bruise the joint, should never be used. The pain of this operation is trifling, unless a branch of the internal Saphena nerve happen to be divided. The wound may be closed with anti- septic plaster, and compresses of cotton sprinkled thickly with iodoform ap- plied. It is after the operation that medical treatment is the most impor- tant. To prevent inflammation of the synovial membrane, it would be well to frequently administer doses of aconite, or if other symptoms are present, those medicines already mentioned in the treatment of synovitis must be employed. After the wound has healed, spurious anchylosis may follow, which may be relieved by the administration of arn., rhus, bry., or caust., together with moderate motion, which should be daily increased. If the patient recover with partial stiffness of a joint, the operation may be considered successful. Fleshy and gristly twmors may produce symptoms similar to those belong- ing to movable cartilage. The treatment is the same. The procedure of Mr. Syme is, however, the best that has heretofore been devised for the removal of movable cartilage, and the results published by those who have had opportunity of testing its efficacy, should lead to its immediate adoption in preference to any other mode. The cartilage is firmly fixed on either side of the joint, and while it is held in situ by an assistant, the skin is punctured by a long tenotomy knife, about two inches from the cartilage, and by a semicircular sweep, the areolar tissue is sepa- rated from the subjacent fascia, and the synovial membrane upon the car- tilage freely denuded. The cartilage is now pressed through the opening in the synovial membrane, and slid along the subcutaneous tract, and there fixed with a pad of lint, adhesive plaster and bandage; a straight splint is applied along the back of the limb, which is placed at an angle of forty-five degrees, and generally a cold-water dressing is applied. At a proper time, the cartilage is excised, and the remaining portion of the wound heals without difficulty. - - - - In the treatment of nine cases, the joint was opened thirteen times, and neither pain, inflammatory action, nor any serious symptom occurred in a single case. . . - TAT,IPES. 633 Talipes—Club Foot.—Talipes, which is generally a congenital affection, although in some instances it may be acquired, is divided by writers into four varieties, equinus, varus, valgus, and calcaneus. There are also other names given to deformities of this class, as they appear to be a combina- tion of two of the above, thus, equino-varus, calcaneo-varus, etc. There is also a condition known as talipes cavus or plantaris, in which the deformity is occasioned by the contraction of the plantar fascia. The deformity in the majority of cases is caused by paralysis of one set of muscles, which allows the antagonizing ones by their normal traction to displace the position of the foot. The disorder is also thought by some #. to be hereditary, males being more liable to the affection than emales. When one set of muscles spasmodically contracts, whether the action be rapid or progressive, and not under the control of the will, similar deform- ity results. Such cases are denominated spastic or spasmodic distortions. With reference to the degrees of severity with which patients are affected, Mr. Little writes: “It is convenient, for practical purposes, to divide congenital club foot into three degrees of severity: the slightest, that in which the position of the front of the foot, when inverted, is such that the angle formed by it with the inside of the leg is greater than a right angle, and in which the contrac- tion is so moderate that the toes can easily be brought temporarily by the hand of the surgeon into a straight line with the leg, and the heel be de- pressed to a natural position. The second class includes those in which the inversion of the foot and elevation of the heel appear the same or little greater than in those of the first class, but in which no reasonable effort of the surgeon’s hand will temporarily extinguish the contraction and de- formity. The third class comprises those in which the contraction of the soft FIG. 328. FIG, 329. FIG. 330. **. % º à % º % % à º º º à- sº % % % atº 3. ; º 㺠# % % % \,: w * -º Wººl º . º lº. º º % % º * %Af % .# 2. % º % % #: %; ź - § % | | º % # | º º º 3% º ſº, º ğ.ź º % % # º º % / #. % - 4. %% % #. wº zº Varus. Equinus. Valgus. parts and displacement of hard parts reaches the highest degree, so that the inner margin of the foot is situated at an acute angle with the inside of the leg, sometimes, or even almost in contact with it. Cases of the first and second grades may be respectively converted into the second and third grades by delay in the application of remedies, and by the effects of im- proper locomotion.” 634 A SYSTEM OF SURGERY. That variety which is most frequently encountered is talipes varus, which is generally accompanied with drawing upward of the heel, and receives the name equino-varw8. Talipes Varus.-In this variety of the affection, the foot is turned inward (Fig. 328), and the patient walks upon its outer edge, the sole looking in- ward; it is produced by contraction of the tibialis, or the adductors, and when partaking of the equine variety, by the gastrocnemius, and also by the strong contraction of the fascia plantaris. This form of club foot is often congenital. Talipes Equinus.-In this deformity, there is extension of the foot more or less complete, the heel is drawn up, the points of the toes touch the ground, which position is caused by contraction of the tendo Achillis, in addition to which there is flexion of the toes (Fig. 329). Talipes Valgus.-The foot in this form of the affection turns outward to a greater or lesser degree, in some instances the entire sole looking outward; in others, there being but slight eversion; the arch of the foot is lost. Flat foot is T. Valgus in a modified or slight form. The peroneus longus and the peroneus tertius are the muscles chiefly at fault in this deformity, together with the fascia (Fig. 330). In Talipes calcaneus, which is the reverse of equinus, the foot rests upon the heel, the sole looks forward, the toes are pointed upward. The deform- ity is very rare, is generally congenital, and is caused by a contraction of the tibialis anticus and the extensor muscles of the foot, the tendons being protuberant under the skin. One or both feet may be affected. If but one, the affected limb is found thinner and more flabby than the other, and, from arrest of development or imperfect nutrition, is weakened and shortened. Treatment.—The treatment of club foot should be commenced as early as the deformity is noticed; frictions and motions in the right direction—early employed, skilfully adapted, and duly persevered with—are alone sufficient to effect a normal relation of parts. Daily and for hours together the dis- torted foot should be held as nearly as possible in a normal position. Man such cases occur; and often it is quite unnecessary to subject the little patients to the pain of tenotomy. After a short period adhesive straps properly applied will assist in main- taining the foot in the proper position. An excellent method to accomplish this both before and after tenotomy is the plaster-of-Paris bandage. The foot must be placed as nearly as possi- ble in its normal position, and over the inequalities should be placed layers of cotton batting. The bandage should then be carefully applied, and the limb held in position until the plaster has “set.” - In talipes varus, provided both feet are affected, Professor Hamilton places the feet in Scarpa's shoes or in common laced boots. To the sole of each shoe, immediately under the ball of the foot, is placed a steel loop. The heels are then tied together with a tape, a steel bar, four or five inches in length and fitted with a shoulder at each end, is fitted into the loops, and thus keeps the toes well apart and the feet on the same plane. Dr. Newton M. Shaffer's% club-foot extension apparatus (Fig. 331), though somewhat complicated, is decidedly the most effective instrument in use. He explains its application as follows: “The club-foot extension apparatus, 1, consists of the ordinary uprights, A, A, fastened to the conventional heel-piece, B, by a plain joint on one side, * Medical Record, November 28th, 1878. TALIPES-TREATMENT. 635 and an endless screw, C, on the other. This screw, C, allows us, by using the key, D, to place the foot-piece of the apparatus, as a whole, in any an- tero-posterior position we choose, and to alter it at will, either before or after application to the foot. The dotted line, P, P, is supposed to represent the arc of a circle, the centre of which is the screw, C. That part of the foot-piece, E, which corresponds with the tarsus and metatarsus, is joined by a common extension rod, F (shown in 2), to the portion which lies under the os calcis. With the key, G, we are enabled to extend the anterior part of the foot-piece, E, at pleasure. 2 shows the apparatus lying on its side, with a full view of the under surface of the foot-piece, E, and the extension rod, F. At K, K, is a leather or rubber heel, built up on either side of the extension cylinder, and L represents a wooden sole, which is elevated to a FIG. 331. height corresponding with the rubber heel. So far as this apparatus is concerned, I may say that it presents no novelty, save the extension rod, and the modifications which this addition to the apparatus makes neces- Sal V. yTo apply this instrument, we first, by means of the key, D, place the foot-piece in a position that will exactly correspond with the antero-posterior position of the foot (whether tenotomy has been performed or not). We then secure the heel by tying the heel-strap, H, as represented in 3. We then bind the foot, anterior to the medio-tarsal joint, to the extension part of the foot-piece, E, by means of adhesive plaster, vide 3. We first apply four or five strips to the plantar integument, which are reversed as they pass over the end of the foot-piece, and are then fastened to the under part (wooden) of the foot-plate. Five or six strips are now passed longitudinally over the toes, and underneath, where they are also secured. Transverse pieces are then passed around the tarsus and metatarsus—also underneath the foot- plate—and secured at convenient points. . (The plantar strips are not shown in the engraving, and the artist has placed key G too far forward.) A band- age is then applied to protect the adhesive plaster. The key, D, is now used to flex the foot, in overcoming to the desired extent the tendo Achillis resistance.” . Fig. 332 represents the shoes of Dengler. In this apparatus the heels are connected by a chain, to allow some motion. The bar in front is connected with short chains as substitutes for steel springs. The shoes are constructed with coiled wire bands or elastic rubber, which, with a joint at the sole, allows considerable lateral motion. 636 A SYSTEM OF SURGERY. Fig. 333 shows Tiemann's modification of Scarpa's shoe. A spring, a, draws the foot outward, which tension can be increased by fitting the spring into sockets, c. There is a single outside steel bar fitted around the leg by FIG. 332. G. T. EMANN & Co. Dengler's Shoe. sº FIG. 833. Tiemann's Modification of Scarpa's Shoe. a belt, d, to this is attached a spring which passes around a wheel fastened to the outside bar above the ankle, and is fastened near the toes on the out- ºft D. º sº § ſ § \\ | 2. ' % ſ % ºº: gº Ayy a gº-ºº: G TIEMANN & G0 ° Sayre's Shoe. FIG, 335. Eisºtºl; Jāº; Shoe for Talipes Calcaneus. side of the foot. The action of this instrument tends to elevate the toes, and put the tendo Achillis on the stretch. This apparatus also, with reversed action, answers for talipes valgus. Dr. L. A. Sayre has introduced a shoe for both varus and valgus, and I have used it many times with excellent results. It consists (Fig. 334) of: A, cushioned iron cup to receive the heel, the leather covering of which is TALIPES-TREATMENT. 637 carried over the instep and ankle, and fastened by lacing. ... N, Elastic tubing to go in front of the ankle-joint, to further secure the heel in position, and fastening at C, an iron hook on outside of heel cup. D, Sole of shoe, cushioned and laced securely in front of the medio-tarsal articulation. E, Ball-and-socket joint connecting sole with heel. F, Elevated plate of iron, properly cushioned, to make pressure against the base of first metatarsal bone. G, Steel bars connecting the shoe with H, strap to go around the calf. K, Joint opposite the ankle. L, Stationary hooks, opposite the toes, for attaching the india-rubber muscles, M M M. These india-rubber tubes have chains attached, for the purpose of making flexion and ever- S1OIl. Fig. 335 shows apparatus for talipes calcaneus. Dr. Sayre lays down the following rule for ascertaining whether the ten- dons or fascia should be divided. He says:* “Place the part contracted as nearly as possible in its normal position, by means of manual tension, gradu- ally applied, and then carefully retain it in that position; while the parts are thus placed upon the stretch, make additional point pressure, with the end of the finger or thumb, upon the parts thus rendered tense, and if such additional pressure produces reflex contractions, that tendon, fascia or muscle must be divided, and the point at which the reflex spasm is excited, is the point where the operation should be performed. If, on the contrary, while the parts are brought into their normal position, by means of manual ten- sion gradually applied, the additional point pressure does not produce reflex contractions, the deformity can be permanently overcome by means of con- stant elastic tension.” Dr. Newton M. Shaffer, i speaking of the importance of properly ap- plied traction in club-foot, and the imperfectness of most of the apparatuses, Says: “In no part of the human body is the substitution of a purely mechanical force for the power generated by the contraction of muscular fibre—a very difficult proceeding in any event—more easily applied than at the foot. It seems easy to construct an apparatus with a joint to correspond with the tibio-astragaloid articulation, and to make this joint the centre of an arti- ficial movement imparted to the anterior part of the foot through the medium of the foot-plate. But let us see what happens when we attempt to do this with the ordinary forms of apparatus. The centre of motion, so far as the equinus position is concerned, is at the tibio-astragaloid articula- tion. The resistance lies in the post-tibial muscles, and the power is ap- plied in front to the tarsus and metatarsus—the object being simply to flex the foot and bring down the heel. As the anterior part of the foot rotates upon its artificial ankle-joint centre, or as we crowd the os calcis into the heel-cup, and attempt to flex the foot in the same way we would shut the half-opened blade of a knife, the heel, unless restrained, slips forward. One of the effects of mechanical flexion as applied in the customary forms of apparatus, to overcome either a post-tibial or a plantar contraction, is to crowd the tarsal bones together.” If the foot placed in the apparatus could be made to follow the direction imparted to it, our artificial would then correspond to the human mechanism. But it is found through various causes their relations become changed, and the results are often discour- agling. *omy—If the means above mentioned are not sufficient, tenotomy, or the subcutaneous division of tendons, must be effected. In talipes equinus, division of the tendo Achillis is usually sufficient. In * Lectures on Orthopaedic Surgery, p. 27. f Medical Record, November 23d, 1878, No. 420. 638 A SYSTEM OF SURGERY. talipes varus, division of this tendon may suffice, together with the use of mechanical aid. But very frequently it is also necessary to divide the tibialis posticus. In confirmed cases, the tibialis anticus and extensor proprius pollicis must be added to the list. In talipes valgus, the peronei are divided along with the tendo Achillis. In talipes calcaneus, the tibialis anticus is cut, along with the extensors of the toes. The knives which are best adapted to the perform- ance of tenotomy (tenotomes) are thin-bladed, with different-shaped cutting edges and points, as seen in Fig. 336. To divide the tendo Achillis. The patient should be placed prone upon a table, with the foot extending be- yond the edge. An assistant should then render the tendon tense, and the surgeon, feeling for the margin of the tendon, should enter a sharp-pointed tenotome flat- wise beneath the skin, and pass it behind the tendon; the cutting edge should then be turned backward and with a slight sawing motion the cord divided. The sur- geon, during the division of the tendon, should keep his finger on the parts to be cut (Fig. 337), and as soon as - they are divided and the knife withdrawn, he should place his finger over the opening, and retain it there for some minutes; a pledget of lint is then applied, and fixed by strapping. Division of the tendon of the tibialis anticus should be performed in the fol- lowing manner: An assistant steadies the knee and the surgeon takes the foot in his left hand, making the tendons as tense as possible by abducting FIG. 338. Division of the Tendo Achillis. Division of the Tendon of the Tibialis Anticus. the foot. The knife is then entered flatwise, about in front of the malleolus internus (Fig. 338) perpendicular to the surface, and carried down through the fascia; the sharp-pointed knife should now be laid aside, and a probe- pointed tenotome introduced behind the tendon, the edge turned forward and the division effected. - In Valgus it may be necessary to divide the tendons of the peronei. The SPURIOUS TALIPES-WEAK ANKLES. 639 foot must be adducted, the knife introduced behind the external malleolus, between the fibula and the tendons, and the cords divided in the same manner as before. The posterior tibial tendon is cut by entering the knife perpendicularly midway between the anterior and posterior borders of the leg on its inner aspect, and penetrating down to its tendons. A probe-pointed tenotome should then }. substituted for the sharp-pointed, and carried close to the bone, between it and the tendon; the edge is turned outward, and division effected by a sawing motion. Attention has lately been directed to excision of the bones of the tarsus for the cure of congenital talipes. The opinion of the profession is yet di- vided upon this subject. L. Werebelyi's records a case of congenital club-foot affecting both limbs, in which after tenotomy and the plaster-of-Paris bandage had failed, the astragalus was removed by subperiosteal resection, and by the application of proper retentive apparatus a cure was effected. Mr. Davies Colleyi re- moved almost the entire tarsus with success. The operation was performed on both feet. Hollow Club-foot—Pes Cavus.—This deformity is occasioned by paralysis of the interosseous muscles, with chronic contractions of those tendons which extend to the phalanges and also of those muscles which draw up the toes. The paralysis is chiefly confined to the short flexor and abductor of the great toe as well as the muscles which run to the first phalanges. This disease is always accompanied by a tendency to talipes equino-varus. The treatment is, first, to endeavor to stimulate the paralyzed muscles, and second, to divide subcutaneously those tendons which, by their contrac- tion, have a tendency to increase the malformation. The shoe of Scarpa, with a band across the toe, into which screws may be inserted to force down small padded blocks over the toes, and thus keep them in an extended position, may be employed and in some instances without division of the tendons. Spurious Talipes—Weak Ankles.—There is a variety of deformity known as weak ankles, or spurious talipes, which generally partakes of the valgus FIG. 339. Apparatus for Weak Ankles. variety, and is found in rapidly growing children. The ligamentous struc- ture gives way, the arch of the foot is lost, and the peronei muscles con- * London Medical Record, November 15th, 1877. f Archives of Clinical Surgery, vol. i., p. 266. 640 A SYSTEM OF SURGERY. tract. This deformity is also known as flat foot. The affection may be confined to either one or both feet, and if neglected, gives rise to serious deformity as well as lameness. Treatment.—In the milder forms, rest and a steel arch placed in the sole of the shoe, are of great service; but in most cases a shoe giving support to the ankle should be used. As seen in the cut (Fig. 339), a steel bar passes under the shoe, which has a joint, a. The bar is attached above to a band, b, and the ankle is supported by a broad strap and buckle, c. If there should be a tendency to contraction of the tendo Achillis, a strap, e, is affixed (Fig. 340). - Genu Valgum—Knock-knee.—This affection is caused by a weakness of the muscles and ligaments affecting the knee-joint, in which the internal hamstring tendons have a tendency to contract; or it may be occasioned either by an enlargement of the inner condyle of the femur, or by atrophy of the external condyle. The affection is so well known as to need little description. Treatment.—The first thing to be done in the treatment of knock-knee, is to take the child off its feet, allow it to exercise but a certain period of time each day and then to rest. It is not necessary to put on irons, unless the case is far advanced and the patient cannot be kept in bed. Then an ap- propriate apparatus, very light and carefully made, may be used. When FIG. 341. the tendons are very much contracted, and : the patient several years of age, it is neces- i. mºs sary to divide the rigid and contracted cords, Gº-> I, which I have done in many cases with most ; Euº excellent results. Fig. 341 represents Tie- mann’s apparatus. It consists (if the deformity be double) of two lateral stems, with joints at the ankles, knees, and hips, extending from the heel of strong shoes, a, to a well-padded pelvic band, b. The pelvic band is made in two halves, in order to admit of adjustment; the tight- ening of the posterior buckle everts the toes, that of the front buckle inverts them. A pair of padded straps, secured to each other crosswise, act in the following manner: End 1 is buttoned to the thigh-stem, c, car- ried from behind, below the inner condyle to the front, terminating in end 2, which is but- toned to the leg-stem, d. The end 3, buttons to c, is carried to the back of the knee, passing over the inner condyle, and secured to the button, d. In this manner they support both the head of the tibia and femur, whilst their combined direction of force being outwards, gradually corrects the deformity. Subcutaneous Osteotomy for Genu Valgum.—It is interesting in this con- nection to note the ages at which rachitic deformities occur. Out of 346 cases of rickets, 98 occurred during the first year, 111 during the second and third years, 29 during the fourth and fifth years, 5 from the sixth to the twelfth years, and 3 occurred before birth. Genu valgum and varum appears from the first to the eighteenth year, and it is a curious fact that the earlier these deformities appear the more likely are they to be complicated with other malformations, as anterior tibial and femoral curves, and various twists of these bones. As a rule, however, if knock-knees and bow-legs occur after the sixth year they are &º *:: Apparatus for Genu Valgum. SUPRA-CONDYLOID OSTEOTOMY. 641 generally uncomplicated. It has been discovered that genu valgum cannot be accounted for by a single curve, but that several inequalities of surface are necessary for the production of the deformity; for instance, there is gen- erally an internal curve at the lower end of the femur ; out of 166 cases of knock-knees, 120 had internal curves in the lower end of the thigh-bone. In 12 there was an anterior curve at the middle third. In the majority of cases the internal condyle of the femur is elongated and the tibia also is involved, showing a flattening of the external articular surface, or, in other M. the shaft of the tibia is placed at an angle with the head of the Oſle. § In Mr. Ogston's operation, the internal condyle of the femur is pushed upward and is placed on a higher level than the external, which produces the irregular articular surface and leaves untouched the tendons on the outside of the joint, and therefore osteotomy below the knee, which was performed by Mayer in 1851, may be the preferable operation. In this the incision is made at a point # of an inch below the tubercle of the tibia, and curved downward to almost surround the front and inner side of the head of the tibia. The flap is then turned upward and the periosteum is cut in the same line. This flap is separated by an osteotome. By means of a round saw, two incisions, each converging towards the posterior part of the tibia, are made to meet about a line and a half from the surface; this incision does not quite separate the bone into two parts. The wedge is then excised and the sawn surfaces approximated without dividing the fibula. Sometimes double osteotomy, consisting in the division of the tibia and the femur, is necessary, and, in aggravated cases, triple Osteotomy, or the division of the femur, tibia, and fibula, may be called for. Supra-Condyloid Osteotomy.—Probably, however, the best operation for the relief of the deformity, is that known as Supra-condyloid osteotomy, which is thus performed by Macewenn & The patient having been thoroughly anaesthetized, Esmarch's bandage is applied, and the limb laid upon a sand pillow, which forms a firm support. An assistant holds the upper part of the tibia while another steadies the lower portion of the femur. Two lines are then drawn transversely, one a finger's breadth above the tip of the external condyle, and another half an inch in front of the adductor magnus tendon. Where these lines intersect, a strong sharp-pointed Scalpel is entered and made to penetrate at once through the tissues to the bone, and a cut is made longitudinally of sufficient length to admit the finger with the scalpel; the largest osteotome is slid down by the side of the scalpel until it reaches the bone. The scalpel is now withdrawn and the osteotome is turned transversely across the shaft. It must then be drawn over the bone until it reaches the posterior internal border, when the in- strument is made to penetrate from behind forward and towards the outer side. After this incision is completed, the osteotome is turned to the inner side of the bone, severing it as it passes on until it has divided the upper- most part of the internal border, when it is directed from before back- ward towards the outer posterior angle of the femur. After the inner portion of the bone is divided, a finer instrument can be passed over the first, which is then withdrawn and sufficient pressure made to divide the bone. The osteotome is withdrawn and a sponge saturated with one to forty carbolized watery solution is placed over the wound. The Surgeon, holding the thigh in one hand, grasps the limb lower down and bends it steadily until the bone snaps or is bent in the proper position. The leg is then wrapped in an antiseptic solution and a similar process adopted with the other leg. * AEtiology and Pathology of Knock-knees and Bow-legs, London, 1880. 41 642 A SYSTEM OF SURGERY. Mr. Chiene operates in the following manner:* “Taking the tubercle into which the tendon of the adductor magnus is inserted as a guide, a vertical incision is made through the skin and fascia; then, on drawing these aside, the oblique fibres of the vastus externus can be seen in front, and the peri- osteum exposed. The internal articular artery is next secured by a double ligature, and divided. Lastly, the periosteum is raised up, and a wedge- shaped piece of bone is cut, by chisel and mallet, from the substance of the internal condyle. By gentle pressure the leg is now brought to its normal axis. The knee-joint is not opened. In the case exhibited, the wounds in each leg healed in a fortnight, but splints were kept applied for two months. Esmarch's bandage and careful antiseptic measures were used during the operation. The immediate after-treatment is not stated.” In some cases, it may be necessary to take wedge-shaped portions of bone from the femur and tibia, as is well illustrated in the following case. F. B., aged thirty, came from Minnesota, with a deformity of the leg, which was daily growing worse, was giving him considerable pain, and rendering him incompetent for any business. He had suffered when about fourteen years of age with a softening and disintegration of the cartilages of the knee and the articular extremities of the bone, especially the external condyle, which had finally left him, but in the condition as shown by Fig. 342. All appearance of disease had disappeared, and there was not even * † 2 = : ; ;-- Dotted lines show portion of bone removed After the operation, from a photograph. with the saw. tenderness of the parts remaining. I first endeavored to relieve the deform- ity by the application of an iron splint, with screws, having previously divided the ham-string tendons. This produced no effect, and he begged that an operation might be performed. The accompanying cut, Fig. 342, taken from a photograph, illustrates the deformity and the peculiarity of ºnkiejoint the patient being unable to set the foot flat upon the TOUlDOl. - - g Accordingly, on the 16th of October, in the presence of several medical gentlemen, the patient was brought fully under the influence of chloroform, * Loc. cit., December, 1877. BOW LEGSe 643 and the H incisions made; the two lateral being four inches and a half in length, the transverse uniting the two below the patella and exposing the joint. A triangular portion of bone was then sawn away from the head of the tibia and the condyles of the femur, the patella removed, and the limb brought into a straight position. A gutta-percha splint, moulded to fit the leg, and one to fit the thigh, secured together by straps, was next ap- plied. The apparatus was intended to keep the cut surfaces of the bone in close apposition. , a An anterior splint was then bound firmly upon the limb, which was placed in a straight fracture-box, with hinged sides. After several months the patient made an excellent recovery. Fig. 343 shows the patient after the operation. There was also considerable motion of the joint, much more than could have been anticipated. Bow Legs.-In children, though much relief may be obtained by wearing an apparatus such as is seen in the cut (Fig. 344), and which consists in binding to the outer side of the bow leg a spring the tendency of which is to bow outward, and fastening the same by means of a bandage; the best method of cure is by subcutaneous osteotomy. This operation must always be performed with the strictest antiseptic precautions. A longitudinal in- cision is made through the integuments, of sufficient length to allow the FIG. 344. Éi Harris's Bow-leg Spring. introduction of the chisel-blade. After the incisions through the muscular tissue down to the bone, every small twig of bleeding vessels must be secured, either by the ligature or by torsion, the chisel is turned trans- versely, and the bone partly cut through. The surgeon then takes the shaft of the femur in the left hand and the upper part of the leg in the right, and bends the leg to a straight position. The wound should be carefully closed, and the limb placed in a plaster-of-Paris mould. Mr. Ormsby, of Dublin, speaks highly of reducing bow-legs to a natural ‘position by forcibly fracturing the bent bones. This he avers can easily be accomplished by grasping the limb with two hands and laying the one against the other, or by bending the limb across the surgeon's knee. Mr. Ormsby states, “that this operation he has performed very many times, and has never noticed a single complication. He states also that several times 644 A SYSTEM OF SURGERY. he produced fracture; but that he never failed to rectify the deformity and never produced a compound fracture.” Hysterical Joints—Gonalgia.-There is a variety of nervous disease of the joint, especially noticeable in the knee (to which the name gonalgia is given) which is often very troublesome to treat. From the cases I have observed, I think females are more liable to be affected than males. I have seen it twice in young men, in one of whom I am quite sure it arose from pro- longed masturbation. It is often, though not always, accompanied by hysteria, but is usually connected with uterine symptoms. It is not an uncommon attendant upon the menstrual period, some women suffering intensely during that time. The pains are often aching and boring, and are apparently unbearable, confining the patient to bed during the period. The pains also sometimes attack the wrist, the ankle, the shoulder, and other joints, and intermit or pass away during any mental excitement. In some cases, especially in the knee, a cracking sensation is noticed, giving the idea that the joint has given way, with accompanying weakness of the limb. In one of my cases I noticed a peculiar rubbing or grating Sound similar to that found in arthritis. Together with these symptoms, there is generally apprehension and fear of moving the joint, from which cause alone stiffness may result. Treatment.—It is better that patients with hysterical joints should rest them, and that constitutional treatment should be adopted, such as is de- manded by the symptoms. Of the medicines I have used, ignatia, macrotin, caulophyllin, bryonia, and bromide of potash have done most service, which, combined with electricity, will often suffice. Relapses are frequent, and must be guarded against. Trigger Finger (Doigt a Ressort).-This is a rare and very peculiar affec- tion, and consists in a sudden loss of power to flex the finger, or after it is flexed to extend it. The voluntary power, however, of the flexors or ex- tensors is not entirely absent, for by an effort of the will the finger may be partially bent, then suddenly the action of the muscles, to complete the flexion, is lost, and the digit remains semi-bent. If the attempt now be made by mechanical means, or by an increase of will, to forcibly close the joint, the finger suddenly shuts down, or goes back with a snap. For ex- ample: Let the student take out his pocket-knife and open the blade at right angles with the handle. The blade represents the finger, the handle the metacarpal bones of the hand. Let him either fully open the blade, or close it, and the manner in which it shuts or opens with a snap, will repre- sent the mechanical action of “trigger finger.” The pain during this peculiar “snap' is often intense, and causes the patient to cry out, and, as a rule, mechanical interference is not necessary to complete the acts of flexion or extension; increased muscular effort being generally sufficient. This peculiar lack of power is occasioned either by a nodosity, or a thick- ening in the course of the flexor tendons, at a considerable distance from the articulation. Dr. George W. Jacoby,” who has made an interesting table of the cases of this affection, writes: “In looking over the cases pub- lished, and which I have tabulated, we find that, of thirty-three cases, twenty-one were in women and only ten in men, two cases not being speci- fied, a preponderance of women which is rather striking. All cases were in adults except two—a case of Berger's, occurring in a child five and a half years of age, and one of Leisrink's in a girl of ten. Occupation does not seem to have any influence upon the production. The fingers affected were, the thumb sixteen times, the ring-finger fifteen, the middle finger six, the * New York Medical Journal, June 19th, 1886. DISEASE OF THE SACRO-ILIAC SYNCHONDROSIS. 645 little finger twice, and the index only once—a total of forty fingers in thirty- one cases, five cases having more than one finger affected. These fingers show that the thumb and ring-finger are most frequently affected, and the index and little finger least frequently. Either hand may be affected indis- criminately. The aetiology must, in the majority of cases, be sought in rheumatism; next in frequency comes traumatism (cases of Notta, Dumarest, Vogt, and Blum), and in some cases no direct cause can be found, it being apparently of spontaneous origin. The début may be sudden, without any prodromal symptoms, but, as a rule, it is preceded by a series of symptoms, and then the affection develops slowly. These symptoms are frequent sharp pains in the metacarpo-phalangeal joint of the affected finger, pains going up along the volar surface of the arm to the elbow, but not localized over any particular nerve-trunks. The diagnosis is easy, as there is no dis- ease with which it could be confounded after once having seen a case, or even having read a description of it. The affection is so characteristic and peculiar, so different from any other disorder of motion, that a mistake can not easily occur.” Treatment.—In the treatment, electricity is said to be the most service- able agent. I should suppose also that potassium iodide would be of use, together with strychnine, in small doses, or physostigma hypodermically administered. If, however, the nodosity could be discovered, the surgical measure would be its immediate removal. I have never seen a case of doigt à ressort, and can, therefore, speak with no authority regarding treatment. Sometimes splints may be necessary, but according to Jacoby, massage does no good. The removal by the knife, if the nodosity can be found, to my mind presents the best chances of success. Disease of the Sacro-iliac Synchondrosis.--This is not a common disease, and is often, from its symptoms and its similarity to other joint affections, very difficult to diagnose. Dr. Charles T. Poore* has written a valuable treatise on the subject, having collected fifty-eight cases, two of which were from his own practice. He finds that Males. Females. Under 10 years of age, 4 3 Between 10 and 20, . 4 3 & & 20 and 30, . 9 9 6& 30 and 40, . 3 4 & 4 40 and 50, 2 3 Adults, © 7 5 Over sixty, * tº tº º © te © º 1 0 Sex not given, . e * e e tº tº tº e ... 1 1 30 27 The symptoms vary somewhat. There is lameness and pain on pressure upon the sacro-iliac synchondrosis. The limp gradually increases, and shows but little, alteration either in the morning, or in the evening. If direct pressure is made on the great trochanter, pain of more or less aggravated nature is experienced, which is also increased by striking the sole of the foot while the leg is extended. It is not necessary, however, that the pain should be confined to the affected part, for in the most extreme case that came under my observation, most of the suffering was referred to the knee. Another point which makes the diagnosis often difficult, is the flexion of the limb, thereby simulating morbus coxarius. Dr. Sayre believes the disease to be essentially traumatic, and says, with reference to examination for diagnosis, that when the wings of the ilia are held firm, and then an examination of the hip is made, no pain is experienced. In hip disease * American Journal of the Medical Sciences, January, 1878, p. 63. 646 A SYSTEM OF SURGERY. the different rotatory motions with abduction or adduction give pain; in Sacro-iliac disease these motions do not ; while pressing the ilia together against the sacrum, and making pressure along the sacro-iliac synchondro- sis always gives rise to suffering. Again he says:* “In Sacro-iliac disease, this lengthening of the limb is absolute, while in hip-joint disease it is only apparent.” - Abscesses, both intra- and extra-pelvic, are found in the advanced stages of this disease, in which case there may be flexion of the thigh, which will add also to the difficulty of diagnosis. In Dr. Poore's article, already mentioned, the following diagnostic points are mentioned, which I have arranged in a tabular form: SACRO-ILIAC DISEASE. Pain behind hip-joint, or may be referred to knee or thigh. No flexure of thigh, or if it appears, it comes after the formation of intra-pelvic abscess. No lordosis. Motion of hip-joint smooth, free, and pain- less. Pelvis does not move with thigh. No pain on pressure, either below Pou- part's ligament, in front or behind the tro- chanter. Pressure on ilium, at right angles to body, or attempted rotation of this bone causes pain. Tenderness over joint. No sudden pain at night. No shortening. Intra-pelvic abscess may come early. Locomotion more painful. Attitude different, body thrown to sound IIIP-JOINT DISEASE. Pain in the joint, or in the knee. Flexure of thigh early, without abscess. Early lordosis. Limited and painful. Pelvis moves with thigh. The reverse. Contrary. None. Sudden attacks of pain at night. In advanced hip disease always shorten- 1I] gº. Inºpelvic abscesses come late. Not so painful. Thigh flexed and pelvis twisted. side. In the treatment of this affection a good deal may be accomplished with medication, but the essential requisite is rest. To ensure immobility of the joint, a well-fitting wire cuirass, a plaster bandage, or perfect rest in bed must be resorted to. Dr. Sayre recommends the patient to use crutches, and to wear on the sound side a shoe with a sole of sufficient thickness to allow the affected limb to swing clear—thus making extension and counter- extension. - Flat-Foot—Splay-Foot.—This deformity, which also receives the name Pes valgus, is one by no means uncommon, but is according to my experi- ence very difficult to cure or to even relieve. The deformity is either con- genital or acquired, and, I am disposed to believe, may result in some in- stances from infantile paralysis. It is often hereditary, several members of one family being frequently affected. Injury of the spinal cord is another fruitful cause of the trouble; indeed, more than half the cases that have come under my notice could be attributed to such accidents, generally occurring during infancy and being overlooked. A badly treated Pott's fracture results often in flat-foot, and, as might be expected, it is frequently found in rachitic patients. In Pes valgus, as the name implies, the lateral and longitudinal arches of the foot are lost, the instep sinks, so that the entire sole of the foot rests upon the ground and is slightly everted, thus causing the weight of the body to be thrown on the inside line of the sole * Orthopaedic Surgery, p. 330. FLAT-FOOT-SPLAY-FOOT. 647 of the foot, in fact the inner side of the plantar arch falls down because, from one cause or another, the astragalo-Scaphoid and calcaneo-cuboid joints give way. The disease generally begins in youth and progresses as the child grows, the weight of the body being placed more and more upon the weakened joints. If the deformity is slight, it almost entirely disappears upon lifting the foot, but as soon as the patient assumes the erect position, the weakness of the joint shows itself at once. Other bones of the tarsus, as the disease advances, become implicated. The entire foot becomes thinner and longer than the other, and the great or the second toe becomes deformed, turning outward and lapping in a greater or lesser degree over the others. With these changes another symptom is noted: the partial dragging of the front portion of the foot, -the patient often stumbling over slight inequalities on the surface of the floor or ground, over which the other foot swings clear. Finally the os calcis may become so displaced that the posterior protuberance can only be brought to the ground with difficulty. It will readily be seen, that from constant traction of the deltoid ligament, the internal malleolus becomes prominent. ' ' ' .. Treatment.—If the deformity is recognized early and does not procee from any disease of the cord, something may be done, by properly applied mechanical support, to assist in elevating the instep. A steel arch can be constructed between the leathers of the sole of the shoe, which will correspond exactly to the curve of the arch of the instep of the sound side—or inside the shoe an artificial instep may be made of cork or of leather, tapering down gradually towards the end of the tarsus; by these means pressure in the right direction may be maintained, while the inner side of the heel and the sole should be raised by additional bits of º the heel also being made somewhat longer than that of the opposite S1(16. While these mechanical means are being used, severe or prolonged exer- cise should be strictly forbidden. According to my experience, walking on a level road or floor is, up to a certain point, beneficial; but where there are many stones and through a hilly country, this exercise should be strictly prohibited. The foot is weak, the patient has not the same control over it as he has over the other, slight inequalities cause him to trip and fall for- ward, or if inadvertently a loose round stone is stepped upon, a severe twist is likely to occur. Walking down hill is always bad. The game of lawn tennis is especially to be forbidden; jumping to strike the balls, or lean- ing far over on one foot to intercept them may be a source of irreparable Injury. Surgeons and especially Mr. Alexander Ogston, of Aberdeen, have recom- mended and performed operations, the object of which is to establish anchy- losis of the astragalo-scaphoid articulation. Mr. Ogston's procedure is as follows:* An incision is made on the inner border of the foot, parallel to the sole, beginning an inch from the tibia and carried for an inch and a quarter down to the bone to allow the joint (the astragalo-scaphoid) to be fully exposed. The articular cartilages of the joint are to be removed with a thin lamella of bone; this is to be done with a sharp chisel half an inch broad. The arch of the foot is then to be carefully restored. When this is accomplished, the bones are held in their new position by wing pegs, passing from one bone to the other. The patient must be kept at rest from two to three months, and perhaps even for a greater length of time, according to the judgment of the surgeon. This operation has been suc- cessful, Dr. Ogston stating that in seventeen operations performed upon ten * British Medical Journal, January 19th, 1884. 648 A SYSTEM OF SURGERY. patients, all except one were cured, and in that one the peg was extruded. In no case did the temperature rise over 100°, and there were no symptoms of fever developed. ' - CHAPTER XXXIII. DISLOCATIONS OR LUXATIONS. GENERAL ConSIDERATIONS —VARIETIES — DIAGNOSTs —TREATMENT — ExTENSION AND CountER-ExTENSION.—MANIPULATION.—FALSE JOINT—ANCIENT DISLoCATIONs—SPE- CIAL DISLoCATIONs of DIFFERENT Joints. - SURGEONs have divided dislocations into different kinds, according to the degree and extent of the injury. Thus we have the simple and compound, the complete and incomplete, the primitive and consecutive, recent and old. The latter terms carry with them their own explanation. A simple dislocation is when the articular surfaces are separated, the ad- joining soft parts or bones being but slightly injured. A compound dislocation is when the dislocation is accompanied with con- tusion of soft parts, laceration of bloodvessels, fracture, a wound penetrating into the joint, or reaching as far as the dislocated bone. A complete dislocation is that in which the head of the bone is separated entirely from its natural position; the head of the humerus, for example, driven down into the axilla and resting upon the edge of the scapula. In an incomplete luxation the parts still are partially in contact, as when the head of the humerus touches the coracoid process of the Scapula. In a primitive dislocation the displaced part remains in the place into which it was first forced; while in a consecutive dislocation it leaves its orig- inal seat and passes into another. Congenital dislocations are rare, and these have, in most instances, been confined to the shoulder, wrist, and hip ; sometimes several joints in the same infant are affected. Instances go to establish the fact of their being, at times, hereditary. Of their cause no satisfactory reason has been given. Probably they may be the result either of internal or external force, or dis- ease in the joints of the embryo. The bones farthest from the trunk are considered as those dislocated, those of the ankle excepted, in which case the foot is regarded as the fixed part. Besides violence, undue muscular action may produce displacement, espe- cially if the parts adjoining the joint are in a relaxed or unhealthy condi- tion. Parts subjected to frequent and extensive movement are most liable to be luxated, therefore the accident is more frequent in the ball-and-socket joints. The middle-aged and those advanced in life are most liable to be affected, and the dislocated part may be thrown either backwards, forwards, wpwards, or downwards, according to the formation of the joint and the direction of the force applied. - * : There are certain individuals in whom there is a peculiar looseness of the joints, who are particularly liable to dislocations. M. Tillaux* records a case in which the shoulder was out of joint several times a day, and I have in mind a remarkable case, in which by voluntary action a man could place the head of the humerus beneath the coracoid process at will, and of another loose-jointed individual who could throw the head of the femur to the dor- sum ilii whenever he so desired. General Diagnosis between Fractures and Dislocations.—In fracture there * Monthly Abstract of Medical Science, November, 1876, vol. iii., No. 2. GENERAL TREATMENT OF DISLOCATIONS. 649 is increased mobility, crepitus, and when the broken extremities are placed in apposition, they will not thus remain without external support, while in luxations there is unnatural rigidity, and the displaced part remains fixed. These differences are generally discovered ; at times, however, ex- ceptions present themselves. The rasping sound and sensation produced by dislocated bones have by the inexperienced been mistaken for the real crepitus of fractures. There is likewise discoloration, pain, and swelling; at times temporary paralysis; the limb is shortened, very seldom lengthened. When the dislocated ...Y of the bone can be felt, it will be found in an un- natural location, and a depression be detected in the place that the extremity of the bone occupied. - General Treatment.—The sooner the bone is replaced the better. The replacement is then most easily effected, and in a majority of instances can be accomplished without the aid of other means than the hands. To do this with certainty requires an accurate knowledge of the ligaments and muscles. The adverse action of muscles may at times be overcome by di- verting the patient's thoughts, especially at the moment when the final effort is made to replace the bone. He may be startled by having communicated to him intelligence which would be deeply interesting; or by suddenly attracting his attention to surrounding objects, or otherwise so interesting him, that his thoughts may be diverted from the accident and his muscles thereby be somewhat relaxed. Unless a dislocation is reduced soon after the accident, a partial or com- plete inability to move the part may continue during life. Even if the replacement has been accomplished in a short time after the occurrence, the movements of the joint may for a considerable period, sometimes for years, be constrained. The two forces employed to reduce dislocations are extension and counter- extension. The former is applied to the extremity of the dislocated bone, the latter by retaining firmly and immovably the upper parts nearest to the dislocated extremity. If the hands alone are not sufficient to effect reduction, a handkerchief with a clovehitch (Fig. 345), or a French knot or bandages must be employed. In dislocations of large bones, compound pul- leys or the rope windlass may be required. In the treatment of individual dislocations, the proper mode of applying these different means will be explained. If an anaesthetic be employed during the operation, the method of administration may be found by referring to the chapter upon that subject. Reduction of dislocations, even of the larger joints, by manipulation alone, is now attracting much attention. It has been ascer- tained that shoulder and hip luxations, which were formerly supposed to require a great degree of force for their reduc- tion, can, by proper handling, be brought to their natural positions. This, however, requires a perfect knowledge of the mechanical action of the muscles and ligaments surrounding the joints, in order that those which offer the most stubborn resistance be made to relax. Among those who have made this subject a specialty are found the names of Professor Nathan Smith, the father of Professor Nathan R. Smith, of Baltimore, who, as far back as 1824, testified under oath: “I do not think that the mechanical powers, such as the wheel and axle, or the pulleys, are necessary to reduce a dislocated hip or any other dislocation.” Kluge, Rust, 650 A SYSTEM OF SURGERY. Reid, Markoe, Hamilton, and Bigelow have given the subject careful con- sideration—the last-named having given to the profession a treatise on The Mechanism of Dislocation and Fracture of the Hip, reference to which will be found in the section on Dislocations of the Femur. After a dislocation has continued for a length of time, various pathologi- cal changes ensue, the functions of the muscles are altered, tendons form new attachments, plastic effusions take place, and adventitious formation of bone often results, the head of the bone has changed its locality, and gradually taken to itself a new resting-place, and a cavity is formed for its reception. A species of cartilage caps the surfaces, and a new or false joint is the result. In some cases it is extremely difficult to diagnose whether such formation has taken place, orif the case is a chronic rheumatic arthritis. While these adventitious growths are taking place, the bloodvessels and nerves of the parts are imbedded in them, or incrusted with new forma- tions, rendering them brittle, and therefore in attempting the reduction of these chronic dislocations, too much force must not be applied. Fatal haem- orrhage has followed such forcible endeavors. It would be a source of satisfaction to the surgeon if more light pene- trated a subject unfortunately enveloped in much obscurity, especially if he knew the time required for the formation of false joints, or those plastic effusions, the presence of which renders the reduction of dislocations dan- gerous. This varies so much in different cases, that no specific time can be mentioned. Perhaps it may be admissible to attempt reduction within three months after the accident. The operator, however, must be the judge. Dislocation of the Clavicle.—The luxation of the sternaţ extremity of the clavicle is rather an uncommon accident, and is occasioned by great violence applied to the shoulder. When the scapula is fixed, the directions are for- ward, wipward, and backward. Dislocation forward (Fig. 346).-This luxation is sometimes incomplete, as I have noticed on two occasions in children. In such instances, the prom- inence is well marked, and in the ma- jority of cases the luxation may be reduced by pressing back the shoulders and forcing the end of the bone into its place. When the dislocation is complete, the symptoms are: 1. Head of the bone forming a tumor on the articulation. 2. Head of bone depressed and gener- ally pointing downward. 3. Shortening of shoulder from its prominence to sternum. The upward dislocation is very rare. Malgaigne, Hamilton, and Mr. Bryant mention such cases, the latter gentleman having seen both clavicles dislo- cated upward. In this accident, 1. The shoulder is shortened. 2. The head of the bone rests on the top of the sternum. 3. The tumor moves with the shoulder. b 4. The injury is generally apparent from the exposed situation of the On 6S. - Dislocation backward is genegally caused by direct force, or violence forcing the shoulder forward, or more frequently it may be produced by disease, as in the instance reported by Sir Astley Cooper, in which it was TREATMENT OF DISLOCATION OF THE CLAVICLE. 651 occasioned by curvature of the spine. In these cases the principal symp- toms are : 1. Difficulty of respiration if the bone presses on the trachea, or, 2. Difficulty of deglutition if the pressure is made upon the oesophagus. 3. Head generally inclines forward. 4. Shortening from middle line to the acromion. Treatment.—In the dislocation forward, by drawing the shoulder outward and pressing down the head of the bone, reduction may be effected, or by placing the knee between the scapula as a fulcrum, and drawing the shoul- ders backward, the bone can be pushed to its place. After reduction, the apparatus of Levis for fractured clavicle (see page 561) will answer extremely well, and to keep the head of the bone in position an ordinary truss, as recommended by Nélaton, with the pad on the projecting bone, and the end of the spring in the axilla or on the shoulder, will prove satisfactory. The pressure should be kept up seven or eight weeks. An interesting case of this dislocation occurred in the practice of my friend Dr. B. A. Clements, U. S. A. It is well worth reporting, as the result was so satisfactory. Sergeant S. Martin, general mounted service, a spare and active man, aged about thirty-six years, fell head foremost down a dry well at St. Louis Barracks, Missouri, on March 6th, 1873. The well was sixteen feet deep, and at ten feet from the top there was a large projecting rock. He struck the latter with the back of his left shoulder. The shock of the injury was considerable. On examination, the left shoulder and the back of his neck and of his left arm were found much scraped and bruised, but there was no fracture. The following morning it was seen that the sternal end of the clavicle was dislocated backward and somewhat downward. * - Pulling the shoulders strongly backward, and at the same time placing the knee between the scapula, partly restored the bone to its proper posi- tion, but not entirely so, it being also necessary to pull up the end by the fingers, which procedure was not difficult owing to his lack of flesh. A large pad was put between his shoulders and he was laid on his back; this, however, did not suffice to keep the bone in position, and the ordinary rings and tapes, so useful in fractured clavicle, were applied, and with great success, the end of the bone being kept well in position. The apparatus was removed on April 10th, five weeks after the receipt of the injury, and the bone found to be firmly joined to its attachments. He complained now solely of stiffness of his left shoulder, and inability to use his arm as well as formerly. w - He continued under observation until August, and frictions and iodine were used to his left shoulder-joint without much benefit. There was no swelling about the joint, but there was a shrinking of the deltoid—not great, but yet perceptible. He could raise his arm only to an angle of some sixty degrees. No improvement in this condition having occurred in the course of four months, he was discharged the service on August 3d, 1873. He would seem to have recovered in great measure the use of the deltoid, as a few months after his discharge he was employed in driving a street car. This rare injury was caused, as will be observed, by the shoulder being driven forward and inward. The success of the treatment with the ring apparatus for fractured clavicle was perfect, the dislocated bone being firmly ; in its position, till reunion of the ligaments took place. In the upward luxation, by drawing back the shoulders, reduction is, in the majority of instances, readily accomplished, but it is a very difficult matter to keep the bone in situ. The best that can be done is to apply to the shoulders a figure-of-eight bandage, and to place a compress over the head 652 A SYSTEM OF SURGERY. of the bone, holding it as firmly in place as possible with broad adhesive straps crossing each other at right angles, or the hernia truss, as already mentioned. It is, however, satisfactory to know that both Malgaigne and Hamilton found the function of the clavicle perfectly restored, excepting when an attempt was made to lift weights above the head. In the backward variety the same method of drawing back the shoulders must be tried, and as is recorded in Mr. De Morgen's case,” a splint should be placed across the shoulders with a pad between it and the spine, the shoulders being drawn to the splint by a bandage. The apparatus of Mayor for dislocation of the clavicle is seen in Fig. 347, a representing sling; b and c shoulder belts. Dislocation of the Lower Jaw.—Luxation of the inferior maxillary bone is the effect of direct violence upon the chin, or it may be produced by muscular action, as laughing, or yawning. From the peculiar formation of the joint, the direction forward is the only one in which the dislocation occurs. The symptoms are (Fig. 348): - 1. Open mouth. 2. Condyles rest in front of the base of the zygomatic arch. 3. Condyloid space vacant. - 4. Prominence beneath zygoma. 5. Articulation painful and indistinct. Treatment.—Having enveloped the thumbs in a piece of stout cloth, they must be placed upon the molar teeth, while the fingers and hand are placed beneath the chin and base of the bone. Pressure must now be made with FIG. 347. FIG. 348. the thumbs whilst the chin is elevated by the fingers; the moment the bone is slipping into place, the thumbs, protected by a pair of thick gloves, are slipped from the teeth upon the gums. If there be difficulty in reducing both condyles at the same time, one should be reduced before the other is attempted; this generally is successful. ... º º In persons disposed to spontaneous dislocation of the jaw from gaping, etc., a return of the displacement may probably be prevented by the exhi; bition of a dose of staphis, ten drops of the 3d attenuation every night and * Holmes's System of Surgery, vol. ii., p. 805, DISLOCATION OF THE PUBIS. 653 morning for three months. Should this medicine not accomplish the desired object, rhus tox., from its known specific action upon ligamentous tissue, might be tried, in like manner. A successful preventive treatment of this accident is much to be desired ; its frequent repetition in some individuals, especially women, is a source of considerable annoyance as well as pain. islocation of the Pelvic Bones.—Dislocation of the pelvis is the result of great violence, the nature of the force being generally that of crushing. In the majority of instances these dislocations are of serious import, as the force required to separate the bones is very great, internal organs being more or less involved. The danger is to be estimated from the amount of injury sustained by the abdominal organs. In some cases very severe inju- ries of this kind have been followed by recovery. Dislocation of the Pubis.--It appears that the separations of the symphyses, or, as they may be called, dislocations of the pelvis, especially those occur- ring at the symphysis pubis, are those which are most likely to be followed by favorable results, especially those that occur during parturition, of which I have known three instances, all of which recovered. In Malgaigne's cases, seventeen of which occurred during labor, ten died and seven recov- ered ; and of the four cases attributed to accident, two died and but one recovered. Dr. Bryant* relates the case of a woman aged 30, under his care, in which the pubic bones were displaced on the right side for more than an inch, leaving a curious deformity, the pubic bone, with the adductor muscle attached, being curved out, leaving a hollow on the inside of the thigh. The same author reports a second case in that of a female child, in whom there was great separation of the pubic bones, the contents of the pelvis being pressed out through the opening, a foot of the large intestine, the ute- rus and bladder all being outside. This patient also recovered. It is quite proper to mention here, that an accident of this character, viz., separation of the pubic bones, may occur during a labor without either the patient or the practitioner being aware of the accident at the time. A suit occurred in Brooklyn, in which I was called upon to testify, where such an occurrence took place. - The dislocations which occur from violence are much more liable to implicate the pelvic viscera, and therefore are much more serious. Dr. Lente, of the New York Hospital, reports+ (also quoted by Hamilton), the case of a man aet. 18, crushed between two cars; there was a separation of the symphysis, and the patient died in two days. The post-mortem i. a rent in the apex of the bladder large enough to admit a man's thumb. Sir Astley Cooper gives, also, a case of separation of the symphysis of about two fingers’ breadth, which recovered after a considerable period. The most marked case of separation of the symphysis which I have seen, occurred in the practice of Dr. Lewis Grasmuck, of Kansas, and was re- ported by Dr. S. B. Parsons.S His description of this case shows so well the symptoms of such a condition that I shall quote therefrom, particularly as I was cognizant of many of the facts, and also had the satisfaction of examining the woman myself. The patient was the mother of four children; was married at the age of fourteen. Her first child was born during her fifteenth year. The labor lasted nine days, and finally to facilitate the process, large quantities of a decoction of ergot (“half a saucerful every two hours”) were administered. “The pains then became intense and constant, and severe local suffering * Practice of Surgery, p. 944, English edition. † New York Journal of Medicine. - ºf Cooper and Traver's Surgical Essays. 3 Western Homoeopathic Observer, March, 1866. 654 A SYSTEM OF SURGERY. was felt at the symphysis pubis, growing more and more aggravated at each effort of the uterus. So agonizing were the labor throes that consciousness was lost three hours before delivery, and did not return for some time there- after, consequently she knew nothing of what transpired during those ob- livious moments.” - Her recovery was slow, and the following were the symptoms noted, which I have numerically arranged: 1. Strangury. 2. Irritation and inflammation of the labia. 3. Constipa- tion. 4. Abscesses above the mons veneris, which opened above the clitoris. 5. Inability to walk without severe pain at the symphysis pubis, and also at the right Sacro-iliac symphysis. 6. Shooting pains along the pubic bone, extending down the thigh whenever movement of the pelvic bones was at- tempted. 7. Crepitus was distinct, and remained for four months and then disappeared, to return at the second, third, and fifth labors. The above- mentioned symptoms were all present, except the abscess, on each of the Occasions. 8. The pains in the symphysis were intolerable, and confined her to her bed during the later months of gestation. In the recumbent position the symptoms were much relieved. 9. When I saw her the arch of the pubis was expanded; there was considerable swelling of the entire vulva. On the anterior surface of the mons veneris a groove could be readily detected, showing the separation of the pubic bones. 10. The ex- tremities of the bones were sensitive to pressure. 11. The right pubic bone was found also projecting a little anterior to the left. These were the symptoms that were especially noticeable, and I have condensed them as showing what peculiar manifestations may be present, in order to assist in pointing out the true nature of the case, which might be obscure, especially in the hands of the inexperienced. . The second case of separation of the symphysis which came under my care was congenital, and occurred in that remarkable case of extrophy of º bladder, with one kidney and one ureter, which I have recorded else- WIlere. The treatment is, first, the constant use of the catheter, if necessary; Second, perfect rest, in the supine position, a pad on each side of the sym- physis, and a wide roller bandage applied around the hips. This appli- ance is not difficult to put on, but very troublesome to keep in position. It must be secured by perineal bands, which must be fastened at the pubis and the sacrum, to keep the bandage from riding upward. A well- padded leather belt, with appropriate straps and pads, would, in my judg- ment, answer the indications better than any other apparatus. During the period that the patient is in the recumbent position, appropriate treatment (I mean internal medication) must be adopted. Symphy- tum is recommended by some surgeons in this country, as well as by Dr. Ruddock, of England. My preference is for one of the preparations of lime or phosphorus, or both in combination, as the symptoms may indi- Cate. - Separation at the Sacro-iliac Symphysis.-There are not many examples of this accident upon record. In the memoir of M. Viluysken on the subject, which I find condensed in Ranking's Abstract, vol. vi., 1848, there are five cases reported, and in the Provincial Medical and Surgical Journal, for November 17th, 1847, also quoted in the eighth volume of the same compendium, two others. Besides these cases there is one reported by Phillipi, at Chartres; another in 1731, by Bassius; the cases by Enaux, Hoin, and Chaussier; that of Baron Larrey; that of Harris, in the Journal of the Medical and Physical Sciences, of Philadelphia, vol. xv.; and two cases by Heidewreide, in 1839. I have condensed the symptoms of several of these cases, as they are DISLOCATION OF THE RIBS. 655 especially instructive. In one instance the separation was caused by a fall from a height of six feet upon the left tuber ischii; the patient was a woman aged 24, and the accident occurred on the 7th of May, 1798; the suffering at first was intense at the tuber ischii; there was no crepitation; the limbs were found to be about the same length. After eight days the pain gradu- ally disappeared, and she was allowed to cautiously exercise. In thirteen days the pain returned; the left limb grew shorter than its fellow, and the more she walked the more perceptible became the shortening, it amounting to nearly two inches. Every time she endeavored to support herself on her left foot, the body was so suddenly flexed laterally toward the left side, that it might be said that the superior edge of the ilium approached with vio- lence towards the false ribs. The form and motion of the left leg were unimpaired, but the iliac crest of the left side was higher than that on the right side, but upon steady pressure the elevation could be made to descend to its proper level, the limbs being then brought to their proper length. The treatment of this case was extension and counter-extension, the pa- tient in the horizontal position, and the parts rendered immovable by an ap- paratus resembling the splint of Dessault; an elastic band eight inches wide was so applied that its upper border corresponded with a line drawn about an inch above the crests of the ilia, and its inferior edge with the lower parts of the sacrum. The apparatus was put on on the 13th of June, and removed on the 15th day of September, the patient being perfectly cured. In another case the limb was shortened after several days; the coxo-femoral motions, however, being executed with freedom and without any pain. The posterior part of the ilium was movable and painful, and the crest of the ilium on the injured side was more elevated than the other. A similar ap- paratus was applied and a cure resulted. In another case, besides the above-mentioned symptoms, there was pa- ralysis of the rectum and bladder, and the crests of the ilia nearly touched the false ribs. No attempt was made to reduce the bones, and the patient recovered by being merely kept in the horizontal position. From these cases, to which I have briefly alluded, and from the study of the few others I have been able to find, we may infer that in separations of the sacro-iliac symphysis, there is not immediate shortening, but that from eight to ten days after the injury this condition may occur; in this particu- lar resembling the intracapsular fracture of the neck of the femur. The diagnosis, however, may be readily made out by remembering that in the latter there is eversion of the foot, inability to raise the heel from the bed, and inability to perform the usual movements of the coxo-femoral articula- tion. The shortening in the dislocation may be relieved by extension, and pressure upon the elevated crista ilii. In the separation of the bones there may be a sudden falling of the body to one side, when the patient endeavors to stand on the affected limb. The crest of the ilium is also more or less elevated, and may reach almost to the cartilages of the false ribs. There may be crepitus and preternatural mobility at the seat of the joint, and paralysis of the bladder and rectum may also be present. For these cases the treatment consists in extension and counter-extension ; pressure on the elevated crest of the ilium ; a broad belt with appropriate pads around the pelvis, and extension maintained either by Buck's, Hamilton's, or #º extension apparatus, or perhaps by the anterior splint of Nathan R. Smith. Dislocations at the junction of the pelvic bones in the acetabulum, are considered under the head of fractures of those bones. Dislocation of the Ribs from their cartilages sometimes occurs, and may be recognized by an unnatural protuberance. Treatment.—These cases are managed by placing a compress upon the 656 A SYSTEM OF SURGERY. extremity of the rib, and passing a roller around the chest, to secure the compress, and controlin a measure the action of the muscles. Dislocation of the Vertebrae can hardly occur without fracture, and is the result of such violence that other symptoms demand our attention. Abso- lute rest is the most important object ºf treatment. Dislocation of the Lower Extremity—Coxo-femoral Dislocations—Dislocation of the Hip-joint.—As ordinarily described, there are four dislocations of the head of the femur. 1. Upward and backward on the dorsum of the ilium (Fig. 349). 2. Upward and backward into the ischiatic notch (Fig. 350). 3. FIG. 349. Fig. 350. º ". ſº º "W", -- - - ". | Iliac Dislocation. Sciatic Dislocation. Downward and forward into the thyroid foramen (Fig. 351, see next page). 4. Upward and fºrward upon the pubis (Fig. 352, see next page). Besides these there are other or irregular dislocations of the bone, which vary accord- ing to circumstances. Dr. M. H. Henry reports an interesting case of the latter.” A man (aet. 19), well developed and muscular, fell from a tree, receiving a blow on or near the trochanter of the left side, and on examination a few days after, a dislocation of the head of the femur on the pubis was discovered. The limb was shortened less than an inch, somewhat flexed, abducted, and everted. After being placed in bed, and ice-bags applied over the surface of the dislocated parts, the limb was extended; and a week after another unsuc- cessful attempt was made to reduce the dislocation, which was finally accomplished “by strong abduction, combined with extension, and the limb resumed its normal position twenty-six days after the injury.” It may be remarked that in the efforts at reduction the adjacent parts, though seriously injured, soon recovered. The difficulty in the reduction of hip-joint luxations, and the powerful means often unavailingly employed, have been subjects of careful investi- * American Journal of the Medical Sciences, January, 1878, No. cxlix, new series. DISLOCATION OF THE HIP-JOINT. 657 gation by many distinguished surgeons. The fact that, in some instances, after considerable mechanical force had been unsuccessfully applied, a dis- location was reduced by accidental manipulation, has given rise to many experimental researches on the best methods of reducing luxations of the hip. The additional fact that complete muscular relaxation produced by anaesthesia does not overcome either resistance or deformity, plainly evinces that some force other than myotility is exercised to hold the bone so ob- stinately in its unnatural position. To the capsular ligament this power was attributed by Prof. Gunn in 1853. Prof. Green also was of the same opinion; but Dr. H. J. Bigelow, of Boston,” has, in a satisfactory manner, shown that it is the ilio-femoral ligament and the obturator internus muscle, which offer the chief impediments to the reduction of the hip, and in FIG. 351. FIG. 352. Thyroid Dislocation. Pubic Dislocation. maintaining the deformity. It will be necessary here, for a proper under- standing of the subject, to give the anatomy of the ligament to which such * agency is ascribed, and likewise that of the internal obturator Inuscle. The ilio-femoral ligament (Fig. 353) arises from the anterior inferior º process of the ilium by a strong adhesion, passes downward and slightly outward, and is attached to the anterior intertrochanteric line. The fibres separate slightly as they reach their point of insertion, thus making the ligament somewhat resemble the inverted A. In many subjects, how- ever, this ligament is so closely adherent to the capsular, that it is difficult to separate the two. Dr. Bigelow names this structure the Y ligament. The obturator internus muscle arises for the most part within the pelvis, its attachments being the inner surface of the body of the ischium, the as- cending ramus of that bone, and the descending ramus of the pubis; the fibres converge from tendinous bands, which, iº. the pelvis by the small sciatic notch, pass horizontally outward to be ń. by a strong tendon into the upper border of the trochanter major (Fig. 354). By keep- * The Mechanism of Dislocation and Fracture of the Hip, with the Reduction of the Dis- location by the Flexion Methods. 42 658 A SYSTEM OF SURGERY. ing these anatomical relations well in mind, the further description of the mechanism of the dislocation will be readily understood. Fig. 353. FIG. 354. | | 1. The Inverted A Ligament. Internal Obturator Muscle. Dr. Bigelow maintains that in the so-called regular dislocations the A ligament remains unbroken, and that in the irregular varieties either one or both branches of it are torn asunder. He states that both branches re- main entire, in 1. Dorsal. 2. Dorsal “below the tendon.” 3. Thyroid. 4. Pubic and subspinous. 5. Anterior. Oblique. That the external branch is broken: 1. In the supraspinous. 2. The everted dorsal. Thus making in all seven regular dislocations of the bone, besides the irregular ones, which may occur in almost any direction on account of the rupture of the capsular and the Y ligament. élaton's test, which is an excellent one for dislocation of the hip, con- sists in drawing a line from the anterior superior spinous process of the ilium, to the most prominent portion of the tuberosity of the ischium. If the bone is not dislocated, the top of the trochanter, in all positions of the limb, touches the lower border of this line. In all dislocations, especially backward ones, the trochanter passes above it. Dislocation Upward and Backward on the Dorsum of the Ilium.–In this variety, which is the most common, the triceps is put upon the stretch, the gluteus maximus and medius are doubled over, J. capsular and the liga. mentum teres are torn, the former perhaps only sufficiently to allow the head of the bone to escape through |. rent. TREATMENT OF DISLOCATION OF THE HIP-JOINT. 659 Diagnosis.-1. Limb shortened one and a half to three inches. 2. Toe rests upon the top of sound foot. 3. Limb rotated inward. 4. Limb slightly flexed. 5. Knee advanced upon the other. 6. Trochanter major is nearer the anterior superior spinous process than usual. 7. Adduction of limb. 8. Abduction almost impossible. 9. Body bent forward, 10. Roundness of hip lost. 11. In the absence of swelling, by rotating, the knee, the head of the femur may be felt moving on the dorsum of the ilium. - Fig. 355 represents position of patient suffering from this dislocation. Fig. 349, page 656, shows the position of the bone. - --- Fig. 356 . the dislocation of the bone, and the relations of the ilio- femoral ligament, holding the greater trochanter to the pelvis, and thereby inverting the limb. In some instances there happens to be what is termed an “everted dorsal dislocation,” in which the limb is everted and may also be abducted. This FIG. 356. Position of Patientin Dislocation on the Dorsum. Ilio-femoral Ligament Inverting the Thigh. condition is believed by Dr. Bigelow to be owing to a rupture of the outer fibres of the ilio-femoral ligament. In such cases the luxation must first be reduced to an ordinary dorsal dislocation, and then reduced completely. Treatment—Manipulation.—As long ago as 1815, Nathan Smith taught re- duction of the dorsal dislocation by manipulation, and it has been practiced frequently by many surgeons. *. patient should be etherized and placed either upon the floor or upon a hard couch. The surgeon grasps firmly the knee of the affected side with one hand, and the ankle with the other. The leg is flexed on the thigh, and the thigh on the abdomen, which relaxes the ilio-femoral. The knee must then be carried upward across the opposite thigh as high as the um- bilicus, if possible, when it should be rotated across the abdomen to the injured side. The next procedure is to bring the thigh gradually down by abducting the knee, the foot being carried across the sound limb. Fig. 357 represents the mechanism, the dotted lines showing the rotation of the head of the femur and the knee. Dr. Bigelow asserts that all regular dislocations can be reduced by flexing 660 - A SYSTEM OF SURGERY. the thigh on the abdomen to relax the ilio-femoral ligament, and making extension directly forward. _* FIG. 357. Mechanism of Reduction of the Hip by Manipulation. Method with Pulleys.-Astrong band well padded is placed in the perinaeum and made to pass over the outer surface of the pelvis, and made fast to a fixed point. A roller is wetted, and bound above the knee; over this a towel is placed, made into a clovehitch, to which is attached, by means of a hook or otherwise, the pulley, which must be in a direct line to the perineal band. The knee must be flexed at a right angle, and steady and continu- ous traction put upon the muscles by the pulleys; as the head of the bone draws near the acetabulum, the surgeon should rotate the limb inward, and the bone will slip into the socket (Fig. 358). It may happen that the ele- FIG. 358, all'? .2°º go” NNV" º ** r jº/ * ... ts'. ....th r , º, ø : ºr"." & % *Nº. ... " \\h, ºr **ś & A. |h. "'thuis.” #!" : "Sº, ºs-S * ºf fººt ºf A . . . . maj ſº * . . *, * - Sººn %£4%ſ " - N º U “ . sº-- * Yº : º ***, ** º. => . . . . . . ſº * S Fºº { Wºº § | re-a=-TIT-T-TS ºn mº º wº t? - |t|| \ - §§§ |||| t \,\! Reduction by Means of Pulleys. wated margin of the acetabulum acts as a barrier to complete reduction; in such an event, a towel passed around the thigh near the groin, and drawn out- ward, will lift the head of the bone over the ridge and thus facilitate its re- duction. After the limb has been reduced it should be laid parallel to the other, and several towels or a roller passed around both limbs, and the patient kept quiet for a fortnight. Care must be taken in all these efforts, whether by manipulation or extension by pulleys, that the bone be not fractured. Fig. 359 represents the “Tripod” for vertical extension as recommended by Dr. Bigelow; or if this be not at hand the foot, unbooted, should be placed on the pelvis, and the leg lifted from the knee. The so-called “automatic method " of reduction of dorsal hip-joint dislo- cations consists of placing the patient on his back on the floor (having him fully anaesthetized), and flexing the legs at right angles with the thighs, and the thighs at right angles with the pelvis. This relaxes the ilio-femoral TREATMENT OF DISLOCATION OF THE HIP-JOINT. 661 ligament. The hands are then placed under the calves of the legs, as close to the knees as possible, and the pelvis raised from the floor, at the same FIG. 359. FIG. Rºſ), ~! -* ** *-- - s \ \,\ | () |. -W M. w &N Sº Yº Šº Position of patient with Ischiatic Dislocation. Internal Obturator in Sciatic Luxation.—BIGELow. time slight abduction being made. This method was accidentally discovered by Dr. S. J. Allen, of Vermont, who, while endeavoring to get a patient suf- 662 . A SYSTEM OF SURGERY. fering from hip dislocation in proper position for reduction, lifted him in the manner described above, and had the satisfaction of hearing the head of the bone slip into its place. Dr. Allen mentioned the method of reduction to the late Dr. A. B. Crosby, who practiced it with success in the wards of Bellevue Hospital and published the same to the profession in the Phila- delphia Medical Times.* - . islocation Upward and Backward into the Sciatic Notch, or, as it is called by Dr. Bigelow, dislocation “below the tendon” (Fig. 350, page 656). * Diagnosis.-1. Shortening about an inch. 2. Thigh flexed, more so in recumbent position. 3. Thigh adducted and rotated inward. . 4. Great toe of luxated limb touches ball of toe of the sound one. 5. Head of the bone felt in its abnormal position. 6. Knee and foot inward. 7. Heel does not reach to the ground. 8. Knee in advance of the other. 9. Limb fixed; rotation scarcely possible. g Dr. Dawsonf speaks of a peculiar symptom, hitherto not mentioned, in ischiatic dislocation. It is shortness of the affected limb, when the thighs FIG. 362, Recumbent position of patient with Is- chiatic Dislocation (below the tendon).- º BIGELOW. * Appearance in Thyroid Dislocation. are flexed; in other words, when the patient lies on the back with extended limbs, there is but a slight degree of shortening; when the thighs are flexed upon the trunk at a right angle, then the affected knee is considerably shorter, say two inches, than the sound one. This symptom with its ex- planation had been noticed earlier by Dr. Oscar H. Allis.j. Fig. 360 shows the general appearance of a person with dislocation into the sciatic notch, or ischiatic luxation, as it is sometimes called. Fig. 361 is a correct representation of this dislocation, with the position of the obturator internus muscle. * Hospital Gazette and Archives of Clinical Surgery, November, 1877, p. 269. # Hospital Gazette and Archives of Clinical Surgery, January 1st, 1878. † Philadelphia Medical Times, March 28th, 1874. TREATMENT OF THY ROID DISLOCATION. 663 Fig. 362 shows the recumbent position of a patient affected with dislocation upward and backward, in which there is extreme flexion and rotation of the limb from the action of the obturator internus and the capsular ligament. Dislocation Downward into the Foramen Ovale—Thyroid Dislocation—Diag- nosis.-1. Limb two inches longer. 2. In thin subjects, head of the bone felt towards the perinaeum. 3. Limb advanced, toes point forward. 4. Body bent forward. 5. Trochanter less prominent. , 6. Head of thigh bone below and a little anterior to the axis of the acetabulum. 7. Depression below Poupart's ligament. 8. Limb abducted (Fig. 363). Treatment—Manipulation.—Bearing constantly in mind the relations the ilio-femoral ligament has to this dislocation, flex the thigh upon the abdo- men in a state of abduction, the limb being moved inward and brought down in an abducted position until the knee comes within a short distance below the pubes, when the thigh should be rotated inward. (Fig. 364.) Bigelow says: “Flex the limb towards a perpendicular, and abduct it a little, to disengage the head of the bone, then rotate the thigh strongly in- FIG. 364. FIG. 365. Reduction of Thyroid Dislocation by Manipulation. Reduction of º Dislocation with yS. ward, adducting it and carrying the knee to the floor. The trochanter is then fixed by the (ilio-femoral) ligament and the obturator muscle, which serve as a fulcrum. While these are wound up and shortened by rotation, the descending knee raises the head upward and outward to the socket.” Extension.—Patient to be laid on the back. A band is placed around the injured thigh to embrace the perinaeum. This band should be hooked to a pulley made fast to a point obliquely above the hip. In addition, a counter- extending girth must be placed around the ilium and fastened to a point opposite the injured hip. A gradual strain is made upon the part with the compound pulley, and as the head of the bone moves from the foramen 664 A SystEM OF SURGERY. ovale, the surgeon should firmly grasp the ankle and draw it towards the median line of the body, when the º of the bone will pass into the acetabulum. This method is seen in Fig. 365. Dislocation Forward upon the Pubes—This variety of luxation is rare, and may be caused by the same forces as occasion the thyroid dislocation. By referring to the wood-cut (Fig. 366), it will be seen what relation the ilio- femoral ligament bears to this variety of dislocation, which being remem- ...} its relaxation by flexion in the manipulation method will be under- STOOOl. FIG. 365. FIG. 367. The Femoral Ligament in Pubic Dislocation.- Appearance of Patient. BIGELow. ubic Dislocation. Diagnosis.-1. Limb an inch or more shortened. 2. Knee and foot ab- ducted, and cannot be rotated inward. 3. The head of the bone felt upon the pubis, sometimes above the level of Poupart's ligament, at the outer side of the femoral artery and vein. 4. The trochanter major is nearly lost. 5. On rotating the thigh, the head of the bone is felt to move with it. Fig. 367 shows general appearance of patient with this dislocation. It is in this that there is both shortening and eversion, and therefore it is neces- ary that care be taken in the diagnosis. In fracture- . The head of the bone cannot be felt. . The trochanter major rotates on shorter radius. . Crepitus is present. . Shortening not so great. . No abduction. Eversion of the foot not so great and more easily overcome. . Much greater mobility. Treatment.—Manipulation.—The patient must be placed upon the back, and brought under anaesthetic influence. The thigh then must be rotated IXISLOCATION OF THE PATELLA. 665 and abducted outward, which will in the majority of cases require consid- erable force. By this means the head of the bone is thrown forward on the pubic bones. This being accomplished, the limb must be forcibly flexed and adducted, and then rotation inward performed. In some cases b simply carrying the limb to an extreme abduction, rotating the thigh in- ward, and pressing upon the head of the bone, the reduction may be effected. In this dislocation the surgeon may try various methods of manipulation, according to the presenting symptoms. Extension with Pulleys.-The patient is placed on the sound side, or half on his back and half on his side, a perineal band, well padded, applied over the pelvis and fixed to a point in front of a line with the body (Fig. 368). The Sº SS ==== Yº | | | | t il|}} > * > - 5. - gº-ºº - - º - | - v Tºtº:*-------Tº l, * : T T T--— Reduction of Pubic Dislocation by Extension. band is then applied, as before directed, above the knee, to which, by means of the clovehitch, or other appliance, the compound pulleys are attached, which must be made fast to a point behind the axis of the body, that the bone, when traction is made, may be drawn backward. As the bone ap- proaches its natural position, it must be assisted over the pubis and edge of the acetabulum by means of a band or towel. The subsequent treatment consists in rest and a bandage to keep the legs in a horizontal position. Dislocation of the Patella.-The patella is luxated laterally, outward or inward, the former being the more common of the two. An upward dis- location can only occur from a rupture of the tendon of the quadriceps. The signs of the outward variety are: 1. Patella lies at external face of joint; the inner edge being directed forward. 2. Depression in front of the knee. 3. Prominence on outside of knee. 4. Inner condyle of the femur can be felt under the integument. 5. It is impossible to flex the leg. In the inward dislocation the symptoms and appearances are the reverse of the above. 3. Treatment.—The patient should be placed supine, and the thigh flexed upon the abdomen. The surgeon then sitting on the side of the bed, places upon his shoulder the lower part of the leg, when, by pressure made by the thumbs from without inward, in the outward dislocation, and from within outward in the inward variety, the bone will slip to its place. It is not always necessary to use this manipulation, as any movement having a tendency to completely relax the tendon of the patella will answer equally well. . In some instances the bone may be vertically dislocated by a sudden and forcible twist of the joint. In these cases the leg is straight, the outer edge of the bone is prominent, and there is a deep depression upon each condyle. Dr. A. N. Dougherty, of Newark, N. J.” relates a “singular ” accident of * N. Y. Med. Record, December 30th, 1876. 666 A SYSTEM OF SURGERY. this kind which came under his treatment. It occurred to a young man who was painting a house, and seemed to be caused by a sudden wrench of the knee in turning the body, while a foot was lodged in the gutter of the roof. The left lower extremity was in a state of extreme extension, and the patella was tilted up on its inner edge, the posterior surface of the bone looking directly upward, and the extensor tendon correspondingly tilted up and stretched. Reduction was effected in a few minutes by manipulation, which consisted in depressing with a joggling motion the projecting edge toward the outer condyle. Contrary to the recommendation of Gross, the thigh was not flexed; next day the patient was walking about, and suffer- *# In O II). COIn Venlen Ce. reatment.—The thigh must be strongly flexed upon the abdomen, and the knee then suddenly bent, and as suddenly brought into a vertical posi- tion, the surgeon at the same time endeavoring to turn the bone to its place. DISLOCATION OF THE LEG. Dislocation of the Tibia at the Knee.—This occurs in four directions,— forward, backward, inward, and outward. The last two are rare and incomplete. In dislocation forward (Fig. 369), the signs are: FIG. 369. FIG. 870. Dislocation Forward of Dislocation of the Head Head of Tibia. of Tibia Backward. 1. Patella prominent in front of the joint. 2. Tibia and fibula prominent in front. 3. Condyles of femur project posteriorly. 4. Pain from pressure in popliteal space from stretching of parts. Treatment.—Place the patient on his back, make extension (sometimes the pulleys may be necessary), and alternately flex and extend the leg, at the same time making a slight rotary motion, with pressure upon the head of the dislocated bone. The parts must then be placed in splints, and passive motion made for several days. Dislocation of the Head of the Tibia Backward (Fig. 370).-The signs are: 1. Leg bent forward. 2. Depression of the ligamentum patellae. 3. Shortening of the limb. 4. Projection of the condyles of the femur anteriorly. The accident is easily recognized. . DISLOCATION OF THE TIBIA. 667 Treatment.—Place the patient in the recumbent posture, and make ex- treme and forcible flexion. This will, in the majority of cases, produce the desired result. If not, extension combined with pressure on the dislocated extremity of the bone will reduce the luxation. In Dislocation Inward the following are the marks of the accident: 1. Tibia projects on the inner side of the joint. - 2. Inner condyle of femur rests on the centre of the head of the tibia. 3. Joint increased in breadth. 4. Patella pushed outward. - 5. Outer condyle of femur presents a tumor on the outer side of the joint. Treatment.—Extension for a short time, with pressure in the proper direc- tion, generally effects reduction without difficulty. Dislocation Outward is known by the following: 1. Tibia projects on the outer side of the joint. 2. Outer condyle of the femur rests on the articulating surface of the tibia. 3. Inner condyle of the femur presents a tumor on theinner side of the joint. 4. Increase in the breadth of the joint. 5. Patella pushed outward. Treatment.—The same as for dislocation inward, excepting that the pres- sure is reversed. As has been before observed, these dislocations are gen- erally incomplete. When they are complete, they are in most instances accompanied by fracture and other injury demanding immediate amputa- tion. The Head of the Fibula may be dislocated, and generally this takes place backward. In some of the cases which have been noticed, the misplacement was occasioned by muscular action. The signs are: 1. Head of the bone felt on the outer and posterior surface of the leg. 2. Fatigue from walking or exercise. Treatment.—The bone is readily replaced, but almost immediately slips 'from its position. After having reduced the luxation, a solution of arnica should be applied to the part; this may have the effect of producing ab- sorption of the superabundant synovia ; or ledum may be used, as this medicine acts powerfully upon the knee-joint, and also upon the absorbent vessels generally. After this, a compress should be placed behind the head of the bone, and bound tightly to the tibia, either by a bandage or strap buckled around the upper part of the leg. Dislocation of the Tibia at the Ankle-joint.—There is sometimes a confusion of ideas, especially among students, regarding the nomenclature of these dislocations. It should, therefore, be remembered that a dislocation of the lower end of the tibia inward is a dislocation of the foot outward, and that a dislocation of the tibia outward at the ankle-joint is the same as a dislo- cation of the foot inward. A majority of these are accompanied with fracture. They are caused by falls and twists of the foot, and are often very serious accidents. The direc- tion of the dislocation which is most frequent is inward. Dislocation of the Foot Outward.—The symptoms are: 1. Internal malleolus very prominent. 2. Foot everted. (Fig. 371.) 3. Foot rotates on its axis. 4. Generally a depression is found three to five inches above the external malleolus, indicating a fracture of the fibula at that point. 5. Preternatural mobility in a lateral direction. 6. Patient cannot move the foot. In this dislocation there is a rupture of the internal tibio-tarsal ligament, and sometimes a fracture of the internal malleolus. 668 A SYSTEM OF SURGERY. Treatment.—The patient should be placed in a recumbent position, and the leg flexed at a right angle with the thigh. An assistant should fix - the thigh firmly, either by grasp- FIG. 371. ing it with his hands or by passing a towel or folded sheet beneath the lower extremity of the thigh. Extension should then be made, either with the pulleys or with the hands, late- ral pressure being made on the projecting bone in the direction ºlº of the joint, and thus the defor- ºº) mity is removed. Dupuytren's "Wº" " , apparatus for fracture of the lower part of the fibula is now to be applied, or splints and band- ages, to keep the foot at rest and at a right angle with the leg, and the patient kept in bed five or six weeks. Ten or twelve weeks will have elapsed before the use of the foot is restored. After the eighth week passive motion will be required to restore the mobility of the joint. Causticum, lycopo- dium, or rhus, will facilitate the lat- ter object. First, however, the inflam- mation must be attended to, as in all other cases of dislocation. Dislocation of the Lower End of the Tibia Outward (Dislocation of the Foot Inward).-This luxation is very serious, and demands the unceasing vigilance of the surgeon. It is caused by the same kind of accidents which produce the former. Fracture of the lower end of the fibula, or of the in- - =-E. - Dislocation of the Foot Outward. FIG. 372. N T-- \ § *- >~ t §: ternal malleolus, or a rupture of the j peroneo-tarsal ligaments takes place, sº and in some instances the astragalus sº is also broken. The symptoms are: sº 1. The foot is inverted. (Fig. 372.) 2. The tibia is thrown forward and outward upon the astragalus. 3. Great deformity of the joint. 4. Astragalus felt beneath inner malleolus. 5. External malleolus is felt and seen as a prominence on the outside of the ankle-joint. Treatment.—The reduction is ef- fected in a manner similar to that de- tailed for the treatment of the inward luxation, while pressure is made upon the luxated end of the bone. gº After the reduction, a pad should Dislocation of the Foot Inward. be placed upon the outside of the leg, extending from above the ankle, seve- ral inches up the limb. Two side-splints are applied, with a foot-board, and the leg, having been previously lightly bandaged, should be fixed se- curely in the apparatus. Care must be taken to prevent the tibia and fibula DISLOCATION OF THE TIBIA. 669 from slipping from the astragalus. The limb should then be laid on its outer side. After several weeks, passive motion and friction should be re- sorted to. Dislocation of the Lower End of the Tibia Forward (Dislocation of the Foot Backward) (Fig. 373).-The causes of this accident are falls, with twists at the ankle, causing great extension of the foot upon the leg. The symptoms are: 1. Foot fixed. . Foot shortened in front. . Heel projects. Heel firmly fixed. Toes point downward. End of the tibia felt as a tumor on the tarsus. Extensor tendons well defined in front. Tendo Achillis rigid and curved. - . Sometimes crepitus above the external malleolus marks fracture at that point. In many instances there is only a partial dislocation of the tibia on the astragalus, in which case the fibula is broken and the tibia appears to rest half on the scaphoid and half on the astragalus. The symptoms resemble those mentioned, but are not so precisely defined. The foot is shorter, and the toes point downward, while the heel is drawn up, and the foot is immovable. In accidents about the ankle, when a frac- ture of the tibia and fibula has occurred, with laceration of the internal and external lateral ligaments, a dislocation of the tibia forward . result from the contraction of the calf mus- CléS. - Treatment.—This dislocation is in most in- stances quite readily reduced, but, according to my experience, there is the greatest difficulty in keeping the parts in situ. This is more espe- cially the case when there has been severe contu- sion, and laceration, the tumefaction and ecchy- p. mosis rendering every touchinsupportable. When *ś"*T in connection with this, as happened in a case of my own, the patient is of a rheumatic diathesis, and of a phlegmatic tem- perament, the treatment is often very unsatisfactory. - The leg should be flexed upon the thigh, and the foot extended, while pressure is made in front of the tibia. When the reduction has been effected, the leg should be placed in a fracture-box, with a foot-board at a slightly acute angle to the base of the box. The leg should be supported by cushions, and dilute arnica constantly applied. Side splints or carved splints, or those made of wire, afford satisfactory support and keep the foot in proper position. Plaster-of-Paris splints are also useful. islocation of the Lower End of the Tibia Backward—Dislocation of the Foot Forward:—This accident is rather rare, but the symptoms are well marked. 1. Foot lengthened. 2. Heel shortened, or obliterated. 3. Astragalus felt in front of the tibia. 4. Leg shortened. - 5. Malleoli nearer the ground. 6. No space between the tendo Achillis and the posterior surface of the tibia. FIG. 373. . G º : : { } : tº •. : : •. .*: : 670 A SYSTEM OF SURGERY. In the majority of cases, this luxation as well as others near the ankle- joint is accompanied by fracture of either tibia or fibula, or both, in the vicinity of the malleoli. - Treatment.—The patient should be placed upon his back, thigh flexed on abdomen, and the leg placed at right angles with the thigh. Counter- extension is to be made by an assistant holding firmly the thigh in its position. The surgeon takes the foot in his hand and draws it gradu- ally though firmly downward, at the same time carrying it backward to restore the astragalus to its proper position. A compress is placed on the heel and splints applied. Some surgeons, after reduction, place the limb over a double inclined plane: DISLOCATIONS OF THE FOOT. Dislocations of the tarsal bones are occasioned by great violence. The astragalus may be dislocated in several ways, outward, inward, forward, and backward. Sometimes the bone is either partially or entirely rotated #. º axis, or it may be forced like a wedge between the tibia and the Ullà. Fig. 374 shows a dislocation of the astragalus outward, with inversion of the foot. If the bone is dislocated backward, the tibia is slightly thrown to the front, although there is not much FIG. 374. alteration in the position of the foot. Sometimes there is shortening of the leg, * A but in most instances, the unusual promi- % nence of the bone and the position of the foot are the main indications. The prognosis in these cases is bad, gan- grene often results, and amputation may be necessary. In other cases resection may be required. Treatment.—To reduce forward disloca- tion, flex the leg at right angles with the thigh ; an assistant grasps the thigh above the knee; a second extends forcibly the foot; .. the surgeon pressing the dislocated bone % upward and backward. In the backward ‘. dislocation, great difficulty is often experi- "...sº, *, enced in effecting reduction, and in some º cases it has been found impossible. The º foot must be extended, the leg being in the * , , Via S same position as above. The heel must be ** \tº\º) drawn forward and downward by the assis- º Ně sº tant, making extension, and the surgeon pushes the bone forward and upward. In the outward and inward dislocations exten- sion and counter-extension are made in the same manner, the foot always being forcibly held in an opposite direction, Dislocation of the os calcis and astragalus from the other bones of the tarsus may take place. The foot will then be turned inwards, as in talipes Varu S. Reduction is easily effected by extension and direct pressure. The limb should then be supported by splints and bandages. Dislocations of the toes, one from another, occur occasionally, and are with facility recognized and easily reduced by extension and counter-ex- ::tºnion: = ~ * e ee © n e e a o º º © © •es \s; * § i * ! Dislocation of Astragalus Outward. © o DISLOCATION OF THE SHOULDER-JOINT. 671 § º \ W" 2 DISLOCATIONS OF THE UPPER EXTREMITY. Dislocation of the Shoulder-joint.—The humerus may be dislocated from the glenoid cavity in three directions: downward into the axilla, also called subglenoid; forward beneath the pectoral muscle, also receiving the names Subcoracoid and subclavicular ; backward on the dorsum of the scapula, to which the term subspinous is applied. In some the humerus is pushed inward on the coracoid process. This is called the subcoracoid. I have met with one such case; the majority, however, of dislocations of the shoulder being the so-termed downward luxations. Violence, falls, blows, etc., applied to the superior extremity of the humerus, or falls upon the hand and elbow, are generally the causes of this dislocation, in which the scapular ligament is ruptured by violence—the long head of the biceps Separated, the supra- and infraspinatus, as well as the coraco-brachialis and subscapularis, all being involved to a greater or lesser degree. It is well to remember here the test of Dr. Dugas, of Georgia, who demonstrates that FIG, 375. FIG. 376. º W y A grº' 4%) Jº % | º tº 2. ! _ \ * .* * * .* Dislocation of the Humerus Downward. External Appearance of Dislocation of Shoulder Downward. it is a mechanical impossibility, for any one suffering from either of the dislocations of the humerus, to bring the elbow of the affected arm down to the thoraq, and place the fingers upon the sound shoulder. The position of the bone is seen in Fig. 375, and the general appearance of the patient in Fig. 376. The symptoms are: . Depression beneath the acromion. . Flatness of the shoulder. . Slight depression at the point of insertion of the deltoid. . Arm somewhat lengthened. . Elbow stands off from the side of the thorax. . Patient supports the elbow and forearm of injured side with the hand of the opposite side. - 7. If the elbow is moved off from the thorax, the head of the humerus is felt in the axilla. : 672 A SYSTEM OF SURGERY. 8. There is a change in the axis of the humerus, it leading toward the axillary space, and not to the glenoid cavity. 9. Inability to bring the elbow to the side and place the fingers on the sound shoulder. - 10. Inability to raise the hand to the head. 11. Rotation lost. - 12. Forward and backward motion generally retained. 13. Considerable pain from pressure on the brachial plexus. Added to these signs, it must not be forgotten, that at times on moving the limb a species of crepitus may be felt, which is occasioned by effusion of serum and synovia into the cellular tissue; it is not, however, that distinct sensation produced by fracture, and disappears for the time by continued motion. - By referring to the remarks on fracture of the acromion process of the scapula, the differential diagnosis between that injury and dislocation of the humerus downward into the axilla, will be found. The diagnosis between fractures of the surgical neck of the humerus and the dislocation now under consideration, consists chiefly in the absence of crepitus and the position of the elbow, which, in fracture, may be placed upon the thorax. Treatment.—The treatment by manipulation is as follows: The patient should be seated in a chair, and, if there is severe pain, an anaesthetic should be given. The surgeon flexes the forearm on the arm, and raises the latter to a right angle (or as nearly as possible to that position) with FIG. 377. §i)SS Nº. º º f K. : *','º' º *S* wº | º ſº " - ". Reduction of Shoulder Dislocation, by Heel in the Axilla. the chest; using now the forearm as a lever, the surgeon, having the wrist and elbow well in hand, depresses the hand and forearm, which causes forward rotation of the head of the humerus. Many dislocations may be thus reduced. Extension.—The patient is placed upon his back, a ball or pad should be laid in the axilla, and the surgeon, sitting on the side of the couch, and facing the patient, places his unbooted heel upon the ball, and taking hold of the wrist and forearm, makes gradual and steady traction. If this does not effect reduction, a wet bandage may be applied to the arm, and over this a clovehitch, to which an extending band must be applied, and one or more assistants draw steadily upon the arm (Fig. 377), Another method is that which is seen in Fig. 378. The patient is seated in a chair, and a bandage passed around the upper portion of the thorax, TREATMENT OF DISLOCATION OF THE SHOULDER-JOINT. 673 having an opening through which the arm will pass. This band is tied over the Sound shoulder, and given in charge to steady assistants. The wet roller and clovehitch are then placed just above the elbow, and the pulleys applied. After steady traction has been made for some minutes, the surgeon places his foot upon the chair and his knee in the axilla. The acromion FIG. 378. , -] \ 6%!§\ Ağ*:º * *-*. must now be pressed downward and inward with the hand while pressure is made with the knee, by raising the heel. The head of the bone will often enter the glenoid cavity with quite a noisy report. In most instances the pulleys are not necessary, and the bone may be replaced in the following manner: The surgeon, having the patient in the same position as described in the last method, stands a little behind him, places his foot on the chair, his knee in the axilla, and fixing the scapula with one hand, rotates the humerus inward. Thus the knee acts as the fulcrum, the humerus as the lever. This method is known as Sir Astley Cooper's (Fig. 379). - The vertical extension method may be practiced as follows: the patient is laid upon the bed or the floor; the surgeon seats himself on the injured side and above the shoulder, he then forces the scapula down by pressure made §º heel or his hand, and raises the arm in a vertical direction toward the head. M. Tillaux* gives an account of a case of subcoracoid dislocation of the shoulder taking place several times a day. The patient, aged twenty-eight, was subject to epileptic fits; during one of these, occurring at night, he fell out of bed. When he recovered consciousness, at the end of about half an hour, he discovered that he could not bring his right elbow to the body, and that the movements of the arm were very limited. After some efforts the arm resumed its position and function, accompanied by a cracking in the shoulder. The same dislocation occurred again and again, ultimately taking place several times a day. - Generally, the luxation was involuntary, but he could produce it by bringing the arm outwards, a little backwards and upwards. M. Tillaux proposes to remedy this by an apparatus which will place an obstacle in the way of the great abduction of the arm. * Gazette des Hôpitaux, August 12th, Abstract Med. Science, vol. iii., No. xi. 43 674 A SYSTEM OF SURGERY. Dr. G. Lapponiº relates the following interesting case of subcoracoid dis- location of the humerus by muscular contraction. A girl, aged fifteen, being seated, and resting her arm horizontally on a piece of furniture, Sneezed vio- lently twice, and immediately was seized with severe pain, her arm (being raised from the surface on which it was lying) fell useless. Before this she had suffered from chronic inflammation of the right radio-carpal articula- tion, and had also inflammation of the shoulder-joint, but of these no symp- toms were now present. All attempts to move the upper part of the arm produced much pain. When examined, the head of the humerus was found lying beneath the FIG. 379. FIG. 380. sº-s= º º 2 - *~ 5 ºrº-Ease tº + N § º ºs W. 8, \\ º - - º ºf lººk. ... º º | ſº º º º - [. º º t Aſ ſº º 4.22—"" º Sir Astley Cooper's Method of Operating Dislocation of the Humerus Forward. with the Knee in the Axilla. coracoid process. Reduction was then effected by making extension on the forearm and rotating the limb outwards, while the head'of the humerus was guided by manipulation into the glenoid cavity. Dislocation of the Head of the Humerus Forward.—The symptoms are: Depression beneath the acromion. . The head of the humerus forms a tumor below the clavicle (Fig. 380). . Slight shortening of the limb. . Axis outward and backward. . Elbow outward and backward. . Inability to place hand on opposite shoulder while the elbow touches the front of the chest. 7. Forward and backward movements are much impeded. Treatment.—In reducing this variety of dislocation, the same means may be employed as have already been mentioned for the axillary luxation, with this difference, that extension must be made in a backward direction. Dislocation of the Head of the Humerus Backward.—1. Depression under outer end of the acromion. 2. A protuberance on the dorsum of the scapula below the spine. 3. Rotation of the head of the bone in its new position by moving the arm. 4. A space between the coracoid process and the head of the humerus. 5. Arm and forearm carried in front of the chest. 6. Rotation of the humerus inward. i * American Journal of the Medical Sciences, April, 1878. DISLOCATION OF THE ELBOW-JOINT. 675 7. Inability to place the hand on the opposite shoulder while the elbow touches the front of the thorax. Dr. P. S. Conner” thus relates a case of backward (Subacromial) Dislo- cation of the Head of the Humerus: remarkable from the fact that the cause of the luxation was never known. A patient (aet. 39) complained of trouble about his right shoulder, which existed for four weeks. "It was considered a case of sprain, and was so treated. Nine years before, the same shoulder had been luxated, and again, three years after some injury had occurred to it, but its exact nature was unknown. There was almost entire inability to lift the arm from the body, and it could not be rotated outward. 4 * On the 29th day he was etherized, and after much effort, the head of the humerus was replaced in the glenoid cavity, the reduction being accompa- nied by a distinct snap, notwithstanding the completely anaesthetized state of the patient. The after history of the case presented nothing of especial interest, and all bandages were removed in two weeks. Treatment.—The same methods are employed as have already been given, with the exception of the direction in which extension must be made. In the backward variety, the bone should be pulled downward and forward, while an assistant endeavors to push the head of the bone to its place. Sir Astley Cooper succeeded in reducing this dislocation by exactly the same methods as he employed for the axillary. . . As a general rule, after a luxation of the shoulder has remained unre- duced for twelve or fourteen weeks, attempts at reduction should not be made, although ancient dislocations have been reduced after having existed for a much longer period of time. Partial dislocations of the humerus have been described by some authors. Sometimes also the long head of the biceps is removed from the bicipital FIG. 381. FIG. 382. Apparatus for Frequent Dislocations. Dislocation of Elbow Backward. groove. These are rare cases, and the symptoms of each must indicate the method of treatment. The student is referred to the chapter on Injuries and Diseases of the Muscular System. Fig. 381 shows an instrument well adapted to prevent partial dislocation, or to be worn by those persons who appear predisposed to a recurrence of luxation. Dislocation of the Elbow-joint.—In dislocations of the elbow, both bones may be thrown backward or laterally ; the ulna may be dislocated backward, and the radius forward. * American Journal of the Medical Sciences, April, 1878. 676 A SYSTEM OF SURGERY. The backward dislocation of both bones (Fig. 382), occurs most frequently and is known: - 1. By the protuberance on the posterior face of the joint. 2. Lower extremity of humerus forms a hard tumor in the forepart of the elbow-joint. 3. A depression is found on each side of the olecranon process. 4. The forearm and hand are in a state of fixed supination. 5. Inability to flex the joint. Treatment.—The patient is seated on a chair or stool; the surgeon places his foot upon the seat, bringing his knee in the bend of the elbow; taking hold of the wrist (Fig. 383), he bends the limb, at the same time pressing on the radius and ulna with his knee, so as to separate them from the hu- FIG. 383. FIG. 384. º A \! y º: º lſº tº Fº il | , lº sº ... tº v.º.º. *"º'º. Reduction with the Knee in the Bend of the Backward and Outward Dis- Elbow. - location of the Elbow. merus, and throw the coronoid process from the posterior fossa of this bone. Whilst the pressure is kept up by the knee, the #. is slowly and forc- ibly bent upon the arm, and the bones slip into their sockets. This reduction may be accomplished also by bending the arm forcibly, but gradually, around a bedpost, or whilst the patient is seated in an arm- chair, passing the arm through the opening in the back or side, thus fixing the body and limb, and reducing the luxation by forcibly bending the fore- arm, with one hand placed upon the olecranon process to lift the bones into their places. The reduction having been accomplished, the forearm must be placed in a sling, the elbow bent at an obtuse angle, and supported with a splint. Dislocation of both Bones Backward and Outward (Fig. 384) is known by the following symptoms: 1. Coronoid process is found resting upon the external condyle of the humerus. 2. Great projection of the ulna backward (being more marked than when the ulna alone is thrown back. DISLOCATION OF THE CARPUS UPON THE RADIUS AND ULNA. 677 3. The radius forms a hard tumor on the outer side of the joint behind the external condyle. 4. A depression is seen above the head of the bone. 5. By rotating the hand, the head of the radius is felt to move. Dislocation of both Bones Backward and Inward.—The symptoms are easily recognized. They are— 1. Posterior projection of olecranon. 2. Head of the radius lies in the posterior fossa of the humerus. 3. The ulna rests behind the internal condyle. g i. The external condyle of the humerus forms a large tumor on the outer SIOle. Treatment.—In both these varieties of dislocation, the treatment may be conducted upon the same principle as that already mentioned for back- ward dislocation; the pressure being directed inward or outward, according to the lateral displacement. Dislocation of the Ulna Backward.—This variety of dislocation is often Quite difficult to diagnose. Its distinguishing features are: 1. The olecranon can be felt projecting behind the humerus. 2. Forearm cannot be extended. 3. Forearm cannot be flexed to more than a right angle. In this luxation, the chief marks are the contortion of the forearm and hand with the projection of the olecranon on the posterior face of the joint. Treatment.—The surgeon grasps the wrist, places his knee in the bend of the arm (as already shown in Fig. 383, page 676), and drawing the forearm downward, the bone will slip into its socket. Dislocation of the Radius Forward.—In this luxation, the head of the radius will occupy the hollow above the external condyle of the humerus (Fig. 385). The indications are— 1. Slight flexure of the forearm. FIG. 385. 2. Inability to flex the forearm to a right angle. 3. When a sudden endeavor is made to flex the forearm Ön the arm, there is a sudden check. 4. Pronation of the hand. 5. The head of the radius may be felt by pressing the thumb in front and to the inside of the external condyle of the humerus. - 6. By rotating the hand, the head of the radius moves also. Treatment.—The surgeon should make gradual and forcible extension, and, while so doing, should supinate the hand. With the thumb of the other hand, the head of the radius should be pressed down, and the arm placed in a sling. Dislocation of the Head of the Radius Backward can be recognized by the partial loss of motion and the tumor formed by the head of the bone on the back of the external condyle. The reduction is effected ~. on the same principles as the last-named Forward Dislocation of the Radius. dislocation. Dislocation of the Carpus upon the Radius and Ulna.-This luxation may occur in two directions, backward and forward, and is occasioned by direct violence to the wrist. - 678 A SYSTEM OF SURGERY. The backward dislocation may be known— 1. Forearm is shortened when measured from the tip of the little finger to the olecranon. . Distance unchanged between olecranon and styloid process. Prominence of carpus on the back of the forearm. Prominence in front, caused by the projecting ends of radius and ulna. . Below the last-mentioned prominence is a depression. . Styloid processes are not on the same line as the carpal bones. . The wrist is thicker. . Fingers are semiflexed. Treatment, Extension is made at the wrist, and counter-extension at the forearm ; the surgeon, with both thumbs, makes downward pressure on the carpus. Malgaigne prefers extension to be made at the fingers, by means of a band fastened around the metacarpus. In compound disloca- tions, amputation or resection may be required. Dislocation of the Carpal Bones Forward.—In this luxation the carpus is thrown forward on the anterior face of the radius (Fig. 386). The symptoms and methods of reduction are the reverse of those last described. The appearance is well shown in the cut. - Sprains about the wrist, from severe FIG. 386. falls, sometimes assume the appearance of dislocation of these bones, but may be distinguished from it by there being but one swelling in sprain, and that hav- ing come on gradually ; also the rela- tive position of the styloid processes of Dislocation of the Carpal Bones Forward. the radius and ulna with the carpus is unaltered in sprains. Dislocation of the Ulna from the Radius at the wrist occurs oftener than the last mentioned. It is easily recognized by the altered position of the styloid process, the projection of the ulna above the level of the os cunei- form, and the twisting of the hand. Treatment in this case consists in replacing the end of the ulna by exten- sion and direct pressure on the end of the bone, confining it there by means of splints on the back and forepart of the wrist and forearm, and placing a compress upon the end of the bone which has a tendency to displacement, on account of the rupture of the ligament. A roller is then applied to re- tain the compress and splints. Dislocation of the Fingers.-The fingers may be dislocated at their various articulations, though more frequently between the first and second pha- i FIG. 387. langes. The nature of the injury is apparent, and may be reduced by extension (Fig. 387), made by the hand alone, with a bandage or tape ap- plied by a clovehitch. O But a much more convenient apparatus is that of Dr. Levis (Fig. 888), DISLOCATION OF THE FINGERS. 6.79 which consists of “a thin strip of hard wood, about ten inches in length, and one inch, or rather more, in width. One end of the piece is perforated With six or eight holes. The opposite end is cut away, forming a pro- FIG. 388, jecting pin, and leaving a shoulder on each side. Towards this end of the strip a sort of handle-shape is given, so as to insure a secure grasp to the operator. Two pieces of strong tape or other material about one yard in FIG. 389. erºpº” §ſ, J/)); 2*RS sºallº! *Y*.N UN) º - saasaºt? - º *4 == § º tºº # - º %%ſ g - º * *\mu ºrrºr:- iº, | - wº. ! ti lili NJ W C / " % | | | Lewis's Instrument Applied. length are prepared. One of these is passed through the holes at the end of the strip, leaving a loop on one side. The other tape is passed through another pair of holes, according as it may be a thumb or finger to which it is to be applied, or varied to suit the length of the finger, leaving a similar FIG. 390. liº, (i. W Ǻ º 6.7/EMAWAV & co, Charrier's Forceps. loop. If a dislocated thumb is to be acted on, the second tapes should be passed through the holes nearest the first. The ends of each separate tape are then tied together.” {} FIG. 391. Rºs Bºssºsº -_E: &º Luer's Forceps. Fig. 389 shows this instrument applied to the forefinger, though it is especially adapted for the thumb. 680 A SYSTEM OF SURGERY. I Fig. 390 shows Charrier's forceps, used to reduce dislocations of the pha- anges. - Fig. 391 represents Luer's, for the same purpose. Dislocation of the Thumb.-Luxation of the thumb backward on the dor- sum of the metacarpal bone often takes place. Less frequently in the opposite direction. The accident, though easily recognized, is difficult of management. Treatment.—A clovehitch, the apparatus of Levis, or Charrier's forceps should be Fº upon the first phalanx, and continued extension employed. Strong and steady flexion must be made towards the palm of the hand, and, at the same time, firm pressure applied by the thumb of the surgeon upon the head of the bone. By these means the reduction is often accom- plished. The luxation, however, is sometimes so unyielding, as to require the subcutaneous section of one or both lateral ligaments before the desired result is attained. Before, however, the division of the ligaments is made, the following manipulation should be resorted to in difficult cases, and it will generally succeed, as one of the greatest obstructions to the reduction is the lapping of the extremities of the bones, which, from their form, become completely locked. Soak the hand in warm water; apply a piece of wet leather around the thumb, and over this a clovehitch of strong tape. In dislocation up- wards, a loop of tape embraces the upper end of the phalanx, and is drawn with great force by an assistant perpendicularly upwards. Another loop of tape embraces the lower end of the metacarpal bone, and is drawn down- wards by another assistant. While the extremities of the bones are by these means unlocked, the surgeon draws the thumb, by the clovehitch, towards the palm of the hand, and the bone usually slips into its normal position. The metacarpal bones are seldom luxated, except from extraordinary vio- lence, the consequences of which, for the most part, are more serious than the dislocation. The carpal bones being strongly connected to each other by short liga- ments, and by a ball-and-socket joint, are with difficulty luxated. Either from relaxation of the ligaments, or from extreme violence, the cuneiform bone and os magnum may be displaced. These latter are not only difficult to reduce, but when this is accom- plished, if accompanied with relaxed ligaments, the ends of the bones can scarcely ever be kept in their natural position, to maintain which, band- aging, with appropriate treatment, is necessary. After-treatment in Dislocations.—After a bone has been reduced, in all cases, the part should be covered with a cloth wet with a solution of arnica and water, and a bandage applied in such a manner as to prevent motion. In dislocation of the larger joints this rest must be maintained for days, and then motiqn gradually resumed. It is my custom always after such reduction, to administer to the patient a dose of rhus tox, every three or four hours. I have lately had considerable experience with massage, as a means of removing the stiffness which often remains after the reduction of a dislocation, and can highly recommend it. INJURIES AND DISEASES OF THE SPINE. 681 CHAPTER XXXIV. INJURIES AND DISEASES OF THE SPINE. CoNCUSSION OF THE SPINE, INCLUDING “RAILwAY CONCUSSION”—NERvous SHOCK–SPINA BrFIDA—CLEFT SPINE–ROTARY LATERAL CURVATURE—ANGULAR CURVATURE— PoTT's DISEASE—CARIES of THE SPINE—LordoSIS-PSOAS or LUMBAR ABSCESS. Concussion of the Spine is produced by the ordinary accidents of civil or military life; in the former, horseback exercise, gymnastics, falls, and espe- cially railway collisions; in the latter, by blows from muskets, falling from horses, falling trees, blows from blunt instruments, etc. Dr. Otis & relates seventy-nine cases of this character, of which he says: “A few proved fatal from fracture or luxation, or from peritonitis, and in one instance, from the complication of small-pox.” It is a noticeable fact, that slight injuries of the spine, I mean those of apparently so trivial a nature that they may be forgotten by the patient, often produce serious ultimate results, and that the period which elapses between the receipt of such injury and the development of ulterior disease, varies from weeks to months and even years. But a few years since a great deal was said and written by the profession on injuries of the spine caused by railway accidents, and to the disease the name “railway spine” was given. Careful observation, experience, and inquiry, show that the symp- toms of this so-called “new disease ’’ are nothing more nor less than those observable after any great and violent concussion of the spine or shock to the nervous system. It can readily be understood that in a railway accident, besides the actual force with which the person is thrown about, and the injury to the column, there is in addition the horror, the fright, the apprehension, which stirs the nervous system to its foundations. Then, again, there is a constant “vibration,” or as it has been termed “vibra- tory shock,” which may tear into splinters the car, and radiates to every fibre of the human body. The ordinary peculiarities of concussion, and may I not add in some cases contusion of the spine, which need careful attention, are, first, the absence of evidence (external) of any injury to the column; the patient is aware that there has been a wrench, or a blow, or a twist, but there need not necessarily be a bruise or an ecchymosed spot; the patient, in the majority of cases, may be able to go about his ordinary business, with occasionally a stiff or sore feeling; after a time, however, the symptoms of paralysis of the parts supplied with nerves from the seat of the injury supervene. The symptoms are progressive and gradual, lasting with variations from months to years. Finally the sphinc- ters become affected, a gradual decay of the entire body takes place, and death results. Again, a severe injury to the back may produce an inflamma- tion of the meninges of the cord, which will ultimately affect the brain itself. Dr. Purple reports a remarkable case, f quoted by Erichsen, in which a man was struck on the back of the head and shoulders by the bough of a tree which he was cutting; this was followed by such complete anaes- thesia of the lower limbs that both his thighs were amputated without the slightest pain. Again, an injury to the spine may be communicated by a fall on the vertex. Generally, paralysis follows these cases, it may be hemiplegic or paraplegic, but it is mostly fatal. In patients who are * Medical and Surgical History of the War of the Rebellion, vol. ii., part i., p. 426. f Eve's Surgical Cases, p. 90. 682 A SYSTEM OF SURGERY. paralyzed immediately the symptoms are, according to Mr. Erichsen : “1. A diminution or loss of motor power. 2. Rigidity and spasm of mus- cles. 3. Diminution or loss of sensation. 4. Perversion of sensation. 5. Loss of control over the sphincters. 6. Modification of the temperature of the limb.” Beside these there may be haematuria and intestinal haemor- rhage, hiccough, hypermetropia, impairment of the sexual functions, mo- lecular changes in the cord itself, impairment of memory, myelitis, neuralgia, and a host of other affections of serious import. . One important peculiarity of shock and concussion of the spine is thus forcibly laid down by Mr. Erichsen.” He says: “These symptoms of a spinal concussion seldom occur when a serious injury has been in- flicted on one of the limbs, unless the spine itself has at the same time been severely and directly struck. A person who, by any of the accidents of civil life, meets with an injury, by which one of the limbs is fractured or is dislocated, necessarily sustains a very severe shock; but it is a rare thing indeed to find that the spinal cord or the brain has been injuri- ously injured by this shock that has been impressed on the body. It would appear as if the violence of the shock had expended itself in the production of the fracture or of the dislocation, and that a jar of the more delicate nervous structures is thus avoided. . . . . How the jars, shakes, shocks, or concussions of the spinal cord directly influence its action, I cannot say with certainty. We do not know how it is, that when a magnet is struck a heavy blow with a hammer, the magnetic force is jarred, shaken, or concussed out of the horseshoe. But we know that it is so, and that the iron has lost its magnetic power. So, if the spine is badly jarred, shaken, or concussed by a blow or shock of any kind communicated to the body, we find that the nervous force is, to a certain extent, shaken out of the man, and that he has some way lost nerve power.” Treatment.—The main feature in this treatment is rest. Dr. S. Weir Mitchell, f of Philadelphia, has given the profession some valuable sug- gestions on the importance of rest in all forms of nervous disorders. I have known the great importance of this method of treatment for years; in fact I never have been an advocate for “early getting up ’’ after any medical or surgical disease, nor have I been as prodigal in my advice “to go out and exercise in the open air" as many of my professional brethren. It is a mistake in the practice of medicine, it is a mistake in the practice of surgery, to urge the patient to exercise. It is like overloading a dys- peptic stomach with strong food; it does great harm. Rest after injury of the spine must be absolute, and must be prolonged; it is the factor in the cure, and is a difficult thing to accomplish, because in many cases the injury appears so trifling that patients cannot understand what disastrous results may follow. Arnica internally, and applications of the same in solu- tion to the spine will generally be of service. Frictions do harm. I am convinced of the fact from actual experience. The muscles must be rested and pressure taken away from the column. For such the plaster jacket, put on by an experienced hand, would no doubt accomplish much. ... When secondary symptoms begin to manifest them- selves, aconite, belladonna, phosphorus, nux vomica, strychnia, cicuta, lumbum, rhus tox., veratrum, cantharides, hyoscyamus, Calabar bean, chloral hydrate, opium, and camphor should be used according to the pre- senting symptoms. Spina # * if: Spine.—This affection or deformity of the vertebral column consists essentially in an arrest of development of some portion of * On Concussion of the Spine, Nervous Shocks, p. 156. f Rest in Nervous Diseases. Blood and Fat, and How to Make Them. SPINA BIFIDA—CLEFT SPINE. 683 the bones of the spine, through which the membranes of the cord pro- trude; indeed, it may be said to be a hernia of the spinal cord. The affec- tion is congenital, and often is accompanied by other deformities. In twenty-seven cases, twelve were found uncomplicated with any other de- formity; in eleven there was incontinence of urine and faeces; paralysis of the lower extremities existed in four ; hydrocephalus accompanied four others; naevus two, and talipes one. Of these cases, the lumbar region was the site of thirteen; there were four in the lumbo-sacral region, and nine in the sacral. These specifications approximate a correct estimate of the location and complications of the affection. In some cases the integument is perfect at birth and afterwards ulcerates, showing the protrusion of the membranes or the cord itself. In other cases, at birth, nothing but a membrane appears to cover the parts. Fig. 392, taken from a photograph, represents a case which occurred in the practice of my friend, the late Dr. J. J. Youlin, of Jersey City, and of which he furnished me a description. The cut gives an example of those usually seen. At birth, the child had in the lum- bar region a dark-colored spot, having \\"Nº. 4 # 5 j Rs. N. somewhat the appearance of a bed-sore, Şs º, & ºs- at the base of which was a thin membrane. - § 5 # 3 Upon pressure, this was found to possess . considerable elasticity, and became more § dense as the tumor developed itself, which rapidly advanced from the cleft, always retaining its dark color and elasticity. It R& #1 likewise was moist. As it continued to sº º § ; increase, it divided into two parts, as seen case of spina Bifida, from n in the figure, the lower being the larger. In the centre of the upper part a small orifice Soon made its appearance, from which jets of cerebro-spinal fluid were ejected during coughing, sneez- ing, crying, or any rapid movement of the body. The child lived six weeks and died in convulsions. I have seen many similar ones. Treatment.—In most cases of cleft spine, death results early, but there are instances of recovery, and those also in which the patients have reached adult life. Hamilton records one of the latter kind coming under his own observation.* In ten cases under my supervision six died of convulsions in six to ten weeks. One was operated on by injection, and lived two years, the others survived from one to three years. The first care should be to protect the tumor from injury. An excellent method of so doing is with a framework of wire filled with soft cotton-wool. In other instances, cotton applied and kept in position with a bandage answers well, the parts having been previously painted with collodion. It must be borne in mind that a certain amount of pressure is sometimes serviceable, and therefore the band securing the cotton may be drawn with moderate tightness around the protrusion. Tapping the sac and drawing off the fluid (the smallest-sized needle of the aspirator being used) I have also practiced, and as I have stated successfully. The proceeding is often, however, followed by convulsions and death. Gradual constriction of the neck of the sac, when there is but a slight pedicle, may also be tried. In the effort to draw off the fluid the puncture should be made at the side of the tumor, in order to avoid the spinal cord, and the whole amount FIG. 392. à ature. * Principles and Practice of Surgery, p. 454. 684 A SYSTEM OF SURGERY. should never be evacuated at once. If injection be used, after the partial withdrawal, iodine, five or six drops to the drachm of water, may be em- ployed, the strength of the solution being increased if sufficient inflamma- tion is not excited. - tº Brainerd’s injection, which has been successful, is composed of five grains of iodine, fifteen of iodide of potassium, and an ounce of water. Finally, immediate removal with the écraseur has been tried. M. Mouchet has operated upon spina bifida with success by the elastic ligature,” puncturing the sac in one case before using the ligature, and in another by immediately applying the ligature without previous puncture. Six cases have been reported as treated by this method, of which three Succeeded, one failed, and two died. Another case is reported by Dr. Baldassare, in which compression with the elastic ligature, lasting sixteen days, was successful.i. In some cases I have had a moderate degree of success by Brainerd’s injection, that is, the lives of the children have been prolonged; the ma- jority, however, ultimately died. In several other cases, death followed in a day or two after the evacuation of the fluid with the aspirator. At best, the results of all these methods have not been favorable, but they are worth trial, as occasionally a case has been cured by their employ- ment. Rotary Lateral Curvature of the Spine–Scoliosis.-This affection, which appears to be rapidly on the increase, especially in large cities and among the wealthy and luxurious, is more frequent in girls than in boys, and com- mences in an insidious manner. Patients have informed me that they are certain the affection must have appeared in a few days, because while “trying on a dress,” or changing clothes, or bathing, the deformity was sud- denly recognized, it having progressed for a considerable time without being discovered. Lateral curvature is produced by a want of harmony in the many antag- onistic muscles which are attached to the different portions of the spine. There is no disease of the internal organs; in fact, there is no disease any- where. One set of muscles—from bad positions, contracted at school or at home, bad positions in bed, bad positions at table, bad positions in riding and walking—become weakened; while the other set, acting more forcibly, draw the spine to one side. - There is a variation in the degree of this deformity, but great or small, there are two curvatures, the one balancing, as it were, the other, the higher equalizing the lower portion of the column. I have noticed regularity and precision in the course of these curvatures. Examining the lumbar curve, the column is bent from its base to the left side in the majority of cases, making the concavity to the right, then fol- lowing the general rule, the dorsal curve is deflected to the right, having the concavity on the left side. Patients suffering from lateral curvature seem more “dumpy” in their bodies, their arms are lengthened, there is a clumsiness about the waist, the hip is elevated and seems of greater size than its fellow, there appears to be a convergence of the ribs; as they pass from the vertebral column they ex- pand and enlarge the intercostal spaces. The right shoulder is elevated and bulging and projects backward; and, in Some instances, the chest ap- pears as though it were twisted entirely around. By passing the fingers along the spinous processes, a certain amount of deformity can be recog- nized, but it must be borne in mind that the spinous processes incline to the * Monthly Abstract of Med. Science, October, 1876; Obstetrical Journal of Great Britain. t Medical Times and Gazette, August 25th, 1877. TREATMENT OF LATERAL CURVATURE. 685 concave side of each curve, giving the appearance of a tolerably straight column, so far as the tips of the spinous processes are concerned, whereas the bodies of the vertebrae are drawn far away in the lateral displacement; in other words, rotated. This condition may be readily explained. If we examine carefully the muscular and ligamentous attachments of the spinal column, it will be seen that the anterior portions, of the bodies of the vertebrae are almost entirely free from such connections, while the spinous processes and the posterior portion of the bones are much more firmly j in the median line by these Symmetrical supports. This fact was recognized, and, as far as I am aware, first pointed out by Dr. A. B. Judson,” who attributes the rotation observed in cases of lateral curvature of the spine to the peculiarities above noticed. He states also that it is not the disparity of action of a single muscle, or even of sets of muscles, by which the rotation is produced, but to the combined action of all. This reasonable explanation would regulate somewhat the application of mechanical contrivances, and although difficulty will always be found in getting the direct pressure upon the bodies of the vertebrae, still a general support of the sides of the chest and thorax aids somewhat, if not entirely, in restoring the rotated bodies, at least of preventing further motion in that direction. , Dr. Sayre recommends for this reason the plaster jacket in rota- tory lateral curvature. Treatment.—As there is no disease existing in lateral curvature, there need be no medicines given internally. If noticed early, the cases may be cured by proper gymnastic exercises, tending to bring strength to those muscles at fault. Dr. Roth and Dr. C. F. Taylor have described very minutely the exercises tending to such a result. The postures of the children must be rectified; they should be removed from school, and allowed exercise in the open air. Riding, walking, rowing (not boat- ing), all should be practiced. Frictions of alco- FIG. 393. hol and salt, or whiskey and water, should be 2% º } º 5 y غ made upon the spinal column, over the affected Ø sº parts, night and morning. The diet should re- § ceive minute attention, all unwholesome food, such as cakes, pastry, candies, etc., being strictly forbidden; a proper position in bed enjoined, a low pillow only being allowed. Daily calisthenics are of great service, and the “movement cure,” under the direction of judi- cious specialists, should be resorted to. In the latter stages of the disease, appropriate supports are often beneficial, although they are objec- tionable from the pressure and inconvenience to which they give rise. Of all the methods I have used, I prefer the apparatus of Mr. Bar- well, as modified by Dr. Sayre. I have made Some excellent cures with it. At present, how- ever, the application of the plaster of Paris jacket, as described in the next article, is said to super- 5::::::" sede all others. Tiemann's Apparatus. In some obstinate cases, section of the latissi- mus dorsi muscle must be resorted to. It was first performed by Prof. Lewis A. Sayre, in 1876.f The muscle was divided subcutaneously, with the effect * Medical Record, April 22d, 1876. & f N. Y. Medical Record, January 22d, 1876. 686 A SYSTEM OF SURGERY. of straightening the patient almost upon the instant, so far as the lateral curvature was concerned, the angle of the ribs upon the opposite side being about the only deformity left. The pain of the operation was trifling, and by means of a suitable apparatus of bands and elastic straps, the body was afterwards retained in a perfectly straight position. Angular Curvature of the Spine—Caries of the Spine–Pott's Disease—Spon- dylitis.--Dr. Sayre * objects to the term Pott's disease, and prefers the word 8pondylitis as being more applicable to the aetiology, course, and termination of the affection. Above it was remarked that in lateral curvature no distinct disease ex- isted, but that the deformity of the column was occasioned by a lack of equalizing power of the muscles on each side of the vertebrae; not so, how- ever, is it in angular curvature, a distinct disease being the cause of the deformity. Pott's disease is usually developed in scrofulous children, its immediate cause being, in the majority of cases, some local injury; in other instances, no local origin can be found, and a slight protuberance in the line of the spinal column is the first indication of the approaching disease. It is said that, in the majority of instances, the affection commences in the inter- vertebral substance, the inflammation extending itself to the bodies of the vertebrae, which become carious and crumble, causing the head and trunk to fall forward and the posterior portions of the vertebrae to protrude. In the earlier stages, and especially when the lumbar vertebrae are affected, there is a lateral curvature, together with the forward deviation. This fact must be remembered in making an early diagnosis, as an error at this period would probably be the source of disastrous results. There are always some presenting symptoms, generally however obscure, before the “knuckle” is seen; these manifestations being of a nervous char- acter and occasioned by irritation of the lateral portions of the vertebrae near the foramina giving passage to the spinal nerves. If the disease ap- pears in the cervical region, there is cough and some difficulty of breathing; if in the dorsal, a catch in the breath and an inability to take a full respira- tion; if in the lumbar, there are colicky pains, constipation, etc.; all these symptoms, together with the pallor and emaciation which belong to those children afflicted with Pott's disease, suggest that the patient is suffering from some verminous affection. An important point also, as noticed by Dr. Lee, is this, that pressure downward on the spinous processes in many cases does not produce pain, but squeezing the sides of the thorax together in order to force the heads of the ribs upon their articular facets, will give rise to more or less suffer- ing. In fact, if the patient is on the face in a recumbent posture, pressure on the spinous processes may relieve rather than aggravate the pain. When it is necessary to examine a patient with Pott's disease, he may be suspended by an assistant holding him under the arms, or may be laid upon the lap, having the arms hanging over one knee and the legs over the other. By then separating gradually the knees, traction is made on the column and the patient will breathe better, and perhaps the “knuckle” will not be so well marked. When a child, affected with angular curvature, attempts to walk, the ten- dency of the head is forward and there is a loss of the proper equilibrium, to remedy which the patient, as he slides carefully along, having a great liability to trip, places his hands upon the thighs. This position is also assumed when standing. There is likewise a backward inclination of the head and a tendency to carry the body back. By the continuation of these * Medical News and Library, vol. xxxvi., p. 49. TREATMENT OF POTT's DISEASE. 687 motions the angle also is carried back and the “humped-back" becomes more conspicuous. When the affection is seated in the dorsal region, the whole thorax par- ticipates in the deformity; its antero-posterior diameter is increased, and . sternum protrudes greatly, and the well-known “chicken-breast” is pro- uced. After a time, a spinal abscess sometimes results, which increases the dif- ficulties. . . - In many instances, however, even after the formation and evacuation of pus, solidification of the vertebrae takes place, and the patient recovers, with a deformity, but with good health. Many strong and sturdy humped-back men are seen on the streets pursuing their daily avocations, and apparently in the enjoyment of unimpaired health. Treatment.—In the early stages of the disease, a great deal can be done by medication, by diet and rest. The great desideratum is to take the super- incumbent weight off the diseased bone, and the best method to accom- plish this is rest in the horizontal posture. This must be absolute and pro- longed, and during it the patient steadily given proper medicine. Those which have been very efficacious in my hands are especially silicea, asa- foetida, mezereum, and calcarea. These I give in trituration, a powder every night. Great attention must be given during this period to the bathing and diet of the child. The latter is often found especially difficult, as children affected with these diseases are much petted and fed without discretion. In the mechanical treatment of Pott's dis- ease, I have been successful with the brace of Dr. C. F. Taylor (Fig. 394). I have used also with good success the plaster-of-Paris jacket of Dr. Sayre. One thing is certain. It can be $: 22- applied in any location. It costs nothing, I *\,.4% mean when compared to the other expensive gº º apparatusus devised for the treatment of this § º disease, and the results that have been recorded ºº: , " ... by Dr. Sayre and others in this country and in Europe bid fair to make it yet the appa- ratus for this deformity. It is to be applied as follows, according to Dr. Sayre's own direc- tions:* “When you wish to apply a jacket, the pa- tient is to be suspended by means of an appa- ratus prepared for the purpose, consisting of a curved iron bar with hooks at either end, from which pass straps that are attached to pads, that go through the axillae and also un- der the occiput and chin, and are capable of being made shorter or longer, according to the length of the patient's neck. The iron bar is a/55 KWDEAES-00 suspended from the ceiling by means of a compound pulley, through which gradual extension can be made until the patient is drawn up so that the feet swing clear from the floor. . . “Previous to the suspension, however, a thin flexible leaden strip should be laid upon the spinous processes for the entire length of the spinal column, and bent into all the sinuosities, so that it may take a perfect outline of the FIG. 394. * Report on Pott's Disease, or Caries of the Spine; treated by extension and the plaster-of- Paris bandage. By Lewis A. Sayre. 1877. 688 A SYSTEM OF SURGERY. deformity. This strip is then laid upon paper and its outline marked with ink, and we have a perfect mathematical outline of the irregularities along the spinal column. After the patient has been suspended, the same leaden strip should again be applied along the spinous processes, as in the first in- stance, and another pattern made upon paper by the side of the first. “Now we have a means by which comparison can be made, and we are able to determine exactly what changes have taken place in the curve. The shirt, which should be woven or knit without seams, and tightly fitting the body, is next pulled down, and an opening made in front and rear, through which a ribbon or piece of bandage is passed for the purpose of holding in place a handkerchief placed in the perinaeum, and at the same time making the shirt fit the hips exactly; for the tighter the shirt fits, the less number of wrinkles there will be in it. The roller bandages, previously prepared, are now set on end in a vessel containing sufficient depth of water to cover them entirely, and, at first, bubbles of gas will escape through the water freely. When the bubbles cease to escape, the bandages are ready for use. Then taking a roller in the hand, and squeezing it gently so as to remove all surplus water, commence just around the smallest part of the body, go- ing to the crest of the ilium and a little below it, and lay it around the body smoothly, but do not draw upon it at all; simply unroll the bandage with one hand while the other follows and brings it into smooth close contact with all the irregularities of the surface, over the ilium and dipping into the groin, over the abdomen and dipping into the groin again, and so on, from below upwards in a spiral direction until the entire trunk has been inclosed from the pelvis to the axillae. After one or two thicknesses of bandage have been laid around the body in the manner described, narrow strips of perforated tin are placed parallel with each other upon either side of the spine, from two to three inches apart, and in number sufficient to surround the body, and another plaster-roller carried around the body, covering them, in the manner in which the first bandage was applied. “These few strips strengthen the bandage, and obviate the necessity of increasing its weight by the application of a larger amount of plaster. If there are any very prominent spinous processes, which at the same time may have become inflamed, in consequence of pressure produced by instru- ments previously worn, or from lying in bed, it is well to guard such places by means of little pads of cotton or cloth, or little glove fingers filled with wool which is elastic, which are to be placed upon either side of them before applying the bandage. “Another suggestion, which I have found to be of practical value, is to take two or three thicknesses of roller bandage three or four inches long, and place them over the anterior superior spinous process of each ilium. These little pads are to be removed just before the plaster has completely set, and consequently leave the bony part free from pressure after the soft parts have shrunken under the influence of the continued pressure pro- duced by the plaster dressing. It is also well, just before the plaster has set completely, to place one hand in front of the ilium and the other over the buttocks, and squeeze the cast together so as to increase this space over the bony prominences. In a very short time the plaster becomes set, suffi- ciently so that the patients can be removed from the suspending apparatus, and laid upon the face or back on an air bed, where they are to remain until the hardening process is complete. A hair mattress answers a very good purpose, but the air-bed is preferable, especially if there is much projection of the spinous processes or the sternum. “If there are any abscesses present, they must be freely opened at the most dependent part, and their contents completely extracted by means of the wide rubber cupping-glass. Sometimes large masses of sloughing con- TREATMENT OF POTT's DISEASE. 689 nective tissue will be found, which look like wads of wet cotton; all these must be removed. After the abscesses have been thoroughly evacuated, oakum should be placed over the opening, and then covered with a piece of oil-silk, before the shirt is pulled down over the body. A hole is then cut in the shirt, which is to indicate the size of the fenestrum subsequently to be cut in the plaster jacket, and in it is set a folded piece of pasteboard of the same size, and carrying a long sharp pin thrust through its outermost leaf. Now each turn of the bandage can be carried over the pin without crowding it into the abscess below, and you also have a guide in making an opening that shall lead directly to it. When the plaster has nearly set, you can take hold of the pin, and cut around it until the pasteboard is reached, and an opening made sufficiently large to allow of its easy removal. The FIG. 395. FIG. 396. - FIG. 397. * > Sayre's Jury-mast. Taylor's Apparatus. Darrach's Wheel-Crutch and Chair. pasteboard removed, you come at once upon the oil-silk, which is to be starred, or cut from the centre into strips, so that when they are reversed, they will cover the edges of the opening in the plaster, where they can be glued down with gum-shellac, and now you have left a fenestrum for drainage that leads directly to the abscess.” When the disease attacks the cervical vertebræ, Dr. Sayre applies what he calls a “jury-mast,” which suspends the head. This appliance is seen in Fig. 395, and is held firmly in place by the “plaster jacket.” It is applied after the body has been encased by the application of the bandage twice; it is then laid over and secured by repeated turns of the roller several times 44 690 A SYSTEM OF SURGERY. up and down the chest. In Taylor's splint the pressure is made on the chin and the prominent vertebrae, thus lifting the weight from the diseased bodies. (Fig. 396.) Another contrivance, which has been productive of satisfactory results, is that of S. A. Darrach, of Newark. (Fig. 397.) It will be seen how the weight is taken entirely from the spinal column, while free exercise is allowed to other parts of the body. "I have known excellent results FIG. 398. --- ! º The Meigs-Case Apparatus for Pott's Disease. from this crutch, in connection with the body-brace. The corset is made of hide prepared in a peculiar manner, and readily moulds itself to the parts. Dr. Franklin makes, with a plaster bandage around the ilia, what he denominates an artificial Sacrum, to support the upper dressings. He also introduced a modification of the jury-mast, to take off pressure from the cervical vertebrae, and render the entire dressing more firm. The Meigs-Case apparatus, Fig. 398, I have used also with satisfactory results. PSOAS OR LUMBAR ABSCESS, 691 The student must, however, be cautioned against forgetting, through admiration of these newer methods, that there are other ways in which these deformities are cured. Rest, medication, the exercise of certain muscles, and proper braces, will cure the disease, and have so done, long before these admirable plaster contrivances came into general use. It must be also remembered that distinguished and successful specialists, by means of their own contrivances, are constantly producing good results. Kyphosis.-This term is given to a general antero-posterior curve, which is noticed in weakly children and in the aged. It is occasioned in infants by allowing them to sit up too early. This can also be cured by the plaster- of-Paris jacket. - Lordosis, or “saddle-back,” is generally produced by congenital dislocation of the hip. It must be considered as a secondary affection. It will easily be seen that in the dislocation of the hip there is a backward displacement of the centre of gravity, which makes the forward inclination of the pelvis necessary to establish the equilibrium. In this variety the cause must be removed, the endeavor being made to reduce and fix in position the dis- placed bone, or if anchylosis exist, performing subcutaneous Osteotomy at the neck of the thigh. Psoas or Lumbar Abscess.--This disease in most instances, is chronic, the collection of pus being very gradual. Cases, however, may occur, in which the affection is acute, the matter making its appearance in a short time after the premonitory symptoms have been noticed by the patient. The first manifestations do not, in many cases, receive sufficient atten- tion, and are allowed to pass unnoticed, until the disorder is far advanced and the danger too proximate to escape attention. In the incipient stage, the patients are unable to walk with their usual facility, there is a degree of uneasiness experienced about the lumbar region, but there is little acute pain; rigors are frequently present, the patients also being un- able to use any violent exercise. As the disease advances, the testicle of the affected side is drawn up, and there is more or less pain extending along the course of the spermatic cord. Glandular enlargement takes place in the groin, and there is a slight protrusion noticed at that part; the swell- ing then appears on the inner side of the femoral vessels, beneath the pubic portion of the fascia lata. The precursory symptoms may continue sev- eral months, before rigors, loss of appetite, hectic, and other symptoms which denote suppuration, are developed. Mr. Cooper remarks: “The abscess sometimes forms a swelling above Poupart's ligament, sometimes below it, and frequently the matter glides under the fascia of the thigh; occasion- ally it makes its way through the sacro-ischiatic foramen, and assumes rather the appearance of a fistula in ano. When the matter gravitates into the thigh, beneath the fascia, Mr. Hunter would have termed it a disease in, not of the part.” The swelling is more prominent in the erect position, and is also increased by exertion of the abdominal muscles; an impulse is also imparted to it when coughing. As the suppuration continues, fluctuation is perceived, generally in some portion of the groin, but large and neglected collections of pus may make their way towards the surface in two or three directions. Lumbar abscess most frequently arises from disease of the vertebrae, but, says a distinguished surgeon, “It must be confessed that we can hardly ever know the existence of the disorder, before the tumor, by presenting itself externally, leads us to such information.” The pus discharged from a lumbar abscess is generally thin, gleety, and mixed with cheesy flocculi, or with a curdlike substance; in Some rare in- stances, however, the matter has been found laudable. From post-mortem examinations on patients who have died from this 692 . A SYSTEM OF SURGERY. affection, we learn that the purulent secretion is completely inclosed in a cyst, which is often very extensive. If the contents of such abscesses were not circumscribed by such boundaries, the pus would spread rapidly among the cells of the surrounding cellular texture, as does the water in anasarca. The cysts are lined with the pyogenic membrane, that, as has been before mentioned, appears to possess the property of Secretion ; indeed, during the treatment of lumbar abscess, it is wonderful to observe the im- mense quantity of pus that is discharged. This disease is often attributable to a sprain or wrench of the loins, or is induced by exposure to cold and overfatigue. Occasionally the mischief is confined entirely to the soft parts; although the vertebræ, a portion of the os innominatum, or the sacrum may be denuded and of irregular surface, evidently the result of the pressure of the abscess. A strong example of this and of the extensive destruction of parts which this affection sometimes produces, may be briefly stated. A large lumbar abscess formed within a few weeks, in consequence of great and continued fatigue and exposure to bad weather. At first it had been trifled with. At last it was opened, in the usual situation in the thigh, and a large quantity of matter evacuated. Thirty-six hours afterwards the patient was suffocated with a flow of puru- lent matter into and through the air-passages. On dissection, the cavity was found which opened through the diaphragm into the adherent lung, and communicated with the bronchi. The forepart of the lumbar vertebrae were exposed, and in some instances stripped of their theca; but there were no cavities in the bone, and no disease of the interposed cartilages. Cases are now and then met with, of abscess in the loins, not originating in any vice, either of the bones or of any other part of the apparatus of the spinal column. Most frequently, however, the collections have their foun- dation in disease of the bodies of the vertebrae. The causes of this complaint are generally obscure. It is most prevalent among the lower classes who are scantily clothed and fed, and exposed to vicissitudes of weather, extreme fatigue and other hardships. Individuals affected with scrofula are most obnoxious to the disease, and it is said to be more prevalent in Europe than on this continent. Dr. Gibson*, thus wrote: “I have seen only four cases of the disease during the last thirteen years, although professionally connected with extensive hospitals and almshouses during a greater part of the time.” Dr. Physick also stated, he had never met with a case of psoas abscess in America, unconnected with disease of the spine. Treatment.—In the treatment of lumbar abscess, the prognosis is always unfavorable; the radical cure of the affection can scarcely be effected, even when the patient applies for relief at the earlier stages of the disease, which in far the great majority of instances is not the case, because the pain in the loins, and other premonitory symptoms, are attributed to other causes. The following medicines, although they may not effect a cure, will greatly alleviate the sufferings of the patient; indeed, there have been cases in which, by the careful administration of medicine, the abscess has been par- tially healed, and there are some who maintain that if the diagnosis is formed correctly, at an early period of the affection, a cure may be reason- ably anticipated. The medicines chiefly to be used are, ars, asaf, aur., calc, c., hepar, lyc., merc., mez., phosph. ac., silic, sulph. If there are unhealthy granulations and a disposition of the abscess to spread, silicea may prove beneficial. The treatment, in many cases, may be com- * Institutes and Practice of Surgery, vol. i., p. 214. EXCISIONS OF BONES AND JOINTS. 693 menced with the administration of sulph., which will prove serviceable as an antipsoric. There is some difficulty in diagnosing a lumbar abscess, as it often points very readily at that region where an inguinal hernia would protrude; how- ever, by carefully examining the patient, and inquiring particularly into the history of the case, the error of mistaking the one disease for the other may be avoided. In opening a lumbar abscess the aspirator should always be used. As the disease is chronic, and the matter has been secreting for sometime, it must not be forgotten that the evacuation of a large quantity of pus at once might be productive of serious consequences. CHAPTER XXXV. EXCISIONS OF BONES AND JOINTS. GENERAL REMARKS – INSTRUMENTs — RESECTION OF BONES IN THEIR ContLNUITY— ExCISION OF THE BONES OF THE HAND–OF THE WRIST-OF THE FOREARM–OF THE ELBow—OF THE HUMERUS—OF THE SHOULDER—OF THE SCAPULA—OF THE CLAVICLE–OF THE RIBs—OF THE CALcis—OF THE Toe—OF THE KNEE—OF THE LEG-OF THE HIP. - General Remarks.-Conservative surgery is one of the most interesting fields of science. The vis medicatria naturae, when not interfered with, is an extraordinary power. Nature restores what man would ofttimes destroy ; and converts into living structure parts of the body which man would reject as worthless. - Excision of articular surfaces and of bones in their continuity forms an important part of conservative surgery, and the results which are daily obtained by these operations continue to verify their importance. Like all other improvements in science a long period elapsed before resections came into general favor, and though here and there an operation was successfully performed, surgeons, until recently, did not consider conserva- tive operations among the legitimate and systematized proceedings of the art. It was proved by Boucher, in 1753, that wounds of considerable severity entering into a joint might be treated by simply removing the fragments of bone. In 1740, Thomas resected the head of the humerus in a child four years old, particulars of which may be found in Guthrie's work on Gunshot Wounds. White made an incision at the upper part of the humerus, dislocated and removed its upper end, which was carious; the patient lost about two ounces of blood during the operation, and in five weeks the boy had so far recovered as to be able to lift a heavy weight. After two months Quite a piece of the remaining bone separated and was removed, after which the wound healed, the patient being perfectly cured in four months. The arm was shortened about one inch. It is worthy of remark that neither splints, bandages, nor the like were used. Gooch reports that he sawed off the heads of the tibia, the fibula, and the radius, and also the second bone of the thumb. A somewhat similar operation is reported to have been performed on a girl at the hip-joint. Syme made a flap in the shape of a V, and then brought out the head of the humerus and removed it. Walther was the first to demonstrate upon the dead subject the practicability of removing the scapula; and in a case where a tumor had become attached to this bone, it was excised with success by Haymann. Park, wishing to know if he could remove the knee without cutting into the 694 A SYSTEM OF SURGERY. popliteal vessels, made various experiments on the cadaver. An incision Was made from about two inches above the patella to the same distance below, another across this, just above the patella, extending nearly half around the limb. The two lower angles were dissected up and the knee-cap removed, after which the upper angles were raised, so as to lay bare the condyles of the femur and to allow a small catling to be passed back of the bone, in their rear. The condyles were then sawn off. The head of the tibia was removed, as was also a considerable part of the capsular ligament. On examination it was found that the vessels had incurred little danger during the operation. Excision was next performed at the elbow. An incision was made from about two inches above to the same distance below the olecranon. It was at first attempted to divide the lateral liga- ments, but as it proved very difficult, the olecranon was removed; the joint was now dislocated with ease, and the lower end of the humerus sawn off, together with the heads of the ulna and radius. This, however, is more difficult when the parts are diseased. Park first performed this operation on a living subject in 1781. It gave him great trouble in the after- treatment, abscesses and sinuses forming, obliging the patient to keep his bed nine or ten weeks, the cure being completed some months after. The patient, in time, went to sea, and was able to do his duty well. The same Surgeon soon after performed this operation again, but the patient did not live four months. Moreau, Jr., thought that two flaps were needed in excision of the elbow, and that it was unnecessary to remove the olecranon unless it were diseased. In our own country great impetus has been given to resection, by the successful removal of almost every bone in the body. The clavicle and Scapula, the maxillary bones, the hip, knee, wrist, and ankle-joints, all have been excised by American surgeons, the importance and success of the oper- ations being unsurpassed. The names of the distinguished men who have achieved triumphs in this field are too numerous to mention, but they have won laurels which will never fade, and their names everywhere are honored and respected. Dr. Deadrick, of Tennessee, in 1810, removed half of the inferior max- illary, and Charles McCreary, of Kentucky, 1813, exsected the entire clavicle. Dr. Mott, in 1828, performed the same difficult operation, and Dr. Franklin, in 1862, removed the sternal two-thirds of the bone. McClellan, Stevens, Carnochan, Wood, and Rogers, also made resections of the upper and lower jaws. Butt, of Virginia, resected the radius in 1825; while Pancoast, Gross, Mütter, Blackman, Ackley, Stone, Hamilton, Buck, and others, are all equally entitled to elevated positions in this field of surgery. The conditions which call for resection of bones and joints are caries and necrosis, extensive injuries and malignant disease, and the operations are to be resorted to when all other means have failed. Then the question arises between amputation and resection. In every case where there is a probability of saving the patient a limb, though it be stiff, resection should have the preference. - FIG. 399. The instruments for excision of bones are varied, and consist, first, of the ordinary knives for making flesh-wounds; metallic retractors to hold the INSTRUMENTS FOR EXCISION OF BONES. 695 soft parts away from the Osseous, and strong bone forceps, used either to hold and lift away bone, or to divide the osseous structures. Fig. 399 shows a modification of Fergusson's Lion-jawed Forceps. FIG. 400. FIG. 401. ºš= Gº G.T | EMPANN & CO, Bone-cutters are of different shapes. Fig. 400 shows Satterlee's Bone For- ceps; Fig. 401, Liston's Bone Forceps, knee-curve; Fig. 402, Liston's Forceps, ºf curved on the flat. - º These forceps are of various sizes, some large, and with long handles, to give powerful leverage when great force is required. FIG. 403. º © gº sº.º. ºº & º - - * * * * º <> sº ~ gº & º & º >2<>º ×3. & º -*s & Bº tº: <& **.*.*.*-*.*.*:: *- Blunt instruments are also used to denude the bone of muscles and peri- osteum. Fig. 403 represents Sands's interosseous knife, and Fig. 404 the instrument of Dr. Sayre for the removal of the periosteum. FIG. 404. G.T.EMANN-C0,NY. Sayre's Periosteotome. The saws used are of various shapes and sizes. Fig. 405 is curved and made expressly for the maxilla. FIG. 405. º º - Fºº º, NºN & N& §º §º º: §§ º º: º: º: ºzº - tº tºº º- . §§§º &\º Tºlli Fº Sºº-ººººº Yº crºw: Massy-Co- Maxilla Saw. Fig. 406, a narrow, fine-toothed saw, introduced by Dr. Lente, is very use- ful when working in a limited space. FIG. 406. G.T E M Assº. -- a . . Lente's Interosseous Saw. Besides these, there are other saws bearing the names of the surgeons who devised them. 696 A SYSTEM OF SURGERY. Fig. 407, chain-saw with the rotating handles of Tiemann. Fig. 408 shows an instrument devised for carrying the chain-saw. - . Dr. John A. Wyeth” speaks very highly of an instrument for resection, invented by Mr. Gowan, of Guy’s Hospital, and which is manufactured in New York, by Tiemann & Co. Dr. Wyeth has employed the instrument FIG. 407. FIG. 408. t; \ WN º -D º \ \\ W TIENANN-CUV | \ c & º l_2< gº º | | | } Q [. *A. & º cº B & | d * ! s: | cº Instrument for carrying Chain-saw. for exsection of the shoulder, elbow, and hip, the radius, the metatarsus and portions of the Scapula. The instrument is represented in the cut as made after the model of Mr. Gowan, and is thus described (Fig. 409): “It consists of a handle about a foot long, made of metal and covered partly by vulcanized rubber. This handle is hollowed out for the passage of the steel bar b, which runs the entire length of the apparatus to act on the jaw of the forceps. . On a portion of its inferior edge, at about its middle, cogs are cut in which the teeth of the lever a catch, and the degree of pressure of the jaws c on the bone to be held is regulated by the pressure of the fin- gers of the operator upon the lever a. The saw e is in shape like a chisel, and works into a shield at d. Method of using: The bone to be exsected having been exposed, with its periosteum peeled off in common with all the circumjacent tissues, the operator, holding the handle of the instrument in his left hand (the saw being entirely removed), depresses the lever a, draws back the bar b, and opens the jaws c wide enough to insinuate them about the bone. As soon as this is accomplished the bar b is pushed forward against the heel of the jaw and the lever a is pressed toward the handle. * Medical Record, March 29th, 1884. INSTRUMENTS FOR EXCISION OF BONES. 697 With the right hand slide the saw into the shield d down until the teeth engage against the bone. A slight oscillation of the handle of the saw car- ries it through the bone with remarkable rapidity, and without wounding or bruising the contiguous soft tissues. The shield d not only rotates, but FIG. 409. e is reversible, and can be changed from one side to the other. In the modi- fied instrument I have had constructed a narrower saw and shield, so that it may be used in exsections of small bones closely related to each other, as the metacarpal bones. º “The modified exsector is seen in Fig. 410, and is cheaper as to cost and simpler as to mechanism than the preceding. The handles work with a FIG. 410. ; double-jointed motion, and have a fixation clamp, f, like the Russian needle- holder. By opening or closing the handle, the jaws, g, are separated or closed. The action of the rotating shield, h, and the saw, l, are the same.” 698: A SYSTEM OF SURGERY. Professor Hamilton has invented a bone-cutter with strong serrated jaws for dividing bone (Fig. 411), and also a pair of bone-forceps (Fig. 412), which are well adapted to the uses for which they are employed. FIG. 411. Hamilton's Serrated Bone-cutter. FIG. 412. Hamilton's Bone Forceps (half-size). Resection of Bones in their Continuity.—Many bones of the body, from in- jury or from disease, can be resected in their continuity, and thus the sur- rounding parts be preserved sufficiently to prevent much deformity. When, in such cases, the periosteum can be protected, which should always be the endeavor of the surgeon, the bone may be almost entirely reproduced. There are no operations which have shown more success than those intro- duced by modern conservative surgery, and none which ought to be more acceptable to the public. In olden times where the loss of an entire limb, or a terrible operation about the mouth, was considered absolutely necessary for the preservation of life, it is now certain that diseased portions of bone may be sawed out or cut away, and the ossific structures reproduced. Since the introduction of Esmarch's bandage these operations are much more sat- isfactorily performed, and successful cases of the entire reproduction of bone have been noted in all countries. Sometimes bones or portions of bone may be removed by subcutaneous incisions, and when such can be accomplished it saves the unsightliness of a, SC&I’. Excision of the Bones of the Hand.—Case.—A man presented himself at the clinic with the following history: Many years ago while using an axe he severely bruised the palm of his hand. Intense inflammation followed, with severe pain; suppuration ensued, and the pus was allowed to find an exit, which it did after a considerable time, on the dorsum of the hand. No professional advice was sought for many months. A probe revealed the roughened surfaces of the middle and ring metacarpals. He was placed under anaesthetic influence; the arm and hand pronated on the table, and an incision made on the dorsum of the hand, of V-shape; the apex at the wrist and the ends of the diverging cuts terminating at the EXCISION OF THE WRIST. 699 knuckle of each of the diseased bones. This incision was merely car- ried through the integument and fascia, which were dissected up. The muscles and tendons were separated with a blunt periosteotome, and held aside with retractors. Each bone was divided with the pliers, held at right angles with the shaft. The cutting pliers were then reliquished for a pair of lion-jawed forceps, with which each extremity of the bones was raised sepa- rately and dissected away. The flap was brought down, there was no haemor- rhage; the lips of the wound were united with silver sutures. A compress wet with calendula and water was the only dressing, and the cure was complete. If only a single metacarpal bone is to be exsected, a longitudinal incision on the dorsum of the hand over the course of the bone is all that is required. If the metacarpal bone of the thumb is to be removed, the thumb must also be taken with it, as has been mentioned in amputation of that portion of the hand. It is inexpedient to resort to resection of the phalanges. Excision of the Wrist.—The diseases which frequently call for removal of the radio-carpal articulation, the carpus and metacarpal joints (which are comprised in excision of the wrist), are synovitis and caries, the latter espe- cially, as well as gunshot and other injuries. The operation may be partial, in which portions of the diseased bones are removed, and complete, when the entire joint and bones entering therein have to be excised. Moreau, the younger, is said to have performed the operation of excision of the wrist, and other European surgeons have occasionally resorted to it. In England its revival is due to Mr. Fergusson, who, on August 16th, 1851, performed it. On October 9th, 1852, Mr. Simon operated on a lad aged nineteen years. On May 21st, 1853, the same surgeon had recourse to the procedure. In October of the same year, Mr. Erichsen removed the wrist-joint. Mr. Butcher and Mr. Liston have also given great attention to the subject. The operation may be performed in several ways; an excellent method being the following: Two longitudinal incisions are made, one on the radial and the other on the ulnar side of the wrist on its dorsal surface ; these are united by a transverse cut, avoiding the extensor tendons of the fingers and thumb. The supinator tendons and the extensor tendons of the carpus are then divided. The joint must next be flexed forcibly, and cautiously opened. The operator carefully selects the uncut tendons, and having drawn them to one side, places them in charge of an assistant, who protects them from injury. The surgeon, then, with a saw, cutting pliers, or the chain-saw, successively divides the articular ends of the radius, the carpal, and bases of the metacarpal bones. Mr. Fergusson believed a single ulnar incision sufficient, but it appears to me that this method is better suited to partial excision. A curvilinear incision answers a good purpose. The knife should be entered at the styloid process of the radius, and be carried downward across the back of the joint, and around up to the styloid process of the ulna. The extensor tendons of the thumb and fingers on the ulnar side must be avoided, the supinator tendons and extensor carpi divided, and the joint entered as before, Lister's method is excellent, and is as follows: The radial incision is made on the dorsal aspect of that bone to avoid the tendons of the extensor ossis metacarpi pollicis, and the extensor secundi internodii. The bones are removed as before. When the bones have been separated, the wound must be thoroughly cleansed with a stream of warm water, and sprayed over with carbolic acid water, the first centesimal dilution (1 to 100). The hand should be laid upon a carved splint, similar to Bond's, with a pro- tuberance at the end over which the fingers may be bent. The thumb should be moved daily, and soon pronation and supination be resorted 700 A SYSTEM OF SURGERY. to. Gentle passive motion of the fingers is made in a few days after the operation. The parts must be kept moist with calendula solution. Excision of the Bones of the Forearm.—Portions of the radius and the ulna have been removed by different surgeons, leaving, in some instances, little deformity. When the radius is to be exsected, the incision should be made on the posterior and outer aspect of the bone, the structures carefully sepa- rated, and the bone divided in its middle. This greatly facilitates the oper- ation. By seizing one of the divided ends with the lion forceps, it can be raised and taken away, the knife always being kept close to the bone. The ulna is removed in like manner, excepting the incision is made on the inside of the arm. The brachial artery may be compressed, but neither the radial nor the ulnar will be touched in the majority of cases if a moderate amount of care be used in the dissection. In removal of the olecranon, a V-shaped incision is made, the flap dissected up and the saw applied. • Excision of the # ow.—Excision of the elbow-joint is a standard operation of conservative surgery, and the success which has attended its performance, together with the usefulness of the limb which often remains after the operation, are sufficient inducements for the judicious surgeon to attempt the proceeding. Before describing the operation, let us look into the anatomy of the parts concerned. Three bones enter into the formation of the elbow ; and the joint is a compound one, a ginglymoid and a diarthrodial. On the anterior face of the humerus are two muscles, which connect the forearm with the arm. One of these, the biceps, is inserted into the tuberosity of the radius; the other, the brachialis anticus, is fixed to the lower portion of the coronoid process of the ulna. If we draw a line from the outer side of the axillary space between the folds of the axilla to a point or depression midway between the condyles of the humerus (which depression marks the boundary between the inner border of the coraco-brachialis and biceps), we have the direct course of the brachial artery, which is comparatively superficial in front of the joint, before its bifurcation. These structures, being in front, are, in a measure, out of harm's way. But there is a point in the surgical anatomy of this joint, to which I desire to particularly call attention. It is the course of the ulnar nerve, which comes from the inner cord of the brachial plexus, and lies on the inner side of the artery. From this course it diverges, pierces the inter-muscular septum, and winding around, passes into the groove between the internal condyle of the humerus and the olecranon process of the ulna. It is necessary to preserve this nerve from injury during the operation. There are a variety of methods recommended for resecting the elbow- joint; but the truth is, as in all surgical operations, the size of the flaps and their number, and the direction of the incisions, are to be influenced by the circumstances attendant upon each particular case. Perhaps the single straight incision is, as Druitt says, the best theoretically. Moreau preferred the H incision, as does also Professor Hamilton; although the position of the patient (on his belly), as recommended by the former surgeon, I conceive to be inadmissible on account of the danger from the full and prolonged anaesthesia. Manne made two semi-lunar incisions, and Roux recommended the cut to be made in the shape of the letter T. Resection by the single long incision, as recommended by distinguished Surgeons, appears to have been performed in London about the same time by Mr. Paget, Mr. Fergusson, and Mr. Erichsen ; and considerable time and thought were expended on the merits of the operation before its introduction. The H incision was made first; then it was discovered that the long cut on the radial side of the arm could be omitted ; thus EXCISION OF THE ELBOW. 701 the incision was converted into the T-shaped. It is said that Langenbeck showed that the cross-cut could also be omitted, thus leaving the single linear incision. I have practiced the H incision, although an excellent method is the V-shaped cut, the apex of which should terminate above the olecranon (Fig. 413). The flap must be dissected down, the triceps detached, and the parts having been held aside, the saw may be applied in such manner as to divide the olecranon at its base, and the radius at its neck (Fig. 414). The condyles of the humerus are exposed, the ulnar nerve sought after and put aside from the condyle, and the soft parts being well protected, the #. portions removed with the saw. In the following operation the reverse of the preceding was practiced: J. T., aged 42, suffered from caries and necrosis of the elbow-joint, of many years’ duration. The patient was placed on the table so that his arm projected over the edge, his shoulders were elevated, and the anaesthetic administered. I began by making a straight incision, commencing four FIG. 413. inches above the joint, and prolonging the same four inches below, carrying the scalpel directly through the tissues down to the bone, opening in its course the fistulous orifice. Keeping the edge of the knife close to the bone, I separated the tissues, and º the index finger of my left hand into the lower extremity of the joint, found the head of the radius, loosened the same from its connection, and pushed it through the wound. The retractor was placed under the head of the bone, which was removed by means of the saw. Next I proceeded to excise the condyles of the humerus. It was found necessary to prolong the incision upward, on account of the dis- ease extending far up the shaft of the arm-bone. The tissues were very much diseased and infiltrated with pus, and a transverse incision was made across the joint, about two inches in length, at right angles with the first. After the muscles had been separated, I inserted my finger into the angle of the wound, and distinctly felt the ulnar nerve lying in its groove; this I pushed over the process, and the lower extremity of the humerus, being disengaged, was sawn off. The third step was the removal of the ole- cranon, which I took off with the chain-saw; and after having drawn the wound together with interrupted sutures placed the arm on a pillow, dressed it with calendula lotion, and fixed it in a splint bent at an obtuse angle. After the joint has been resected, it should be flexed at an obtuse angle, 702 A SYSTEM OF SURGERY. and an anterior splint of rubber, tin, or felt applied, which may be strapped above and below the joint, thereby giving free access to the wound, and allowing the escape of effete discharges. The cut surfaces are to be treated on general principles. It may, in some instances, be a matter of consideration, whether excis- ion of the joint or amputation should be resorted to. If disease has affected the lower portion of the condyles of the humerus, leaving some healthy bone above for the attachment of the flexors and pronators, the extensors and supinators, exsection of the diseased mass should certainly be practiced. If the whole of the olecranon be involved, together with the sigmoid notches, and even a part of the coronoid process, leaving, however, a healthy point for the insertion of the anterior brachial muscle, the limb may be saved. If, together with this, the head and neck of the radius be implicated, leaving the tubercle for the attachment of the biceps, exsection is the remedy. But if, on the contrary, both condyles of the humerus and the ridges lead- FIG. 415. Fºº. | \\ *W º º | º f º %kº jº, j|| || º º IB | i". A. AM & || || , ; ;-------- º, "... " \\ \\ *" ; i. %\ fºss º º º - %. .." ..I. g "º ſº, i. indi % al | & S 2: - g & | | ſ J; ſ º tºº ºffº/lºiº .." tº ſºft' º º * * lſ ; , , , , .. 3 'I'''Wºº a - º t *º : Å ºf ... | ſº 3. * * : *tj% *::. tº: º t & «"... ." *H a fiº,”f ſº tº, tº Yºmiuſº A 3 Nº. *ś. fºr ºf a .p. Carious Olecranon and Head of Radius, from Author's collection. ing to them, together with the shaft of the bone itself, the coronoid process of the ulna, and the tubercle of the radius and body of the bones be in a state of disorganization, nothing but amputation can be performed with a reasonable hope of success. According to statistics of Erichsen, of the University College Hospital, the results, after exsections of the elbow, are far more favorable than those after amputation. The Surgeon-General's Circular, No. 6, shows that of 315 cases of ex- cision of the elbow, practiced for gunshot injuries, in 16 amputation was necessary, and 62 cases terminated fatally, making an average mortality of 21.67 per cent., which is somewhat greater than that resulting from am- putation. Fig. 415, drawn from one of my cases, three days after operation, shows the carious olecranon, B, with head of radius, C, united thereto by bony deposits. This was quite a troublesome case, on account of extensive infil- tration of the soft parts. Dr. H. J. Bigelow, to avoid cutting the fascia and muscles which unite the arm to the forearm, excises the elbow-joint by the longitudinal incision, EXCISION OF THE SHOULDER-JOINT. 703 first removing the head of the ulna, then the articulating surface of the hu- merus, leaving the condyles, if not diseased, by sawing immediately below them from each side upwards and inwards, and last of all removing the head of the radius. Excision of the Humerus in its Continuity.—In some instances from caries or gunshot injury it may be necessary to remove a portion of the shaft of the humerus. Before performing the operation it is well to bear in mind that there is scarcely any likelihood of bony union taking place, and that even if a small portion of the bone is removed non-union will probably re- Sult, although there are cases upon record in which such fortunate results have taken place. One has come under my observation in which at least three FIG. 416. inches of the shaft of the humerus was excised. There was no attempt made to bring the ends of the bone together. The arm was laid upon a pillow, and the wound allowed to heal. By means of a shoulder brace, with two small steel rods passing to a band which was secured just above the elbow, as seen in Fig. 416, the patient had considerable motion of the arm and per- fect use of the forearm and hand. There was scarcely a noticeable deformity. Therefore when there is disease of the shaft of the bone to that degree that am- putation would otherwise have to be resorted to, the removal of the shaft and the application of the proper instru- ment would be the preferable procedure, ſº moderate motion at the shoulder and the use of the elbow and 8,Il Ci. - The incision, a straight one, as many inches in length as may be desired, should be made on the outside of the arm down to the bone, and the tis- sues removed by careful dissection with blunt instruments and occasional touches with the edge of the scalpel; beneath the bone a chain-saw should be applied, or the instrument of Butcher, and the bone removed. The wound is then to be syringed with carbolic acid solution, and if but a small portion has been cut away, the ends of the bone brought together and Se- cured by wire sutures. If several inches are to be removed, the arm should be placed on a leather or gutta-percha splint, and no attempt at union of bone made. - - Excision of the Shoulder-joint.—This excision is practiced for either dis- ease or accident, and the results of the operation are encouraging. Caries and necrosis of the head of the humerus, generally commencing in a synovitis, or from a wound, and anchylosis of the joint, are the frequent causes that require the operation. Of the 50 cases of excision of the joint collected by Hodges, 8 died, but in seven of the eight cases the articular surface of the glenoid cavity had been implicated. Of 30 cases published by Mr. Thomas Gant, the mortality amounted to 1 in 4. In 575 excisions of the shoulder-joint for gunshot injuries, practiced during the late civil war, in which there were 252 primary and 323 secondary excisions, 165 died, 343 recovered, and 67 cases remained with undetermined results; the per- centage of mortality being 23.8 in the primary, 38.59 in the Secondary, or a mean of 32.48. When these figures are compared with those of amputa- tion of the shoulder-joint, the average mortality of which is 39.24, we find a percentage of 6.76 in favor of excision. 704 A SYSTEM OF SURGERY. According to Esmarch the resection of the right shoulder gives the best returns, although such statement has not been verified.* Thomas, an English surgeon, in 1740, performed this resection, although White, of Manchester, in 1768, is generally FIG. 417. supposed to have priority in the operation. º Vigaroux, of Montpelier, in 1767; and Redo- _º wald, in 1770, also performed excision of the º head of the humerus. *º In 1786 the elder Moreau excised completely º - - --~~~~ --~~~~ ->eº - the joint, including a portion of the acromion * and neck of the scapula. After this period the operation fell into disrepute, but was rescued * from oblivion, and advocated in 1826 by Mr. - Syme. 2 The following is the manner of operation, º if only the head of the humerus is to be re- 㺠moved. A single straight incision from the º * point of the shoulder near the acromion (see º Fig. 417), four and a half inches in length, should be made and carried down to the bone. 㺠The tissues must be dissected up and held ** aside with metallie retractors. If it be possible during this dissection, the long head of the biceps must be saved, and drawn aside; in some instances necessity may require its division. The insertion of the rotator muscles must be carefully divided. The capsule of the joint is next entered, and disarticulation effected by the entire separation of all the tissues. The arm must be pushed º and the elbow carried across the chest to expose the head of the bone, which is removed, either with a chain-saw or the ordinary instrument. In other cases the U-incision is preferred, especially when portions of the clavicle or scapula are implicated. In such a strong scalpel must be entered near the posterior border of the acromion, penetrating to the bone, and carried downward across the insertion of the deltoid, and upward toward the inner border of the coracoid process of the scapula. The flap is raised, the capsular ligament º (provided it has escaped the ravages of disease), the humerus rotated and adducted, to carry the head of the bone from the glenoid cavity, and while assistants protect the soft parts with retractors, the bone is sawn off. Pieces of carious bone should be gouged or scraped away, and the flaps approximated with silver sutures. I have found that when the entire joint has been involved, the following incisions exposed it: Commence about two inches from the point of the shoulder . carry an incision along the border of the clavicle outward to the joint. This cut is joined by another of the same length along the upper º: of the acromion process. This makes a Vincision, the apex of which is the point of the shoulder; here commence a longitudinal incision and carry the same down the arm to the insertion of the deltoid. This exposes the joint thoroughly and allows room for manipulation with pliers and saw. In a case lately operated upon, where most extensive disease existed, I practiced this method with excellent results. Dr. W. D. Foster,t of Hannibal, Mo., successfully removed the head of * Medical Record, December 2d, 1872, p. 54, quotation from G. E. Ulrich, “De Ossium Resectione.” † Western Homoeopathic Observer, 1867, vol. iv., p. 13. ExCISION OF THE CLAVICLE. 705 the right humerus in 1865. The case gave rise to considerable discus- SIOI). - Dr. L. H. Willard,” of Allegheny City, reports a successful excision of the humerus; also one of the tibia, in a boy. - - My colleague, Dr. Liebold, while surgeon in the army, performed several Successful resections. tº . Excision of the Scapula.-The shoulder-blade has been removed a number of times for necrosis and for tumors of malignant character, the former Operation being generally the easiest and safest; the latter in most instances being protracted and bloody. I notice that Mr. Symet is given the credit of having first successfully performed the operation for the removal of the scapula and its processes in 1856; other operators allowing the neck to remain. Walther, of Bonn, ten years previously, performed the opera- tion with good result. In 1837, Dr. Mussey, of Cincinnati, removed the Scapula and a great portion of the clavicle with wonderful result, the wound healing almost entirely by first intention, and the man en- joying good health when heard from thirty-four years after the opera- tion. In 1838, Dr. George McClellan also removed the bone, and Gilbert and Gross report successful cases. Dr. A. Hammer, of St. Louis, has exsected the Scapula and part of the clavicle with success; the patient was a female, and when I saw her had considerable motion of the à.I’Iſl. - M. Péan extirpated the scapula of a man aged nineteen, at the Hospital St. Louis, Paris, April 14th, 1877, the operation being followed by a rapid recovery.f - - It is impossible to give explicit directions for the removal of this bone, as the size of the tumor or the direction of the sinuses will often indicate the line and length of the incisions. The patient having been etherized, the subclavian artery must be com- pressed by an assistant, to restrain haemorrhage from the subscapular and its branches. The integument must then be dissected entirely away from the tumor and turned back. The growth must be pulled away from the body, and the muscles on the vertebral border of the bone severed rapidly from the inferior angle upward. As the arteries are divided they must be secured. The division of the clavicle should be deferred to the last, as the weight of the tumor and arm draw away the bone from im- portant structures underneath. If the bone is to be removed for necrosis, the lines of incision must be made according to the sinuses, or the diseased portions of the bone. Excision of the Clavicle.—The collar-bone has to be removed for caries, necrosis, tumors, and gunshot wounds. The operation is one of difficulty and delicacy, on account of the underlying important structures, and must be performed with deliberation and care. There must be no hurry and no “flurry.” According to Gross, Mr. Davie, of Bungay, “many years ago excised the inner extremity of the clavicle, in a case of dislocation back- ward from deformity of the spine; the luxated head causing such a degree of pressure upon the oesophagus as to endanger life from suffocation.” In 1813, Dr. Charles McCreary; in 1828, Dr. Mott; in 1849, Dr. Gross; in 1852, Dr. Wedderburne; in 1856, Dr. Blackman and Dr. Curtis; and in 1862, Dr. Franklin removed either a great portion, or the entire clavicle. When the bone is to be removed for caries or necrosis, a single longitudinal incision is made over the entire part to be removed. The knife must be kept close * Loc. cit., vol. vi., p. 92. - † Holmes's System of Surgery, vol. v., p. 670. * , i Monthly Abstract of Medical Science, September, 1877; Lancet, July 28th, 1877. 45 706 A SYSTEM OF SURGERY. to the bone, and the handle used as much as possible; the chain-saw be applied cautiously, and the bone carefully removed. When there exists a large tumor, the risk is still greater, and still more caution must be employed. The lines of incision should be left to the judgment of the surgeon, and the handle of the knife be more in requisition than its point or its edge. The arteries must be tied as they are divided. Time is no object in these try- ing and difficult operations. Dr. Mott was four hours in his excision of this bone, and applied over forty ligatures. Excision of the Ribs.-As a general rule there is not much difficulty in the removal of portions of the rib. In the cases that have fallen under my observation, two of which were from gunshot wounds received during the war, the chief trouble was the thickness of adipose tissue; I have learned from this, that in such cases the incision should be very long, and should extend considerably beyond the diseased bone. The parts are freed, and the chain-saw or that of Hey applied. In the dissection the knife must be ºp close to the bone. The saw is applied from the top of the rib down- WarC1. - Excision of the 0s Calcis-There is a special tendency for the calcaneum to become inflamed independently of other bones of the tarsus. Being larger than any other tarsal bone, it has the greater share in bearing the weight of the body; so that, in pressure during standing and locomotion, its vertical growth may be arrested, and the anterior calcanean process becomes by degrees depressed. Disease of the os calcis usually remains restricted to this bone and does not spread to other osseous parts of the foot, while a remarkable immunity in scrofulous disease of the tarsus is seen. Out of 52 cases of caries of the tarsal bones reported by Czerny the calcaneum was affected in 13. The reader is referred to the chapter on Caries for treatment other than surgical. I would say, however, that complete excision offers better chances of success than any other resource if the disease be well advanced. * The removal of the os calcis, either in part or entire, was formerly regarded as impracticable, for two reasons: First, because it was a well-known fact that this bone sustains about half the weight of the entire body; and second, because it was formerly held that division of the tendo Achillis deprived the limb of a great amount of mobility. Some surgeons (among whom was Moreau) even taught that if the tendo Achillis be destroyed, amputation was the only feasible resort. Paré regarded a fracture of this bone as a fatal injury. These opinions, however, have proved erroneous; and both the division of the tendon and the removal of the bone can be effected with slight resulting deformity. In an interesting paper, “On the entire Excision of the Os Calcis,” by F. A. Burrall, M.D., of New York, a tabulated statement of forty-eight cases is given. An analysis of this table is interesting as regards the history of the cases requiring operation. We find that young persons of the male sex were the subjects on whom it was most frequently performed, the ages being from ten to twenty years. There were five between the ages of forty and fifty-four. Of the forty-six cases in which the sex is recorded, thirty-eight were males and but eight females. The diseases which called for the operation were in forty-three cases caries and necrosis, the others being accidents, pressure, friction, etc. Only one death occurred, and that was but indirectly attributable to the operation. One was afterward lost from diphtheria, one from pyamia, and two from phthisis; of the latter it may be said that the disease reappeared in one case in eighteen months, and in the other four years after the opera- tion. Seven secondary amputations were necessary. - The lessons we learn from these cases are: that complete excision of the EXCISION OF THE OS CALCIS. 707 Os calcaneum can be practiced with success, leaving a good foot; that caries and necrosis furnish by far the greater part of the cases for the operation; that the young are more liable to the diseases requiring either resection or excision; and that the male sex is more prone to them than the female. Besides the forty-eight cases to which we have alluded, there is an ac- count of three cases of “Excision of the Os Calcis,” by Dr. Hunter McGuire, of Richmond, Va.” In his report, the ages were twenty-one, seventeen, and twenty-three years, all males; the disease in each was caries, and caused in every instance by injury. Thus in Case I. the patient was wounded by a nail driven into the heel. In Case II. the heel was severely bruised by a cricket ball, and Case III. was that of a wound from a shell. In all these there was but a slight limp resulting from the operation. At the termination of the paper, Professor McGuire gives two interesting records to show with what facility a patient can walk after the destruction of the heel-tendon. Complete excision of the bone must always give rise to deformity, as the arch of the foot is taken away. In the majority of instances, caries does not invade the entire substance of the bone, its posterior surface being generally affected. In such instances it is well to remove the posterior por- tion of the os calcaneum, and ascertain the depth to which the ulcerative process has extended, and then, if possible, remove with the gouge and chisel the diseased masses. Of this proceeding Dr. Heyfelder says: “Partial resection is to be preferred to extirpation, when possible, both for the sake of leaving intact the joint and adjacent bones, as well as to preserve the muscular and ligamentous attachments. But partial resections of the calcaneum are not always successful [five failures in fifty-four cases], and amputations of the foot [twice] or extirpation of the bone [once] have been necessary. In sixty cases of partial excision, in which superficial or deeper wedge-shaped portions, or even larger parts of the bone were removed, none ended fatally. Relapses occurred in five out of fifty-four cases, ren- dering amputation necessary in three.”f According to these remarks of the German surgeon, the results of partial resection are very good, and it is so desirable to save the arch of the foot, if possible, that it appears to me that the partial resection should at least be first attempted. Then if, after the posterior portion of the heel has been sawn off, the disease proves to have extended far into the plantar surface, the entire bone must be removed, unless the caries can be reached with the gouge, and can be taken away with that instrument. There are several methods of operating for excision of the os calcis. The chief point is to keep the incisions without the sole of the foot, as the cicatrices are liable to inflame from friction, and afterwards to suppurate and ulcerate. Mr. T. Holmes's method is as follows: Enter the knife at the inner border of the tendo Achillis, carry it steadily around the back and outer side of the foot, along the upper margin of the os calcis, to a point midway between the heel and the projection of the fifth metatarsal bone, which point marks the calcaneo-cuboid articulation. From the anterior extremity of the inci- sion a second one is commenced, and carried downward and into the sole of the foot, terminating near the inner border of the os calcis, thus avoid- ing the posterior tibial artery and its branches. The joint between the cu- boid bone and the astragalus is laid open, and the bone, having been grasped with the lion forceps, is strongly everted, and the soft parts on its inner side detached, keeping the edge of the knife close to the bone. * Medical Times, October, 1870. f Bellevue and Charity Hospital Reports, 1870, p. 202. 708 A systEM of SURGERY. This operation commends itself for its simplicity, and from the fact that the incisions avoid the posterior tibial artery; however, I do not think that the bone is so easily reached as in the dissection proposed by Erichsen, and recommended by Dr. Gross, which is practiced in the following manner: So soon as perfect unconsciousness is obtained, an incision is commenced in the mesian line of the heel, an inch above the insertion of the tendo Achillis, and carried perpendicularly down to the sole; a second incision is then made around the margin of the os calcis, joining the lower end of the first cut as it passes around the sole of the foot, and extending farther on the outer than on the inner margin of the bone. The lateral flaps are dissected up, the gouge applied, and the carious parts removed. If, however, the whole posterior surface is involved, the tendo Achillis must be cut through, the sole-flap dissected away from the bone, and with a metacarpal saw the posterior surface, sliced off. The gouge and gouging- forceps are used freely, and all the diseased portions removed. The flaps are brought together, and united by silver sutures. A dressing of prepared oakum, iodoform, and antiseptic cotton should be applied. If the entire bone is to be taken away, the lateral incision must be longer, and the joint opened from the inside, the bone seized with the lion forceps and dissected out. * - - - Recently in two cases, one of removal of the posterior portion of the os calcis, the other of the entire bone, I found that by careful dissection the posterior tibial vessels can be retained in the flaps, by the method of opera- tion last named. In both, which were entirely successful, there was but little trouble from bleeding; the dissection, however, was very tedious. Excision of the Astragalus.--This bone may be removed when in com- pound fracture, or dislocation, its unnatural position gives rise to untoward Symptoms; in such cases the capsular ligament is torn, and the bone thrown either partially or entirely from its socket, and can generally be re- moved with comparative ease. In other cases, the incision must be carried in front of the dorsum of the foot down to the bone, the foot having mean- while been forcibly put upon the stretch. After the incision, the assistant flexes slightly the foot, and the muscles and tendons are turned off and held out of harm's way by retractors. The pliers may be put into requi- sition, and the head of the bone cut off. Disarticulation is then readily effected. '. The cuboid, cuneiform, and Scaphoid bones may also be exsected, in rare in- stances, but in the majority of cases amputation, either by Syme’s, Chopart's or Pirogoff’s method, is followed by better results than excision. In several cases after long and tedious dissections, I have found the disease so exten- sive that amputation was necessary. Excision of the Joint between the 0s Calcis and Astragalus-This opera- tion is comparatively new, and has been practiced and thoroughly studied by Mr. Thomas Annandale. The object is to save the foot, and to do away, in some instances, with the complete excision of the os calcis or the astragalus. I will give the operation in Mr. Annandale's own words: “The importance of recognizing and treating early disease originating in this articulation, especially after suppuration has taken place, must be acknowledged, for, owing to the situation and connections of this joint, there must always be a peculiar risk of the gradual implication of the sur- rounding bones and joints. “Having carefully studied the anatomical relations of the joint under consideration, I found that its entire extent could be best exposed without injury to surrounding structures in the following way: The foot having been placed in the extended position, and resting on its inner aspect, an in- cision commencing about an inch above the tip of the external malleolus EXCISION OF THE ANKLE-JOINT. 709 and carried along its posterior border in a curved direction to the calcaneo- cuboid joint, thoroughly exposes the posterior and external portion of the joint, when the peroneal tendons have been drawn outwards and some liga- mentous bands divided. This incision will be found to run along the in- ner border of the tendon of the peroneus brevis muscle. The anterior and internal portion of the joint can then be exposed by placing the foot, still in the extended position, on its outer aspect, and making an incision from the tip of the internal malleolus along the course of the tendon of the tibialis posticus, as far as the prominence of the scaphoid bone, drawing forwards this tendon, and carefully drawing backwards the other tendons and the posterior tibial vessels and nerve. By making the first incision through the skin and cellular tissue only, and so ascertaining the exact position of the tendons likely to be injured, then cutting down through the periosteum to the bone, and with a periosteal scraper separat- ing to a sufficient extent the periosteum, together with all the other superfi- cial tissues, there is little risk of injuring any of the tendons or other important structures. “Both aspects of the joint having in this way been exposed, it will be found that E. means of the chisel and mallet the articular surfaces can be easily and accurately removed, the posterior portion being removed through the external incision, and the anterior portion through the internal one. Should there be any disease in the hollow or fossa between the two articu- lar surfaces, it can be readily reached and removed with the chisel or gouge through either incision.” Excision of the Ankle-joint.—The lower ends of the tibia may have to be removed after compound dislocations, and also portions of the fibula cut away. It appears from excellent authority that the operation is much bet- ter as a secondary than as a primary one. Mr. Hancock” gives nineteen successful cases, and points out very forcibly the advantages of total over partial excision of this joint. Mr. Hey, of Leeds, was the first surgeon who resected the lower ends of the tibia and fibula for disease, which operation was performed in 1766. Moreau, in 1792, did the same for like cause. Mr. Thomas Bryant gives to Mr. Hancock priority in resection of the entire joint. The following is a description of the operation as practiced by Hancock, modified by Barwell, and published in Bryant’s Practice of Surgery: “The foot is first laid on its inside, an incision is made over the lower three inches of the posterior edge of the fibula. When it has reached the lower end of the malleolus it forms an angle, and runs downward and forward to within about half an inch of the base of the outer metatarsal bone. The angular flap is reflected forwards, the fibula for about two inches above the malleo- lus is cleared sufficiently of soft parts to allow cutting forceps to be placed over it, and the bone is then nipped in two, and carefully dissected out, leaving the peronaeus longus and brevis tendons uncut. The foot is now to be turned over. A similar incision is made on the inner side, the portion in the foot terminating over the projection of the inner cuneiform bone. The flap is to be turned back and the sheath of the flexor digitorum and the posterior tendons exposed, the knife being kept close to the bone, avoid- ing the artery and nerve. The internal lateral ligament is then carefully to be severed close to the bone, and now the foot is twisted outward and the astragalus and tibia will present at the inner wound. A narrow-bladed saw put in between the tendons, into the inner wound, projects through the outer. The lower end of the tibia, then the top of the astragalus may be sawn off in a proper direction.” * London Lancet, 1867. 710 A SYSTEM OF SURGERY. I may say here that in several cases I have succeeded in curing caries of the ankle-joint, which threatened a necessity for resection, by entire rest, and the prolonged and frequent use of silicea. I speak emphatically here of the trituration as superior in its efficacy to the dilution, and of the almost specific influence of this medicine upon the bones of the ankle-joint. Excision of the Toes.—In the majority of cases amputation is to be pre- ferred to excision of the bones of the toes. If, however, the metatarsus is to be removed, an incision must be made on the dorsal surface of the diseased bone and the tissues held aside, whila, with a strong pair of pliers held perpendicularly the bone is divided, which greatly facilitates the operation. Its extremities are then raised by means of lion-jawed forceps, and, keeping the edge of the knife close to the bone, each half is succes- sively removed. Excision of the Knee-joint.—To Mr. Henry Park, of Liverpool, belongs the credit of having originated the operation of resection of the knee-joint. He, however, gives the credit of the first actual performance of the operation to Percival Pott, the date of which was July, 1781. Soon after the publica- tion of the Park pamphlet, Mr. Filkin, of Norwich, declared that he had performed the operation as early as 1762. On the 5th day of November, 1789, Dr. Simmons performed a similar operation. M. Moreau, in 1792, excised the whole of a carious knee-joint; in 1809, Mulder removed it; in the year 1823, Sir Philip Crampton, and in 1829 and 1830, Mr. Syme re- sected the articulation. These latter operations were not successful, and the procedure gradually fell into disrepute until it was revived by Mr. Fergusson in 1850. In the following table, altered a little from Butcher, the names of the surgeons, the dates of the operations, and the results are shown, embracing a period of eighty-seven years or up to the time of its revival: DATE. SURGEON. SEX. AGE. RESULT. 1762 Filkin. Male. Recovered in three months. 1781 POtt. Male. 33 Recovered in One ar. 1789 Simmons. Male. 30 Died in four months. 1792 Moreau, Sr. Male. 20 Died in three months. 1802 Moreau, Sr. Male. 18 Died in four months. 1809 Moulder. Female. 34 Died in three and a half months. 1811 Moreau, Jr. Recovered. 1816 ROux. Male. 32 Died. 1823 Crampton. Female. 23 Died. 1823 Crampton. Female 22 Recovered. 1829 Syme. Male. 8 Recovered. 1829 Syme. Female 7 ied. 1830 Jaeger. ale. 28 Recovered. 1832 TextOr. Female 26 Died. 1832 Fricke. Female. 8 Recovered. 1832 Fricke. Died. 1835 Fricke. Died. 1885 Demme. Male. 36 Recovered. 1836 Fricke. Male. 18 Recovered. 1839 TextOr. Female. 23 Died. 1840 Lang. Male. 24 Died. 1842 TextOr. Female. 23 Recovered. 1842 Demme. ied. 1842 Demme. 1845 Textor. Female. 44 flºutation; recovered. 1845 Textor. Male. 29 Died. 1848 Heusser. Male. 20 Recovered. 1849 Heusser. Male. 32 Died. 1849 Heusser. Male. 6 Recovered. 1849 Textor. Female 29 Died. 1849 Heyfelder. Male. 21 Died. I find,” in addition, the record of thirteen cases performed by conti- mental surgeons since 1850. Thus: three times by Mr. Fergusson, six times * Medical Times and Gazette, 1853. EXCISION OF THE KNEE-JOINT. 711 by Mr. Jones, once by Mr. Page, once by Dr. Stewart, and twice by Dr. Mac- kenzie. Of these cases two died from the operations, one from dysentery, and the remaining ten recovered, with limbs not very serviceable, but all of them in better condition than if amputation had been performed. Butcher gives a second table of fifty-one cases operated on from 1854 to 1856. Of these there were twenty-two cured, fifteen having recovered when the table was made, one was relieved, and one in a precarious state. The deaths only numbered ten. Since that period the operation has been performed many times and with success, both in this country and in Europe. In America we have the record of an operation performed by Gurdon Buck, at the New York Hospital, in the month of October, 1844. The operation was resorted to in order to straighten a limb, which was bent at right angles.* Dr. Bauer, formerly of Brooklyn, now of St. Louis, records an interesting case in which the operation was performed for genu valgum, f with traumatic diastasis of the lower epiphysis of the left femur. - Diseases Calling for #ºn of the Knee.—The disease which properly directs to resection of the knee is generally a strumous inflammation of the joint. This may commence either in the synovial membrane, or in the spongy structure of the long bones, which become filled with strumous de- posit, and are much degenerated, enlarged, and softened. The inflammatory action is generally of the subacute character; there is increase of tempera- ture of the parts involved; the cancellated structure of the bone is filled with a reddish grumous deposit; the patients waste in flesh, have feverish exacerbations at night, and become sallow and cachectic in appearance. If this process is not arrested in due time, the pain increases, and there takes place within the bone-cells a lardaceous or oily deposit, and, the disease increasing, a chemical change is effected in the constituents of the bone. The calcareous matter lessens, or even, in severe cases, may be entirely de- ficient, and the compact structure is reduced to a mere shell. The perios- teum also becomes very much thickened, and is less adherent to the bone than normal. Suppuration then may follow, and the débris is cast out with an ill-conditioned and sanious pus. This disease, no doubt, has been often mistaken for caries of the ends of the bones; but there is a consider- able difference between the two, one belonging more especially to the simple ulcerative process, the disintegration, molecule by molecule; the other being accompanied by, or essentially consisting in, an absolute de- generation of the spongy structure, and a deposit and infiltration of stru- mous matter in the cancellated structure of the bone itself. In such an affection, after suppuration has occurred, the joint should be excised. Other affections which may lead to resection are: white swelling, degen- eration of the cartilages, caries of the extremities of the bones, deformity of the legs, injuries of the joint, etc. - There is a question of some import in relation to the removal of the pa- tella in this operation. If the bone be diseased, remove it; if it is not, refresh its under surface, that it may adhere to the parts below. I am quite certain that the rule adopted by some surgeons that the patella, whether implicated or otherwise, should be removed, is not a good one. The excision requires considerable dissection; it leaves a cavity which has to fill by granulation; it increases the suppuration, and prevents the application of an anterior splint, if such be necessary. In resection of the knee-joint, I have divided the hamstring tendons before the operation was performed, with the idea of preventing muscular contractions from separating the extremities of the * Velpeau's Operative Surgery, vol. i., p. 810. f Bauer's Orthopaedic Surgery, p. 193. 712 A SYSTEM OF SURGERY. bones, but I found that the spasmodic action still would occur and occa- sion great pain. I should therefore rely on the internal administration of ignatia, cuprum, chloral, or the bromide of soda, or sometimes a few drops of tinc. hyoscyami. Again, surgeons have recommended that, after the extremities of the bones have been sawn off, an opening be made in the º space, in order to allow drainage. I should think that this would e an excellent suggestion in some cases, but would much prefer to wait FIG, 418. | | | - | | | | FIG. 420. º ſººº º --~~~~ --- Butcher's Saw. until the symptoms of extensive *P. developed, because with calen- dula, carbolic acid, iodoform, the bichloride of mercury, and strict anti- septic measures, I believe we have great control over the suppurative process. I have positive evidence of the reliability of these agents, and have per- formed the operation without removing the first dressing for two weeks, the wound healing almost entirely by first intention. The best incisions, as a general rule, are those which will freely expose ExCISION OF THE KNEE-JoſNT. 713 the joint, and allow the removal of the bones with greater facility. The Sweep of the knife may be semicircular, commencing at a point opposite the inner condyle, and extending below the tubercle of the tibia to a point opposite the external condyle. Mr. Park preferred the crucial cut, as did also Mülder. Moreau operated by two lateral incisions in front of the ham, which were united by a hori- Zontal cut below the patella (Fig. 419). The H incision for many cases is the most desirable. The incisions should be about four inches in length on each side, beginning at the condyles, and extending downward; they should be crossed by a second cut, which will open the joint; the flaps are turned aside, and the condyles rapidly freed with careful strokes of the knife; the leg is then forcibly flexed, and the crucial ligaments divided ; retractors of metal should now be slid behind the head of the tibia, which must be removed first (Fig. 420). The condyles of the femur are treated in like manner. Butcher's saw (Fig. 418) can be used with advantage in the operation, as it cuts from behind forward, and by the screw the blade can be made to assume any angle that may be necessary. The after-treatment is very essential, and requires care in its man- agement. I have no hesitation in recommending the swinging splint of Dr. Hodgen, the modification of that by Dr. E. A. Clark, or Smith's ante- rior splint. The method of application of each of these can be found in Chapter XXXI., p. 592. Sometimes, however, a fracture-box filled with bran, to absorb the discharge, is very useful in many particulars. To illustrate the operation, the accidents which may be expected, the beneficial effects of treatment, and good recovery with a straight limb, shortened but one-eighth of an inch, the student is referred to pages 641–643. Professor Volkmann, of Halle, proposes a new operation for resection of the knee, by a cross-section of the patella. A horizontal incision is made over the patella, which is sawn in half, the parts to be reunited by catgut sutures after the completion of the operation. The following will explain the method more fully. The incision extends horizontally across the patella, from the anterior border of the epicondyle on one side, to the anterior border of the epicon- dyle on the other side. The joint is opened on both sides of the patella and the index finger passed under the bone, which is then divided with the saw or knife. The lower half of the patella is now drawn downwards and Secured out of the way, while the lateral and crucial ligaments are divided and the end of the femur resected. The head of the tibia is next pressed forward into the wound, and the semilunar cartilages are seized at their posterior borders and removed along with the remains of the crucial liga- ments, and the greater part of the adipose tissue which covers the posterior surface of the ligamentum patellae. The head of the tibia is then laid bare and resected, the capsule is dissected out, and any carious spots in the re- sected bones or in the patella are gouged out. Finally the resected surfaces of the femur and tibia are brought together by two strong catgut sutures placed internally, and the two halves of the patella are united also by two catgut sutures. The sutures are introduced into both the epiphyses and the patella by means of strong curved needles. The operation should always be preceded by an exploratory incision, which will enable the surgeon to examine the joint by both finger and eye; for this purpose the incision should at first only be carried from the epicondyle as far as the border of the patella. If this exploratory incision shows that the operation can possibly be avoided, a drainage-tube should be introduced and the wound dressed antiseptically. The patella will sometimes be found firmly attached to the femur, but it can be easily separated with the chisel. : 71.4 A SYSTEM OF SURGERY. Mr. William Knight Treves* thus describes his method of removal of the knee-joint: - First. A semilunar incision about three inches in length on each side of the joint is made, the lowest point of each being dependent for the exit of pus or serum. - Second. The division of the lateral ligaments on each side and reflection of the tissues till the synovial cavity in front is opened. - Third. A metal retractor is inserted in front of the bones to secure from injury the tissues in front, which are loosened from the sides, whilst the bones are being sawn; a saw is passed behind the joint, and, this being con- nected with its frame, a thin slice is cut from the end of each bone; the Sawn surface is examined, and, if it appears to be healthy, the wound should be closed and dressed antiseptically. The advantages gained by this method are: 1. Decided improvement in the after-appearance of the limb. 2. Increased power of extension, for by this operation the patient can lift the leg even before union is firm, and thereby have increased advantage. 3. The extensor tendon being still attached to the tibia in front, the bones are not so loose, and the leg is more under control. 4. This is more like a subcutaneous operation; the sawn surfaces are still left under their natural covering, are not exposed under an extensive Wound, and, being protected, unite more readily than after the usual opera- tion. - - With very little practice, it may be said to be not difficult to perform. Excision of the Bones of the Leg.—The fibula may be resected in its entire extent or in part, the weight of the body not falling upon that bone. The operation was first suggested by Dessault, and executed by Percy, Suetin, and others. The incision must be a longitudinal and long one, and the bone denuded, and if possible the periosteum saved, by using the blunt instruments shown in the first portion of the chapter. The bone should be divided by pliers, and the ends lifted by means of the lion-forceps and removed. The peroneal artery is frequently divided, and there is often a good deal of haemorrhage from other vessels. - Portions of the tibia may also be resected with a good result. An in- teresting case came under my care some years since. It was a compound fracture which had never been reduced. The broken bones had united, pre- senting a hideous deformity. The foot was twisted entirely around, and three inches of the tibia, covered with a thick crop of dark-red granulations, protruded from the leg. There was a suppurating and offensive ulcer on the posterior portion º the right leg, occupying the whole belly of the gas- trocnemius; another sore about the hip-joint, together with rigid contraction of the toes and knee-joint. The patient was also much emaciated, with a dry, brown, hard tongue, pulse one hundred and thirty beats to the minute, tympanites, and all the well-marked symptoms of typhus gravior. The extent and gravity of his injuries, the exhausting suppuration, the depri- vation of proper nourishment, were certainly data on which to found a very unfavorable prognosis. - & The first medicine prescribed was arsenicum 3, about two grains every three hours, while brandy and water three times a day, with occasional spoonfuls of beef essence, were administered. The ulcer on the right leg was dressed with calendula lotion, which was also applied over the pro- truding extremities of the fractured bones. It was some days before much improvement was noticed ; but gradually the symptoms began to abate in their severity, excepting excessive pain in the region of the hip-joint; * Braithwaite's Retrospect of Practical Medicine and Surgery, July, 1877, Part 75. EXCISION OF THE HIP-JOINT. - 715 the acute pain beginning at evening and lasting through the entire night. The screams of the boy were such that the other patients in the ward were unable to sleep. The application of compresses saturated with strong tincture of aconite gave relief in time to this distressing symptom. The tympanites was relieved by turpentine in three to five drop doses taken once in four hours, and the remaining symptoms combated as they presented with bryonia, rhus tox., and sulphur. About this time a diar- rhoea became troublesome, but was successfully treated with phosphorus and phosphoric acid. During this treatment stimulants were constantly given, and their good effect was very appreciable. At length the disease WaS OVércOIY) e. As the danger to life passed, the deformed and misshapen limb began to claim the attention it deserved, and which it should have received when the injury was first inflicted. My first impression, and I believe that of those who saw him, was that amputation must be resorted to, but upon reflection, I thought that resection might be practiced, and upon consultation it was agreed to attempt it. On the 2d of March, assisted by and in the presence of several medical gentlemen, having placed the boy fully under anaesthetic influence, I began the operation by dissecting from the protruding bones the mass of granulations; then, beginning about five inches above the site of frac- ture, I made a longitudinal incision along the spine of the tibia, and continued it three or four inches below the protruding bones; this in- cision was crossed at the centre by a second transverse cut, and the four flaps dissected up. Keeping the edge of the knife close to the bone, the aponeurosis of the tibialis anticus was divided, and the anterior tibial artery protected from injury. The ends of the bones were then sawed off, about two inches being taken away, and the bony adhesions of the fibula, which had united firmly with the shin-bone, were, with consid- erable force, refractured. The foot was then twisted back, placed in its position, and fixed securely in a splint, leaving a space between the divided extremities of the bones, from which two inches of the ends had been removed. During the operation the ha-morrhage was not impor- tant, but when I visited the patient in the evening, there had been so pro- fuse a discharge of blood, that I feared the teeth of the saw had wounded the anterior tibial artery. All dressings were therefore removed, but I found the bleeding to arise from the medullary canal. Compresses wet with a solution of the liquor ferri persulphatis were applied, which, after two days, arrested the haemorrhage. On the 5th of March the limb was placed in a fracture-box, extension made to keep the leg the proper length, and bran packed closely around it. This bran dressing was most serviceable; the leg was never moved from its position; the wound could be cleansed readily and as often as was necessary, could be examined at any time, and could receive the benefits of the cold calendula lotion, which was constantly applied. Moreover, as suppuration took place the pus was absorbed by the bran, which it formed into hard masses that were easily removed, and the space refilled with fresh material. On the 25th, a sequestrum came away. On the 27th, the leg was taken out of the bran, the fracture-box cleansed, refilled and reapplied as before. On April 4th, the whole apparatus was dispensed with, a slight splint applied on the inside of the leg, and held in situ by adhesive strips. The boy was soon about the house; has a leg of the same length as the other, though not quite so Strong. - #ion of the Hip-joint.—There are several forms of hip-joint disease, some requiring excision of the head and neck of the femur, and others for- bidding the same. The different locations of the inflammatory process in the 716 A SYSTEM OF SURGERY. hip have been already alluded to. It may commence in the soft structure within the joint, or in the head of the femur, or in the interarticular carti- lage, or in the acetabulum. When, however, there is undoubted caries of the head of the bone, or it has been dislocated and thrown outward and backward upon the acetabulum, the operation presents fair hope of suc- Cess, º if the pelvic bones be }. from disease; if together with this the patient be healthy, is young, and originally of good constitu- tion, though prostrated by continued profuse discharge and hectic, the removal of the head and neck of the bone is perfectly justifiable. This is true conservatism, and when compared with J. terrible alternative, ampu- tation at the hip-joint, the comparative ease of the performance of excision, the slight shock, the less amount of haemorrhage, the comparative quickness of healing, the size of the wound, and above all, the saving ºf a useful limb, there can be no doubt of the preponderance of argument in favor of ex- CIS1011. - The operation may be performed either by a single long incision directly over the head of the bone, or by a T incision, made somewhat obli º: OT a V-shaped cut (Fig. 421). These incisions should be made directly down to the bone, and an assistant on either side, with broad metallic retractors, should separate the structures with the handle of a scalpel, or with an in- FIG. 421. FIG. 422. Chain Saw applied. strument slightly curved upon the flat, fixed in a stout handle, with a blade about four inches in length, and a blunt cutting-edge similar to that recom- mended by Dr. Gross for separating the structures from the inner side of the condyle of the inferior maxillary, when that bone is to be removed at the articulation. The soft parts remaining must be separated from the bone, and, by a rotary motion, the head may be abducted, and a chain-saw passed beneath the head of the bone, and, with a rapid though gentle mo- tion, the caput and as much of the cervix as necessary may be taken away (Fig. 422). In some cases the long bone-forceps of Liston may be used, or, having placed a retractor or a towel beneath the bone, to prevent the soft structures from being injured, the ordinary amputating-saw can be used. Fºxcisios OF THE HIP-JOINT. 717 I much prefer, however, the saw of Mr. Butcher (Fig. 418), which is so arranged that it cuts from within outward, by the direction the saw is made to take. I have already mentioned that disease of the acetab- ulum and head of the thigh together, does, as a general rule, contra- indicate the operation, though there are some surgeons who hold a * opinion. The celebrated Mr. Hancock thus expresses him- Sel1: “In deciding apon this operation, we would be guided by the condition of the patient, and not by any arbitrary stages of the disease, and whilst I always have and still continue to deprecate unnecessary and ill-considered operations, I believe it to be our duty, when we have assured ourselves that the case is one of hip-disease, that the patient is dying, and there is no hope of saving him by the ordinary means, to perform, or at all events to propose the operation, without reference as to whether, pathologically speaking, the disease be in this or that stage, or whether the bone be dislocated, the acetabulum healthy or not.” There is great truth in these remarks, and from late successful operations, in which not only the head and cervix of the femur but also parts of the pelvic bones have been removed, it would seem to be the duty of the surgeon to attempt operative measures even in extreme cases. At all events, an exploratory incision may be made from the anterior inferior spi- nous process of the ilium to the trochanter major, and the feasibility of the operation as- certained. The following are the directions of Dr. Lewis A. Sayre: “When the disease has gone on to another stage, when sinuses have occurred and discharged pus, when a probe leads down to dead bone, there is nothing to be done but to exsectit by making a small incision above the trochanter major, midway between it and the crest of the ilium, over the top of the acetabulum—a semilu- marincision, the belly of the D covering the pos- terior part of the trochanter major, going straight down to the bone, through the periosteum. You then pull the soft tissues on one side, and, taking a small but strong curved bistoury, go as far around the bone on each side as you can reach, at right angles to your first incision, so as to divide the periosteum com- pletely; youthen take a strong firm periosteal elevator, with a large handle and the end slightly curved, and go into this little triangle; you peel off the periosteum, and, as a matter of course, all the muscles with it; by open- ing the joint thoroughly and turning the head of the bone out, the periosteum is peeled off from the inner portion; you then saw off the bone above the trochanter minor. I believe that this is better than cutting through the neck. If you go through the neck, the trochanter major comes over the hole and prevents discharges; whereas by cutting off the trochanter major along with the neck of the bone you leave a perfectly free opening for the discharges from the diseased joint; and by peeling off the periosteum in the way which I have described, you carry with it all the muscles that move the joint; and if you then keep the leg pulled out to its proper length, by FIG. 423. Wire Breeches. 718 A SYSTEM OF SURGERY. * putting on a pair of wire breeches (Fig. 423) you can send the patient out into the air the very next day.” - In my operations I formerly used the T incision, but have in more recent ones resorted to the cut of Sayre, already described, carrying the knife down to the bone, turning back the flaps, removing the head of the bone with the chain-saw, applying the gouge and chisel, if necessary, to remove all traces of diseased bone, and then placing the patient in a Smith's anterior splint, according to the directions given for this, appliance in the Chapter on Fractures of the Femur. Bauer’s wire breeches are also of great service. They keep the parts in good apposition. Dr. J. H. McClellan, of Pittsburgh, reports a successful case of excision of both condyles of the femur at the Pittsburgh Homoeopathic Hospital. Dr. H. W. Koehler, of Louisville, Ky., reported an excellent case of resec- tion of the neck and trochanter major of the femur.f CHAPTER XXXVI. INJURIES AND DISEASES OF THE HEAD. Wounds—GUNSHOT Wounds of THE SCALP—FRACTURES OF THE SEULL–CONCUSSION AND COMPRESSION.—APPLICATION OF THE TREPHINE—CEREBRAL MoToR LOCALIZA- TIONS. - Wounds of the Scalp.–Mr. Pott has observed that though the scalp be called the common integument of the head, yet from its structure, connec- tions, and uses, injuries inflicted upon it by external violence become of much more consequence than those of other parts of the body. It is a well-known fact that wounds, however slight, when inflicted on the head, are very liable to be followed by inflammation and suppuration either within or without the cranium. In some instances the lips of the wound will unite readily, and little inconvenience result; in others, however, adhesion will take place only at certain points, while suppuration will occur at others; this is particularly noticed in contused wounds, in which the integument has immediately been destroyed by the violence of the injury, or in cases in which the scalp has suffered considerable laceration. Small wounds, that is, such as are caused by instruments or bodies which pierce or puncture, rather than cut, are in general more liable to become in- flamed, and are known to be productive of greater constitutional disturb- ance than those which are of a greater extent. - - If the wound affect the cellular membrane only, and has not reached the aponeurosis or pericranium, the inflammation and tumefaction involve the whole head and face: the latter frequently assuming a jaundiced hue, and being covered with small bullae containing yellow serum. Treatment.—If a blow on the head has caused extravasation of blood beneath the scalp (cephalhaematoma), and if there be visible increase of the accumulation of fluid, the surgeon may suspect that an artery has been divided ; in this case the course of the vessel, if possible, should be ascer- tained, and pressure made in order to arrest the haemorrhage; after which, compresses saturated with a solution of arnica should be applied to the contused part. If the scalp be nearly or quite detached, it should be care- * Braithwaite's Retrospect, January, 1872, p. 114. f Western Homoeopathic Observer, July and August, 1870. FRACTURES OF THE SECULL. 719 fully washed and replaced as nearly in situ as possible, and aqua calendulae be used as a lotion; the parts should be brought together with adhesive straps, and a bandage lightly placed around the cranium; sutures in the generality of instances should be dispensed with, as the punctures made by the needle are liable to become the seat of inflammatory action. If erysipelas supervene, bell. or rhus radicans may be administered inter- nally; the latter exerting a beneficial action over erysipelas of the scalp. If the fever be high, aconite and bell. may be administered, in accordance with symptoms that have already been mentioned in various places in this work. Should symptoms of effusion within the cavity of the cranium be pres- ent, arn., bell., hell., cup., or zincum are the most appropriate medicines. If suppuration ensue beneath the scalp or occipito-frontalis muscle, the pus should be evacuated by early incision, and calend, hepar, merc., or silicea be exhibited. If extravasated blood be noticed beneath the scalp, there is no need of incision, for by enjoining perfect rest, with the employment of arnica externally and internally, absorption of the clot will in all prob- ability take place. Gunshot Wounds of Scalp.–Of 3420 cases of this variety of wound which could be traced, occurring during the war of the Rebellion, the fatal cases amount to 2.09 per cent., or about 1 in 48 cases. The British annals of the Crimean war give a mortality of 1.83. From these figures, it will be seen that gunshot fractures of the scalp are rarely fatal, and when they are, death is occasioned by secondary complications. These are encepha- litis, erysipelas, gangrene, ulceration, and sloughing. In this variety of wound, primary bleeding seldom occurs, while secondary hamorrhage is frequent, especially during the separation of sloughs and sequestra. In some cases tetanus follows, and typhoid symptoms are not uncommon. According to the Surgeon-General's report, 72.6 per cent., or nearly three- fourths of gunshot wounds of the scalp, are caused by small-arm missiles, and it is a remarkable fact, that the scalp may be wounded by the largest projectiles, even from artillery, without injury to the skull, or concussion of the brain. It is also important to bear in mind, that, in the majority of instances, when there is sufficient contusion of the scalp to produce ecchymosis, even wººny solution of continuity of the scalp, brain symptoms may be expected. reatment.—The wound must be washed thoroughly, and compresses wet with a solution of arnica, one part to five, be j and a few drops of the same medicine administered internally. So soon as suppuration has begun, calendula must be substituted for the arnica and silicea, or sulphur must be given. Fractures of the Skull.—This accident frequently occurs, and is occa- sioned by blows and falls upon the head. It may be either a simple fissure, or a separation of the entire bony structure. There are several varieties of the accident, thus: simple, compound, comminuted, or depressed. The external table may be the seat of injury, or the internal may be broken, or both may be implicated. Again, there is fracture with depres- sion of the bone, and breakage without any such untoward circumstance. In simple fissure or fracture without depression, there is nothing to do but to keep the patient in a quiescent condition and apply to the part a compress saturated with a mixture of arnica and water, at the same time arnica is to be given internally. When the fracture is accompanied with depression, the case is far different, as the depth of the depressed frag- ments may regulate the amount of compression upon the brain. There may be considerable depression without symptoms of compression manifesting 720 • A systEM OF SURGERY. themselves. Again, there may be a severe fracture, the tables being broken into many pieces, and spiculae of bone so pressing upon the meninges as to render inflammation and suppuration inevitable. Under these circum- stances, the correct course is to elevate the bone and remove the spiculae with the forceps. If the injury shows but slight depression, it is conserva- tive to wait and watch the case carefully. - A “starred ” fracture is one in which the fissures radiate in all directions, often involving more than one bone, and extending to the base of the cra- nium. Such fractures may also be “guttered,” or “saucer-shaped,” accord- ing as the instrument is blunt, as when inflicted with a spade; or round, as when made with a hammer. - Fracture with Depression.—When there is much depression the symp- toms are well marked. The patient is more or less comatose, the pupils are dilated, and the breathing stertorous. In such cases the diagnosis is apparent, and the trephine should immediately be used. I cannot under- stand, when the symptoms call so greatly for relief, why there should be any delay in the application of the proper remedial means; there can certainly nothing be gained by delay, and every moment of hesitation gives the patient less hope of recovery. Many fractures of the skull are compound, the scalp being more or less torn and lacerated. Often the wounds are filled with dirt or other extraneous matter, particularly if the fracture be caused by a severe fall. In these cases, after having cleansed the wound thoroughly, the depressed bone must be elevated and all spiculae removed; this having been done, the edges of the wound ma be approximated with sutures. A blow or a fall upon the top of the head, or upon the occiput, may cause a longitudinal fracture at the base of the skull. When this takes place haemorrhages occur from ears, nose, and mouth, caused by tearing of the sinuses of the dura mater. There are likewise immediate and well-marked symptoms of compression. After a day or two, or longer, a thin watery discharge takes place from the ear, supposed to be the fluid from the sac of the arachnoid. An injury inflicted upon the frontal bone may fracture the anterior fossa of the base. In all fractures about the head, care must be taken to distinguish between those symptoms which belong to compression and those which signify concussion, and it must be borne in mind that symptoms of the former may be occasioned by the formation of clots within the ventricles. Frac- tures at the base of the skull are always considered dangerous, as the patients generally succumb in a few days. - - From what has been said it will be seen that three symptoms, when appearing together, point conclusively to fracture of the base of the skull; these are, 1st, haemorrhage from the ear; 2d, discharge of a watery fluid from the ear; 3d, facial paralysis. Each of these may exist alone without fracture, but when they present together the diagnosis is cer- tain. In most cases, especially those which recover, in which the cerebro-spinal fluid exudes, the flow comes from the fractured labyrinth. If this should be cerebro-spinal, there must be a considerable rent in the dura mater—in itself an almost fatal injury—and the tear must gape considerably to allow the fluid to pass for a considerable time. In the former case, the fluid may exude without any inflammatory meningeal symptoms. There is another fracture of the skull which is denominated a punctured fracture. This is caused by a nail, a spike, the sharp extremity of a pick- axe, of a rail, or a bar of iron being driven into the skull. In this latter accident, there is always more or less injury done to the brain, and more or less depression of both tables. The symptoms of compression are not FRACTURES OF THE SECULL. 721 always imminent, but the accident must be considered serious, and calls for the immediate use of the trephine. - James McA., a slater by trade, while performing his avocation on the roof of a three-story brick house, lost his balance and was precipitated head- foremost to the street below. He struck upon a pile of paving-stones with the right side of his head, and lay for a time insensible. I was in the neighborhood at the time and was called to the accident. I found him bleeding profusely from an extensive scalp-wound, which beginning at the temporal ridge extended downward to the right eye, thence across the eye- lid to the internal canthus. The upper part of the eyeball with the inser- tion of the trochlear muscle were distinctly visible. The flesh was rolled up and the wound filled with dirt. The bleeding was so profuse that I was obliged to ligate the anterior and middle temporal arteries in the street where he was lying, and, having extemporized a stretcher, I sent him to the Good Samaritan Hospital. Upon cleansing the wound and carefully inserting the finger, several pieces of loose bone (one an inch square) were detected and taken away, the larger one forming a part of the outer rim of the orbit, and a part of the base of the zygoma. The wound was brought together with silver su- tures, and the other injuries examined. There was a Colles fracture of the left arm, which was dressed with a carved splint made for the purpose ; not so perfect as Levis’s apparatus, but sufficient to make an excellent cure. A dislocation of the right elbow-joint (olecranon backwards) was then reduced, and a severe contusion of the right knee bandaged. Arnica 3 was given internally, and the patient, much exhausted from his suffer- ings, allowed to rest. Fever, delirium, and coma set in, which were controlled by aconite during the first days, and opium thereafter. Slowly the young man recovered from his injuries, and a good constitution carried him through. An orphan boy about five years of age, was leaning from the third-story window of a schoolhouse, when he fell forward violently, striking his head upon the ground. He was insensible, and was brought a distance of five miles to the hospital. When I saw him, about six hours after the injury, I found him still deprived of consciousness, his urine had passed involuntarily, the pulse was hard, full, and slow, the mouth drawn to one side, with other symptoms of an alarming character. Upon ex- amining the wound I found a depression in the skull on the right side, caused by an irregular fracture of about an inch and a quarter in length. This was, with a little difficulty, raised with the elevator, and the external wound allowed to remain open. Six hours after, a slight return of con- sciousness was indicated by sensibility to pain. He was given arnica.6th every two hours, and arnica solution applied to the open surface. The next º the wound was brought together, and the patient rapidly re- COWere Ci. Ambrose Paré is said to have been the first who pointed out that the inner table of the skull may be fractured without the external being broken, or there may be a depressed fracture of the inner table without a breakage of the outer, though the latter may be divested of its periosteum. This curious condition is chiefly found in gunshot fractures of the cranium. The breakage of the internal table, until the year 1865, was supposed to be due to the greater brittleness of the vitreous bone, but Mr. Treevan has proved that fracture always commences in the line of extension, not that of compression. If there is apparently a simple fracture of the skull, and there be doubt about its diagnosis, the proper method is to cut down upon it ... and ascertain its nature and extent. This is in direct opposition to 46 722 A SYSTEM OF SURGERY. the rules of all the older surgeons, who saw in scalp wounds, erysipelas, hamorrhage, and death. Experience, however, proves this to be the best rule, and it may be followed in every case of the kind. Concussion of the Brain may be divided into three stages. The first, that of insensibility and derangement of the bodily powers, which immedi- ately succeeds the accident. While in this condition the patient is appar- ently insensible to externalimpressions, but can generally be aroused, the pulse is intermitting, the extremities cold, and breathing difficult, but in the gene- rality of instances without stertor. The pupils may be dilated or contracted, or one may be dilated and the other contracted. This stage has a short duration, and is succeeded by the second, in which the symptoms ſº disappear, the pulse and respiration become more natural, and thoug not entirely normal, are sufficient to diffuse warmth throughout the extreme parts of the body, and to maintain life. As the effects of the concussion still diminish, the capability of exerting the mind becomes increased, the patient can reply to questions, and refers the chief cause of his sufferings to the head. Vomiting often occurs at this time, and is not an unfavorable symptom. As long as stupor remains, inflammatory action appears to be moderate, and as the former abates, the latter increases; and this con- stitutes the third and most important stage of concussion. Death, how- ever, sometimes instantaneously supervenes, from cessation of the heart's action. These are the symptoms that are laid down as belonging to concussion. The question, however, arises in the fatal cases as to how much contusion there is of the brain-substance. Mr. Bryant* makes the following remark- able statement: “At Guy's Hospital, during the last fifteen years, no case is recorded of death from concussion without change of brain structures.” He also says: “Mr. Hewett states: “In every case in which I have seen death occur shortly after, and in consequence of an injury to the head, I have invari- ably found ample evidence of the damage done to the cranial contents;’ and Mr. Le Gros Clark, of St. Thomas's Hospital, says: “I have never made nor witnessed a post-mortem after speedy death from a blow on the head, where there was not palpable physical lesion of the brain;’ and Dr. Neudorfer, of the Austrian army, declares that he has never seen concussion, properly so- called, except in apparently trivial injuries. “M. Fano, a recent French writer, has also come to the conclusion, “that the symptoms generally attributed to concussion are due, not to the concus- sion itself, but to contusion of the brain, or to extravasation of blood.” In fact, all now agree, when death follows a severe shaking of the brain, or concussion, that contusion or bruising of the brain is invariably found.” Treatment.—The medicine that is most serviceable in the treatment of concussion, is arnica; and its early administration, if the injury be not severe, will not only prevent many of the evil consequences that may result, but by its influence upon the vessels may limit extravasa- tion of blood within the cavity of the cranium. If the injury be severe, and there is extreme restlessness and jactitation of the muscles, quick small pulse, rigors, and delirium, bell, must be employed. If there be jerking of the tendons of the extremities or clenched hands, with foam at the mouth, stram. will be of service. If the patient roll the head from side to side, and there is much depression, stertorous breathing, hiccough, etc., hyos. is indicated. The medicines that are homoeopathic to irritation, and which should be employed at the commencement of the third stage, are ignatia and cicuta virosa. It would be the better practice, when the * The Practice of Surgery, p. 63, Fourth American Edition. COMPRESSION OF THE BRAIN. 723 cause of the affection is considered, to alternate armica with other medi- cines which the symptoms may render applicable. Aconite should not be forgotten, when after the injury the mental faculties of the patient appear considerably impaired, as inability to think, weakness of memory, vertigo on raising the head, blackness before the eyes, nausea, and some- times vomiting; when the latter symptom is prominent and the matter ejected is blackish or brownish, with prostration of the vital powers, ars. should be employed. Compression of the Brain.-The brain may be compressed in four ways: 1st, from effusion of inflammatory products; 2d, extravasated blood ; 3d, from suppuration, and 4th, by depressed bone. Assistance in the diagnosis from either of the above causes is derived from a knowledge of the time at which the symptoms of compression occur. Thus a blow with a hammer, fracturing both tables of the skull, produces immediate symptoms. An extravasation of blood takes place more slowly, and the symptoms follow gradually in severity as more fluid is poured out. Effusion from inflam- mation takes a longer time for its appearance than the extravasation of blood, and suppuration, which is generally caused by the presence of a for- eign substance, occupies a still longer period, while depression of bone, either of one or both tables, produces in many cases immediate symptoms. The records of surgery furnish numerous examples of recovery after extensive depressions, from which the patients sustained little incon- venience, and for the relief of which no operations were performed. On the other hand, cases occasionally occur in which from depression of both tables or from extensive fracture of the inner, urgent symptoms have resulted, but have been speedily relieved upon elevating the bone to its natural level. The symptoms of compression resemble those of apoplexy. If the cere- bral functions cease totally or partially in consequence of the pressure of extravasated blood upon the brain, the symptoms of nervous apoplexy or paralysis are present, which in many respects closely resemble those pro- duced by violent concussion. The patient is extremely pale, with pulse feeble and irregular, and the whole body appears totally paralyzed; vomit- ing sometimes occurs. In some instances, after such a condition has existed for a time, the pulse becomes fuller, the face assumes a more natural color, or becomes very red, and all other symptoms of hyperamia make their appearance, precisely as after concussion. In other cases the patient is deprived of consciousness or sensation, is totally or partially paralyzed, faeces and urine pass off involuntarily, or the latter may be retained; the breathing is stertorous, the pulse is hard, full, and slow, the eyelids droop as if paralyzed, the mouth is drawn to the side, and the eyes are staring and protruded, with insensible and often dilated pupils. In many cases the patient vomits, and the face looks livid and turgescent. Pus, or coagula formed by extravasated blood, may also pro- duce compression. Suppuration, however, does not immediately follow an injury of the skull, and often proceeds from irritation occasioned by the shattered fragments of the internal table. Mr. Bryant lays down the fol- lowing important diagnostic points: “When a patient receives a direct blow upon one side of the head, and a fracture with depression of the bone ensues, associated with paralysis of the opposite side of the body as an immediate result of the injury, and a fixed and dilated pupil on the side of the injury, the conclusion is inevitable that the depressed bone is the cause of the paralysis, by producing pressure upon the brain; the depression must, however, be very great to give rise to such symptoms. “When another patient sustains a similar injury, with or without depres- 724 A SYSTEM OF SURGERY. sion of the bone, but followed after a distinct interval of time by paralysis of one side of the body, whether of the injured side or not, it is quite fair to infer that haemorrhage has taken place inside the skull, and is the cause of the compression. “In both of these cases a local injury is followed by local mischief, causing a local paralysis, and surgical treatment is of great promise. In these cases the mode of production of the injury and the history form the surgeon's best guide to its nature. These cases are, however, very rare.” The following is the differential diagnosis between concussion and com- preSSIon: CONCUSSION. COMPRESSION. Symptoms immediate. Interval from a few minutes to a quarter of an hour. Patient, able to answer questions, with diffi- Power of speech lost. culty, and in monosyllables. Power retained by special senses. Not retained. Nausea and sometimes vomiting. Stomach not active. Relaxed bowels. - Torpid bowels. Respiration, without much noise. Stertorous. P. of urine involuntary, power re- Atony of bladder. tained. & - Contracted pupils, lids movable. Dilated and unaffected by light. Treatment.—The first act of the surgeon, when called to a patient suffering from compression of the brain, is to administer a dose of arnica. This medicine is employed by many distinguished surgeons in the treatment of this injury. If symptoms are present that in a measure call for the exhibition of other medicines, they may be administered in alternation with a.I’IllC8,. Veratrum should be employed when there is coldness of the whole person, with distorted and protruded eyes, disfigured countenance, flabby muscles, trismus, and imperceptible breathing. Coffea by the mouth and anus has frequently succeeded in relieving such symptoms. Aconite is an important medicine in the treatment of compression, and belladonna has frequently produced desirable results. Opium also restores the reactive power of the organism, and is indicated when there is stupor, with coma, stertorous breathing, red, bloated face, full slow pulse, and profuse Sweat. Lauroc., hyos., stram., merc., plumb., and iodine, are useful medicines; the latter especially when there are violent pulsations of the whole body, with anguish and dyspnoea. Other remedial agents may be called for, but want of space will not permit their insertion. When this treatment does not relieve the patient, and there is reason to believe that the brain is still oppressed by a coagulum, the trephine must be resorted to, and the foreign substance removed. If after injury inflicted upon the skull, a depression is observed and there are but slight symptoms of compression, the surgeon must remember that fragments of bone, though at first producing little irritation, may after a time provoke the inflammatory process, which may terminate in suppura- tion, and thus disastrous consequences may ensue. The question of operation in this, as in all other cases, requires serious consideration. The Application of the Trephine.—The use of the trephine was known from remote ages. Bones have been exhumed from the tombs of the Incas in Peru which present undoubted signs of having been perforated with this instrument. From this we learn that the trephine must have been known prior to the times of Cortez. At present there is perhaps no subject within the domain of sur- gery upon which surgeons are so divided in opinion as that of the applica- TREATMENT OF COMPRESSION OF THE BRAIN. 725 tion of the trephine in injuries of the head. Mr. Gamgee has well stated that “the lesson very impressively taught by a careful study of the subject is this, that whereas the trephine was almost indiscriminately employed before surgery attained to the position of a science, its use has steadily decreased as enlightened experience has accumulated.” From a careful study of the literature of this subject, I believe that the presence of brain symptoms, or, in other words, the appearance of those symptoms which indicate that the brain itself is being much interfered with, and that the lesion is on the increase, is the indication that the trephine should be employed. Listoni thus wrote years ago: “When fracture of the skull is complicated with wound of the scalp, the surgeon will not in general mend matters much by trephining, as has been advised, merely because there is a wound; if the depression is pretty extensive, and unless he has a better reason to give for the proceeding than the mere circumstance of the fracture being compound, as it is called, he will often thus add as much to the injury and to the risk which the patient is subjected to by it, as he would by dividing the scalp in simple fractures.” And to-day, after a careful review and comparison of the practice of various surgeons, Mr. Gamgee thus finishes his scholarly lecture: “Many surgeons, from being advocates of the trephine, have gradually abandoned it; but, so far as my researches have extended, I cannot find an instance of conversion to the practice of trephining by a surgeon whose rea- son indisposed him to adopt it, or whose experience had once led him to relinquish it. That there may be cases of compound depressed fracture of the skull justifying operative interference, I do not deny, and I myself had occasion to operate successfully on such cases in this theatre. For the pres- ent, I shall limit myself to again impressing upon you my conviction that, in compound depressed fractures of the skull, without brain symptoms, the proper course of practice is not to trephine.” In a report of 106 cases of fracture of the cranium, by M. C. Sédillot, it is found “that in fracture of the internal table of the cranial vault, with displacement of fragments, trephining is the only means of preventing com- plications which are almost inevitably fatal.” . Of the 106 cases of fracture collated, 77 were trephined: of the remaining 26 cases, no operation was performed. Of the latter, but a single one recovered. Of the 77 patients who were trephined, 30 recovered and 47 died; 9 were operated upon before the appearance of any untoward symptoms; of these 6 recovered and 3 died. Of the 21 cases in which the operation was performed before the sixth day, 8 ended in recovery, and 13 in death. Of the remaining 47 patients who were trephined after the sixth day, 15 recovered and 32 died; showing that the mortality is in direct proportion to the time of operating. Two- thirds of the cases were cured by preventive trephining; more than one- half by early trephining (before the sixth day), and less than one-third by late trephining (on or after the sixth day). Cerebral Motor Localizations.—In injuries of the head there is consider- able discussion among surgeons as to whether, disregarding depressing frac- tures, the application of the trephine should be determined by internal symptoms, or, if the operation has been decided upon, to localize the spot * On the Treatment of Compound Depressed Fractures of the Skull, by Sampson Gamgee, Esq., F.R.S.; Braithwaite's Am. Ed., January, 1877, p. 116. # Practical Surgery, p. 45. $ f American Journal of the Medical Sciences, April, 1877, also Gaz. Médicale de Paris, No. 39, 1876. 726 A SYSTEM OF SURGERY. where the instrument should be applied by the presenting subjective symp- toms. Especially in recent cases of traumatism is this method of deter- mining the point of operation said to be the most serviceable. According as one or another set of muscles are implicated, the surgeon may be able to determine the particular motor centre that has been injured. It should be, however, borne in mind that by reflex nerve irritation remote parts may be affected, and symptoms, therefore, being only secondary, trephining at the wrong point might be indicated. This, however, we know, that, if there exists a convulsion, and, above all, paralysis of a group of muscles, there also exists some lesion of a motor centre, and since physiology teaches where these centres are, it should be an easy matter to refer them to their corresponding points in the cranium. M. Lucas Championnière tells us, that what are termed the cortical centres Occupy a space limited to the vault of the cranium, and that all the centres and all the convolutions which form them, are grouped around the fissure of Rolando, and immediately below the anterior half of the pa- rietal bone. The method of finding it is thus described. It is known that in man the fissure of Rolando commences fifty-three millimeters behind the bregma; fifty-five millimeters are to be measured behind it and marked on the skull. Next we must measure behind the external orbital process a horizontal line, seven centimeters long, and erect a line at right angles to its extreme edge, three centimeters long, and the point thus found will corre- spond with the inferior extremity of the fissure of Rolando. If, between these two points, we mark on the integument a straight line, we obtain the “ line of Rolando,” and if the trephine be applied exactly over this line, the fissure of Rolando is met with invariably. These measurements are rather less in females. It must be remembered that, although this method of measurement is true for certain regions, individual convolutions vary somewhat in their positions, and are not always constant towards the vertex, and that the size of the crown of the trephine must be taken into consideration according to the presumable exactness of the diagnosis.” MM. Charcot and Pitres have made some interesting experiments, and arrived at conclusions which will materially assist in the more precise localization of the cerebral motor tracts, and, if carefully studied, will give the operator valuable assistance, as to the spot whereupon to place his trephine. I have taken the conclusions drawn by these distinguished authors, from a notice of their labors, in the editorial columns of a recent medical periodical.i. These conclusions are as follows: 1. The cortex of the cerebral hemispheres in man may be divided, func- tionally, into two parts; motor and non-motor, according as destructive lesions do or do not cause permanent paralysis of the opposite side of the body. 2. The non-motor 20me comprehends: a. All the prefrontal region of the brain (orbital lobe first, second, and third frontal convolutions). b. All the occipito-parietal region (occipital lobe, superior and inferior parietal lobules). c. All the tempero-sphenoidal lobe. 3. The motor zone includes only the ascending frontal and ascending pa- rietal convolutions and the paracentral lobule. 4. The paralyses produced by destructive lesions of the motor zone have different clinical forms according to the location of the lesion. Thus com- plete hemiplegias of cortical origin are produced by diffused lesions of the ascending convolutions; partial paralyses are produced by circumscribed * Monthly Abstract of Medical Science, vol. iv., No. viii. f Medical Record, November 10th, 1883. TREATMENT OF COMPRESSION OF THE BRAIN. 727 lesions of these same convolutions. The location of the lesion in some of these partial paralyses or monoplegias can be determined. MM. Charcot and Pitres announce the following as data for such determination: a. The brachio-facial monoplegias coincide with lesions in the inferior half of the ascending convolutions. b. The brachio-crural monoplegias coincide with lesions in the upper half of the ascending convolutions. c. The facial and lingual monoplegias depend upon very circumscribed lesions of the lower extremity of the ascending convolutions, particularly of the ascending frontal. d. The brachial monoplegias depend upon a very limited lesion of the motor zone; particularly of the middle third of the ascending frontal. e. The crural monoplegias depend upon very limited lesions of the para- central lobule. 5. Whether those paralyses caused by destructive lesions be general or limited, they will in time be followed by secondary contractures of the paralyzed muscles with descending degenerations of the voluntary pyra- midal tracts. 6. Irritative lesions of the cortex can give rise to epileptiform convul- “sions (partial or Jacksonian epilepsy), which are different from those of true epilepsy. They begin with a motor aura, and may be either general- ized or limited. 7. In general the irritative lesions, which cause epileptiform convulsions, are located at or near those centres which, if destroyed, would cause paral- yses in the muscles affected by the convulsion. But these lesions may be even in the non-motor Zone, and their relations to the functionally affected centres is not so close as is that of * paralyses and destructive lesions. FIG. 424. In conclusion, the authors reaf- firm their belief that no facts op- posed to the doctrine of cerebral motor localizations have been es- r/eſſa/WW-CO tablished. Their own observations Plain Crown Trephine. and studies, as shown above, do not so much add that which is FIG. 425. new, as they make definite and certain our previous views. They contradict, to some extent, the con- clusion of Esner, regarding the existence of diffused and over- lapping centres. We are inclined to believe, however, that the method employed by Charcot and Pitres is more trustworthy than the unusual one adopted by Es- IlêI’. The instruments to be employed TICMAWWe CO Trephine Handle. are found in the trephining cases, & or are placed in the ordinary amputating, resecting, or general operating cases of the day. They consist of a couple of scalpels, a lenticular-shaped knife, a trephine or two which can be set in one handle (Fig. 424 represents the shape of the ordinary instrument; Fig. 425 shows Galt's trephine, and Fig. 426 the handle), the ordinary artery forceps and tenaculum, a brush to clean the trephine, a sharp-pointed piece of wood, or a wire or toothpick to clean the groove made by working the instrument. - The patient generally being in a comatose condition, or in a state of par- tial insensibility, an anaesthetic agent is unnecessary. If the fracture is compound, it may be requisite to enlarge the incision. If the fracture is a 728 A SYSTEM OF SURGERY. simple one, with depressions, then incisions may vary according to the judgment of the operator. They may be made either of the above shapes FIG. 427. (Fig. 427). After having raised the flap sufficiently, the crown of the tre- phine is placed over the part to be removed, and fixed in its place by press- FIG. 428. FIG. 429. ing down the pin in the centre, which must be, by a little rotation and pressure, fixed in the skull; the instrument is then rotated—without pressure FIG. 430. The mark of the trephine is seen at the corner of the sound bone, a, and it has also just touched the end of the depressed bone, b, and the traces of Hey's saw, which has been used to take off the over-hanging edges of the sound bone, are very distinctly marked, c. The depressed bone, has all been very fairly elevated, and the operation did temporarily relieve the symptoms of compression, as the patient became a little more sensible, and was able to speak, but he only lived a few hours. Death was caused mainly, as it seems, by hamorrhage between the bone and dura mater, the source of which was not precisely ascertained. The fracture passed across one of the main grooves for the middle meningeal artery, but the vessel itself appeared uninjured. The dura mater was not torn, but the lower part of the middle lobe of the brain was contused on each side. The depression seen at the back of this preparation *Pºº #. due to some old injury, but nothing is known about it.—St. George's Hospital Museum, Ser. 1., NO. 16.-HOLMES. —backward and forward, being removed from time to time to clean away the dust with a brush, and to cleanse the groove with the quill; as the lower INJURIES AND DISEASES OF THE NOSE. 729 table of the skull is reached more care is required, and when the “button’’ is sawn out it may be lifted away with the forceps, elevator, or a gimlet made for the purpose. If it is possible, in using the trephine, the sinuses of the dura mater and the large vessels should be avoided. It may also be borne in mind that there is often space enough left between the fractured bones to introduce an instrument and elevate the depressed portion without applying the trephine. Again, it is not always necessary, when endeavoring to elevate a portion of bone, to remove the entire circle with the trephine; all that is required is sufficient space for raising the fragments; this may be done by fixing the pin on the edge of the sound bone, and removing with the saw only the segment of a circle. Figs. 428 and 429 show the methods of operating, and Fig. 430, from Holmes, shows the method of placing the crown of the trephine partly in sound bone. CHAPTER XXXVII. INJURIES AND DISEASES OF THE NOSE. MALFORMATIONs—For EIGN BODIES-EPISTAxIs—LIPOMA NASI—ULCERATION.—OzAENA —PolyPUs NASI—MYxoMA—NASO-PHARYNGEAL PolyPUs—OSTEO-PLASTIC RESEC- TION.—RHINOSCOPY. Malformations.—The nose is occasionally subject to malformations, the chief of which is a deviation of the septum from the centre to one side, or in some instances, downward. In two cases that came under my supervision, I was enabled to remedy the deformity by excising the misplaced septum. In one case I was obliged to cut through the central cartilage, and in the other to slice off a portion of it, and restore it to position by plugging with tinfoil the nostril encroached upon. In both instances I was astonished at the amount of blood lost, although no vessels were large enough to ligate. Foreign Bodies.—Foreign bodies, such as beads, peas, bits of wood, cotton, pieces of pencil, etc., are thrust into the nose, especially by children. They often occasion not only a good deal of inconvenience and fright, but lead to serious ulceration, if not speedily removed. If they can be seen, a small pair of curved and delicate forceps, with the blades spread widely apart, should be introduced carefully along the floor of the mares and the foreign FIG. 431. 7/7/4///-CO WY Bristle Probang. body grasped and removed. If this is not sufficient, a bristle probang closed (Fig. 431) should be passed into the nostril and the handle with- drawn. This bends the bristles, fills the nares, and the body is removed. In other cases longer instruments are required. On all occasions gentleness 730 A SYSTEM OF SURGERY. and patience should be employed, and in the majority of instances an anaes- thetic should be used. Strong snuff may sometimes produce sufficiently violent sneezing to dislodge the foreign body. Epistaxis—Haemorrhage.—Bleeding from the nose is a frequent occurrence, especially in young subjects. It may occur as a critical discharge and be considered favorable, or it may appear in enfeebled constitutions and be a dangerous symptom. Some persons are more prone to epistaxis than others, the bleeding occurring upon slight provocation, or in many instances with- out any assignable cause. Puberty and old age are the periods at which haemorrhage from the nose is most likely to occur. In some cases it is so profuse as to cause great prostration; indeed, instances are recorded which terminated fatally. Treatment.—The Materia Medica furnishes a number of medicines which are efficacious in the treatment of nosebleed, even of a violent character. Among these are: acon., carbo veg., china, crocus, erigeron, ham., nux vom., verat., Secale. When there is passive haemorrhage in old people, carbo veg. is excellent. Trillium also may be employed. Thlaspi bursa pastoris, arsenicum, pulsatilla, rhus tox., mercurius, and agaricus, are also medicines of importance. If these fail in arresting the bleeding and the patient is sinking, or shows symptoms of prostration, I have frequently stopped the hamorrhage by Bellocq's Canula. cutting strips of cotton cloth, half an inch wide and six inches in length, twisting them upon themselves, and then, having dipped them in a solution of alum or tannin, passed them into the nostrils with a female catheter. In other instances it may become necessary to plug the posterior nares. This is effected as follows: Prepare two dossils of lint, each somewhat larger than the openings of the posterior nares (Ende's styptic cotton would answer admirably for this purpose), and having secured them by tying around their middle a strong cord, pass into the nostrils a Bellocq's canula (Fig. 432) with the piston drawn out; having carried the instrument carefully along the floor of the nares, its curve will project down behind the velum palati: then push forward the piston, which brings the spring, with the eyelet at its extremity, into the cavity of the mouth. Into the eyelet pass the end of the cord at- tached to one of the dossils of lint, and draw out the piston; this brings for- ward the thread, and the dossil is forced into one of the openings of the nares. A similar proceeding is adopted with the other nostril. The plugs should be .#to remain a day or two, before they are carefully removed. Professor Weber discovered that when a person breathes entirely through the mouth, the posterior nares are closed by the soft palate; therefore the nasal douche should be employed. The water should be hot, and contain a small quantity of liquor ferri persulphatis. Dr. Beverly Robinson* records a most severe case, in which styptics had * Medical Record, March, 1876. TJLCERATION.—OZAENA. 731 failed, but pressure on the facial (made with pads of lint) on the superior maxillary bones, just before the vessels reach the alae, was successful. Hypodermic Use of Ergotin.—Dr. Porak” speaking of epistaxis, arrested by subcutaneous injections of ergotin, remarks, that he used a solution of 2. grms. (30 grs.) of Bonjean's Ergotin in 30 grms. of glycerine, and injected 20 drops into the lip or cheek. He records three cases of persistent epistaxis, in each of which the haemorrhage was controlled by a single injection of ergotin under the skin. Lipoma Nasi–Hypertrophy.—This affection consists of a hypertrophic condition of the integumentary substance of the nose, which may arise from various causes: often from acne rosacea of long standing, and from deposi- tions of fatty substance around the alae nasi. The growths, as we most commonly see them, are globular or lobed, and vary in number and size. Cases are upon record in which they attained such magnitude, that they hung down on the chin, interfering with respiration and speech. In other cases, these growths may be flattened, and again in others, they may be pedunculated. They are gristly and hard when cut into, and though they may attain a remarkable size—growing externally—they never invade either the mucous membrane or cartilaginous substance of the nose. The color of lipomata is dusky red, or purplish; and they rarely appear in persons under fifty years of age. Treatment.—Nothing but the knife will be of any avail. The growths must be cut away, or better, a flap of integument dissected from them, and then enucleation effected. There is often a good deal of nicety required in the dissection to prevent the cartilages from being cut through. To obviate this, the surgeon should keep his finger constantly in the nostril. Ulceration—Ozaena.-This affection is a troublesome ulceration of the lin- ing membrane of the nostrils, attended with fetid purulent discharge. Occa- sionally it is followed by destruction of the nasal FIG. 433 - cartilages, and by caries of the nasal bones. In • It nº Jºe some instances the senses of smell and taste are entirely destroyed. Though the origin of the disease is somewhat obscure, yet there is reason to believe that, in most instances, it is connected with the primary or secondary forms of syphilis; and in others with a purely scrofulous diathesis. The most disagreeable feature of the affection is the ac- cumulation of inspissated mucus or incrusta- tions within the nasal cavities, which sometimes form in such considerable quantity as to entirely close the passages. After ulceration is fairly es- tablished, not only is the cartilaginous septum affected, but the ethmoid, the spongy, and other bones of the nose; and, in the worst cases—par- ticularly when there is complication with syphi- litic or mercurial disease—even the palate and superior maxillary bones exfoliate, and in con- sequence of such ravages the contour of the nose is destroyed, and frightful deformity of the face results. Treatment.—The medicine which has been productive of most beneficial results in my hands is the bichromate of potash. The secret of success is its prolonged use, sometimes it being steadily taken for months. I use * The Medical Record, November 16th, 1878, No. 419. 732 - A SYSTEM OF SURGERY. the third trituration, and give one powder per day. In addition to this every morning the nasal douche (Fig. 433) is employed, the water being at a temperature of 68° or 70°, and containing salt sufficient to render it brackish. Patients, in the majority of cases, express themselves as experiencing great relief after its use. In some cases, it cannot be borne, giving rise to pain and sometimes even haemorrhage. In such, of course, cleanliness must be obtained by the use of a small syringe. With reference to the insufflation of alum or tannin, or the local application of various sub- stances by means of steam atomizers, I cannot speak in very high terms, nor can I of the injections of carbolic acid, per- manganate of potash, sulphate of copper, and other drugs. The properly selected medicine and cleanliness are much more successful than local measures, according to my personal ex- perience. * Other remedies which have chiefly been em- ployed in this affection are: alumina, teucrium, puls., Sulph., calc., magnes. mur., bryonia, bell., lycopod., natr. mur., and causticum, in the first stage; when the secretion has been transformed into pus, and the nasal bones are affected, with fetid odor from the nose and loss of smell, mercurius and aurum are to be administered. These may be followed if re- quired, in ozaema scrofulosa, by sulph., sil, acid. nit., phosph., conium, or kali bich. In syphi- litic Ozana, mercurius constitutes the principal remedy; if, however, the patient has been sub- jected to an injurious course of treatment with this medicine, potassium iodide is pre- ferred, and sometimes nit. acid, hepar, asafoe- tida, conium, or thuja. Baptisia, hydrastis, phytolacca, and sangui- naria, are recommended in The New Remedies, by Drs. Hale, Powers, and others, for this troublesome affection. Polypus Nasi.-A polypus of the nose may arise from any portion of the Schneiderian membrane, but it originates most frequently from either the superior or inferior spongy bones. Occasionally the seat of the tumor is So high, that instead of falling toward the an- terior nares, it takes a backward direction, hanging behind the palate, and sometimes even reaching the pharynx. . It is commonly pyriform, narrow at its base and expanded below, though this depends much upon the - º form of the cavity in which it is situ- g w Forceps. ated ; sometimes the base of the tumor is ex- Simcock's Polypus Forcep ceedingly large. Either one or both nostrils may be affected, and when the latter the patient breathes with much diffi- culty, and with a peculiar rattling noise. In damp weather the tumors often project beyond the exterior of the nostrils, but assume their former position upon the reappearance of a dry atmosphere. - The consistence of nasal polypi is not less variable than their form. In Some instances they are soft, and in reality consist of enlarged mucous Sub- FIG. 434. i POLYPUs NASI. 733 stances; to these the term myxomata is given. These are the most amen- able to treatment. The fibrous polypus is a dangerous and obstinate growth. It is not frequently met with, has none of the softness of the first variety, grows from the periosteum, is opaque, reddish in color while in 8itu, being traversed with large vessels. When it projects into the pharynx, the term naso-pharyngeal polypus is given to it. It often produces by its pressure caries of the ethmoid and spongy bones, inflammation of the brain, etc. Treatment.—The medicines which have proved most efficacious are calc. carb., teucrium, Sulphur, and phos.;” puls., silicea, staph., carbo an., and sepia may also be called for in some cases. - * The best remedies are undoubtedly calc. carb., teucrium, phosphorus, and sulph. I treated successfully a case of returned polypus, for which an operation had been performed in New Orleans, by teucrium, phosph., and filix mas, with occasionally a dose of calcarea carb. and sulph. Dr. John E. James speaks highly of freshly powdered sanguinaria cana- densis root, blown through a quill or other cylindrical tube over the whole polypus; in many, if not most cases, three applications, at intervals of from three to seven days, being sufficient to effect a radical cure, and should the polypus be so large as to necessitate forcible removal, the application once or twice will give temporary relief before the operation. Dr. Thomas Bryant, after an experience of three or four years, also speaks highly of the use of tannin in a similar manner. Sometimes it is necessary, when medicines cannot effect a cure, to remove the polypus by mechanical means; this may done in a variety of ways, but in most cases the use of the forceps is preferable. These should be stronger than the ordinary dressing forceps, well serrated and slightly curved. The patient is seated on a low chair, before a powerful light, with the head moderately thrown back and firmly supported; the surgeon carefully intro- duces the instrument with its blades expanded, grasps the tumor firmly at its root, and by twisting rather than pulling removes it. Although in many surgical works the extraction of a polypus is treated as an easy operation, yet my experience proves that a strong polypus, situated far back, with the greater part of its bulk posteriorly, is by no means readily detached. In the first place, the straight forceps usually found in pocket cases is not long enough, either in the handle or in the blades, and from its shape is not well adapted to the meati. The better variety of instrument should be eight inches in length, with a curve in the blades, with deep serrations at their extremities for the purpose of grasping firmly the polypus. Even these may sometimes have to be repeatedly introduced before a successful result is obtained. A better instrument is that of Simcock, Fig. 434. Its handle is well de- ressed, and there are fenestrae in the extremities of the blades, which are ong and narrow. Fig. 435. Z”. 2 P4,-1 ºr, fºr Z **) === Gºeſ: =ces - º: Gooch's Canula for Nasal Polypus. Ligature is employed often with success when the polypus cannot be extracted with the forceps. Many kinds have been used, as silk cord, silver or iron wire, catgut, etc.; probably the best is that composed of the latter and silver wire twisted together. A double canula should be introduced as * For several interesting cases of polypinasi, cured by the three former of these medicines, see British Journal of Homoeopathy, vol. viii., p. 283; and vol. x., p. 484. 734 A SYSTEM OF SURGERY. far as possible into the nares, and the loop of ligature pushed back to embrace, if possible, the foreign growth; this is aided by the introduction of the finger into the pharynx. The growth must then be constricted. For this purpose the canula of Gooch answers better than the old- fashioned double cylinder, Fig. 435. . Naso-pharyngeal Polypus-In consequence of the difficulties experienced in obtaining access to the naso-pharyngeal polypus many operations have been recommended as preliminary measures to the extirpation of the growth itself. Hence we have the division of the external nose, advocated by Hippocrates; the total resection of the superior maxilla, as performed by Syme in 1832, and by Flauvert in 1840; but this always left great disfigurement and functional disturbance, and for this reason was opposed by Langenbeck in 1861, who proposed to make the resection in such a manner that, after the second or fundamental operation is performed, the divided bone can be restored to its normal position. Probably the most satisfactory operation for gaining access to the seat of this form of polypus is that advised by Professor Bruns, of Tübingen, which he calls an “Osteoplastic Resection of the External Nose for the Removal of Naso-pharyngeal Polypi.” It consists of a temporary resection of the bony skeleton of the external nose, allowing the bony and cartilag- inous portions in connection with covering soft parts to be turned sideways. Either one-half or the whole external nose, according to circumstances, requires the opening of one or both nasal cavities. In the first instance the opera- tor divides, temporarily, the processus nasalis of the superior maxilla, and the nasal bone of the same side, then, by violently forcing asunder the suture of both nasal bones, the hinge movement is obtained; while in the Second case, a temporary resection is made of the processus nasalis, of the Superior maxilla, of the septum nasi, and of both nasal bones; and here the movement proceeds at the junction of the nasal bones and of the pro- cessus nasalis of the superior maxillary of the opposite side. In order that the modus operandi may be fully understood, suppose a case where the whole external nose is to be laid over on FIG. 436. the right cheek. The first incision is made in the skin, beginning just below the inferior edge of the right ala nasi, and is carried in a hori- zontal direction through the upper lip toward the left as far as the first molar of that side. The section is made through the inferior bony edge of the apertura pyriformis, and there the point of the knife is directed obliquely upward in order that the parts where the mu- cous membrane passes over into the gums may be uninjured. The second incision runs hori- zontally over the root of the nose, corresponding to the naso-frontal suture, the point of beginning and ending being one continuation in- ward and upward from the internal angle of the eye. The third incision connects the extreme left points of the two horizontal incisions, extending from the inner angle of the left eye, somewhat obliquely outwards and downwards along NASO-PHARYNGEAL POLYPUS. 735 the left lateral wall of the nose, and forming a junction with the inferior *...*. at the first molar on the same side. These incisions are seen in ig. 436. º these cuts must be carried through the periosteum down to the bone. With the saw, the nasal spine is divided at its base, and with the bone-scissors the section is carried still farther in the bony septum of the nose. A pointed saw is now inserted in the left inferior angle of the pyri- form opening, and following closely the incision in the skin, cuts its way at first horizontally outward through the superior maxilla and then obliquely upward and inward along the course of the third incision to the naso-frontal suture. During this act, the point of the saw is constantly in the nasal cavity, and the internal wall of the maxillary cavity is not opened unless it has already been perforated by the tumor, but the exterior end of the inferior concha of the nose is cut through. The bases of both nasal bones are divided with a saw along the naso-frontal suture. There now only re- mains the vertical division of the septum marium, which is accomplished by the scalpel or bone-scissors, carried obliquely backwards, partly from the upper and partly from the lower half of the cross cut, thus forming in the septum an angle open in front. Now, by inserting a lever in the upper end of the vertical sawed cleft, the connection of the nasal bone and of the nasal process of the superior maxilla will be forced asunder and the entire external nose laid over on the right cheek (see Fig. 437). Thus the FIG. 437. FIG. 488. whole nasal cavity on both sides becomes directly exposed, and the space thus gained may i. further enlarged by removal of the concha by horizontal incision and lateral dislodgment, or total removal of the septum, according to circumstances, whenever the neoplasm does not itself push away these º or render them atrophied. The posterior wall of the palate can now e easily reached, and also the base of the skull, which usually forms the seat of naso-palatinal polypus (Fig. 438). In Fig. 437 the normal relations of the parts after operation are exhibited, and the same are shown in Fig. 438 after the removal of the septum and the concha of the left side. While such a procedure is demanded for the removal of very large polypi, the opening of one cavity only will be sufficient in lighter cases, as when one nasal cavity is filled by the neoplasm and is greatly dilated by dislo- cation of the septum towards the opposite side. The measures adopted in 736 A SYSTEM OF SURGERY. such a temporary resection of one side of the external nose differs but slightly from the one already described. The incision through the integu- ment is the same, only both horizontal sections begin somewhat nearer the median line. A modification might be also made in the lower hori- Zontal incision by putting the knife into the external angle of the nostril, dividing the lower edge of it, and then continuing the cut in a lateral direction. The section is thus made somewhat smaller and does not touch the upper lip ; but the continuity of the aperture of the nostril remains intact. The sawing through of the bone with the pointed saw, begins at the lower external angle of the apertura pyriformis, at first horizontally, and then as before, upward and inward to the naso-frontal suture. From here the base of the nasal bone, on the same side, is sawn across to the median line; then, by the use of the lever, the suture connecting both nasal bones is opened, and the one-half of the nose is by the hinge movement turned over to the opposite side. This portion of the operation requires but a few moments, and presents no serious difficulties. The solution of continuity causes very slight func- tional disturbance, if any. None of the neighboring parts are in danger of being injured, except the lachrymal duct, which might be wounded by º,” closely to the inner angle of the eye, but which can readily be avoided. The haemorrhage in this region is never great, and generally ceases spontaneously, as no large bloodvessel is cut through. Having finished the temporary operation, the nose remains in its lateral position, till the fundamental one, removal of the polypus, is completed. In favorable cases the preliminary and the fundamental operations are executed at the same time; immediately followed by reposition and re- union of the nose. But in difficult cases the complete extirpation of the polypus is not advisable at the first operation, as when it has exten- sive attachments to the walls of the nose and palate, or when the opera- tion has to be interrupted on account of fainting or great hamorrhage. By the tampon, the bleeding from the tumor is stopped, filling up the whole cavity with lint or cotton, and by this means the wound is kept open till in one or more consecutive sittings all the foreign growth is removed. In one case, reposition of the nose was performed only after twelve days, and in another after twenty-one days. It has been found possible to delay the replacement of the nose for several weeks, and this fact is of consider- able importance to those surgeons who see in the supplementary application of caustics to the seat of the growth, a provision against a reappearance of the polypus. During this time nutrition is maintained by anastomosis with the sound side, so that no alteration in color or temperature of the skin appears on the divided parts. When reposition is adopted immediately, the application of a few sutures soon effects speedy union, except when the division of the bony sutures is imperfect or jagged, then strips of adhe- sive plaster will aid in keeping the parts in direct apposition. . Where re- union is delayed, the edges of the wound must be lightly freshened, and the necrosed bony edges removed with the bone-cutting forceps. Reunion takes place in a few days, and the sequestration is never ob- served. In immediate reunion the cicatrix is only linear and scarcely visible, but in later cases the eschar is somewhat broader, and the disfigure- ment more apparent.* Professor Tiffanyt relates a successful case of the removal of a naso- * For the description of this important operation, I am indebted to my friend Dr. Lilienthal, who translated it from the original German. # The Medical Record, October 26th, 1878, No. 416. RHINOPLASTY. 737 pººl polypus by the temporary depression of both upper jaws, as OILOWS : - - The polypus was growing from the base of the skull, occluding the right nostril, and had been removed, but returned in four months. It was then decided to depress the two upper maxillary bones and perform a provisional tracheotomy. Six days later, the operation was resumed. “An incision was carried down on either side of the nose, at the juncture of the nose and cheek, then around the ala and through the middle line of the upper lip into the mouth; the cheeks were then freely dissected from the upper jaws as high as the nasal bones, infra-orbital foramen, and malar bones; the nose was separated from the upper jaws and turned up towards the forehead. Both upper jaws were depressed, hinging upon the pterygoid processes, and the polypus thus removed.” - Besides the methods already alluded to, the operation of Furneaux Jordan” demands consideration. The object of the proceeding is to thor- oughly uncover the nasal cavity, and this is done by making a triangular flap of the upper lip and the side of the nose. A curved bistoury is carried under the lip into the affected nostril and made to cut its way out, and then the soft part of the nose is divided at one side of the middle line, in a line with the cut in the lip; a few strokes of the knife will allow the flap to be turned well outward. The nasal cavity is then well open and defined, and easy for manipulation. By passing one or two fingers into the pharynx, and one or two in front, the tumor may be readily detached by snips of the scissors. If the bone opening be too small it may be enlarged by the points of the forceps. Rhinoplasty.—The nose is often destroyed by disease, by accident, or by caustics. It may be that either a portion or the whole is removed, including the septum, turbinated bones, lips and roof of the mouth, making hideous deformity, thus rendering the patients revolting not only to themselves but to others. In such cases, the operation of rhinoplasty has accomplished changes of a satisfactory character. Dr. Gurdon Buck and Dr. Hamilton, of New York, Drs. Pancoast and Gross, of Philadelphia, the Warrens, of Boston, together with many European surgeons, have made successful rhinoplastic operations. Rhinoplasty may be performed by either sliding the flaps forward from each cheek, by jumping them by a twist, or by taking them from remote parts. To remedy a partial destruction of the nose is an operation which may be often completely successful; but to restore the entire organ, is a much more difficult task. If one or both alae of the nose be destroyed, a flap “jumped ” from the cheek and twisted by half a circle, may prove satisfactory. The following case was successful. . Mrs. T., a middle aged and respectable married lady, applied to me to ascertain if any means could be devised to remedy a deformity of the nose which was produced in the following manner: - - She had some time since a painful tubercle on the right ala nasi, which had caused her much worriment; and being fearful of malignant dis- ease, she had consulted a cancer doctor(?), who applied a paste which took away the tubercle, and with it the whole ala of that side, causing a severe ulceration, which extended to the internal angle of the eye. This solution of continuity had healed, leaving an ugly cicatrix. I explained to her the nature of the operation which could be performed for the restora- tion of the absent ala, to which she assented, and which was per- formed on the second day after our interview. The edge of the gap next * British Medical Journal, May 5th, 1885. 47 - 738 A SYSTEM OF SURGERY. to the face was very thin; indeed, was formed of a portion of the cicatrix already mentioned; while toward the tip of the nose the border was full, healthy, and prominent. The trouble, if there should be any, would evi. dently be at the thin margin during the process of cicatrization. The operation was thus performed: Before she was brought under anaes- thetic influence, a piece of wet parchment was laid over the nose, and cut the exact shape of the cavity to be filled, though one-third larger all around. This was turned back upon the cheek and its outline marked with a pen and ink, by dotted lines. The patient was then rendered insensible, and the flap dissected up, leaving a pedicle. I did not, however, make an inci- Sion perpendicularly through the tissues to the cellular substance, but en- tered the scalpel in an oblique direction, thus making a bevelled edge around the entire flap, leaving the pedicle as near as possible to the ala nasi. In a similar manner the edges of the entire gap were refreshed, thus making two tolerably broad raw surfaces. The flap was then twisted to its place, and Secured by pins of pure silver, around each of which a single turn of silk was passed. The ends of the pins were then cut with the nippers, and when fully recovered from the anaesthetic, the patient was allowed to return home. On the third day after, I visited her, and removed two of the pins, and applied a strap across the face and over the nose, extending from one cheek to the other. In two days I removed the remaining pins and a single suture which I had applied to draw the flap close down to the septum. The recovery was complete, and the astonishing manner in which the new ala has been rounded off by nature, and the almost imperceptible scar which remains from the wound in the cheek, render the operation one satisfactory both to patient and surgeon. If the whole nose is destroyed, the flap “jumped ” from the forehead is generally préferred, as seen in Fig. 439. Having moulded a piece of wax, the size and shape of the organ to be repro- duced, over it a piece of wet parchment should be laid and accurately fitted; this should be turned back upon the forehead, and twisted over the mould two or three times, until an “accurate fit ’’ is obtained. Many measurements and many adjust- ments are always necessary. Having fitted the pattern, it must be flattened out, laid on the forehead, and a line drawn an eighth to a quarter of an inch ::: ſº - from its margin around it. The nostrils # / f should then be filled with rolls of tenax, FIG. 489. * @% “prepared tow,” and the flap raised. The edges of the chasm must then be carefully . pared, in an oblique direction, and the flap brought downward, placed in position and secured by twisted silver wire. After the parts have regained their vitality, the restoration of the columna may be attempted. Of this Mr. Liston wrote, years ago : “Restoration of the columna is an operation which, in this and other civilized countries, must be more frequently required than the restoration of the whole nose. This latter operation came to be practiced in conse- quence of the frequency of mutilations as a punishment; but the punish- ment for some of our sins is left to nature, and she generally relents before the whole of the organ disappears. The columna is very frequently de- INJURIES AND DISEASES OF THE MOUTH AND THROAT. 739 stroyed by ulceration. The deformity produced by its loss is not far short of that caused by destruction of the whole nose. Happily, after the ulcer- ation has been checked, the part can be renewed neatly, safely, and without much suffering to the patient. The operation, which I have practiced suc- cessfully for some years, and in many instances, is thus performed: The inner surface of the apex is first pared. A sharp-pointed bistoury is then passed through the upper lip—previously stretched and raised by an assist- ant—close to the ruins of the former columna, and about an eighth of an inch on one side of the mesial line. This incision is continued down, in a straight direction, to the free margin of the lip; and a similar one, parallel to the former, is made on the opposite side of the mesial line, so as to insulate a flap about a quarter of an inch in breadth, and composed of skin, mucous membrane, and interposed substance. The franulum is then divided, and the prolabium of the flap removed. In order to fix the new columna firmly and with accuracy in its proper place, a sewing-needle is passed from without through the apex of the nose, and obliquely through the extremity of the elevated flap; a few turns of thread over this suffice to approximate and retain the surface. It is to be observed that the flap is not twisted round, as in the operation already detailed, but simply ele- wated, so as to do away with the risk of failure. Twisting is here unneces- sary, for the mucous lining of the lip, forming the outer surface of the columna, readily assumes the color and appearance of integument, after ex- posure for some time. The fixing of the columna having been accomplished, the edges of the lip must be neatly brought together.” A third method is that known as the Italian, and was first practiced by Taliacotius. It consists in removing the flap from the arm, and bringing the arm over to the head, and fixing it by means of a cap and jacket made of strong drilling. - - Dr. McFarland, of Philadelphia, performed this operation in a successful * but since the introduction of antiseptics it is seldom if ever O]] 62. For the treatment of lupus, epithelioma, and fracture of the nasal bones, the student is referred to the consideration of those subjects in other por- tions of this work. CHAPTER XXXVIII. INJURIES AND DISEASES OF THE MOUTH AND THROAT. HARE-LIP–DOUBLE HARE-LIP–RESTORATION OF THE UPPER LIP-EPITHELIOMA— ENLARGED LABIAL GLANDs—CYSTs of THE LIP–WASCULAR TUMoRs—RESTOR- ATION OF THE Low ER LIP–CLEFT PALATE AND STAPHYLORRAPHY-GINGIVITIS —TUMoRS OF THE TONGUE—GLOSSITIS-ABSCESS OF THE TONGUE–HYPERTROPHY —AMPUTATION OF THE TONGUE–MALFORMATION OF THE FRAENUM-RANULA— SALIVARY CALCULUS AND FISTULA—ToNSILLITIS-QUINSY—RHINOSCOPY-PHARYN- GITIS-GANGRENOUS PHARYNGITIS-Post-PHARYNGEAL ABSCESS—ELONGATION OF THE UVULA—SPASM AND CEDEMA OF THE GLOTTIs. Hare-lip—Labium Leporinum—Cheiloplasty.—It is scarcely necessary to state that the first two terms are used to designate a fissure, generally in the upper lip, * involving all the structures concerned in its formation; in most instances situate to one side of the mesian line, and extending to and often within the nostrils. Cheiloplasty is the operation for restoration of the parts. * There are two exceptions to this rule mentioned by Christopher Seliger and Nicati. 740 A SYSTEM OF SURGERY. . The arrest of development is more frequent in the male than in the female, in the proportion of 70 to 30, and it is said that a complicated hare-lip seldom occurs in a female child; although Butcher, of Dublin, has recorded several cases of this remarkable deformity, and I have seen two cases. The malformation may be single, consisting of one fissure, or double, con- sisting of two; simple, or complicated with other malformations, Fig. 440. The causes of hare-lip appear to have perplexed the minds of many medical and surgical writers. In some instances the fissure has been attrib- uted to an impression excited on the mind of the mother during the period of utero-gestation. M. Moulin relates the case of a woman who in the fifth month of her pregnancy, was much startled by the sight of a hare, which her husband had skinned in her presence. During the last months FIG. 440. Different Varieties of Hare-lip.-BRYANT. of her pregnancy her imagination presented to her the sight of a hare de- nuded of its skin, and she feared that her child would be subject to hare-lip. Her prediction was verified by the event. M. le Professor Roux has ob- served precisely a similar fact.* There is undoubted evidence, however, that children are born with such malformation—if the affection may so be termed—when it can be referred to no such cause. Others are of opinion that the cleft in the lip arises from an arrest of development; that, in their earlier formation, the lips have three or even more points of growth, a middle or two or more lateral, and that the deformity is occasioned by an arrest in the development in one of these primitive notches or fissures, proof being found in the occur- rence of the cleft in the majority of instances to one side of the mesian line. This idea, viz., the arrest of development in the substance of the lip, was advocated by Blumenbach, Meckel, and others. Dr. Grossi writes, “Of the causes of hare-lip we are entirely ignorant; that it is the result of arrest of development is certain, but how this result is produced is a circum- stance in the history of foetal life which has not been satisfactorily ex- plained.” Velpeauf differs from the above; he says: “Numerous researches on embryos and the foetus at every period, induce me to believe that these ideas are the results of erroneous observations or gratuitous suppositions. Hare-lip is not always without loss of substance, and the lips are no more formed of two, three, or four portions, at three, four, six or eight weeks, than at three or four months. . . . . . Hare-lip, like most other monstrosi- ties, has appeared to me to be much more frequently ascribable to some disease than to a defect in its natural evolution.” M. Cruveilhier is of like OTO1][11OI). "ººhills on this point says: “I shall, in the remainder of the chapter, notice hare-lip and cleft-palate, which are arrests of development, and imper- forate anus, which is a malformation.” Bouchutſ thus writes: “The force of growth which presides at the dis- position of parts, at their juxtaposition, at their reunion, interrupted in its * Wide Bouchut, On Diseases of Children, p. 389. f Operative Surgery, vol. ii., p. 613. † Operative Surgery, vol. iii., p. 329. & Diseases of Children, p. 405. | Diseases of Children, p. 390. TREATMENT OF HARE-LIP. 741 efforts, ceases to act, and the lips formed from three points of increase, one median and two lateral, which this force incites to fusion, remain separated so as to resemble the lip of the hare. When the reunion does not take place at all, the hare-lip is double, when it takes place between two of these points only, the median and a lateral, the hare-lip is single, and is only observed on one side of the mouth.” Todd and Bowman” believe that the hare-lip does not arise from an arrest of development as does cleft-palate, for, say they, speaking on this point: “The fissure of the lip seems to arise from the alteration of the deeper parts, for as such a fissure exists at no period of embryonic life in the Soft parts, it cannot, like the bony fissure above described, be dependent upon an arrest of development.” Rokitansky takes a somewhat similar view of the matter; he believes the cleft to be occasioned by an arrest of development, but not in the substance of the lip, but that it can be referred to the bony casement beneath; he says:f “The most common and important cases of arrest of development are: fissures of the upper lip, on either or both sides of the mesian line, corresponding to the union of the intermaxillary with . superior maxillary bones, which may or may not present the fissure alSO. As is usual in these discussions, nothing definite has been reached. Treatment.—The treatment is essentially surgical, and although the opera- tion for the relief of the simple variety of the deformity is not generally a difficult proceeding when carefully performed, yet there are cases, particularly those of a complicated nature, which require a steady hand and a good knowledge of the parts, not only during but after the operation, for, writes Dr. Mott, S “There is no operation in surgery apparently so for- midable, and which may so frequently be made so in reality, by want of delicate and adroit manipulation in the operator, as this of hare-lip in infants, in all its forms.” Yet there are some points of interest which have arrested the attention of the greatest surgeons in the world, to which due importance should be given, and among these we notice, the period of time which should be allowed to elapse after birth before the operation is re- sorted to. Much discrepancy prevails on this point. Dr. Mason Warrenſ recommends the performance of the operation at as early an age as possible, he having frequently resorted to it twenty-four hours after birth, and with better success than in older children. He states that at this period less resistance is offered by the child, and the healing process being great at that age, it is enabled to suckle almost as soon as if nothing abnormal had been present. Dr. Dawson, of Dungannon, operated seven hours after birth; the pins were removed in forty-eight hours, and in two days more the union was so perfect that the adhesive straps were removed. Dr. Dawson is confirmed in his determination to operate in similar cases soon after birth." Anselm also states that long experience has convinced him of the expe- diency of early operation. Bonfils, of Nancy, also coincides in these views. M. Guersant observes that there are three periods at which this operation may be performed with different chances of success. The best is offered within the first fifteen days from birth. At a later period a favorable termi- nation is less frequent, and when the child has reached an age of from twelve to fifteen years, the successful result is more certain. & * Physiological Anatomy, p. 877. # Pathological Anatomy, vol. iii., p. 17. f Operative Surgery (Welpeau), vol. i., p. 28. * ź American Journal of the Medical Sciences, No. xxx., pp. 327–28. | Union Médicale, No. lxxvi. | Ranking's Half-Yearly Abstract, June, 1847, p. 218. 742 A SYSTEM OF SURGERY. M. Paul Dubois has also expressed himself in favor of early operations.# Grossi writes, “the most eligible period is from the third to the sixth month, or a short time before the appearance of the milk-teeth; the opera- tion is then generally borne well, there is no danger of convulsions, and the adhesive process generally proceeds kindly.” Mr. Bransby Cooper says: “For my own part, I agree entirely with Sir Astley Cooper, in regarding it as unsafe to operate upon infants before weaning.” This opinion is also advocated by Roux, and also by Velpeau.j I was formerly of the opinion that this operation should not be performed until the sixth or the eighth month, but from a more extended experience I have changed my opinion. I have performed the operation for double hare-lip, with complications, on the third day after birth, and quite fre- quently within the first week, without a single untoward symptom; and although there may be some advantages in waiting for several months, chiefly shown in the increased development of the flaps, thus giving more integument to the operator, and requiring less delicacy of manipulation, yet on the whole, often for the sake of the feelings of the family, the opera- tion should be made at a very early age. If the early operation has been determined upon, chloroform is not necessary, especially if the parts are painted a few times with a 4 per cent. solution of cocaine. This method I have employed with gratifying results, the child being easily held, particularly if enveloped in a large strong towel. If, however, the infant has reached the age of six or eight months, or a later age, a few inhalations of the anaesthetic will be found of service, and during the operation it is well to put the child in a strongly made pillow- case and draw the strings around the neck. Some operators prefer scissors to the knife, among whom may be noted Dr. Wheeler, Mr. Butcher, Malgaigne, and Mr. Thomas Smith. The first named gentleman has invented an admirable scissors (Figs. 441 and 442), which is made either straight or curved. These instruments are so con- structed (see figure) as to prevent bruising the tissues. A small-sized, sharply-pointed, keen scalpel, with a firmly set handle, or a sharp teno- tome, is the best instrument that can be used; for no matter how sharp may be the edge of the scissors, there is necessarily some bruising of structure, which is unfavorable to the adhesive process by the first intention, and is liable to leave a much larger cicatrix. Together with the scalpel, the sur- geon should provide himself with the proper variety of sutures (the ordi- nary hare-lip pins, silver wire, curved needles, or the silver button of Mr. Wood), a pair of wire nippers, sponges, adhesive straps, collodion, etc. It is a rare case when the coronary arteries require ligature, the hamorrhage being readily controlled by pressure, and by the apposition of the parts. There is, however, one point in this connection which must be remem- bered, and that is, that blood may escape into the mouth, and by passing into the larynx cause the death of the patient; there is a case of this kind, mentioned by M. Roux, $ in which but little blood was lost during the operation, but what there was remained in the mouth ; a large clot of blood being swallowed by the infant, a portion of it passed into the larynx during deglutition, and occasioned such extreme asphyxia that the surgeon believed the child to be dead. By the introduction of a catheter into the larynx the coagulum was withdrawn and life preserved. There are some other cases upon record in which the hamorrhage was profuse, but these may certainly be considered as the exceptions. The method which I consider the best in the performance of the operation * Ranking's Half-Yearly Abstract of the Medical Sciences, 1849, p. 257. + Operative Surgery, vol. ii., p. 613. - f Operative Surgery, vol. iii., p. 341. ź Ranking's Half-Yearly Abstract of the Medical Sciences, 1846, p. 138. TREATMENT OF HARE-LIP. 743 for hare-lip is the following, and is known as Malgaigne's: The operator seats himself with his face toward the window, and places a small pillow upon his lap, upon which is spread a sheet of thin india-rubber. The nurse having passed a towel around the arms of the child, faces the operator, and places the head of the patient on the pillow. Two assistants kneel, one on each side of the surgeon, each taking between his thumb and forefinger the side of the cleft nearest him, making sufficient pressure to arrest the circulation in the coronary arteries. The surgeon takes a small FIG. 441. FIG. 442, Dr. Wheeler's Straight Hare-lip Scissors. Curved Scissors (open). narrow sharp pointed knife (I generally use a tenotome), and inserts its point, with its cutting edge toward the chin, into the cleft of the fissure on the right side, and marking with his eyes the size of the flap to be made, cuts with a gentle sawing motion entirely through the thickness of the lip to the vermilion border, or a few lines beyond. The knife is then with- drawn, and a similar method of paring proceeded with on the left side (see Fig. FIG. 443. FIG. 444. 443); b and b' represent the incisions, and tº a and aſ the flaps. An assistant then draws downward the flaps (see Fig. 444), Z/\6' a, a', leaving the raw surfaces b and b'. A hare-lip pin, held in a stout forceps, with oº lat' a depression in the jaws, in which the head of the pin fits, is then passed through the flap (two-thirds of its thickness), on the right side, at the vermilion border, entered at a point directly similar on the opposite flap, and brought 744 A SYSTEM OF SURGERY. out about a quarter of an inch from the pared edge on the left side. A second pin is then introduced nearer the nostrilin the same manner, and while º assistant still holds the flaps downward, the threads, figure-of- eight fashion, are to be applied. A needle threaded with fine silk or catgut is now passed through the flaps, and tied sufficiently tight to bring the raw surfaces neatly together. The points of the pins are to be cut off with the nippers, and the little teat formed by the flaps allowed to remain; this shrinks considerably after a month or two, and then may be snipped off with the scissors. The old, and no doubt an excellent method, is to insert a piece of thin wood or stiff pasteboard under the lip (Fig. 445), and to refresh or pare the margins of the cleft with a sharp straight bistoury. There need not be much dread of taking away too great a part of the flesh, and it is better to make a free incision than not to cut out enough of the labial substance. The knife is laid aside, and a hare-lip pin, composed of steel or silver, is passed into the lip, nearest the prolabium, on the right side from below upward, and on the left side from above downward, beginning about a quarter of an inch or more from the cut surface, and bringing out the point in the centre of the thickness of the lip; the point is then entered Fig. 446. at a corresponding part of the refreshed edge of the opposite side, and brought out at the healthy skin at the same distance from the cut as it was entered on the other side. Another pin is introduced in a similar manner, above the first, and, if necessary, a third just below the nose. Beginning at the upper pin, a figure-of-eight suture is wound around it. Use a separate piece of silk for each pin. I have found that one ligature extending from one pin to the other materially interferes with the circula- tion. After the wound is thus thoroughly closed the points of the pins must be cut off with the wire nippers (Fig. 446), and the blunt ends covered with pieces of white wax, and the whole lip, pins, ligatures, etc., covered with a thick coating of collodion. So soon as this applica- tion is thoroughly dry, two adhesive straps, of sufficient length to extend from ear to ear, are to be applied upon the cheeks, crossing each other on the upper lip, at the site of the wound. If the points of the pins remain uncovered they may catch in the pillow, or in the clothes of the mother, and, by a single motion of the child's head, the work of the sur- geon is destroyed; or a severe catarrh may set in on the second or third day after the operation, and an acrid discharge from the nostrils may irritate the wound, prevent adhesion, and thus spoil the whole performance. Such an unfortunate result is obviated by the collodion, while the strips of plaster prevent too great traction being made upon the pins, and assist materially in closing the wound. TREATMENT OF HARE-LIP. 745 The application of straps, which are always at hand, is a modification of the spring truss invented by Dr. Dewar, of Aberdeen, which is known by the name of Dewar's Compressor, and which, if the surgeon can procure it, may be used in preference to the plaster. - Dr. Buck contrived a needle for the more exact coaptation of the wound: “The instrument consists of a needle, of the slightness of an ordinary knitting-needle, fixed on a handle and slightly curved (Fig. 447). It grows a little larger round for half an inch near its point. Its extremity is bevelled off to a sharp point on its concave side, and perforated lengthwise on its bevelled face like the stem of a hypodermic syringe, such as is in common use. The mode of using it is as follows: The edges of the wound intended to be brought into coaptation, having been traversed by the con- ductor guided by one hand, a pin held between the thumb and fingers of the other hand is engaged by its point in the perforated hole at the end of FIG. 447. 6, 7/A/A/W/W & 00. W.Y the conductor, and held steadily in place, while the conductor is withdrawn and the pin made to follow it, which it does with unerring certainty. A soft iron or silver wire may be inserted in the same manner as the pin, if it is intended to employ a wire suture.” Mr. Wood, of Gloucester Hospital, introduced what is termed the button hare-lip suture. . This apparatus is composed of two perforated silver disks, having wires, soldered to their backs, over which a double ligature is tied, after having been passed through the lip. Mr. Wood believes that by thus avoiding the pinching and rigidity of the needles he obtains a more efficient and unobjectionable mode of union, and recommends the same suture in cases of divided perinaeum. Dr. J. Marion Sims placed the most reliance on the silver suture. Accord- ing to his direction the wires should not be further apart than three-six- teenths of an inch, or even less, thus affording good support and perfect coap- tation. . He says further, “As it is important to prevent any mark from their unequal pressure, a thin plate of some transparent material may be placed like a delicate splint on the coapted edges, over which the wire may be tied, thus preventing the tender cuticle of the child’s lip from their cutting pres- SUlre. . . . . A clarified goosequill, split into sections, and softened in boil- ing water, and then flattened out by heavy pressure, fulfils every indication in this hare-lip suture.” Another method of curing hare-lip is by what is termed the living suture, which mode is highly recommended by surgeons of the present day. The same inverted W incisions are made, taking care, however, not to carry the '746 A SYSTEM OF SURGERY. knife entirely down to the lip; the flap is then turned down, and the sides of the lozenge-shaped opening, which is thus made, are placed in contact by one or more sutures; now, even if these should yield to the pressure, the living suture still holds, and by degrees the hole that is left becomes oblit- erated. . The advantages claimed for this form of suture are these : that the edges of the wound soon swell and become covered with healthy granula- tions and a natural suture is thus produced and remains, even if, by mis- management or accident, the other sutures are displaced, at that very point where structure is most needed, and where a cleft so often remains. Erichsen, after having tried many methods, prefers the simple interrupted suture without using any pins; he states that he has treated many cases of the malformation occurring in children from a few days to four years of age, with perfect success, and with less marking of the lip than when union is effected by the twisted suture. Dr. Smith recommends the following mode of procedure: “Take two of the forceps invented by Dr. Alden March, of Albany; provide them with catches like artery forceps, and have transverse limes marked upon them Mø. FS <-ºu" * º FS), * lill Hutchinson's Forceps. at distances of a quarter of an inch, so that a means may be furnished of exactly and rapidly determining the situation of the sutures. I modify the method of operating by applying these two exactly similar forceps, one to each side of the cleft, fastening them there by the catch, introducing the sutures about half an inch from the margin of the forceps, exactly opposite the transverse lines, and finally cutting away the margins of the cleft inclosed in the forceps. Nothing now remains to be done but to close the cleft, which, on account of the mechanically exact introduction of the sutures, is effected instantaneously. Metallic sutures being used, their prior introduction does not expose them to the danger of being cut. According to Lisfranc's method I would not, at the labial margin, entirely sever the portion pared from the margin of the cleft, but would suffer it to remain on each side, until the cleft being accurately adjusted, these parings may be shortened to suit, a suture being passed through them, forming a decided V-shaped projection downwards. I deem this precaution necessary, in addition to curving the lines of incision after the manner of Celsus, because I never yet saw any one, years after the operation, in whom an unseemly notch did not exist.” Fig. 448 represents a pair of forceps devised by Hutchinson to facilitate the operation and render the parts perfectly adapted to each other. Malgaigne's operation consists in paring the edges of the fissure so as to FESTORATION OF THE UPPER LIP. 747 leave two angular flaps at the vermilion border, which when brought together would prevent the prolabial notch. This notch of the prolabium is often difficult to prevent. It consists in an imperfect closure of the wound, which by cicatrizing and contracting leaves an indentation in the upper lip. Double Hare-lip.–In cases of double hare-lip, much has to be left to the judgment of the surgeon, particularly with reference to the disposal of the intermaxillary bones; if these be on the same plane with the other sides of the fissures, the operation for simple hare-lip must be repeated on the other cleft. Frequently, however, the intermediate portion is composed of a rounded protuberance of bone and skin, which is connected with the septum narium. It may be horizontal or oblique, contain the germs of the incisor teeth, and very frequently exists with cleft palate. In such cases, especially when the projecting intermaxillary bone is very prominent, it is necessary to cut it away with the forceps before adjusting the fissure. There is always a good deal of haemorrhage following the operation, which torsion or pressure controls. The integument must be left pendent in view of forming a columna afterward. If the hare-lip is complicated with cleft palate, the latter must be first attended to, if it be desirable to attempt its closure. For directions for performing this operation, see “Staphylorraphy.” Restoration of #. Upper Lip.–Several plans have been adopted for the production of a new upper lip. Berard made almost vertical incisions to FIG. 449. FIG. 450. Sédillot's Operation. Teale's Operation. include a portion of the cheek on each side of the nose, and brought the flaps downward and connected them in the median line. Sédillot cut out a square portion of the skin from the cheek, a, b, as shown in Fig. 449. The centre piece was then pared, and b brought down to b'. The mucous surfaces formed the border of the lip, where the parts were united in the centre. Mr. Teale made a crucial incision at its point of intersection below the septum of the nose (Fig. 450), each limb of the incision being about one- FIG. 451. FIG. 452. Dieffenbach’s Method. half an inch in length. The two limbs on each side diverge moderately as they pass outward from the cheek, and inclose between them a flap of an acute angle composed of skin and fascia. The parts marked out by the Q 748 A SYSTEM OF SURGERY. incision are loosened from their attachment by a few strokes of the scalpel, the knife being inserted close to the bone. The flaps thus formed are then drawn across the mouth, the one dove-tailing into the other, and are held in position by a pin and twisted suture. - Dieffenbach made an incision similar to the letter “s” on each side of the alae of the nose, and having dissected up the flaps secured them in the median line. (Figs. 451 and 452.) Epithelioma of the Lip.—Cancer rarely attacks the upper lip, while the lower is subject to epithelioma. In the commencement, there is observed, beneath the integument covering the vermilion portion of the lip, a small round tumor, resembling a shot, which, when pressed upon, rolls under the finger. The tumor in this state gives no pain, but if frequently handled by the patient, or otherwise irritated, grows rapidly and soon adheres to the surrounding parts. In other cases, a firm and immovable lump of considerable size, is, from the first, deeply imbedded in the Substance of the lip. This gradually approaches the surface, finally ulcer- ates, and throws out a prolific fungus of a dark-red color, so large as in Some instances to envelop the whole mouth. A third variety is found in the form of a chocolate-colored warty excrescence; this never attains a large size, but is constantly casting off scabs, the places of which are speedily supplied by others. These tumors are all capable of contami- nating by extension the adjoining portions of the neck, especially the lymphatic glands, and when this occurs, there is very little hope of the patient's recovery. Venereal ulceration of the lip and lupus have been mistaken for cancer, and treated accordingly. The surgeon should be on his guard, and never without full investigation, pronounce decisively as to the nature of the complaint, or propose an operation, unless well assured of the existence of cancer. Treatment.—I have treated many cases of epithelioma of the lip, and have found this variety more amenable than any other form of cancer. It appears, from considerable experience, that the enucleation process of Marsden and McLimont (see Treatment of Cancer), has had more decided effect than any other. This, combined with the internal administration of arsenic, hydrastis, or phytolacca, has proved efficacious; indeed, cures have been performed by this combination of caustic and medical treatment. I employ the escharotic first, and afterwards continue the medical treatment for at least a year. The chief medicine in cancer of the face is arsenic. This medicine is the basis of most of the “far-famed ” remedies for this disease; and, writes Dr. Wurmb, of Vienna, “There is no affection, except ague, in which it has been, and still is, so often administered. Even among the ancients it was considered a specific against cancer, and at the present day it has the same reputation; it was also known then, as well as now, to be capable of producing cancerous ulcers. The whole difference, therefore, between ancient and modern practice, lies in fact, that now it is known, or might be known, or ought to be known, that the therapeutic employment of arsenic in cancer, rests on the law of similarity; but that it is no absolute specific against that disease, because there exists no such thing as an abso- lute specific ; further, that we possess certain indications for its exhibition, and understand the method of giving it in suitable doses. “As regards the choice of arsenic in cancer of the lips, it is an easy task for the physician, well acquainted with the positive effects of medicines, to distinguish the cases in which arsenic suits, from those in which other remedies are indicated. Thus, arsenic is to be preferred before belladonna, baryta carbonica, or conium, in very malignant ulcers, which increase on all sides, bleed easily, and have not been caused by any external injury, ENLARGEMENT OF THE MUCOUS GLANDS OF THE LIP. 749 such as blows or bruises, but from the first, show plainly that they are the outward sign of a deeply-seated inward disease, and are, therefore, often met with in cachectic individuals. Carbo veg., indeed, approaches very near to arsenic in this respect; yet the latter is to be preferred uncondi- tionally when the tendency to destroy the surrounding parts is distinctly marked in the ulcer.” Arsenic may sometimes be required in alternation with some other medicine, but it is, undoubtedly, the most valuable when the cancerous dyscrasia has contaminated the organism; it is a reliable medicine for cancer of the nose, tongue, and alveolae. Clematis is asserted to be useful in carcinoma of the lips, arising from syphilitico-mercurial ulcers. - - 3. Aurum met. is also serviceable for cancer complicated with syphilitic or mercurial symptoms; or this medicine may be adapted to scirrhus, appear- ing in individuals of a scrofulous diathesis. The muriate of gold is also recommended for this disease, and may, in aggravated cases, be alternated with arsenic. Mercurius may be of service if the bones have already become affected; or nit. acid may be useful if the sore be irritable and bleed profusely. Conium has been employed with success in carcinomatous affections aris- ing from contusions; it is particularly indicated by a scrofulous diathesis, and when the ulcers on the face and lips spread rapidly, present a blackish appearance, and discharge a bloody and fetid ichor. In cancer of the lip, when the patient complains of violent burning pain in the ulcers, which may be covered with large scurfs that spread rapidly and become very thick, sepia is often the appropriate medicine; it is also of importance when there exudes from beneath the scab a corrosive ichor, which, by irritating the surrounding parts, essentially favors the extension of the disease. The disposition of the patient should also be remembered when this medicine is to be prescribed. Dr. Attomyri relates the following cure of cancer of the lip : “Aloysia Lyde, six years old, lost the left half of the upper lip, and the soft parts extending upward to the zygoma, and sideways a considerable portion round the angle of the mouth, by a cancerous ulcer. Arsenic (6th dilution), re- peated every eight days, brought about the healing of the ulcer in six weeks. As a detergent application, the decoction of marshmallows was used outwardly.” To my mind this case is open to doubt. When it is necessary to remove the lip, which is easily effected, provided the caustic treatment has not already been employed, a W-shaped incision embracing the whole mass should be made, and the parts brought together with hare-lip pins and the figure-of-eight suture. It is astonishing how much of the lip may be removed, and yet how little deformity may remain afterward. Ligatures are not required, as the nice approximation of the wound is generally sufficient to arrest haemorrhage. Enlargement of the Mucous Glands of the Lip.—This affection, which amounts to hypertrophy, and which is by some authorities classed as such, consists of a protrusion of the lip, the mucous membrane being everted. A cause of this may be a vicious habit of biting the lip, and I have seen it accompanied with immobility of the jaws, and destruction of the cheek. Treatment.—With a pair of good strong scissors, an elliptical portion of the mucous membrane and a portion of the subjacent structures must be removed, the edges are then brought together and held in position with wire SutureS. * British Journal of Homoeopathy, vol. iv., p. 250. f British Journal of Homoeopathy, vol. iv., p. 257. 750 - A SYSTEM OF SURGERY. Wascular Tumors of the Lip.–These tumors may involve a portion of or the entire lip. They are, in the majority of instances, aneurisms by anasto- mosis, and in many cases are not amenable to treatment. Sometimes, how- ever, as in Pancoast's case, acupressure may arrest the flow of blood. The only true remedy is excision, if there can be found sufficiently healthy structure in which to make the incisions. Fig. 453 represents a case in FIG. 453. º d , ZZ % Author's case of Vascular Tumor of Lip, which I tied both facial arteries and used acupressure on the inferior dentals with but slight temporary improvement, having previously tried both digital and instrumental compression. The former was effected by a class of students, and was continued for over twenty-four hours; the latter by tortoise-shell clamps and Screws. In such cases ligation of the carotids may be resorted to, but it appears to me too serious an operation. The end would scarcely justify the means. Restoration of the Lower Lip.–The best operation for restoring the lower lip is that of Buchanan, who as long ago as the year 1835 made use of it FIG. 454. FIG, 455. FIG. 456, ** * * * **T*ee-ee **** Buchanan's Method. Chopart's Method. for the removal of cancer of the lower lip. It is thus described by its originator.” The line aa, Fig. 454, represents the commissure of the mouth, the line aba * London Gazette, vol. v., p. 79, CLEFT PALATE AND STAPHYLORRAPHY. 751 the incision by which the carcinomatous mass was removed. The new lip was formed by means of two flaps taken from the side of the chin, each, however, by a curvilinear incision dc and a straight one bc, these flaps were raised and brought together in the median line as seen in Fig. 455. Chopart performs a different operation. From the angle of the lip on each side he makes a straight incision and carries it below the chin. The second incision, beginning sufficiently below the cancerous mass to be madein healthy texture, is carried transversely from one incision to the other. The balance of the quadrilateral flap is then dissected up and drawn upward and fixed to the angles of the upper lip, as seen in the figure (Fig. 456). Mr. Syme thus describes his own operation:* “Two incisions are made from the angles of the mouth AC so as to meet at the chin B, and thus the morbid part is removed, in a triangular form. The lines AB and BC in the figure (Fig. 457) are supposed to represent these incisions. I cut from the point B downward, and outward on each side to D and E in a straight direction, and then with a slight curve outward and upward to F and G. The flaps ABDG and CBEF are next detached from their subcutaneous connections, and raised upward so that the edges AB and CB come into a FIG. 457. . FIG. 458. Aſ B C P D A E F. G 7) E horizontal line, while those represented by BD and BE meet together in a vertical direction, and the latter extends to F and G. Allow sufficient free- dom to prevent any puckering or straining.” Cystic Tumors of the Lip.–Tumors of a cystic character are generally found in the lower lip beneath the mucous membrane. By cutting off the tops of the cysts (not merely incising them), they are generally cured. Cleft Palate and Staphylorraphy.-Cleft palate is an arrest of development in the Osseous structures of the roof of the mouth, accompanied by a deficiency in the corresponding Soft parts. It is, therefore, a fissure in the hard and soft structures of the roof of the mouth. It may exist either with or without hare-lip, but the two generally are found together. It may also coexist with deformities of the posterior nares. The palate, in common parlance, means the whole of the roof of the mouth, from the Superior alveolar arch to the pharynx, and includes the velum palati. The surgeon divides it into two parts, the hard and soft palate. The hard palate extends from the internal surface of the upper teeth to the velum. It is formed by the horizontal plates of the palate and superior maxilla, a fibrous structure, and mucous membrane. It is supplied with arteries, veins, and nerves. . The bony portion forms the roof of the mouth by its inferior surface, and its superior is the floor of the Il2,I’6S. The soft palate or velum pendulum palati is a movable fold of mucous membrane, inclosing muscular fibres, aponeuroses, vessels, nerves, and mu- cous glands; it is suspended from the posterior border of the hard palate, like a curtain, and forms an incomplete septum between the mouth and pharynx. - The arched structure of the mouth, with the curtain that divides the oral * Miller's Practice of Surgery, p. 163. 752 A SYSTEM OF SURGERY. cavity from the pharynx behind, exerts powerful influence on articula- tion, moulding the sounds which are created in the larynx, and giving them scope and reverberation. In its normal state it gives smoothness and sweetness to the varied tones of which human language is composed. In the cleft state, every agreeable quality of tone is lost, and the nasal, guttural, and half-suffocative sounds that are produced often prevent even the ordinary intercourse of man with man, and frequently cause the sufferer to avoid society, and, from the seclusion which naturally follows, to become unhappy and misanthropic. Many of the simplest ele- mentary Sounds of our language are unutterable by those afflicted with cleft palate. . The hard sound of “g,” for instance, is made by pressing the root of the tongue against the uvula in order to close the throat, as in beginning to articulate the word “go ", without the “o.” Again, the sound of “1,” which is a vocal-lingual-dental sound, and is made by pressing the tongue against the upper gums, hard palate, or roof of the mouth, is rendered imperfect, and indicates the deformity. So also with “w, u, v,” and many other letters. If, therefore, these element- ary sounds are wholly wanting, or even imperfect, it may well be imagined how defective utterance will be. In order to completely understand the subject, I shall call attention more minutely to the anatomical structure of the parts. Those who are familiar with the anatomy of the base of the skull, must bear in mind the relative position of the pterygoid processes of the sphenoid with the horizontal plates of the palate bones, for it is to these that the muscular portions of the velum are attached. These muscles are nine in number ; four on each side, and a central strip of muscular fibres—the azygos uvulæ. They may be divided into elevators and depressors. The elevators are the levator palati and the tensor palati or circumflexus palati. The depressors are the palato-glossus and palato- pharyngeus. The levator palati has its origin from the inferior surface of the apex of the petrous portion of the temporal bone and from the under and internal portion of the cartilage of the Eustachian tube. The fibres descend and enter into the pharynx above the superior constrictor muscle, and then expand to assist in the construction of the soft palate; thus, with its fellow of the opposite side, it forms a stratum of muscular fibres, which is also in conjunction with the two planes of palato-pharyngeus muscle. The circumflexus palati, or tensor palati, as it is often called, is a small, narrow band of muscular fibres, partly tendinous, between the pterygoid muscle and the internal pterygoid plate of the sphenoid bone. It is attached to the Scaphoid fossa, at the base of the pterygoid process, and also to the Eustachian tube. Besides these, there are some smaller fasciculi which have their points of origin from the vaginal process of the temporal bone and extend to the spinous process of the sphenoid. The fibres at the lower part of the muscle end in a tendon which winds around the trochlea or hamular process of the internal pterygoid plate of the sphenoid bone, and is inserted into the posterior border of the palate. Of the depressors of the palate, the palato-pharyngeus is the largest, and assists in the formation of the posterior pillar of the fauces. The muscle arises from the posterior border of the thyroid cartilage, and ascending behind the tonsil, enters the side of the palate, where it separates into two fasciculi; the anterior, which is deeper and much the stronger of the two, enters the substance of the palate between the levator and tensor, and joins also at the middle line a corresponding portion of the opposite muscle. In the palate, the muscle incloses the levator palati and azygos uvulae between its fibres. The palato-glossus assists in the formation of the anterior pillar of the CLEFT PALATE AND STAPHYLORRAPHY. 753 fauces, and extends to the sides of the posterior surfaces of the tongue; or it may be said to arise from this point; and then, passing a little upward and backward, in front of the tonsil, it completes the triangular space for º lodgment of the tonsil, and is inserted into its fellow of the opposite S1C16. - The azygos uvulae muscle arises from the posterior nasal spine, situated at the posterior junction of the processes of the palate-bone. This muscle forms the substance of the uvula, and has no insertion, the tip of the muscle hanging free in the fauces. A small band of the palato-pharyngeus sepa- rates the posterior surface of this muscle from the mucous membrane, by which it is enveloped. These muscles are covered with mucous membrane, and, it will be seen, are more or less blended or interlaced at their points of insertion, and act upon the soft palate as follows: . The levatores palati elevate the velum. The tensores palati muscles, by their contraction and arrangement of the tendons around the hamular pro- cesses of the pterygoid plates, draw each side of the palate outward. The palato-pharyngeus acts downward and backward, the palato-glossus down- ward and forward. It is important to consider the normal action of these muscular fibres for the proper understanding of the surgical anatomy of cleft palate. It is necessary to bring to notice another muscle, or at least a portion of muscular fibres known as the superior constrictor of the pharynx. As usually studied, points of origin are situated anteriorly, but where one of these is in a state of division, its origin should be considered as the median raphé on the posterior wall of the pharynx, together with the aponeu- rosis of the same. The fibres pass around on either side of the pharynx, and are inserted in the inner surface of the internal pterygoid plate (par- ticularly the lower third), in the hamular process, the posterior part of the mylo-hyoid ridge, the mucous membrane of the mouth, and the sides of the tongue. Particular attention should be given to the upper border, which consists of arched fibres, with which the levator and tensor palati muscles are connected. - Having now in mind the elevators and depressors of the velum, let us give Mr. Fergusson’s idea on the subject. He tells us that the extreme mobility of two portions of the cleft palate has long been noticed, but that not much attention has been given to the moving powers. If a per- son with cleft palate be desired to swallow a little water slowly, with the mouth partially open, the back parts of the fissure may be seen to ap- proach each other, and it is this approximation which was formerly sup- posed to render the case favorable for an operation. The cause of this movement had escaped the notice of the physiologist for two hundred years, and even so close an observer as Malgaigne had allowed it to pass unobserved. “The semicircle,” says Mr. Fergusson, “which these mus- cles form on the back and sides of the pharynx is, during deglutition, drawn almost into a straight line; the fibres come forward, inward, and downward, so that the soft structures immediately in front—being the two portions of the split palate—are pushed in similar directions, and thus the posterior part of the fissure is made to close.” It was from a careful study of these words that I thought it preferable, when speaking of the origin and insertion of the superior constrictor, to reverse the usual manner of describing it, because it is easier to understand how, by the superior arched border of the muscle, the margins of the cleft are pushed together. In other essays on the subject, he speaks of three conditions in which the flaps of a cleft palate are noticed to be acted upon by the muscles in question. - 48 754 A SYSTEM OF SURGERY. First. When the parts are not irritated, and are in a quiescent condition, the lateral flaps are distinct, the posterior nares and the upper part of the pharynx being observed above and behind. Second. If the flaps are touched or irritated, they are pressed upward by a motion that appears to commence at the middle of each. Third. If the parts be still further irritated by pressing the finger against them in the fissure, each flap is forcibly drawn upward and outward, and can scarcely be distinguished from the rest of the parts which enter into FIG. 460. | i* : [. Whitehead's Gag in position. i the formation of the sides of the nos- trils and throat. These peculiar actions will be understood after study of the preceding anatomical details. The next point to be remembered is the position of the Eustachian tubes, which open on each side of the upper part of the pharynx, at the back of the inferior meatus; just below and in front of these openings, we have parts of the muscles which it is necessary to divide for the successful termination of staphylorraphy. The arteries are the posterior and inferior palatine, one being given off from the internal max- illary and the other from the facial. These vessels may be divided in form- ing the flaps, and it is well to recol- lect what has been said regarding per- formance of a part of the operation at one time. Staphylorraphy.—By this term is understood the operation for the closure of cleft palate. Synonymous with this word are the terms cionorraphy, uraniscorraphy, kionorraphy, and velosynthesis. Surgeons now agree that the division of the palatine muscles is an essen- tial step in the operation. It is not easy to imagine a more delicate pro- CLEFT PALATE AND STAPHYLORRAPHY. 755 ceeding than a carefully conducted operation for cleft palate. The follow- ing are the most important considerations: First. Preparation of the patient: For some time before the operation, the patient should accustom the parts to the presence of foreign bodies, by introducing substances into the fauces, and while touching the sides of the cleft, endeavor to control the muscles, and thus avoid their being Whitehead's Needle, pressed aside or spasmodically contracted. The operation should never be attempted until the child has arrived at an age to appreciate its difficulties, and be willing to bear a little pain for the benefit to be derived from surgical interference. Second. A favorable condition of the weather is a desideratum, and the operation should not be performed unless the day be bright and clear. A room facing the sun should, if possible, be chosen, and the curtain blinds removed from the windows to allow a full supply of light. Third. The patient should be placed on the table, with his head sup- º by a º The jaws should be separated with Whitehead's gag, ig. 459. Fourth. If anaesthesia be used, chloroform is preferable, as it is less likely to produce salivation. There is some diver- sity of opinion as to the employment of anaesthetics in these operations. In my opinion they should be used. Fifth. There should be at least three as- sistants, one to give the anaesthetic, a sec- ond to assist the operator, and a third to throw light into the mouth by means of a good-sized mirror. This last precaution is of great importance, though not generally mentioned by writers on the subject. For this purpose I now use the electric light, already alluded to. Sixth. The instruments are: a long for- ceps with bent handles, and the jaws armed with fine teeth, whereby the flaps can be held; a pair of long curved scissors in case the operator prefers it to the knife. Several knives with long handles and shanks (Fig. FIG. 462. 460), but with a short cutting ". also º, two knives, each with a double edge, and paringºsors. the blade at right angles with the handle, to separate the flaps from the hard palate; a periosteotome; several small curved needles not more than an inch in length, with a double edge, and a needle to carry silver wire; a needle-holder, or Whitehead's needle, Fig. 461; a dressing forceps, slightly curved at the jaws, to seize the needles after they have been passed into the flaps; a pair of long curved scissors; two lead or silver plates, with perforations to correspond with the proposed sutures. Several perforated buckshot; an instrument to forcibly compress the shot; also one shaped somewhat like an ordinary 756 A SYSTEM OF SURGERY. fork, which may be affixed to the end of forceps, or set in a handle, for passing the shot up to the cleft before it is closed; several sponges, set in Sponge holders, to cleanse the blood from the throat, and also to remove i. ºus which often accumulates; a hypodermic syringe charged with randy. Seventh. The surgeon should sit on the right of the patient with a steady assistant on his left, with forceps or hook. The lower portion of the margin of the left side of the fissure is seized and put gradually on the stretch. The surgeon is then ready to commence. gº Eighth. If the fissure be large, it is better not to attempt to close it at one operation, on account of the danger which may arise if both palatine arteries be divided, when the thin flaps would be imperfectly nourished, and thereby sloughing ensue. By allowing some weeks to pass between the first and second operation, the collateral circulation becomes established, and this danger is avoided. Ninth. The assistant having put the flaps on the stretch by the forceps, the edges may be pared from below upward, if it be designed to close the soft parts first. If, on the contrary, it is deemed requisite to unite the parts of the hard palate, the knife, or scissors, is entered at the anterior margin of the cleft, and the edges refreshed to as great an extent as is deemed advisable. (Fig. 462.) In paring the edges, care must be taken, on the one hand, not to take off too much, and thus widen the gap; but, on the other, a sufficient amount of tissue must be removed to allow a fair chance for the healing process. Tenth. If the hard palate is to be closed, the soft structures must be loosened with one of the double-edged knives with the cutting surface bent at right angles with the shank. The pointed edge of the knife is introduced close to the bone, and by a lateral motion the flap is, as gently as possible, separated. Great care must be taken not to bruise the flaps. Eleventh. The next step is the division of the palatine muscles, which, if the flaps do not drop together, should be done with care, and by means FIG. 463. rºº Whitehead's Forceps. of a sharp-pointed, double-edged and long-handled knife, after the flaps have been put upon the stretch. Dr. Whitehead has invented a forceps (Fig. 463), which grasps the muscle and much facilitates its division. Twelfth. The next step is the introduction of the sutures. All things considered, silver wire, well annealed, forms the best. The needles should not be more than three-quarters of an inch in length. They are to be armed with wire, and inserted into the needle-holder at any angle which may be most convenient. Beginning at the lower margin of the fissure, a needle should be passed through the flap. So soon as the point is seen in the cleft, the needle-holder is opened, and the needle drawn out into the cavity of the mouth by means of an ordinary forceps held by an assistant. The needle is then again inserted into the holder, and introduced at a point directly opposite, on the other margin of the cleft, and again drawn out into the mouth. It is well, as the wires are drawn without the buccal cavity, to mark them, in order that when the sutures are tightened, the operator may not become confused, or lose time in disentangling them. A very good plan is to tie a single Jºnot on the end CLEFT PALATE AND STAPHYLORRAPHY. 757 of the first wire, two knots in the second, three knots in the third, and four knots for the fourth. Three, four, or even more sutures may be required. Another excellent method, especially for surgeons who are not ambidex- trous, is that of Mr. Mason.* A curved needle, fixed in a handle with an eye in its point, is armed with a thread and passed through the palate at about a quarter of an inch from the free edge. When the point appears in the cleft, the thread may be grasped by a tenaculum or forceps and the needle withdrawn. This leaves a loop of thread in the mouth, which may be drawn forward. The needle is now re- threaded and passed through the oppo- site side in the same manner and the needle withdrawn. One loop is then passed through the other, and by making traction on the free end of one of the loops the other is readily drawn through. It now only remains to draw one end of the loop out, and the passage of the thread is complete. (Fig. 464.) Thirteenth. We are now ready to close the fissure. This is easily effected: Take one set of wires which are outside of the mouth, untie the knots which have been made for marking them, and pass the ends through a thin plate of FIG. 464. Method of passing and tying the sutures in fissured palate: b shows the single suture lead or silver which has been perforated at points to correspond to the sutures. Do this with all the wires on both sides, and slide the plates up to their places, on each side of the fissure. Slip a per- forated buckshot on the end of each wire, and taking hold of it with the jaws of passed through the left half of the palate, the double suture through the right, and the end of the single suture passed into the loop of the double one, which is drawn Out of the mouth for that purpose. . a shows the loop drawn back again, carrying the single thread with it, which now lies across the cleft. c shows the running knot made by casting a knot on one string and passing the other end through it before it is tightened. the compressor, slide it gently to its place, and press it firmly up to the hole in the plate. The wires are cut off quite near to the shot, and their ends bent over, to prevent injury to the tongue, and to hold the parts together. Fourteenth. After-treatment: The patient should sit up in bed for several nights, or lie with his shoulders well elevated, in order to prevent any dis- charge from irritating or tickling the fauces, and thus avoid the risk of coughing, Sneezing, or hawking. He must not be allowed to talk; let him make his wants known, or answer any necessary questions by writing. All hawking or actions with the throat must be avoided. No solid food is to be allowed; the diet being soups, gruel, milk, or other liquid substances. The sutures may be taken away between the fifth and the ninth day, according to the circumstances of the case; but it is preferable not to be in a hurry if the parts are doing well. To remove them it is necessary to hold the shot with forceps, and with a curved scissors clip the wire between the plate and the shot. Sir William Fergusson detached a piece of bone on each side of the cleft, and then forced the bone, periosteum, and mucous membrane towards the middle line, and fixed them there. After division of the levatores palati and palato-pharyngei muscles by means of a rectangular knife, he pared the * Hare-lip and Cleft Palate, by Francis Wm. Mason, F.R.C.S., London, p. 83. 7.58 A SYSTEM OF SURGERY, mucous membrane from the edges of the cleft, and then, close to the edge on each side of the fissure, he made two apertures with an awl. Fine silk sutures were passed through the holes into the nasal cavity, and after traversing the floor of the nares, they were made to enter the mouth through the corresponding holes on the other side. When the hard and Soft palates were operated upon at the same time, he put two sutures into the hard palate, and three into the soft, and tied them in the fol- lowing order: first, from before backwards, the second suture in the hard palate, then the three in the soft, and last, the foremost suture in the hard palate. Lint was packed into the apertures in the hard palate, and allowed to remain from two to four days. The hard palate soon became So consolidated that, in a few months, it appeared bony throughout. Mr. Mason is of opinion that by this method the bone is likely to exfoliate, to prevent which, he says:* “I have since applied a very simple method, which I brought before the notice of the profession in 1874. It consists in boring holes with an ordinary brad-awl on each side straight through the hard palate, exactly in the line in which the chisel is to be applied.” He then employs a small “screwdriver with a sharp edge ’’ for cutting between the holes drilled in the bone, of which he says the least pressure will “at Once divide the bone without splintering.” Dr. Parsons, of St. Louis, has reported a successful operation. Before closing this subject, attention should be given to the use of nitric acid, as suggested by Mr. Mason in the treatment of cleft palate. He thinks that this method of effecting union is applicable to cases in which the cleft is of average extent, and even where the hard palate is partially impli- cated. In more severe instances the ordinary operation may be required. Mr. Mason finds that the application of the acid is attended with no pain or inconvenience, and although the cure is more slowly accomplished, it has the advantage of being sure, and of completely closing the fissure in a perfect manner, without the risk of the parts giving way, either wholly or partially, as too often happens after the usual operation of staphylorraphy. A further gain seems to be that the cases may be dealt with as out-patients, as in all the examples now under notice. Mr. Mason, after many trials, prefers the strong nitric acid to any other form of caustic. He says: “I first produce a raw surface by carefully applying with a stick (not a glass rod), the acid. nitric. of specific gravity 1.500, and in a few days afterward, I use in the same way the acid. nitric. specific gravity 1,420 (Ph. Brit.), about twice a week to the part, especially the fork of the i. He states that others besides himself have succeeded with this method. Gingivitis.-The gums often become inflamed ; the inflammation may confine itself to the alveolar dental membrane, or that lining the socket of the tooth, constituting periodontitis. The disease is known by an uneasy feeling in the alveoli when the teeth are pressed together; they are some- times forced outwards, in consequence of which they cannot be precisely placed in contact. The pain is throbbing. The inflammation may extend and be manifested on the outside of the gums, the teeth may loosen, and pus, which has been formed, may be discharged between them and the gums. In some cases the alveoli become carious, and a fistulous ulcer of the gum ensues; the tooth or teeth then become permanently loose, occasioning, especially in chewing, much annoyance and pain. The causes of this disease are cold and hot fluids taken into the mouth, and exposure to cold and moisture. * Monthly Abstract of Medical Science, January, 1876; Lancet, November 6th, 1875. f Hare-lip and Cleft Palate, by Francis Mason, F.R.C.S., London, p. 77. ABSCESS OF THE TONGUE. 7.59 The dental membrane itself also becomes inflamed, constituting endodom- titis, or inflammation of the lining membrane of the teeth; it cannot in the majority of cases be diagnosed from neuralgia. Acute local inflammation of the gums proceeding rapidly to suppuration often occurs, the symptoms of which are swelling, redness, heat, throbbing, and pain; this inflammation may terminate in suppuration or gumboil, parulis, apostema parulis. The gums sometimes shrink away, to which condition the term ulatrophia is given; this produces looseness of the teeth, and they sometimes fall out without being decayed. The causes are ºrial and the accumulation of tartar around the necks of the teeth. - Treatment.—For sore gums, which become detached from the teeth, bleed readily when touched, and are very red, with looseness of the teeth, and bad odor from the mouth, and if occasioned by mercury, also if the gums are painful during mastication, or look pale and bleed readily, with frequent pains in the sound teeth, potassium iodide from 3 to 5 grains at a dose, three times a day, will generally effect a cure. Sulphur for swelling of the gums, with tendency to suppuration. Staphi- sagria is the specific for excrescences on the gums, also when such morbid growths arise on the inner cheek; and for white, pale, painful, and swollen gums. I will not enter into the details of symptoms, nor the specific remedies for these affections. Physicians are not often called upon to treat these ailments separately, as they generally fall into the hands of dental surgeons. These morbid conditions being readily recognized, no difficulty will be experienced in ascertaining the appropriate remedies, Diseases of the Tongue.—Wounds of the tongue bleed profusely, but from the cases I have seen, heal with marvellous rapidity. Sutures are neces- sary, if the wound be of any magnitude. I have known the tongue nearly severed by the teeth, the patient being kicked on the chin by a horse. In this the sutures were removed in three days, when the wound was per- º healed. I advise that the mouth be washed with a solution of calen- Ullà. - Glossitis.-Inflammation of the tongue is frequently met with in children, and is not, in the main, a dangerous disease, but acute glossitis, occurring in the adult or the aged, must always be regarded as a serious affection, The causes are not always recognizable ; atmospheric changes, malarial poison, irritating substances taken into the mouth, are numbered among them. The patient generally has a prodromic stage of “miserableness,” when the tongue begins to swell, and rapidly attains a large size; indeed, in many instances, it protrudes from the mouth and may threaten suffoca- tion from closure of the glottis. Salivation is profuse, is often very offen- sive, and the teeth and gums are covered with sordes. The superior surface of the tongue is hard and dry, often immovable, speech and deglutition are impaired, but the temperature of the patient rarely rises higher than 102° or the pulse to 100. The disease runs a rapid course, and may termi- nate in resolution or abscess. - Abscess of the Tongue.—Acute abscess of the tongue, or suppuration following rapidly upon acute glossitis is a rare affection, and is scarcely alluded to by many surgical writers. Chronic abscess is more frequently seen, and has been mistaken for cancer. In such cases there is swelling and redness, but not pronounced to such a degree as in the acute form. The formation of pus takes place slowly until finally a circumscribed tumor, on one side or the other of the tongue, is formed. When the pus is evacuated, the disorder rapidly subsides. I have seen a singular and fatal case of acute abscess of this organ in consultation with Prof. St. 760 A SYSTEM OF SURGERY. Clair Smith, of which the following is an abstract: The gentleman was about 72 years old, had always enjoyed fair health, and was of robust constitution. He had been feeling unwell for several days, when with- Out any apparent cause, his tongue began to enlarge and salivation of fetid character developed. His pulse was not very rapid, nor was his temperature very high. I saw him with Dr. Smith on the fifth day after the attack, and found him as follows: He was lying quite flat on his back, the tip of his tongue protruding from his mouth, and his teeth had sordes upon them, which had to be constantly removed. The top of the tongue was hard and dry, and the odor from the mouth offensive, although not so much so as it had been. Deposits of exudation were seen in little points beneath the tongue, but were easily removed and showed no ulceration beneath them. Upon pressing down the tongue, which was difficult to accomplish on account of the swelling and pain, the arches of the palate were seen flexible and but little swollen. His breathing was moderately good, but occasionally inclined to be stertorous, and his articulation in- distinct, though we could understand what he said. By reflected light, the top of the velum could be seen, which was not abnormal, and was flexible and moist. The medicine prescribed by Dr. Smith was lachesis, and the report of the case on the next night was that there was no especial change, excepting the tongue was a little broader on the right side. While this report was being made the patient died suddenly. The post-mortem ex- amination revealed a deep abscess at the root of the tongue, which had burst into the trachea. Such a case, namely, acute abscess of the tongue, is extremely rare, and I mention it for the sake of speaking of the treat- ment. Treatment.—In the early stages when the disease is appearing, the best medicine is aconite, but when salivation commences, mercurius solubilis in the second or third trituration should be given every two hours. If the tongue assume a bluish appearance, lachesis is the appropriate medicine. Perhaps tarantula cub. would be advisable in such a case. If, however, the fever continue, and there are no symptoms pointing to resolution, and the tongue is still swollen,_instead of the old-fashioned method of scarify- ing the dorsum of the organ, I would recommend that an aspirating needle of medium size be entered at the tip of the tongue and pushed gradually towards its back part. If there be pus it will probably be found, and if not no harm can result. I am taught this by the experience elicited from the case just recorded. - In chronic abscesses, which are usually of small size, there is not much to fear from apnoea, and an incision made over the swelling and the free evacu- ation of the pus will speedily remedy the evil. It is a question for the sur- geon to decide, whether the application of leeches at the early stage of the disease would not be advisable, to reduce swelling and prevent oadema of the glottis. Malignant Tumors of the Tongue having all the appearance of scirrhus, frequently arise from disorders of the digestive organs, or from irritation produced by carious and ragged teeth. Sometimes the whole tongue be- comes enormously enlarged, fills the mouth, and hangs below the chin. Many cases of this kind are recorded, and in particular two remarkable ones by Percy. The tongue is likewise studded over with small excres- cences, having broad tops and narrow pedicles, resembling mushrooms. At other times deep fissures or irregular cracks occupy the whole surface of the organ. The genuine epitheliomatous or carcinomatous ulceration, which is recognized by the hard, rough, broad-bottomed, wart-like tumor, is usually situated about the middle of the tongue towards the tip ; this sometimes appears as a ragged, ill-conditioned sore, covered with a fungous HYPERTROPHY OF THE TONGUE. 761 growth, bleeding from the slightest irritation, accompanied by deep-seated lancinating pain, extending to the throat and base of the skull, and termi- nating, if its progress be not interrupted, in the total annihilation of the organ. There are two varieties of epithelioma, the superficial and deep; the first having mild symptoms of itching and burning, and raised papillae; the Second presenting severer manifestations, as related above. Children are occasionally subject to this disease, but it occurs more frequently in persons beyond middle age. Carcinomatous affections of the cheek and nose commence in the same manner, and pass through the same stages as have been noticed in other forms of cancer. The proximate causes may be blows or contusions, the injudicious treat- ment of ulcers, indurations, or excrescences on the face, suppression of natu- ral Secretions, the Smoking of clay pipes, etc. - Treatment.—The medicines for cancer of the tongue are the same as those for cancer elsewhere. The student will find them at page 185. If one medicine appears to have more effect on the tongue than another, it is galium aperinum. The formula for its use can be found on that page. If an operation be deemed necessary the ligature, the galvano-caustic wire, or the écraseur may be selected. These will be described further on in this chapter under “Amputation of the Tongue.” Hypertrophy of the Tongue.—Rokitansky+ says very little about this affection, and that almost indirectly, when speaking of hypertrophy in the system of voluntary muscles. Jones and Sieveking f have the following paragraph: “The tongue is liable to be affected with an extraordinary hypertrophic enlargement, in consequence of which it protrudes from the mouth, sometimes as much as two and a half inches; the structure is altered, becoming much more dense than natural; but it has not been de- termined exactly in what the alteration consists. In one case, recorded by Mr. Liston, the enlargement of the organ seemed to have been occasioned by the development of a navus-like substance.” Cooper } mentions enlargements of the tongue consequent upon various diseases, and Dr. M. Reese, in his valuable appendix to the same work, re- cords in a few lines the following facts, viz.: That Dr. Thomas Harris, of Philadelphia, twice performed amputation of the tongue for hypertrophy of that organ; and that Dr. Mütter also successfully resorted to the same oper- ation. That in 1838, Dr. Mussey, of Cincinnati, and in 1836, Dr. Donnelan, of Louisiana, removed portions of the tongue, the latter gentleman by using ligature in preference to the knife. Mr. Muller has two paragraphs on the subject, including symptoms and treatment, the latter chiefly consisting in the administration of the iodide of potassium and the application of leeches, and these means failing, recommending operative procedure. Neither Paget nor Cragie makes allusion to the subject, but Gross is much more explicit. He tells us that all the structures which enter into the for- mation of the organ may be separately or conjointly affected, that the pro- jecting substance is dense and rigid, “protruding considerably beyond the teeth, and causing serious obstruction to the functions of the mouth, and a wasting discharge of saliva.” For a description of the affection I will narrate a case that came under my supervision: The patient, a girl aged eleven and a half years, was admitted to the hos- pital with a congenital hypertrophy of the tongue (Fig. 465); the organ at * Pathological Anatomy, vol. iii, p. 233. # A Manual of Pathological Anatomy, p. 453. † Surgical Dictionary—article, Tongue. 762 A SYSTEM OF SURGERY. times became enormously enlarged, and protruded from her mouth from three to four inches. The sufferer had been, during her life, subject to catarrhal fever upon exposure, at which times the FIG. 465. enlargement increased considerably. She - was somewhat emaciated, and the saliva dribbled from her mouth to such a degree that she was obliged to wear thick cloths across her chest, which for cleanliness and comfort had to be frequently renewed. The jaws never having been brought to- gether, the rami of the inferior maxillary did not form the usual angle with its body; and the growing teeth, having con- stantly upon them the superincumbent weight of the tongue, projected from the is . # s lower jaw more like the tusks of an animal § ºss º than the regularly developed masticating tº § sº organs of a human being; they also, im- Th sº s.Sº. pinging upon the under surface of the hy- e Author's Case of Hypertrophy of the e & Tongue; from a Photograph. pertrophied mass, caused extensive fissures and ulcerations. On the superior surface of the tongue, two longitudinal and rough depressions were seen. Fig. 465, from a photograph, will give an idea of the deformity. Treatment.-In such cases, compression is of no avail, and amputation of the tongue, or the superabundant part of it, is the only resource. Amputation of the Tongue.—W. G. Delaney,” M.D., reports an operation for congenital glossocele or hypertrophied tongue, in which the V-shaped incision was used, and in which the appearances were similar to the case I have reported. Mr. Humphrey'sf case was very like the above, the parts being removed by the knife. That gentleman further says, after the operation: “The lips could not at first be brought together, and the thick stump could always be seen, though never protruding.” Mr. Cross's case was one in which pressure with bandages soaked in a solution of alum water, after a long period produced the desired effect. Mr. Syme removed the protruding portion in another case, by the knife, but the patient died of inflammation of the tongue and parts about the larvnx. Nº. Liston recorded a case in which the haemorrhage, after operative procedure, was so great that ligatures had to be applied to both lingual arteries; inflammation, suppuration, sloughing, and death followed in rapid succession. Mr. Hodgson's case was operated upon by means of a ligature. After the parts had sloughed away; “the tongue was quite within the lips, but very thick in the horizontal direction; the altered shape of the lower jaw pre- vented its being brought into contact anteriorly with the upper.” At present amputations of the tongue are performed by the écraseur or the galvano-caustic wire, the latter being in every way the better instru- ment. The following interesting case will show a method which was suc- cessful: The patient was placed in a chair facing a window, her head being sup- ported by an assistant; when the anaesthetic influence was complete, I * American Journal of the Medical Sciences, October, 1848. # Ranking's Abstract, 1853, p. 126. AMPUTATION OF THE TONGUE. 763 inserted the teeth of a hooked forceps into the substance of the tongue and drew it forward, handing the instrument to an assistant to retain it in that position; then standing on the left and a little to the rear of the patient, I passed the chain of the écraseur diagonally across the protruded portion of the organ, allowing the handle or cylinder to touch the right angle of the lip (Fig. 466). The screw was turned, the chain tightened, constricted, and cut through the substance, which was as hard as gristle. After that portion had been removed, I changed my position to the right of the patient, allowed the handle of the écraseur to touch the left angle of the mouth, and worked it as before until the part was removed. It will be seen that by this method I was enabled to point the tongue, and though the apex at first was rather sharp, it has since been a source of grati- FIG. 466. fication that I adopted this plan. The whole proceeding occupied about twenty minutes, and the amount of blood lost did not exceed half an Oll. Il Cé. The patient was placed in bed with her shoulders elevated, and an iced solution of calendula was applied to the cut surfaces. - For two weeks after the operation the tongue was swollen enormously, but it gradually declined as the raw surfaces healed, until it could with ease be retained within the mouth. It is gratifying, however, to witness the manner in which nature healed the wounded parts; instead of leaving them angular, as necessarily left by the chain of the écraseur, they are rounded almost as well as though the original margin of the organ remained. The girl, never having brought her jaws in apposition, had a tendency to allow the inferior maxillary to drop on account of the shortness of the branches of the bone. I therefore procured a piece of gutta-percha, bent it and made an oval gag or mouth-piece, cutting in the centre a small opening sufficient to admit air, but not large enough to allow her to protrude her tongue. To keep the bone in apposition and at the same time to endeavor to force back the symphysis, I used the splint and strap for fracture of the jaw-bone. The cure was complete, and to this day the girl speaks and sings without impediment. In the performance of either partial or complete amputation of the tongue it is necessary to remember the position of the genio-hyoid and genio-hyo- glossus muscles, and the relations of the lingual and the ranine arteries. The division of these muscles allows the tongue sometimes to fall backward, thus closing the epiglottis and producing symptoms of Suffocation. It must 764 A SYSTEM OF SURGERY. be remembered, that operations upon the tongue often are followed by alarming hamorrhage, due to the great vascularity of the structure. Partial Amputation, which I have successfully employed, is thus per- formed. In place of the ordinary wire écraseur the galvano-caustic wire may be used. - A needle, armed with a double thread, is passed through the tip of the tongue, the needle cut off and the loose ends tied, enabling the organ to be drawn out. Goodwillie's mouth-gag, without the tongue piece, is then applied at the corners of the mouth to hold the jaws apart. A stout pin is inserted through the tongue from above, to compel the chain of the écraseur to start properly in the sound tissue behind and inside the tumor. The écraseur chain is applied by means of a needle through the base of the tongue from below upward, which being united to the écraseur is worked, cutting anteriorly in the direction toward the tip, almost in the median line. The écraseur chain looped is next passed backward, the diseased portion of the tongue protruding through the loop, and marked out by three pins, which form a fence, outside of which the chain works at right angles with the tongue; the screw is gradually turned, cutting laterally. Calendula applications and ice-water gargles should be used. If the galvano-caustic wire is employed, the entire diseased mass should be marked out with pins, passed through the sound tissue, the loop of wire is then applied outside the fence, the battery put in operation, and the dis- eased part slowly removed. In many amputations that I have made of the tongue, I have been care- ful to notice three facts: first, that the tissue of this organ is rapidly repro- duced, owing, I suppose, to the plentiful blood supply; second, that removal of large portions of the tongue does not materially impair articulation; third, that the operation above described, with pins and the écraseur, or the gal- §ºtic wire, is preferable to the more severe proceedings of Syme or UIIllſle||V. - Hºnºu of the Entire Tongue is thus performed: It is a modification of that of Mr. Syme. The object is to allow the application of the ordinary or the galvanic ēcraseur to the base of the tongue above the os hyoides. The incision is made in the median line of the chin, dividing the lower lip and extending to the hyoid bone; this will allow a sufficient dissection of the lip on either side, which should be raised about a quarter of an inch. A hole is made on both sides of the symphysis of the jaw, which must be divided with a fine saw. The halves of the bone must be drawn aside with hooks, and the genio-hyo-glossi muscles cut with scissors. The attachment of the genio-hyoid muscles must not be cut. With the aid of the fingers and scissors the tongue must be raised with the sublingual glands and mucous membrane, until it is free to the hyoid bone. By means of a cord passed through the tip of the tongue it must be drawn downwards, which will put the palato-glossi muscles on the stretch, which must be divided with blunt-pointed scissors. The chain, or wire, should be passed around the base of the tongue close to the bone, and the parts gradually severed, either by turning the handle of the screw or the action of the battery. As the parts are separated the operator must be prepared with a stout needle set in a handle, and threaded, to pass through the stump in case it should fall backward. & A piece of wire should be passed through the holes previously made in the jaw, and twisted securely, to bring the bone into its natural position, and its ends turned up between the bone and the lip. The lip is then brought together with the hare-lip pins and figure-of-eight suture. * Wide A Course of Operative Surgery, by Christopher Heath, F.R.C.S. Philadelphia, 1878. P. 55. MALFORMATION OF THE FRAENUM LINGUAE. 765 Mr. Whitehead” has successfully performed ablation of the entire tongue, with the Scissors, without division of the symphysis or submental incision. A mouth-gag was inserted as usual, and the tongue secured by a ligature passed through its tip. This thread was firmly taken hold of and traction made; the fraenum and muscular tissues were divided successively. The tongue was then drawn out of the mouth and severed by cutting first on one side and then on the other. Two vessels were ligated, but secondary hamorrhage coming on, recourse was had to the thermo-cautery. Dr. George F. Shrady, f in an excellent article on ligation of the lingual artery, prior to the extirpation of cancerous or other diseases of the tongue, arrives at the following conclusions: - “1. In cancer of the tongue, whenever it is possible, the disease should be removed through the mouth. “2. Ligation of the lingual artery is a very necessary preliminary to such a procedure. - “3. Ligation of the lingual artery, if performed at all, should be near the origin of the vessel, as by that means the whole of the blood-supply of one side of the tongue is completely cut off. “4. The operation of ligation of the lingual artery, even in that situation, is less difficult than the securing of the vessel in the wound during the operation of extirpation of the tongue, and when there is free haemorrhage deep in the mouth. “5. The distance between the external carotid and the point of ligature is sufficient for the formation of a firm clot and the prevention of secondary haemorrhage. “6. The use of the scissors and the knife place the wound in a condition more favorable for rapid healing than when the écraseur or any variety of cautery is used. - - “7. Ligation of the lingual may have a tendency to retard the return of the disease.” In the case which he records, the vessel was ligated just at the point where the artery passes under the posterior edge of the hyo-glossus muscle. Malformation º the Fraenum Linguæ.—It sometimes happens, though by no means, so frequently as is imagined, that children are born with the franum of the tongue so short that they are unable to raise the organ to the palate, and consequently sucking is materially impeded. This condi- tion is made apparent by raising the point of the tongue with a spatula. If the surgeon should fail in this attempt and the tongue appear, upon ex- amining it laterally, to be unnaturally confined, little doubt can remain of the franum being defective. & Treatment.—This complaint is readily removed by an operation which, however trifling it may be considered, is one which should not be lightly performed, nor upon every ordinary occasion. Petit relates two instances in which death followed from the franum being so much loosened as to permit the tongue to fall backwards into the pharynx, thereby occasioning suffocation; other cases are recorded of fatal haemorrhage following the operation from wounds of the ranine arteries and veins. A pair of probe-pointed scissors are used. The tongue should be pressed upwards by means of the index and middle fingers of the left hand, and the franum should be divided in its transparent portion as far as may be deemed necessary; at the same time taking care to direct the point of the instrument downward, keeping as close to the lower jaw as possible, that the arteries and veins may be avoided. If carefully per- * Medical Times and Gazette, December 15th, 1877. f Medical Record, September 14th, 1878. 766 A SYSTEM OF SURGERY. formed, there is scarcely any ha'morrhage; but, if bleeding should result, it may be arrested by applying small pieces of sponge, a solution of alum, gun-cotton, or other styptics. Ranula-By the term ranula was formerly understood an obstruction of one or more of the ducts of the sublingual glands, giving rise to the forma- tion of a semi-pellucid tumor, supposed by the older anatomists to resemble the belly of a frog, hence the name. - More recent investigations have demonstrated that the affection is pro- duced by obstruction of the mucous glands situated beneath the tongue, such as the glands and ducts of Rivini. From six cases observed by Professor Michel,” of Nancy, he concludes that, in the majority of cases, it originates in the areola of the connective tissue about the franum of the tongue. In none of the cases “could a reaction resembling that produced by saliva be obtained,” and the micro- scope only revealed tessellated and globular epithelium and crystals of cholesterin. The swelling may attain a considerable size, interfere with deglutition, or even displace the teeth; the tumor is cystic, and is generally filled with a fluid resembling albumen, but not saliva. It arises from a natural im- perfection or adhesion of the duct, or from the lodgment of a calculous concretion within its passage. This disease chiefly affects children. Treatment.—The medicines which have been successful in this affection are merc. sol., calc., and thuja. Mercurius should be employed where there is an excessive secretion of saliva, with soreness of the surrounding gums, and * is disposition to profuse sweat; the sufferings being aggravated at night. . Čºrea carb. is an excellent medicine, and is particularly adapted to children affected with scrofulosis; when there is violent burning in the buccal cavity, with difficulty of speech. Thuja should be employed when the disease is accompanied with sore- ness of the whole palate, and with swelling of the salivary glands. Other medicines are petrol., puls., silicea, stram., staph., and sulphur. If medicinal means fail, an attempt must be made to open the ducts from within, which may often be difficult. The better plan is to raise the upper part of the cyst with a pair of forceps or a tenaculum, and cut off the upper surface; then introduce cotton or lint soaked with a solution of iodine. If there should be great enlargement of the glands, an incision should be made on the outside through the integument, as cutting deeply within the cavity of the mouth might result seriously. I have succeeded in several cases by passing a double silken ligature through the base of the tumor and tying the threads on either side, thus producing strangu- lation. An excellent and efficacious treatment of ranula is that introduced by Professor Panas, which consists of injecting from three to eight drops of a solution of Tºr in strength of chloride of zinc, without withdrawal of the fluid. He states that ranulae, which had resisted treatment by excision, suture, and drainage, were promptly cured by this method. Salivary Calculus.-Calculi are found in the ducts of the salivary glands, but are chiefly confined to Wharton's duct, and are often present with ranula. The formation no doubt originates in a deposit from the Secre- tion of the gland. These calculi are not generally larger than a pea, although I have seen one, more than an inch in length, removed by the late * Monthly Abstract of Medical Science, September, 1877; Gazette Hebdom., No. 16, 1877 - + American Journal of the Medical Sciences, January, 1877, p. 255. TONSILLITIS. 767 Dr. Hartshorne, of Philadelphia. . A cautiously made incision directly over the calculus will allow its removal. Salivary Fistula.—After operations upon the mouth and jaws, in which Steno's duct has been necessarily divided, or as a consequence of abscess, a salivary fistula is formed. The saliva flows from the wound over the cheek, and there is a corresponding dryness within the buccal cavity. Mr. Holmes gives the following operation for its cure: “The disease is to be treated by restoring the passage for the saliva from the gland into the mouth. For this purpose the proximal part of the duct (i. e., the part of the duct which is still in connection with the gland) should be found by examination of the wound; then the cheek should be everted, and along the natural opening of the duct, in the interior of the ‘mouth (which is generally found without difficulty, opposite the second upper molar tooth), a probe or leaden string is to be passed across the wound and along the duct in the direction of the gland. The probe or string is fixed in its position by bending its extremity round the commissure of the lips on to the cheek, where it can be secured. When the saliva is thus guided into the mouth the fistula will probably heal, either of itself or on its edges being refreshed and brought together. In some cases the opening of the duct in the mouth cannot be found, and when this is the case, the distal opening of the duct as well as the proximal must be sought in the wound; or if that part of the duct is obliterated, an artificial passage must be made and kept open ; but such cases are far less promising. And indeed many cases of salivary fistula present very considerable difficulty, from the rottenness of the tissues surrounding the wounded duct, which renders them very unapt to unite when brought together, and favors the percolation of the saliva through the wound which it is intended to unite.” - Tonsillitis—Quins.y.—(Squinsy or squinancy of old writers; the cyman- che or angina of the medical books; paristhmia, from tapa and to 390s, literally, morbus faucium, or throat affection; the signification of angina is strangulation; the patient complains of difficulty in swallowing.) No matter which part or parts be affected, there is swelling of the mucous membrane of the fauces, pain, redness, and glossy appearance; dryness in the first instance, but subsequently a secretion of ropy mucus, which in- creases the difficulty of deglutition. When the inflammation extends to the uvula, it swells, and there is a constant desire to swallow (empty deglu- tition), and there is nausea and retching in consequence of the irritation produced in the throat by the elongated uvula and the secreted mucus. The smell, hearing, and breathing often become impaired in consequence of the disease spreading into the posterior nares, the Eustachian tube, and top of the larynx. The food is sometimes returned by the mouth, and solids are more easily swallowed than liquids; in consequence of some muscular fibres only being able to act, the particles of fluid, having but little cohesion, slip from each other. There is a constant desire to hawk up mucus, and the patient breathes with his mouth open. If the angina be excessive, the jugular veins swell, the face becomes purple and livid, there is headache, delirium, and other symptoms of febrile excitement. When the inflammation attacks the tonsils, constituting cymanche tonsillaris or amygdalitis, the following group of symptoms present. At first, slight chills, followed by much fever, with uneasiness in the fauces, and more or less difficulty of deglutition, with a sensation of a foreign body in the throat during the effort; after a while pain is experienced in the tonsils, the difficulty of swallowing increases, or it is impracticable; one or both tonsils, on examination, are found much enlarged, and the surface of the fauces red and somewhat swollen. The tongue is white and covered with a thick layer of transparent, viscid mucus, and is swollen; the pain shoots 768 A SYSTEM OF SURGERY. from the fauces into the ears, particularly when attempting to speak or swallow, and the mouth is opened with great pain and difficulty; a thick ropy mucus adheres to the inflamed surface and impedes respi- ration; the adjoining parts are red and swollen, but the principal pain and difficulty of breathing arise from the enlarged tonsils, which may easily come in contact, confining the swollen uvula behind them, or press- ing it forwards into the mouth. The outside of the throat opposite to the tonsils is always somewhat swollen, and tender to the touch. In Some instances the mucous membrane is less vividly red, or is red in spots, and covered with a pappy, gray, white-yellow mucus, which ex- tends to the tongue. One tonsil is generally inflamed first, the left Sooner and more violently than the right. Sometimes slight ulcerations take place, which arise from small, yellowish pustules. These burst' and pour out a lymph-like fluid, which hardens into a whitish, pseudo- membranous layer on the surface of the tonsil; this after awhile sepa- rates, leaving the part bright-red, eroded, and discharging a purulent matter. - This disease may terminate in resolution, suppuration (abscess of the tonsil), gangrene, very rarely; or in permanent enlargement of the tonsils (chronic hypertrophy). The causes are such as induce other, inflammatory affections—wearing damp linen; cold applied to the neck; sitting in damp rooms; getting the feet wet ; violent exertion of the voice; blowing wind instruments; suppres- sion of customary evacuations; acrid substances irritating the fauces. The circumstances indicating resolution are less fever, freer respiration, deglutition not so much impeded, the inflammation being of a lighter red color, with copious salivation. If about to terminate in suppuration, dyspnoea and difficulty of swallowing increase, and it is altogether im- possible to open the mouth. The pus may be discharged suddenly with immediate relief, by hawking or coughing, or the matter may be dis- charged without an aggravation of symptoms and be swallowed by the patient. The disease is supposed to affect particularly the young and sanguine, but this does not accord with general experience. It is often met with in adults and in different temperaments. After having occurred several times, unless treated by specifics, it appears to establish a peculiar habit or dia- thesis; in such it can be readily excited and by slight causes. Treatment.—The principal medicines for cynanche tonsillaris are acon., bell., merc. Sol., merc. Subl., hepar sulph., cham., ars, ignatia, nit. ac., nux vom., baryta, silicea, and sulphur, also gelsem., phytolac., Sanguin., and podophyl. In the first stages, when the patient is troubled with an undue secre- tion of saliva, inducing constant and painful deglutition, and when the inflammation is accompanied by synochal fever, aconite should be pre- scribed. After the fever has been subdued, bell. is particularly efficacious, and frequently in alternation with aconite cures the affection. It is espe- cially indicated by the following symptoms: Phlegmonous redness of the tonsil, with shooting pains during deglutition; sensation as if the fauces were spasmodically constricted, with slimy white mucus on the throat and tongue. # chronic enlargement and induration of the amygdalae, the medicines are chiefly bell., baryta c., merc., silic., sulph. Or sep., puls., ars., nit. ac., etc. Chronic enlargement of the tonsils is a disease which for successful treat- ment requires patience and perseverance, not only of the practitioner, but of the patient. The medicines must be well selected and administered at considerable intervals; at the same time it is of great importance that the TREATMENT OF TONSILLITIS. - 769 patient should observe the proper dietetic rules, and avoid exposure to a damp or cloudy atmosphere. It may be asserted that from negligence of patients, and want of perseverance of practitioners, many cases quite curable are abandoned as hopeless. It is suggested by Dr. Porter,” that the enlarged tonsils be injected with a watery solution of iodine three drops to ten. The instrument used is a hºmic syringe with a long needle. Half the quantity is to be injected into each. I have succeeded in removing tonsils without the aid of the knife, by the application of caustic paste. - Dr. Fournier, of Paris, reports fifty-two cases cured by the application of the Vienna Paste; the minimum time required was two weeks, the maxi- mum, one month. Dr. Morrell Mackenzie, of London, has introduced what he terms the London Paste, which I have used in many cases with success. Dr. Ruppanerf reports one hundred and twenty-three successful cases operated upon in this manner. The following is the method recommended by Dr. Ruppaner. The London Paste is prepared of equal parts of caustic soda and lime, moistened with a little alcohol. It must be kept in a well-stoppered bottle, since caustic soda and lime have a powerful affinity for carbonic acid. If exposed, therefore, to the air, the causticity of the paste is lost. Various tests have satisfied me, that it is necessary to employ absolute alcohol in its preparation. I proceed as follows: A quantity of equal parts of finely pulverized and well-mixed caustic soda and unslacked lime is kept prepared. When an application is to be made to the tonsils, a little of the powder is FIG. 467. l put into a small porcelain cup, a few drops of absolute alcohol, which is kept near at hand, are added, the two are carefully mixed with a glass rod, when the paste is ready for use. The patient must be placed in a good light, a tongue-depressor used, and the paste applied and allowed to remain for several seconds, until an eschar is produced. Then it is washed off, and the parts allowed to slough, when it must again be applied. Care must be taken to apply the escharotic only to affected parts. If too * U. S. Medical Investigator, December 15th, 1877. # Medical and Surgical Reporter, November 20th, 1869. 49 770 A SYSTEM OF SURGERY. much is placed upon the rod, some of it may drop off, and cause excoria- tion. When excision is preferred, it is to be performed in the following manner: The patientis seated in a chair, before a good light, and the mouth kept wide open. In examining the mouth and throat, some tact is required, especially in children; in looking for enlarged tonsils, in diphtheria, and other affections of the pharynx, as well as in operating for cleft palate, or examining the pharynx, a suitable tongue-depressor is essential, especially if the examina- tion has to be prolonged. Fig. 467 represents Elsberg's tongue-depressor. The surgeon passes the ring of Fahnestock's tonsillotome (Fig. 468) around about half the tonsil (it is not necessary as a general rule to remove the whole gland), FIG. 468. Fahnestock's TOnsillotome. slides the pin through, and draws back the handle. The after-treatment con- sists of gargling with calendula and water. Fig. 469 shows Tiemann's one-bladed tonsillotome, which seizes the gland as it is removed. Some surgeons prefer a hook and a curved bistoury, as FIG. 469. One-Bladed TonsillotOme. seen in Figs. 470 and 471. The hook is inserted into the tonsil, and drawn forward, and the tonsil, or a portion of it, removed by a stroke or two of the knife. tº & An ordinary curved probe-pointed bistoury, wrapped with a piece of cotton, or an instrument prepared for the purpose, will answer in lieu of the tonsillotome. . Rhinoscopy.—By the term rhinoscopy is understood an inspection of the nose and its cavities. It may be divided into anterior and posterior, the former being through the nostrils, the latter (called also choanoscopy), be- hind, through the fauces. RHINOSCOPY. 771 The ordinary bivalve speculum is often sufficient for anterior rhinoscopy, or the speculum of Folsom (Fig. 472) answers well; oftentimes by throwing the head back, and allowing strong sunlight to shine into the nostrils, and FIG. 470. FIG. 471. FIG. 472. | §º Hook and Knife for * º Excising Tonsils. Rhinoscope and Tongue Depressor in Position. pressing the thumb lightly on the tip of the nose, an examination can be made. Metz's nasal speculum consists of two instruments or curved 772 A SYSTEM OF SURGERY. spatulae, slightly concave and polished; one is held in the right hand, the other in the left, and thus the alae of the nose are held apart. In posterior rhinoscopy, either sunlight or artificial light is to be used; the mirror may be placed upon the head of the operator, or the laryngoscope used. The patient is so seated that the light may be caught upon the re- flector and directed within the mouth. The operator, taking a blunt flat hook, set in a long handle and curved somewhat to keep the hand out of the way of vision, introduces it behind the uvula, which is gently drawn forward. The mirror, also set in a long curved handle, like that used in laryngoscopy, being slightly warmed, is introduced, the glass looking up- ward and forward. The glass may be moved backward and forward until the nares are well examined. Several examinations are often required before the parts are brought into sight, some persons being more easily managed than others. However, even an unsatisfactory view throws light on diagnosis, and facilitates the performance of operations. Another method is that of depressing the tongue with an ordinary right- angled spatula, and introducing the mirror as seen in Fig. 473. Pharyngitis.-The pharnyx is liable to inflammation, constituting the disease called angina pharyngea or pharyngitis. The same tissues are attacked as when other portions of the isthmus of the fauces are affected. If the inflammation be high up, it may be dis- cerned by an examination of the mouth, when the parietes of the posterior wall of the isthmus will be perceived to be inflamed. Deglutition is pain- ful, and, from the dryness of the parts, much impeded; the food frequently returns by the nose, and a violent and spasmodic cough is produced in the endeavor to swallow. The voice is sometimes hoarse; the inflam- mation spreads to the nasal fossae and larynx, but respiration is not often #. It frequently accompanies amygdalitis, and often follows angina a U1CIUIII]. The throat-inflammation in hydrophobia is somewhat similar to that of angina pharyngea, and sometimes ends in suppuration. The stylo-hyoidei, stylo-glossi, mylo-hyoidei, hyo-glossi, stylo-pharyngei, and the constrictor muscles of the pharynx are those affected. Gangrenous Pharyngitis.-The pharynx is also liable to gangrenous inflam- nation ; angina maligna, putrida, wicerosa; ulcerated, putrid, or malignant Sore throat. This disease is an inflammation of a peculiar kind. Although it is true that ordinary pharyngitis may terminate in gangrene, still such a result is rare. This variety is marked from the first by peculiar symptoms, which are typhous in character. It is perceived in Scarlatina, but is not peculiar to it, as it sometimes appears without, at others with, the scarlet rash; it may be sporadic or epidemic. The symptoms, from the first, are of the most alarm- ing kind. The disease seems to depend upon a humid or peculiar atmospheric con- dition, atta king chiefly children, and those of weak, lax fibre. When one member of a family is affected the others seldom escape, and hence its contagious character is inferred. It sometimes follows measles of a malig- nant kind. Its first symptoms are: shivering, nausea, vomiting, and anxiety, followed by heat, thirst, dyspnoea, and restlessness; the face is flushed, the eyes bloodshot, the neck stiff, respiration hurried, accompanied with hoarse- ness and sore throat; the internal ſauces are of a dark-red color, the tonsils slightly inflamed, but not sufficiently 80 to obstruct respiration or deglutition ; in a short time, sloughs, in color between a light ash and a dark brown, can be seen on the tonsils, velum pendulum palati, and uvula ; the tongue is cov- ered with a thick brown fur, the breath is highly offensive, the insides of TREATMENT OF PHARYNGITIS. 773 the lips are covered with vesicles, which contain an acrid matter, which excoriates the corners of the mouth and other parts. There is also a dis- charge of corrosive pus from the nostrils. Diarrhoea occurs, especially in infants, the thin ichorous fæces excoriating the anus. From the first, the fever is high, the pulse small, frequent, and irregular; the temperature in the morning being 102°, in the evening 104°. There is loss of strength, low muttering delirium, or coma. On the second or third day, large patches of a dark-red color appear about the face and neck, which by degrees dis- perse themselves over the body, even to the extremities of the fingers, which are swollen and stiff; these red patches continue for about four days, and disappear without producing any change of symptoms. The inflam- mation sometimes spreads along the Eustachian tubes to the internal ear, where it produces ulceration, and indeed destroys the structure of that organ. In other cases, the parotid, maxillary, and other glands become pain- ful and swollen; the entire neck swells and assumes a dark-red color. As the sloughing spreads, the parts become darker-colored, the spaces between the sloughs assume a purple hue, new spots appear, and the whole internal fauces become covered with thick sloughs, which after their separation leave deep ulcerations. If the case be aggravated the fauces become black, the ulceration becomes deeper and deeper; these disturbances spreading through the alimentary tube often terminate in gangrene, with which increase of symptoms, colli- quative diarrhoea appears. An unfavorable prognosis must be given if there be sudden abatement of violent symptoms, as of pain; the tonsils becoming dry, flaccid, and unequal, and of a pale-brown or livid color; the .inflammation changing to a dull-red, interspersed with spots of a dark hue (so long as the specks remain white, less apprehension may be experienced); the pulse becomes small, weak, and irregular, the face cadaverous. If clammy, cold sweat, and cold extremities, fetid breath, great anxiety, subsultus tendinum, foam at the mouth, coma and delirium appear, or the tonsils become so large as to threaten suffocation, the prognosis is bad. The eruption is not uniformly diffused, but appears in blotches or small points, scattered over the trunk and extremities, of a dark purple or livid hue, and which terminate with scanty desguamation. Treatment.—The remedies for these conditions are : Aconite in the beginning of the affection, when there is dulness and fever, should be given. - Belladonna is frequently called for, especially in persons of full habit, with tendency to cerebral hyperamia, flushed face, and extreme conges- tion of the mucous membrane. It is especially useful in those cases where there is great dryness and purple hue of the pharynx. Mercurius is next in importance to belladonna. This remedial agent is indicated in those anginas which appear on the slightest change of weather, and in individuals who have suffered from and are consequently liable to angina; also in those anginose affections which occur after acute cutaneous diseases, which arise from a slight cold ; they appear in spring and autumn in young robust individuals. When catarrhs are frequent, such subjects are exempt from them but are affected with angina. Arsenicum is the medicine when there is a rapid failing of strength, with intense burning thirst, drinking often and but little at a time; dry and black patches in the mouth, fetid breath, hard, dry, and black tongue, watery diarrhoea, rapid emaciation, and profuse sweating. In fact, in gan- grenous pharyngitis, this medicine in alternation with lachesis is generally indicated. Chamomilla, in mild cases of angina pharyngea, may be useful, but rather 774 A SYSTEM OF SURGERY. for the collateral or consensual symptoms. It is also adapted to cases of children, or where the disease is brought on by checked perspiration. Nux vomica is adapted to inflammation of the uvula, tonsils, and phar- ynx, especially the latter, if arising from gastric derangement, indicated by eructation of a burning fluid which constantly irritates the pharynx. These varieties are often connected with catarrhal complaints. When the uvula itself is affected, nux vomica is the remedy. Pulsatilla is indicated when the inflamed surfaces are dark red, with vari- cose enlargement of the bloodvessels. Ignatia is called for when there is a feeling of a plug in the throat, with red and inflammatory swelling of the tonsils and palate. Dulcamara is specific for angina when produced by exposure to wet and when the secretion of mucus is excessive. It acts more promptly and effectually if preceded by mercurius, or if given in alternation with bell. and merc. - Cantharides may be given where the tonsils are inflamed and covered with vesicles, together with an astringent sensation in the pharynx, and burning, which sometimes extends down the oesophagus into the stomach. It answers well at the commencement of some cases of angina, or at the con- clusion of the disease, especially when there are suppuration and destruc- tion of the mucous membrane. Baryta carb. should be given if there be a chronic disposition to inflamed throat, and indurated tonsils resembling scirrhus. Iodine, mixed with an equal portion of glycerine, may be used topically in the gangrenous variety, and cases have been much benefited by the hydrochlorate of pilocarpine, one-tenth grain three or four times a day. Post-pharyngeal Abscess.-Inflammation of the connective tissue in the posterior portion of the pharynx, whether occasioned by disease of the bones of the vertebrae or otherwise, sometimes terminates in suppuration, the tumor bulging forward into the pharynx, and causing, in accordance with its size, symptoms of suffocation. If the bone is diseased, the prog- nosis is bad; if the inflammation has been produced by ordinary causes, and the pus is discharged by the mouth, a cure may result. In several instances I have succeeded in drawing off the fluid with the aspirator, although, when the children are young, I have found it difficult to keep the needle in position. Professor Bókai, of Pesth, in a paper in Jahrbuch für Kinderheilkunde,” gives the particulars of 144 cases of this disease, observed and treated by him, in the Children's Hospital at Pesth, between the years 1854 and 1876. Of these, 129 were idiopathic; 3 were secondary to abscesses in the neck; 4 were secondary to spondylitis cervicalis; 7 occurred during the course of scarlet fever, and ought properly to be classed with the idiopathic cases, as the anatomical processes were the same in both ; and 1 case was of traumatic origin. In addition, he observed 43 cases of lymphadenitis retropharyn- gealis, which he classed with the idiopathic retropharyngeal abscesses, because he believed that the latter always result from the former. In idiopathic retropharyngeal abscesses, Professor Bókai found at first a firm tumor, as large as a hazelnut or a pigeon's egg, behind one or other tonsil, not often in the middle of the retropharyngeal space. . These tumors could be felt externally by deep pressure near the angle of the jaw. Later they became soft and elastic, fluctuated, and gave exit to pus when opened. Only 11 of the 144 cases proved fatal. Spontaneous opening of the abscess occurred in 19 cases. In 2, pus discharged into the trachea, * Medical Record, November 18th, 1876. SPASM AND CEDEMA OF THE GLOTTIS. 775 and asphyxiated the children, but respiratory movements and cough were excited by the application of electricity, and life was restored. Facial paralysis occurred in 3 cases. The medicines used in the treatment are those employed for abscess. Mercury and hepar are the most useful. Continuous spray from a steam atomizer should be kept up on the parts as long as the patient can bear it, and repeated frequently. - Elongation of the Uvula.-The uvula frequently becomes elongated from Various causes, sometimes from an angina, sometimes from inflammation, and in some cases from sympathetic action in gastric derangements. Some persons are more predisposed to the disorder than others, and if the elonga- tion is not removed, severe sympathetic irritation may extend to the throat and lungs. The symptoms are dry hacking cough, caused by titillation in the throat, which is worse when lying down; a constant desire to swallow; oftentimes nausea is occasioned by the constant tickling. Children are subject to the affection, and the common expression, having “the palate down,” finds an explanation in this unnatural relaxation. reatment.—The medicines to be relied upon are aconite, belladonna, coffea, ignatia, lachesis, nux vom., and phosphorus. As there are but few FIG. 474. Sajous's Uvula Scissors. Symptoms, the selection of the medicine must depend upon the peculiar idiosyncrasy of each patient. Great temporary relief is obtained, especially at night, when the cough prevents sleep, by sucking small pieces of ice or gargling the throat with cold water, or with a solution of alum, grs. xx–3j. Ferric alum or sulphate of zinc may be used in the proportion of grs. xii–3j. The medicines which have given me most satisfaction are cham., ignat., coffea, and nux vomica. My usual practice, however, is to end the trouble by excising the lower part of the uvula. A pair of forceps will readily seize the end of the uvula, which, being drawn forward, may be cut off at its lower half with a pair of long-handled scissors, such as are found in the uterine sets. An excellent instrument has been devised by Dr. Sajous for this purpose. (Fig. 474.) pasm and QEdema of the 㺗The glottis or upper part of the larynx is sometimes affected with spasm, the aperture closing, and often producing fatal dyspnoea. The symptoms are well marked when the disease is fully established, but the attacks are insidious, beginning merely with a short dyspnoea, which lasts but a moment, and is often overlooked. As the dis- order advances, a sudden whistling, crowing noise is made during the efforts 776 - A SYSTEM OF SURGERY. at deglutition, coughing, or sneezing. The face becomes purple, the veins turgid, and all the symptoms of death from suffocation are present. If the spasm subsides, in a short time the patient regains his ordinary appearance, and all symptoms disappear until another attack follows. The disease may be caused by injuries from, and the presence of, foreign bodies in the air-passages, or the pressure of tumors or aneurisms upon the nervus vagus. Treatment.—The medicines are chiefly bromine, iodine, Spong., cuprum, plumbum, and moschus. Dr. Carroll Dunham advised bromine water. In the cases which have come under my care, iodine has been most satisfactory. To persons liable to attacks, I always advise that a small vial of chloroform and a hand- kerchief be kept in readiness, as a few inhalations will generally relieve the spasm. If the spasm should be caused by the pressure of a tumor, or should be so great as to present symptoms of imminent danger, tracheotomy must be immediately resorted to. The inhalation of nitrite of amyl has been used with success. (Edema of the Glottis.-This disease, which often proves fatal, notwith- standing skilful treatment, consists of a serous infiltration of the submu- cous cellular tissue of the glottis and adjacent structures. There is no vascularity in the swelling, which is of a yellowish color, like the surface of an ordinary blister. It may occur during an attack of Scarlatina, small- pox, tonsillitis, or typhoid fever, or from the inhalation of steam, flame, or swallowing hot liquids. Its effect is to produce mechanical obstruction during inspiration, while expiration remains un- FIG. 475. embarrassed. The dyspnaea is marked, and con- stantly increases as the disease advances. The voice is altered, and a dry, croupy, convulsive cough, with frequent paroxysms of Suffocation soon exhaust the strength of the patient. With the above is a sense of fulness in the throat, with great Soreness but an almost entire absence of pain. As the symptoms are both alarming and distressing, some relief must be soon gained, or a fatal termination will speedily follow. Treatment.—Among the medicines, iodine is the best. It can be administered in the form of inhalations of vapor or spray, and given inter- nally. Bromine may afford relief. Other medi- § – “...” cines to be remembered are apis, lach., musk, CEdema. Glottidis. and rhus tox. - When the symptoms are very urgent, the swol- len parts should be freely scarified with a long probe-pointed bistoury, * thus gºing vent to the effusion, after which the iodine vapor may again be used. If, however, these means fail, and the waning strength and dark livid hue of the skin show that the blood is becoming carbonized, then tracheotomy must be performed, and many desperate cases have recovered after this procedure. The cut (Fig. 475) represents Oedema of the glottis. * A knife admirably adapted for this purpose, was invented by Dr. Buck, of New York. ABSCESS OF THE ANTRUM HIGHMORIANUM. 777 CHAPTER XXXIX. INJURIES AND DISEASES OF THE JAWS. ABSCESS OF THE ANTRUM HIGHMORIANUM-TUMoRS OF THE ANTRUM-OSTEO-PIASTIC OPERATION FOR ExPOSING THE CAVITY OF THE ANTRUM-EPULIs—CYSTIC TU- MORs—NECROSIS OF THE JAW-Bon ES-PHOSPHORUS NECROSIS-ExCISION OF THE UPPER J Aw—Excision of THE LOWER JAw—OF THE ENTIRE Low ER JAw—AN- CHYLOSIs OF THE INFERIOR MAXIILARY. Abscess of the Antrum Highmorianum.—Abscesses of the antrum high- morianum fortunately are not of frequent occurrence; they are, in the majority of instances, tedious to cure, and productive of much pain. The disease may arise from blows on the face, chronic inflammation of the pituitary membrane lining the nostrils, exposure to a cold and damp atmos- phere, but more frequently from decayed teeth, which, by the irritation they occasion in the membrane lining the cavity, produce the inflammatory process which terminates in the formation of pus. This affection in its early stages is difficult to diagnose; the first inti- mation the patient receives is pain, which is generally referred to a carious tooth, and laboring under such a mistake, several teeth are often extracted; this, however, does not relieve the suffering unless one of the fangs has penetrated through the floor of the antrum, and, being removed, allows exit to the matter that has accumulated in the cavity. If this is not the case the pain continues, extending farther up, and more in the direc- tion of the nose and orbit than is the case in ordinary toothache; but even this. does not lead the patient or practitioner to suspect the true nature of the affection; in fact, such pain may often be present in facial neuralgia, without any disease of the antrum. The sufferings of the patient continue for a length of a time, increasing in violence, until finally a tumor becomes perceptible below the malar bone; this enlargement may extend over the whole cheek, but there is a circumscribed hardness situated above the posterior molars. The pus may be evacuated through the cheek, or the matter may move towards the palate, forming a swelling there, and rendering the bone in the vicinity carious, unless the patient is relieved; or a portion of it may be discharged through the nose, when the patient is lying with his head low, and on the side opposite to that which is affected; or the matter may trickle down between the fang and the socket of the tooth. The pus that is discharged is often so extremely fetid that no one can enter the room without being disgusted with the odor, and the patient is rendered disagreeable to himself on account of the matter flowing into the mouth and throat when lying down. The pain is severe and generally throbbing; sometimes it remits for a short period, returning again with increased violence. - The formation of pus in the antrum is often attended with disease of the superior maxillary bone, and is in all instances tedious, and in many cases difficult to cure. Treatment.—The first step must be to evacuate the pus, after which the surgeon can more readily ascertain the condition of the cavity, whether there be caries, or if any morbid growth be present within; the selection of remedial measures consequently being rendered more certain. All the grinding teeth of the superior maxillary bone, excepting the first molar, correspond with the floor of the antrum. These teeth sometimes extend into it, and the fangs are only covered by the membrane lining the 778 A SYSTEM OF SURGERY. cavity; therefore, the simplest method of evacuating the pus is by drawing one of the teeth. A carious tooth or a continued ache in one of the molars should decide the practitioner which tooth to extract; but if all appear to be sound, the surgeon should gently strike each one of them, and that which appears most tender, or gives rise to most pain, should be removed. The third or fourth molar generally is extracted, after which, if the pus is discharged, no further operation is required ; if the matter does not follow the removal of the tooth, a stilet or small trocar must be pushed into the cavity to produce the desired effect. After the evacuation of the pus, a probe may be gently inserted into the antrum, and the condition of the bone, etc., ascertained. After the contents of the cavity have been discharged, the part should be cleansed by means of an injection thrown into it from a small syringe, with a somewhat curved pipe. A piece of bougie must also be worn, to allow the matter that collects to be evacuated, and hepar, ars, lyc., or silic. be administered, or other medicines (men- tioned in the Chapter upon Abscesses) employed, according to the presenting symptoms. “Dr. Gullen, of Weimar, from experience in several cases, strongly recom- mends ars, and lyc. in this complaint. Arsenic generally removes the dreadful throbbing, divulsive pain, which assumes the quotidian type for the most part ; and lyc. is useful in arresting the thick yellow discharge, which frequently continues after the pain has ceased. Dr. Gullen recom- mends the higher dilutions of both these remedies, and the use of silic. after the discharge has abated.” To obviate the necessity of extracting teeth, La Morier, of Montpellier, pro- posed to perforate the antrum above the alveolar processes, immediately over the third grinder; but, says Dr. Gibson, “the disease, however, so seldom occurs without being accompanied or caused by carious teeth, that such an operation, though practicable, can scarcely ever be rendered necessary.” After the evacuation of pus, the cavity must be carefully examined by means of gentle probing. If the internal lining membrane be diseased, calc. c., mez., or phos. ac, may prove serviceable, if other syptoms cor- respond; should, however, the affection have been produced by a decayed tooth, its extraction and the discharge of the matter will afford great relief, and the exciting cause being removed, the medicines will exert their beneficial actions. But too frequently the disease has extended, not only to the membrane lining the cavity, but also to the bone itself; in such instances, the treatment, of course, must be directed to the carious bone. The medicines that have proved serviceable for disease of the Osseous structure, are: calc., lyc., merc., phos. ac., silic., staphis., Sulph. ; or ars., asaf, aur., hepar, nit. ac., or Hecla lava. From numerous cases that have been recorded, we learn, that phosph. is an excellent medicinal agent for diseases of the bones, particularly caries or necrosis. Long ago, the British Journal of Homoeopathy't gave an inter- esting account of a child that became affected with diseased bones from the vapor of phosphorus. Such testimony as this should lead the prac- titioner to investigate more thoroughly the action of medicines, as in these instances especially, the power of drugs over diseases is distinctly perceptible. Aurum and nit. acid are excellent medicines when the patient has pre- viously been affected with syphilis; mez. will be found efficacious in miti- gating, and often arresting, the intolerable burning pains which are present, particularly at night. * British Journal of Homoeopathy, vol. i., p. 407. f Vol. vi., p. 284. TUMORS OF THE ANTRUM. 779 This medicine, perhaps, is better adapted to the disease when the bone itself has not been implicated, but when the lining membrane of the cavity is in an abnormal condition, mezereum acting more particularly on periosteum than on bone. Kali hydriodicum is a medicine that has been frequently overlooked in the treatment of this disease; it is suitable not only to those cases that have originated from syphilitic poison, but is likewise serviceable when the characteristic nightly aggravation pathognomonic of periostitis is present, together with excessive accumulation of saliva. As palliatives for the pain, which is often so severe as to be almost unbearable, spigelia, nux vom., china, or phosph., will be found of much Service. Tumors of the Antrum.—There are several varieties of tumors affecting the antrum, the chief of which are myeloid and spindle-celled. The descrip- tion of these tumors will be found in the chapter on this subject. The remedy is removal. Formerly it was supposed necessary to excise the whole bone, but recent operations, termed osteoplastic, mostly performed by the German surgeons, have given brilliant results. Osteoplastic Operation for Exposing the Cavity of the Antrum for the Re- moval of Tumors.—The patient having been thoroughly etherized, enter the knife a few lines below the inner canthus of the eye, and carry it down to the ala of the nose. This incision must extend through the periosteum down to the bone. With a fine saw, such as is seen in Fig. 406, the nasal process must be divided; the instrument is then temporarily relinquished, and the knife entered at the superior extremity of the first incision, and carried parallel with the lower margin of the lid, a little beyond the external canthus. The saw is now resumed, and the bone freely divided. Again the knife must be used, with its point entering the lower end of the first incision, passing around the ala nasi, and terminating within the nostril; its course must then be changed, by bringing the edge directly downward, thus dividing the upper lip. The saw is now introduced within the nostril, and the hard palate divided; by inserting a strong elevator into the last incision, the bone may be turned directly outward. This latter proceeding requires considerable force, but when the bone is displaced, the cavity is fully exposed, and any tumor or abnormal growth which may exist within the antrum or nares can readily be removed. The bone is replaced, and held in situ, either by silver wire around the teeth, or wire sutures through the bone itself. The skin-flaps are approxi- mated in the usual manner, and comparatively little deformity follows the operation. - Trendelenberg recommended, in 1869, what he termed prophylactic tracheotomy, with tamponing the trachea, in all bloody operations upon the larynx, or in the buccal, nasal, or faucial cavities, thus preventing the escape of blood into the air-tubes. Edmund Rose more recently recom- mended that, for the same purpose, the patient should be placed in the supine position, with the head thrown backward almost to a right angle, and that the operation be made with the parts in this position. By the old methods there is always more or less danger from suffocation, and Nussbaum noticed that even the frequent sponging of the fauces to pre- vent such untoward occurrence was followed by abscesses and irritation of the parts. There is said to be little danger in retaining the head in this position for a length of time, and that its evil results have been much overes- timated. This is proven by the position (standing on the head) taken by gymnasts in their performances. To make the matter more certain, experiments were made by several physicians and medical students, who 780 A SYSTEM OF SURGERY. found that the position could be maintained for three-quarters of an hour without inconvenience, save some unpleasant feeling during the first few minutes, and that conversation and discussion were kept up during the time. The position would appear to favor the administration of anaesthetics, for experiments have proved that neither death nor asphyxia has been known to occur in patients in the inverted position, indeed, when such danger threatened, Nélaton especially recommended the suspension of the patient. During anaesthesia the cerebral bloodvessels are in a state of anaemia. There can be no doubt that often venous hæmorrhage may be increased by this position, and to prevent this Volkmann frequently per- forms the division of the soft structures with the patient in the ordinary posture. - Those who have operated upon persons in this position say, that they appear more bloody because all the blood runs on the floor and is seen, Nº. certainly is preferable to having the fluid pass unnoticed into the trachea. * Rose operated successfully in this manner for cleft palate, restoration of the nose (rhinoplasty), and also resected the upper and lower maxillary bones. Burow removed an alveolar sarcoma of the hard palate. Hahn extracted a ball from the upper maxilla. Maas extirpated the larynx and removed a cancerous tongue, and others have, with the patient in this position, exsected the nerves and performed tracheotomy. Epulis.--This is a peculiar recurrent fibroid or fibroplastic growth arising from the jaw. It first appears in the form of a small papilla, which gives little pain; in some instances, it grows rapidly and may have two or three lobes, which appear attached to the gum by a pedicle, whereas they, in all instances, are attached to the periosteum or bone. Epulis may be distinguished from myeloid tumor by its density, its similarity to surrounding tissues, its tolerance of manipulation, the comparatively healthy condition of adjacent structures, and the absence of sympathetic irritation of the neighboring glands; there is also little tendency to ulceration. It is flabby, does not readily bleed, and if cut off speedily recurs. Even the actual cautery has but little effect upon it. I have applied the hot iron many times in those cases which have come under my observation, with but temporary relief. The only sure method is to remove the portion of bone from which the disease springs. Cystic Tumors.-Cysts are sometimes developed in the jaw-bones. I mean primary cysts, not those tumors which are formed from degeneration of certain tumors. In these cases, as the cysts enlarge the bones expand, and form a covering for the tumor. The fluid found in them is serous, gelatinous, sometimes even sanguinolent. The most peculiar variety, and that to which attention is especially directed, is known as “dentigerous cyst.” In such cases the cysts are associated with a diseased condition of the fang of the tooth. They may occur from the misplacement or from the presence of supernumerary teeth. A singular fact is noticed, that the disease is known to attack only the permanent teeth. The cysts are called by Holmes “tooth-bearing,” and are actually to be looked upon as complications of the natural process of dentition, and are found when there is a deviation in the anatomical distribution of the teeth. Jourdain records the case of a girl, in which the first and second molars (perma- nent) on the right side were inverted, and a serous cyst had formed in the cavity of the antrum around them. The pressure of the tumor had distorted the face and closed the nostril. There are other interesting cases on record, proving the fact that deviation of the second set of teeth is the chief factor in the production of the disease. The symptoms are local. There is EXCISION OF THE UPPER. J.A.W. 781 at times, after long continuance of the disease, some constitutional disturb- ance, the bone expands, and there is a kind of “crackling” or “crepitation ” of the tumor under the finger. If the bone becomes sufficiently thinned, fluctuation is apparent. The chief sign, which may be regarded as pathognomonic, is this: If a patient presents himself with a tumor, with fluctuation about the jaw, and the mouth is carefully examined, and teeth are found wanting, or mot arranged in their anatomical order, and their absence cannot be accounted for by accident or extraction, the diagnosis of dentigerous cyst will be generally COrrect. Treatment.—The cyst must be evacuated, and the teeth or tooth removed ; then a portion of the expanded bone should be cut away from the tumor, and the balance will be, in time, removed by absorption. The tooth is gen- erally discovered at the bottom of the cyst. Necrosis of the Jaw-bones is not an uncommon affection. It is noticed in children after severe forms of exanthematous affections, the disease ease making its appearance on the decline of the fever. The swelling com- mences round the gums, suppuration rapidly follows, fetor emanates from the mouth, and in some instances the entire bone is destroyed. In many cases the reproductive power appears to be as great as the disintegrating process, and the entire mass of dead bone is thrown off as a sequestrum, and a new bone, not so perfect in its contour as the old one, is formed. I have seen several cases of this kind. In the majority, however, the disease is confined to the alveolus. g Phosphorus Necrosis, not so common since the improved method of manu- facturing matches has been introduced, was first clearly described in Eng- land by Dr. Wilks.” He says: “I have seen several cases of it in my own practice, and in a case wherein I removed the entire lower jaw, the patient had been in the habit of holding the illuminating ends of matches in the mouth ; indeed, after the removal of the bone, small portions of the sticks were found in the alveolar sockets. In this disease, the pain is first referred to the teeth, the patient complaining of toothache. In a short time, and without very much pain, the bone appears to enlarge. During this period the constitutional symptoms are well marked; there are rigors, sweats, loss of appetite, emaciation, and great depression. Necrosis rapidly supervenes with great fetor. The teeth become loose and drop out, and fluctuating points are observed in the gum. The point where the pus is discharged varies in different cases, but when it is carried off, as is usual, the patient's sufferings are greatly relieved. Many sinuses form, leading hither and thither throughout the bone, and the swelling in some cases becomes per- fectly enormous, puffing the face to the forehead, shutting the eyes and nose, and everting the lips. Around the diseased bone a large amount of exuda- tion takes place, which is fibro-plastic in its nature.” - A peculiarity of phosphorus disease, and one of interest to our school, is the liability of those affected, to suffer with different diseases of the lungs and bronchi. Asthma, especially, has been noticed as a compli- cation. If portions of bone are diseased, they may be removed with the chisel and gouge; if the entire bone is affected, it must be taken away. For the medicines for necrosis, the reader is referred to the Chapter on Diseases of the Bones. Excision of the Upper Jaw.—There are a variety of tumors, both simple and malignant, solid and semi-solid, which, growing upon the Superior maxilla, demand its removal. Besides these affections, caries and necrosis, especially * Guy’s Hospital Reports. 782 A SYSTEM OF SURGERY. that last considered, and abnormal conditions of the antrum, call for excision of either a portion or the whole of the bone. The method of Sir William Fergusson is often adopted. In this the upper lip is divided to some distance within the nostril. The incision is carried around the ala of the nose up to the inner angle of the eye, and from thence parallel with the lower margin of the lid to the external can- thus. By this means the large vessels and nerves are avoided. The hard º is sawn through and other bony attachments severed, either with bone-cutters or the saw, and the bone is thus removed. The lion-jawed forceps will be found most useful in steadying the bone and in breaking it away from its attachments. The surgeon must bearin mind, while perform- ing this operation, the course of theinternal maxillary artery, as fatalhaemor- rhage might ensue were it divided low down. - Another method is that, I think, originally devised by Mr. Liston, and which I have practiced with success, and although in the first incision there is generally quite profuse haemorrhage, this can usually be arrested by acupressure. The operation is as follows: Enter the knife at the outer commissure of the lip and make a curvilinear cut, the convexity of which is toward the angle of the jaw extending to the centre of the malar bone. From this a second incision is carried beneath the lower lid to the inner angle of the eye, as seen in Fig. 476, which was made from a photograph FIG. 476. FIG. 477. Incision for Excision of the Upper Jaw. Chain Saw Applied. of a patient of mine, who suffered from malignant disease of the upper jaw from which he subsequently died. The soft structures must be dis- sected off and the bone entirely denuded of its covering. The palatine process must be sawn through, and the junction with the malar bone separated with the chain-saw, as seen in Fig. 477, or with pliers; other connections are severed, until the whole mass can be taken from its place. During these operations chisels, gouges, and various bone forceps are EXCISION OF THE UPPER JAW. 783 required. According to Dr. Chisholm,” the operation of Dieffenbach is far superior to all others for removing the upper jaw. In the communi- cation referred to, he states a remarkable fact, that in the recent works of Holmes, Erichsen, Fergusson, Gross, and Gant, the operation is not even mentioned; and I confess that it was entirely new to myself. FIG. 478. G. 7/ATAMA/V W & CO Dr. Chisholm thus describes the mode of procedure: “Commencing at the root of the nose, an incision slits the nose and the upper lip in the median line; a short incision, joining the first at right angles, extends from the root of the nose to the inner angle of the eye. The lower lid being drawn downward the knife is carried along the entire length of the con- junctival cul-de-sac, separating this lid from its orbital connection, and FIG. 479. utilizing the entire length of the lower lid in the horizontal flap. When the flap, as defined by the vertical and horizontal incisions, is dissected up, it will lay bare the entire front, and if necessary, the side of the face, without having divided any large bloodvessel or important nerve branch. With such an exposure the superior maxillary bone can be isolated with great ease, as every surface of contact with neighboring bones can be clearly brought into view. With no additional incision I found no difficulty in FIG. 480. removing from the living subject the superior maxilla, malar and palate bones, which enabled me to extirpate a large fibroid with extensive adhe- sions to the roof of the pharynx. - “After the removal of the maxilla, when the flap is brought back to its normal position and carefully adjusted by several points of suture, union speedily ensues. This operation leaves so little deformity, that in the ma- jority of cases the line of the incision will escape detection unless the scar be sought.” FIG. 481. G.T | EMANN & C 0. Dr. D. H. Goodwillie, of New York, has published an interesting mono- graph on Resection of the Maxillary Bones without External Incision, and has invented instruments for operations of this kind. Fig. 478 shows a cheek-holder, which can be used at any angle. Figs. 479 and 480 illustrate periosteotomes for denuding bone. *— * Medical Record, April 1st, 1873. 784 A SYSTEM OF SURGERY. º 481 represents an oral saw, consisting of a handle fixed with a U shank, so contrived that knives and saws of different sizes may be set into it, and which can be made to cut in four directions. Excision of the Lower Jaw—Resection of the lower jaw is a standard operation, and is frequently performed. Prof. Valentine Mott was the first to excise half of the bone at its articulation on one side for osteo- sarcoma; and I am of opinion that he never laid claim to anything further. His first operation was performed November 17th, 1821. Velpeau's gives the credit to Dupuytren; he says: “Nevertheless, facts of this kind had remained without application until Dupuytren came to the determination to º almost the entire body of a cancerous lower jaw, by a method entirely new, and which has been received into practice under *. title of a surgical conquest.” - The priority of resection belongs, however, to a Western surgeon, Dr. W. H. Deaderick, of Rogersville, Tenn., who performed the operation, February 6th, 1810, for a tumor of the bone, on a patient aged fourteen years. In some instances it may be necessary to disarticulate the bone on both sides. This operation was first performed in Europe by Walther, of Bonn, in 1826, and in this country by Carnochan, of New York, in 1851. There are several methods of removing the inferior maxillary. An in- cision may be commenced at the mesian line of the lower lip, and carried - to the chin; from this another Fig. 482. incision can be carried around - the lower margin of the body and ramus of the bone (Fig. 482). This large flap must be dissected up, the facial artery secured, and the bone sawn through at a point some dis- tance beyond the diseased por- tion. Holding that part to be removed with a pair of lion forceps, the structures connect- ing the jaw with the mouth must be dissected away, keep- ing the edge of the knife close to the bone. If the disease has extended to the articulation additional care is necessary; and it is well, as we approach the joint, to separate the soft parts with an instrument de- vised for the purpose by Dr. Gross. Having reached the zy- goma, with a pair of scissors Incisions for Removal of the Jaw. with round ends, carefully snip the tendon of the temporal muscle from its connection with the coronoid process, and then turn the bone outward, to more fully expose the joint, and move the internal sur- face as much as possible from the internal maxillary artery, which lies in close proximity. Then carefully open the capsular ligament of the joint in front, turn out the condyle, and the removal is completed. Do not imagine that this is easy of execution. Many difficulties arise, which com- F. the proceeding. There is a great tendency of the tongue to fall ackward and close the glottis; and when the entire jaw is to be removed, * Operative Surgery, vol. ii., p. 713. |EXCISION OF THE ENTIRE LOWER JAW. 785 as a precautionary measure, a needle armed with a strong cord should be passed through the tongue near its tip, and given to an assistant to hold during the entire operation. When the flaps are brought down, a large acu- pressure pin should be passed through the integument, near the submaxillary glands, and caught into the several ends of the glossi muscles, and these pinned down to the neck until a sufficient period has elapsed for their adhe- sion. The wound must be thoroughly washed out before the edges are united, and great nicety is necessary in coaptating the vermilion border of the lip. There is another accident to which I would direct attention ; it is the escape of blood into the trachea ; this sometimes causes much embar- rassment, therefore there should always be on hand several sponge probangs to clear the throat of clots. - Some surgeons prefer leaving the border of the lip entire, and begin the incision below the vermilion edge. Again, large portions of the bone have been removed by what is termed the single linear incision, which extends around the jaw on a line corresponding to the lower margin of its body. Excision of the Entire Lower Jaw.—In some cases, either for tumors or diseases of the bone itself, it may be necessary to remove the entire lower Jaw. It is in the excision of this bone that periosteal surgery has made some of its wonderful triumphs. The celebrated case of Dr. James R. Wood, in which the bone was reproduced entire, is well known. The new jaw, ob- tained after the death of the patient a number of years after the operation, travelled over Europe, the admiration of all surgeons.” Dr. Gouleyi has collected valuable statistics of this operation, to which the student is referred. Dr. R. A. McLean I reports reproduction of bone four months after exsec- tion of half of the inferior maxilla of a child four years of age. It is, there- fore, necessary, in every instance, to elevate the periosteum, and retain as much as possible thereof if we wish for reproduction of bone. In the month of May, 1867, I was requested to see a lad suffering from necrosis of the inferior maxillary bone, and, if necessary, to take such sur- gical measures into consideration as would prove efficient for his relief. Upon visiting the patient, I found him in apparently good health, but with an excessively swollen face. Upon depressing the lower lip, the sym- physis of the inferior maxillary, entirely necrosed, could be seen, and was movable in a vertical direction; lateral motion, however, was so slight, that at the first examination it was doubtful whether the diseased action had in- volved the entire bone; further and more minute investigation decided me in the opinion that its complete excision was the only resource. Operation.—An incision was commenced at the middle of the vermilion border of the lower lip, and carried down to the chin ; from this point, a second cut was made along the lower border of the bone almost to the con- dyle on the left side, and a similar division effected on the right. These flaps were dissected up and the bone was found bare. In endeavoring to remove the left ramus it broke, but with slight traction with the pliers the part was taken away. The right side was much more firmly fixed at the articulation, and required an extension of the external incision, and a separation of the soft parts from the bone, together with some prying with the handles of the bone-forceps before it could be enucleated. It came away entire. After the extraction of some spiculae, and the ligation of several vessels, the wound—a gaping and extensive one—was brought together and held in position by interrupted sutures. I was informed by letter, that the * Lancet, June 2d, 1877. # Transactions of the International Congress, Philadelphia, p. 605. † Western Lancet, April, 1877; Monthly Abstract of Medical Science, June, 1877. 50 786 A SYSTEM OF SURGERY. cuts healed almost entirely by first intention, and in the remarkably short space of twelve or fourteen days. The following cut (Fig. 483), copied from a photograph taken two years after the operation, shows the appearance of the boy. A strong fibro-car- . tilage, which may have ere this become ossi- FIG. 483. fied, had formed, and the patient was in the enjoyment of perfect health. The most difficult and critical part of the operation is the disarticulation of the bone. After the flaps have been made as directed, the tendon of the temporal muscle must be divided at its insertion into the coronoid pro- cess. With blunt instruments or periosteum knives the structures are to be separated on the inside of the mouth, keeping the instru- ments close to the bone, to prevent injury to º: internal maxillary artery, lº. º in — y *... close proximity to the ramus. The joint then The Authºrºval of the must be jºi from the outside and a little forward, and the condyle turned forward by depressing the bone. If the bone is turned outward, the artery may be twisted around the condyle and accidentally severed, giving rise to severe and troublesome haemorrhage. The disarticulation will be materially facili- tated by sawing the bone through at the symphysis, seizing the fragment with a lion forceps and depressing it. Drs. Beebe, Beckwith, Franklin, and Hall have removed, successfully, parts of the inferior maxillary bone. The after-treatment consists in the application of carbolated calendula, or a solution of the latter, to the parts. The pins ought to be removed on the third to the fifth day. * Mr. Stanley,” before operating on the lower jaw, took the precaution to apply an acupressure pin to the facial artery, which effectually checked the haemorrhage. On several occasions I have adopted this procedure. - It appears, from an examination of surgical literature, that immense tumors, bony and others, have been removed with the entire bone, or por- tions of it, with success. Anchylosis of the Inferior Maxillary.—Anchylosis of the lower jaw may occur in three localities: First. The head of the condyle may become fixed in its glenoid cavity. This is the most frequent form, examples of which are recorded by Sandi- fort, Blandin, Cruveilhier, Howslip, Holscher, Hyrtl, and others. Second. The coronoid process may attach itself to the zygomatic arch ; of this but few observations are recorded, and these chiefly by Sebastian, in his essay, published at Groeningen, 1826. - Third. Alveolar processes may become conjoined; of these there are four examples on record, which are to be found in Walther's Museum of Anatomy, in Rust’s Magazine, and in Bennett's cited from Kunholz, and in the British and Foreign Medico-Chirurgical Review. Of the fifteen cases of anchylosis collected by Dr. Lewis, both sides of the jaw were affected in seven cases, and one side in eight. In the three examples of osseous connection of the alveoli, the incisors were somewhat separated. It has been supposed by Cruveilhier and others that anchylosis of one side entails that of the other, by the complete immobility it induces; but in seven of the fifteen cases quoted, the joint on one side remained quite * Wide Simpson on Acupressure. † Museum of Anatomy, vol. iv. ANCHYLOSIS OF THE INFERIOR MAXIII, ARY. 787 free. To what degree prolonged immobility is a cause of anchylosis may be judged by the case I record, in which it had continued seven years, and by others in which it had lasted for nearly a quarter of a century. Immobility of the inferior maxillary bone, causing closure of the jaws, is an affection which is of comparatively rare occurrence; and as the em- ployment of poisonous doses of mercury is decreasing such unfortunate occurrences will be still less frequent. Speaking of this deformity, Dr. Grossº remarks: “The most common cause, according to my observation, is profuse ptyalism, followed by gan- grene of the lips, cheek, and jaw, and the formation of a firm, dense, un- yielding inodular tissue, by which the lower jaw is closed and tightly pressed against the upper. Such an occurrence used to be extremely frequent in our Southwestern States during the prevalence of the calomel practice, as it was termed, but is now fortunately rapidly diminishing.” . The same author appears to have encountered a number of such cases during his residence in Kentucky, and upon referring to Dr. Mott's record, published in the appendix to Velpeau's Surgery, it will be perceived that the majority of persons suffering from this affection who applied to him for relief, resided in the Southern and Western portions of the United States. The prevalence, therefore, of such disorders in the West and South, can truly be attributed to the too free exhibition of mercurials in the fevers peculiar to those sections of country. Besides the abuses of mercury just referred to, other causes may be enumerated, as anchylosis, in consequence either of arthritic disease or trau- matic lesion, in either of which cases, an effusion of plastic element may be thrown around the joint, which finally may be converted into cartilaginous or Osseous formations, effectually impeding the motion of the jaws. Again, the pressure of a neighboring tumor may produce a similar result, and an entire Osseous connection may take place between the jaws in any part where the previous disease has manifested itself, either between the ramus of the inferior FIG. 484. and the boss of the superior maxillary, º-- or between the alveolar processes; or, as Mott observes, “by means of a bony plate which extends from the coronoid process to the superior maxillary bone.” From no matter which of the above- mentioned causes the closure proceeds, it is a difficult and tedious affection to treat, and the prognosis is doubt- ful and cannot be hastily formed, be- cause it is impossible to state certainly by what means the jaws are closed; perhaps it may be by one, perhaps another of the tissues mentioned; or, as in the case seen in Fig. 484, two S. N. S…º.º.º. S or three substances may firmly unite s § * ss the & maxillae. In his chapter on this The Author's Case of Anchylosis of the Jaw, subject, Dr. Mott says: “It is, in our with destruction of orbit, eye, and cheek. opinion, an important surgical subject, and especially so since it is one which is frequently very difficult to treat.” Gross, also, in his article, writes as follows: “When the immobility depends upon the presence of inodular tissue, the proper remedy is excision of the offending substance, an operation which is both tedious, painful, and bloody, * Operative Surgery, vol. ii., p. 584. 788 A SYSTEM OF SURGERY. and unfortunately not often followed by any but the most transient relief, owing to the tendency of the parts to reproduce the adhesions, however carefully and thoroughly they may have been removed. . . . . The great difficulty, however, is the obscurity of the diagnosis.” In general, however, the joint is affected with spurious anchylosis, true Synostosis not having occurred within the capsule, while along some portions of the bone Osseous connections may have been thrown out. Nevertheless, muscular contractions, fibrous tissue, cicatrices, or even fibrous degenera- tion of the articular cartilage, may hold the jaw perfectly immovable. In the diagnosis of such cases it is well to bear in mind the advice of Brodhurst.” who thus writes: “False anchylosis is the rule; it is so common, that adhesions should always be held to be fibrous until they are proved to be bony. Immobility alone is not a sign of synostosis; it not unfrequently exists where the adhesions are fibrous. And even where chloroform has been administered immobility may be as great as before. . . . . Whenever the muscles can be thrown into action, so as to render the tendons promi- nent and tense about a joint, the adhesions are not bony.” Treatment.—The parts must be carefully dissected away from the jaws, and one of the instruments depicted in Fig. 485 or Fig. 486 inserted be- FIG. 486. N. "ºffhº Sº | | | | | . .", .. | | | | | | . . . . . | ſ ºiſºlºiſhihi G.7/EMAWW-C0 tween the teeth; then with a steady turn of the screw, the jaws are gradu- ally opened. As the jaws open the adhesions separate with a loud snap. Fig. 484 shows a case in which the patient had suffered from ptyalism to such a degree that there was necrosis of the lower jaw, together with death of the external angular process of the frontal bone, which entirely destroyed the eye. Her cheek also ulcerated and the jaws became so firmly locked that teeth which had decayed and dropped into her mouth she was obliged to swallow, not being able to separate the jaws sufficiently to expel them. After many operations, I succeeded in making a cure of this remarkable Ca,Sé. * Practical Observations on the Diseases of the Joints involving Anchylosis, and on the Treatment for the Restoration of Motion. London, John Churchill, 1861. CUT THROAT. 789. Formation of an Artificial Joint.—In some, perhaps the majority of cases, the tendency to the reformation of cicatricial bands cannot be prevented, and the last state of the patient becomes worse than the first. The construc- tion of an artificial joint then becomes necessary. Keil and Rizzoli about the same time (1855) suggested and performed division of the lower jaw below the cicatricial bands. This was done by dividing the bone within the mouth with a strong pair of forceps, and inserting a slice of india rubber between the ends. Esmarch later practiced the excision of a wedge-shaped portion of bone, the apex of which pointed to the alveolar border. This is to be done with a small saw, through an incision on the outside, made at the lower margin of the bone. Even in this operation there is great difficulty in preventing bony or fibrous reunion. #. most thorough operation is that of removal of the condyle of the bone, which should be jºi for synostosis of the joint, especially if other means have failed. This is a delicate procedure, on account of the close proximity of the internal maxillary artery. The operation, as done by Konig, is as follows: The first incision—about an inch or an inch and a half in length—is made over the lower border of the zygomatic process. A second cut, starting from the end of the first, which is nearer to the ear, is then made downwards at right angles, and about an inch in length. The latter, to avoid severing the facial nerve, is only skin deep. The masseter muscle must be divided and the joint exposed. A small chisel is then applied to the neck, and the condyle severed and carefully removed. The late Dr. Little performed the operation in 1873, the elder Gross in 1874 (he, however, making a single semilunar cut in front of the articula- tion), Dr. J. Ewing Mears in 1875, Dr. Robert Abbe in 1879, and Dr. Mears again in 1884. On the Continent, Ranke, Hagedorn, Langenbeck and Konig have all reported cases. The operation is one of rarity, there being up to the present but fifteen reported cases. CHAPTER XL. INJURIES AND DISEASES OF THE NECK. CUT THROAT—TorTICOLLIS, WRY NECK. DISEASES OF THE GLANDS OF THE NECK— PAROTITIs, MUMPs—ABSCEss of THE PAROTID—GANGRENE of THE PAROTID— MALIGNANT DISEASES OF THE PAROTID—ExTIRPATION OF THE PAROTID—AFFEC- TIONS OF THE DUCT OF STENo—DISEASES OF THE SUBMAxILLARY GLAND–CYSTIC TUMoRS OF THE NECK—GoITRE–BRONCHOCELE—DERBYSHIRE NECK. DISEASES of THE CESOPHAGUs—RUPTURE OF THE CESOPHAGUs—CESOPHAGITIS, INFLAMMATIO CESOPHAGI—STRICTURE OF THE CESOPHAGUs—FoEEIGN Bodies IN THE CESOPHAGUS —INTRODUCTION OF TUBES-CESOPHAGOTOMY, SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA—SYPHILITIC LARYNGITIS-Foreign Bodi ES IN THE LAR- YNx AND TRACHEA—BRONCHOToMY—LARYNGOTOMY-TRACHEOTOMY-TRACHEOT- OMY WITH THE THERMO-CAUTERY-INTUBATION OF THE GLOTTIs—LARYNGOSCOPY —NEOPLASMs—ExTIRPATION of THE LARYNx. Cut Throat.—It is not as well understood as it should be, that many of the incisions which are made, by suicides or murderers, in the neck are not fatal. Because of the prevalent opinion, that if the windpipe is opened, death is inevitable, the incisions are generally made in the front of the neck, and, the great vessels and nerves of the lateral portions being intact, the patient recovers. 790 A SYSTEM OF SURGERY. Holmes asserts that of 158 unselected cases the wound was situated Above the hyoid bone in . . © © e G tº º . 11 cases. Through the thyro-hyoid membrane in . tº . . . . 45 “ Through the thyroid cartilage in ſe & te e º tº . 35 “ Through the crico-thyroid membrane in . ſº o º e . 26 “ Into the trachea in . e G e iº e e ſº e . 41 “ The respiratory tract was open in about two-thirds of the cases. How- ever, there is often considerable bleeding from the thyroid arteries and sev- ered veins. Death, also, may ensue from the flowing of blood into the air-passages and lungs. Treatment.—The first care of the surgeon, of course, is to arrest the bleed- ing, and to wait a considerable time to ascertain that no internal haemor- rhage is taking place. If the cut has been made high up, at the junction of the neck and chin, a portion of the epiglottis may be cut off; if a part is left hanging, it should be excised. If the wound is lower down, the rings of the trachea may be brought together by passing fine silver wire through the perichondrium, and twisting it, allowing the ends to protrude through the wound. - If muscles are severed, they must be treated in like manner. The head must be placed in such position that there be no traction on the sutures, and the parts covered with compresses wet with a solution of calendula and water. Torticollis—Wry Neck.—This distortion and consequent unnatural posi- tion of the head may be either congenital or acquired, paralytic or spastic. Sometimes the manipulations of the accoucheur during a tedious labor may produce it. When thus noticed it increases gradually, the head being drawn from one side or the other, until great deformity results. In other cases it may arise from scrofula, rheumatism, or from the sloughing conse- quent upon burns, lacerated or gunshot wounds. The head leans to the side of the contracted muscles, and may be drawn slightly forward. The chin is directed to one side, and the ear approaches the shoulder. The affected muscles are first and most frequently the sterno-mastoid, next the trapezius and scaleni. The fascia sometimes plays an important part in the affection. The sterno-mastoid and trapezius muscles are supplied by the spinal accessory nerve, and any cause exciting an irritation of its tract may pro- duce torticollis. Indeed, a reflex irritation from the pneumogastric has been known to produce the spasmodic variety of this disease. There may be also a clonic torticollis and a tonic torticollis, and the surgeon must be careful not to mistake the tonic contraction which occurs on one side for the paralytic condition of the other. There is a peculiar form of this affection noticed by Dr. Mills;" it is “bilateral spasm of the muscles sup- plied by the accessorius; it is not common, and, when it does occur, is a most striking and curious affection, causing peculiar and alternate or syn- chronous movements of the head—a form of the nodding or salaam convul- sions particularly observed in children.” Treatment.—If torticollis arise from improper positions assumed by the patient, braces or other mechanical means to prevent an indulgence in the pernicious habit must be employed. If the inclination of the head, is caused by glandular swellings, the medicines that are suitable for such in- durations will probably rectify the evil. Among these may be rhus, carbo an., conium, mercury, potash, baryta carb., calc. - * Spasmodic Torticollis, Am. Journal of the Medical Sciences, October, 1877, p. 431. TORTICOLLIS-WRY NECK. 791 If wry neck is occasioned by rheumatic or other inflammatory affections, it may be advantageously treated with bry., puls., bell., acon., etc. For pains as if the cervical vertebrae were dislocated, which are often felt in the affected part, bry., nux vom., and cinnabar may be suitable. For the con- traction of single tendons of the cervical muscles, natrum muriat., rhus tox., Stram., hyos., dulc., zincum, Selen, or arsenicum, are appropriate medicines. In the absence of any mechani- FIG. 487 cal contrivance, a band of adhesive - ~" plaster well applied around the fore- i. head, to which a second extending to the back is attached, will often meet the indications. An extem- poraneous apparatus may be formed by a skull-cap made of stout cloth, having an india-rubber band at- tached near the forehead; this band must extend to the back, and be fastened to a strap passing around the thorax. The instrument-makers construct many props and supports, which are preferable to the old-fashioned one of Jorg. In most cases, how- ever, the subcutaneous division of the tendons at fault, may be prac- ticed. If only the sternal portion of the sterno-mastoid should be the tendon affected, which can be ascertained by its spastic rigidity, the patient being etherized, the finger of the left hand must be inserted under the tendon, and a delicate tenotome passed flatwise beneath it, the edge of the knife is turned forward, an assistant makes traction on the head, and the tendon often snaps when divided. If the clavicular portion of the sterno-mastoid is also to be cut, a second puncture must be made, and this had better be somewhat further above the bone than the puncture at the sternal end, as the fibres come more closely over the bone at the clavicular than the sternal margin. After having made this puncture with the sharp- pointed knife, it must be relinquished, and a probe-pointed tenotome sub- stituted; this must be introduced flatwise, and the cutting edge turned forward, and with a sawing motion of the handle the fibres divided. Fig. 487 shows the introduction of the instrument in division of the clavicular fibres. After the attachments have been divided, either of the #. apparatuses may be used. Fig. 488 represents that made by Mr. Reynders. It consists of a well-padded pelvic band, a, to which an upright steel bar, b, is attached, passing upwards along the spine to the upper dorsal region. A cross-bar, c, is fixed to its upper end, passing from one axilla to the other, and fastened to two crutches, k, fitting well under the arms. These are connected to the pelvic band by two lateral bars, m, which by means of a slot and screw can be raised and lowered some- what, at will. The part of the apparatus so far described is applied firmly to the trunk by means of straps passing over the shoulders and fastened to the axillary cross-bar at c c. A firm hold of the head is secured by a pad (sheet steel inside), reaching almost from eye to eye backwards around the skull, with apertures for the ears, and fastened to the head by straps over the forehead and under the chin. To its back part, a steel bar & s º Puncture for Torticollis. 792 A SYSTEM OF SURGERY. is riveted, d, which connects the upper part of the apparatus with that applied to the trunk. The lower end of this steel bar is ratcheted and ad- justed in a slide at the upper end of the steel rod, passing up along the spine, and held in a desired position by a thumb-screw, shown near the FIG. 488, FIG. 489. *...*.*.* Reynders's Apparatus for Wry Neck. Markoe's Apparatus for Torticollis. letter h (on the figure). This connecting bar is intercepted by three different joints, e, f, and g, by which flexion can be made in any direction when worked by the key. At the joint, g, flexion can be made to the right or left, at f forward and backward, and at e rotation. The advantage of this apparatus over others is, that a firm hold is maintained on the head and trunk, and that the head can be brought in a proper position by a true and irresistible mechanism. The instrument when worn is almost hidden under the clothing, and patients cannot easily withdraw themselves from its action. Markoe's apparatus, Fig. 489, is in principle the same as above-named. A ball and clamp socket-joint allows movements of the head in the proper position. A short stem projects backwards from the back of the headband, terminating in a ball, which is grasped by a clamp at the end of the upright bar passing along the spine. The pressure of this clamp is regulated by a thumb-screw, which is tightened after the head has been brought into proper osition. I) Diseases of the Glands of the Neck.-The parotid gland is subject to inflam- mation, abscess, and sometimes to tumors, which are º; malignant. Its duct is in rare instances the seat of calcareous bodies, of wounds, and of fistulae. - Parotitis or Mumps is an idiopathic inflammation of this gland, and almost wholly confined to the young. It is a contagious disease, and gen- erally appears as an epidemic, being more frequent in males than in females. Although painful, it is ordinarily a simple affection, but may become dan- gerous when, by metastasis, it extends to the brain or testicle; it may prove fatal in the former-case, and in the latter may result in atrophy or loss of function. The severity of the symptoms may generally be controlled by THE DUCT OF STENO. 793 bell., merc., and rhus. For further treatment the student may refer to works on the practice of medicine. Abscess of the Parotid may be the result of simple inflammation, direct injury, or of erysipelas, typhoid fever, small-pox, and other eruptive dis- orders. In consequence of its proximity to certain important nerve branches, it often proves a painful affection. In many instances, by reason of the firmness of its coverings, the presence of pus is difficult to deter- mine, and may be allowed to burrow along the sheath of the muscles or large cervical vessels, causing much destruction in the cellular tissue. This disastrous condition may be avoided by making a free vertical incision in the most prominent part of the swelling, and keeping the wound open until the abscess is obliterated. The administration of the proper remedies will materially hasten the cure. Gangrene may appear in this gland during a severe attack of erysip- elas, scarlatina, small-pox, or typhoid fever, especially when these assume the adynamic type. When this complication occurs the yeast or charcoal poultice should be applied, and the appropriate remedy administered. Arsen., carbo veg., and lach. are frequently demanded. For further treat- ment see Gangrene and Mortification. Extirpation of the Parotid should only be attempted when it becomes the seat of a simple or benign growth. These tumors, in common with those situated in the submaxillary gland, are fibro-cartilaginous. They are mostly encysted, have a peculiar, hard, elastic feel, and often attain great size; their early removal is advisable. In performing the operation of extirpation the surgeon makes an incision directly over the tumor, well down to the capsule, and then endeavors to enucleate the mass. It will be necessary to proceed with the greatest cau- tion when attempting to free the deep-seated parts, lest the facial nerve, or the internal carotid artery, or the jugular vein be wounded. The danger of this occurrence should be explained to the patient previous to the opera- tion. In total extirpation of the gland the motor branch of the seventh pair of nerves is divided, resulting sometimes in temporary and sometimes in permanent paralysis of the face on that side. It is always well to remove the gland from below upward, for by this means the external carotid is brought into view during the first stage of the operation, and can be placed under control. Immobility of the gland contraindicates the operation. Malignant Tumors of the Parotid should be rarely disturbed ; on exami- nation they seem fixed, diffuse, and deeply seated. Any attempt at motion of the part causes pain, and paralysis of the facial nerve is generally pres- ent. They are fibrous, scirrhous, melanotic, or encephaloid in character, and prove fatal by constitutional irritation, or by ulceration and profuse discharge. ſº The Duct of Steno.—The excretory canal of the parotid may suffer in face wounds, or from ulceration, abscess, or gangrene. Such an occurrence is unfortunate, as it may establish an obstinate form of salivary fistula. If the canal is divided by a wound the ends should be carefully adjusted and held in place by the twisted suture and a compress. This will ordi- narily effect a cure. When the fistula is the result of the other causes mentioned, a cure is not readily obtained, but may be accomplished by cauterizing the parts, thus causing the external orifice to close by granulation. If, however, the oral end of the duct is obstructed, it will be necessary either to open it by a probe passed through the fistula into the mouth, or by, forming a new opening near the oral end of the duct. This should be kept open by a seton, till a free channel for the saliva is established, when, upon the removal of the seton, the external opening will con- tract and close itself. If the process of cicatrization is tardy, it may be 794 A SYSTEM OF SURGERY. hastèned by the application of caustics. Should these measures fail, a plas- tic operation can be resorted to. A Salivary Calculus may sometimes obstruct this duct. If the attending symptoms are severe, it must be removed by opening the duct within the mouth, which is easily accomplished. The Submaxillary Gland occupies a position so well protected that it is rarely the seat of any disease demanding surgical interference. It is sub- ject to enlargement and indurations caused by decaying teeth, cancer of the tongue, or affections of the neighboring lymphatics; but this condition will subside on removal of the cause of irritation. In common with the parotid, it may be attacked by the same forms of malignant disease to which that gland is liable. A careful distinction should be made between simple and malignant disease of this organ; for in the former case, the removal of the cause is followed by speedy recovery, Y. in the latter, no permanent benefit may be expected. See chapter on Ulſ] OTS. Operations in this region involve the facial and the sublingual artery and the hypoglossal nerve, which are to be avoided. g? Calcareous Formations are occasionally found in the excretory duct of this gland also, and give rise to symptoms similar to those found in obstruc- tion of Steno's duct; swelling of the side of the tongue and jaw, with pain and difficulty of mastication. They may be removed by incision. Cystic Tumors of the Neck.-Cysts develop in the neck either beneath the ear and jaw or above the clavicle. If lying beneath the deep cervical fascia, they are at their inception somewhat difficult to diagnose, as the tense fascia covering them obscures their fluctuation and increases their elasticity, thereby mixing their more obvious characteristics. These neo- plasms are painless, the suffering arising from the pressure symptoms. For further information the reader is referred to the latter part of the chapter upon Tumors (vide Cystic Tumors, page 190). Goitre, Bronchocele, or Derbyshire Neck is a chronic enlargement of the thyroid gland. It usually affects both lobes (see Fig. 490); in some cases it is confined to the isthmus of the gland. The swelling varies in size from a slight increase of natural structure, to the bulk of an adult head; Aliberti relates a case in which the hypertrophied gland hung as low as the thigh. Goitre seems to be endemic in certain parts of Swit- zerland and England. It is more common in women than in men, and in some cases seems to be hereditary. It is found associated with cretinism, and also with “exophthal- mic goitre,” generally known as Basedow’s or Graves's disease. Other tumors of the neck may be mistaken for goitre, but the latter may readily be diag- nosed, by directing the patient to imitate the act of swallowing; if the tumor follows the motions of the larynx and trachea, and at the same time occupies the natural situation of the thyroid gland, there can be little doubt of its nature. The causes of the dis- ease have not been satisfactorily explained. By many it is supposed, though erroneously, to be a scrofulous affection, Unwholesome diet, intermittent fevers, and drinking of snow-water, have been imagined by others to give rise to it; but all these causes are hypothetical. FIG. 490. Bronchocele. TREATMENT OF GOITRE. 79.5 Treatment.—The principal medicine in the treatment of this disease is iodine, which has been used by practitioners from a remote date, but with inconsiderable success from its improper administration; indeed, in many instances, the drug, instead of ameliorating, has aggravated the affection. The iodine should be used in drop doses, and, according to Mr. Cameron,” repeated every second day. . Natr. carb., continued for some time, relieved a globular and somewhat indurated enlargement of the upper part of the thyroid gland. In another case calc. carb. afforded speedy relief. Staphis., together with lyc., has also been of service. Spongia, is a medicine of power in producing relief, if it does not absolutely cure the disease. Halei recommends phytolacca dec. and podophyllum as successful, and iris vers. would seem from its provings to be useful. Dr. Craig has found Sal ammoniac more successful than any remedy here- tofore tried by him. M. Maumene, a French chemist, says, that in countries where goitre pre- vails, fluorides are contained in the water; he declares that he has proved it and has artificially produced goitre with fluoride of potassium in animals. In addition to these medicines, a judicious hygienic treatment should be adopted. In districts where chalk, lime, or magnesia abound, the water should be filtered or distilled before using. The practice of placing solid iodine in the room occupied by the patient, and thus keeping the air im- pregnated by its exhalations, has produced happy results. An ointment of iodine may be applied with benefit, and Dr. Mouat, of Bengal, speaks i highly in favor of an ointment composed of biniodide of mercury, three drachms to one pound of lard. This is to be rubbed upon the tumor thoroughly, then the patient allows the rays of the sun to fall upon the parts as long as they can be endured. In a short time another application is made, and in many instances no further interference is necessary. He reports an almost incredible number of cases cured by this method. I have used this treatment with success in several cases, substituting the heat from a kitchen-range for the rays of the sun, and administering iodine internally. Sometimes a better heat may be obtained by allowing the patient to sit in the Sun, bringing its rays to a focus by means of a convex lens upon the enlarged gland. - Some surgeons have recommended and practiced the injection of tinct- ure of iódine into the tumor, while other speak favorably of the use of the Seton. At present, electrolysis is perhaps the most successful method of treat- ing goitre. See chapter on Minor Surgery. Extirpation of the gland has been practiced, and the later results are some- what more favorable than the earlier; however, the operation is scarcely jus- tifiable, especially since Prof. Bruns, of Tübingen, has noted that when the thyroid body has been completely removed, the patients within two or three years began to waste and became cachectic, and finally died. Dr. John A. Wyeth has, however, successfully removed the thyroid gland on two occasions, and Burckhardt, of Stuttgart, has operated seventeen times with success.S. He first exposes the capsule of the gland by an incision in the median line or along the border of the sterno-cleido mastoid. The ves- sels above and below are carefully ligated, and the cyst laid open. The sac must then be enucleated with the fingers, every adhesion being tied in two, * An interesting and important paper on Bronchocele, by H. Cameron, Esq., M.R.C.S.E.,. British Journal of Homoeopathy, vol. iii., p. 469. † New Remedies, pp. 771 and 817. † India Annals of Medical Science, 1857. 3 Centralblatt für Chirurgie, No. xliii., 1884. 796 A SYSTEM OF SURGERY. places, and severed between the ligatures. Drainage tubes are finally in- serted and the wounds closed. Dr. W. W. Green, of Maine, reported three operations successfully performed by him. - Ligation of the arteries which supply the gland (“starvation of the tumor") has been tried with varying results, the cases reported as cured by this method being few. In exceptional cases the tumor may so compress the trachea as to render tracheotomy necessary. I have received from Dr. E. J. Whitney, of Brooklyn, a synopsis of Dr. Mackenzie's treatment of goitre. Dr. Whitney spent a season in London visiting Dr. Mackenzie's clinics, and speaks highly of the success of the treatment: he informs me that Mackenzie divides bronchocele into seven classes: 1. Adenoid or simple. 2. Fibrous. 3. Cystic. 4. Fibro-cystic. 5. Fibro-modular. 6. Colloid. 7. Vascular. The first class require little treatment except of a constitutional character, as the disposition of these growths tends toward recovery without local interference. In fibrous bronchocele, the treatment consists of a seton passed trans- versely through the whole of the gland. The seton is composed of from six to twelve threads of cotton twine, according to the size of the tumor, and its insertion may be rendered comparatively painless by applying a spray of ether to the points of entrance and exit of the needle. These threads are allowed to remain until suppuration is well established, when they must be withdrawn and the tumor treated as an abscess. The cystic bronchocele varies greatly in size, but is always of a globular or ovoid form. As a first step in the treatment of this variety, he empties the cyst by entering a small trocar as near the median line as possible, and at the most dependent portion of the tumor; having pierced the wall of the cyst, the trocar may be withdrawn, and the canula stopped by a key or plug. If the growth should be multilocular, the canula may be moved about within the tumor, breaking down the walls of the several cysts, which having been accomplished, the plug is removed, and the fluid contents allowed to escape through the tube. He then injects into the sac about one drachm of a solution of ferri perchloridi, 3ij of the salt to water 3.j, replaces the plug and retains the canula in position with adhesive plaster. This process is repeated at intervals of two or three days, until suppuration takes place, when the tube is removed and a poultice applied, as in abscess. When several cysts exist, by opening them within the tumor much dis- figurement from scars may be avoided. It will be seen that the treatment consists in converting the tumor into a chronic abscess, and following with the appropriate after-treatment. Mackenzie states that out of 39 cases of cystic goitre, 38 underwent this operation, and it proved successful in every instance. - In fibro-cystic bronchocele the treatment is a judicious combination of the seton and puncture. The fibro-modular has not been treated with much success. Colloid bronchocele has been treated with electricity, but the results are not satisfactory. It is believed that the seton could be used with benefit. The seventh form, the vascular bronchocele, is so rare that no treatment is recommended. It is improbable that a case would be met with in the course of a long and extended practice. Rupture of the CEsophagus.-The oesophagus may be ruptured during life; it may be occasioned in different ways. The common causes are perfora- tions made by abscesses, by aneurisms, by the sharp projections of foreign bodies, or by sloughing from caustics. These cases are not uncommon. STRICTURE OF THE CESOPHAGUS. 797 Others are caused by straining during vomiting, or by the effort to expel impacted bodies. Dr. George C. Allen, of Boston, recorded such a case, and Dr. Fitzº has given much time to looking up its literature. He states that Boerhaave, Ziesner, Dryden, Kade, and others, who have reported cases of ruptured Oesophagus, find that pain is not a prominent early Symptom, and that nausea and vomiting and sometimes vomiting of blood are always present. In conclusion he remarks: “The patient falls into a condition of great exhaustion after the violent straining, from which he rallies in the course of twenty-four hours, when fever is evident. The emphysema advances, the patient has difficulty of breathing, there may be orthopnoea even, also slight cyanosis, and death may occur within fifty hours, or may be postponed seven or eight days. When the disease assumes a protracted course, it is essentially a gangrene of the mediastinum, combined with gangrenous pleurisy; there are con- tinued fever, great prostration, mild delirium, pains in the stomach and chest, and bloody stools after a time. Tetanic convulsions may occur, if the inflammation in the mediastinum involves the nerves along the spine. - All these symptoms are equivocal, and Hamberger says, “We must admit that up to the present, the diagnosis is first made on the corpse, and often contrary to all expectation.” In the treatment little can be done, but small quantities of food must be taken at a time. If by any means a proper tube could be passed from the mouth to the stomach, and the patient fed through it, an opportunity might be given for the rent to heal. I am not aware that this method has been tried, or even recommended by any one, but it strikes me as feasible. (Esophagitis, Inflammatio (Esophagi—This is a disease of infrequent occurrence and cannot be seen by an examination. There is local pain behind the trachea and between the shoulder-blades towards the heart, along the spine, under the sternum or xiphoid cartilage; the pain is constant, and of an aching, stinging, and burning kind. There is little fever, although much thirst, which the patient cannot gratify in con- sequence of the pain occasioned by swallowing. Food passes with pain and difficulty, and is at times thrown upward in consequence of a spasmodic action of the parts; there is nausea, vomiting, much tena- cious mucus in the mouth, hiccough with anguish, distorted and pale face, pulse small and contracted, congestion of blood to the head, con- vulsions. Treatment.—The medicines for this disease are: Belladonna, arnica, coc- culus, arsenicum, sabadilla, rhus rad., rhus tox., daphne mezereum, lauro- cerasus, carbo vegetabilis, mercurius solubilis. - Stricture of the CEsophagus is a disease possessed of interest both to the surgeon and the physician. Its causes are various: sometimes they are attributable to the action of irritants; sometimes to injuries; at times to compression from external growths, and frequently to an irritation of the tube arising from chronic indigestion. When we consider the anatomical structure of the oesophagus, and the great variety of substances that are taken into the stomach, both hot and cold, sour and sweet, the rich and highly seasoned compounds of the kitchen and the indigestible aliment of the confectioner, all of which pass over the mucous membrane of the tube; it is a matter of surprise that more disease is not developed in this portion of the alimen- tary tract. * American Journal of the Medical Sciences, January, 1877, p. 17. 798 A SYSTEM OF SURGERY. So far as my observation and reading extend, I believe that stricture of the Oesophagus is rarely idiopathic, being generally accompanied by disease of other portions of #. digestive apparatus, notwithstanding cases have occurred in which it can be attributed to the action of medicinal substances. Wolfº reports the case of a man, aged twenty-six, who accidentally swal- lowed some oil of vitriol; great inflammation followed, contraction of the Oesophagus resulted, and increased to such a degree that, upon his admission into the hospital, he had lost all power of swallowing—a perfect stricture hav- ing formed. A similar case, arising from swallowing carbolic acid, occurred in my practice. There are three varieties of stricture: first, the spasmodic ; second, the chronic induration ; third, the malignant ; the latter arising from carcinoma, and attended with ulceration and perforation. Many excellent authori- ties make but two divisions, the first being the spasmodic, the second the organic, the latter embracing the chronic induration and the malignant variety. In spasmodic stricture the circular muscular fibres are the seat of the affection; the disease occurs at intervals, the patient suddenly finding him- self incapable of swallowing, at the same time experiencing a sensation of choking; added to this, there is not much emaciation, although there is generally great nervous irritability of the whole system. The disease is more prevalent among females than males, and is amenable to internal medicines. One of the most interesting cases of this kind has been recorded by Dr. B. F. Joslin, Jr., of New York. The patient suffered extremely, and, not- withstanding the best-directed efforts, finally suc- FIG. 491. cumbed to the disorder. The post-mortem ex- - amination revealed a small, hard, Osseous tumor, an inch long, and half an inch in breadth, with various spiculae of bone projecting from it, situ- ated just above the bifurcation of the trachea ; a merve was found very intimately connected with the anterior face of this tumor. Dr. Joslin considers this filament to have been a cardiac branch of the pneumogastric nerve, the irritation of which, by the presence of the tumor, caused the difficulty in swallowing. The writer says, the bony tumor “ did not press on the oesophagus, and was only loosely attached to the trachea; it was firmly adherent to the posterior portion of the vena cava superior; it could only be implicated in the production of the symptoms by its relations with the pneumogastric nerve.”f In organic stricture (Fig. 491) the symptoms are different: there is always accompanying in- digestion, and the symptoms of dysphagia are: generally the same; there is a peculiar expres- sion of face, the features being pointed and exhibiting tokens of anguish and distress; ema- O ic Stricture of the * s tº * & *ś. ciation is marked. The patient swallows food or drink, or at least passes it through the fauces and along the oesophagus until it meets with the stricture, there it remains for a moment and is regurgitated. The constant effort made * Ranking's Abstract, No. xviii., p. 246. f A Singular Case of Spasmodic Stricture of the CEsophagus. By B. F. Joslin, Jr., M.D., North American Journal, No. xxxiii., p. 134. TREATMENT OF STRICTURE OF THE CESOPHAGUS. Pºw 799 by the patient to effect an entrance into the stomach, and the presence of the food immediately above the stricture, in time develop an enlargement of the part, so that in many cases of organic constriction there is formed above the site of the disease an expansion or pouch. This sacculation may be enormous. Rokitansky mentions a case in which the passage was large enough to admit a man’s arm. Mottº refers to a case in which a pouch was formed four inches in diameter; and there are other cases noted in which the dilatation was considerable. Mott's case is interesting because it points to the fact that beside the mucous and submucous tissues, muscular fibre also may enter into the formation of organic constriction; in which view, Gross and Miller coincide, although the former states that only in the aggravated cases the last-named constituent assists in the formation of the stricture, while in ordinary cases, the mucous and submucous coats are affected, there being a deposit of plastic material in the part, causing thick- ening of the tube.f. The seat of stricture is said to be generally opposite the cricoid cartilage. In the carcinomatous stricture, the disease is generally scirrhus, and begins in the submucous tissue, posterior to the thyroid cartilage or upper por- tion of the trachea. There is difficult deglutition, with severe pain, often of a burning character, when swallowing, liquids being more easily managed than solids. The pain in some instances is referred to the thorax and sometimes to a spot between the shoulders. The lancinating pains common to cancer are always present, as are the constitutional symptoms, viz., general emaciation, sallow, cadaverous skin, entire loss of appetite, and prostration. The patient may die of hectic, inanition, or haemorrhage from ulceration. r . - Treatment.—The medicines that are adapted to the treatment of the dis- ease are bell., hyos., and conium. These agents, judging from their patho- geneses, would be most appropriate; indeed, the latter (hyos. and con.) are recommended by allopathic authority; other medicines may be required, among which are lyc., nux, stram., acid. Sulph., verat., etc. - Dr. B. F. Joslin, of New York, has given the pathogeneses of several medi- cines applicable to stricture of the oesophagus, to which the student may refer. See note, page 798. For carcinomatous stricture the medicines are: arsen., phytolacca, apis, carbo veg., lachesis, gallium aperinum, and those which have already been noted in the chapter on Cancer. Should the administration of these fail to relieve the patient, they may be employed together with the use of the bougie, which instrument should be curved to correspond to the passage. The patient should be directed to throw his head well back, and to swallow while the surgeon introduces the bougie, which should be warmed, and passed steadily and gradually from the posterior part of the pharynx to the seat of stricture. The instrument is to remain a short time within the oesophagus, and the operation repeated once or twice a day, or at longer or shorter intervals, according to the judg- ment of the surgeon. A good method of treating stricture of the oesophagus is that introduced by Jameson, who used eight or ten separate graded probangs, each consisting of a stick of whalebone having affixed to one of its extremities a spindle- shaped piece of ivory. The instrument first introduced is small, but after the stricture has been removed sufficiently to readily admit the passage of one probang, a larger size must be selected. The operation must be frequently * Operative Surgery, vol. iii., p. 499. f Gross's Operative Surgery, vol. ii., p. 656. 800 e A SYSTEM OF SURGERY. repeated, each time using a larger-sized instrument, until the obstruction is removed. These probangs are now made of hard rubber. Electrolysis, however, is the best method. In a severe case of stricture of the oesophagus, which had been pronounced incurable by a distinguished specialist, and in which I had patiently tried dilatation, the patient was entirely cured by electrolysis in the hands of my friend Dr. Butler. In applying this, no one but a skilled specialist should be trusted. The operation is difficult and delieate, and unless the operator is familiar with the use of the electrodes injury and danger may be apprehended. - . Foreign Bodies in the CEsophagus.-Extraneous matters frequently lodge in the Oesophagus; particularly articles of food, portions of which, from hurry or voraciousness in swallowing, are impacted in the superior portion of the tube; such articles are beef, gristle, tripe, cheese, etc. On other occa- Sions the patient is choked from having accidentally swallowed articles carelessly placed in the mouth, as coins, pins, needles, etc. In these days of cheap false teeth, many more cases of obstructed oesophagi are noted, most of them being the accidental displacement of poorly-fitting artificial i. (Wide section on CEsophagotomy.) Death has ensued from such acci- entS. Dr. Aschenborn” relates the following interesting case: “A young man felt severe pains during respiration, but had two days before suffered pains in the epigastric region and along the gullet after Swallowing what he supposed was a hard morsel of bread. On the fifth day an incision was made in the posterior wall of the pharynx, yielding an offensive sanious fluid of a dark color, but no pus. During the night a copious stool of pure blood was passed. He rallied somewhat during the day from the use of port wine and camphor, but without warning, immense haemorrhage from the mouth ensued, and he died soon after. The necropsy revealed a rent two-fifths of an inch in the oesophagus, about four inches from the cardia, at right angles to which was found a needle about two inches long, piercing both walls of the descending aorta from before backwards.” Treatment.—The foreign substance in many instances is lodged between the thyroid cartilage and the cornua of the os hyoides; in this situation, FIG. 492. Burge's CEsophagotomy Forceps. if the body be large, it may be reached and extracted with the fingers; if small, as a fishbone, a pin, or a needle, forceps should be employed. Fig. 492 shows Burge's forceps, which are curved, with handles at a right angle. Sometimes, by tickling the fauces with a feather or by exciting vomiting by emetics, the irritating substance can be expelled. Curved and other forceps have been employed, but when the surgeon is called to a patient who is in imminent danger of suffocation, these instruments may not be at hand, and delay occasioned in procuring them may prove fatal. In such instances the handle of a spoon, the fingers, or other convenient article should be selected, and the foreign substance * The American Journal of the Medical Sciences, April, 1878, No. cl. INTRODUCTION OF TUBES. 801 either dislodged, withdrawn, or, if the article be digestible, forced into the stomach. The ordinary probang—a whalebone rod with a round piece of Sponge attached to one end and a blunt hook to the other—is the instrument used by surgeons for this purpose. A forceps known as the alligator forceps (Fig. 493) is useful for ex- tracting foreign bodies. By referring to the figure, the mechanism can be FIG. 493. Alligator Forceps. understood. The bristle or umbrella probang is also a serviceable instru- ment, as is the flexible tube of Tiemann (Fig. 494). FIG. 494. Tiemann's Spiral Throat Forceps. After the extraneous matter has been dislodged, the patient should gar- gle the throat, frequently with a weak solution of arnica, and the same medicine should be administered internally. Introduction of Tubes.—The successful passage of tubes, whether for the dilatation of stricture, or the introduction of the stomach-pump, must de- pend upon a knowledge of anatomy and dexterity in manipulation of the FIG. 495. & #==== 23 agº. ſ: instrument. The stomach-tube should be twelve to eighteen inches in length, and should be well oiled. The patient then opening the mouth wide, with the head thrown backward, the surgeon should pass the tube directly backward to the fauces; when it touches the posterior wall of the pharynx it will, if of sufficient flexibility, be made to glide into the oesoph- agus and down into the stomach without difficulty. In cases of cancer of 51 802 A SYSTEM OF SURGERY. the pharynx and oesophagus, or in organic stricture, it may be necessary to inject food into the stomach; in cases of poisoning, the injection into the stomach of large quantities of water, and the withdrawal of the same with- out moving the instrument, is a great desideratum; for this purpose the stomach-pump is furnished with valves in the piston, which may be opened and shut by turning the handle. The cut (Fig. 495) represents an improved pump, which possesses many advantages. To empty the stomach use the instrument as represented in the cut. To pump fluids into the stomach attach the catheter to the piston nozzle, b, and the soft tube to a. GEsophagotomy.—It may be necessary, when foreign bodies are lodged in the º to perform oesophagotomy, otherwise ulceration, perfora- tion, and death may ensue. It was first done in France. In the year 1738, Goursauld removed a piece of bone one inch long and six inches in breadth, by opening the oesophagus; the operation was afterward performed in 1833 in England, and to Dr. Cheever, of Boston, is said to belong the credit of the first operation in this country. The operation is not so difficult as is supposed, and is often followed by gratifying results. In twenty-one oesophagotomies for the removal of foreign bodies, seventeen were successful and four fatal. The opera- FIG. 496. tion is to be performed at either side of the neck, the point of selection being, if pºli. determined by the presence of the foreign substance; if it be felt from the exterior, the incision should be made over it, the tube passing rather to the left than to the right side of the neck; the former situation might be more favorable. The head of the patient should be thrown back, and taking the sterno-mastoid muscle as a guide, an incision four or five inches in length should be made through the integument and platysma myoides, in a line of the depression between the larynx and the sterno-mastoid, from a point near the upper border of the thyroid cartilage to near the sterno-clavicular articulation (see Fig. 496). The carotid sheath and the sterno-mastoid must be drawn outward with one retractor, and the larynx drawn inward by a second. By passing a canula into the mouth, OESOPHAGOTOMY. - S03 and down to the foreign substance, a guide is made for the incision, which may be done from without, or, if the canula is armed with a trocar, the tube can be opened from within. The foreign body must then be brought away with the forceps. The wound should be allowed to heal, few sutures being used. For the first few days the patient must be fed through a tube passing beyond the wound. Dr. Le Roy McLean, surgeon to the Troy Hospital, N. Y., reports” two cases of this operation for the removal of gold and silver plates, with teeth attached, which had been accidentally swallowed, and Dr. La Garde,i U. S.A., gives an interesting case, in which, for a similar purpose, he performed a successful opsophagotomy. Dr. McLean operated as follows: Chloroform having been administered, an incision was made on the left side of the neck, midway between the margin of the sterno-cleido-mastoid muscle and the thyroid cartilage, extending to within half an inch of the sternum. The parts containing the carotid were then separated from the trachea and held aside by retractors, as was the left lobe of the thyroid body after careful dissection. The inferior thyroid artery having been exposed and pushed aside, the oesophagus was plainly seen. A large-sized lithotomy staff was passed through the mouth, it being more easily introduced than a stomach-tube, and the oesophagus pushed well forward and to the left. This served as a guide, and held the oesophagus in position, rendering the in- cision into it less difficult than it otherwise would have been, owing to the spasmodic efforts of swallowing, which were very frequent after the admin- istration of the anaesthetic. The incision was made longitudinally from the staff to the side of the cricoid cartilage, and the plate removed by the finger with some difficulty. Forty-eight hours after the operation the patient Swallowed fluids readily, and eighteen days later the wound had closed, and he resumed his business. After this the voice, which had been faint and husky since the accident, gradually grew stronger, until it reached its natural standard. In the second case, the difficulty of swallowing being felt only at intervals, and the patient suffering no essential inconvenience, the teeth were for some time supposed to have passed into the stomach, and the operation was not determined upon until eleven months from the date of the accident. It was then performed in the same manner as de- scribed, the incision being made as near the top of the sternum as possible. The silver plate was grasped and brought up by forceps, but the teeth be- coming detached passed into the stomach, and were voided by the rectum. Thirty-two hours after the operation the patient drank half a pint of coffee without losing a drop, and his recovery was rapid and complete. The voice suffered no injury. The same surgeon has since operated on three other cases, with one death from exhaustion, and in his pamphleti gives a table of 33 cases, which is inserted on the following page. CEsophagotomy for cancerous formations, however, is an operation which at this period is sub judice. Dr. S. W. Gross $ in an exhaustive paper has collected important sta- tistics on the subject. It is found that of 21 operations, 12 died from the performance of it and 5 were lost from exhaustion; and of the 4 surviving not one lived over 16 months, and one died in 2 months, making a mor- tality so large that the judicious surgeon would hesitate before submitting any patient to it. * New York Medical Record, April 29th, 1876. + American Journal of the Medical Sciences, April, 1884, p. 406. † Successful CEsophagotomy for the Removal of Foreign Bodies, by Le Roy McLean, M.D., 1884. - 3 American Journal of the Medical Sciences, July, 1884. TABLE OF CASEs of ExTERNAL CESOPHAGOTOMY FOR THE REMOVAL OF FOREIGN BoDIEs. rººm. ro ..] dº | P: 3. # # Source of Information. Nature of Foreign Body. | Point of Impaction. Tººre Time of Operation. Result. Cause of Death. Operator. OD 11738 M. Boston City Hospital Rep., p. 522. Portion of bone one inch long CEsophagus—where not Attempts to push]...................................|Cured. ...|Goursault. and six lines broad. stated; felt outside. down. 2:::::::::::: “Boston 9ity Hospital Rep., p. 52?..............................................l…...............…........::::::................................................................."Cured. .........[Roland. 3.1831M Amer. Jour. Med. Sci., vol. xiii, Portion of bone. Below cricoid carti-Forceps and probang.[12th day. Cured. ......[Begin. p. 251. From Jour. Hebdom., lage. April, 1833, No. 135. . 4.1831M. Amer. Jour, Med. Sci., vol. xiii, Portion of bone. CEsophagus; lower part Emetics, forceps, and 8th day. Cured. ...[Begin. p. 251. From Jour. Hebdom., of neck. probang. - April, 1833, No. 135. 51833Child. St. Barth. Hosp. Re ., vol. iv, p. Fragment bone (spinous pro-Lower part of phar-Emetics and variousAfter 5 weeks, on right'Death in 56 hours. Pneumonia at time|Arnott. | 204. From Med.-Chir. Trans. cess, dorsal vertebra, sheep) ynx. tºps to dis- #. * * Middlesex of Operation. Odge. QSpital. 61842.M. Half-Yearly Abst. Med. Sci., vol. Portion of bone. CESophagus perforated;.................................. 8th day. Cured. ...|De Lavacherie. iii, p. 215. - From Jour. de Chir- lying on carotid. urg., Nov. 1, 1845, p. 337. 7.1844. M. Half-Yearly Abst. Med. Sci., vol. Portion of bone. Felt outside over claw-Bleeding, tartar emet-4th º: bone swal-Death in 2 days. Collapse; pharynx|Martini. ii, p. 120. icle. ic into veins, bella- lowed. g a ng re n Ou S ; donna en e m at a, stomach inflam- and sixty attempts ed; bone found g g to dislodge. in rectum. * Boston City Hospital Rep., p. 522. Small fish. Pº tail seen in Aºi, t O #.raw Several days. Cured in 6 weeks. [..............................Antoniecz, * e auges. . rough mouth. e 9.1853.M. Boston City Hospital Rep., p. 522. Fragment of beef-bone. CEsophagus, in neck. Attempts to extract. 9th day. Death 2d day. Pººh iro nt. Flaubert. * and penind; re- tro-ph a ryngeal - abscesses reach g e stomach. 101854. F. Boston City Hospital Rep., p. 522. One-franc piece. Upper part of oesopha-Used Graefe's sound 10th day. Death 3d day. R. etro-oesophageal Demarquay. gllS. and forceps repeat- abscess opening i. into pleura. * tº º ſº tº e º 'º e º Boston City Hospital Rep., p. 522. Portion of bone. ºus ** not be reached 16th day. Cured in 2 weeks.h.............................. Syme. OTſſle Ol. y forceps. 12.1856.M. Guy's Hospital Rep., N. S., vol. Gold tooth plate with false|Junction of pharynx. Forceps and emetics. 4th day. Cured in 4 weeks;|..............................|Cock. iv, p. 217. incisor. and Oesophagus; no, permanent al- external projection. teration of voice. 131861|F., 45. Brit, Med. Jour., Aug. 24, 1861, p. Flat piece of mutton-bone Esophagus; no exter-Could not be touched 6th day. Cured in 2 weeks.l..............................Syme. 193. ſº one inch square. nāl projection, | by forceps. 14|1862.M., 21. Bºſed. Jour., March 22, 1862, Copper coin. Opposite top of ster-Touched by bougie. 3 months. Chºº ºllowed ..............................Syme. & ſº ºf ºlº p In Ulm. Ill i WěCK. 151862 M. Bëº, City Hospital Rep., p. 522. Fragment of bone 2 in. long. Top of oesophagus. Attempts to extract. 2d day. Cured in 4 Weeks.l..............................[Inzani. 161863 M. Boston City Hospital Rep., p. 522. Bone. “.…........…..................….......................l................................... Cured. © & ..................Sourier. Boston City Hospital Rep., p. 522. Peach-Stone. “...........................l..................................l................................... Cured. ...............Arnold. ExTERNAL CEsophagotoMY-(Continued.) rd ... d5 H 3. # # Source of Information. Nature of Foreign Body. | Point of Impaction. tºº Time of Operation. Result. Cause of Death. Operator. CD 18:1866 M. Boston City Hospital Rep., p. 522. Codfish-bone. Junction of pharynx|Vomiting; finger and 3d day (right side). Cured. ......|Cheever, and Oesophagus; no probang; rigors. projection. - e * Boston City Hospital Rep., p. 522. * pin. Below top of sternum; Wºng; long pro-3d day. Cured in 5 weeks.l..............................|Cheever. no projection. 8, Ilg. 201867M., 33. Gº ºp. Rep., 3d Series, vºws: tooth-plate. Opposite left cricoid. Attempts to extract. ..|Cured. ... Cock. XIll., p. 1. 21|1867 F., 49. Boston Med. and Surg. Jour., N. Common pin. Apparently opposite|Attermpts during four. After 4 months no for-Cured. ...|Hitchcock. S., vol. i., p. 373. | eft Cricoid. months. eign body found. - 22.1868.F. Boston City Hospital Rep., p. 522. Supposed to have been a pin. Junction of pharynx|Various attempts. After 8 months no Cured. ....|Cheever. and Oesophagus. foreign body found. 28.1870 F. Boston Med. and Surg. Jour., N.A. cent one inch in diameter. Junction of pharynx|Repeated efforts to re-5th day, Cured. ...|Atherton. | S., vol. vi., p. 81. and Qesophagus. In OWe. 24,1874.M., 30 Med. Rec., vol. xi, p. 282. Crescent-shaped (one and Behind thyroid carti-Attempts with for-...................................|Cured in 22 days...............................|McLean. t one-half inches by one-half lage. Ceps (voice impair- inch) gold tooth-plate. ed, but recovered). 25.1874 M. Med. Rec., vol. xi, p. 282. Dislodged four false teeth Cardiac portion of Attempts to remove. 11 months 7 days. Cured. ...'McLean. with plate; remained elev- Oesophagus, en months and seven days, and formed stricture. 26...... F. Med. Rec., vol. xi, p. 828. From Fragment of bone. ...|Attempts to push]............ .....|Cured. ... Cozin. §"is º Med. et Chirurg., down. ov., 1876. 27|1878.F., 49. Boston Med. and Surg. Jour., N.Flat fish-bone one and three-Opposite cricoid car-Sponge and bristle Next day, Cured in 20 days,|.............................. Gay. | S., vol. C., p. 356. - fourths inches long by one- º in posterior probang. third inch Wide. wall of pharynx. 28.1878 F. Trans. Clin. Soc. of London, Vol. False teeth. oº:: middle of Probang. 3 Weeks. Cured. .............McKeown. xi, p. 233. thyroid cartilage, © and extending i nearly to sternum. 29.1879F., 30. Lancet, Feb. 1, 1879, p. 155. Piece of vulcanite , tooth-Behind glottis, but Attempts with for-13 days. Cured. ...|Alexander. plate one-half inch long by disappeared by pa- ceps. - one-quarter inch broad. tient's own efforts to remove; pain at • middle of gullet. * F., 16 Med. Rec., vol. xxvi, p. 281. Nickel cent. Below levelof clavicle.|Probang. 5th day. Cured. ......'McLean. In OS. *. 36. Med. Rec., vol. xxvi, p. 282. Tºplate with two incisor Cº., portion of Olive pointed pro-12 years and 2 months.|Death in 48 hours. Exhaustion. McLean. €6th. Oesophagus. ang. sºlesºn, 26. Am. Jour. Med. Sci., vol. lxxxvii, Portion of tooth-plate. Oº the cricoid Probang and forceps. 2d day. Cured. ...!La Garde. cartilage. Probang. 6th day. Cured. & a tº tº a 4 …McLean. **. sexed. Rec., vol. xxvi, p. 282. Tºplate With four incluº portion o eeth. Oesophagus. In the above cases of Oesophagotomy, twenty-eight were cured and five died. 806 A SYSTEM OF SURGERY. SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA. Syphilitic Laryngitis.--This affection is very common, and oftentimes in- tractable. The use of the laryngoscope has facilitated the diagnosis of the different forms of secondary syphilitic disease which are found in the larynx, and which, before the use of the instrument, were much involved in obscurity. The more simple form is that of erythema, in which slightly elevated mucous patches are seen, of a dark reddish hue, accompanied by dryness of the fauces, hoarseness, and sometimes a slight tickling cough ; after a time, a syphilitic ulceration results, which extends frequently to the pharynx and throat. In the tertiary form of the disease, elevations and ulcerations are discovered throughout the mucous membrane, the former resembling condylomatous growths. They also occur in the shape of sub- mucous patches and tubercles, which readily ulcerate. Treatment.—In the treatment of erythema of the larynx the following remedies will be found indicated: Aurum, arsenicum, kali iod., merc. Sol., nit. ac. Mucous Tubercles will readily yield to argent. nit., calcarea, nitric ac., uls., or thuja. If the disease extend into the nose, favorable results will ollow the use of argent. nit., aurum, kali c., creasot., lycop., merc. corr., nit. ac., phos. ac., puls., rhus, Sepia, staph., and thuja. For deep-8eated tubercles administer arsen., carbo veg, natrum mur., and zincum. For further treatment the student is referred to the Chapter upon “Syphilis.” Foreign Bodies in the Larynx and Trachea.—Although the presence of foreign bodies in the air-passages is to be regarded as a serious occur- rence, it is astonishing what a length of time a foreign substance may be impacted in the larynx, and the patient be unaware of its presence, attributing the symptoms to some other cause. Both Gross and Hamilton record cases of this description, and many others are upon record. In my practice I have seen several examples of this kind. In one case, a subject to epilepsy accidentally swallowed during a convulsion a plate to which were attached two artificial teeth. He supposed he had lost them, and was shortly after seized with cough, which continued with profuse expectoration for many months, accompanied with night-sweats, emacia- tion, and hectic. He was seen by distinguished stethoscopists, who pro- nounced the case one of laryngeal phthisis. (This was before the days of laryngoscopy.) He was regarded as incurable. Upon one occasion, when a procession was passing the house, he was supported at a window; in attempting to cheer some friends whom he recognized, he was seized with a fit of coughing and the foreign substance was expelled. The pa- tient made a good recovery. In another case, a child swallowed a bone button, and, with the excep- tion of occasional attacks of dyspnoea, suffered nothing for three years, when the button was expelled. A number of cases in which the offending substance was removed without resorting to artificial means are upon record. - Goodall, of Dublin, pointed out the fact that foreign bodies were more likely to lodge in the right bronchus than in the left, owing to the large size of that tube. The symptoms are those of stenosis of the air-passages, and at times there is difficulty in diagnosing whether these manifesta- tions are those of disease or of mechanical obstruction. There is violent, abrupt, convulsive cough, coming in paroxysms, accompanied with blue- ness of the face and stridulous breathing. The cough remits and recurs often upon the slightest exertion. The voice is altered, sometimes being entirely gone and at others only impaired. It must be remembered that TRACHEOTOMY. 807 death may occur, not alone from the presence of the foreign substance, but from spasm of the glottis induced by its presence. If the surgeon is unable to determine whether the foreign body is in the larynx or pharynx, the patient should be made to swallow; if the obstruction is in the latter, there will be difficulty, and vice versa. Treatment.—The first thing to be done when called to see a case in which a foreign substance has become lodged in the air-passages, is to raise the patient by the heels and slap him upon the back, giving him an occasional shake. It must be borne in mind that this procedure may have a tendency to shut the glottis, and, therefore, the surgeon must be prepared for an emergency. In general, it is necessary to perform bronchotomy. Bronchotomy.—Bronchotomy is a general term applied to the operation of opening the windpipe, and includes three separate operations, known as laryngotomy, tracheotomy, and laryngo-tracheotomy, and which derive their names from the parts involved in the procedure. The object of either of these is to admit the passage of air into the lungs when some obstruction exists, or to remove a foreign body or morbid growth from within the air- passages. The conditions which render one of the above advisable, are foreign bodies in the air-passages, acute or chronic laryngitis, Oedema glotti- dis, polypi, tonsillitis, abscess of tonsils or pharynx, aneurism of the carotid artery, and membranous croup. Sometimes a mass of food may become impacted in the Oesophagus, and by its pressure on the trachea so obstruct respiration that an operation becomes necessary; and the same thing may be called for occasionally in suspended animation. - Laryngotomy is an operation by no means difficult, and is rarely de- manded, except in adults, when some obstruction exists above the rima glottidis. Place the patient upon the back with the head thrown back- ward and the shoulders elevated ; make an incision in the median line from the top of the thyroid cartilage to the base of the cricoid, dividing succes- sively the integument and superficial fascia. The only important vessel likely to suffer is the crico-thyroid artery, which may be controlled by torsion or the ligature. It only remains to divide the crico-thyroid mem- brane in the line of the wound already made. Tracheotomy.—According to Dr. Charles A. Leale,” tracheotomy was first successfully performed in 1782 by Dr. John Andree, of London. In 1825 Bretonneau was successful, and in 1832 Trousseau followed his example. Voss has collected 1249 cases with 249 recoveries. According to the statistics published by Sanne in 1877, and presented by Dr. John C. Peterst to the New York Academy of Medicine, in March of the same year, in 2290 cases there were 516 recoveries. Gayi finds that in the Boston City Hospital, out of 206 cases of trache- otomy performed within twenty years, there were 65 recoveries, or about 31 per cent., and Agnew $ shows that in 11,000 cases, the recoveries are about 30 per cent. - The operation is not always simple, and the difficulties attending its performance are sufficient to demand coolness and caution. It may be necessary to work rapidly, but hurried movements may cause unfortu- nate complications. Tracheotomy in children is especially troublesome, on account of their short thick necks, and the cries and struggles by which they resist any manipulations; for this reason, an anaesthetic should be administered whenever practicable. The incision begins immediately below the cricoid cartilage, and extends for two or two and a half inches * Medical Record, March 24th, 1877. f Loc. cit. † Reference Hand-Book of the Medical Sciences, vol. ii. Croup. New York, 1886. 3 Principles and Practice of Surgery, vol. iii., 1885. 808 A SYSTEM OF SURGERY. along the median line towards the top of the sternum. With the handle of the scalpel, the sterno-hyoid and sterno-thyroid muscles of each side are separated and held apart by blunt hooks; the plexus of thyroid veins are then brought to view, and drawn aside by a retractor. The left index FIG. 497. FIG, 499. Tracheal Dilator, FIG. 498. Tracheal Dilator. - Chassaignac's Tracheal Dilator. finger serves as an excellent guide, and should be kept constantly in the wound until the rings of the trachea are felt, then the parts should be carefully separated with the knife handle until the white cartilaginous rings of the trachea can be seen, and when this point has been reached, the trachea may be opened by entering the knife at right angles to the FIG. 500. FIG. 501, lane of the wound, cutting upward in the line of the incision. Care must i. taken to avoid wounding the isthmus of the thyroid gland, but if this accident should occur, the hamorrhage is to be controlled by ligatures. The tracheak incision should be at least one inch in length, and is at once indicated by a rush of air, blood, and mucus. TRACHEOTOMY. 809 As soon as the rings of the trachea are opened, a dilator, as seen either in Fig. 497 or in Fig. 498, should be introduced into the wound, and the handles opened until the trachea is sufficiently dilated to admit the tubes. Fig. 499 shows the tracheal dilator of Chassaignac. Through this opening the canula (Fig. 500) with its pilot, is introduced and confined by tapes passing around the nape of the neck (Fig. 501). sº º º T Forceps for extracting Foreign Bodies through the Canula. If a foreign substance is the offending object, the opening may be dilated by retractors, when it will generally be expelled, or may be sought for by the forceps (Fig. 502). Mr. Stohlmann has modified the doublecanula of Mr. Durham, of England. The instrument has an outer tube with a sliding portion which works in a collar and is fixed by a screw. This allows the tube to be either shortened FIG. 503. \UITIIIſº jº Tilſill | illillºs *} F #!, # E. : :=º or lengthened in accordance with the depth of the trachea. The inside tube is flexible, and is furnished with a blunt “pilot ” which also bends. When the canula is entered, the “pilot ” is withdrawn and the inner tube inserted in its place (Fig. 503). Dr. I. T. Talbot, of Boston, has performed tracheotomy many times, and expresses himself to me on the subject: “Since June, 1855, when I had my first successful case of tracheotomy, the first, so far as I have been able to learn, in this country, I have performed the operation seventy-six times. This has been invariably done as a last resource; forty-two of these, a little over fifty-five per cent., have recovered. One ceased breathing while preparing for the operation and two did not rally from the operation, although artificial respiration was resorted to and continued for some time, with all three. Three others required artificial respiration, and rallied to life under it and made successful recoveries. 810 A SYSTEM OF SURGERY. “Of late years I have found membranous croup more frequently connected yºphtheria than formerly, with offensive breath and enlarged cervical glands. & “If the respiration is impeded above the trachea and albuminuria has not supervened, even in cases of diphtheritic croup the operation is often Successful. “A cushion of gauze moistened in warm carbolized water, placed directly over the open tube, obviates the necessity of the cumbersome steam appa- ratus and the high temperature. The efficacy of homoeopathic medicine is nowhere exhibited so efficaciously as in croup after tracheotomy.” My friend Dr. Doughty has performed tracheotomy for diphtheritic croup with encouraging success. His mortality rate so far is the best in the country. The period of time that the tube is allowed to remain in the trachea varies according to the character of the disease for which the operation has been performed. I have seen a case of sub-glottic oedema, in which I per- formed tracheotomy upon an apparently moribund patient, where it was necessary to allow the tube to be worn for two months. Thrice I removed it, and within twenty-four hours the symptoms of suffocation were so immi- nent that I was obliged to reinsert it. As a general rule, I have taken out the tube in ten days to a fortnight without untoward results. In cases of stenosis from tumors and other causes, the canula may have to be worn permanently. Laryngo-tracheotomy, a combination of the two operations already de- scribed, is performed when the division of the crico-thyroid membrane does not afford an opening sufficiently large to accomplish the result desired. It is readily performed by dividing the balance of the cricoid cartilage with two or three of the upper rings of the trachea. The only attendant danger consists in wounding the isthmus of the thyroid gland and the Su- perior thyroid artery. After these operations the air of the room should be kept moist and warm, the wound cleaned, the tube freed of mucus, and a piece of gauze should be worn over the orifice to prevent the inhalation of foreign particles. In the case of infants it will be found difficult to make an opening sufficiently large below the thyroid isthmus; in which case the incision may be made immediately below the cricoid ring, and even this may be divided if more space is required. Dr Smith, of Bristol, Penna., has introduced new instruments for trache- otomy. He believes that by their use the haemorrhage is much less, and that union of the wound is in no way impeded; he says: “In the course of a series of experiments on respiration, performed some time since, I had occasion very frequently to perform tracheotomy on animals, and being generally without an assistant, experienced much delay and embarrass- ment from the extreme caution necessary to prevent troublesome hamor- rhage. This led me to seek for some instrument for the division of the tissues between the skin and the trachea, which should be safer than a knife, and more expeditious and certain than the fingers or the handle of the scalpel. Accordingly I had two instruments made, resembling the hook used in the operation for strabismus, but stronger and somewhat more pointed at the extremity. Taking one of these in each hand, and operat- ing something as one would with dissecting-needles, I was enabled to divide one layer of tissue after another with the utmost safety and dispatch. The points of the instrument were so blunt as to render it almost impos- sible to penetrate the coats of a vessel, and hence the liability to ha-mor- rhage, which constitutes the chief danger in this operation, was avoided. Indeed, I have often opened the trachea almost without shedding a drop INTUBATION OF THE GLOTTIS AND LARYNX. 811 of blood, except that from the skin and from the trachea, itself. In an operation recently performed upon a child by the aid of these instru- ments, I did not find it necessary to employ a sponge during the whole operation.” Tracheotomy with Thermo-cautery.*—The platinum knife of the thermo- cautery, at a dull red heat, is made, 1st, to slowly incise the skin and superficial fascia from above downwards, by one stroke in the median line of the neck, beginning immediately below the lower border of the cricoid cartilage; 2d, to pass slowly, as before, through the intermuscular tissue down to the trachea by a single stroke; 3d, the point of the knife is made to pass perpendicularly into the trachea, the incision rapidly en- larged, and the knife withdrawn as quickly as possible. The operation requires but a minute, is attended by no hº and can be per- formed without assistance. The thermo-cautery of Paquelin was employed by * Poinsot and Mauriac, who have operated with success by, this method. Intubation of the Glottis and Larynx.--Dr. Joseph O'Dwyer, of New York, has recently introduced a method of intubation of the larynx, which, although it has not been long enough before the profession to become established, yet has been sufficiently successful to demand serious consid- eration. - The method consists of introducing into the larynx, between the vocal cords, certain peculiarly shaped tubes, which allow free access of air, thus dispensing with tracheotomy. - Dr. Ingalst states that the operations may be called for : “1. For diphtheritic and croupous stenosis of the larynx occurring in children under three and one-half years of age. - “2. For cases of the same affections in older children in which from any cause the physician wishes to defer the operation of tracheotomy. “3. For those cases in which consent to tracheotomy cannot be obtained. “4. For those cases in which proper nursing could not be secured. f 5. For severe cases of spasmodic croup in children less than ten years Or age. “6. For simple stenosis of the larynx, not diphtheritic, in children. “7. With proper-sized tubes it might be of value in the treatment of va- rious forms of laryngeal stenosis in adults.” According to recent statistics i the largest number of “intubations' have been performed by Dr. F. E. Waxham, of Chicago, who reports 17 cases and 8 recoveries. Dr. D. Brown has had 15 cases with 4 recoveries, and E. F. Ingals, 2 cases with 2 deaths. This may appear a large mortality, but when it is remem- bered that the cases were all those of pseudo-membranous laryngitis, the figures compare favorably with those of tracheotomy for a similar condi- tion. The following description of the instruments and methods of introduc- tion are taken from that furnished by Tiemann & Co. The numbers on the scale (Fig. 506) indicate the years for which the cor- responding tubes are suitable. For instance, the smallest tube when ap- plied to the scale will reach to the first line, marked 1, and is intended to be used up to the age of twelve or fifteen months; the size marked 2 is suit- able for the next year, 3 and 4 for these years, and so on. When the proper * Monthly Abstract of Medical Science, January, 1878; Ilondon Medical Record, March 15th, 1877; Gazette Médicale de Bordeaux, September 20th, 1876. f Journal of the American Medical Association, February 6th, 1886. † Medical Record, April 24th, 1886. 812 A SYSTEM OF SURGERY. tube is selected for the case to be operated on, a fine thread is passed through the Small hole near its anterior angle, and left long enough to hang out of the mouth, its object being to remove the tube should it be found to have passed into the Oesophagus instead of the larynx. The obturator is then screwed tightly to the introductor, to prevent the possibility of its rotating while being inserted and passed into the tube. The following is the method of introducing the tube, which is done without the use of an anaesthetic. The child is held upright in the arms of a nurse, FIG. 504. Ž %22. *. FIG. 505. FIG. 506. O'Dwyer's Instruments for Intubation of the Larynx. FIG. 504,-Mouth Gag. FIG. 506.—Scale, FIG. 505.-Larynx Tubes and Introducer. FIG. 507.-Extractor. and the gag (Fig. 504) inserted in the left angle of the mouth, well back be- tween the teeth, and opened widely; an assistant holds the head, thrown somewhat backward, while the operator inserts the index finger of the left hand to elevate the epiglottis and direct the tube into the larynx. The handle of the introductor (Fig. 505) is held close to the patient’s chest in the beginning of the operation, and rapidly elevated as the canula approaches the glottis. The tube is pushed downwards, without using much force. It is then detached. The joint in the shank of the obturator is for the purpose of facilitating this part of the operation. As soon as the obturator is removed, and it is ascertained that the tube is in the larynx, the thread is removed, but at the same time the finger is kept in contact with the tube to prevent its being also withdrawn." - LARYINGOSCOPY. ** 813 It is important that the attempt at introduction be made quickly, as respiration is practically suspended from the time that the finger enters the larynx until the obturator is removed. It is, under the circumstances, safer to make several abortive attempts than one prolonged effort, even if Successful. For the purpose of removal the patient is held in a similar position, ex- cept that the head is not inclined backwards, or very slightly so, and the extractor passed into the tube guided by the index finger of the left hand, which also fixes the epiglottis, and is brought in contact with the head of the canula. Firm pressure with the thumb is then made on the lever above the handle while the tube is being withdrawn. If secondary dyspnoea super- venes at any time, the tube should be removed and a larger one substituted. To avoid accidents it is essential to have some preliminary practice on the cadaver, particularly in extracting, which is the more difficult operation, owing to the aperture of the tube being so much smaller than that of the larynx. These tubes will also prove valuable as dilators in chronic stenosis of the larynx or trachea. - Laryngoscopy.—In 1827, Senn, of Geneva, endeavored, by means of a small mirror introduced into the mouth, to examine the larynx, In 1829, B. C. Babbington introduced the glottiscope. In 1837, M. Sellique made for Trousseau an instrument for the same purpose. In 1838, Baumes, of Lyons, invented a laryngeal speculum. Liston, in 1840, conceived the idea of examining the larynx with a small mirror in the fauces. In 1844, War- den used artificial light and a prism. Avery, in 1854, is said to have con- structed a laryngoscope, but did not publish an account of it. Garcia, in 1855, conceived the simplest method of auto-laryngoscopy, viz., standing FIG. 508. G.TIENMANN & CO.NY. Elsberg's Laryngoscope. with his back to the sun with a small mirror in the fauces. Dr. Ludwig Türck was the next to follow in the construction of the instrument, and in 1858 Czermak followed in a measure the suggestions of Türck and Tobold. In Türck’s laryngoscope the mirror was fitted to the forehead and sup- ported by a spring. Tiemann has invented an excellent mirror for the head, which may be used for any illuminating purpose. Fig. 508 represents Elsberg's pocket laryngoscope; and Fig. 509 shows the position of the patient and examiner, with illumination adapted to Tobold’s. As seen in Fig. 509, the operator is seated in front of the patient, who sits directly to one side and behind the instrument; the tongue is pro- jected from the mouth and held down by a small napkin; the mirror is then thoroughly cleaned and warmed over the light. The patient opens his mouth and is requested to say “Ah!” and prolong the sound. This raises the velum pendulum palati, and the mirror, with a rapid though gentle move- 814 A SYSTEM OF SURGERY. ment, is placed face downwards in the fauces, holding up in a measure the palate. There must be no wavering or uncertainty in the introduction of the mirror, otherwise there may be gagging or even vomiting. Since the in- troduction of the electric light, an excellent adaptation of it for the laryn- goscope has been made by Sajous, of Philadelphia, as seen in Fig. 510, a rep- resents the storage-battery; b, the incandescent light; and c, the circuit-closer. FIG. 509. ź º ſº º º % - º: % y ºff fº % º º 7%/ º % % * / & ºff º Ž FIG. 510. gº E. lºſſº º º º º | º * | |. º } ] º * º º w; 5 Nov O EDS.º Sajous's Electric Lamp. GROWTHS IN THE LARYNX. 815 The laryngoscope, like the ophthalmoscope, has greatly facilitated the diagnosis of most laryngeal affections and insures greater certainty in the performance of surgical operations. The point to be established is to ascertain what medicines are applicable to the varied abnormal condi- tions, and to render unnecessary so much local treatment, to which, I am persuaded, too many laryngoscopists direct their entire attention. Neoplasms.-There are several varieties of new growths which are found in the larynx; indeed, since the introduction of the laryngoscope, they are discovered to be more frequent than was formerly supposed. It is asserted by some that two per cent. of all diseases of the larynx are local in their nature, and consist of abnormal growths; of these, in 244 cases, there were warty, 110; fibrous, 23; sarcomatous, 52; adeno- matous, 6; cystic, 14; cartilaginous, 4; epitheliomatous, 19; not clearly lººd, 16. Of these, 158 were recognized during life, and 86 after eath. Whatever be the nature of the growth in the larynx, the symptoms are much the same. There is always more or less dyspnoea caused from the size of the neoplasm obstructing the windpipe, or from the pressure upon the laryngeal nerve; the voice becomes husky, hoarse, or even extinct; or, in some instances, there may be only spasmodic difficulty of breathing, at times the patient being perfectly well. A tumor may exist for a long time in the air-passages without the patient being aware of its presence; indeed, as will be seen by referring to the figures above, many are not recognized during life, and are only discovered after death. Growths in . the upper part of the air-passages may cause dangerous symptoms, and even death by spasm of the glottis or oadema-glottidis. In general, inspiration is more difficult than expiration, excepting in those cases in which the growth is low down, when both the acts are performed with difficulty. The cough is slight in some cases; in others more Severe, and is accompanied with mucous or muco-purulent expectora- tion. Many of the symptoms which are present from foreign bodies resemble so closely those of spasmus and oedema-glottidis, or the pressure of tumors, that before the introduction of the laryngoscope great difficulty of diagnosis obtained; however, since the era of reflected light in surgery, a new age has dawned upon diseases of the windpipe. Warty Growths generally arise from the mucous membrane of the upper part of the larynx, and often are multiple; they resemble a cauliflower in shape and are in some instances pedunculated. Sometimes portions are detached and expectorated, while at others the growth is so rapid as to demand tracheotomy. Polypi.-The fibro-cellular growths are round, oval, and generally pedun- culated; they are solitary, and partake of the nature of these tumors in other parts of the body. The symptoms are those already described. Adenoid Growths.—The color of this variety of abnormal formations, when examined by the laryngoscope, is at first reddish, but as they grow it becomes of a paler hue. They change more rapidly than any of the laryngeal tumors, an attack of ordinary catarrh or catarrhal laryngitis causing rapid enlargement. When they are sessile, they cover quite a large extent of surface, and are lobulated. They are generally found at the base of the epiglottis, or growing from the mucous membrane, covering the arytenoid cartilages. Cystic Tumors and, indeed, osseous growths, together with carcinoma, some- times occur in the larynx, all demanding the use of the laryngoscope. * Holmes's System of Surgery, vol. iv., p. 575. 816 A SYSTEM OF SURGERY. Treatment.—I have not had much experience in the treatment of growths in the larynx, and but little with the laryngoscope, and as the use of the instrument and the treatment of those diseases which it has taught us to detect and relieve is an established specialty, it is probable that ere long some member of our school will publish a full description of laryngeal affections and their treatment. - For the warty growths, I should recommend thuja, calc., sepia, lyc., or Sulphur, according to the symptoms. For the glandular, one of the different preparations of mercury, or perhaps kali iod., nit. acid, lachesis, kali bromat., calcarea, or silicea. For the cancerous, those medicines which are already mentioned in the chapter upon the Treatment of Malignant Tumors. The Surgical treatment varies considerably. It may be deemed neces- sary, especially if the growth is large, to perform tracheotomy (vide page 807) before proceeding to remove the tumor, which may be done in one FIG. 511. -- " -: *- Fiº Seeger's Brush-holder with Flexible Stem. of two ways, viz., either through the natural passages by the aid of the laryngoscope, or by incisions from without. In the first method, which is generally preferred, the patient is seated and examined by the laryngoscope, and if caustics are to be used, the brush, as seen in Fig. 511, applied to the FIG. 512. FIG. 513. C. *Ss - 5. º (i. i;ſº parts, to thoroughly cleanse them; after this it may be desirable to apply medicines directly by means of the atomizer. Figs. 512–13 show the working of the instruments. In Fig. 512 the medicated substance is placed in the graded bottle; in Fig. 513 it is placed in the cup. The chief substances inhaled are aqua picea mixed with alu- mina, or amm. mur., or zinci sulphat. Zinci iodidum, acid. tannic., and hydrarg. bichlor. have also been used. These are, however, for affections of the larynx other than tumors. To growths, the solid nitrate of silver, nitric and chromic acids, the TREATMENT OF GROWTHS IN THE LARYNX. 817 Vienna paste, and the London paste, already described in the article on “Tonsillitis,” have all been successfully applied. These escharotics should FIG. 514. | _º. Il tº ANN co. T- be used with the greatest caution, and a concealed caustic carrier, as seen in Fig. 514, must always be employed. In removing neoplasms with the forceps, it is often necessary to repeat the operation at several sittings. Of those best adapted, are the alligator forceps, a cut of which is seen on page 801. FIG. 515. ||| “... . . . | | Fauvel's Laryngeal Polypus Forceps. Fig. 515 shows Fauvel's laryngeal forceps, and Fig. 516 illustrates Tie- mann's laryngeal scoop. FIG. 516. Tiemann's Laryngeal Scoop. The knife is sometimes preferred to the forceps; in such cases that of Semelder, properly curved, is the best. The growth must be carefully raised before the knife is used. - Galvano-caustic Wire.—In the half dozen cases that have come under my observation, the removal of the growths has been satisfactorily accom- plished by the galvano-cautery. Tracheotomy is generally necessary, and in one instance the trachea was opened and the laryngeal growth, a fibroid, successfully removed through the opening with caustic wire. In making incisions from without the cut must be in the mesial line, the cavity of the larynx laid open, and the growth removed with the galvano- caustic wire or the écraseur. This would certainly be the best method. In these operations the cricoid cartilage should, if possible, be left intact. 52 818 A SYSTEM OF SURGERY. Extirpation of the Larynx,−According to Paul Berger,” it was Koeberlé who made the first suggestions toward the removal or extirpation of the larynx. This was about 1856. In 1870, by experiments performed on dogs, Czerny demonstrated that the operation could be successfully per- formed; but to Billroth is due the credit of having made the first success. He removed the larynx, in 1873, from a patient affected with cancer; the wound healed in two months, and the patient was enabled to speak, though in monotone, with great distinctness. The contrivance for articulation has Since received the name of Gussenbauer's tubes. Throughout the medical periodicals, since Billroth's exploit, there are a number of records of operations of this character. The incisions must vary somewhat in accordance with the disease, but the point to be observed is to prevent foreign matters (blood, pus, or other discharges) from entering the air-tubes. The incision should extend from the lower border of the hyoid bone to a point about an inch below the centre of the cricoid. Then, the soft parts are to be carefully dissected away from the alae of the thyroid, and also from the thyro-hyoid membrane. Here, the operator should stop, secure any vessels that are bleeding, and Wait a few moments for the oozing to cease. The trachea is then to be pulled forward and divided at its first ring. The next step is to prevent blood from entering the trachea, as the operation proceeds, which may be done by a silver or india-rubber siphon, or a cork with a tube through it, or whatever contrivance the surgeon may think best. The lower extremity of the larynx is thus freed. The remainder of the operation depends mainly on the extent of the disease. If the upper margins of the thyroid can be left, it is advisable to keep them in the wound, as they arch over the parts and prevent the collapse of the tissues. If, however, they are dis- eased, they should be removed, and the arytenoid may answer the purpose, or even the cornua may assist in holding open the parts sufficiently. After the disease has been thus extirpated, the upper end of the trachea must be securely fastened by wire or catgut to the surrounding tissues, and leaving in position the tracheotomy, or other tube, the wound allowed to heal. In some cases of extirpation of the larynx the incisions may be made as follows, the dissection being from below upward instead of from above downward, as practiced by Dr. Von Brune:f Tracheotomy need not be performed at the commencement. An incision is made from the lower jaw to the sternum in the median line and the deep dissection continued until the hyoid bone, the thyro-hyoid ligament, the thyroid cartilage, and the upper rings of the trachea are laid bare. No great bleeding takes place, and the operation is not a protracted one. The following interesting case is reported by Dr. D. Foulis.j. A man (aet. 28) complaining of hoarseness, had a warty-looking growth projecting under the anterior end of the left vocal cord, which was removed by external incision, and proved to be a papilloma; but a nodule had reappeared on the old site, growing steadily. Thyrotomy was performed, the growth clipped out, and its seat cauterized. Again it reappeared, and with the consent of the patient removal of the larynx was decided on. The incision began at the lower edge of the hyoid bone and ran down the middle line to about an inch below the cricoid cartilage, lint being applied to prevent blood entering the air-passages. The soft tissues were carefully dissected and any small vessels ligatured that were bleeding. The —º * Hayem's Révue des Sciences Médicales, t. ix, part 1, p. 298. t London Medical Record, January 15th, 1879. † The American Journal of the Medical Sciences, January, 1878. & INJURIES OF THE CHEST. 819 operation lasted two hours and a half, and recovery took place without any accident. The last feature in the treatment was the introduction of Gussen- bauer's artificial vocal apparatus—not, however, until the wound was fairly healed and contracted. Cohen, in his tables of removal of the larynx, states that the opera- tion has been performed 65 times—5 for sarcoma, 4 for non-malignant disease, and the remainder for carcinoma. Of the non-malignant cases 2 died. All those performed for sarcoma recovered ; of the 56 remaining, 42 died and 14 recovered, of which 6 only were alive one year after the operation. CHAPTER XLI. INJURIES AND DISEASES OF THE THORAX. Wount's OF THE CHEST-HYDROTHORAx—EMPYEMA–ASPIRATION OF THE THORAx— THORACENTESIs—PUNCTURE OF THE PERICARDIUM.–PLEUROTOMY-THoRACIC GRAD- UAL DRAINAGE — APNCEA : FROM DROwnING, FROM HANGING — MAMMARY LYM- PHANGITIS-MASTITIS-CARCINOMA OF THE MAMMA-BENIGN TUMoRs—AMPUTA- TION OF THE BREAST. - Injuries of the Chest.—In wounds of the lungs, danger is to be appre- hended from inflammation, suppuration, or hamorrhage. The patient generally experiences great dyspnoea, with a sense of suffocation. Arterial blood, mixed occasionally with clots, is expectorated, or, if the wound be extensive, there may be profuse hamorrhage from the mouth. Inflam- mation always supervenes, and, unless the abnormal process be prevented, profuse suppuration, hectic, and debility result. Treatment.—If the external opening be large and the lung protrude (pneumocele), it should be returned by gentle pressure, and retained within the cavity by means of bandages and compresses. It is important that the latter be moistened with a solution of arnica, as by such applica- tion bleeding may be restrained, inflammation prevented, and the healing process advanced; the internal administration of the same medicine, in alternation with aconite, if the fever be intense, will assist in accomplish- ing a favorable result. - If the intercostal artery has been wounded, it must be ligated, even though extension of the opening be necessary. If extraneous matter have lodged within the lung or surrounding textures, it should be gently re- moved, otherwise profuse suppuration may follow, and the patient be de- stroyed. Secondary hamorrhage may be arrested by the internal admin- istration of aconite, arnica, crocus, diadema, phosphorus, and, in some instances, bryonia; the latter particularly is applicable when, with the cough, there is expectoration of blood-streaked mucus, with stitching or sticking pains, especially when the pleura is attacked by the inflammatory process. Phosphorus is an important medicine when, after granulation has commenced, there is threatened inflammation of the parenchyma of the lung, with prostration, and dulness on percussion. 820 A SYSTEM OF SURGERY. The external wound should be closed with lint, plaster, and bandage, the patient kept perfectly quiet in a well-ventilated apartment, and all causes of excitement avoided. - In simple contusion, a bandage should be placed around the chest, arnica administered internally and externally, and inflammation of the contents of the thorax combated by those means already adverted to. Hydrothorax.-By the term hydrothorax is understood an accumulation of fluid in the cavity of the chest; empyema may be included in this definition; but generally by the latter term surgeons understand a collec- tion of pus within the thorax. In this place hydrothorax is applied to an accumulation of serous fluid in one or both pleural cavities. In the incip- ient stage, the symptoms are uncertain, and may be mistaken for those of affections of the lungs, heart, etc. There is transitory oppression of the chest, after exercise, talking or ascending an eminence, with increased dyspnoea in the evening. This condition may pass away with expectoration or profuse sweat; but it is liable to return, particularly in the warm season. The difficulty of breathing increases, the patient is unable to lie down on account of the gravitation of the fluid, there is palpitation of the heart, livid countenance, disturbed sleep, and dulness on percussion. If the effusion is on one side only, the patient lies most comfortably on that which is affected. The above symptoms are paroxysmal; in time, Sopor and insensibility supervene. There is often cough, with extreme irritation of the chest. Where the percussion-sound is faint the respiratory murmur disappears; and when there is much effusion bronchial respiration is some- times heard. The vibrations of the thorax when talking are feeble or entirely absent. - It is important that the practitioner should remember that the diaphragm, liver, and spleen are often forced downward into the abdominal cavity, presenting appearances analogous to those observed in ascites. Persons of advanced age, with weak lungs, occasioned by frequent re- turning catarrhs, are peculiarly liable to this affection. Malformations of the thorax, curvatures of the vertebral column, and deformities of the ribs and sternum, also engender the disease. Treatment.—Ars. alb. is one of the principal medicines; it corresponds to many of the symptoms, particularly the dyspnoea and torturing feeling of suffocation. Other indications which call for its exhibition are the com- plete prostration of the patient and burning thirst, together with nocturnal exacerbations. - Ipecac, pulsatilla, and ignatia may, in some cases, be called for. Scilla is an efficient medicine when there is constant cough, with expectoration and dyspnoea. When there are rheumatic and constrictive pains in the chest, palpitation of the heart, restlessness, and excessive anxiety, carbo veg. is indicated, particularly when the disease arises from excessive loss of animal fluids. Lycopodium should be prescribed when, together with the dyspnoea, there is excessive palpitation of the heart, occurring principally after a meal, with cold feet. Hartmann” states that he has cured hydrothorax with ammonium carb. - Other medicines are bry., china, coloh., dig., hell., kali carb., spigelia, and sometimes stannum and dulcamara. Frequently by the exhibition of these medecines the disease is arrested. Empyema.-Empyema is a collection of pus within the cavity of the thorax; it may be the result of acute inflammation, whether traumatic or idiopathic. The symptoms are similar to those of hydrothorax. * Chronic Diseases, vol. i., p. 194. ASPIRATION OF THE THORAX. 821 Empyema may result from certain inflammatory conditions, from severe Contusions, and as a sequel of certain diseases. In two of the worst cases that have come under my observation, one was caused by a severe fall down a hatchway, in which the patient not only suffered from the contu- Sion, but fractured the surgical neck of the humerus; in the other the purulent effusion followed malignant diphtheria. With reference to the diagnosis between collections of pus and the ordinary effusions, there is always some difficulty, the history of the case and the constitutional symp- toms being the most reliable signs. I cannot agree with Professor Bacceli, who makes the extraordinary statementº that the denser the fluid, the less clear will be the sound of the voice. According to all physical laws, the contrary is the case, and wherever I have had an opportunity of putting the same to actual experiment, I have found that the sounds of the voice were much more clear in empyema. Emphysema, or a collection of air within the pleura, may be caused by wounds of the lungs, fractures of the ribs, and penetrating wounds of the chest. According to Hastings, “There is absence of respiratory murmur upon the affected side, where it is caused by wound of the lungs, with an exceedingly clear sound on percussion, with immobility of the ribs. On the sound side there is puerile respiration. When the injury is dependent upon the bursting of an abscess, a metallic tinkling is audible, and upon directing the patient to cough, a drop of fluid falls from the orifice in the lung, and drops to the bottom of the chest with this peculiar sound; or if the chest be shaken, the fluid can be heard to splash.” Aspiration of the Thorax.-The most practical divisions of effusions into the thorax are: 1st. Those resulting from acute diseases; 2d. Those from chronic diseases; and 3d. Those consisting of pus accumulations. In the first variety the effusions should, in the majority of cases, be left to nature, though there may happen cases of such severity and so imminent in dan- ger, that it may be necessary to withdraw the effused material. In the second variety, where the fluid is gradually and steadily poured out, the danger is much greater. In empyema, there should be free drainage, not always with the expectation of a radical cure (although such may take place), but for the sake of relieving the patient of distressing symptoms, and of prolonging life. I have had under my charge several other dis- tressing cases of empyema, and have been surprised at the relief which has been immediately experienced by aspirating the thorax, and also at the number of times the chest may be punctured without detriment. In a case of Dr. Minton, of Brooklyn, in which I operated at midnight upon a patient almost in articulo, and withdrew a large basinful of pus, the patient sank into a slumber and recovered rapidly, while in another case I think I aspirated the thorax at least sixty times. - After aspiration the cavity of the thorax must be washed out with some antiseptic fluid, and the best is salt and water. I was led to this method by reading the remarks of M. Howzé de l’Aulnot. The operation of thora- centesis had been performed and the cavity washed out each time with an antiseptic fluid without success, when a concentrated solution of salt and water produced a cure. Dr. Goodheart, S of Guy's Hospital, has analyzed 350 cases of pleuritic effusions, and the results are in the main unfavorable to operation for the re- moval of the ordinary acute forms of the disease. For the withdrawal of pus * American Journal of the Medical Sciences, July, 1876. + Practice of Surgery, p. 248. † Medical Record, November, 1878, No. 419. & British Medical Journal, November 4th and December 18th, 1877. 822 A SYSTEM OF SURGERY. the results also are not encouraging, so far as cure is concerned. In 26 not operated upon for the ordinary forms of effusion there were 15 recoveries, and in 51 operated upon, 28 recovered and 23 died. Dr. Wilson Fox, who has collected 15,000 cases, finds the mean mortality to be from 10 to 17 per cent. In pleurisy the ratio is greater after paracem- tesis. In empyema the results are encouraging, but are not such as to lead us to expect much save temporary amelioration. In aspiration some surgeons prefer the spaces between the sixth, seventh, or eighth ribs in which to introduce the needle. From my experience I think I may state that it may be introduced at the spot where the fluctua- tion is most distinct, either on the anterior or posterior walls, high up or low down, and that the operation may be performed upon the child or the adult. A case is reported * in which aspiration was performed upon a child two years old. I have entered the needle at many sites, and never, but in a single case, was there any untoward result, and in that instance, the symp- toms, though instantaneous and severe, lasted but a short time. The pre- caution of using the dome trocar needle, which conceals the point after its introduction, should always be taken. . Before º to aspirate the thorax, it is well for the surgeon to in- form the friends of the patient that the operation is not by any means free from danger, and that immediate death may result from it. Indeed, the Sudden and rapid evacuation of the fluid may produce pulmonary oedema to an alarming extent. Again, syncope may cause death, or, as has been supposed, the very puncture has, from reflex action, caused the death of the patient from cessation of the heart’s action. In drawing off the fluid, whether by the aspirator or trocar, it must be done with caution, and allowed to run slowly; indeed, it may be better to make two operations, and allow the lung to expand from the compres- sion made upon it by the fluid, and thus prevent the venous blood from being forced in too great quantity into the right heart, for if this were to happen to any considerable degree, cardiac paralysis and death would cer- tainly result. Thoracentesis.--To evacuate the fluid, the operation of thoracentesis may be preferred, and is thus performed: An incision into the chest is made with a knife and a canula passed into the opening; or a trocar may be thrust directly into the cavity, the stilet withdrawn, and the canula, to which an india-rubber tube is attached, the end of which tube should rest in a basin containing water, allowed to remain. In this operation care should be taken, while passing the instrument within the cavity, that the lung be not irritated, else troublesome cough will be the consequence; the part selected for the operation should be as dependent as possible, and the patient placed with the face up and the head and shoulders thrown back. Whichever method is resorted to, the instrument should be made to pass in close prox- imity with the superior edge of the sixth or seventh rib, to avoid wounding the intercostal artery, which courses along the inferior margin of the bone. The opening should be valvular, to prevent the passage of air into the cavity; this can readily be effected by drawing tense the integument over the place of entrance; it will be found that when the instrument is with- drawn, the skin will roll over the aperture, thus forming an integumental valve. Thoracic Gradual Drainage.—Dr. Southey j recommends highly the use of a capillary drainage-tube, allowed to remain in the chest for a con- * Medical Record, April 12th, 1874. f M. Tenneson, Union Médicale, February 22d, 1876. † American Journal of the Medical Sciences, No. cliv. --> PLEUROTOMY. 823 siderable time. These drainage-tubes are attached to a very fine canula, and are of different sizes. I have employed this method in several cases with excellent results; the idea being not to entirely empty the chest at once, but to allow the fluid to gradually drain away and the lung to expand as the pressure is removed. The operation of thoracentesis is facilitated by the construction of instru- ments for the purpose. Fig. 517 shows Flint's apparatus for thoracentesis. Dr. Flint preferred the posterior portion of the chest, between the eighth and ninth ribs, for the introduction of the trocar, which is plunged into the FIG. 517. ſº 42.É.- : º: (232 Rs. iº 22 - * ... .º ź - 2-3 º Flint's Apparatus for Thoracentesis. intercostal space, withdrawn, and the tube attached. The stopcock is to be turned while the attachment is being made; by using the hand-ball the fluid is withdrawn. Pleurotomy.—An opening made into the pleural cavity by incision, and the establishment of free drainage, is preferred by many surgeons to aspi- ration. Dr. Herbert Clapp * gives excellent advice in the performance of this operation, which I quote: “The patient generally being in the semi- recumbent position, an incision of from one to two inches is made, usually in the sixth, seventh, or eighth intercostal space, in the posterior axillary line, or a little back of it. This location may be varied somewhat, accord- ing to the thickness of the muscles, the possible bulging between the ribs, or for other reasons. Marshall (London Lancet, March, 1882) recommends the fifth space in front, where nature oftenest makes her opening (or a spot on the same level in the axilla), but every other authority that I re- member is strongly opposed to an anterior opening. Having made such an opening in one case in the hospital several years ago, I should not want to try it again. When the patient, as very often happens, is quite weak and confined to the bed, it is exceedingly awkward to wash out and drain the pleural cavity from an opening in front, and most patients do not relish being turned on their faces for this purpose. One of the prime requi- sites being a good position for drainage, the first impulse would naturally be to select the very lowest intercostal space in the back where pus could be found; but this is not wise, because, owing to the anatomy of the lower part of the pleural cavity, the diaphragmatic and the costal pleurae might unite above the opening after drainage had been established, leaving a large pus-cavity undrained above. Such an occurrence is a matter of record. The diaphragm and other structures also have been wounded by too low an * Twenty-four Cases of the Radical Operation for Empyema, by Herbert Clapp, M.D., Boston, 1886. 824 A systEM of SURGERY. operation; and in case none of these accidents happen, the tube is apt to E. against and irritate the diaphragm. At first I used to open the chest y one incision through skin and all the subjacent tissues, running the knife down the groove of an exploring needle, as the manner of some is; but I Soon abandoned this method, and now divide carefully one layer after another. Thus there is less danger of wounding the intercostal artery and the rib ; the internal opening can be made shorter than the external, which to some extent prevents the disagreeable burrowing of pus and air into the subcutaneous cellular tissue, and the parts can be more neatly adapted to the tube. It is generally advisable to pursue exactly the same course, even if nature has already made an opening through the parietes in front, or into a bronchial tube. The old-fashioned method of making two openings, and passing a fenestrated rubber tube through both, and tying the ends on the outside, is now seldom resorted to. It acts as a seton, and perpetuates the formation of pus. “Resection of a part of one or two ribs has been occasionally made by Some operators, in order to gain room for more thorough washing out, when the intercostal space is originally narrow, or when the ribs gradually ap- proximate more and more during contraction of the chest, as they often do. Resection of three or four ribs has also been tried sometimes, when other measures have failed, in old cases where the lung cannot expand, and the chest-walls cannot without this help fall in sufficiently to obliterate the large cavity. In the latter case it should not be done until plenty of time has elapsed to wait for nature, assisted by art, to do the same thing ; and not in the former case at all, if it can be avoided—certainly not in a routine manner. In case of necrosis of the rib from periostitis, resection is of course desirable.” Puncture of the Pericardium.—I have performed this operation several times with great relief to the patient; in one case often, and without any bad results. In all, the patients succumbed to the disease, but the aspirator was a boon to them during the time they survived. The student must remember in the performance of this operation, that the internal mammary artery runs perpendicularly behind the cartilages of the ribs about half an inch from the sternum. The apex of the heart can be found by marking a point about two inches below the left nipple, and about an inch towards the sternum. This point will be between the fifth and sixth ribs, at which space the bulging will generally be found. The needle should be a fine one and cautiously introduced. Dr. Villeneuve, in the Archives Méd. Belges,” reported the case of a child five years old, who suffered from pericarditis with effusion, the trouble dating from a fall two months before. The symptoms becoming alarming, and medical treatment affording no prospect of success, the tumor was punctured at its most prominent part by a Dieulafoy's aspirator, and two syringefuls of clear yellowish fluid were withdrawn. The result was marked relief. The wound continued open and discharging for six months. The matter was at first clear, and afterwards became purulent. The fistula finally healed, and recovery was complete. It must be borne in mind by the young surgeon that all drainage-tubes are liable to slip into the thoracic cavity. Indeed, it is remarkable how many cases of this accident have been recorded. To prevent this the drain- age-tube must be carefully secured, either with bits of adhesive plaster or, as I prefer, with a large diaper-pin. * Journ. de Méd., August, 1875; New York Medical Record, June 8th, 1876. ſe † Drainage-tubes Accidentally Lost in the Pleural Cavity. By F. Huber, M.D. Medical Record, January 3d, 1885. APNOEA FROM DROWNING. 825 Apnoea from Drowning.—As soon as the body of a person who has been submerged for a length of time in water has been recovered, the face should be turned downward, the mouth opened, and the water allowed to drain away for a moment; then the finger should be pushed backward toward the fauces, and the effort made to allow further escape of the fluid ; the tongue may be drawn forward to favor the same result. The clothing must be removed, the patient placed in a warm bed, and frictions to the entire body be kept up with theº: of several persons. Flannels should be wrung out of warm water and placed on those portions of the body that are not being rubbed. During this time, if there are no signs of life, artifi- cial respiration must be employed. There are two methods of performing artificial respiration, one known as Marshall Hall's, the other as Sylvester's. Hall's Ready Method.—The patient is to be placed prone on the face; pressure with both hands is then gently made on the back; the body is turned on the side, and then turned on the face again, and pressure used On the back. This manoeuvre must be made about sixteen times in a minute. . Sylvester's method, which is preferable, is as follows: The patient is laid on the back, or what is better, on an inclined plane; the tongue is drawn FIG. 518. Sylvester's Method of Performing Artificial Respiration. First Position. forward, and the operator, standing at the head of the patient, flexes the forearms on the arms, and brings the elbows over the front of the body until they almost meet in front of the chest. (See Fig. 518.) Then the arms are rapidly drawn away from the sides of the body and upward until they meet over the head. (Fig. 519.) It is by these movements expansion of the chest takes place. By the pectoral muscles being drawn out, a vacuum is created, and a species of inspiration produced. The arms are made to retrace the curve they have already taken, and again are forced to meet at the epigastrium. This motion should be made for at least fifteen minutes, at 826 A SYSTEM OF SURGERY. the rate of sixteen times to the minute. Each movement should therefore occupy about four seconds. ſº In all forms of apnoea or suspended animation the nitrite of amyl should be remembered. It must be given cautiously by inhalation, and from FIG. 519. Sylvester's Method. Second Position. its powerful influence on the heart's action, will often restore circulation when other means have proved unavailing. Apnoea from Hanging.—A person may be suspended by the neck for five minutes and be resuscitated, provided no injury has been inflicted upon the spinal cord. Death, however, may occur almost immediately from disloca- tion or fracture of the first or second vertebra, causing concussion and pressure on the cord; in other instances, the constriction of the jugulars may give rise to apoplexy. The patient must be immediately cut down, and frictions made to the extremities, ammonia applied to the nostrils and artificial respiration (as already directed) made for a considerable time. Mammary Lymphangitis, Mastitis, although frequently occurring in fe- males who are nursing, may be present in women who have never been pregnant; indeed, by some writers we are informed that men have been affected with the disease. A patient about to suffer from this affection experiences, for a day or two before the local inflammation manifests itself, general lassitude, restlessness, and uneasiness, together with slight soreness of the gland. Afterwards, there may be coldness of the body and shiverings; the mamma becomes enlarged, heavy, painful, and may assume a redness all over its surface, or the tint may be deeper in some parts than in others. If the glandular por- tion be most affected, the breast appears, when handled, to be lobulated and hard; but if the skin and cellular tissue are the seat of the disease, the tense- ness is uniform throughout. As inflammatory action proceeds, the pain TREATMENT OF MAMMARY LYMPHANGITIS. 827 becomes throbbing, extends to the axilla, is often intense, and the patient is unable to bear the slightest pressure upon the part, even the contact of clothing aggravating the sufferings. The disease is most common about two or three weeks after delivery, or during the weaning period, when a large quantity of milk, by distending the breasts and obstructing the lymphatic channels, gives rise to the inflammatory process which termi- nates in the formation of pus, thus producing mammary abscess. It is said that when the inflammation is confined to the integument, suppuration follows more speedily than when the true glandular substance is affected. After the symptoms have continued for four or five days, unless the progress of the inflammation has been arrested, suppuration may be ex- pected; but there are cases in which the process proceeds so slowly that pus is not formed for a much longer period, during which time the patient ºnes exhausted by loss of rest, excessive pain, and the accompanying €Ver. The common causes of this variety of abscess are, besides suppression of milk, a current of air upon the breasts, an accumulation of milk through Some fault in suckling the child, from weaning, external injuries, or stimu- lants, which are too frequently allowed to nurses or mothers suckling their children. There is a somewhat peculiar abscess of the mammary gland, first noticed by Mr. Hey. The inflammation is deep-seated, the process tedious, and when suppuration has supervened and the matter has extended towards the surface, it is discharged through several openings, which become fistu- lous, and when these sinuses are opened, a soft, purple fungus is discovered beneath them ; the surrounding parts of the gland are hard and lobulated. This form of mammary abscess is difficult to heal; the discharge continues for a length of time, hectic is superinduced, and the patient may be placed in a precarious position. This is the chronic interstitial abscess of modern writers. Treatment.—In the first stages of mammary inflammation, suppuration may be prevented by medicine and rubbing. The nurse should stand be- hind the patient, who should be seated in a chair; the breast be supported by one hand of the nurse, passed under the arm of the patient, and gentle friction from the circumference of the gland to the nipple be continued for some time, the parts having been first covered with warm lard. I cannot speak too highly in this place of the treatment of mastitis by pressure, applied over the entire breast and around the body, with an ordi- nary roller bandage. The relief is often immediate, and suppuration pre- vented; or the handkerchief bandage may be used as follows: The diseased breast is covered with a layer of cotton-wool, and a bandage applied, which is known in minor surgery as the bandage of Mayor or the triangular bon- net of the breast. The form of the handkerchief is a triangle, a yard in length from one extremity to the other, and fifty centimeters (nearly twenty inches) from the apex to the base. The base of the triangle is placed obliquely under the diseased breast, one of its extremities is directed under the corresponding armpit and the other over the opposite shoulder, and there united behind the shoulder-blade. The apex of the triangle is then lifted in front of the diseased breast, is carried over the corresponding shoulder and firmly fixed behind. In the cut, Fig. 520, an excellent method of bandaging the breast is shown. It may answer either for mammary abscess, pendulous breast, or to support the parts after the gland has been removed. It consists of a large bandage with two tails, one of which is fastened around the waist, the other supports the breast from the opposite shoulder, and is fixed to the first behind. 828 A SYSTEM OF SURGERY. If, after the chilliness, the patient experience a tensive, burning, or dart- ing pain in the breasts, if they are somewhat swollen and red, bryonia should be prescribed ; or, if before the symptoms above mentioned appear, and there is only slight swelling, aconite. These two medicines are often suffi- cient to produce resolution; the child, however, should be allowed to suck, though pain is produced. In some instances the breast-pump is service- able, when the female is desirous of weaning the infant, but often it may FIG. 520. - : : aº 4% Afºx. º tº ** * %. - ° ºf Aº ºf ſº º; º - Method of Bandaging the Breast. be dispensed with, the treatment being sufficient to cure the affection. If the milk continue to be secreted in too great quantity, and bryonia does not relieve, puls. will be found of service. Calc. carb. has been used with suc- cess, and lycop. was effectual in an obstinate case. The drug which has proved in my hands most efficacious is kali hydriod. in five-grain doses three or four times daily. Belladonna must be given when there is, together with the throbbing pain, a shining erysipelatous redness; and when the inflammation is caused by suppression of the milk by violent emotions, if the patient be robust, with tendency to congestions. If this does not relieve, and the patient com- plains of chilliness, and shuddering, which at this stage indicate the forma- tion of pus, mercurius should be administered, or, if the symptoms require, hepar should be prescribed. If these are not sufficient and suppuration is progressing, phosph. has been recommended by Dr. Croserio; he says: “Since I have seen the marvellous effects of phosph. in abscess of the breasts, I have employed no other medicine when there have been evident signs of suppuration.” So soon as fluctuation is distinct, the abscess should be freely opened. My plan is to use a sharp-pointed curved bistoury, and cut from within outward. The parts are to be covered with a poultice and calcium sulphide administered. After a day or two the poultice must be removed and a sim- ple dressing of carbolic acid and glycerin applied. If indurations remain, conium, merc., phosph. ac., or sulph. may be administered. If the inflammation be consequent upon bruises, arnica may be applied externally, in a weak solution, and internally in the 2d dec. dilution; and, CARCINOMA OF THE MAMMA. 829 should much pain or fever be present, in alternation with it, aconite may be prescribed. - When called to treat old cases, in which there are several sinuses, I first inject them with a preparation of hydrastis 3.j to 3.j of water, and apply over the parts compressed sponge, which I tightly strap to the breast; . the fluids exude the sponge expands, and constant pressure is thus ept up. *homa of the Mamma-This disease frequently arises from small indurations, which are sometimes discovered in the breasts at an early age. If these do not receive timely attention they frequently enlarge and become painful at the critical period. The usual origin and development of epithelial cancer of the mammary gland is as follows: A hard tumor is discovered in the breast, appearing either spontane- ously, or in consequence of pressure, shock, etc. At first the growth is round and movable; as it increases in dimensions it becomes uneven ; other swellings develop which appear to be united by cords of indurated cellular tissue. These tumors enlarge, combine into one, involve the whole glandular structure, and sometimes spread to the axilla. Lanci- nating pains at this stage are experienced, extending to the shoulder and arm, and not aggravated by pressure. The integument, if invaded, as- sumes a streaked, cicatrized appearance, and the follicular glands are frequently filled with a blackish substance. The skin in a short time adheres to the tumor, which becomes elevated and inflamed. These symptoms may disappear, but finally the nipple retracts, forming a cavity, the skin breaks and reveals a spreading ulcer, with hard, dark red, shining edges and an unclean bottom ; the discharge is neither very copious nor fetid, and the ulcer resembles a deep fissure devoid of excrescences. The axillary, the glands in the clavicular region, and the cervical ganglia, may enlarge, provided swelling has not taken place previously. At this period, when the tumor is seated, immovable, and hard, the patient com- plains of a troublesome feeling of heaviness, with almost constant sting- ing, boring, shooting, lancinating pains, proceeding to the shoulder, and from the mamma in various directions; also, of rheumatic pains in various parts, particularly in the loins and thighs. The reproduc- tive process suffers considerably; the face assumes a pallid appearance ; the arm of the affected side commences to swell, its movement is im- peded, and at length excruciating pains and supervening colliquations produce death. Besides these phenomena, there are a variety of conditions that may occur during the course of carcinoma of the mamma. Sometimes the disease remains for a long time latent; at others its development is quite sudden, and it extends with rapidity, attended with severe symptoms of constitutional disturbance. Ulceration of the tumor is frequently produced by external violence—a blow, a fall, or a bruise, may create suppuration and degeneration, or sometimes the ulcerative process is established imme- diately after the suppression of the menstrual discharge. There are cases in which cancerous ulcerations are accompanied with slight pain; in the generality of instances, however, the suffering is severe, and their peculiar lancinating character is almost unbearable. The dura- tion of the suffering, when it is severe, is less than when it is not so excru- ciating, and from this circumstance a distinguishing characteristic may be drawn between acute and chronic cancer of the mammae. The former commences with a hard, deep-seated tumor in the breast, which adheres to the integument for a time, the skin becomes slightly discolored, the whole mamma gradually partakes of the induration; elevations may be observed 830 A SYSTEM OF SURGERY. in Some portions of the gland, while at others there are marked depressions; the surface becomes soft, and presents those appearances that designate the presence of fluid; the pain becomes sharper, and resembles in many re- spects that experienced by patients suffering from whitlow. The ulcerative process progresses rapidly, the pains increase, the countenance exhibits an expression of anxiety, the skin has a jaundiced appearance, and the patient is much debilitated and very desponding; the edges of the ulcer are raised, and present those characteristics of cancerous ulceration that have already been mentioned. True Scirrhus is dry and of a cartilaginous hardness, and shrinks after having attained a certain degree of development, the contraction and shrivelling of the integument forming various indentations; the accom- panying pains are not great, and by proper treatment the disease may remain in this condition for a considerable length of time. This form of FIG. 521. Medullary Cancer. “From a lymphatic gland—secondary to hard cancer of the breast. This form of cancer differs from the scirrhous only in the proportion of the cell element to the fibrous stroma—the cells being here seen to be still of the epithelial type, and lying close together without any visible inter- cellular substance.” From Arnott (HOLMES). cancer is most frequently encountered in elderly women of spare habit of body, and of dry rigid constitution. In certain cases a secondary medul- lary cancer may develop in the axillary glands, the breast being affected with scirrhus. (See Fig. 521.) Encephaloid cancer is not so hard as scirrhus, and the superficial veins are much enlarged; as the tumor grows, it presents on the surface one or more purplish and fluctuating spots, which, as the tissue degenerates, give way, and haemorrhage is the result. As soon as ulceration begins, the discharge is excessively fetid. The surface of the ulcer is covered with the peculiar brain-like substance from which the disease takes its name, haemorrhages are frequent, the constitution breaks down rapidly, and death ensues. Treatment.—The scirrhous indurations in the breasts of young girls, which arise without any assignable cause, sometimes yield to phosphorus, phyto- lacca, hydrastis, or chimaphila. The medicines best adapted to cancer, not only when it affects the mamma, but in any other organ, are arsenicum and conium ; the former has been used, with more or less success, from a very remote date; and the famed “cancer curers” of the present day, no doubt, following the example BENIGN TUMCRS OF THE BREAST. 831 of their predecessors, employ the arsenical pastes. Conium is a superior medicine, and should be remembered in the treatment of this affection, particularly when contusion or abrasion of surface has hastened the carci- noma. When I administer conium internally, I apply the same medicine in the shape of the hemlock plaster, over the entire affected mamma. The plaster made by Seabury & Johnson, of New York, has served an excellent purpose, and may be employed, not only in hard scirrhous tumors, but in any variety of hard nodule in the breast. The prognosis is always to be formed with foresight and judgment, but in the generality of cases it has been found unfavorable. -- A great deal has recently been written regarding the aetiology and prog- nosis in cases of carcinoma of the breast, and many have gone so far as to express their conviction, that the disease is originally local, that amputation ought always to be performed, and even if the axillary glands are impli- cated, their thorough removal will prevent recurrence. This sweeping asser- tion I do not believe. In the majority of cases the disease will return sooner or later, but I am, on the other hand, convinced that early and complete removal of the breast, together with the extirpation of every suspicious morsel of gland or flesh, will not only prolong life but save an immense amount of suffering. Benign Tumors.-The most frequently encountered growths are, fibroid, cystic, fibro-cystic, and adenomatous. In regard to the diagnosis of all tumors of the breast, the fact of their being capsuled or not is of great import. }. the treatise on Innocent Tumors of the Breast, by Labbé and Coyne,+ the relation between cancerous and non-malignant growths is clearly set forth. It is there shown that the microscopical characteristics of a growth at any particular time, are not sufficient in and of themselves to determine definitely as to the malignity of that growth, for the pathology of tumors is thoroughly to be known only by clinical study combined with anatomo- pathological study. It is further held, that the idea of a specific morpho- logical element or “cancer cell” (as held and taught by Lebert and others, in 1854), is without foundation, for what was called the “cancer cell’ is not always found in the cancerous, and may often be found in the non-cancer- ous tumors. Mode of life rather than structure, is to be consulted in the diagnosis and classification of all, and especially of cancerous tumors. All benignant tumors of the breast have, however, one common character: they are limited by a fibrous capsule, whose formation is explained by the anat- omy of the breast, and by the point of departure of the morbid processes, and they derive their origin from a modification of the parts that compose the primitive lobule of the mammary gland. The conclusions arrived at regarding these benignant growths, may be summed up as follows: 1. A group of tumors exists in the breast that may be called benignant tumors. The character of benignity they all offer in different degree, is due to the special anatomical fact that they are clearly limited by a fibrous capsule that isolates them from the rest of the gland and the surrounding tissues. 2. These growths are of different classes, varying in anatomical character, and in the symptoms shown in each, but all benignant as compared with can- cer. 3. Simple enucleation constitutes an incomplete operation; partial or, —as in the case of sarcomas, myxomas, or any voluminous tumors of rapid development, total amputation of the breast must be resorted to for a com- plete operation. * Wide American Journal of the Medical Sciences, July, 1877, p. 137. | 832 A SYSTEM OF SURGERY. Amputation of the Breast.—When it becomes necessary to remove a mamma, the operation should be performed in the following manner: The patient should be placed on a table of proper height, the light being so ar- ranged that it will fall directly upon the part to be removed. As soon as anaesthesia is complete, the arm is drawn away from the body, and held in that position by an assistant. The breast should be washed with corrosive sublimate solution 1 to 2000. A saturated solution of iodoform in ether is then poured over the tumor. The surgeon, marking with his eye the part to be removed, makes an incision through the integument only, around the outer portion of the gland. In the generality of instances this cut should have its concavity toward the clavicle. The second incision should be made above the tumor, and should join the first at its extrem- ities, thus making an oval cut, which should embrace the tumor and about two inches around it. The knife is then carried quickly below the growth in the line of the first incision, down to the pectoral muscle, and the tumor dissected out. After removal, the wound should be carefully exam- ined, and every particle of suspicious tissue removed. If the axillary glands are enlarged, or even present a doubtful appearance, the incision should be extended and their removal effected. After the breast has been extirpated, it is my invariable custom to wash the parts thoroughly with a solution of corrosive mercury. I also lay great stress on the importance of ligating all the arterial twigs with carbolized gut. It takes a little more time, but saves trouble afterward. The wound must again be thor- oughly irrigated with bichloride solution, and three or four sutures of strong silver wire passed through the flaps an inch from the cut margins, down to the bottom of the wound and through on the other side. Before these sutures are drawn tight, a decalcified bone drainage tube should be placed in the angle of the cut nearest the axilla, and the deep portions of the wound should be brought together by traction made on the wires, which should be secured with leaden buttons on each side. The lips of the cut are then to be carefully stitched together with a continuous gut suture and the entire breast again washed with the bichloride water; over this a dress- ing of sublimated absorbent cotton encased in borated gauze should be placed, upon which a piece of oiled silk is laid, and held in position by a carbolized bandage around the chest. As a rule this dressing need not be removed for ten or fifteen days, and when it is, the cut has entirely healed. CHAPTER XLII. INJURIES AND DISEASES OF THE ABDOMEN. Woun DS OF THE ABDOMINAL VISCERA—SUTURING THE INTESTINE–ARTIFICIAL ANUs —ABSCESS OF THE ABDOMINAL PARIETES-HEPATITIS-DISEASEs OF THE GALL BLADDER—GALL STONES-CHOLECYSTOTOMY-HEPATIC ABSCEss—PARACENTESIs— OBSTRUCTION OF THE BOWELS – OPERATIONS FOR-CoIOTOMY — PERITYPHLITIC ABSCESS—GASTROTOMY AND GASTROSTOMY-SPLENECTOMY-RESECTION OF THE PYLORUS—DIGITAL DIVULSION OF THE PYLORUS. Wounds of the Abdominal Wiscera.--Wounds of the abdominal viscera have generally been considered more perilous than those of other parts of the body; the danger, however, must depend on the organ that is wounded, and the extent of the injury inflicted. Superficial wounds of the abdomi- TREATMENT OF WOUNDS OF THE ABDOMEN. 833 nal muscles, or their integuments, are seldom of much consequence, and should be treated according to common principles. When the wound is penetrating and extends deeply into the cavity, the peritoneum is involved. Inflammation of this membrane constitutes the chief source of danger in all wounds of the abdomen. But though it is liable to inflammatory ac- tion, cases have occurred in which balls, swords, or bayonets have passed through the abdomen, transfixing the peritoneum and several convolutions of intestine without proving fatal, and giving rise to but few untoward Symptoms. t In general, however, the patient first exhibits symptoms of collapse. These are paleness of the face, profuse perspiration, rapid fluctuating pulse, coldness of the extremities, great restlessness and sometimes in- voluntary discharge of fecal matter. In the majority of instances the small intestine is involved, although cases are recorded in which the large bowel has been ruptured or received a stab wound. In addition to shock, and speaking clinically, emphysema is always present and when associated with the collapse is sufficient evidence of the seat of the injury. Together with the manifestations mentioned there is generally extravasation of fecal matter, and when faeces make their appearance at the seat of the injury, the diagnosis is certain ; it must be remembered in this connec- tion, that extreme extravasation and the escape of fecal matter may take place within the peritoneal cavity and may not be discovered until the abdomen be explored. A fecal odor arising from the wound is always suspicious and generally indicates that the coats of the viscera have been punctured or ruptured. The amount of shock in each particular case de- pends on the nervous irritability of the patient; in some individuals the shock is rapid and profound, but the length of its duration must be re- garded as more important than its intensity, prolonged shock being con- sidered worse than its profundity. Other symptoms which may be noticed are the following: A tympanic sound over the liver would lead to the suspicion that there is perforation of the bowel in that neighborhood. Sudden distension of the abdomen, with persistent pain in one locality with rapid perspiration, reten- tion of urine, bloody passages, sinking pulse and temperature are all symp- toms which indicate a rupture of the intestinal tract. In these cases suturing the intestime must be resorted to. Wounds of the duodenum are more dangerous than those of the larger intestines, as there is greater difficulty in nourishing the patient, and more risk of effusion. Wounds of the stomach may be known by the seat of injury, great de- pression, vomiting of blood, and by the matter that escapes. In wounds of the intestines, faeces sometimes are extravasated into the peritoneal sac, giving rise to excruciating pain. In these the danger always is immi- nent. Wounds of the substance of the liver are almost certainly fatal, from the great vascularity of the organ. From slight injury of this viscus, patients, however, recover. Wounds of the kidneys may be suspected from the position and direction of the injury, and a discharge of bloody urine ; this accident is dangerous from three causes, haemorrhage, inflammation, and profuse and continued Suppuration. Treatment of Wounds of the Abdomen.—When the surgeon is called to treat a wound of the abdomen, probing should be dispensed with as much as possible—such examinations made thoughtlessly, are productive of mischief. If an intestine protrude, it should be replaced ; or, if this be im- practicable on account of the distension of the gut with flatus, etc., a dose 53 834 A SYSTEM OF SURGERY. of nux vomica should be prescribed; or, if there be considerable vomiting, and cold, clammy skin, and great prostration, a dose or two of veratrum in alternation with the nux. When the distension abates, and vomiting and other symptoms are relieved, the intestine should be returned, and the lips of the wound brought together and silver sutures applied. If there be no solution of continuity of the external parietes, and the peritoneum has sustained injury from external violence, arnica should be prescribed internally, and at the same time a diluted tincture of the medi- cine should be externally applied. If either from blows or from wounds the symptoms of peritoneal inflammation arise—which are, painful tension and tumefaction of the abdomen, with excessive sensibility to touch, and frequently ischuria and constipation—aconite, bell., bry., should be em- ployed in accordance with the presenting symptoms. Nux wom. is the proper medicine when there is painful sensibility and distension of the abdomen, with vomiting and other symptoms of gastric derangement, to- gether with ischuria. Mercurius should be employed when there is quick, weak pulse, nocturnal Sweats, and prostration. When the features are collapsed, and there is rapid sinking of the vital energies, and if the inflammation appear to have extended to the upper portion of the alimentary canal, with vomiting of blackish matter, arsenicum is indicated; in other instances, carbo veg. is demanded. - If the kidney is the seat of injury, the wound should be treated in ac- cordance with principles already laid down; and the inflammation of the gland combated with the means employed in the treatment of nephritis. If the intestine or part of the stomach that protrudes from the wound is divided, the parts may be brought together with fine silver wire, or carbo- lized animal ligatures, which may be cut off close to the knot, and returned into the abdominal cavity. In this operation, care should be taken to bring the edges together in such a manner that the two surfaces of the outer or serous membrane be applied to each other, as adhesion does not take place as well between mucous surfaces. - Enterectomy—Suturing the Intestines.—Since the recent improvements in abdominal surgery, combined with cleanliness and disinfection, it has been found that the intestines may not only be readily sutured, but that portions of the bowels may be excised and the cut surfaces joined together, the patients making good recoveries. These operations may be performed in several ways. An incision is made in the linea alba, and the abdomen explored until the diseased intestine has been found; then two pairs of forceps, their blades having been wrapped with antiseptic flannel, or in- cased in pieces of rubber drainage-tube, are applied, one on each side of the gut to be removed. This is to prevent extravasation, or the extrusion of fecal matter during the progress of the operation. The gut is cut away between the blades of the forceps, and a W-shaped piece of the mesentery is removed with it. The relation of the mesentery with the gut is a very important point in all cases of wounds of the intestines, and is one which must influence the surgeon in his decision regarding resection, and that is, how far the mesen- tery is separated from the bowels. It has been shown by Zesas,” that the removal of the mesentery from the gut, interferes so materially with the circulation of the part, that gangrene is likely to result, and that, there- fore, if in a wound of the intestine the mesentery has separated from the bowel, it should be resected at once; and, on the other hand, if an inch or more of the mesentery remain attached to the wounded gut, resection is * Archiv für Klinische Chirurgie, Bd. xxiii., Heft 2; Medical News, May 29th, 1886. ENTERECTOMY. 835 not required. These important considerations, must be carefully weighed by the surgeon in questions of resection of the intestine. The sutures for the purpose should be made of carbolized catgut or silkworm gut, and may be introduced in several ways. The needle should FIG, 523. Lembert's Suture for the Intestine. Continuous Suture. be a fine round one, and should be introduced in such manner that the serous surface of the intestine can be brought into good apposition. To FIG. 525. FIG. 524. §§ = 1 * \ Jobert's Suture for the Intestine. accomplish this object Lembert thus proceeds: The needle is entered about a quarter of an inch from the side of the wound, and should pass as far as the submucous tissue, it is then brought out about one- sixth of an inch from the cut on that side, and is made to enter the 836 A SYSTEM OF SURGERY. opposite side of the rent, one-sixth of an inch from the edge of the cut, and brought out at one-fourth of an inch from the cut surface, or, in other words, at a similar distance from the wound on the side in which it was introduced. These stitches must be very numerous, must all be passed before they are tightened, and should not be more than a line apart. (Fig. 522.) It will be seen that when the strings are drawn together, the serous surface of the intestine will be approximated. The end of the º should be cut short and the gut returned into the abdominal cavity. The continuous or glover's suture may also be used with advantage, as seen in Fig. 523. When the intestine is completely divided, the lower end is turned in, while the upper is simply pushed within the former and united by fine sutures, So that only the serous surfaces are in contact. The mesentery is previously torn from the intestine for a short distance on both sides (Jobert) (Figs. 524 and 525.) Artificial Anus not unfrequently follows gunshot wounds of the intestines; or it may be the sequence of a penetrating wound, an abscess, or ulcera- tion. “In all examples of this description I have seen,” writes Dr. Gib- Son,” “spontaneous cures have taken place, after the contents of the bowels have been discharged, for several weeks, through the fistulous opening.” There are two varieties of artificial anus: one in which the adhesion takes place between the outer wall of the gut to the internal parietes of the abdomen, the side of the intestine having previously sloughed; in this Variety the canal remains open. In the second the adhesions take place in the same manner, but a knuckle of intestine having sloughed, there remains a membranous partition between the two portions of the canal formed by the inner wall having been folded upon itself. Treatment.—The first variety generally gets well, as already mentioned, spontaneously. For the second, the following is the operation of Physick. It consists in passing a ligature through the septum and tying it upon the tissues; this is allowed to remain eight or ten days, during which time ad- hesions are formed between the peritoneal surfaces, when as much of the Septum may be cut away as necessary. Dupuytren's enterotome consists of a forceps with oval fenestrated blades, which are made with a screw in order to compress the septum. The principal medicines in this affection are calcarea, causticum, phosph., silic., and sulph. - - Abscess of the Abdominal Parietes.—When, as a consequence of wound or contusion, abscess of the abdominal parietes takes place, the location of the secreted matter is generally between the layers of tissue constituting the walls of the abdomen. In the first stages a hard and painful tumor is observed, which increases in size, becomes softer, and, in some instances, fluctuation may be felt. The seat of these abscesses is generally in the posterior abdominal walls, the lumbar and iliac regions, the anterior parietes being not often affected, unless the disease is connected with abscesses of the internal organs, as the appendix vermiformis, liver, spleen, etc. I have seen a case of anterior abdominal parietal abscess, in consultation with Dr. T. F. Allen, of New York. The purulent collection was immense; the pus had formed between the oblique muscles, and required a deep in- cision for its exit. The patient made a good recovery. In this variety there is tendency of the pus to burrow, and if the tumor * Institutes and Practice of Surgery, vol. i., p. 185. INFLAMMATION OF THE LIVER, 837 does not rupture internally, the matter may find its way between the apo- neuroses and along sheaths and tendons, and discharge at a distance from the original site of the inflammation. If suppuration be the result of a wound, a free incision should be made as soon as possible; some surgeons recommend that an opening be made with a knife in the most prominent part of the tumor, before the inflam- matory process terminates in suppuration, and thus avoid the danger that the contents of the abscess will be emptied into the cavity of the abdomen, and, as a further result, be followed by ulceration of the intestines. This, however, is not a warrantable proceeding. The case must be watched, and, when symptoms of suppuration show themselves, an exploring needle or the aspirator be used. After this, a free incision should be made and the pus evacuated. Hepatitis—Empresma Hepatis—Inflammatio Hepatis—Inflammatio Jeci- noris.-The symptoms of hepatitis are a dull heavy pain occurring in the right side, increased by pressure, cough, or deep respiration, sometimes relieved by bending the body forwards; the pain may be either stinging, cutting, burning, tensive, dull, or aching; sometimes an acute pain is ex- perienced in the right shoulder, clavicle, or arm, as though numb ; the same want of feeling may be experienced in the entire right half of the body, with pain along the vertebral column. If the size and consistence of the liver be increased, it projects beyond the false ribs, and extends more or less into the abdomen; the pulse is hard and frequent ; the patient lies on the right side, being often unable to rest either on the left, or on his back; respiration and digestion are interfered with ; sometimes a slight, dry or hollow, and deep cough is present; the conjunctiva and the skin acquire a yellow tinge; there is also constipation, the faces being grayish and discolored. The hepatic region may be covered with red spots, and throbbing in the hypo- gastric region may attend the disease. If the convex surface be affected, hepatitis simulates pneumonia or pleurisy; if the concave, gastric symp- toms predominate. The affection may assume a chronic form. The ter- minations of inflamed liver are various: it may end in resolution, suppura- tion, or gangrene. When resolution takes place, the symptoms disappear gradually; when it suppurates, hectic fever appears, also tumefaction and increased weight in the hepatic region; and if adhesion take place between the peritoneal covering of the liver and the peritoneum proper, the matter finds its way externally. In India, where this organ is frequently affected, the tendency to abscess is great, the pus forming in the parenchyma of the organ. The liver enlarges from hyperamia; it becomes hypertrophied, when its tissues exceed a healthy size, and may be atrophied from defective nutri- tion. It also becomes softened, or indurated, or assumes a yellow color (cir- rhosis of the liver), as well as granulated and tuberculated; these granula- tions are found to vary in size from that of a large shot to a cherry, and are found at the surface and within the organ; the liver is smaller than natural and shrivelled, and its tissue more dense. These granulations are red, brown, or yellow ; some are of a canary color. Melanosis of the liver is that condition wherein the tissue is converted into a black, hard, homogeneous mass, near which ulcers or cavities form, owing to the softening of the substance itself, or of some other morbid tissue, of tubercles especially. Inflammation of the liver is distinguished from pneumonia by the pleu- ritic pains being less severe, and chiefly confined to the course of the phrenic nerve (ascending to the top of the shoulder); by the pain in hepa- titis being increased by pressure, while in pneumonia this is not the case; by the difficulty in pneumonia of lying on the affected side, the reverse being true in hepatitis; by the sallow countenance; by the physical signs 838 A SYSTEM OF SURGERY. revealed by auscultation and percussion. From enteritis it is distinguished by the seat of the disease, which is discovered by tenderness upon pressure, by the sympathetic pain in the clavicle and shoulder, by the prostration being less, by the greater fulness of the pulse, by the color of the stools and Ulr1116. - The causes of hepatitis are those which induce inflammation: emetics, drastic cathartics, acrid bile, biliary concretions, external injuries, violent passions, intense heat, the inordinate use of spirituous drinks, metastasis of piles, of inflamed joints, diarrhoea, dysentery. Treatment.—This should begin with aconite, especially if the fever be high, the pains in the liver shooting, and the pulse full, accelerated, and irregular, more so than when it is hard and frequent. If icteric symptoms ºn, and the disease be produced by chagrin, chamomilla affords rel161. Bryonia.--When the pain is oppressive, increased by touch, coughing, moving, breathing, especially upon inspiring, together with a congestive condition, the fever increasing at night. Belladonna.-For restless nights; vertigo ; congestion to the head, with dimness of vision; burning thirst ; restlessness, sleeplessness. It is suited to those cases where the inflammation exists chiefly in the lower surface of the liver, when the pain is increased by cough, pressure, inspiration; the ains resembling those of pleuritis. * After belladonna, mercurius is frequently required; also in enlargement and hardening of the liver, and when suppuration has taken place. Nux vomica for induration and enlargement, and when there are gastric symptoms in the chronic form. - Diseases of the Gall-bladder.—The gall-bladder is a membranous pear- shaped reservoir, situate in a superficial depression at the inferior surface of the right lobe of the liver. It receives, by the hepatic and cystic ducts, a portion of the bile secreted when the stomach is empty; which becomes in it more thick, acrid, and bitter. It receives the cystic artery; its veins empty into the vena porta; the hepatic plexus supplies its nerves; and its lymphatic vessels unite with those of the liver. Idiopathic inflammation of this receptacle is not of frequent occurrence, but it is a concomitant of affections of the liver, and also of biliary calculi. The symptoms are de- scribed as sudden, acute, agonizing pain at the margin of the false ribs, increased by pressure, by inspiration, and lying on the back; the patient can scarcely straighten himself, and lies on the left side with the lower limbs drawn up ; the paroxysm of pain continues a few hours, and as it subsides, jaundice appears; dyspeptic symptoms and vomiting are present; fever, temperature 103°; great thirst ; no shivering, nor heat of skin. The intensity of the disease may render it fatal, or the gall-bladder may be per- forated and the bile poured into the peritoneal cavity, producing peritonitis. The remedies for this disease are those adapted to biliary calculi. Calculi Fellei seu Biliarii–Gall-stones.—These stones are not of infre- quent formation; when in the gall-bladder they are not necessarily pro- ductive of uneasiness, but in their passage through the ducts they give rise to what is denominated “hepatic colic.” When in the gall-bladder their presence is known by pressive pain in the right epigastric region, ex- tending towards the side and back, with some disorder of the stomach; sometimes by cramps with vomiting; the skin becomes at the same time yellowish. Collections so large as to be detected by external examination, and even producing enlargement under the cartilages of the ribs, have in some instances occasioned little inconvenience. But when moving through the ducts, the paroxysms of pain are intense in the region of the stomach CHOI,ECYSTOTOMY. 839 and liver. There is vomiting; the abdominal muscles become violently con- tracted, the extremities cold and the body covered with sweat. A diagnostic sign is the pulse not being altered. After these symptoms have lasted awhile, there may be an interval of rest, to be followed by a recurrence of the pain. If the faeces be examined, biliary calculi will be observed. These stones consist of a peculiar fatty substance, coloring matter, cholesterin combined with soda, picromel, mucus, Soda, phosphate of soda, phosphate of lime, and chloride of sodium. Some are almost pure cholesterin, which is an inodorous, insipid substance, in white shining scales, fusible and crystalliz- ing on cooling in radiated fibres. Others are composed of resinous matter, the real nature of which is not ascertained. The greatest number, however, consist of thickened bile and cholesterin. Young children are not often affected; persons aged between 40 and 50 are most obnoxious to the dis- ease; women suffer more frequently than men. - Causes: quantities of fat animal food, sedentary life, scanty use of water as a drink, choleric temperament, Treatment.—I wish to call attention to two remedies which I have used in this disease; the one highly recommended by Dr. Thayer, of Boston, the other by Dr. Kimball, of New Jersey. They are china and berberis. I have given them with surprising results, and have cured many cases, Some of which were alarming and chronic. The china I give in the first decimal trituration; the barberry in infusion. For the agonizing pain oc- casioned by the passage of gall-stones, it is necessary to give hypodermic injections of morphia sufficiently often to relieve the pain. To prevent a recurrence of the sufferings, the medicines above named should be given, or colocynth, nux vomica, mercury, podophyllin, or ipecac. Cholecystotomy.—In certain cases of obstruction of the gall-ducts the operation of cholecystotomy must be performed, or in cases of malignant º the operation of Langenbuch, known as “cholecystectomy,” may € CIOIlê. Musser and Keene,” in an exhaustive treatise on cholecystotomy, state that there are four conditions, all of them well pronounced, which may call for operative procedure; they are obstructive jaundice, as differentiated from jaundice by Suppression; an enlarged gall-bladder, protruding as a tumor in the right hypochondriac region; symptoms of suppuration and fre- quent attacks of paroxysmal and severe pain. It is said that the itching which is present in many cases of jaundice indicates the obstructive variety. Of this, however, I am not sure, as I have in mind two cases of such se- vere itching accompanying jaundice that the patients were rendered nearly frantic by the pruritus. One was emaciated to a skeleton, and could only lie on the bed naked and covered with a sheet, not being able to bear the contact of ordinary clothing, which he would actually tear from his person, in the irresistible desire to scratch. Both of these patients would recover by changing climate, neither had any of the pain of obstruction, but both would relapse after six months or a year's exemption. Besides gall-stones, the biliary ducts can be closed by parasites, by ex- ternal tumors, by adhesive inflammation, or the cicatrization of ulcers; all of which will necessarily give rise to the symptoms alluded to. An enlarged gall-bladder presents itself in the right hypochondriac region, and is generally globular. Sometimes the swelling partially disappears (as in a case of my own) to recur again with severe paroxysmal pain. An indication stated by Musser and Keene as being one of the proofs that a tumor presenting in that locality is the enlarged gall-bladder, is, that intes- * American Journal of the Medical Sciences, October, 1884. 84() A SYSTEM OF SURGERY. tine is never found in front of the growth. To make the diagnosis certain, the small aspirating needle must be employed. The dreadful pain that accompanies the passage of biliary calculi is well known to all surgeons, and when such is frequent, and the patient shows symptoms of great ex- haustion, then the operation is indicated. It must be remembered that severe biliary colic may be present without jaundice, and yet the stones be found in the gall-bladder and in the cystic duct. Symptoms of internal suppuration would in these days call at least for explorative laparotomy. In an interesting and original paper on this subject, Dr. A. C. Bernays * submits the following conclusions, which are worthy of much thought. He says: “I. The causes which indicate an operative interference with the system of gall-vessels are: a, jaundices; b, paroxysmal pain or a tumor in the right hypochondriac region; c, suppuration; d, peritonitis; these conditions to be either collectively or singly recognizable, the presumable origin being biliary calculi; e, malignant disease. “II. Explorative laparotomy must be preferred to acupuncture or aspi- ration as a diagnostic measure. “III. The incision in the linea alba is preferable when there is much doubt regarding the seat of the obstruction, because the large ducts can be reached much better from this incision than from the incision parallel to the free border of the ribs. “IV. The escape of bile through an abdominal fistula is not injurious to the process of normal digestion. The bile is an excretion, and probably of no more use in the intestinal canal than the urine in the bladder. “V. Jaundice, when caused by an obstruction of the common duct, is no contraindication to natural cholecystotomy. We may often save life by its early performance. “VI. Cholecystotomy, natural and ideal, and cholecystectomy are the three operations at our service; cholecystenterostomy may be useful, but it has not yet earned a place among approved surgical procedures. “VII. Ideal cholecystotomy is indicated when the bladder is normal in structure and when the gall-ducts have been cleared of obstructing calculi. “VIII. Natural cholecystotomy is indicated when the bladder is ulcer- ated or suppurating, or when there are permanent obstructions beyond reach at the time of operation. “IX. Cholecystectomy should be limited to cases of otherwise incurable or malignant disease of the gall-bladder.” There are several methods of performing cholecystotomy; one being the incision into the gall-bladder, the removal of the stone, and the establish- ment of a biliary fistula; another, that of removal of the stone and after- wards stitching together the wound of the gall-bladder, returning the same into the abdominal cavity, and closing the wound as after ordinary lapa- rotomy, and another known as cholecystenterostomy, which consists in the formation of an opening between the gall-bladder and duodenum. I have read of several interesting experiments made upon dogs by Dr. J. McF. Gasten, f of Atlanta, to restore the course of the bile, and to prevent the loss of the secretion through abdominal fistula. As above noted, Bernays pre- fers the incision in the linea alba, Dr. Lange i made his cut six inches in length “through the external border of the rectus abdominis,” Taits makes * Ideal Cholecystotomy, I. H. Chambers & Co., St. Louis, Mo., 1885. + Gaillard's Journal, October, 1884. j Annals of Surgery, May, 1886, p. 381. & Surgical Treatment of Gall-Stones, Lancet, 1885, vol. ii., p. 239. HEPATIC ABSCESS. 841 a vertical incision from the margin of the ribs downwards over the hepatic notch. Musser and Keene prefer a cut three inches long over the centre of the tumor and “parallel to the free border of the ribs.” Whichever be the line of incision selected, the knife should be carried carefully through the tissues, each bleeding point secured with ha'mostatic forceps, until the peritoneum is reached. The vessels—every one of them—should be secured with fine catgut and the forceps removed. The peritoneum should be opened and incised with scissors on a director. Two fingers or the hand may then be introduced into the abdominal cavity, and the nature of the tumor ascertained, and the points if possible where the obstructions (gall- stones or other impediments) are located. If the latter be found and are movable, the surgeon should gently attempt to push them into the duo- denum. If this be impossible, they should be pressed into the gall-bladder. The tumor should then be aspirated, care being taken not to allow the bile to enter the cavity of the abdomen. The wall of the gall-bladder should now be carefully drawn forward through the cut and held by a pair of forceps, while an incision is made into it; the finger or a scoop should be used to extract the foreign body or bodies. This is often difficult, and in some cases, in the hands of distinguished operators, a stone has been allowed to remain, being so impacted that the force required for its removal would have been dangerous to the patient. The margins of the cut bladder must be stitched to the abdominal walls and a drainage-tube inserted. Bernays, however, has accomplished a better result by stitching the cut walls of the gall-bladder together with the Czerny-Lembert suture, and closing the abdominal wound. Cholecystotomy was first proposed by Thudichum, and though other surgeons had given attention to it, Dr. Bobbs first opened the gall-bladder in June, 1867, and Dr. Sims arranged and practiced it in 1878. The results of the operation as given in Musser and Keene's tables, show but ten deaths in thirty-five cases. Hepatic Abscess.-The occurrence of hepatic abscess is less under homoeo- pathic than allopathic treatment, because by the administration of homoeo- pathic medicines, the inflammation existing in the liver is generally subdued before suppuration ensues. - There are cases that, notwithstanding the best-directed efforts to procure resolution, terminate in suppuration, and among these may be classed those that are occasioned by wounds or other injuries; or when the disease is present in individuals who are weakened by constitutional affections, biliary concretions, or the presence of worms in the biliary duct. Kirkland” relates a remarkable instance of the latter; and also Dr. Thomas Bond,i and Dr. Gibson, of Philadelphia. The latter gentleman writes: “A very beautiful preparation, made by the late Dr. Wesenhall, of Maryland, of a liver, the substance and ducts of which are filled and per- forated in every direction, by numerous and very large lumbrici, which de- stroyed the child by irritation and suppuration, is contained in my surgical cabinet deposited in the University.” . In abscess of the liver, or rather before suppuration has been estab- lished, the patient experiences a stinging, burning pain in the right hypo- chondrium, below and around the false ribs, frequently extending to the epigastric region or sternum, and in some instances, even to the thorax. This pain may be severe, or it may be a continual, dull aching, aggravated by lying on the affected side, or by external pressure; there is also more or less pain experienced in the right shoulder. *— * Inquiry into the Present State of Medical Science, vol. iii., p. 186. # Medical Observations and Inquiries, vol. i., p. 68. † Gibson s Institutes and Practice of Surgery, vol. i., p. 209. 842 A SYSTEM OF SURGERY. There are also present gastric symptoms, such as hiccough, loathing, eructations, attended with anguish, or there may be nausea, vomiting, bitter taste, and yellow tongue. Rigors generally precede the immediate formation of pus, and swelling may appear in the right side, and, as the disease progresses, fluctuation be perceived. The pus burrows in various directions, in accordance with the situation of the abscess; it may proceed to the region of the hip, along the dorsal vertebrae, or be discharged into the transverse colon, stomach, duodenum, or into the lung; the latter is an unfavorable situation, as the patient frequently dies of hectic.” After the abscess has opened, the pus discharged changes its character; at first it is thick and creamy, but after a time it becomes greenish, fetid, or of a dark-brown color. Large cavities are formed in the liver, and in Some instances the whole structure of the organ may be destroyed, and there are cases on record where this has been the case, as revealed by post- mortem examinations. It is well known that there are many points of exit through which hepatic pus may pass, and patients have been known to recover after the rupture of large hepatic abscesses; on the other hand an operation is attended with some risk, and not many have survived its performance—I mean recovered their wonted health. Again, we know that many at once succumb to the inflammatory action engendered by the purulent matter from the liver escaping into other parts of the body. It is interesting to observe how many points have been the site of rup- ture of large hepatic abscesses. Cragief says that, besides the abscess discharging into the abdominal cavity, the pus may pass through the air- cells into the bronchi, by the adhesive process into some part of the intestinal canal, the stomach, transverse arch of the colon, or even the duodenum ; and Rokitansky, with his usual system and accuracy, mentions several other outlets, as into the gall-bladder, or one of the larger branches of the hepatic duct, through the diaphragm into the pericardium, and even into large vessels, as the vena cava. He mentions a case in which communica- tion was established between a hepatic abscess and the vena portae and the duodenum. Another hazard is much to be dreaded. On this point Budd $ writes: “A source of far greater danger is the circumstance which has been before noticed, that the inflammation which leads to abscess is often confined to the substance of the liver, and does not involve its capsule. As the abscess approaches the surface, adhesive inflammation of the peritoneum imme- diately above it usually takes place, and a small quantity of lymph is poured out, which causes adhesions between the wall of the abscess and the parts with which it is brought into contact. These adhesions are often of very small extent; sometimes they do not form at all, and as I have before re- marked, the abscess bursts into the cavity of the peritoneum, causing speedy collapse and death. By opening an abscess of the liver before adhesions have formed, we may be directly instrumental in bringing on this fatal issue; the pus may escape into the cavity of the peritoneum, and the patient die in a few hours, obviously in consequence of the operation.” Another danger is encountered in allowing air to enter the cavity of the abscess; then decomposition of both air and pus results, and fresh inflammatory action is developed. In a case of my own I was for a time puzzled, because the pus was * Sometimes the abscess has discharged itself into the pericardium. See London Lancet, August, 1845, p. 154. f Pathological Anatomy, 859, 860. † Ibid., vol. ii., p. 108. 3 Diseases of the Liver, p. 323. HEPATIC ABSCESS. 843 dark brown or reddish. Upon consulting authorities upon the subject, I found that the suppurative process in the liver generally ended in the formation of the ordinary purulent matter. Budd” says: “The matter in a hepatic abscess is usually white or yellowish, and is free from odor, unless it is in close proximity to the lungs, where it sometimes becomes decomposed and fetid from the admission of air.” He then goes on to state that many of the older writers described the pus of abscesses of the liver as being generally red or claret-colored; but according to his experience, such observations are incorrect. It is well to bear this statement in mind in order to explain wherein Mr. Budd is right, and wherein also the “old writers ” are correct. This will appear from the following facts. Roki- tanskyi states: “In reference to its contents, the hepatic abscess presents considerable differences at different periods, depending in part upon the communication established in the biliary vessels; and a large abscess of long standing invariably contains pus, mixed with a considerable amount of bile, which arises from a communication which is established between the larger gall ducts.” Jones and Sievekingſ have also the following, which is worthy of remark: “When an enlarging abscess reaches a hepatic duct branch, it does not set up inflammation in its walls and cause its obstruc- tion, but it ulcerates through its tunic, and establishes a communication between the efferent channel and its own cavity. Hence it occurs that the pus contained in large abscesses is always mingled with a consider- able amount of bile, while that of the smaller or recent abscesses is almost Ulre. - p From these facts we would draw the deduction that in the majority of cases éxamined by Mr. Budd, the abscesses were recent and of limited ex- tent, while the observations of the older authors were probably based upon the appearances derived from large collections of hepatic pus. In the present case the admixture of the bile no doubt was the cause of the peculiar color of the liquid, and the explanation is readily found, as mentioned in the above quotations, in the destruction of the walls of the vaginal hepatic ducts. Treatment.—We may here pause, to speak of the various methods that have been devised for the opening of these abscesses, premising that the aspirator is the instrument par excellence, but I have met with cases in which, though I introduced the largest needle, the fluid was so thick that the suction of the air-pump failed to relieve. In such, other meth- ods must be employed. We must recollect the dangers that are to be encountered ; these are two, the first being the risk that adhesion has not taken place between the peritoneum and the wall of the abscess; and that by the puncture an opening may be made that would allow a quan- tity of pus to escape into the cavity of the peritoneum, thereby causing inflammatory action and speedy death; and secondly, the danger of the admission of air into the cavity, thereby setting up decomposition of the pus already formed, and exciting the pyogenic membrane lining the abscess to fresh production of purulent matter. To obviate the first difficulty, viz., the discharge of pus into the peritoneal cavity, the following process has been devised by Dr. Graves, and is recommended by other surgeons, viz.: to make free incisions through the muscular parietes of the abdomen, and to press to the bottom of the wounds thus made, pledgets of lint, thereby exciting adhesive inflammation between * Suppurative Inflammation of the Liver, p. 107. f Pathological Anatomy, vol. ii., p. 107. f Ibid., pp. 510, 511. 844 A SYSTEM OF SURGERY. the reflected layer of the peritoneum and that covering the abscess, thus making sure that no pus can enter the abdominal cavity after the punc- ture. The admission of air can also be prevented, first, by making a valvu- lar opening, or by having screwed to the canula, a bladder with a stop-cock attached (as recommended in the puncture of the thoracic walls); by turn- ing the valve the air is prevented from passing through the canula, and the bladder may be emptied at pleasure; taking, however, the precaution of drawing the integument well over the spot at which the puncture is to be made, and holding it firmly in that position while the trocar is entered obliquely, it will readily be perceived that so soon as the canula is with- drawn, the skin by its natural elasticity will retract to its usual position, and thus effectually close the opening. The medicines which have been detailed in the chapter upon Abscess must be given, especially in the earlier stages, with the hope of producing resolution. The most serviceable in effecting such a result are, acon., bell., bry., cham., merc., nux vom., sulph. The indications for their use will be found in any work upon the practice of medicine. The medicines that are adapted to hepatic abscess are, ars., bell., hepar, merc., silic, sulph. If the matter has made its way towards the surface, the prognosis is more favorable than when it is discharged into any of the Surrounding tissues or organs. If the pus has commenced to form, hepar should be administered, or if the process of formation be slow, merc. and silic. may hasten the suppuration, and allay pain; the latter is the better, particularly where there is hardness of the surrounding parts, with disten- sion, or if there is a continual stitching pain below the floating ribs; mer- curius is to be preferred, when there is burning in the region of the liver, with distension from within outwards, accompanied with perspiration, that is excited by the slightest motion. If the swelling appear to protrude through the intercostal spaces, the pus should be immediately evacuated, by means of the lancet or aspirator, or trocar; if this be not done, the matter may be discharged in another direction, and give rise to unfavorable symptoms. If, after the opening is made, the discharge continue, and become thin, Sanious, and unhealthy, ars., carbo veg., or nit. acid must be administered; the directions for their use have been already mentioned in a preceding portion of this work. If the opening have a tendency to become fistulous, calc., silic., sulph., or phosph. should be exhibited. - In all cases, the patient should be kept at perfect rest, and if extremely weak, a moderate stimulus should be allowed. $ In some instances, when there is a large quantity of pus, it should be evacuated by openings, at longer or shorter intervals; to determine this, however, the general constitutional symptoms of the patient must be taken into consideration. If he be robust and previously healthy, and the in- flammation has gone through its stages rapidly though completely, there need be no fear in allowing free vent to the purulent secretion. If the patient has been long suffering from previous disease, the constitution weak, temperament nervous, and the signs of a chronic hepatitis have been present, care should be taken that the removal of a large quantity of matter does not produce alarming symptoms of debility and exhaus- tion; it is then better to practice the method recommended by Abernethy, already alluded to in the chapter upon Abscess, or apply the aspirator. Ascites.—By ascites is understood a dropsical effusion in the cavity of the peritoneum; it may be complicated with hydrothorax or general anasarca. Dyspnoea, cough, dryness of the skin, diminished secretion of urine, loss of appetite, constipation and prostration of strength, are symptoms which PARACENTESIs ABDOMINIS. 845 are generally present in the commencement of the affection; these are succeeded by fulness of the abdomen, and by a sense of fluctuation easily recognized by percussion, which should be performed by pressing one hand on the side of the abdomen and striking it with the other on the opposite side. The causes are disease of the viscera: the kidneys and heart, the liver, and pancreas. In some instances, an immense amount of fluid collects in the cavity of the peritoneum. The prognosis depends upon the nature of the case, and the age and temperament of the patient. When combined with organic disease of the abdominal viscera, or when occurring in individuals of a sickly con- stitution, or in persons of advanced age, apprehensions may be entertained of an unfavorable termination. Treatment.—The principal medicines in the treatment of ascites are, ars., apocy., cann., bry., china, hell., ledum, lyc., merc. Sol., sulph., apis mel., digital., iris V., Senec., grac. In some instances, in the first stages of the disease, aconite is useful to allay vascular excitement ; after which hellebore should be prescribed, if there is a tendency to torpor, prostration, extremely scanty secretion of urine, with shooting pains in the extremities. Other medicines are euphorb., solanum, kali carb., conium, sulph., iod., Zincum, ol. tereb. Dr. Stephen Mackenzie” recommends abdominal compression in the treatment of ascites. It is said that compression hastens the resorption of the fluid, when this has been begun by other methods, and that it seems to possess the power of exciting absorption without the intervention of other treatment. Dr. Mackenzie relates a case in which, after some treatment, a flannel bandage was tightly applied to the abdomen, the pressure, at first, causing a feeling of nausea; but soon after it appeared to afford relief. It was in a few hours replaced by an elastic abdominal supporter, tightened considerably, and the ascites gradually disappeared and in three years had not returned. The doctor is convinced that in spite of the abnormal condition of the liver, the recovery may be regarded as perfect, since the portions of the or- gan that remained healthy were sufficient to perform its necessary work. Paracentesis Abdominis.--This operation is frequently called for in the advanced stages of the disease, to palliate the sufferings of the patient. It is performed as follows: The patient is seated on the side of the bed, or on a chair, the bladder hav- ing been previously evacuated, and a broad bandage placed around the abdomen in the following manner: Its middle should be on the anterior wall of the abdomen, and its ends should be of sufficient length to be brought around the body and firmly held by an assistant. In the centre of this band, in the lower part of the abdomen, and directly opposite the linea alba, an opening should be made, sufficiently large to admit of the introduction of the trocar, which with its canula should be thrust through the abdominal parietes at the point aforesaid, in an oblique direction; after it has pierced through the integuments the trocar should be withdrawn, allowing the canula to remain, through which the fluid generally passes in a continuous stream. If the intestine or omentum obstruct the passage of the fluid, it should be gently removed by the introduction of a probe through the canula ; and if, after a considerable portion of the water has * Medical Record, August 31st, 1878, No. 408. 846 A SYSTEM OF SURGERY. been withdrawn, the stream lessens, the bandage may be tightened by trac- tion made upon its extremities, which compressing the abdominal parietes forces out the remaining fluid. Care is necessary, in the performance of this operation, that the evacua- tion of the abnormal secretion be not too speedily effected, lest the pa- tient, already somewhat debilitated by the loss of so large an amount of fluid, incur great risk from extreme prostration; indeed, in most in- stances, when the water has been withdrawn slowly, towards the end of the operation a feeling of faintness is experienced, to relieve which, a small quantity of brandy and water is required, after which china or arsenicum may be administered. Obstruction of the Bowels.-There are many causes which give rise to obstruction of the bowels, exclusive of hernia, which will receive special attention in another place. Of these, besides congenital malformations, we have foreign substances lodged in the bowels, twists, false membranes, invagination, as the mechanical causes; and, as the result of diseased ac- tion, constipation, chronic peritonitis, strictures, and tumors. Substances of an indigestible nature taken into the stomach become a nucleus around which other matter forms, and thus the bowel is occluded. The pits or stones of fruit or large quantities of undigested food occasion such obstruction. In one of my cases there was complete impaction and fecal vomiting, occasioned by a quantity of green apples being taken into the Stomach. - Wolvulus.--When twists cause the symptoms, the rotation is usually found either in the sigmoid flexure, the caecum or small intestine, and the pain is aggravated from the first; it is agonizing, is circumscribed and accom- panied with constipation; the abdomen soon distends, and the convolu- tions of the intestines may be distinctly seen. The pain is very severe, and is paroxysmal; there is vomiting, first of ingesta, then of bile, and afterwards of faeces. Finally, gangrene of the intestine or perforation takes place. In twists of the bowels, a predisposition to such a condition exists which may be either congenital or acquired, and which consists in a large, flabby, or loose mesentery. Again, strangulation may be occasioned by false membrane binding down two portions of the intestine, as in one of my cases, or a loop of omentum may twist around the small intestine, giving rise to alarming symptoms. Intussusception of the bowels, or invagination, as it is sometimes called, consists in an inversion of the intestinal tube into the gut immediately be- low, in the same manner as we invert the top of a stocking when we desire to draw it over the foot. In rare instances the lower part of a gut is pushed into the upper part of the tube. The symptoms are much the same; great desire to go to stool, with passage of blood and mucus. The pain is gen- erally located in the region of the ileo-caºcal valve, and there is vomiting of ingesta, bile, and faces. After the invagination has continued, a change rapidly takes place in the implicated intestine; congestion and inflammation supervene, and often the entire peritoneum is involved, giving rise to diffuse peritonitis. Finally, the constricted portion may become gangrenous and the slough be passed per anum and the patient recover. Holmes records a case in which eight inches of the ileum, the cacum with its appendix, with four inches of colon, were passed by the rectum and the patient recovered, the bowels acting regularly. tº º Constipation is another cause of obstruction of the bowels. The follow- ing table, taken from Mr. Hinton, will show the causes of intestinal ob- struction in 135 cases in the order of their frequency: OPERATION FOR INTESTINAL OBSTRUCTION. 847 Diseased uterus, 1 Brought up, & ºt . . 19 Stricture of ileum, . º e . 1 Cancer of small intestine, e ... 2 Calculi, foreign bodies, . dº ... 7 Doubtful, º tº g & ... 8 INTERNAL HIERNIAE : Peritoneal adhesions, . tº . 9 Inguinal, high up, 1 | Stricture sigmoid flexure, . . 10 Diaphragmatic, 3 || 8 44 colon, . * º . 11 Mesocolic, sº 2 | 4 & rectum, . º & . 11 Obturator, g © 3 J Intussusception, . . . . 24 Fecal accumulation, . ... 3 By bands, adherent diverticula, Twist of sigmoid flexure, . ... 4 etc., e Q . 36 19 135 Treatment.—In the treatment of any of these varieties of obstruction, it may be laid down as a rule that drastic purgatives do harm, even when the case is that of constipation. Knowing the value of certain medicines in relieving strangulation and restoring the peristaltic action of the intes- tines, we can in many instances relieve intussusception. All the mechanical means of relief must come from the anus upward, excepting in those rare cases in which the invagination takes place from below upward, and the injection must be made through the long tube, passed as nearly as possible to the seat of stricture, and the enema pumped into the abdominal cavity in large quantities (by the gallon, if necessary). The injection should contain soap and ox gall. If we have reason to suspect that there is obstruction from twist, volvulus, or invagination, opium, plumbum, nux, verat, acon., bella., may in Some instances be required. - Dioscorea villosa, given in the form of decoction, a wineglassful at a time, has produced in four of my cases more marked results than any other medicine. Inflation of the intestines with air, after the suggestion of Hip- pocrates, has proved curative. The best method of performing this is by an ordinary good-sized bellows. If we have reason to believe that impaction causes the obstruction, olive oil may be given in considerable quantities with the injection as already mentioned. I have known these means result in the cure of a severe and aggravated case. peration for Intestinal Obstruction.—When laparotomy has been decided upon, the following is the best method : The incision is made in the linea alba, and as soon as the cavity is reached it will be found in the majority of instances that the dilated portions of the gut are usually nearest the surface. The surgeon should carefully examine these, and if he discovers one portion of the intestine more purple or crimson than the other, he must follow the coils until he reaches the seat of obstruction. Of course, as the bowel is drawn from the abdomen or as it protrudes it should be covered with layers of hot flannel or with a large sponge which has been saturated with a hot carbolic or boracic solution, and by tracing the dark- ened portion of the intestine we will be certain to arrive at the seat of obstruction. If there be such distension that the examination cannot be satisfactorily made, the gut may be punctured and the wound sutured. A . good rule is that which is laid down by Mr. J. Greig Smith, when he says: “Never consider an operation for intestinal obstruction finished until the bowels are relieved from over-distension.” If the volvulus occur at the sigmoid flexure, at which point it is found to be the most frequent, the following treatment may be adopted: and I am not sure that frequent, pro- longed, and forcible injections tend to increase rather than diminish the twist in the gut; however, injections of oil, water, and Ox gall, as solvents, may be used, and if no result is accomplished then laparotomy should be 848 A SYSTEM OF SURGERY. performed. It is necessary, after the cavity of the abdomen has been opened, to puncture the gut immediately, allow the imprisoned air to be evacuated, and attempt its reduction. If these means fail the volvulus may be unfolded and an artificial anus be made, which would be about at the summit of the sigmoid flexure. In acute intussusception, after the abdomen has been opened, the invagi- nation should be reduced by gently pressing the upper end of the gut with one hand while steady traction is made on the end of the intestine with the other. If a moderate degree of pressure does not suffice, the gut must be resected, and the abdominal wound closed with silver or catgut sutures. For the methods of resection of the intestine, and to prevent repetition, the student is referred to the chapter on Hernia, Resection of the Gangrenous Gut, and to the section in this chapter on Suturing the Intestine. - Mr. Howard Marsh reports a successful abdominal section for intussus- ception in an infant seven months old. Mr. Henry Howse also gives one in which he operated similarly upon an adult, with cure. Mr. Jonathan Hutchinson reports a case in which death resulted after reduction. He advises that the lower end of the intussusception should be first sought and brought into the wound. The sheath should be drawn “downwards from off its contents, instead of drawing the contents upwards from within the sheath.” In a discussion in the Royal Medical and Chirurgical Society, it was brought out that failure to reduce by all other means, and the appear- ance of blood in the stools, formed the justifiable indications for section of the abdomen. There was a difference of opinion upon the length of the incision, Mr. J. Hutchinson saying that he would not make a larger cut than was absolutely necessary. In each the bowel was withdrawn from the abdominal cavity before reduction was effected. In the infant's case at least one-half of the colon and an equal part of the small intestine were invagi- nated. In the adult, the length of the included bowel was eighteen inches. Both recovered without an untoward symptom. The third case (Mr. Hutch- inson's) was that of an infant six months old, in whom the intussusception involved the whole length of the colon and ileo-caºcal valve. Considerable difficulty was encountered in replacing the intestines within the abdomen. They were accordingly punctured in two or three places, and to these punc- tures the operator attributed the fatal issue, which took place within six hours afterward from peritonitis.” Dr. Sands,f of New York, has also made a successful operation. - Formation of an Artificial Anus—Colotomy.—In giving the varied condi- tions which call expressly for this operation, I cannot do better than quote from Mr. Bryant, who perhaps has had a larger experience in the operation than any other surgeon, he having, up to the present time, performed eighty-two colotomies—surely a very large number for one surgeon. He says that lumbar colotomy should be performed: 1st. In all cases of cancerous stricture of the rectum or colon, including the annular, which are not amenable to lumbar colectomy or anal excision, right or left lumbar colotomy is strongly to be advocated, with the well- grounded hope of relieving suffering, retarding the progress of the disease, and prolonging life for five or six years. 2d. That lumbar colotomy is valuable as a curative operation in syphilitic and simple ulcerations of the bowel which resist other treatment, including cases of recto-vaginal fistula, and that it is remedial in examples of volvulus of the sigmoid flexure, as well as of obstructions caused by tumors. * Lancet, December 18th, 1875. . + Month. Abs. of Med. Science, February, 1876; Med. Times and Gazette, January 8th, 1876. FORMATION OF AN ARTIFICIAL ANUS—COLOTOMY. 849 3d. To secure these advantages it is necessary that the operation be per- formed before the pernicious effects of obstruction occur. There are three methods which can be employed for the formation of artificial anus, one of which is known as Littre's, one as Callisen's, and the third as Amussat's. The first consists in opening the abdomen and peri- toneum, and the formation of an artificial anus in their walls by opening the gut and stitching the cut surfaces to the parietes of the belly; the second (Callisen's) in opening the left loin, should the obstruction be found seated higher than the rectum; or, third, if the trouble exist in the sigmoid flexure or the transverse colon, the operation of Amussat. Whether it be the right or left loin that is to be opened, the same principles guide us, with the dif- ference that Callisen advised a vertical incision, while Amussat preferred and used the transverse. This latter may be used on either side. The operation is thus performed: The patient should be placed on his right side with a cushion beneath him, that the loin may be bent. The quadratus lumborum and the latissimus dorsi muscles must be sought after and their location fixed. An incision six inches in length should be made in front of the latissimus, or in the outer border of the quadratus muscle; this latter can be found half an inch posterior to the centre of the crest of the FIG. 526. Left Lumbar Colotomy. ilium. The integument and fascia are to be divided, the latter upon a director. The abdominal muscles are carefully to be cut through. During this proceeding there may be haemorrhage from muscular branches; the vessels must all be secured before further steps are proceeded with. We next come upon the transversalis fascia, which must be raised and divided upon a director, after which we generally encounter adipose tissue, which must be opened in the same manner; beneath this last layer the gut is found. The intestine should be hooked up with a stout curved needle, and two strong ligatures passed through one lip of the wound into the gut and 54 850 A SYSTEM OF SURGERY. out again through the other lip of the wound. These ligatures should only pass through integument and gut, the muscles being left out of the way. By this means the intestine is brought up even with the cut surfaces. A longitudinal incision should be made in the intestine over the ligatures, and, in the majority of cases, a gush of feculent matter and gas passes. The centre of each ligature should afterwards be drawn out and divided, thus making four ligatures, two on each side, which, when tied, fix the margins of the gut to the abdominal walls; to make the whole more secure, an additional suture or two may be made, and the artificial anus is complete. It is well to oil the cut surfaces after the operation to prevent the irritation of fecal matter. The direction of incision is well illustrated in Fig. 526. After the wound has healed, a folded napkin secured by a roller can be worn, or an ivory ball made to fit the artificial anus and fastened by a Spring answers the purpose. - Some surgeons advise an india-rubber ball with a portion of its surface cut away, to be placed over the wound; being cup-shaped it can receive any accumulation which may pass through the artificial anus. Sometimes a contraction of the artificial opening takes place; in such instances a Sponge tent is the remedy. Perityphlitis.-The connective tissue which attaches the cascum and the colon together, is often attacked with inflammation. The symptoms are intense pain in the cascal region, tenderness on pressure, general debility, high fever, worse at night, and varying in intensity during the day; tym- panites is often present; the bowels are constipated, and all the symptoms of severe inflammation present. We also have a secondary perityphlitis, which begins with a chill, and presents many symptoms of pyamia. The acute disease is caused by cold or traumatic agencies; the secondary is found during the course of typhus, in puerperal fever, or from absorption of septic material; often the inflammation terminates in suppuration; we then have the perityphlitic abscess, the surgical treatment of which must be considered. The operations are varied, but in my cases, I have invariably used the as- pirator, enlarged the opening if necessary, and washed out the abdominal cavity with carbolic acid solution, 1 to 200, in the same manner as after ovariotomy. I give the early history of this operation, as it is a feature in surgical literature. Perityphlitic Abscess.-Prof. Erskine Mason and Dr. Gurdon Buck ob- served * that the first published account of it is contained in the London Medical Gazette for 1848. This refers to a case related by Mr. Hancock to the Medical Society of London, the operation having been performed April 17th, 1848. Little notice was taken of the announcement, either in England or in this country; and it was not until 1867, when Dr. Willard Parker i published his paper, giving the history of four successful cases, that the operation became fully established. Dr. Parker's first operation was in 1843, thus antedating those of all others. In December, 1875, three cases were described by Dr. L. Weber before the New York Academy of Medicine. The operations were performed on the 7th, 8th, and 9th days respectively. In all, he followed Dr. Willard Parker's method, by making a long incision over the region of the suspected abscess until the fascia transversalis was reached. At this point the operation was suspended, and the abscess ruptured spontaneously, after a short time in one case, and in the remaining two, under the pressure of the finger, while searching for fluctuation. Perfect recoveries ensued. * Medical Record, January 1st and June 10th, 1876. # Ibid., March 1st, 1867. † Ibid., January 1st, 1876. PERITYPHLITIC ABSCESS. 851 Dr. Gurdon Buck reports a case in detail,” which affords a good example of the method preferred by him. The patient was a gentleman, aged 26, of good constitution and regular habits. On the eleventh day of the disease, the precise seat of sensitiveness having been determined by careful and re- peated examinations, a puncture was made through the skin at the point chosen upon the surface of the tumor, and a sharp-pointed canula was advanced cautiously through the parietes of the abdomen to the depth of Over one inch, when pus escaped. The canula serving as a guide, a sharp- pointed bistoury was conducted into the cavity of the abscess, and its open- ing enlarged. At the same time, the external wound was extended nearly two inches, and the entrance of the abscess further dilated by the introduc- tion of a dressing-forceps. A discharge of fetid pus followed, together with an abundant escape of gas. On the twenty-eighth day after, the wound had healed, and the patient was out of doors. A case which terminated fatally seventy-four days after the abscess had been freely opened, has been related by Prof. Erskine Mason.f His theory as to the cause of the fatal result is, that some foreign body passing from the intestine had become lodged in a recess in the walls of the abscess, and, failing to be removed by the daily injections, had excitated irritation and ulcerative action, which resulted in perforation into the peritoneal cavitv. A. ise is reported by Edgar Holden, M.D., of Newark, N. J., of a stout robust man, in which, on the twelfth day of the disease, no satisfactory evidence of actual suppuration had presented. An operation was performed, and twenty-three days after the wound had entirely closed, and the patient appeared well. Dr. J. C. Adams, of Lake City, Minn., performed the operation in the case of an Irish woman, forty years of age, and the mother of eleven chil- dren. § Two weeks later, the wound was almost closed, and the patient fast regaining her usual health. Leonard Weber, M.D., in a paper read before the New York Academy of Medicine, gives the history of three cases since 1874. In all, the opera- tion was done in the same way, and it is a good one—I have employed it a number of times with success. The incision is made as follows: Put- ting the thumb of the left hand in the inguinal fold close to Poupart's ligament, the four fingers are laid upon the upper circumference of the abscess, making gentle but firm pressure downward. Midway between thumb and fingers thus placed, skin, fascia, and the fibres of the external and internal oblique muscles are to be divided, the exploring needle entered at a point where there is certainty from previous repeated exam- inations that pus will be found, and, when obtained, the knife is carried through the remaining tissues by a single cut. Immediately after the opera- tion, the cavity of the abscess should be washed with carbolized water, and twice daily thereafter until the discharge has lost its fetid character, and the wound has become too small for the further introduction of a drainage-tube. The following case was noted in the service of Dr. H. B. Sands, attending surgeon, New York Hospital." Five days after admission, and fifteen days after the onset of the disease, suppuration was detected low down in the abdomen, near the median line. Thereupon an incision, about two inches in length, was made, parallel with Poupart's ligament. The discharge of pus was great; and the finger being introduced into the cavity of the * Medical Record, Jan. 15th, 1876. # Ibid., June 10th, 1876. † Ibid., December 23d, 1876. 3 Ibid., March 24th, 1877. | Ibid., January 19th, 1878. - T Ibid., February 18th, 1878. 852 A SYSTEM OF SURGERY. abscess, it was found to extend upward and outward in the direction of the Caput coli. The pus was offensive, but contained apparently no fecal matter. The temperature at once fell to the normal standard, and the pa- tient recovered, the only drawback being difficulty in passing urine, which continued for a few days. Gastrostomy.—An article by Dr. J. H. Pooley, of Columbus, Ohio,” con- tains a table of 11 cases of gastrostomy performed for removal of foreign bodies, dating from 1613 up to 1856. All but one of these cases recovered. He gives a similarly arranged table of 18 cases of gastrostomy, performed for stricture of the oesophagus, from 1849 to 1872. The result in all these was death. Verneuilt gives an account of the first successful case of gastrostomy on record. The operation was performed on a boy of seventeen, in whom the stricture was caused by swallowing a solution of caustic potash. An oblique incision two inches in length was made parallel to the cartilagin- ous border of the false ribs. When the stomach presented itself, it was immediately transfixed and held in the wound by two long acupuncture needles. Fourteen metallic sutures were then passed through the skin, parietal peritoneum and wall of the stomach; the acupuncture needles were withdrawn, and an incision made through the wall of the stomach, just large enough to admit a large gum catheter, which was secured in posi- tion by tapes and collodion applied over the abdomen. The slight haemor- rhage was controlled by hamostatic forceps, a dozen or more pairs of which were used to secure the parietal layer of the peritoneum while apply- ing the sutures. The antiseptic method was strictly followed. There was no fever. The sutures fell out spontaneously, and a small portion of the gastric wall included between them sloughed, so that the opening became larger than at first. The patient was fed through the catheter with soup, milk, eggs, wine, etc. In two months he had completely regained his strength and energy. He experienced hunger, and fed himself with all sorts of food. The operation, however, is a doubtful one, and is well described by Mr. Bryant (ether or chloroform may be administered): “The patient should be placed upon his back, and an incision made below the ribs on the left side, the object of the surgeon being to find the cardiac end of the stomach in preference to the pyloric. The line of the linea semilunaris is the ordi- nary one that has been used for the incision, a cut three or four inches long being made carefully through the tissues seriatim down to the fascia lining the muscles, every vessel being twisted or tied as it bleeds. In my own operation I made an oblique incision along the lower borders of the ribs, commencing at the linea semilunaris, with the view of catching the cardiac end of the stomach, and I may say that I picked the stomach up with my fingers very readily; the fascia and peritoneum are then to be divided. With the thumb and finger the stomach is now to be sought, and when caught, held. This is best effected by the passage of a needle armed with a double silk through its coats, the silk being left with long ends; a second should also be passed about three-quarters of an inch lower down. The surgeon has then to fasten the stomach to the margins of the wound, and the quill suture seems to be the best means to use. To do this he may first pass the needles that have already traversed the stomach, and are still armed, through one side of the wound, and with a second needle draw the free ends of the ligature, when threaded, through the other. The stomach should then be opened over the ligatures that have been passed through it, * Medical Record, November 26th, 1876. f Gaz. Méd. de Paris, October 28th, 1876. RESECTION OF THE PYLORUS—PYLORECTOMY. 853 the incision being made in the line of the wound; the centre of the double ligatures will then be exposed, and these should be drawn well out and divided. There will then be two double ligatures through each side of the opening in the stomach and the margin of the wound. On tying the two ends over two pieces of bougie, one introduced against the inner surface of the stomach, and the other upon the integument, the parts are Secured, the bougies admirably compressing the thin walls of the stomach against the integuments, and retaining them there. One or two other sutures will probably be required to close the wound, and an additional one at either end of the opening in the stomach to keep it in its place; the operation is then completed. When the quill suture is not used, the stomach must be stitched to the margins of the wound in the ordinary way, but a more accurate adaptation of the parts and greater security is acquired by the Quill suture than any other, and what is more, the pieces of bougie are capital guides to the orifice into the stomach, the slightest traction upon them rendering it patent for purposes of feeding; for this purpose one of the sutures should be left long on either lip of the wound. After the opera- tion it is well to desist from giving food a few hours, to give the stomach rest. Where enemata can be tolerated they should be used. After a day or so, according to circumstances, liquid nourishment should be adminis- tered in small quantities through a tube; milk and eggs being probably the best, or milk alone. Care should be observed that too much food is not given, as it retards progress, a quart or three pints of milk in twenty-four hours being ample. The edges of the wound should be carefully protected by oiled lint. The sutures may probably be removed, wholly or in part, on the fifth or sixth day.” Resection of the Pylorus.-Pylorectomy.—This operation was first per- formed by Péan in 1879, the patient living but a few days; the next case, which was still more unsuccessful, was operated upon by Rydygier in 1880, and survived but a few hours. To Billroth belongs the credit of having performed the first successful resection of the stomach. The patient was a woman, her age 43 years, and she made such rapid recovery that I have been assured by my colleague, Dr. Wilcox, who was present at the opera- tion, that within a day or two after the removal she was fed upon butter- milk, and on the twenty-first day ate and digested a mutton-chop. Since Billroth's operation, the procedure has been repeated several times with varying success. Method of Proceeding.—The patient several days before the operation should be fed upon easily digested liquid food—milk and eggs, oatmeal gruel, Soup, beef tea, porridge, and the like. The skin should be bathed and the bowels attended to. An hour before the operation the stomach should be washed out with the stomach-pump, to remove mucus and any secretions that may have accumulated. Twenty minutes before the patient is brought to the operating room, she should have a hypodermic injection containing # gr. morphia and Tºp gr. atropine. When laid upon the table and under anaesthetic influence, the entire surface of the abdomen should be washed with corrosive sublimate solution (3 ºrg), and a saturated solu- tion of iodoform in ether poured on the site of the intended wound. The incision should be made over the tumor, above the umbilicus, about three- Quarters of the cut being to the left of the mesian line. As the parts are cut through (the muscular fibres of the abdominal muscles being divided trans- versely) there will be quite free bleeding from small vessels. These must be tied with carbolized gut. The peritoneum must be divided upon a director, and the lips of the wound held open by retractors. This brings the greater omentum in view, which must, together with the lesser, be very carefully separated from the parts until the pyloric extremity of the stomach 854 A SYSTEM OF SURGERY. comes in view. Here the operator, having cleansed his hands, and having a perfectly antiseptic flat and large sponge ready, inserts his fingers or hand within the cavity, and gently draws forward the pylorus. If it is not ad- hered to the surrounding parts, and can be drawn through the wound, the Operation should be continued. If, on the contrary, it is bound down by adhesions, the operation should be abandoned. The pyloric end of the stomach and the duodenum to be excised, are laid upon the sponge, and a pair of forceps with long jaws—the latter protected by bits of antiseptic rubber tubing—should be made to transversely em- brace the duodenum. Another pair should grasp the stomach—the space between the blades of the two pairs of forceps being that to be removed. The stomach is first to be cut through with the scissors, and next the duo- denum. The blades of the forceps will prevent any extrusion of the con- tents of the bowel or stomach. The forceps are now removed, and the cut surfaces—duodenum on one side, stomach on the other—brought into apposition. Of course the circumference of the stomach-wound being much greater than that of the gut, the former, before adaptation can take place, must be fitted to the latter. This is effected by cutting a > shaped piece from the lateral wall, or the superior or inferior curvature of the stomach. The parts should first be brought together with a continued suture (vide Fig. 523, page 835), and over this the Lembert suture (vide Fig. 522, page 835) employed. From fifty to seventy sutures may be required. The stomach is then returned to the cavity of the abdomen and the wound closed and dressed as already directed. The statistics of pylorectomy are not favorable. Winslow * shows that of 61 cases, a little over fifty per cent, died of shock within twenty-six hours, and no case survived three years with immunity. Of 82 cases collected by Kramer, there were 61 deaths. Of these 72 were for carcinoma, of which 55 died in a short period, and, indeed, only one proved a success. Speaking of Billroth’s cases, Dr. Stenn says: i. “Such statistics in the practice of this most eminent surgeon, should definitely settle this question in the mind of any surgeon whose humanity has not succumbed to a morbid desire for transient fame.” Enterectomy.—For the method of performing this operation the student i. referred to “Enterectomy in Gangrenous Hernia,” in the following Chapter. Digital Divulsion of the Pylorus.-In certain cases of stenosis of the pylo- rus of non-malignant character, this operation may be performed. It was originally devised by Loreta, of Bologna, and performed by him in Sep- tember, 1882. The incision is to be made parallel with the ribs, about five inches in length, and the same precautions taken as have already been described in the operation for excision of the pylorus. The stomach is drawn forwards and an incision made between the lesser and greater cur- vature, of sufficient length to admit the two index fingers. Gradual traction is then made until the pyloric orifice is opened for two or three inches, Dr. McBurney$ records an interesting case of this kind; he made his in- cision “about five inches long from a point one inch below and one and a half inches to the left of the ensiform cartilage, downward to the right, par- allel with the border of the ribs.” The orifice was easily found, was much thickened, so that a rectal dilator was used for its first expansion. The fingers were then substituted and the orifice opened three inches. Splenectomy—Extirpation of the Spleen.—This operation has been per- * American Journal of the Medical Sciences, April, 1885. # Medical News, May 22d, 1886. - † Address on Surgery before the American Medical Association, May 5th, 1886. 3 Annals of Surgery, May, 1886. SPLENECTOMY-EXTIRPATION OF THE SPLEEN. 855 formed about thirty times, and curiously enough, when traumatism was the factor, the results have been more favorable than when the organ was removed for disease. In eighteen of the cases in which the operation was performed for disease, all died. There appears to be a peculiar liability to Secondary shock and secondary hamorrhage, after the removal of the spleen. A fact derived from the study of these cases is that all the patients upon whom the operation was performed had immediately an increase in the white blood-corpuscles, which appears to prove the recent physiological idea that the function of the organ is the conversion of white into red blood-corpuscles. After a time, the normal quantity of red blood returns, the office of the spleen being in a measure supplied by the thyroid gland. Blum draws the conclusion that when hernia of the spleen results from a wound, the surgeon is justified in cutting off the protruding portion, and that these operations are generally successful; that, per contra, the operation should not be undertaken either for cancer or for hypertrophy, as the results are uniformly bad. In movable spleen extirpation may be practiced, as it is comparatively easy; and in conclusion, it is remarked that though the opera- tion is practicable, yet it is rarely indicated and is likely to terminate in death either from ha-morrhage or shock. A transverse or curved incision is made over the body of the organ, and the parts divided, layer after layer, on a di- rector, until the spleen is reached. The adhesions must be sought for and broken away and the organ turned out; the splenic arteries and veins are to be secured by a double strong carbolized catgut.ligature, and the spleen cut off above them. The patient must be carefully watched for several days, and especially the first few hours. The operation as yet has hardly taken its place in the regular domain of surgery. Prof. Billroth reports a case of removal of a greatly enlarged spleen (at- tended with leucaemia, the red globules being five to one of the white). The operation was on a woman of forty-five. The patient rallied from the anaesthesia, but died four and a half hours after from hamorrhage due to the giving way of one of the ligatures on account of a strain. Another case is reported in which the hypertrophied spleen was removed from a man of twenty years; this patient also rallied, spoke, and seemed not unduly collapsed, but in making an effort to sit up he fell back and died.* Mr. H. L. Brownef relates his experiments in Extirpation of the Spleen for Rapid Hypertrophy: “A man (ast. 20) had been in good health till six months ago, when he began to grow fat; had no fever, ague, or syphilis, nor had his family. Without receiving any benefit from the use of purgatives and diuretics, the Symptoms growing worse, extirpation was decided on. “There were no adhesions, nor any pedicle of a distinct kind, and no haemorrhage. The tumor—a simple hypertrophy of the spleen—was 18} pounds in weight. The patient’s youth and the absence of other disease were the reasons why the operation was performed.” * American Journal of the Medical Sciences, July, 1877, p. 261. f Ibid., January, 1878. 856 A SYSTEM OF SURGERY. CHAPTER XLIII. HERNIA—RUPTURE. ABDOMINAL HERNIA—FREQUENCY AND SITEs—VARIETIES AND NoMENCLATURE—MEDI. CAL MANAGEMENT—DIAGNOSIs—TAxis—PUNCTURING THE INTESTINE–REDUCTION BY ESMARCH's BANDAGE—TRUSSEs—HERNIoToMY-KELOTOMY-ENTERECTOMY FoR GANGRENOUS HERNIA — RADICAL CURE — By LIGATURE OF SAC–HEATONIAN METHOD—WooD's OPERATION.—INGUINAL HERNIA—SURGICAL ANATOMY-DIFFER- ENTIAL DIAGNOSIS-OPERATION.—FEMORAL HERNIA — DIAGNOSIs — OPERATION.— OVARIAN HERNIA—UMBILICAL HERNIA—OBTURATOR HERNIA—IsCHIATIC–DIA- PHRAGMATIC–PUDENDAL. IN surgical literature there is scarcely a subject that covers so wide, important, and interesting a field as that of hernia. There are so many Varieties of the affection and so many individuals who suffer from it, so nu- merous are the operations and apparatus recommended for its relief, and its symptoms are so important and yet of such variable character—at the One time indicating rapid dissolution, and at another endured for years with apparently slight inconvenience—that we cannot but regard it as every way worthy of careful thought, reading, and experiments of both the physi- cian and surgeon. The Frequency and Sites of Hernia.-The frequency of hernia has given rise to much discussion, and, from Malgaigne's tables, the number of males suffering from it is 1 to 8; and of females, 1 to 13. The figures showing the relative frequency of the different varieties of rupture indicate the far greater frequency of oblique inguinal, than of any of the other forms of protrusion. The reports from the Surgeon-General's office in this respect are instructive. Out of 334,321 recruits examined for army admission, no less than 17,296 were rejected for hernia in one form or another, showing a ratio of about 50 per thousand ; and this percentage may be considered a tolerably fair estimate of the relative frequency of hernia among the labor- ing classes. Of these the right inguinal are by far the most numerous, be- ing 8598; the next is the left inguinal which numbered 5420; the double inguinal, 1166; thus making the number of inguinal herniae—single and double—16,178, out of 17,296. If we take into consideration that from the total must be deducted 651 cases of unspecified herniae, the immense proportion of inguinal over every other variety of rupture can at once be perceived. In Kingdon's reports we are told that in every 100 cases of rupture, there are 84 inguinal, 10 femoral, and 5 umbilical; and that in a total of 96,886 persons applying to the Truss Society for relief, no less than 78,394 were males, and 18,492 females, making the proportion of males to females as 4 to 1. It has been found that the average age of those suffering from strangulated inguinal hernia is 43, while those affected with strangulated femoral hernia was 55.” Nomenclature.—By the term hernia, may be understood a protrusion of the contents of any cavity of the body; thus by encephalocele we mean a hernia of the brain, and by pneumocele a hernia of the thorax; the term by common consent is now restricted to those protrusions that occur from within the abdominal cavity through natural openings or such parts as * Bryant's Surgery, Am. Ed., p. 487. EIFRNIA. 857 are but comparatively slightly covered by the tissues. Hernia taking place through rents in the abdominal walls is known as “Ventral hernia.” The varieties of herniae may be thus classified: A. Abdominal hernia proper through so-called natural openings. B. Abdominal ventral hernia through rents in the abdominal walls. 1. A. ABDOMINAL HERNIA PROPER ACCORDING TO ANATOMICAL SITE. Inguinal or Supra-pubian { §: € The difference between these two varieties is indicated by the terms designating them. In the first, the gut protrudes through the external ring, having pushed with it the conjoined tendon of the internal oblique and transversalis muscles; while in the second the intestine, entering the ingui- nal canal at the internal ring, passes through the entire length of the ingui- nal canal, taking as one of its coverings a few of the lower fibres of the internal oblique muscle (cremasteric fascia), and protruding through the external ring. In certain cases of direct hernia the gut passes out of the abdomen through Hesselbach’s triangle. i; : t : . Femoral, Crural.—Escaping through the crural canal. . Infra-pubian, or Obturator.—Escaping through the opening giving pas- sage to the obturator vessels. . Ischiatic.—Escaping through the sciatic notch. . Diaphragmatic.—Escaping through the diaphragm. . Ovarian.—When an ovary enters the abdominal ring. . Umbilical.—Escaping through the umbilicus. B. VENTRAL HERNIA. . Epigastric.—Escaping through linea alba above the umbilicus. . Hypogastric.—Escaping through the linea alba below the umbilicus. . Perimeal.—Escaping through the levator ani muscle. Abdominal Hernia according to the parts protruded. . Enterocele.—If the intestines be alone displaced. . Epiplocele.—If the omentum be alone displaced. . Entero-epiplocele.—If both the intestines and omentum protrude. . Gastrocele.—If the stomach fills the sac. . Splenocele.—If the spleen fills the sac. Hepatocele.—If the liver fills the sac. . Cystocele.—If the bladder protrudes either above the pubes in the male or through the vagina in females. . Rectocele.—The rectum protruding through the vagina. Abdominal Hernia according to the Condition of the Gut. . Reducible. . Irreducible. . Incarcerated. . Strangulated. The terms explaining themselves. 858 A SYSTEM OF SURGERY. The first variety may partake of the nature of the last two: thus we may have an inguinal hernia (direct) which may be an entero-epiplocele and irreducible. Besides the terms already given as designating the varieties of gut and omental protrusions, there is as yet a nomenclature to be explained which has often caused confusion in the student's mind; thus Congenital Hernia occurs soon after birth. At this time the intestine or Omentum passes out of the abdomen, accompanies the testicle in its descent and becomes lodged in the pouch of peritoneum which forms the tunica vaginalis testis, tubular vaginal process, before its communication with the general peritoneal cavity has become obliterated. The sac of this hernia is, therefore, formed by the tunica vaginalis testis, having all the other cover- ings of the oblique variety. The Congenital Form of Hernia—Malgaigne's Hernia of Infancy—according to Birkett, is that form of the congenital which may appear in after life, from the tubular vaginal process not having been entirely closed; from Some effort on the part of the patient the adhesions give way, and the gut descends. This hernia also receives the name of “Hernia into the vaginal process of the peritoneum.” Infantile Hernia of Hey—Encysted Hernia Infantalis of Sir Astley Cooper— is an acquired hernia, is more complicated than the latter, because it has, as it were, two sacs. The communication between the cavity of the tunica vaginalis and that of the abdomen is closed at its upper part, but the former is unusually large and continues high up the cord, and contains more or less serous fluid. Behind this is found a hernia invested by the ordinary peritoneal sac. Funicular Hernia—Birkett.—If the tubular process of the peritoneum closes over the testicle and yet leaves a pouch above, into which a gut descends, then we have “a hernia into the funicular portion of the vaginal rocess.” p Interstitial Hernia is the same as that known as “inter-parietal’’ or the hermia en bissac of the French. It is formed by the stretching of the neck of the vaginal process to such a degree that it becomes a sac, and insinuates itself between the abdominal tissues upwards or downwards as seen in the Cut. The following diagrams with their explanations I have taken from Bryant. They are the best descriptions of the different varieties of hernia that I have seen, and convey to the eye of the student an explanation of many important points in the nomenclature. Reducible Hernia.-In this variety the tumor increases in size or descends when the patient is erect, and diminishes or disappears during the recum- bent position. Sufficient inflammation has not taken place to cause adhesion of the sac or rings, and no stricture exists to prevent the return of the bowel. The symptoms are well marked: when the gut returns to the abdomen, either spontaneously or by taxis, a peculiar gurgling sound is heard by the surgeon and patient. . The tumor is larger after a meal, and an impulse is communicated to it when the patient coughs. If the tumor contain omen- tum, a peculiar doughy sensation is communicated to the hand of the ex- aminer. The hernia may, however, consist of both intestine and omentum (entero-epiplocele). If suffered to increase, a reducible hernia may become enormously large, and the patient not only experience great disorder of the digestive organs, but be constantly liable to strangulation of the gut. IRREDUCIBLE HERNIA. 859 Irreducible Hernia is that form in which there exists a protrusion of the bowel which cannot be returned to the abdomen. e FIG. 527. FIG. 528. FIG. 529. FIG. 530. FIG. 531. 1) J iſ uſ tſ FIG. 527.-The diagram illustrates the tubular vaginal process of peritoneum open down to the testicle, into which a hernia may descend; when the descent occurs at birth it is called “congenital”; when at a later period of life the “congenital form " of hernia, Birkett's “hernia into the vaginal process of peri- toneum,” or Malgaigne's “hernia of infancy.” * FIG. 528.-The same process of peritoneum º half-way down the cord, into which a hernia may de- scend at birth or at a later period. Birkett's “hernia into the funicular portion of the vaginal process of the peritoneum.” FIG. 529.—The same process undergoing natural contraction above the testicle, explaining the hour- glass contraction met with in the congenital form of scrotal hernia as well as in hydrocele. FIG. 530.-Diagram showing the formation of the “acquired congenital form of hernia,” the “encysted of Sir A. Cooper,” “the infantile of Hey,” the acquired hernial sac being pushed into the open tunica vaginalis which incloses it. * FIG. 531.-Diagram illustrating the formation of the “acquired” hermial sac distinct from the testicle or vaginal process of peritoneum, which has closed. This condition is caused either by adhesion of the sac to its contents, or to the parts into which it has passed, by membranous bands extending across the mouth of the sac, by enlargement of the gut, or by contraction of the opening through which the tumor has descended. From the greater or less obstruction to the passage of fecal matter, and the fact of its being a foreign FIG. 532. - FIG. 533. FIG. 534. FIG. 535. FIG. 532.-Illustrates the neck of the hermial sac pushed back beneath the abdominal parietes with the strangulated bowel. FIG. 533.-Shows the space in the subperitoneal connective tissue into which intestine may be Fººd through a rupture in the neck of the hernial sac ; the intestine being still strangulated by the Il tº C k. FIG.,534–Diagram. showing how the neck of the vaginal process may be so stretched into a sag placed between the tissues of the abdominal walls either upwards or downwards between the skin and muscles, muscles themselves, or between the muscles and the internal abdominal fascia-forming the jºrietal, intermuscular, or interstitial sac ; hernia en bissac of the French ; “additional sac’’ of IFKCUU. FIG. 535.—Diagram illustrating the reduction of the sac of a femoral hernia em masse with the strangulated intestine. body, an irreducible hernia gives rise to certain symptoms, such as dragging in the abdomen, sickness at the stomach, vomiting of an obstinate character, colic, and constipation. If the patient be corpulent, the above symptoms are more troublesome; and if it be a woman, and she become pregnant, these conditions will be aggravated. These tumors are, of course, exposed to all the consequences of violence and injury, hence several cases are recorded in which the pro- truded bowel has been ruptured by falls or blows. 860 A SYSTEM OF SURGERY. A Strangulated Hernia is one in which the contents of the intestines are prevented from passing to the anus and the venous circulation is impeded. A hermial tumor may become strangulated when the contents of the sac increase its size, or it becomes enlarged from inflammation. The symp- toms are, in the majority of instances, so well expressed as to allow easy recognition. Yet it Occasionally happens that the abnormal condition is confounded with ileus and other intestinal affections. The tumor resists the impression of the fingers, is painful to the touch, and the pain is in- creased by coughing, sneezing, or standing upright. If not relieved, these symptoms are soon followed by sickness of the stomach, frequent retching, stoppage of alvine discharges, hard, frequent pulse, high fever, and great pain all over the abdomen. Convulsive hic- cough sets in, and all these conditions continue to increase in severity. Vomiting, first of ingesta, then of bile, and finally of faeces, results. If relief is not afforded, the patient in a short time becomes perfectly easy, and all the previous symptoms subside. But the skin becomes cold and moist ; the eyes glassy; the tumor has an emphysematous feel, and communicates crepitus to the fingers. This indicates gangrene. Even now the gut may return spontaneously or by gentle pressure, and the patient express himself relieved, but death will almost inevitably follow in a short time. An Incarcerated Hernia is one in which the protruded portions of the abdominal contents are retained in their abnormal situation without being strangulated or giving rise to the inflammatory process. The generation of gases or the accumulation of fluids and solids in the sac may prevent its reduction. General Diagnosis.—Of all considerations connected with herniae, the diag- nosis is most important. The cough impulse, the disappearance of the Swelling in the recumbent position, the inability to introduce the finger into the rings are the main general symptoms which satisfy the surgeon in regard to the nature of his case. All this is simple, yet on the other hand, there is nothing more difficult than to diagnose a complicated rupture; indeed I have some- times been puzzled to distinguish, especially in women, a femoral from an inguinal protrusion. It is well known that a femoral hernia turns itself upward and rides over Poupart's ligament and when this is the case, and the hernia is irreducible, it requires great care and considerable time to get the gut sufficiently down, that the finger may be introduced into the in- guinal ring, which in the female, is much less open than in the male and is sometimes difficult to find even by dissection. This fact may be made evi- dent, in the performance of Alexander-Adams’ operation for shortening the round ligament, for uterine misplacement. I have known an hour to be expended in the endeavor to find it. The specific forms of diagnosis will be pointed out when treating of the varied forms of rupture, but an important symptom is that shown by urinary analyses. Albuminuria.-It has recently been proven by Dr.I. Englisch * that when strangulation of the bowels takes place, the presence of albumen in the urine may be detected. How this occurs is not accurately determined, but it probably arises from disordered nerve force, and the arrest in the functions of assimilation and digestion. It is therefore important that in cases of strangulated hernia, the urine be carefully examined, for if the case be one of enterocele, albuminuria will * Wiener Med. Jahrbücher, Heft. 2, 1884. MEDICAL TREATMENT OF HERNIA. 861 be present, and if it be epiplocele, this substance will be absent. If in ad- dition to the albumen, casts or blood be present, with rapid increase in these elements, collapse and death may be expected. Cough Impulse.—The cough impulse is a symptom of great importance, and when perfect may make a diagnosis clear in a moment, but it must be remembered, that not only may this symptom be obscure, but be absent, especially in cases of epiplocele. I have lately operated upon two such cases (one complicated with hydrocele) in which there was not the slightest im- pulse from coughing; both cases were oscheoceles, and both irreducible. In such I can see no method of making a diagnosis, save by exclusion, ex- perience, or an exploratory incision. It must be borne in mind that abdominal organs may lodge in the in- guinal canal, and give rise to a protrusion that may be difficult to diag- nose. Dr. E. C. Went mentions the case of an old woman, aged eighty-five, who had died of various senile disorders, and who had worn a truss for years for a supposed inguinal hernia; the post-mortem examination re- vealed the right kidney in the canal, a portion protruding externally, with a short ureter, no pelvis, and connected by a firm fibrous band to the uterus.* It is not well to neglect the examination of apparently trivial cases, for hernia in some instances may be mistaken for simple orchitis; and a no less distinguished surgeon than Dr. Valentine Mott plainly stated that he was willing to stake his surgical reputation in a case presented to him by Dr. Post, of New York, that the patient was suffering from a traumatic orchitis, when, as the result proved, he had a large knuckle of intestine within the scrotum. And a still more remarkable case is reported by Voght, in which there was a hernia of the stomach into the scrotum. Medical Treatment of Hernia.-In the treatment of hernia there is no doubt of the efficacy of medication, not only in the early stages of strangu- lation, but in advanced states of this disorder, even after fecal vomiting has commenced. I am positive in this assertion, and speak from experience in many cases, so much so indeed that I am not obliged to operate for strangulated inguinal hernia nearly as often as formerly. With the femoral, though I have not been so successful, yet medicines have sometimes given satisfactory results, the principal being nux vom., opium, and veratrum. Others that are efficacious are aconite, sulph. ac., lycopodium, and in some cases rhus tox. and sulph. Aconite should be employed when there is inflammation of the affected part with excessive sensibility to the touch, accompanied with considerable fever, and quick, hard, and full pulse. Dr. H. G. Dunnell, of New York,+ reports the cure of a strangulated in- guinal hernia, after stercoraceous vomiting had set in, and after Prof. Willard Parker had pronounced the case incurable without an operation. Opium 1, three grains every two hours, appears to have produced the most decided effect in this case; although acon., arsen., nux, sulph., and verat. were employed. Nux vomica for its specific action is, however, the most important medi- cine in the treatment, and is to be preferred when respiration is laborious and oppressed, when the tumor is sensitive to pressure, but not in so great a degree as when aconite is called for. When there is bitter vomiting, and when strangulation has been occasioned from errors in diet or exposure to cold, nux is demanded. * Medical Record, December 201h, 1884. + North American Journal of Homoeopathy, November, 1861. 862 A SYSTEM OF SURGERY. Perhaps a surer method of treatment in the generality of instances, unless the particular indications of a single medicine are very prominent, would be to exhibit nux and aconite in alternation; both should be administered in tincture. According to Hartmann, sulph. ac. is a specific not only for certain cases of hernia, but for the chronic diathesis which leads to intestinal protru- SIOIl. If the above medicines do not produce the desired effect, and there be cold moist skin, coldness of the extremities, and profuse vomiting, vera- trum should be given; but if after a few doses of this medicine relief be not obtained, and there be vomiting of fecal matter, with hard dis- tended abdomen and a somewhat comatose condition, opium should be exhibited. - Dr. Laurie* gives some practical remarks of Mr. Traub on the homoe- opathic treatment of strangulated hernia. The latter gentleman, from his own experience, recommends highly nux vomica, sulph. ac., lycopodium, belladonna, and, moreover, remarks concerning aconite, that, although it does not often, in the series of symptoms that it is capable of producing, exhibit those which accompany the formation and incarceration of a hernia, yet it cannot be dispensed with as an intermediate auxiliary remedy in certain forms of incarcerated displacement, on account of the unlimited in- fluence which it exercises upon the vascular, and especially upon the cap- illary system; and accordingly not only comprises among its symptoms the type of inflammatory fever, but also the state of acute local inflamma- tion. - The Use of Coffee.—An interesting item in this particular regarding the use of coffee in strangulated hernia is mentioned by Sarra, who relates that he was called one evening to attend a man, 63 years of age, suffering from a strangulated femoral hernia. The patient was nearly moribund, there was no appreciable radial pulse, the face was pinched, the extremi- ties cold, and the attempts to vomit were almost incessant. Happening to remember the report of a similar case relieved by coffee, Dr. Sarra ordered an infusion of this substance to be employed as a drink and also exter- nally, and took leave of the patient, warning the family that death was in- evitable unless a prompt amelioration ensued. Upon returning early the next morning, he was surprised to find his patient in perfect health. The man stated that soon after taking the coffee, he experienced a feeling of warmth and returning strength, then a large quantity of gas was expelled above and below, and when he put his hands upon the tumor, it at once slipped back into the abdominal cavity, much to his astonishment as well as Joy. axis.-By taxis is understood the endeavor to reduce hernia by certain manipulations, for the purpose of restoring the protruded intestine to its normal position. It is the opinion of the writer that taxis, in the majority of cases, is over- done, and performed often too roughly ; that instead of restoring the intes- tine, it frequently excites so much additional inflammation that further strangulation occurs, and the life of the patient is additionally imperilled. The proper pressure to be made should be inversely to the course of the gut in its descent. The position of the patient during taxis is of importance, and attention to it will often facilitate the success of the operation. The pelvis should be placed higher than the shoulders, and the patient avoid as much as possible * Homoeopathic Practice of Physic, page 503. TAXIS. 863 every exertion of the abdominal muscles. There are several postures, each or all of which may be tried in performing taxis. 1. Place the patient upon the back, flex the leg upon the thigh, the thigh upon the abdomen, and by rotating the limb inward relax the columns of the ring. With the patient in this position I have been able to reduce hernia where others have failed. 2. Advantage may be derived by elevating the hips and depressing the trunk, together with flexion and rotation of the leg. 3. By inversion of the patient I have known a severe case of strangulated hernia reduced. I had been called to perform herniotomy, but was unable, from a previous engagement, to proceed at once to the house of the patient. In the meantime my friend, Dr. Youlin, was sent for. Arriving, he turned the sufferer “topsy turvy,” and suddenly with a gurgling sound the * returned into the abdomen after having been strangulated nearly two days. 4. The patient placed upon the side on which the hernia exists, in the Semi-prone position, with the thigh flexed upon the body. 5. The upright position may be a novel one, yet it is urged by those who have had experience in the reduction of hernia, that it succeeds after other means fail. Dr. F. H. Nichols, of Cumming, Ga.," in giving his opinion of taxis says: “I hold that every case of strangulated hernia can be reduced and can be cured by the hands alone. And I also believe that active cathartics or powerful anodynes are seldom useful or necessary in such cases.” Dr. Nichols follows a plan of local treatment similar to that which I have often adopted, viz., hot cloths, saturated with chloroform. Of the more in- tractable strangulations, the doctor says: “In such cases I do not despair. I carefully readjust the pressure, reduce or lessen the tumor as much as possible, holding the part, and making the pressure close to the point of stricture with one hand, and with the other, after holding it in cold water a few minutes, I suddenly seize the abdomen below the navel, and carry it upwards, at the same time using a little more force or pressure with my other hand at the stricture. “I know this by experience, and I fully believe that it is the remedy ‘par excellence' in every obstinate case of Strangulated hernia. This retractive power can be excited at our will, can be united with external pressure, is without risk to the patient, and in my hands has always proved successful.” The various manipulations employed in the ordinary operation of taxis are substantially as follows: It will generally be found desirable that the bladder and rectum be thoroughly evacuated. The patient having assumed that position (among those already de- scribed) best calculated to relax the constricted parts, ether should be administered, to the extent of complete obliviousness in all severe cases. Having obtained a thorough relaxation of the system, the surgeon grasps the tumor in his right hand and draws it gently downward, in order to dis- engage it from the neck of the sac, and at the same time give it the proper direction in relation to the opening through which he desires it to return into the abdomen. This being done, a gentle, steady, uniform pressure is applied to the tumor with the right hand to force out its contents, while the left thumb and index-finger encircle the upper part of the tumor to fix it at that point and thus facilitate reduction. The direction of the pressure must * Medical and Surgical Reporter, Philadelphia, January 4th, 1873. 864 A SYSTEM OF SURGERY. correspond inversely to the course and situation of the hernial protrusion. In oblique inguinal hernia the force should be directed obliquely upward and outward, in the course of the inguinal canal; whereas in the direct variety the parts should be pushed directly upward, or upward with a slight incli- nation outward. Acting upon the same principle in femoral hernia, the tumor is first pushed directly backward until fairly beyond the reach of the ligament of Hey, then the pressure being made in an upward direction, the reduction is accomplished. If in any case the hermial tumor be of large size, the manipulations should be performed with both hands, but always with caution, lest the parts sustain further injury. . Soon after the continuous application of this pressure, the operator will generally be aware of some diminution in the size of the tumor, from the escape of gas or fecal matter, and by steadily continuing the treatment, will find one portion after another receding, until, with a distinct gurgling Sound, the sac is emptied of its contents. Sometimes a trifling pressure is sufficient for complete replacement, while at others considerable force is required. The length of time that may be devoted to these efforts will vary accord- ing to circumstances. In general an old hernia will bear pressure better and longer than one of recent date, and one of large size will be found more tolerant than a smaller one. An excellent evaporating lotion, used by my friend Dr. Belden, is com- posed of equal parts of alcohol, nitrate of potash, and vinegar. The salt must be dissolved with the acid, and the alcohol quickly added and applied before using taxis. Puncturing the Intestine.—I believe that puncturing the intestine, where reduction is impracticable, will in many cases supersede other operative measures. The common-sense of the proceeding is evident. From the cases that have already been relieved in this manner, it should be attempted before resorting to hermiotomy. Mr. Thomas Bryant, of Guy’s Hospital, is much in favor of this method and has adopted it with success; in several instances I have resorted to it. A fine aspirating needle should be carefully intro- duced into the tumor, and the fluid cautiously and slowly withdrawn. The puncture may be made, as I practiced several times, with a good-sized hypodermic syringe. - In a severe case of intestinal occlusion, in which the entire abdominal wall was incised, it was impossible for either Dr. Talbot or myself to return the intestines into the abdominal cavity, until several punctures were made, whereupon an immense amount of gas escaped, and the intestines were easily replaced. : Traction in Taxis.--It must be remembered in attempting taxis, that traction is efficacious, and really by this means it is, that the method of Dr. Nichols above mentioned, is successful. Dr. Karl Nikolaus” has made some interesting experiments to show how difficult it often is, to push up intestine through a constricted ring. If a portion of intestine, two or three feet long, is passed through a piece of tub- ing a couple of inches in length, and the protruding end of the gut be filled with water, it will be found difficult, if not impossible, to force the water by pressure through the tube; but if suction be made at the other end, the fluid soon passes upward. The position, therefore, of a patient suffering from strangulated hernia should be upon the knees, with the shoulders on the bed, or in the ordinary Sims’ position (the patient resting on the side opposite the hernia), with the hips much elevated. * Centralblatt für Chirurgie, February, 1886. TRUSSES. 865 By this position suction is produced, which may be increased by the bladder and rectum being thoroughly emptied. The incarcerated gut is also emptied, and the intestine, partly by suction and partly by gravity, will be drawn within the abdominal cavity. Reduction of Hernia by the Rubber Bandage.—Another method of reduction is by the use of the india-rubber band. It is applied by first placing the patient in a recumbent position. A linen bandage is wound around the body two or three times and attached to the rubber band; the latter, if it be an inguinal or umbilical hernia, is then wrapped quite firmly around the base, and carried more loosely over the remaining portion of the incar- cerated bowel. The amount of pressure is regulated by the number of folds of the elastic. This will generally force some, or all, of the contents of the strangulated bowel back into the abdominal cavity, after which the reduction can easily be effected by taxis. - Dr. Maisonneuve has an instrument for hernia, which consists, first, in a lumbar plate, which rests upon the small of the back, and on either ex- tremity carries a small hook; second, in a screw arranged nearly like a Petit's tourniquet. It consists in a slightly concave pad, above which, and playing upon a cylindrical endless screw, is a metallic rod, about eight inches long, and armed with hooks. The pad is fitted over the hernia and the hooks at the extremities of the lumbar pad connected by rubber bands to the hooks of the metallic rod. The pressure of the pad upon the hernia can be intensified or diminished by elevating or lowering the rod, and in this way increasing or lessening the tension of the rubber bands. This apparatus is especially adapted to small herniae. M. Chapelle” mentions two cases of strangulated hernia reduced by Esmarch's bandage after all other means had failed. One was of scrotal hernia, the patient being seventy-two years old; the other a femoral hernia in a female. Trusses.—At the present day there are a great variety of trusses, which have been devised for retaining the bowel within the abdomen after the reduction of hernia. Some of these present advantages, and others are worse than useless. I am well assured of one fact, that a truss that will be of Service in one case, may failin another, and a truss may suit a case of hernia at one time and not at another. A truss is nothing more than a pad which fits upon the rings, with a spring or a bandage to keep this pad in place. In many instances, besides the spring, a perineal band is necessary. An inguinal hernia is more readily kept in position than a femoral, and there are but one or two trusses that I have found that are of any service in the latter variety. There are some that have no circular spring, but are supported by elastic bands; of these the Mocmain lever and the Rainbow elastic are good examples; they are peculiarly suited to elderly people, where the inguinal rings require but little support, but in younger per- Sons, especially those of the laboring classes, the pressure upon the rings is not sufficient to prevent the escape of the intestine. It would be impossible to enter into the description of many trusses. I can simply repeat that different cases require different trusses, and that those instruments which combine lightness, elasticity, steady pressure, and i. i. likely to shift position from the varied movements of the body, are the best. The instruments made by the New York Truss and Bandage Institute appear to be reliable. In the radical cure truss, Figs. 536 and 537, the * The Medical Record, October 12th, 1878, No. 414. 55 866 A SYSTEM OF SURGERY. front pads are made rights and lefts, and each consists of a ring with a metal foundation, which is made of felt or blanket covered with kid or buckskin on the inside and calfskin on the outside, in the centre of which is an ivory ball attached to an adjusting spring connected by screws to the spring and a piece of metal termed a fork. These forks are made also as FIG. 536. FIG. 537. | º - * | | º - -º-º: º º || || ºf |º | ". - - -- º |-- - - G º/*Tºº º - ºl --- º - º: º º º S º º º º Haskell's Double Radical Cure Truss. Single Radical Cure Truss, rights and lefts. The springs are constructed of tempered steel and sus- ceptible (by the aid of a pair of pliers) of being shaped to the form of the body, and the pressure regulated by the same instrument from one ounce to fifteen pounds. The back pad is so constructed that it forms a bridge over the spine, the entire pressure is on each side of the column and directly over the rupture; the spring is so fitted that there is no pressure on the body from it. The form of the front pad is such that when it is in its proper place it closes the internal ring and thereby prevents the escape of any part of the rupture, while, at the same time, the pad creates an external irritation which may ultimately produce an obliteration of the FIG. 538. FIG. 539. Single Ball and Socket. Double Ball and Socket. ring. By continuing to wear the truss a sufficient length of time to create an induration, a radical cure can be effected. - Haskell has an excellent palliative instrument (Figs. 538 and 539) con- structed as follows: The interior of the front pad is a metal plate, to which is riveted another in which is a metal ball working in a socket, which is attached to a carriage piece having a flange to receive the spring, and is fastened by a stud-screw having a head for fastening the strap. The back pad is similar to the radical cure truss, and is applied HERNIOTOMY. 867 in the same manner. The merit of this instrument consists in a front pad working in the ball and socket. When the truss is properly applied, it covers the internal ring and will remain in place no matter in what ; the body may be. The spring may move, but the pad will not be affected. - I have used a truss manufactured by Pomeroy, known as the “finger pad,” which held a hernia that had eluded many other instruments. - After a truss has been applied, the patient should run, cough, and strain, in order to see if any portion of the intestine escape beneath the pad, for i it does the truss is not adapted to the case, and may be a source of great 8,I).956I’. ūral Considerations regarding Herniotomy—Kelotomy.—Having ex- hausted all the previously described methods of relief without success, or having decided from the extreme severity and urgency of the symptoms that nothing less than operative procedure can be of avail, measures should be taken for performing herniotomy. - - This operation should not be regarded as the dernier ressort, to be de- ferred until all hope is lost, for indeed in many instances it may be con- sidered as the first resource. - The danger from the operation is but slight compared with that which threatens the patient if the strangulation is allowed to continue for a length of time. The more severe the symptoms, the more urgent the demand for prompt and positive removal of the cause. Premising that, in all cases which are severe enough to demand operative interference, some anaesthetic has already been administered during the taxis, the division of the constricted part should be performed while the patient is insensible. The character of the operation will be deter- mined by the seat of the stricture and the condition of the strangulated protrusion. The constriction may be situated either in the tissues surrounding the neck of the sac and forming the hernial opening, within the neck of the sac, or in the contents of the sac. According to the Register-General's report as given by Mr. Spanton, there were 1119 deaths from hernia in a single year, of which 23.5 per cent. had undergone operations for strangulation. The same author asserts that the mortality after kelotomy, in eleven hospitals, is 41.8 per cent. Division of the Stricture External to the Sac.—Respecting this method the opinions of surgeons are at variance. All must agree that the less the hernial sac and its contents are subjected to manual interference, the less likely is severe inflammation, which is such a fruitful source of danger, to 3.TISé. It may be urged that as the bowel is not exposed to inspection, there exists a great liability of returning into the abdominal cavity some portion of intestine already gangrenous, thereby giving rise to fatal results. This objection is answered by the fact that such a condition can almost inva- riably be recognized without opening the sac, and also that such a degree of inflammation would have produced sufficient adhesions to prevent the reduction of the tumor after simply dividing the tissues external to the sac. And further, if this method is found insufficient, the division of the stricture inside of the neck of the sac, or the laying open and displaying its contents, are but additional steps in the same direction. It must be remem- bered that there may be an omental as well as a peritoneal sac, as seen in Fig. 540. * à general, when there is reason to believe, from the character and duration of the symptoms, that strangulation does not depend upon 868 A SYSTEM OF SURGERY. adhesive inflammation, in fact, when taxis has been considered appli- cable but has failed, the operation external to the sac is certainly justifi- able, and when complete reduction follows, all that could be gained by any plan of treatment, has been accomplished, and manual injury of the peritoneum has been avoided. If, after dividing the edges of the hermial opening, the re- duction is still impossible, or if something remains in the sac which would raise a doubt as to the con- dition of its contents, or when from the severity or long continuance of the strangulation, there is fecal vomiting, a dark appearance and leathery feel of the sac, with pros- tration, indicating that gangrene has already taken place, then it should be freely º open, and its contents carefully examined and judiciously dealt with. It is said that Langenbeck operated for stran- gulated hernia º opening the sac, and lost but three cases in fifty- nine operations. Theilhaberº says that empty her- nial sacs, especially if exudation occur rapidly in them, give rise to symptoms closely resembling stran- gulation of the intestine, and gives An “omental sac,” from a casein which the stricture was relieved by operation, the omentum being divided in order to reach the bowel; a, points to a densefibrous membrane, apparently a condensation of the different fasciae and neighboring areolar tissue; b, to the perito- neal sac, c, the external surface of the omentum, which is spread out over the interior of the whole of the her- nial sac, d, the wound made in the operation; e, the testicle. This preparation is from one of the cases referred to by Mr. Hewitt, in Med.-Chir. Trans., vol. xxvii., and is in the Museum of St. George's Hospital.-Holmes. two cases, Directions for the Performance of Herniotomy.-0ld Operation.—The patient, being under the influence of an anaesthetic, with the bladder emptied and the hair shaved from the parts, is placed, with shoulders slightly raised and knees flexed, in a position similar to that assumed during the taxis. An incision is made directly over the neck of the sac, in inguinal hernia from the internal to below the external ring, in the course of the inguinal canal; while in femoral hernia, a vertical inci- sion is made over and to the inner side of the crural ring. Divide the coverings consecutively until the sac is reached, making free use of the grooved director and scalpel handle when exposing the deeper structures. Any important haemorrhage must be controlled by torsion or the liga- ture. It will not be possible to demonstrate the precise number of coverings of the intestine, for if there has been considerable inflammation, the coats may be almost indistinguishable, or additional layers may have been deposited. * Abstract of Medical Science, vol. iv., No. viii. (Aertzliches Intelligenz-Blatt, 7, 1877). HERNIOTOMY. 869 The seat of the stricture is to be ascertained by passing the left index finger into the upper extremity of the wound, and if it be found outside of the 8ac, a director is passed beneath the obstruction, and with a hernia knife, herniotome, or probe-pointed bistoury, the stricture is divided by a short incision upward, this being more likely to avoid the epigastric artery. Care should be taken to make the division as small as possible, just enough to allow the return of the intestine without force. This being done, reduction is carefully attempted, and if the bowel goes back readily, the object is ac- complished. . $ But if this result does not follow, and any of the hernial contents remain in the sac, then it must be opened freely, care being observed not to wound the intestine. To avoid this make a small incision to admit the director, and carrying it along close to the walls of the sac, divide them with a bis- toury. Generally some fluid will escape, although in recent strangulation the quantity may be small. The contents having been exposed, they should be examined with care and gentleness. Upon examination, the intestine may be much discolored, almost black from congestion, or covered by the products of exudative inflammation, yet if it be neither ruptured nor gangrenous, it should be restored to the cavity of the abdomen. Cases will be met, in which doubt exists as to the propriety of the above procedure, and judgment and discrimination will be demanded to decide the question. If a large amount of intestine be found to be injured, it will be wiser to leave it, simply dividing the stricture. Care should be taken in cutting the neck of the sac, lest the already in- flamed and weakened bowel sustain further injury. y Having introduced the finger into the neck of the sac, a probe-pointed bistoury is passed flatwise along the finger till underneath the constriction, when by turning the edge of the knife upward, it is immediately divided. An incision of one or two lines in length is generally sufficient. This will be the best method of treatment if the vitality of the bowel seems destroyed beyond reasonable hope of recovery. To determine this, aid may be given by the history of the case, the size of the tumor, duration of con- striction, and the condition of the patient. - Greater danger of mortification exists when the hernia is small, recent, º the strangulation has been protracted, than when, opposite conditions obtain. If the ordinary phenomena of constricted hernia are succeeded by a Hippocratic countenance, feeble wavering pulse, hiccough, and crackling state of the tumor, with sudden cessation of pain, and great prostration of the vital forces, it may be positively assumed that gangrene is pres- ent. When, however, the symptoms are less marked, the prognosis will be assisted by recourse to the following measures: all constriction being re- lieved, warm fomentations should be applied to the parts for ten or fifteen minutes, in hope of restoring the circulation; but if at the end of that time there is no change in the appearance of the tumor, if no blood issues on puncturing the vessels, and if, superadded to these, the intestine is found soft and flaccid, its sensibility lost, and its temperature decreased, the pres- ence of mortification becomes a certainty. Under these circumstances, the gangrenous gut may be resected or the sur- geon may wait for the formation of an “artificial anus.” If the surgeon pre- fers the latter course, nothing remains but to support the patient, giving care to the wound, in the hope that nature may be able to effect a sponta- neous cure. No apprehension need be felt that the intestine will retract 870. A SYSTEM OF SURGERY. into the abdomen, for such strong adhesions have been formed at the neck of the sac that such a result is for the time prevented. Later, this attempt at retraction of the bowel is nature's method of perfecting a cure. If the bowel be ruptured or perforation has taken place, the stricture should be relieved at once, and resection performed. Should there be but a Small perforation, a delicate ligature may be carried around it, cutting the ends close to the knot and leaving it at the orifice of the sac. In all cases of epiplocele or entero-epiplocele, in which strangulation has occurred, it must be remembered that the omentum cannot bear with Safety as much injury as the intestine, and when there is inflammation, hypertrophy, or that loss of consistence which follows these two conditions, the diseased portion should be removed with the knife, carefully ligating all the vessels separately, as this tissue is quite vascular. Before perform- ing this part of the operation the tumor should be closely examined, lest it contain a knuckle of intestine concealed within its folds. There may exist an omental sac, in which case care must be exercised; the intestine and omentum being returned separately, if reducible, with the precaution that there remain no adhesions or bands at the neck which will prolong the constriction. The after-treatment is by no means unimportant. The patient is kept quiet, and after the wound has been closed by sutures, a compress and bandage are to be applied. All action of the bowels is to be prevented by an opiate or suppository of morphia. Very little aliment should be taken by the mouth ; but if the patient is very feeble he must be sup- º by a little brandy and water, or small lumps of ice may be freely administered if there be thirst. Should there be high fever or symptoms of peritonitis, they must be met by the appropriate remedies. Enterectomy in Gangrenous Hernia.—As has been mentioned, it becomes a matter for consideration what to do with the gangrenous gut after the operation for strangulated hernia. For years the direction has been to make an artificial anus by stitching the intestine, previously slit, to the walls of the incision. The operation has generally been looked upon with disfavor, not only on account of its mortality, but also because the wretched ºion in which it leaves the patient is, in many instances, worse than eath. To remedy such evil, in 1727, Ramdohr successfully resected nearly two feet of intestine. Among the first in this country to perform the operation, was the late George D. Beebe, who resected four feet of intestine in a case of umbilical hernia in a woman—the patient, though pregnant, recover- ing. The establishment of communication between the cut intestines was effected by means of clamps. Of late, the “circular resection and suture of the intestines' has been performed about seventy times, and of sixty-seven of these there were twenty-one cures which were perfect; two imperfect, recovering with an artificial anus; and forty-four deaths, making a mortality of about 65.57 per cent. In removing a portion of the intestine, the first consideration is to effectually occlude the gut, to prevent effusion; this may be done with a ligature, or with a pair of forceps having the blades covered with an antiseptic gauze. Billroth and Czerny recom- mend the fingers as the best medium of occlusion. The mesentery at- tached to gangrenous intestine should be removed in a triangular piece, and the vessels therein ligated. If the mesentery be not gangrenous it may be ligated, although the former procedure is preferable. The greatest caution is to be used during this part of the operation, to prevent the separation of the mesentery any further than from that portion of the bowel to be removed. If such an accident should happen, gangrene of the FADICAL CURE OF HERNIA. 871 edges of the wound will follow. The intestine is cut off at right angles and the sutures inserted. The Czerny-Lembert suture is the one ap- plicable to this condition. This suture is made as follows: The needle is passed entirely FIG. 541. through the walls of the gut, about an eighth NNNººSS of an inch from the margin of the cut, and brought out on the opposite side. When the entire circle of intestine is thus brought to- gether, then the original Lembert suture, pass- ing only through the serous coat of the bowel, is made, and, when completed, the sutured in- testine is returned into the abdominal cavity. The first suture should be entered upon the mesenteric side of the gut. The incisions should be made in sound intestine. Radical Cure of Hernia.-In most of these so-called radical methods, the patient is required to wear the truss, if not for life, for a considerable time, so that these procedures are not as satisfactory as we are led to believe. The operations of Gerdy, Wutzer, Woods, Chisholm, and Wells, are all open to objection, that of the latter giving me the most satisfaction, until the adoption of the more recent method. We must be careful, in studying these, not to confound the operation of Dr. T. Wood, of Cincinnati, with that of Professor John Wood, of London, although they are similar. Dowell, of Texas, has an excellent method. Jamison, of Baltimore, fol- lowed Dzondis' transplantation plan, and the “local irritation and com- pression methods " of Pancoast, Velpeau, Armsby, and Riggs have had their stanch supporters. The two operations which are at present engag- ing the attention of the profession are: 1st, that known as the radical cure by cutting off the sac, or the “open method,” and the “radical cure by Heaton's injection.” The Open Method has been a development of successive stages. The ligature of the neck of the sac, and extirpation of its fundus, was first de- scribed by Riesel, of Germany, in 1876. The stitching together of the edges of the ring was first performed by Professor Czerny, of Heidelberg, in 1879. His method was to cut down upon the hernia, isolate the sac, ligate its neck, cut away the fundus, return it within the abdomen, and, finally, to stitch together the refreshened edges of the ring with cat- gut. Two years later Dr. Gross, of Philadelphia, adopted the plan as above, with the modification of using silver wire in place of catgut for closing the ring. With this alteration the method of Czerny has been freely used by the surgeons of Liverpool with remarkable results. In all, one hundred and twenty-five cases have been operated upon without a single death. Little is said about the recurrence of the hernia. Of twenty-one operations performed by Dr. Banks (which are included in the one hundred and twenty-five), and in which sufficient time had elapsed to distinguish successes from failures, fifteen were complete cures, four partial successes, and two failures. Of twelve operated upon in the Northern Hospital, ten were cured and two failed, making, for the entire thirty-three, a percentage of failure of 24.2. - In 1883 Dr. Leisrink, of Hamburg, collated 390 cases. Of 202 opera- tions upon reducible hernia, 187 recovered and 15 died; of the former 20% per cent. recovered. Of 188 operations for strangulated hernia, 155 recovered and 33 died. Nothing is stated regarding relapses. Combining the results of the Liverpool cases and those collated by Leis- rink, we find that of 515 operations for reducible and strangulated hernia, 9.3 per cent. died, 2 per cent. of which may be ascribed to the strangulation, Mesentery 872 A SYSTEM OF SURGERY. it being shown by Leisrink's statistics that the mortality in reducible cases is about 7.4 per cent. - - The operation as at present performed is applicable to all kinds of hernia, reducible and irreducible, but should only be employed when the patient is incapacitated, or his life made miserable by the rupture. te The operation should be made in the following manner: The strictest antiseptic precautions should be taken, and the pubes, Scrotum, and the inner sides of the thighs shaven and carefully washed with a bichloride solution, of one to one thousand. The first incision should be full and free, that the operator be not cramped in his fur- ther manipulation; and it is important that the surgeon should recog- nize the Sac when he reaches it, and not mistake other tissue for the peritoneal covering. When the sac is found all the smaller bloodvessels should be either tied or torsioned, and the sac drawn forward. The con- tents of the bowel should be pushed back into the cavity of the abdomen and kept there by the finger of an assistant; then the sac should be freely opened that the surgeon may ascertain beyond doubt that there is no knuckle of the intestine nor fold of omentum contained. The sac must then be drawn further out, ligated with a strong catgut ligature, and cut off just anterior thereto. The stump of the gut may be stitched to the pillars of the ring, or pins may be placed at right angles through the stump, passing through the rings, which will prevent the retrac- tion of the stump. The pillars of the ring may be stitched together, which is readily effected by three or four sutures of silver wire, and the wound closed in the usual manner. I have employed both catgut and whale tendon ligatures for this purpose, and found them to answer well. My modification of this process is to encircle the base of the sac with a piece of catgut ligature not drawn too tightly, to obstruct circulation, and to twist around the remaining portion of the extruded peritoneum a piece of catgut two feet in length by which an elastic plug is made. I then turn this plug around, fitting its extremity into the abdominal ring, and hold it in position by a suture passing through both pillars. Drainage-tubes are inserted and the integument brought together. If the protrusion is an epiplocele, I ligate the omentum close to the ring and cut off the protruded portion, using the stump as before in the opening. - Heaton's Method of Radical Cure.—Dr. Heaton, of Boston,” has devised procedures for the radical cure of rupture, which deserve attention in this place. He has two methods, which he denominates the “liquid” and the “solid,” in accordance with the character of the substance employed. In the one it is solid and in the other liquid. He insists on one point, and that is that but a slight degree of inflammation must be excited; indeed, he denominates the process as “the method of tendinous irritation.” The irritant he employs in the “liquid method "is composed of half an ounce of Thayer's fluid extract (prepared in vacuo) of Quercus alba, tritu- rated, with the aid of gentle heat, with fourteen grains of the solid alco- holic extract of Quercus alba, adding the sulphate of morphia in the pro- portion of a grain to the ounce. These substances must be triturated for a long time. The “solid method” differs, not in the operation, but merely in the character of the substances, which are the same as above; the solid being mixed with the fluid extract of Quercus alba until a thick paste is formed. The advantages of the latter over the former are, that a much smaller amount is required to produce the irritation, and the paste can * The Cure of Rupture, Reducible and Irreducible, also of Varicocele and Hydrocele, by New Methods, by George Heaton, M.D., Boston. - HEATON'S METHOD OF RADICAL CURE. 873 be smeared over the fibrous surfaces with less risk of producing inflam- mation. The instruments required are really hypodermic syringes (Fig. 542), the cylinder being made of silver and the needle made of Solid steel, bored. This latter is considered an essential point, as firmness and strength are FIG. 542. required to pierce the tissues. The directions for performing the oper- ation I give in Dr. Heaton's own (tºm *º-sº . . . . words: “The hernia and, if possi- ble, the sac, should be returned into Heaton's Hernia Syringe. the abdominal cavity, and the pa- tient in the recumbent position. Invaginate the right forefinger in the scrotum and find the external abdominal ring; then with the left forefinger press perpendicularly upon the integument directly over this ring, and use sufficient force to, if possible, press the integument together with the finger, directly into the ring, the left forefinger being at or in the ring, the sper- matic cord and the sac, if in the way, are to be pushed to one side, so that nothing may remain between the external pillar of the ring and the finger except the integument and subjacent superficial fascia. Keeping the left forefinger thus, take the instrument in the right hand and introduce its freshly sharpened and polished beak quickly, penetrating the integument and superficial fasciae, just passing but not grazing the external pillar, and entering the canal at once. Then remove the left forefinger and gently in- sinuate the beak further on, well into the canal, exercising the greatest care not to impinge upon the spermatic cord, which is sensitive to the slightest touch, or upon the fibrous walls of the canal. . . . . . Having satisfied him- self that the beak of the instrument is in the canal, the surgeon then de- posits about ten minims of the liquid irritant, emitting it drop by drop, and spreading it as much as possible. . . . . . Particular care should be taken that the intercolumnar or arciform fibres, and the inner edges of the external ring are wet with the irritant. A well-fitting bandage, with a pad over the ring, should be applied before the patient is allowed to get up, and it is better to keep him quiet for some time in bed.” Dr. Warren, however, has lately improved the Heatonian method, not only in regard to the material injected, but in the apparatus for throwing in the fluid. He objects to the ordinary fl. ex. of Quercus because the solidº portions of it are very liable to become impacted in the syringe, and when ejected to be unequally distributed upon the fascia. He also differs in the explanation of the method of cure. He believes that the operation is successful, not because, as Dr. Heaton avers, “a tendi- mous irritation ” is produced, but because it produces a local inflammation without suppuration. He gives also some modifications of his original formulae; thus,t Formula A.—For infants and children, whether the hernia, be accidental or congenital: B. Fl. ext, quercus albaº, 3ij, reduced by distillation to 3.j; alcohol (90 per cent.) 5ij; ether sulph., 5; morph. Sulph., gr. ss. M. Sig. Inject 8–10 IIll Ill IſlS. . * B.—For old and long-standing herniae, whether congenital or ac- Ullred . B. Fl. ext, quercus albæ, 3iv, reduced by distillation to 3.j; alcohol (90 * Medical Record, October 18th, 1879, p. 368. f Glasgow Medical Journal, May, 1883, p. 339. 874 A SYSTEM OF SURGERY. per cent.), 5iij; ether sulph., 5ij; morph. Sulph., gr. ii. M. Sig. Inject 10–25 minims. Formula C.—Best in the majority of cases: B. Fl. ext, quercus albæ, 3v.j, reduced by distillation to 3ij; alcohol (90 per cent.), 3ss; ether sulph., 3ij; morph. Sulph., gr. iv.; tinc. veratri viridis, 3ij. M. Sig. Inject 15–20 minims in small and recent herniae; but 25–50 minims in large or old hernia. “This fluid will cause a marked reduction of pulse and temperature, and it may be necessary to put a hot water bottle to the patient's feet. This reduction may last as long as 48 hours, and gives a decided advantage in obtaining a more decided local effect of the irritant.” Dr. Warren invented several instruments whereby the injection can be made. The first (which I found so cumbersome that I soon laid it aside) has been superseded by another, as seen in the cut (Fig. 543). De Garmo FIG. 543. Warren's Syringe. has invented a good syringe for the same purpose, as seen in Fig. 544. After the injection a truss must be worn, and Dr. Warren lays emphasis on a device of his, known as the anatomical truss, the pad of which is made of silver wire gauze, the object of the latter construction being to facilitate FIG. 544. De Garmo's Syringe. the application of medicated substances to the parts beneath should they become irritated or inflamed. The truss has a large pad (as seen in Fig. 545) which has a tendency to bring the rings nearer together. The instru- ment should be worn from three to five months. I have used this method many times with a success which has surprised me; at other times with failure; and again, at others, I have been disap- pointed to find that after the removal of the ordinary truss which I have used (I have not applied Warren's) the gut would reappear at the open- ing of the ring, and, though not coming downwards as far as before the operation, yet would cause sufficient inconvenience to require a second injection. My experience is that about half the operations succeed ; in my recent treatments I have had recourse to two injections before allowing the patient to leave his bed. The second, consisting of ten or fifteen minims, is given on the fifth day. Lately, I use a hypodermic syringe with a little larger point than usual, and have discarded all the instruments devised for this special purpose. RADICAL CURE OF HERNIA. 875 In looking over some old medical and surgical literature I was surprised to find that the celebrated Mr. Lizars employed a preparation of white oak bark as an application for rupture, and that he spoke highly of its use. º º | Warren's Truss. According to Dr. Schwalbé, who has written in favor of the method, twenty injections are required to effect a cure, and the period of time extends from two months to a year. Lately Mr. Keetley has operated upon eleven cases, nine of which were cured, and two benefited. Mr. Keetley* makes something of a cutting operation as well as the injection method. The integument is incised down to the ring and a director passed under the intercolumnar fascia; upon the director the nozzle of the syringe is passed and a concentrated solution of white oak bark is injected into the canal. After this is thoroughly done, the pillars of the ring are drawn together by two catgut sutures. - The following is Wood's description of his radical cure operations, of which in 155 cases, there were but 2 deaths, 40 failures, and 113 cures: “The patient being laid upon his back, with the shoulders well raised and the knees bent, the pubes cleanly shaved, the rupture completely reduced and chloroform administered, an oblique incision, about an inch long, is made in the skin of the scrotum over the fundus of the hermial sac. A small tenotomy knife is then carried flatwise over the margin of the inci- sion, so as to separate the skin from the deeper coverings of the sac to the extent of about an inch or rather more all round. The forefinger is then passed into the wound, and the detached fascia and fundus of the sac in- vaginated into the canal. The finger then feels for the lower border of the internal oblique muscle, lifting it forwards to the surface. By this means the outer edge of the conjoined tendon is felt to the inner side of the finger. A stout semicircular needle, mounted in a strong handle, with a point flat- tened antero-posteriorly, and with an eye in its point, is then carried care- fully up to the point of the finger along its inner side, and made to transfix the conjoined tendon and also the inner pillar of the external ring ; when * British Medical Journal, September 19th, 1885. 876 A SYSTEM OF SURGERY. the point is seen to raise the skin, the latter is drawn over toward the mesian line, and the needle made to pierce it as far outward as possible. A piece of stout copper wire, silvered, about two feet long, is then hooked into the eye of the needle, drawn back with it into the scrotum, and then detached. The finger is next placed behind the FIG. 546. outer pillar of the ring and made to raise that and Poupart’s ligament as much as possible from the deeper structures. (Fig. 546.) . The needle is then passed along the outer side of the finger and pushed through Poupart's liga- ment, a little below the deep hernial opening (the internal ring). The point is then directed through the same skin-puncture already made, the other end of the wire hooked on to it, drawn back into the scrotal puncture, as before, and then detached. Next, the sac, at the scrotal incision, is pinched up between the finger and thumb, and the cord slipped back from it, as in taking up varicose veins. The needle is then passed across behind the sac, entering and gº-h emerging at the opposite ends of the scrotal * A incision. The inner end of the wire is again hooked in and drawn back across the sac ; both Wood's Operation.—BRYANT. ends of the wire are then drawn down until the loop is near the surface of the groin above, and are twisted together down into the incision, and cut off to a convenient length. Traction is then made upon the loop ; this invaginates the Sac and scrotal fascia well up in the hermial canal. The loop of wire is finally twisted down close into the upper puncture, and bent down to be joined to the two ends, in a bow or arch, tº: which is placed a stout pad of lint. The whole is held steady by a spica bandage. The wire is kept in from ten to fourteen days, and even longer if the amount of consolidation is not satisfactory. Very little suppuration usually follows, but after a few days the parts can be felt thickened by adhesive deposit. The wire becomes loosened by ulceration in its track until it can be untwisted and withdrawn wpwards. In this operation the hermial canal is closed along its whole length, and an extended adherent surface is obtained to resist future pro- trusion.” After this operation, as in others, the truss must be worn for a long time, and always when lifting or straining. For the radical cure of hernia, Langenbeck succeeded by dissecting up as thick a flap of skin as possible, corresponding in width with the hernial opening. In inguinal hernia, he begins at the external ring, and dissects upwards and outwards for an inch and a half. He then makes room for the flap, by introducing his finger into the inguinal canal, and forces the flap into it without twisting, and finally closes the external wound over the flap. For a femoral hernia, the flap is made from the fossa ovalis, and is about one-half as long. The flap in umbilical hernia is made in any direc- tion, † over the ligamentum teres. - Inguinal Hernia, Its Surgical Anatomy.—The surgical anatomy of inguinal hernia is always a matter of consideration and study, and with careful dis- section in a properly preserved or fresh cadaver the ordinary points may be made out. I have, in 80me instances, been able to find all these cover- ings in the cadaver in persons who have not suffered from hernia during life, but my experience is that in those who have suffered from rupture THE ANATOMY OF INGUINAL HERNIA. 877 during life, there is always more or less alteration of structure (even when there has been no strangulation) from the wearing of trusses, from an occa- sional incarceration, or from the frequent manipulations necessarily per- formed by the patient to restore or keep in position the refractory intestine or omentum. The integument, fascia and peritoneum, and in the femoral, the sheath of the femoral vessels are readily recognized, but the inter- columnar and cremasteric fascia, the septum crurale, and cribriform fascia cannot, in the majority of instances, be discovered. Where strangulation exists these layers need scarcely be looked for. The necessary exuda- tion consequent upon inflammation and strangulation destroys the rela- tive position and even the appearance of the parts; the main object of the surgeon in operating must be the recognition of the peritoneum. These facts should be borne in mind by the inexperienced operator. Long ago they were recognized, and in Pott's celebrated treatise * written over 110 years ago, I find these words which are worth recording: “However incredible or strange it may seem, yet I am convinced that operations have been performed by the information obtained from books only, without any previous anatomical knowledge, any practice on dead bodies, and hardly any, if any, opportunities of seeing any operations performed by others on the living; how grossly must such an operator be deceived, on account of the rings, as they are usually but absurdly called, of the ab- dominal muscles,” etc. - I must, however, describe the actual dissections necessary for the proper understanding of the anatomy of inguinal and femoral hernia, as these two varieties are most frequently encountered by the surgeon and are those which are often subjected to operation, and because once in a while it is good for us to rub off the rust from our anatomy. In studying the anatomy of this region assistance will be derived by adopting certain “fixed points.” Of these points the umbilicus may be regarded as one, the symphysis pubis another, and the anterior superior spinous process of the ilium a third. Draw a line from the symphysis to the umbilicus, carry another from the umbilicus to the superior spinous process of the ilium on each side, and from these to the symphysis pubis. We now have two triangles with a common base, while their apices correspond to the superior spines of the ilia. These are the inguinal triangles. In the dissection of these points, the incisions made will correspond to the common base of the triangles and # the line drawn from the umbilicus to the superior spinous process of each HIll III]. The first covering is the integument, which is removed by reflecting it downward. The second covering is the superficial and deep fascia; the superficial epigastric vessels and nerves being contained between the two layers of the superficial fascia. The third is formed by the intercolumnar fascia, which is a series of curved tendinous fibres arching across the lower portion of the aponeurosis of the external oblique muscle, from the outer third of Poupart's ligament, closing the orifice of the external abdominal ring, and strengthening its pillars by stretching from one to the other, and from this deriving its name, —intercolumnar fascia. The external abdominal ring is not round, but triangular in shape, and any expectation of finding a round aperture will be disappointed. * A Treatise on Ruptures, by Percival Pott. London, 1775, p. 232. 878 A SYSTEM OF SURGERY. In the recent state there is no opening, it being closed, as before stated, by the intercolumnar fascia; otherwise hernial protrusions would be of more frequent occurrence. . This ring is found in the aponeurosis of the external oblique, about an inch or an inch and a quarter upward and outward from the crest of the OS pubis, lying above Poupart's ligament, and transmitting the spermatic cord in the male, and the round ligament in the female. Poupart's ligament is a reflection of the aponeurosis of the external oblique, from the anterior Superior spine of the ilium to the symphysis pubis. This is sometimes called the crural arch. The external pillar of the external abdominal ring is strengthened by a small triangular ligament, which extends from the under surface of Poupart's ligament to the ilio-pectineal line, into which it is inserted to the extent of one inch, and is called Gimbernat's ligament. This may be the seat of stricture. Having removed this fascia, immediately beneath is discovered the in- ternal oblique muscle, the lower border of which gives the fourth covering, the cremasteric fascia. The cremaster muscle consists of the lower fibres of the internal oblique, taken away by the descent of the testes in the foetus. These fibres are continued in loops upon the spermatic cord, and being held together by dense areolar tissue, constitute the fascia of which we speak. It has also received the name of tunica erythrodes. The internal oblique muscle arises by fleshy fibres from the outer half of Poupart's ligament, from the anterior two-thirds of the middle lip of the crest of the ilium, and from the neighboring fascia. From these several points of origin, the fibres diverge; the posterior ones ascend and are inserted into the cartilages of the four lower ribs; those from Poupart's ligament pass downwards and inwards, join with the aponeurosis of the transversalis in forming the conjoined tendon, and are inserted into the crest of the os pubis and the pectineal line. Those from the spine and crest of the ilium are directed forward, upward, and inward, terminating in a broad aponeurosis; the upper three-fourths divides and sends one portion in front, and the other behind the rectus muscle, but unites again at its inner border to be inserted in the linea alba; while the lower fourth is continued forward unseparated in front of the rectus to the linea alba, where it is also inserted. . - When the muscle is removed, the transversalis is brought into view, but i. gives no covering to hernia, as the viscus passes beneath its lower OrCléI’. Laying back the rectus, the transversalis fascia is reached. This is an aponeurosis lying between the under surface of the transversalis muscle and the peritoneum, and forming the fifth covering of the hernia by a funnel- shaped process called the infundibuliform process of the transversalis fascia. The internal abdominal ring is found in this fascia at a point about equi- distant between the spine of the pubis and the anterior superior spine of the ilium, and about a half inch above Poupart's ligament. Its size differs in individuals, being larger in the male than in the female; it is of oval shape, and its oval extremities are directed upward and down- ward. Above, it is bounded by the arched fibres of the transversalis, and internally by the epigastric artery. - The inguinal or spermatic canal is about an inch and a half in length, is directed upward and outward, placed parallel with and a little above Pou- part's ligament, and extends from the internal to the external abdominal ring. It transmits the spermatic cord in the male, and the round ligament in the female. Immediately underlying the transversalis fascia, and form- ing the sixth and last covering of hernia, is found the peritoneum, which may be recognized by its white glassy appearance—and this forms the Sac EPIGASTRIC ARTERY. 879 of the hernia. Between this and the gut is the subserous areolar tissue, which by some is considered an additional investment of the intestine. An oblique inguinal hernia passes through both rings, and through the inguinal canal (Fig. 547); a direct inguinal hernia escapes through the abdominal wall and the external ring (Fig. 548). The two varieties have Guy's Hosp. Mus., 47815. Oblique Inguinal Guy's Hosp. Mus., 48030. Direct In- Hernia. Bubonocele on right side, but pass- guinal Hernia.-BRYANT. ing through external ring on left.—BRYANT. the same coverings, except that in the latter the conjoined tendon is substi- tuted for the cremasteric fascia. Epigastric Artery, its relation with the Internal Ring.—The study of the relations of these vessels has been thoroughly made by M. Jules Cloquet,” from whose dissections these deductions are made. They may seem un- important to the general practitioner, but may be of immense service to the surgeon in case of emergency. The relations of the artery to the inner ring are interesting and important. In general the epigastric artery passes immediately upon the internal border of the internal abdominal ring, so that the spermatic vessels on entering the canal appear at first sight to wind around the artery. In some subjects the epigastric is situated four or five lines to the inner side of this opening, and is not in contact with the spermatic vessels at the point where they form a curve to enter the inguinal canal. The situation of the umbilical artery varies considerably. Converted into fibrous cord, it is, in some instances, situated immediately on the inner side of the superior opening of the inguinal canal ; in others some distance from it. We may, therefore, conclude: first, that the sper- matic vessels are always sustained internally by the inner border of the opening in the fascia transversalis; secondly, that in most instances the epigastric artery contributes to their support; thirdly, that in some cases the umbilical artery assists these two parts in maintaining the cord in its situation. Epigastric Artery, its relation with the Outer Ring.—The relations to the outer ring should not be disregarded. Under ordinary circumstances the epigastric is placed at the distance of about an inch from the outer side of the external ring. There are, however, exceptions to this. When the inguinal ring is of considerable length, its external angle, or rather e- * Anatomical Description of the Parts concerned in Inguinal and Femoral Hernia, trans- lated from the French of M. Jules Cloquet, with lithographic plates, etc., by Andrew Mel- lle McWhinnie, London, 1835. 880 A 8YSTEM OF SURGERY. its summit, is situated a few lines from the epigastric artery. I will ob- serve that the proximity of the external angle of the ring to the epigastric artery is consequent, first, on the deviation of the vessel from its proper course caused by an external inguinal hernia inclosed within the canal; Secondly, by the elongation of this angle towards the epigastric artery which retains its proper situation in relation to internal inguinal hernia; thirdly, these two parts in some cases appear to become opposite to each other, which is observed in large externalinguinal hernia where the obliquity of the inguinal canal is destroyed. The epigastric artery is well known to be situated on the outer side of the neck of the sac of internal inguinal hernia. Before the artery reaches the rectus muscle, it forms the external boundary of a triangular space, the base of which is formed by Poupart's ligament, and the internal border by the rectus muscle. The extent of this Space is proportionate to the distance at which the epigastric artery is placed from the symphysis pubis. Internal inguinal herniae occur in the lower part of this triangular space, frequently near the tendon of the rectus; it rarely happens that the hernia is found on the outer side of the space, that is, near the epigastric vessels. - Diagnosis between Inguinal Hernia and Other Diseases.—Abscesses can be distinguished from inguinal hernia by the history of the case, the appear- ance of the swelling, the absence of cough impulse, and the constitutional symptoms indicating suppuration. It may be remembered that a psoas or lumbar abscess may overlie a protruded intestine, and that the symp- toms of both hernia and suppuration may be present. The hypodermic needle will frequently settle this point. - Haematocele.—The peculiar heaviness of haematocele, with the absence of cough impulse, will in many cases be sufficient to fix the diagnosis. If other symptoms should be wanting, the history of a traumatism, the ready isolation of the cord from the swelling, the firmness of the tumor, and blood following the puncture or filling the hypodermic cylinder will be sufficient evidence that there is no hernia present, Sarcocele is known by the history of the case, absence of cough impulse, and the non-implication of the spermatic cord. It will be seen from the above diagnostic marks that when the gut extends into the scrotum we have the so-called scrotal hermia, which is nothing more than an inguinal hernia, and that the differential diagnosis has been given with this understanding. A Bubo, from the sensation detected by the fingers, method of growth, and its history, differs essentially from hernia; but it must be recollected that there may be an enlargement of the inguinal glands occurring at the same time, with either femoral or inguinal protrusion. In some cases a hernia or a bubo may coexist. It therefore behooves the practitioner to bring all his knowledge to bear upon the diagnosis before an attempt is made to operate. Professor Metcalf, of the University Medical College, of New York, thus writes: “Sometimes the most skilful and careful will be led into error by deceptive appearances, and very often will the inexperienced be led astray. How many would have been deceived, for example, in the following case: A young gentleman consulted a friend of mine, giving the following his- tory of his case: He had had inflammation of one of the inguinal glands, for which his physician had used tincture of iodine externally. Suppu- ration occurring in spite of this, an incision was made and the accumu- lated pus discharged, but the abscess had again filled very rapidly, and his physician having left the city, he wished my friend to relieve him. . Upon an examination of the spot indicated by the patient, it was found reddened EIYDROCELE OF THE HERNIAL SAC. 881 from the recent use of iodine, and a scarcely closed incision showed where the pus had been discharged. Upon palpation the abscess seemed to have again filled, but to the experienced touch of the examiner, into whose hands he had fortunately fallen, a peculiar elastic softness was noticed which caused him to pause, with his knife already in hand, and examine further. To his surprise he found that a hermial protrusion had occurred just under the seat of the abscess I “Had he entered this with his knife, death or a miserable infirmity would have been the almost inevitable result. How many would have been de- ceived by such a case?” The following is the differential diagnosis between inguinal hernia and hydrocele: HERNIA. 1. Hernia is almost invariably opaque, the only exception being in case of a large fold of intestine distended with gas and covered by thin integument. 2. The tumor is always varying in size, and can generally be made to disappear by pressure. 3. The cord can never be distinctly felt in any part. 4. The tumor is enlarged by coughing or exertion (cough impulse). 5. The testicle can be felt distinct and sepa- rate from the tumor at the lower part of BIYDROCELE. 1. Hydrocele simulates hernia, but differs from it by being more or less translucent. 2. The tumor is constant. 3. A part of the cord can be felt distinct from the tumor at its apex. 4. Hydrocele, unless congenital, does not en- large upon or feel the impulse of cough- ing or exertion. 5. Tº testicle can scarcely be felt, if at all. the scrotum. In hydrocele of the cord the tumor is circumscribed, leaving a portion of the cord clearly to be felt above and below the tumor, and has most of the dis- tinguishing signs of hydrocele. But when that portion of the cord within the inguinal canal is the site of such serous effusion, the difficulty of diag- nosis is great, for then the tumor may be caused to disappear on pressure as in hernia. Varicocele is diagnosed from hernia by the following signs: The swelling is not reducible and has the feeling as of a bunch of earthworms. It simu- lates hernia, because its size is reduced in the recumbent position as well as by pressure, and the tumor returns upon assuming the upright posture, not- withstanding the abdominal ring has been closed by pressure; the latter condition would not exist in hernia. When the enlarged veins occupy the upper portion of the cord and the inguinal canal, accompanied by an accumulation of serum, the diagnosis is extremely difficult. Enlargement of the veins of the cord frequently facilitates hernial pro- trusion. The testicle being late in its descent may be arrested either in the inguinal canal or at the external abdominal ring, thus giving rise to a swelling which presents appearances similar to those of rupture. The diagnosis may be formed by the absence of the testicle from that side of the scrotum, and by the peculiarly characteristic sickening sensation occasioned by pressure on that organ. • In non-descent of the testicle, it may be lodged either within the in- guinal canal or at one of its apertures; this forms one of the predisposing causes of hernia. Hydrocele of the Hernial Sac.—This is a condition of hernia (hydrops sacci herniosi) that has never, according to my experience, received the attention it deserves. Very little notice is taken of the condition by writers, 56 882 A SYSTEM OF SURGERY. and in the majority of text-books it is ignored. The existence of fluid in the Sac of a hernia complicates the diagnosis, and must be differentiated from simple hydrocele of the tunica vaginalis, for which it is often mis- taken, and from that condition of dropsy of the cord high up, of which mention has been made. This condition is the result of an exudation from the sac, which has been caused by an inflammation of the neck causing more or less adhesion and consequent occlusion, but not, neces- Sarily, strangulation; the quantity of fluid varies from a few ounces to three or even four quarts. Sometimes after a hernia has been cured the Sac remains open, and may become a receptacle for quite a large amount of ascetical fluid. To make a diagnosis between this affection and ordi- nary hydrocele, the present or past existence of a hermial protrusion, to- gether with its history, the changes it has undergone, the injury it has sustained, and the varied conditions to which it has been subjected, will generally be sufficient to point out the true nature of the case. In the differentiation between this disorder and hydrocele of the cord, more diffi- culty may be encountered, but it must be remembered that, in the “high hydrocele,” the fluid in the recumbent position has a tendency to gurgle back into the abdominal cavity, whereas the occlusion of the sac in the disease we are considering, prevents any especial change in the swelling when the patient lies down. There is another relation of the parts that has given rise to difficulty in recognizing the trouble, and which it is important to remember, and that is, an undescended testicle may lodge in the neck of a congenital hernia; such cases are described by Ball and Mayer, and, therefore, the testicle should be carefully looked for in the scrotum, when a hydrocele of this character is noted, and the absence of the gland should lead to a recognition of the disorder. I may mention that hydrocele of the sac of an acquired hernia is generally chronic and the hernia is irreducible, while hydrocele of the sac in the “congenital form * of hernia is mostly acute, and when, from some known cause, a congenital inguinal hernia Sud- denly with pain and heat enlarges, and the symptoms of strangulation are absent, effusion into the sac takes place, and we have “hydrops Sacci hermiosi acutis.” Simultaneous Internal and External Hernia.-Probably this is the rarest condition that can exist to obscure diagnosis. I am not aware of any other case of its kind on record. It is unique in the literature of hernia, therefore I give the record in full. The patient was employed as a clerk in a trunk manufactory, and in endeavoring to lift a portmanteau and place it upon a shelf higher than his head, he suddenly felt something in the inguinal region “give way,” which was immediately followed by severe pain, sense of faintness, nausea, and finally vomiting, and apparent collapse. Upon examining the parts I found the left side of the scrotum enormously distended, and rapidly turning that peculiar purplish-green hue which is characteristic of gan- grene; the patient was vomiting considerably from time to time, the sub- stance ejected being ingesta, but neither looking nor smelling like fecal matter; but the general condition of the patient pointed to strangulated hernia. After a little manipulation I found it easy to return the gut into the abdominal cavity, which had already been done once or twice by Dr. E. T. Richardson. No sooner had the intestine been replaced, than, upon any exertion of the body, coughing, or retching, it would again protrude, to be as readily returned. Upon invaginating the scrotum with my finger, what was my astonishment to feel the gut readily pass into the abdomen, the two rings being open, and the canal shortened, as we usually find from the dragging of an old rupture upon the parts. After OPERATION FOR STRANGULATED INGUINAL HIERNLA. 883 the return of the bowel, the scrotum did not diminish much in size, nor color, but the vomiting ceased, and the patient appeared, under the use of mild and not often repeated stimulants, to revive from his lethargy. Certainly the case was not one of ordinary strangulated hernia; indeed, there was exactly the opposite condition, both rings being patulous and a canal more open than usual. I concluded to administer veratrum, and watch results. The next night, a telegram summoned me, and, every symptom appearing so aggravated, I determined to cut down upon the canal and into the scrotum, and see if I could find any cause for the symptoms, for I thought, as I had seen before in one or two instances, a small knuckle of gut might be turned up under Gimbernat's ligament, or there might be a twist in the intestine within the canal, which, if the bowel were pushed into the abdomen, the convolution not being undone, the stricture would remain. After some delay in getting the proper lights —it was 1 o'clock at night—and arranging them at a safe distance from the ether, I cut down upon the canal, making an incision from the external (superior) pillar of the lower ring to the fundus of the scrotum. At the second incision, which penetrated the scrotal sac, there followed a large gush of bloody serum, which for the moment startled me, fearing that I had gone into the bowel. Continuing the dissection, I came upon the intestine in the canal, which, save with a slight ecchymosis, appeared per- fectly healthy, and was placed into the abdominal cavity, but, as I have noted, was with difficulty retained there. Still continuing the dissection higher, and exploring the cavity of the abdomen not only in search of obstruction but for the testicle, I could find neither, and therefore closed the wound as usual, and dressed it with calendula. The next day the patient died with the usual symptoms of obstruction of the bowels, including fecal vomiting. The case was a mystery to me, and therefore a post-mortem was demanded, and obtained. I will pass over the usual rigor mortis, and say that all the intestines appeared healthy on their superficial surface, and the left testicle, rather larger than normal, was in its proper place. The secret lay in the following: The right testicle, instead of passing as usual through the rings and entering the scrotum, covered by its proper invest- ment, had taken a directly opposite course; instead of going downward and forward, it had passed downward and backward, taking with it an acquired pouch of peritoneum (in the same manner as the acquired hernia adapts to itself its peritoneal covering), it had gone behind the border of the iliacus internus, and there we found it, with rudimentary cord extending over the roof of the bladder to the vesicula, and crammed in between it and its cov- ering was a small knuckle of intestine, perfectly gangrenous, accounting for every symptom save the bloody serum within the tunica vaginalis, which in all probability was hydrocelic. Operation §r Strangulated Inguinal Hernia.-The patient having been brought thoroughly under anaesthetic influence and the parts shaven, an incision should be made from the external ring to the inferior extremity of the swelling. This cut should be made by the operator pinching up a fold of skin, lifting it from the intestine, and with a small sharp- pointed curved bistoury, cutting from within outward. The director is introduced into the wound, and the incision completed with a probe- pointed bistoury. By this the superficial epigastric will, in the majority of instances, be cut and must be secured. Each successive layer of tissue must be raised with the forceps, nicked with the knife, and the director used constantly. There may be six coverings, or there may be a dozen. No matter how many, the same caution must be used, until the Sac is reached. * This is known by its slightly transparent hue; its vessels, which may 884 A SYSTEM OF SURGERY. be seen ramifying on its surface, which is of a bluish color. The finger should be introduced into the wound, and the endeavor made to discover if the stricture be seated outside the sac; if this can be ascertained and the surgeon assure himself that the intestine is in good condition, the hernia knife, or a curved probe-pointed bistoury, wrapped with cotton or silk to within a quarter of an inch of the point, should be introduced flatwise, on the finger, insinuated beneath the stricture, and turned with its edge º the stricture, and with a sawing motion upward, the point of strangulation divided. If there be the slightest doubt as to the con- dition of the intestine, the sac must be incised after the manner of other fasciae, and the gut exposed. Upon the division of the peritoneal cover- ing, there will generally be a few drops of serum exude. The finger is again introduced as a guide for the knife and the stricture divided as above (see Fig. 549). If the omentum is either gangrenous or ulcerated, parts of it may be removed. If the case be one of entero-epiplocele, the intestine should be replaced first, the omentum afterward. If the surgeon prefers the more modern operation, directions for which are found on a preceding page, he may ligate the sac with catgut, cut off the ligated º and secure the stump in the rings, drawing the pillars together with silver sutures. I have often found that adhesions have taken place. These may be broken up by the finger, and the parts restored to their natural position. The wound must be closed by silver sutures, and the º given nux vom. 3d trit. every half hour, for a considerable length of time. By Mr. Ball, of Dublin, it is held that the best method, after isolating the cord from the sac, is to grasp the latter high up with the clamp, and make torsion until a decided sense of resistance is experienced. The neck of the sac is firmly tied with an antiseptic ligature, and a salmon-gut is passed through the pillars of the ring and the twisted sac to prevent it from untwisting. F. remainder of the operation is completed in the usual manner. In reaching and separating the sac from the cord, the coverings common to both are successively divided, so that nothing is twisted except the thickened peritoneum and subperitoneal tissue. Dr. Ball considers failure more common than generally supposed. In 34 cases collected by OVARIAN HERNIA. 885 Dr. Guenod, from the surgical hospital at Bâle, relapses occurred in 12, and as is shown by the Liverpool statistics, and by those collected by Leisrink, the operation fails in about one case in five. More extended experience and statistics are needed to definitely determine the exact utility of the Operation. Dr. G. A. Hall,” in comparing results of cutting operations for stran- gulated and non-strangulated inguinal herniae, gives interesting figures: Non-strangulated hernia 213 cases; cured, 186; result not reported, 11; à cured, 13; died, 2; strangulated inguinal hernia 29; cured, 18; ied, 11. Congenital Inguinal Hernia in the Male.—This variety generally occurs early in life, but the student must remember that the “congenital form.” may appear in the adult, and is often occasioned by late descent of the testicle and imperfect closure of the inguinal rings. This hernia should be carefully returned at as early a day as possible, and nux vomica given for a time, a well-adjusted pad being worn. Sometimes, in spite of the best- directed efforts at reduction, strangulation occurs. In these cases the inter- nal administration of medicine will often cure. (The student is referred to the early parts of this chapter.) Sometimes, by raising the child by the feet, or placing it upon an inclined plane, the facilities for reduction are much increased. Congenital Inguinal Hernia in Women.—The round ligament passes out from the external ring, and is accompanied by a process of the peritoneum, which in most cases is obliterated in adult life. Sometimes it remains open, and forms the canal through which a hernia may protrude. Ovarian Hernia is a peculiar variety of inguinal hernia, which demands attention. As a testicle may be prevented from descending and fill the abdominal ring, so occasionally an ovary may form a hernia which it is difficult to recognize. When such does occur, it is generally of the con- genital inguinal variety, although in some instances it may be acquired. In the year 1878 Peuch constructed a table of 78 cases of the affection; of these, 12 were of doubtful origin, 47 congenital, and 19 acquired. - In most cases of ovarian hernia, the ovary alone is not found in the sac, there being either a coil of intestine, the Fallopian tube, the uterus, the vagina, and sometimes portions of the Omentum associated with it. Eng- lisch gives a table of 38 cases, in which the ovary alone was found in the sac, and of these 27 were inguinal, 9 femoral, 1 ischiadic, and 1 obturator. In the majority of the cases the affection was congenital. An ovarian hernia may produce strangulation of the intestine, because as the ovary drops down it leaves a cul-de-sac, into which a loop of intestine may pass, and the edge of the pelvis and the side of the uterus form strong bands, which effectually prevent the passage of fecal matter, but these herniae are more frequently incarcerated than strangulated. It is stated by Hegar and Kaltenbach that when ovarian hernia is con- genital, the ovary is immovable, while in the acquired form the ovary is mobile and alone occupies the sac. When such ruptures require operation, an incision should be made into the sac and the ovary removed; before it is cut off, the pedicle should be not only securely tied, to prevent ha-morrhage, but the stump should be either stitched or secured by steel pins to the rings to prevent retraction into the abdominal cavity, which would have a tendency to cause slipping of the ligature, and if bleeding should occur, the stump would be accessible to the operator for the application of a ligature. Professor Andrea Ceccherelli relates the case of a woman thirty-eight * Medical Advance, August, 1886, p. 146. 886 A SYSTEM OF SURGERY. years of age, who entered the hospital on account of a swelling which had appeared the evening before in the right inguinal region simultaneously with the menses. Examination showed a small tumor, a little larger than a walnut, movable and but slightly painful on pressure. Herniotomy being performed, the body was found to be an ovary. The organ was re- turned with difficulty, but the patient made a good recovery and was dis- charged at the expiration of a fortnight. Boinet has collected the statistics of nine cases in which ablation of the ovary was practiced, with the cure of eight. Dr. Ceccherelli advises oëphorectomy in those cases of ovarian hernia in which there are plain indications of disease in the organ at the time of the operation. Such evidence of pathological change is present, he says, only in exceptional cases, so that an endeavor should be made to return the ovary intact into the abdominal cavity.* Crural or Femoral Hernia.-Anatomy-On the inner side of the thigh, be- tween the Sartorius and pectineus muscles, there is a slight depression, known as the fossa ovalis or saphenous opening; this depression has no well-defined inner border, but externally is bounded by the well-developed edge of the fascia covering the sartorius muscle. The floor of this fossa is formed by the pectineal fascia which invests the pectineal muscle. This aponeurosis, at the lower margin of the opening, becomes thicker, turns inward, and is joined by the Sartorial fascia, forming a lunated edge; over this, as is well known, the vena Saphena major turns and joins the great femoral vein. Superiorly the sartorial fascia is connected with Poupart's ligament, or with that reflection of it known as Gimbernat's ; thus forming a lunated border, which receives the name of Hey's ligament. The femoral vessels coming from the abdominal cavity, emerge beneath Poupart's ligament, and consequently under Hey’s ligament, being covered by their sheath, which is formed by the fascia of the iliacus internus pos- teriorly and the fascia transversalis anteriorly. The sheath is loose, and by some writers is called the crural canal, and that part of the canal found at the junction of the thigh with the abdomen receives the name of the femoral ring. This so-called ring is filled with loose tissue, which is called the septum crurale. & The anatomy of crural hernia is plain, but is oftentimes so clumsily described in the books, that students are at a loss to understand the precise relations of the parts. As the femoral vessels come from the cavity of the abdomen to pass out upon the thigh, beneath Poupart's ligament, a space is left between them and the pelvis, slightly guarded by loose tissue, the septum crurale, which, when the intestine protrudes, is necessarily pressed onward before it. Further, an opening in the upper part of the thigh is formed where the superficial join the deeper-seated veins, and this also is filled with a loose tissue—the cribriform fascia. It will be apparent that the bowel, coming from the cavity of the abdomen along the course of the femoral vessels, will protrude on the thigh at the opening where the femoral vein is joined by the Saphena major, as this point is but slightly protected by fascia. Proceeding from within outwards, the following would be the order of the coverings of hernia in this region: First, the peritoneum; secondly, the sep- tum crurale, which covers the ring through which the intestine passes. The gut then follows the crural canal, or, in other words, the sheath of the femoral vessels, until it reaches the fossa ovalis, where it protrudes, pushing before it the sheath of the femoral vessels, which constitutes the third covering. * L'Union Médicale, October 20th, 1885. DIAGNOSIS OF FEMORAL, HERNIA. 887 This coat carries with it the fascia which lies in the fossa ovalis, hence we have as the fourth covering the cribriform fascia, which in turn forces outward the fifth coating or superficial fascia, and with it comes lastly the integument or sixth investment. There is one point in the anatomy of crural hernia which deserves attention, and that is the relations of the gut with the femoral vein, the epigastric artery, the spermatic cord, and occasionally with the obturator artery. In femoral hernia the parts stand in the following order: On the out- side the femoral vein, on the inside the spermatic cord, in front and near the seat of stricture the epigastric, and in some instances the obturator artery, the latter in about one case in four, being given off from the epi- gastric artery. In operating, the most important anatomical points are the relations of the epigastric artery with the internal and external rings as well as with the crural canal. The Epigastric and Obturator Artery and their relations with the Crural Canal.—According to M. Cloquet, after dissection of 250 subjects, the fol- lowing results regarding the relations of these arteries have been determined: Obturator Artery arising from Males. Females. 1st. Hypogastric on both sides in 160 subjects, . º e ſº . 87 73 2d. Epigastric on both sides in 56 subjects, . & iº § º . 21 35 3d. Hypogastric on one side from the epigastric on the other side in 28 subjects, . º te tº {e g º cº e tº . 15 13 4th. The femoral in 6 subjects, . te © i.e. * > * tº ... 2 4 Total, 250 subjects, . . e c e g e . 125 125 The following is the relative proportion in which the obturator has or has not a relation with the hermial sac, placing on one side the cases in which the obturator arises from the epigastric or directly from the femoral, and on the other, those arising from the hypogastric : Obturator Artery arising from Males. Females. The hypogastric in 348 subjects, e iº ſe o ſº * . 191 157 The epigastric or femoral in 152 subjects, tº ſº ſº ę . 58 94 Total, 500 subjects, . e ge tº º º . 249 251 From this calculation we find, First, that the cases in which the obtu- rator takes it origin from the hypogastric are most numerous; that their proportion when compared with those in which it arises from epigastric or femoral, is nearly as three to one ; secondly, that the obturator appears to º more frequently from the hypogastric in the male than in the female. Diagnosis of Femoral Hernia.-A femoral hernia may sometimes be mis- taken for an inguinal; the symptoms differential are as follows: In the former the finger can be introduced into the inguinal canal. Poupart's ligament can be made out even though the gut has ridden over it. An in- guinal hernia lies inside of the spine of the pubis. Sometimes a varia of the femoral vein, as it passes the Saphenous opening, simulates femoral hernia. In such cases a careful examination is necessary to insure a correct diag- IOOSIS. Place the patient on the back and reduce the protrusion. On assuming 888 A SYSTEM OF SURGERY. the erect position, if varix is present, the swelling immediately reappears but if it be hernia, pressure will prevent its recurrence. P30as abscess may, in rare instances, be mistaken for femoral hernia. The many presenting symptoms of spinal disease, the slowness and variability of progress, the fluctuation, and the part at which the abscess points, which, in the majority of cases, is outside of that at which hernia protrudes, serve to form the distinctions necessary. An enlarged gland has been mistaken for hernia by distinguished Sur- geons. Hamilton records one in which several days elapsed before the diagnosis was made, the delay causing the death of the patient. Sir Astley Cooper mentions two fatal cases. The absence of cough impulse, the solidity of the tumor, the history, and the constitution of the patient, must be our chief guides. Operation for Femoral Hernia.-An incision should be made in the long diameter of the swelling. The parts are raised upon the director as before noted when treating of inguinal hernia. The seat of stricture is often, at Hey’s ligament, and sometimes at Gimbernat's. The finger-nail or Little's director is passed beneath the stricture; the hernia knife, or the wrapped probe-pointed bistoury is insinuated underneath the seat of stricture, and the cutting edge turned upward, then with a slight sawing motion the stric- ture is divided. The gut is carefully examined, and if there be any adhe- sions they should be broken up, and the intestine returned. For further information refer to the section on Kelotomy. h The same after-treatment is necessary as that recommended in inguinal €TIlla. - Umbilical Hernia.-In this variety the intestine makes its way through the umbilical ring in the foetus, or through a separation of the fibres of the linea alba; in young persons we find it as congenital, or it may be found in adults, especially in fat women. - The coverings of this form of hernia are very thin, and when the protru- sion is large it may be of various shapes, pyriform, sessile, or pedunculated, and contain omentum, portions of the large and small intestine, and indeed the stomach. Treatment.—In infants I have cured many of these with a well-adjusted pad, in the centre of which a smaller or larger ball of ivory protruded. Sometimes a piece of sheet lead, such as is found in tea-boxes, folded several times, and held in situ with adhesive plaster and a broad band of stout mus- lin, answers the purpose. • Dr. Bowers, of New York, devised a pad for the cure of congenital um- bilical hernia, which is so easily constructed and is productive of such good results, that he used no other for a number of years. The following are the directions for its construction : * Take a piece of sheet lead, thick enough to retain its shape under mode- rate pressure, about one and a half inches square, draw lines diagonally across from corner to corner, and from the centre describe a circle within the square. Then raise a little knob in the centre, and near each corner where the circle cuts the diagonal lines, by placing these points directly over a suitable hole in a board, and forcing the lead down by a blow on a blunt rounded punch, taking care not to break the lead. Round the cor- ners, straighten the square so that it will lie level, and it is ready for use. The central knob may be a little the most prominent, and is to be placed directly on the umbilicus, and secured by a compress and bandage. The superiority of this pad consists in its permanently retaining its place with- out slipping. - Dr. Wilcox has devised an excellent truss for umbilical hernia, which is seen in the figures (Figs. 550, 551). UMIBILICAL HERNIA. 889 A consists of two circular plates of steel connected by four posts. Be- tween the two plates is a stout steel wire running around through the posts. The lower plate, which is the one nearest the skin, is perforated, and is covered with perforated chamois skin. Upon the upper plate are four steel spring catches. C is the pad, made of woven wire and also covered with perforated chamois skin. The screw of C works in the centre piece of B and has a loose attachment to the pad, so that when in position, and more pressure is desired, it can be screwed down by the key D without rubbing the skin of the patient. The four arms of B are made to slip under the four catches in the upper plate A. By means of the screw, the centre pad C can be made to project FIG. 550. FIG. 551. ~~2: $Sº.. * | & * t * - f * A A's % A \º. º: & Nº. * || % º % 2 $$, ſ ºft 3% º/. º,' .. º º from one-half to one inch below the lower plate of A. The whole apparatus is fastened to the body by strips of adhesive plaster which are attached to the wire between the upper and lower plates of A, and which radiate over the abdomen as shown in Fig. 551. - The objects attained by the use of this apparatus are: 1st, the pain in the back is obviated; 2d, by use of the perforated lower plate of A and the centre pad C, the air has constant access to the skin, preventing its chafing; 3d, by screwing down the centre pad C any amount of pressure desired can be made; and, 4th, when the patient lies down and the bowel is not so likely to come out, the whole centre portion can be instantly removed by giving a little twist sidewise on the arms of B, and the skin has a rest from pressure as long as desired. For the radical cure of this hernia several operations have been from time to time proposed. - Mr. Barwell reported in the London Lancet several cases in which he per- formed a radical cure, by pressing the gut back into its position, inserting needles into the sac and twisting either wire or silk over them. In the only cutting operation which I have been called upon to perform for strangulated umbilical hernia, in a young infant, the patient died. For the adult, an incision should be made over the bowel, the layers of tissue be raised upon a director, and the stricture sought and liberated by the smallest possible nick. The after-treatment is the same as in other operations for hernia. It is not a matter of dispute that if the intestine be gangrenous, several inches, and indeed even feet thereof, may be cut away and the patient recover, as in the famous case of my friend, the late 890 A SYSTEM OF SURGERY. . Beebe—vide Resection of the Gangrenous Gut in the former part of this chapter. The radical operation was performed as follows: The hernia being reduced, the sac was caught by ha-mostatic forceps, ligated, cut off, and the stump seared with Paquelin's cautery. Lister's dressing was applied. The child was twenty hours old. The ligatures were removed on the eighth day, and the cure was complete.* Obturator Hernia.-This variety is rare. In it the gut descends through the obturator canal, the thyroid or obturator foramen. It occurs more frequently in females than in males, and the protrusion is generally small. The patients who suffer from it complain of pain along the course of the obturator nerve, and from bowel affections in a greater or lesser degree; sometimes there is cramp in the muscles of the affected limb. In many cases there are complications which render the diagnosis difficult. Treatment.—Taxis may sometimes be sufficient, together with the ad- ministration of medicine, to relieve this affection; should it not, an opera- tion will be necessary. The incision should be made parallel with the femoral artery and outside the femoral vein, beginning at the centre of Poupart's ligament and extending about three inches and a half down- ward. The fasciae are raised on the director and divided according to directions already given. After this the fibres of the pectineus should be divided in the line of the first incision, which will generally allow the tumor to be felt. If it cannot yet be recognized, the fibres of the obturator muscle must be separated. This will expose the protrusion. The stricture must be felt for and divided in the same manner as directed for other strangulations. Ischiatic Hernia.-In an ischiatic hernia, the intestine forms a tumor be- neath the large gluteal muscle. The neck of the sac is generally below the pyriformis. The tumor is frequently reducible. The symptoms are those of other herniae. The operation consists of cutting down upon the Sac and enlarging its mouth. . - Pudendal Hernia.-By the term pudendal hernia is understood the escape of the gut into the labium pudendi. This may occur at an early age. It forms a small and somewhat elastic tumor at the side of the vagina, the neck of the sac lying between the vagina on the inside and the ramus of the ischium on the outside. It may be diagnosed from inguinal hernia by its location by the side of the ramus of the ischium, by its parallelism to the axis of the vagina, and by the ability to feel the inguinal canal. Treatment.—An appropriate bandage and pad. These herniae do not become strangulated. & Diaphragmatic Hernia.—This variety of internal hernia is difficult to diag- nose. By the best authorities it is, like other hernial protrusions, divided into congenital and acquired. The left side of the diaphragm is more fre- quently affected than the right, in the proportion of five to one. This can readily be accounted for, not, as has been laid down by some authorities, on account of the greater weakness of the left side of the diaphragm, but because the right crus is firmer than the left, and because the larger openings for the aorta and oesophagus are found more to the left side, and because the large, firm, smooth convex surface of the liver lies close against the right side of the diaphragm. As far as I can learn, excepting some traumatic cases, there has not been one reported in which the contents of the abdomen have passed through the opening for the inferior cava or the aorta, the general site being through the fleshy portions of the muscle more than through the tendinous; indeed, the weakest points are, first, the tri- * Medical Record, 1881, p. 376. DIAPHRAGMATIC HERNIA. 891 angular space immediately behind the sternum (sometimes called Larrey's space), the oesophageal opening and the larger interstices between the mus- cular bundles on the anterior border of the diaphragm. When the case is traumatic any portion of the muscle may be ripped up, and to such an ex- tent that almost the entire contents of the abdomen, save bladder and kid- neys, pass into the thorax. . In the non-traumatic variety the stomach and small intestines frequently form the hernial protrusion. In the former the edges of the opening are torn and ragged, and in the latter they are smooth and callous; of course the traumatic cases are acute, and there may be chronic diaphragmatic hernia. The symptoms presented are those of compression of the lung, cyanosis, great dyspnoea, and agonizing pain, which generally, in the acute cases, causes death in a few hours; besides this a notable inequality of expansion is found in the chest walls. In the congenital variety these symptoms, with nausea, vomiting, and a small pulse, may continue for years, may abate and return when any disorder of the intestinal tract is noticed. In a case reported by Drs. Galassi and Teneri,” in which a woman died with all the symptoms of strangulation of the bowels, and upon whom lapar- otomy was performed without finding the cause of the obstruction, a post- mortem revealed the transverse colon in the left pleural cavity, the gut had become twisted, thus causing the obstruction. The hernia was not sus- pected during life, and was not revealed by the operation. The case is instructive in several particulars, first, that a diaphragmatic hernia may exist without discovery, even after abdominal and thoracic examination, and that laparotomy sometimes fails to detect the true nature. It is diffi- cult to understand, if the operation was conducted with ordinary care, how the surgeon could avoid missing so large a mass as the transverse colon from the abdominal cavity. Dr. L. Harrist reports an instructive case of diaphragmatic hernia, in which the left pleural cavity contained, besides the left lung, the stomach, almost all the small intestines, the colon, and half the pancreas. The lung was compressed and was eight inches in length, one to two inches in thick- ness, and three inches in breadth, and was crowded into the anterior and upper portion of the chest. The opening in the diaphragm was large enough to admit the closed fist and all the usual vessels. * American Journal of the Medical Sciences, January, 1886, p. 284. f Medical Record, October 11th, 1884, p. 401. 892 A SYSTEM OF SURGERY, CHAPTER XLIV. DISEASES OF THE RECTUM AND ANU.S. ExAMINATION.—IMPERFORATE ANUs AND RECTUM–FoREIGN BoDIES IN THE RECTUM- PROLAPSUs ANI–HAEMORRHOLDs—FISTULA IN ANo—-TUMoRS IN THE RECTUM- Sth ICTURE OF THE RECTUM-LINEAR RECTOTOMY-ULCERS AND FISSURES OF THE ANUS—ExCISION OF THE RECTUM–CARCINOMA OF THE RECTUM. ExAMINATIONs of the rectum were, until recent improvements both in specula and light, unsatisfactory. The old-fashioned anal speculum of glass, with the fenestrated side (Fig. 552) is painful in rotation and affords FIG. 552. G, 77&MA/V/V & CD, Ordinary Anal Speculum. imperfect views of the parts, even when assisted by Bodenhamer's Recto- Colonic Endoscope (Fig. 553). I have tried many specula and dilators, and give the preference to one or two. That of Dr. E. M. Pratt, of Chicago, is superior in many ways Fig. 553. t \ WºłH=# Wºº- tº ||||||}}}}}}}/ É (Fig. 554). It is easier to introduce on account of its bulbous extremities, the latter keeping out of the way the folds of the rectum; it is self-retaining, and by partial closure can be revolved without pain. I have used this instrument and can recommend it. Besides the speculum, Dr. Pratt has DISEASES OF THE RECTUM AND ANUS, 893 introduced a tenaculum (Fig. 555), a blunt rectal hook (Fig. 556), and a pair of rectal scissors (Fig. 557). The tenaculum is needed for seizing papillae or other morbid growths, pendulous mucous membrane, etc. The small blunt hook is indispensable in discovering and raising the rectal pockets. The scissors are constructed so as to remove the hand of the operator from the field of vision. FIG. 554. Pratt's Rectal Speculum. Slight study of these illustrations will explain their uses and advantages. I have used with satisfaction a rectal speculum made after the fashion of a FIG. 555. C- Pratt's Tenaculum. Sims's, often indeed having employed a small size of the latter with excellent results. Of course if the rectangular instruments are used, the patient must be placed in Sims's or the knee-elbow posture. FIG. 556. - = ~3-...---sº-3-3 Hº: º º:::::::::::: sº º- ºr -º-º: SHARP & SMITH, F-...º.º. --> --> CHICAGO Pratt's Blunt Hook. The lithotomy position is the best—and the instrument, carefully oiled, should be insinuated into the rectum, it having been previously thoroughly Pratt's Scissors. emptied, either by a full dose of castor oil or an enema. I have employed the speculum of O'Neil, Fig. 558. - 894 A SYSTEM OF SURGERY. A good deal has been written concerning the examination of the rec- tum with the entire hand, as recommended by Simon. I have tried it, Sometimes having difficulty in passing my hand into the bowel, and Sometimes not encountering much obstruction. The sphincter, however, always closes around the wrist, and the fingers are cramped in their move- ments. The method is useful in recognizing tumors high up, and in making pressure upon the iliacs. The surgeon must remember that hand- rectal examination is likely to be unsatisfactory for two reasons: 1st. The sense of sight cannot be used, the surgeon only being guided by a restricted Sense of touch ; and 2d. The process is by no means free from danger. FIG, 558. O'Neil's Rectum Speculum. Danbridge and Conner * relate that they had examined the pelvis of a man by Simon's method, for the purpose of confirming a diagnosis of psoas ab- scess. The surgeons were gentle and went no higher than the iliac, but the patient was seized with peritonitis and died in a short time. There are other cases of this kind upon record. The rectum is capable of great distension, and its mucous membrane, like other portions of the intestinal tract, only to a greater degree, is supplied with folds or rugae which are visible with a good speculum. Often, indeed, too plainly, for they are liable to drop into the fenestra of the instrument, and not only impede the view, but prevent the specu- lum from being rotated without pain. The lower fourth, the fibrous con- nective tissue holding the mucous coat to the submuscular, is also loose, which, of course, when the canal is empty, increases the number of mucous folds. If we examine the locality below the internal sphincter (of which and sphincter-ani-tertius of Hyrtl more will be said hereafter) a number of semilunar valves, some authors say five or six, and others more—with their concavities looking toward the colon, can be found ; these “form an irregular festooned line which surrounds the canal; their folds, however, are small, and have no tendency to obstruct the passage of fecal mat- ters.”f Of these Cloquet says: “The inner surface of the rectum is com- monly smooth at its upper half, but in the lower there are observed some parallel longitudinal wrinkles which are thicker near the anus and are variable in length. These wrinkles, whose number varies from four to ten or twelve, and which are called the columns of the rectum, are formed by the mucous membrane and the layer of the subjacent cellular tissue. Between these columns there are almost always to be found membranous semi-lunar folds, more or less numerous, oblique or transverse, of which the floating-edge is directed from * Medical Record, November 16th, 1878, No. 419. f Textbook of Human Physiology, by Austin Flint, Jr., M.D., New York, 1882, p. 291. IMPERFORATE ANUS AND RECTUM. 895 below upward toward the cavity of the intestine. These folds form a kind of lacunae of which the bottom is narrow and directed downward.” Again, Kelsey says: * “Between the lower ends of the columnae recti, little arches are stretched from one to the other forming pouches of skin and mucous membrane. These are more developed in old people and may retain small pieces of hardened faeces or foreign bodies in their cavities and thus give rise to suppuration and abscess.” There is a divided opinion regarding the physiological action of these valves, and the part they play in certain functions ascribed to the rectum ; indeed by some the identity of these pouches with a portion of Hyrtl’s sphincter is claimed. When the nervous relations of the lower portion of the rectum including the sphincters are more fully understood, it will be seen that it is not im- possible that severe reflex nervous disturbances may result from irritation at the lower end of the rectum. To how great an extent these may extend we are unable to determine. Imperforate Anus and Rectum.–There are several varieties of imperforate rectum, all of which are more or less serious in character, and which often terminate fatally, after the best-known means have been resorted to for preserving life. There are hundreds of children who die yearly from the malformation in question; how many of whom might have been saved by appropriate treatment, it is impossible to say. - It is a question whether (if life may only be saved by the formation of an artificial anus) it is not better to allow the sufferer to die rather than drag on a miserable existence, with such a loathsome and disgusting afflic- tion, “an artificial anus.” There are several classifications of this malformation : Mr. Holmes di- vides the cases of imperforate rectum into two classes. The first embraces those in which no anus exists (imperforate anus properly so called); the second, those in which there exists an anal opening, which terminates in a short cul-de-sac. These are again subdivided— The former class (imperforate anus) into : 1. Membranous obstruction of the anus. 2. Complete or partial absence of the rectum. 3. Communica- tion of the rectum with the vagina in the female. 4. Communication with the urinary tract in the male. 5. External communication or fistula. The latter (imperforate rectum) may be subdivided: 1. Membranous obstruction. 2. Deficiency of the upper portion of the rectum. Mr. Curling, who has given this subject a great deal of attention, makes a more simple classification thus: Those cases in which there is complete closure of the anus, the rectum being either in part or entirely wanting. Second, those in which there is nothing but a cul-de-sac, surrounding the anal opening; in the third va- - riety, there is no anus, but the rectum terminates in the bladder, vagina, or urethra. An imperforate anus, properly so called, is much sooner recognized than an imperforate rectum, for the reason that the latter is not so easily discovered, and the patient continues to suffer, the causes of indisposi- tion not being rightly understood, and indeed, death may ensue with- out either physician or attendants being aware of the true nature of the malady. It is from a knowledge of these facts that every child should be examined on the second day after birth, if there has been no movement of the bowels. In such an examination the practitioner should not be satisfied * Diseases of the Rectum, p. 8. 896 A SYSTEM OF SURGERY. with the fact that the anus is open, but should institute an exploration with his finger to ascertain as to the viability of the rectum. In many of the cases of imperforate rectum, the intestines terminate in a blind pouch, which may either be high up or low down, or connected with the anal cul-de-sac itself. On this point, Mr. Bryant says: “It seems possible from Curling's and MM. Goyrand and Friedberg’s observations, that such cases are caused by an obliteration of the bowel, which was originally well formed, from some intra-uterine inflammatory action. Some instances being recorded, when the muscular tissue of the intestine was clearly traced.” When the anus is closed by membrane, the constipation, and the “bulging” at the anus, show the nature of the malformation; a simple in- cision generally suffices. If there be no bulging, and the anus is firmly closed, then it is proper to make an exploratory incision, beginning at a point where the centre of the anus should be, and carrying the knife backward toward the sacrum. Forward incisions endanger the bladder, vagina, and other important organs. ... In cases of imperforate rectum, the following method may be successful, # the gut can be reached; the latter is the chief difficulty in the opera- 1OIl. On the 3d of March, I was called by Dr. Richardson, of Williamsburgh, to See a child, thirty-six hours old, who had an imperforate rectum. found an infant, healthy and plump-looking, with enormously distended abdomen, the convolutions of the intestines being distinctly seen. The child had passed urine once. A peculiar feature was that the parents had had another child born with a similar malformation, who had been operated upon, and died. They had, two weeks previously, lost two ºn with measles, and were in an excited and despairing frame of IIll]]Cl, Upon inserting my finger into the anus, I felt a cul-de-sac, which fitted Over the end of the finger like a thimble. This I tore away, and pro- ceeded to search for the gut. It was entirely beyond my reach, and the finger moved about in vacancy. I divided the sphincter toward the Sacrum for half an inch ; and again introducing my finger, I could just touch the intestine, but could not catch it sufficiently to draw it down. By placing a small hook flat-wise on the forefinger of my right hand, I pushed it through the anal orifice, and by using the left hand as a manipulator, and the right as a guide, succeeded in hooking the intestine and drawing it down. The amount of traction required to do this was Surprising. So Soon as I had drawn the gut outside the anus, I passed a needle, threaded with a double silk ligature, through it, and let it retreat into the cavity of the abdomen. With a few strokes of the scalpel, the margins of the anus were scarified. By making traction on the ligature, the gut was brought into sight, and held outside the anal aperture by Dr. Richardson until I had stitched it to the margins of the anus. So soon as this was done, I cut off with a scissors the blind end of the intestine. The amount of faeces that were discharged seemed incredible; several times we were obliged to stop proceedings, on account of faeces issuing from the punctures made by the hook and the needles. The operation was successful. On the third day the anus had to be dilated with the finger, and since then there has been no further trouble. Foreign Bodies in the Rectum.—It is astonishing how many foreign sub- stances, large and small, have been introduced within the rectum; bowls, cups, bottles, pots, pencils, etc., have been removed from the lower bowel. In some cases, the foreign body may come from within, having been PROLAPSUS ANI. 897 accidentally swallowed and thus passed into the alimentary canal. Pins, fish bones, hair, bristles, etc., have been found within anal abscesses, and have been impacted in the rectum. The first thing to be done is to care- fully explore the rectum with the finger to ascertain not only the exact location of the foreign body, but, if possible, its size and shape. The next step is to place the patient thoroughly under anaesthetic influence, in order that the sphincters may be relaxed; the third to inject at least a pint of warm Olive oil into the bowel; and then to use such forceps and scoops as may be required. Fig. 559 shows forceps for this purpose. - FIG. 559. = -------> - + Š-2 6, 74727.3.20. O Forceps for Extracting bodies from the Rectum. The best instrument, however, is a small pair of placenta forceps, those of Loomis being preferable; it may be necessary, and in some cases is both practical and proper, to gradually introduce the hand into the rectum to remove what has become impacted therein. Prolapsus Ani.—A protrusion of a portion of the rectum, or of its internal coat, from the anus, is denominated a prolapsus, or procidentia ami. In some cases a considerable portion of the rectum protrudes. The causes are such as tend to weaken the action of the muscles which support the intestine, and violent exertions of the rectum in consequence of certain irritations. The frequent use of cathartics, especially those which contain aloes, the presence of ascarides in the lower portion of the alimentary canal, habitual costiveness, and haemorrhoids, all occasionally produce prolapsus ani. Cases are on record in which the affection was en- gendered by the tenesmus attending dysentery. In some instances, the intestine remains a considerable length of time un- reduced without any ill effects, but more commonly it swells and inflames speedily. The protruded portion of the bowel is generally oblong in shape, of a bright-red color—especially in recent cases—and covered with mucus. In older cases, the color is purple, and it is difficult to ascertain where the skin is merged into the mucous membrane; sometimes ulceration takes place. Often, especially in old cases, the bladder suffers, and complete retention with violent pain results. The constitution suffers after the dis- ease has existed for a time; the patient is worn with the prolonged suffering, and suffers from severe dyspeptic symptoms. - Treatment.—When called to a person suffering from an ordinary prolapsed rectum, the surgeon should attempt reduction. This is accomplished by grasping the displaced gut, having first smeared the protruded part with fresh lard or simple cerate, and pressing upon it inwards and upwards. It will slowly, or in some instances quickly, return to its natural position. If a large portion has escaped, especially in women of advanced life, a smooth towel folded cone-like, and well greased, must be placed against the central and most dependent part, and pressure made firmly and steadily upwards; from time to time it may be necessary also to press inwards and upwards upon the circumference of the intestine. If the surgeon be not called until the protruded intestine is swollen and painful, an immediate attempt at reduction may prove abortive; therefore a dose of ignatia or nux 57 898 A SYSTEM OF SURGERY. vomica should be administered, and the patient placed in a hot bath. These medicines, º: a powerful influence over the intestinal canal, will probably relieve in a short time, when the bowel may be returned to its normal position. The vapor of hot water retards rather than facilitates reduction. This complaint is apt to recur; to Fig. 560. prevent which the patient should be strictly prohibited overloading the stomach, and the diet should consist of the plainest aliment. Dr. Physick succeeded in completely curing some cases of prolapsus ani, by confining his patients exclusively to a diet of rye mush and sugar. There have been many bandages and con- trivances invented to prevent the recurrence Anal Truss. of prolapsus ani; among the best is that seen in Fig. 560; but they generally failin accom- plishing the desired end, which is more certainly attained by the adminis- tration of appropriate medicines and rigid dietetic observances. The principal medicaments are, ign, nux wom., merc., sulph., or ars, calc., lyc., rut., sepia. For the particular symptoms indicating a choice of the above, the Materia Medica must be consulted. Another method, which is sometimes successful, especially in old cases, is to draw down the rectum with a vulsellum forceps, include the prolapsed portion in Smith's clamp (a cut of º is found FIG. 561. on page 901), and apply nitric acid, as recom- mended in the treatment of haemorrhoids. Haemorrhoids.-There is no disease which is more frequently met with by the surgeon than haemorrhoids. The pain they engender is excru- ciating, the constitutional symptoms various, and their cure often difficult. Piles consist, not only in an enlargement of the veins of the rectum, but of the arterial twigs, together with more or less infiltration into the surrounding structures. They are divided into internal (those within the sphincter), and external (those situated outside and around the anus). The former are of more frequent occurrence than the latter, and are more serious. They generally begin with frequent and often profuse haemorrhage from the rectum after stool, with pains in the back and loins, and more or less suffering during defecation. This condi- tion may exist for a time without much incon- venience. Then tenesmus becomes noticeable, and increases, until with every action of the bowels the piles protrude; there is much haemor- - rhage and great pain. The abnormal growths Old Internal Haemorrhoids. have to be returned, which increases the suffer- ings. Sometimes during exercise, lifting, or strain- ing, they pass beyond the sphincter, it contracts upon them, and agonizing pain results. Fig. 561 represents old internal haemorrhoids as they appear after defecation. There are generally three, four, or five distinct tumors; sometimes they are all sessile, sometimes pedunculated, and bleed easily. Often after excesses these tumors inflame, and fever and severe constitu- º-Ts --- º HAEMORREIOIDS. 899 tional symptoms result. External haemorrhoids at first merely consist of enlarged blood vessels; gradually the parts around become infiltrated, and the coats of the piles more or less thickened. When they are irritated, they rapidly inflame, enlarge, the vessels composing them burst, their con- tents become extravasated, and a series of changes ensue, which render the haemorrhoids quite hard tumors surrounding the anus. Sometimes there are many of these present, varying in size. Sometimes they are enormously enlarged. The largest I have seen was the size of a coffee-cup, and it with two others, each the size of a walnut, I removed successfully with the écraseur. Dyspeptic persons suffering from liver disease, gourmands, hard drinkers, and sedentary men, are all liable to hamorrhoids; in many in- stances there exists a haemorrhoidal diathesis, rendering the patient subject to these tumors upon the slightest indiscretion. Treatment.—In a disease so frequently encountered, the variety of medi- caments, salves, and embrocations, which have been recommended, is legion; and combined medical and surgical treatment rarely fails if persevered in to effect a cure. If a patient has internal piles, and they appear below the verge of the anus at stool, the hot sitz bath, immediately after the evacua- tion, will give relief, and enable the protruded parts to be returned. Man persons having for years suffered with haemorrhoids, and taking cold baths after an evacuation from the bowels, are relieved by the hot water. If there is haemorrhage, apis mel. and hamamelis should be given. H. Strisower* describes the case of a man which had resisted all treatment for profuse haem- orrhoidal bleeding during six months, who was promptly cured by a clyster containing five grains of ergotin in two ounces of glycerin. If severe pain and dyspeptic symptoms are present, nux vonn. and collinsonia canadensis are useful. To allay the severe itching and inconvenience resulting from an action of the bowels, a cerate of aesculus hippocastanum is useful, or the applications mentioned further on in this chapter. Hydrastis has proved efficient in haemorrhoids accompanied with fissures and cracks about the anus. Three or four drops of the tincture, in half a glassful of water, a tablespoonful taken every six hours, is of service. Pond's extract of hamamelis permanently cured an aggravated case of hamorrhoids; it was taken internally and applied externally. Dr. Von Holsbeck praises chelidonium as an excellent remedy for piles. This medicine is in vogue with the inhabitants on the shores of the Seine, and Dr. Von Holsbeck has used it extensively as decoction, tincture, or ex- tract, prepared from the sun-dried root, gathered after the blossoming period. Fumigations have been followed by amelioration of suffering which accom- panies the complaint. Without entering upon the symptomatology of the medicines which are applicable in haemorrhoidal disease, I may say that nux vomica, collinsonia can., and sulphur have produced in my hands the best results. I give a drop of the tincture of nux vomica in a sherryglassful of water an hour after each meal, and at bedtime, for a week. The next week, five-drop doses of collinsonia are given in the same manner. These remedies are continued for two months, with an occasional dose of sulph. 2° trit., five grains in the morning, together with the baths already noticed. If the haemorrhoids are attended with excessive colic, colocynth is an excellent medicine. Sulphur may follow the administration of nux; hepar and bella. symptoms may be present. Other medicines are a sculus, capsi- cum, calc. carb., china, merc., ipecac, and rhus tox. * London Medical Record, February 15th, 1877. 900 A SYSTEM OF SURGERY. A case is recorded where aesculus glabra effected a cure; Dr. R. Hughes reports several cases in which aesculus hip. was successful; Drs. C. H. Lee, George Logan, E. M. Hale, A. A. Bancroft, T. C. Duncan, Cuthbert and L. B. Wells, also verify the action of the medicine. Dr. Lippe men- tions cactus grand. ; Dr. King chelone glabra; Drs. Hale, Carroll, Coe, E. P. Fowler, Holcomb, Stewart, G. W. Barnes, and Jones recommend collinsonia canadensis; Dr. Burt speaks of dioscorea vil. ; Dr. Hale mentions erigeron can, ; the virtues of hamamelis virg. are attested by Hering, Okie, Preston, Burritt, Burt, and Hughes; Hale cites several cases; hydrastis is praised by Dr. Brown; Dr. Paine proves the homoeopathicity of phytolacca decan- dra ; and Talmage, of Brooklyn, records cases showing the virtues of podo- phyllum.* - *. Glycerin in two-drachm doses, given night and morning, is recommended by Dr. D. Young as an efficacious palliative in internal haemorrhoids.f Injection.—In most cases of internal haemorrhoids, when surgical treat- ment is necessary (which often relieves the patient, and allows the medi- cines a better opportunity for displaying their power), the best is the injec- tion into the haemorrhoid of a mixture composed of equal parts of olive oil and carbolic acid. The pile must be brought down as low as possible, and FIG. 562. Bodenhamer's Forceps for Ligature of Haemorrhoidal Tumor. about eight to ten drops of the solution gradually thrown into it. If the connective tissue is dense, it may be broken up with the end of the needle before the piston is thrust home. An indication that the work is successful, is the change of color of the haemorrhoid ; it becomes whitish. Only one pile should be treated at a time, and the parts, well smeared with aesculus cerate, should be returned into the rectum. I have cured the most obstinate cases by this method. - . - Ligature.—In applying the ligature, the patient should sit for a time over hot water, and use every effort to force without the verge of the anus, the offending masses. They may be seized with a rectum polypus forceps, or with that invented by Bodenhamer, Fig. 562, for that purpose. Having a good stout round needle, with a sharp point and no cutting edge (threaded with a double-waxed thread), pass it through the centre of the base of one of the tumors, cut the thread off at the eye of the needle, and tie one side around one portion of the hamorrhoid, and the other ends on the other side. Having treated all the tumors in this manner, and allowing the ends to remain, the parts are well Smeared with hippocastanum or simple ce- rate, and returned within the rectum. * Wide Hale's New Remedies, pp. 19, 159, 191, 250, 311, 319, 488, 500, 791, 826. † American Journal of the Medical Sciences, April, 1878. FISTULA IN ANo. 901 Nitric Acid Treatment.—Where there have been profuse hamorrhages from internal haemorrhoids, I have used the nitric acid treatment with good results. Having drawn the hamorrhoids down, apply to them a Smith's clamp, or the modification thereof by Mr. Stohlmann, which has ivory plates fixed to the blades to prevent the action of the acid on the steel (Fig. 563); this done, turn the screw tightly, and apply the acid FIG. 563. Smith's Haemorrhoidal Clamp (ivory-plates). thoroughly with a glass rod or a brush composed of glass threads, or a piece of wood, and allow it to act for a considerable time. The clamp is then removed, and cold water applied. This must be repeated every few days until the growth is destroyed. craseur.—This is my favorite method of removing all internal haemor- rhoids. The pile is brought well out, by a needle and thread, which is passed through the tumor. By traction on the thread the haemorrhoid is drawn out and kept out until the chain of the instrument bites. The thread may then be removed, and the screw at the handle turned slowly. After the hamorrhoid is cut through, a portion of the mucous membrane generally is impacted between the chain and side of the instrument; this may be divided with scissors. Dr. Nott's rectilinear écraseur is efficient in remov- ing haemorrhoids. The galvano-cautery is another means of removal. It is safe, and the results are successful. Those physicians who possess a battery can have recourse to this method with confidence. I have removed piles often with the écraseur, and without any disastrous result, excepting on one occasion, where a profuse haemorrhage followed, which was arrested by pieces of ice inserted within the rectum ; in this (the patient being a lady of great nervous sensibility) tetanus resulted, from which she made a tedious recovery. There are cases upon record where the use of the écraseur has not been so free from after-results as in my own. - - Fistula in Ano.—When an abscess forms in the cellular membrane sur- rounding the rectum, or about the verge of the anus, and leaves, after its contents are discharged, one or more small openings communicating with its cavity, the disease is denominated fistula in ano. Other appellations have been employed, expressive of the particular situation of the fistulous orifice and the extent of the disease. If the fistula open upon the surface of the integument, it is called an external fistula; if it communicate with the rectum, and not with the integu- ment, an internal fistula; and if the sinus open internally through the rectum, and externally through the skin, a complete fistula. It will be seen that I have excluded the terms “blind internal fistula. " and “blind external fistula,” because I have found the classification per- plexing to the student—one has to stop and think which is the blind end. The formation of a fistula in ano is often denoted by rigors, painful swell- 902 A SYSTEM OF SURGERY. ing about the ischium or perinaeum, difficulty of passing urine, and by irri- tation in the rectum and neck of the bladder. During the progress of the disease, the patient in many instances suffers extremely; at other times, the fistula forms almost without his being aware of its existence. Gener- ally it communicates with the integument by a single opening, but occasion- ally there are three or four. • In healthy constitutions the abscess does not differ from that in other parts of the cellular tissue, but in consumptive and scrofulous subjects the disease assumes a different character. The surface of the integu- ment is covered with an erysipelatous inflammation, the constitutional symptoms are well marked, the matter is discharged in small quantity, º from a sloughy, ill-conditioned opening, or from a ragged, unhealthy SUlrfa,Ce. The causes of fistula in ano cannot be always ascertained. Sometimes it arises from irritation about the rectum ; from local injury; from the lodgment of undigested articles of food taken into the stomach, and passed through the intestine as far as the rectum (for example, small bones of fish or fowls); severe and long-continued exercise, particularly on horse- back, or haemorrhoids. Medical Treatment.—When the inflammation is erysipelatous, and spreads rapidly, bell. Or rhus may be prescribed. Silic. is an important medi- cine, not only in the commencement but when the fistula is fully estab- lished. In the former if the abscess has not discharged, and the cellular membrane be found in a sloughy state, a free incision should be made to permit the escape of the purulent secretion. If healthy action does not display itself, ars, and china must be prescribed. Merc., sulph., silic., hepar, or calc. carb. must be exhibited, if cicatriza- tion proceed imperfectly. If the constitution is impaired before opera- tion, appropriate medicines must be administered, to eradicate any disease that may be present. In cases where the fistula has not been subjected to treatment, merc. or silic. may be given. Hepar may be required after merc. when the fistula is extensive; and phosph. after silic., where there is complication with disease of the lungs. When the digestive apparatus is impaired, calc. carb., nux vom., merc., and silic. will prove valuable. Caust. is important in cases of long standing, and in alternation with silic. I have known a fistula in ano to be healed for a time. Dr. Eggert, of Indianapolis, and Dr. Grasmuck, of Kansas, both report cases cured by internal medication, the latter using aesculus cerate in connection with nux vomica and sulphur. Dr. Scriven, of Dublin, related to me a successfully treated case. As a general rule, Surgical means must be resorted to, although previous medication may do much toward render- ing the operation successful. Dr. Hute employs an ethereal solution of iodine as injection for the cure of fistula. He states that patients are not obliged to keep their beds, and has known several cures after one injection. - Surgical Treatment.—If, after a patient trial of the means above men- tioned, the disease remain unchanged, recourse must be had to surgical measures. I prefer the elastic ligature of Dittel. I have operated with it many times with better results than with the knife, and have devised an instrument for the better carrying of the ligature (Fig. 564). It can be used for complete or incomplete fistulae, and may be explained thus: An examination of the wood-cut shows two buttons (A and B), close to the handle of the instrument. By pushing forward the button A, the blunt end, as seen at F, opens. The elastic ligature is put upon the stretch, FISTULA IN ANO. 903 and, while thus drawn out, is slipped into the notch, and the button A drawn back to its place, and the needle (if the case is one of complete fistula) is ready for use. If this instrument is not at hand, the operator may proceed as follows: Having passed a director through the fistula, I introduce the finger of the left hand into the rectum and draw the point of the instrument out at the anus. It is then pushed over across to the opposite buttock. Having a blunt probe threaded with the elastic, it is passed along the groove in the director and the ligature drawn through. The director is withdrawn. This leaves one end of the ligature hanging from the anus, the other from the fistula. A round circlet of lead, made for the purpose, or a perforated FIG. 564. G, TIEMANN & Co. # , The Author's Elastic Ligature Carrier. leaden ball, is slipped over the ends of the ligature, which are firmly taken hold of with the thumb and finger of the left hand, and drawn out until the thread is about half its ordinary thickness. A good-sized pair of forceps with strong jaws is seized in the right hand and the clamp taken hold of, but not squeezed, with the instrument. Holding the extended elastic in the left hand and keeping it tense, the clamp is slid close up to the fistula, and with a sudden and firm compression of the handles, the jaws of the forceps are closed, thus pressing firmly together the malleable lead and securely fastening the ligature, the ends of which are cut off. The patient is not always confined to bed. By its elasticity the ligature cuts itself out in from four to ten days, with the wound generally granulating behind it. When the knife is preferred, the operation may be performed in the fol- lowing manner: The patient being placed upon his face and knees, the pelvis elevated, with the thighs apart—or upon his back, with the thighs separated and flexed upon the abdomen—the surgeon, oiling the fore- finger of the left hand, introduces it up the rectum; a narrow probe-pointed Scalpel or bistoury (Fig. 565) is passed up the fistula, until it comes in con- tact with the finger. If the intestine be not perforated by the disease, the Surgeon must make an opening into it with the point of the knife, and pass it into the cavity of the intestine; the end of the finger is then firmly fixed upon the probe point of the knife, and by drawing both outwards, the sphincter muscle and all the intervening tissues are divided. - Another method is by passing a grooved director through the fistula, against or into the intestine. Introduce into the bowel a smooth round stick, resembling a rectum bougie, the size of the thumb; the stick having a groove on one side as wide as the finger. This being passed up and held firmly by an assistant, the surgeon takes the director, already in- troduced, and impinges its extremity firmly against the groove in the stick. He now takes a sharp-pointed knife, and runs it forcibly down the groove in the director, and when it comes in contact with the rectum stick, cuts outwardly against this, and thus divides the fistula at one sweep. This operation is performed in a shorter time than the one pre- 904 A SYSTEM OF SURGERY. viously mentioned, with much less pain to the patient, and greater con- venience to the surgeon. An operation which I have performed with success is that I believe devised by Gross. Pass a grooved director (a strong one which will not easily bend, and with a somewhat pointed extremity) into the fistula; if the canal is blind internally, make the internal opening by pressure with the director. Having oiled the finger, pass it into the rectum until it reaches the point of the director, hook the finger over the latter, and draw FIG. 565. FIG.565. Cooper's Knife. the instrument outside the anus. So soon as the point of the director emerges push it with the right hand, which has not .. the handle of the instru- ment, across on the opposite buttock. Then with a bistoury divide all the structures upon the director (Fig. 566). The bowel then returns into the cavity, and is dressed as below. Many French surgeons, after dividing the fistula, dissect out its walls, thus cutting out a tube of the indurated soft parts. In whatever way the operation is performed, after the fistula is divided, lint is to be pushed into the wound to insure its closing from the bottom by granulations, which, as the healing process progresses, force the lint before them. The patient must be kept at rest; and, if there be any constitutional excitement, it may be allayed by aconite and bella. in alternation, after which silicea and sulphur may be exhibited to hasten granulation. There is a point that should not be overlooked. When passing a probe into the fistula the instrument should be carefully used, lest it perforate the walls of the sinus, and pass into the cellular texture of the perinaeum. Deep cutting in this region may be productive of serious results; and as the cure does not call for such risk, it should never be encountered. The service required of the knife is the division of the sphincter muscle; and to accomplish this object an incision an inch or an inch and a half in depth is all-sufficient, and should never be exceeded. There is another point of importance: when an abscess opens around the verge of the anus, treat it at once as if it were a fistula, by dividing the sphincter; otherwise, a cure will not be effected. Ligature—When the internal orifice of the fistula is situated above the internal sphincter, it is safer to use the ligature. Some surgeons prefer this method. Its objection is the length of time required in cutting itself out, which gives rise to more or less constitutional irritation. A good way is to divide the upper portion of the fistula with the ligature and then employ the knife. In passing the thread a flexible probe may be used. It should be insinuated gradually into the sinuosities of the TUMoRs witHIN THE RECTUM. 905 canal until it impinges upon the finger within the rectum. It may be brought out at the anus, as seen in Fig. 567, and the ligature, a good strong cord, fastened to its end. The probe is carefully withdrawn, guided by the fore- finger of the left hand within the rectum. The ligature ends are tied (with suffi- cient strength to somewhat constrict the mass) over a small piece of flat cork. After two or three days these must be again tightened. Dr. Sawyer reports the case of a German man thirty years of age, who from disease seemed very prostrate; therefore he used a ligature drawn through a piece of cork, which was to be tightened every day, at the same time injecting dilute phosphoric acid into the fistulous passage night and morning. He gave arsenicum three times daily. In three weeks the fistula closed. Forcible Dilatation of the Sphincter.—In the treatment of fistula in ano, John Pattison, M.D., of London, has offered, as a substitute either for liga- ture or the knife, a method of dilatation of the sphincter ani. The expan- sion of the muscle is effected by placing both thumbs within the anus, and drawing them forcibly outwards towards the tuberosities of the ischia; and thus paralyzing the sphincter by overstretching. This treatment has in his hands been successful, all his cases, save one, having recovered. He treats the sinuses by injections of hydrastis canadensis, to cleanse them; and afterwards packs with anhydrous sulphate of zinc. Some of the cures reported by Dr. Pattison are remarkable, and the opera- tions are so simple that they are worthy of trial. Dr. Brownell tells of an Irish laborer, aged 39, admitted into Bellevue Hospital, in which, after referring to Dr. Pattison's mode of treating these cases by suddenly paralyzing the sphincter ani, he gives his mode of accom- plishing the same by inserting a sponge compress into the anus, which by subsequent expansion exerts an equable steady pressure outwards, para- lyzing the sphincter; the man, with two or three causes for retarding pro- gress, recovered. The doctor says a second case was cured in a few days, and a third in seven. George W. Bowen, M.D., reports five instances where he employed this treatment successfully. He states that the bowels must be relaxed; after which the sinuses are injected with a solution of nitrate of silver; com- pressed sponge or a fine sponge tent is then introduced into the fistula. Dr. Bowen has found a week sufficient for this treatment. Thebaud’s dilator is probably the best instrument for forcible dilatation. Dr. Brownell refers to a case cured by introducing a bivalve specu- lum at the time of defecation, and washing the rectum before the with- drawal of the speculum to avoid the necessity of confining the bowels, and Dr. Sterling speaks highly of this method. Tumors within the Rectum.—Various abnormal growths have been found within the rectum, and according to their bulk or specific character, excite more or less irritation, inflammation, or diarrhoea. There are cases on record” of enormous tumors of the lower intestine, involving the whole circle of the anus, and extending beyond it many inches. Of these, polypus of the rectum is most frequent. The following example will show the symptoms: * Wide Mr. John Bell's Principles of Surgery, vol. iii., p. 188. 906 A SYSTEM OF SURGERY. $2 A young woman twenty years of age, admitted into the Good Samaritan Hospital, had never menstruated, was short of stature, and dwarfish in appearance. She stated that eight years before she had suffered from a red bleeding substance in the rectum, which had been removed, but that similar growths had returned. She was pale and sickly though not much emaciated, was troubled with a constant diarrhoea and more or less tenesmus, and the passage of a good deal of blood. Upon external examination nothing particular could be noted ; but upon desiring her to attempt to expel the contents of the rectum, there would protrude several elongated bodies, resembling earthworms in shape, but of a brilliant red color. They presented a soft, vascular, shreddy appearance, bearing some resemblance to sarcomatous growths. With the expulsion there was always a yellow, fetid discharge. Upon examination of the faces, they were flattened, and there was flatulent distension of the bowels. Appre- ciating the value of bromide of potassium in the removal of morbid growths, I determined to try the medicine upon this patient and gave the following prescription: B. Potassii bromid., . #j. Aquae font., 3v.j. M. f. sol. S. A teaspoonful three times a day. She continued the treatment from early in February until the middle of May. She soon began to improve in health ; the diarrhoea ceased ; she performed household duties in the hospital, and on the 13th of May, though the fetid fluid was expelled, she was unable to protrude any polypi. The remains of the growths could be felt, but otherwise the patient was in good health. I had endeavored to draw down the polypi and ligate them, but they were too friable, and broke away so easily that I gave up the attempt. Treatment.—The best medicines for such tumors are caust., conium, calc. carb., lyc., phos., sepia, sulph, and thuja; others may be employed accord- ing to the presenting symptoms; when these fail, resort may be had to an operation. If the tumor originate by a narrow pedicle, and admit of motion, it may be pulled down by the forceps (Fig. 568), and a ligature applied to the neck. FIG. 568. Rectum Polypoid Torsion Forceps. If the abnormal formation be large, it should be drawn down as low as possible with the forceps, and several needles armed with ligatures passed through its base, and their ends firmly tied; circulation thus being arrested, sloughing will result. It is especially to these tumors that electrolysis is applicable. - Stricture of the Rectum.—The rectum is sometimes the seat of stricture, which may be either spasmodic or permanent; the former is caused by CARCINOMATOUS STRICTURE. 907 improper or unwholesome articles of food taken into the stomach, which passing undigested through the alimentary canal, excite irritation, which gives rise to the spasm. In the cases that have come under my observation there has always been an actual deposit and permanent stricture of the tube; it is not until the calibre of the rectum has been materially circum- scribed by the deposit that patients apply for relief. Permanent Stricture generally originates from chronic inflammation of the lining membrane of the intestine, causing thickening and contraction of the part or deposit in the submucous cellular tissue. In these diseases there is pain and difficulty in voiding faces, which are passed in narrow flattened fragments, or if fluid, are ejected with considerable force. The stricture may be felt in some instances per amum, by the finger; in others, when the stricture is higher up, an instrument must be used. In examining a patient care should be exercised, especially if the disease be high up in the rectum. Instances are on record where fatal results, from perforation of the bowels, have ensued. The digestive organs become impaired, dilatation takes place above the seat of stricture, which may result in ulceration of the intestine. In such cases the prognosis is unfavorable. Carcinomatous Stricture.—This disease, which, in the majority of in- stances, is of the epithelial variety, is often complicated with hamorrhoids. Many physicians have treated cases as simple constipation when in reality a stricture existed. Such instances have come under my notice; one in particular, in which the stricture existed to such an extent that a small- sized bougie could be introduced with difficulty. In this case the patient vomited faces from time to time. I dilated the stricture at intervals with graduated metallic bougies, and with arsenicum given by the attending physician, was productive of happy results. On one occasion I believe life to have been saved by the timely application of this medicine. The following points will be useful in diagnosing between syphilitic con- traction, carcinomatous and inflammatory stricture. : If the stricture be cancerous, we generally can detect, in and around it, hard nodular masses, with here and there a softened and fluctuating spot. In this there is an uneven deposit around the canal, and this deposit is . Together with these manifestations there is often discharge of blood. If the stricture be syphilitic, there is more or less ulceration from the anus toward the constricted part of the gut, and upon investigating the case, suspicious symptoms and appearances will generally be developed. In this variety, there will be more or less discharge of mucus and bloody matter. - If the stricture be inflammatory (and this is the most favorable for treat- ment), the constriction will be annular, and some previous inflammation or disease of the bowel will have been noticed. Treatment.—In spasmodic stricture, nux vom. is the principal remedy, and will often relieve the affection if the patient observe the strictest dietetic rules. Arsenicum, bell., hyos., sulph ac., and verat. may be called for. To ascertain the position of the stricture it is often necessary to explore the rectum, which, when the seat of the disease is high, is sometimes diffi- cult. In such cases the rectum exploring sound of Bodenhamer is a good instrument (Fig. 570). In permanent stricture, ars., bell., canth., colch., ignatia, nux vom., lyc., merc., sulph., may be indicated, and with the administration of the appro- priate remedy, the bougie (Fig. 569) must be employed. The instrument should be soft, and at first introduced once in three or four days, and al- lowed to remain as long as the patient is able to bear it. After a time a 908 A SYSTEM OF SURGERY. large-sized bougie should be introduced more frequently; in some instances, where there is great constriction, and the smaller-sized bougies cannot be used with facility, it is necessary to divide the stric- ture with a probe-pointed bistoury passed into the intestine upon the forefinger. Linear Rectotomy, anterior and posterior, may be practiced when the stricture is within reach. The patient being etherized, a small Sims's specu- lum is introduced anteriorly. This, with traction, will bring the stricture into view; the forefinger of the left hand should be used as a guide, and passed into the rectum. On this a probe-pointed FIG. 569. FIG. 570. ; Bodenhamer's Rectum Exploring Sound. bistoury should be pushed beyond the finger, and the stricture, mucous membrane, and even a few fibres of the muscular tissue, divided in a per- pendicular line. The speculum is introduced to bring the anterior portion of the rectum to view, and the same method of incision practiced. The haemorrhage will be profuse, and the operation Rectum Bougies. must not be performed if there are internal haemor- rhoids, otherwise disastrous bleeding might be the consequence. Pieces of ice or, as practiced in a recent case, injections of hot water will arrest the bleeding, when a fair-sized bougie (one that will enter without much force) must be introduced and allowed to remain for half an hour. - I cannot place too much stress upon the absolute necessity of caution in these operations. After a day or two a bougie, somewhat larger, may be entered, and by patience and gentleness the obstruction overcome. This method was devised by Dr. Beane, of New York.” Other instruments have been employed for this purpose, as in Fig. 571. Dr. Whitehead iſ has written an excellent article on stricture of the rec- tum, and has devised an instrument for its dilatation. It consists of a bag, as seen in the cut, Fig. 572, which, when collapsed, is easily introduced. Either air or water may be injected, the pressure being thus easily regulated. Æh- —ºr- * American Journal of the Medical Sciences, April, 1878. + American Journal of the Medical Sciences, January, 1871. ULCERS AND FISSURES OF THE ANUS. 909 Ulcers and Fissures of the Anus.-The verge of the anus and the mucous coat of the bowels are often the seat of fissures and small ulcers, which give rise FIG. 571. FIG. 572. to intense pain, and after continuing for a C time, to severe constitutional disturbance. Persons afflicted with dyspepsia are sub- ject to this disorder. The pain during defecation is excessive, but in many cases the suffering does not commence for fifteen or twenty minutes after a movement of the bowels. The stools are covered with blood and mucus, the faeces flattened, constipation is present, and, in fact, the patient is rendered miser- able. It was said, I believe, by the late Baker Brown, that sterility has been noted as an accompaniment of this disease in women, and that upon the cure of the fis- Sure, pregnancy resulted. Treatment.—The medicines that relieve are graphites and nitric ac.; indeed, I have known fissures that have resisted other treatment for a considerable time, yield to the action of these remedial agents, especially the latter. Dr. Perry” has written an article on this subject, and the following are the results of his experience: The chief medicines for the affection are nit. ac. and ignatia; next in order are plumb., sulph., ars., nat. mur., phos., and sepia; lastly, caust., sil., nux vom., thuja, tabac., gratio., and mez. ; petrol. is also an important medi- cine. I have used, with success, to relieve the pain after defecation, a cerate of aesculus #: hippocastanum. Of late, I have found Rectum Dilator. surgical treatment the safest and most speedy. The patient should be anaesthetized, as the pain of this apparently trivial operation is excessive. Opening each fissure, divide thoroughly the mucous membrane at its deepest point. To make sure of the thorough division, pass the finger forcibly into the fissure, and break up any slight adhesions that may remain. Gurdon Buck cured rhagades by dilatation, either with the fingers, as directed in the treatment of fistula in ano, or with Thebaud’s instrument. I have successfully treated fissures in this manner. If ulcers exist with the fissures, then the knife must be carried across the ulcer. Erichseni uses a suppository of 2 grains ext, bell., 2 grains acetate of lead, and 4 grains of tannin. Dr. Créguyſ inserts charpie, soaked in a solution of chloral (1 to 50), Whitehead's Elastic Pressure Rectal Stric- ture Dilator. * Journal de la Société Gallicane, quoted by British Journal of Homoeopathy, vol. viii., . 541. - p + Science and Art of Surgery, vol. ii., p. 850, Philadelphia, 1885. f Monthly Abstract of Medical Science, January, 1876. 910 A SYSTEM OF SURGERY. just within the anus daily, and reports complete cure of two cases within a fortnight. . Itching of the anus is a troublesome and inconvenient affection. Fre- Quently it is an attendant upon verminous diseases, or in other cases it may be purely idiopathic. In most instances it is attended with other symp- toms, as burning and stinging, and is worse at night, and is difficult to manage. * - The following are the appropriate remedies, although internal treatment rarely effects a cure: Alumina, capsicum, iod., terebinth.; after evacuation, antim. tart., or strontia, antim. crud., colohicum, nit. ac., platina, kali carb., plumb. A good local application is that of Créguy. A favorite prescription with me is: B. Acidi hydrocyan. dil, . . © tº tº gº º g . . 388. Cretae preparat., . © * Q e iº g º º - 3.jss. Cerat. cetacei, . • * © tº •º 3. M. Ft. unguent. Apply at night. Dr. T. G. Comstock has found the following serviceable: B. Quiniae bisulph., . tº º tº E ge & • a tº © 3. Vaselini, . tº 3j. M. Ft. unguent. Locally applied at night Carcinoma of the Rectum.—Some of the symptoms of cancer of the rec- tum have been detailed, when speaking of certain forms of stricture; in all malignant diseases of this tube, there is more or less obstruction of the canal. In the earlier stages, the affection is known by the peculiar, hard, uneven (nodular) masses that are felt by the finger, or sometimes seen with the speculum, situated from an inch to four inches beyond the sphincter ani. The symptoms are pain during the efforts at defecation, with occasional loss of blood, which becomes frequent and profuse as the disease advances. The suffering lasts for some hours after stool, which is accompanied with tenesmus. The faces are altered in shape, being thin and tapelike, and the patients become emaciated. After a time, a fetid and acrid discharge escapes from the anus; there is absolute constipation, and an examination reveals a soft and pulpy degenerate tissue, which is reddish or purplish, friable, and readily bleeding. The constitutional symptoms are well marked, and the cancer cachexia is apparent. A portion or the entire walls of the rectum may be involved, but as the disease advances, all the surrounding tissues may be infiltrated and destroyed. I have known instances where the entire sphincter and perinaeum had been destroyed, presenting a hideous and disgusting deformity. . The cases that have come under my care have generally been those of epithelioma. Treatment.—In the early stages of the disease, the medicines are arseni- cum, conium, hydrastis, both internally and externally, lachesis, and nitric acid or thuja. The best local application is electrolysis. I have known cases so far ad- vanced that the patients were apparently beyond hope, in which the disease was arrested by this method. If the surgeon, however, prefer it, the rectum may be excised. £, in of the Rectum.—Prof. Hyrtl, as well as Nelaton and Velpeau, has asserted, that there is a peculiar band of muscular fibres above the internal sphincter ani, which possesses sphincteric powers, and I was dis- posed to believe that this sphincter ani tertius was the muscle that enabled patients after the removal of the lower portions of the rectum to regain the EXCISION OF THE RECTUM. 911 control of the faeces. Hyrtl writes: * “The older surgeons were astonished after having divided the sphincter muscles in operations for fistulae, that no involuntary discharges of the faeces followed. , Paget found after removing the lower end of the rectum from a patient, that he could retain his faeces and flatus, and he explained this upon the hypothesis that a new sphincter must have subsequently formed. Houston was not disinclined to believe that the lower portion of the rectum, where a fold occurs as it passes through the pelvic fascia, was surrounded with a development of circular fibres. Lisfranc, who many times extirpated the terminal portion of the rectum, noticed that such patients were not deprived of the power of holding back their stools, and declared it as his opinion, that as a positive necessity a su- perior sphincter must exist. Likewise every unprejudiced observer must allow of the existence of such a muscle, for the reason that in prolapsus ani, when both the external and internal sphincter are paralyzed, no involuntary stools occur. “In rupture of the perinaeum and congenital opening of the rectum into the vagina (cloaca) the same thing happens. Ricord cites a case of a woman, aged 22, where the rectum opened into the vagina, yet the bowel acted regu- larly, and, what is more remarkable, the husband after having been married three years, had no conception of this abnormal condition in his wife. “When the index finger is introduced into the rectum of a patient who has had no action from the bowels for a few days, as a rule, just above the anus, no faces will be found, and yet the column of faeces would naturally sink down to this point, if not held back by an opposing circular muscle. Kohlrausch offered this view, which presupposes the existence of a third Sphincter, because he found upon dead subjects, as well as in patients, hard Scybala in the lower portion of the rectum ; but I take occasion to mention that the existence of faeces in the rectum upon subjects, simply proves that the sphincter tertius no longer acts, and the same thing in the living (in patients) may be the result of diseased conditions, and which affords an example of an exception to the rule. Enemata which are not introduced high enough into the rectum, are liable to come away immediately; on the contrary, if the canula (extremity) of the syringe is pushed up sufficiently high the injection will be retained a longer time. Dr. O’Beirn called atten- tion to the fact that an elastic tube can be introduced quite a distance into the rectum, before any flatus is given off, and then the discharge came sud- denly. All these observations make it probable, a priori, that a certain dis- tance above the internal sphincter ani, a third sphincter must exist. Nelaton and Velpeau have demonstrated the existence of it, as a thickened band of muscular fibres, four inches above the anus. The muscular development is not always easy to find. To find it upon the cadaver, care should be taken that the rectum is not forcibly distended with air. “In order to demonstrate it well, the rectum should be cut upward longi- tudinally, and stretched upon a board and the several layers carefully dis- sected off, until the muscular layer is reached, when the sphincter tertius, ºn, will be seen as a broad bundle of thickly conglomerated muscular I'êS. Dr. James R. Chadwick, however, denies not only the existence of a complete sphincter tertius, but claims for the bundles of muscular fibres so called expulsory power, declaring that “Detrusor Faecium.” is the appropriate term for the fasiculi in question. He says: “On inflating recta, however, * Handbuch der topographischen Anatomie, Von Joseph Hyrtl, Zwiter Band, p. 130–33. Auflage, Wien, 1860. - # The Functions of the Anal Sphincters, so called, and the act of Defecation. Transactions of the American Gynaecological Society, vol. ii., p. 43. 912 A SYSTEM OF SURGERY. in accordance with the directions given by him (Hyrtl), it is surprising to find that no such annular constrictions appear. At the point of the rectum designated by him is, nevertheless, observable a semi-circular constriction of the rectum confined to its anterior wall; corresponding to this, but an inch or more higher up, is always seen a second semi-circular constriction, affect- ing the posterior wall only. The effect of these two semi-circular constric- tions is to give the rectum the shape of the letter S.” . . . . . . “If now a mass of faeces be supposed to advance through the rectum, following the sinuosities, it is evident that these bundles of fibres, when not in active con- traction, would present scarcely any obstacle to its progress. It is further noticeable that the partial constrictions of the canal, differ only in degree from the constrictions visible in the higher segments, which give to the rec- tum its characteristic sinuous appearance.” From the experiments made also by Goltz and Gowers as well as those of Dr. Chadwick, it would appear also that the internal sphincter ani, instead of obstructing, really materially assists in the expulsion of the fecal matter. In other words the intermittent relaxation and tonic contraction of this portion of the intestine point to distinct inhibitory action of the splanch- nics and vagus—which control or perhaps constitute peristalsis. According then to these views the external sphincter ani “ is the only one of the anal muscles which can properly assume the title of sphincter.” After making myself aware of these interesting points, I was for a time, and indeed am in a measure now, at a loss to understand certain facts which have been made apparent by my operations of extirpation of the rectum. I hold that the external sphincter is per se a partial detrusor faecium. I know that when faeces are passing through the external outlet, the sphincter, with partly automatic and partly involuntary power, propels the mass for- wards, and sometimes with considerable force; and also from the many times in which I have operated for fistula in ano with the knife, that after complete division of the fistula, the patients, in most instances, have had no trouble in retaining their faces. In operations about the anus with the elastic ligature, in some of which the fistulae were very deep, the power of retaining excrement was not materially interfered with. In two cases in which the ligatures cut them- selves out, leaving their tracks entirely open, little difference in the power of retention was noticed. Such facts go to prove Hyrtl’s idea of the action of the sphincter ani tertius. On the other hand, it must be remembered, that after operations for extirpation of the rectum, there is no control of the fecal discharges for several weeks. They pass constantly without effort, often without the knowledge of the patient. Would this be so if the third sphincter possessed anything like obstructive powers ? As a rule in all the recorded cases, and from careful observation, this fact is apparent, that, in proportion as the wounds heal around the margin of the anus, in that proportion does the power of controlling the faces return. I can scarcely account for this, by the increased power said to be obtained by the circular fibres of the rectum, because they are composed of unstriped muscular tissue, exactly similar to that of other portions of the intestinal tract, and must therefore be, in a measure, under central control, and are a part of the general peristaltic system. I therefore conclude, that the sphincter ami, per se, is a muscle of mixed action. That alone, that is uncombined with other muscular force, it may and does assist in expelling fecal masses, that in conjunction with the surrounding muscles it becomes sphincteric, and it is this connection with other sets of muscles that has much to do with the production of the act sphincteric. All the so-called sphincters of the body are in close connection with other muscles, which interlace fibres, and the sphincter ani markedly so, cut through the sphincters on one side, EXCISION OF THE RECTUM. 913 and as a rule there is no difficulty in retaining the faces. Cut off the sphincters, take them out entirely, as in excisions, and just in the ratio as the healing process connects the stump of the rectum with the surrounding tissue, just in that proportion the sphincteric power returns. Still more important is the nervous control of the parts. Dr. Chadwick, in the article alluded to, quotes a remarkable case from Gowers. A man had a violent fall upon the sacrum, apparently º the posterior roots of the sacral nerves; there was no muscular paralysis, excepting of the levator ani, the º: ani and the sphincter vesicae, which were in a state of continuous slightly varying contraction ; a condition generally supposed to constitute sphincteric power; the incontinence of faeces was complete. I know from the peculiar action of other muscles, especially those which surround cavities and are inserted into others, that the fibres of the one act upon the other in a peculiar manner. º - For instance, in a state of health, the velum palati is composed of sym- metrical muscles having a tendency to draw that septum upward and out- ward. In the cleft state from the action of these muscles, we would most naturally expect the cleft to widen during deglutition. The levator of each side draws the fold upward ; the tensor directly outward, by the action of its tendon around the trochlea ; the palato-glossus downward and forward, and the palato-pharyngeus downward and backward. Yet the entire re- verse of this is the case. The cleft shuts during deglutition, from the action of the superior fibres of the constrictor. If this be so, why may not all the muscles in the perinaeum, and especially the levatores, which are in such close connection, produce some such similar results? These are but infer- ences and are offered for consideration. From these cases we may learn, that if Hyrtl's ideas regarding the sphinc- ter tertius be true there would not be such complete inability to control the faces after these operations. That Chadwick's explanations of the action of these bands are sustained. That the full sphincteric power is maintained by the conjoined action of a set of muscles. -- That control is gained over the faces in proportion as the cuts heal and the nervous power is restored. That in a majority of cases, after the operation a retraction of the gut will take place. That the water bag is not as efficient as the simple rectal tube, which ought never to be dispensed with after complete excision, as the accumulation of gases gives rise to great pain. That excision of the rectum is more feasible in women than in men. Lisfranc made this operation popular in 1826, and Prof. Schuh,” in 1868, operated successfully. Of late years, the performance has been revived, with success. Volkmann gave it new impetus, and it has been performed many times with success, in this country. Dr. R. J. Lewis, iſ of Philadel- phia, Drs. Van Buren and Keyes, of New York, Dr. L. A. Stimson, $ Dr. Briddon, and myself were among the first who advocated a renewal of the process. The operation may be described as follows: After the usual precaution of emptying the bowel, and preparing all antiseptic details, a circular incision is carried around the anus, about three-quarters of an inch from its margin ; a second cut is made in the median line from the circular * Medical Record, N. Y., July 13th, 1878. f Archives of Clinical Surgery, vol. i., p. 311, 1877. t Medical Record, N.Y., July 13th, 1878. ź Loc. cit., October 19th, 1878. tº | Archives of Clinical Surgery, vol. i., p. 313. 58 914 A SYSTEM OF SURGERY. one, back to the coccyx, and, if necessary, a forward one, in the perinaeum; the rectum is drawn gradually down and dissected carefully out, or the hand of the operator may be gradually insinuated into the hollow of the sacrum, and the attachments of the gut loosened. The front portion of the bowel must be removed with care, as the peritoneal fold on the anterior face of the rectum is much lower than on the posterior portion of the gut. Threads are now passed through the healthy portion of the intestine, which is stitched carefully to the sides of the aperture and the cancerous portion removed with the knife or scissors. As a necessary precaution, and also as a guide, a good-sized bougie should be introduced into the bladder, and held there during the operation. Volkmann, in one instance, to allow him- self room, resected portions of the sacrum as high up as its promontory, and in another removed a portion of the posterior wall of the vagina. . If the peritoneum is incised, the rent is immediately to be plugged with sponges saturated with a solution of carbolic acid, and afterwards carefully brought together with catgut sutures. If the entire circumference be not involved, a portion may be taken away, and the lips of the wound united by suture. In my casesł I have invariably found that the stitches holding the rectal stump to the margins of the cut, tore out sooner or later, yet withal excellent results followed. CHAPTER XLV. INJURIES AND DISEASES OF THE URINARY ORGANS. .* MALFORMATION.—ExSTROPHY of THE BLADDER—EPIsPADIAs— HYPOSPADIAS – HER- MAPEHRODITEs—CALCULOUS NEPHRALGIA—UNSTABLE (FLOATING) KIDNEYs—NE- PHRECTOMY —NEPHROTOMY —CySTITIs—RETENTION OF URINE – (ISCHURIA WESH- CALIS) —TUBERCULAR CYSTITIs — CATHETERISM – ABSCEss AND FISTULA IN THE PERINAEUM–LACERATION of THE URETHRA — CYSTOTOMY — FoEEIGN BODIES- STRICTURE OF THE URETHRA–INTERNAL AND ExTERNAL URETHROTOMY-CALCULI —STONE IN THE BLADDER—VARIOUs METHODS OF LITHOTOMY-OPERATIONS FOR LITHOTRITY-TUMORS OF BLADDER—PROSTATITIS. Malformations.—Complete absence of the urinary bladder is rarely met with, and if such were the case, the ureters would probably be found open- ing somewhere on the surface of the body—perhaps around the umbilicus, or into the rectum or vulva. Cases have been known of double-bladder, in which a septum more or less perfect has been found, stretching between the walls of the viscus and dividing it into two cavities. Exstrophy of the Bladder.—The variety of malformation which is more frequently seen, but which is also of rare occurrence, is known as exstro- phia, or inversion of the bladder. The term “inversion of the bladder,” does not convey a proper idea of that arrest of development which we are to consider. hen we say inversion of any hollow body, we do not * Pamphlet on Excision of Rectum. ExSTROPHY OF THE BLADDER. 915 necessarily understand that its structure is deficient, but merely that it has been turned inside out or upside down: whereas, in the cases that I have seen, and the descriptions of all those I have read, there has always been a complete deficiency in the anterior wall of the bladder and ab- dominal wall. In the majority of cases, the arrest of development appears to be first in the abdominal walls, second in the symphysis pubis, and third in the struc- tures beneath. In the female, the deformity is often accompanied by an absence of the clitoris, and in the male, by a fissure of the urethra, or “linear epispadias.” In the hypogastric region we find protruding the posterior wall of the bladder, fiery red, with here and there a rudimentary trace of the mucous coat, of a bluish color. The circumference of the organ is lost in the sur- rounding integument, which has the appearance of a cicatrix, and is bluish. The orifices of the ureters are found in the lower half of the organ. The malformation is said to occur more frequently in males than in females; and the late Mr. Earle, of London, stated that, after a careful ex- amination, he found sixty-eight cases upon record, of which sixty were in males. Others have given the ratio as four to one. In twenty instances by Mr. John Wood, but two were found in females. Agnew reports fifty- three, of which but eight were females. I have had five cases of this de- flº and operated upon two; of these, four were males, the last a eIrlale. My first case came to me in St. Louis, in August, 1870. The patient was twenty-four years of age and well ºf ; was over five feet in Fig. 573. Author's Case of Exstrophy of the Bladder. height and enjoyed moderately good health. There was a wide separation of the pubic bones (about two inches), an entire absence of the umbilicus, and the red and fiery mucous membrane of the trigonum vesicae protruded through the abdominal deficiency (see Fig. 573, A). On the left side of the bladder a slight nodule marked i. opening of the ureter, into which a No. 6 bougie (En iº could be passed. The penis was a little over an inch and a half in length, and was completely epispadiac (vide Fig. 573, B), the urethra being split open like a trough. By raising the bladder and depress- ing the urethra, the veru montanum, and the openings of the ejaculatory 916 A SYSTEM OF SURGERY. ducts, were distinctly visible. There was also a rudimentary prostate. The testicles were of good size and apparently perfect; the scrotum large and full, and as the integument extended from the bag to the groins on either side, it became so voluminous that it could readily be grasped. Several methods of operating were considered and rejected, until finally the following was performed on August 20th, 1870, at 12 M., in the pres- ence of Drs. Franklin, Nibelung, Tirrell, Morrell, Goodman, Gundelach, Campbell, Garrett, Read, and others. The lateral flaps were made of the redundant groin-tissue, and drawn over the protruded viscus. The edges of these were fastened in the median line, and the nodular mucous cir- cumference was pared. The tissue was so loose that the flaps were ad- justed without any stretching. A semi-lunar flap was dissected from the abdomen above the bladder, turned down, and slid under the lateral flaps and there secured. The operation lasted an hour and a quarter, and there was hamorrhage from both superficial epigastrica, which were cut. A severe cough, with mucous ràles, appeared on the eighth day; the ner- vous system of the patient suffered materially, and on September 1st he gradually sank and died without pain. The emaciation was so rapid and complete that his friends scarcely could recognize him. On examining the wound, I found the flaps had partially united in the upper part of the median line, the lower portion of the wound was open, and the orifice of the ureter clogged up with calcareous matter. The important and anom- alous conditions found at the necropsy, which was made by Dr. J. S. Read, were the entire absence of the right kidney, and the enormous size of the left, which he thus described: “Lying in the left hypochondriac region, and extending down into the left lumbar region, in immediate contact with the abdominal walls, was found the left kidney, filling the left lumbar region so completely as to leave no space for the descending colon and small intes- tines. The peritoneum was greatly thickened, not only in the renal region, but throughout the whole extent. The renal capsule was quite small—about one-half the normal size—and of very loose texture. Tearing the kidney away from its attachments, it was measured. The great circumference was nineteen and three-fourths inches; around the lower part, twelve and three- fourths inches; near upper end, nine and three-fourths inches. The ureter was twelve inches long, slightly sacculated; towards the lower end, just as it was about to enter the vesical substance, it was much reduced in size; the walls of the ureter varied in thickness from one to three lines, the thickest portion being above. This thickening extended to the pelvis of the kidney, which was enlarged, the appearance being due to the increase in the thick- ness of its walls. The pelvis of the kidney and the ureter were both filled with calcareous matter, about the consistency of thin mortar, the mucous membrane being finely dotted with minute calcareous particles, that were with difficulty rubbed off. The kidney of the right side was entirely absent; not a vestige was there, nothing even rudimentary.” Dr. Gross believed the disease to be almost irremediable, and all things considered, there is but a poor prospect for ultimate recovery. There has been a successful operation reported by Mr. Simon, of London, who caused the ureters to open into the rectum, which was done by introducing threads from the ureters and carrying them to the rectum, and there allowing them to remain until the passage was complete. The patient narrowly escaped with his life. Mr. Loyd's case, in which the communication was effected by a suture, died on the third day. Mr. Sidney Jones, of St. Thomas's Hospital, attempted a similar operation, his patient perishing of fatal peri- tonitis, as did those of Mr. Johnson and Mr. Loyd. Mr. Holmes endeavored to establish a communication between the bladder and rectum by clamping EXSTROPHY OF THE BLADDER. 917 that portion of the exstroverted bladder between the ureters until sloughing and ulceration of the tissues were effected. Dr. Levis, of Philadelphia, tried making a fistulous opening between the bladder and the perinaeum, by the passage of setons, and afterwards by drawing a small bougie in the track of the silk; this was effected. A second operation for the purpose of covering the bladder-wall by turning the scrotum upward and covering the penis and fixing it under a small ºminal flap was attempted. The patient, however, died on the twelfth ay. Covering the bladder by plastic operations, that is, taking the integu- ment from the surrounding structure, is much more satisfactory, and has been done a number of times. It was, I believe, first suggested by Roux and Richards in 1853, and was performed by Dr. Pancoast, of the Jeffer- son College, Philadelphia, in 1853, and by Dr. Ayers, of Brooklyn. The latter was more successful than the former. Afterwards Holmes and Wood, of London, performed similar operations, the latter having practiced it seven- teen times. Dr. Ashhurst, of Philadelphia, has made three operations, two of which were successful. Bryant, also, has been successful in covering the sensitive bladder-wall by taking the flaps from the groin and the scrotum. Maury’s method is a modification of that of Roux. He makes a large convex flap from the groin, perinaeum, and scrotum, cuts a small hole therein for the passage of the penis, turns this flap upward with the cuta- neous side inward. A short flap of integument is then raised on the uppér and ºral portions of the exstrophy, and the first flap slid under it and SéCUII’éCi. The results of these autoplastic operations are more encouraging than those performed for diverting the course of the ureters or the establishment of fistulous openings. Dr. Ashhurst has analyzed fifty-five cases, of which forty-three recovered, four failed, and eight died. - The case which I have presented has some important peculiarities: First. Entire absence of one ureter. Second. Entire absence of one kidney, and the enormous size of its ureter and renal pelvis; and, Third. In the wide and slit-like openings of the seminal ducts. CASE II. Is peculiar in that the parents supposed their child to be a girl, and dressed “it’ in that fashion. - The patient is about sixteen years of age, of light complexion and auburn hair, having the expression of distress that belongs to those suffering long. I must call her “she,” for I have attended the case so long, and have always seen the patient attired in petticoats and frocks, and never observed anything bearing any resemblance to the male but a twisted and deformed epispadiac rudimentary penis. The umbilicus is entirely absent. The pubic bones are widely separated. The scrotum, when in the erect position, is very large, and immense inguinal hernia are seen on either side (C, C, Fig. 574). The odor wrinae is almost intolerable, and the sensitiveness of the red and exstroverted bladder (A, Fig. 574) is only equalled by that exhibited in the rudimentary glans. The urethra is split open to the base of the blad- der, and is about an inch and a half long. The penis (B, Fig. 574) has two corpora cavernosa, and is capable of erection. I may state a fact un- known to me before the first operation, which is that with the arrest of de- velopment of other parts, I found entire deficiency of the recti. Nothing but a moderately thick fascia, which became thinner and thinner as it ap- proached the exstroverted bladder, covered the intestines. The patient was weak, miserable and irritable, with a pulse always at 120 to 130, and a tem- perature 101°. 918 A SYSTEM OF SURGERY. I performed two operations, the first somewhat similar to that I devised for the case already recorded and which is almost identical with that known as Wood's, which has recently been practiced by Ashhurst, of Philadelphia, with success. I began by measuring the flaps and mark- ing them on the abdominal wall. The first was taken from above the bladder, of sufficient size to cover the exstroverted viscus as with a lid (Fig. 574, D), the cutaneous surface being approximated with the mucous coat of the bladder. In making this dissection, unaware of the absence of muscular tissue beneath, I made an incision into the fascia, and a portion of peritoneum protruded. This was brought together with carbolized gut. The side flaps were made with their bases to the scro- tum (Fig. 574, E, E) (to be nourished by the superficial external pudics and superficial epigastrics), twisted over upon themselves, and united in the median line with harelip pins and figure-of-eight sutures; by this means the angles F and FF in Fig. 574 were brought to B, as seen in Fig. 575. The angles of the raw surfaces were approximated and the patient placed in a semi-recumbent position in bed. The wounds were dressed with calendula. FIG. 574. FIG. 575. º: - FIG. 2. Free 8. | =----- º : N g º \ g º A RW : {\!\! * ;: *AW Sº W $: §§ ! D D § º, a 3: WW ! N §§ WW', ,? %; º W\ d § | Mº wº MW, * § NWA “f j Š Nº. § # § \\\ * | ! :º & º \ :#} ſº N *śs. º J º §. d N ...tiliſiº %; \ º-º-º: & lº § | g \\ ! : § jº Nº. #: º zº ſº # §§ º N wºrn .# A\\ N; - §§§ º & \\ R; § \\ N # § & º N §§ sº No N º § º §§ & N sº º: \\ N \; | & Nº. º tº: º N W. º Sº \\ ** jºſ. \\ i º sº § §§' # \ | § § S$ §: ift \ Nº. § § §§ s' 3:# N º §§ § § : º & º & * : ** ...— . . . . . . . . . . 2: § SS ºğ §§ - \ º º: R sº- ---> RN º §§§ s § § s . Šs=sº ==- § .# §§ §s * Fi s º - s ==-“T” f Fig. 575 represents the appearance after the first operation : A the raw surface left by superior flap, B the point of union of the lateral flaps secured with hare-lip pins, C the rudimentary penis, DD the scrotum. The first operation was successful thus far, viz., in the complete union of the flaps in the median line; but the contraction of the cicatrix above had a tendency to draw them up so that the exstroverted bladder was but half covered (E, EPISPADIAS–HYPOSPADIAS. 919 Fig. 575). This operation was productive of much good, inasmuch as the child could bear the weight of the dressings and bedclothes upon the flap, which was almost impossible before. A change was noted in the disposi- tion; from being irritable, morose, and indeed sometimes almost savage, she became so placid and cheerful that the change was noticed by every one who was in attendance upon her. Before the flap-wounds had entirely healed her condition was so much improved that I concluded to try a sec- ond and more extended operation, utilizing the pendulous scrotum for flaps, Castrating the patient, and, if possible, curing the hernia. To that effect, therefore, on January 19th, 1884, I removed a strip of the integument from the lower border of the new flap, about three-quarters of an inch in width (see dotted line E F in Fig. 575). I reduced the hernia on the left side, and about two-thirds of the gut on the right, finding it impossible on that side to return the whole tumor. Beginning then close to the body on the left side, I split the entire scrotum to the body, making the incision on the right side from G to G, and having pared a strip on the tegumental side (vide the shaded space between the dotted line and the margin of the scro- tum) so that the raw surface would come in contact with the denuded edge of the new flap (dotted line E F) made by the previous operation, I turned the anterior half of the scrotum upwards, and fastened it with pins and sutures to the lower margin of the flap above, covering in entirely the rudi- mentary penis, and leaving the raw surface of this scrotal flap (denuded of the tunica vaginalis) exposed. I drew down the left testicle and cut it off, having ligated the cord with catgut, proposing to do the same with the right stone, but it could not be found on account of the hernia on that side being only partially reducible. I, however, returned as much as possible into the abdominal cavity. The next step was to make the side flaps, which I took from each groin and united to the median line over that portion of the bladder which could be seen. I brought the posterior half of the scrotum upward and fixed it to the remaining exposed surface of the already turned-up anterior wall. These wounds healed kindly but slowly, having to skin-graft several of the raw surfaces. Although I made an incision in the anterior scrotal wall as it was turned up, and drew the penis through it, the organ was so un- manageable that it slipped away from the opening. Knowing that Levis, of Philadelphia, had turned the penis in with the anterior scrotal flap, this did not give me much uneasiness; but I found afterwards that I should have amputated the penis, because the titillation of the skin caused erections of the organ, which, pressing upward upon the newly forming connective tissue, gradually separated a portion of the bands of adhesion and allowed a part of the lower flap to fall downward. It will be seen that both these cases were of the male sex. The third, which I have under care, is a female. There is only a rudimentary vulva, no clitoris, no pubic bones, and, I judge, no uterus. - Epispadias—Hypospadias.-In some cases the urethra terminates on the upper portion of the penis, and sometimes from an arrest of development an opening exists in the course of the canal on the lower side of the organ. To the former condition the term epispadiasis applied, to the latter hypospadias. In both instances of exstrophy of the bladder which I have recorded, there was complete hypospadias; indeed, a simple groove covered with mucous membrane existed on the upper part of the penis. As far as my knowl- edge extends, the affection is beyond the reach of medical or surgical treat- ment. In hypospadias, urethroplasty may be attempted. The first proceed- ing is to open that portion of the urethra beyond the fissure, as from want of use, in the majority of cases, it becomes obliterated. This must be con- 920 A SYSTEM OF SURGERY. ducted with great care, and be performed with a round blunt instrument not much larger than a common probe. From experience in the sepa- ration of occluded mucous surfaces, I am confident that greater success º carefully introduced blunt instruments than when the knife is em- ployed. So soon as the canal is opened, a catheter (silver) should be introduced into the bladder, the edges of the fistula pared and approximated with metallic sutures. Nélaton's method consisted of the above, together with a dissection of the skin to relieve tension of flaps, underneath which a slip of india-rubber was placed to prevent the surfaces being injured by the urine. Auger's method, which is probably the best, is thus performed : The first cut must be made about half an inch from the right margin of the groove representing the urethra, from each end of this a transverse cut is made to the urethral line and the flap dissected. A similar flap is to be made on the left side, thus having two square leaves of integument hang- ing by their urethral margins. The right flap is turned over (skin toward the urethra) and secured by stitches thus placed : The needle is entered through the base of the left flap piercing the skin first, and then through the free edge of the right flap from the raw surface toward the skin. It must now be made to catch the edge of the urethral groove on the left side and again passed through the base of the left flap, the stitches must be tightened, and can be removed through the skin surface, a like number of stitches are then passed through the free margin of the left flap, by which it is at- tached to the skin of the penis at the outer edge of the raw surface, from which the right flap was removed. The raw surfaces are thus brought into apposition. As a rule, a small fistulous orifice remains, which may be closed by a second operation. Care must be taken to keep the patient from all excitement, especially sexual, for an erection may undo the entire opera- tion. Such a case happened in the practice of Dr. Wilcox. Erection after erection spoiled the surgeon’s work in spite of the cold coil and many sedatives. The doctor finally contrived an electric bell attached to the penis; as soon as the organ became turgid the bell rang violently. The ex- pedient was a success. Hermaphrodites.—Of all anomalies of form which the anatomist en- counters, there is none so curious as the hermaphrodite. These compli- cated deformities have been considered by different authors, and are found to arise from an arrest of development of the female organs of generation and the formation of the male sexual system, or a part of it, in one indi- vidual, and vice versa. º | Such monstrosities have from time to time been described in medical lit- erature; but, according to Bischoff, Paget, and Müller, many of the cases cannot be considered as reliable. The former of these authors has pointed out the reason for rejecting the examples that have been described. He states that there are numerous sources of error by which the judgment may be warped; as, for example, the great resemblance between the generative organs of the two sexes at an early period, the uniform type in the development of both, the coalition of the corpora Wolffiana, and the errors formerly prevalent as to the primi- tive identity of both sexes. - The existence of testicles and of ovaries on the same side, in their normal position, the development of the uterus, of the seminal vesicles, of the prostate and Cowper's glands, have, strictly speaking, neither in man nor in the higher order of animals, ever occurred. The case that I am about to describe approximates nearer to true hermaphroditism than any on record, there being both testicles (although concealed and abnormally placed), HERMAPHRODITES. 921 ovaries, more than rudimentary Fallopian tubes, uterus, vagina, penis, with glans and prepuce, and scrotum. Hermaphrodites have been thus classified: I. Those which, being, as to the essential organs of generation (testicles and ovaries), distinctly male or female, exhibit nevertheless some anomaly of development—be it arrest, overgrowth (up to the masculine type), or disproportion of some other kind—more or less typical of the opposite SeX. a. “Hypospadias,” in its highest grades, viz., on the one side a cleft scrotum and the formation of a vagina-like sinus; on the other side, as its analogue, diminutive vagina, closure thereof into a raphé or suture, par- tial or entire absence of this organ, with a clitoris developed into the sem- *: of a penis hypospadiaus, or one completed, and channelled with a urethra. b. “Cryptorchism.” Concealed testicles, in the one case; in the other, its parallel condition, descent of the ovaries into the greater labia pudendi, now and then associated with the foregoing form. High grades of these anomalies constitute the so-called transverse hermaphroditism, implying external organs of the one, and internal of the other sex. The case of ex- ternally female and internally male organs, is by far the more common, because due to an arrest in the development of the male organs, whilst the opposite case depends upon the ulterior development of the female organs into the male type. c. The occurrence in the male sex of a womblike organ. d These cases collectively constitute what is termed spurious hermaphro- itism. - II. “Lateral hermaphroditism.” The presence of testicles and was deferens, with or without seminal vesicles on one side, and of ovarium and tube on the other. III. “True hermaphroditism” (hermaphroditism per excessum, androgynus, coexistence of male and female organs on the same side). From these remarks, it would appear that the case represented in the woodcut is remarkable, in possessing the characteristics of all the dif- ferent forms of hermaphroditism (with the exception of the lowest grade, hypospadias) embraced in the above classification. By referring to the drawing, it will be seen that it embraces a high grade of cryptochism, b, or transverse hermaphroditism, viz., external organs of the one and internal of the other sex. Also, c, the occurrence in the male sex not only of a womblike organ, as mentioned in the classification, but of a well-developed uterus and vagina. It comes, to a certain extent, under II, lateral hermaph- ºroditism, and we find it nearly allied to III, hermaphroditism per excessum, or the coexistence of the male and female organs on the same side, the last being a condition of things which is positively denied by some authorities. Gurlt and Meckel have recorded such cases; but Bischoff remarks in refer- ence to them, “that not a single one offers conclusive evidence of the union of the two main organs of generation, the testicle and the ovary, and that the seeming dualism of the rest of the organs is explicable according to the principles of arrest of development.” - From these facts, the anomalies of form, size, and relation of the organs represented in the cut, are certainly worthy of attentive examination. The accompanying sketch (Fig. 576) I made from a cast. The model was taken from the organs themselves shortly after death, and the arrange- ment of the parts is such as will best exhibit them in their connection. The late Professor Brainerd was acquainted with the individual during life; and assured me that a regular menstrual discharge took place, the fluid passing through the vagina into the urethra, and making its exit 922 A SYSTEM OF SURGERY. through the penis. By referring to the cut, it will be seen that the empty. bladder, N N, with the uterus, K, have been, for their better exposure, twisted upon their pedicle, which is the commencement of the urethra, and that the rectum, F, has been flattened out. It is by such an arrange- ment that the cast could be taken to show the entire parts in their con- nection. The penis, A, is well developed, and has a prepuce and glans, B. The scrotum and dartos, fully formed, are represented by C. The pubic Symphysis, D, has been sawn through; the scrotal integument, has been allowed to remain, C, extending to the anus, E, showing the perinaeum, P. F is the rectum, empty and collapsed; G, the partial fimbriation of the Fallopian tubes; H, H, the ovaries; I, I, testicles on each side, covered by FIG. 576. sº-º ºzz º := };}}... =ºff. gº. liſ, Hermaphrodite. deflections of the peritoneum; K, the uterus, well developed; L, the os tincae; M, the vagina, its wall divided to show its internal surface, with rugae, etc., and the position of the cervix uteri; N, the bladder (empty), upon which is lying the uterus. Through the kindness of Dr. John McE. Wetmore, I examined a remark- able case. In this, the breasts were developed, there was a beard on the face, and there was a well-developed penis with prepuce; a vagina of con- siderable capacity, and apparently testicles in each enlarged labium, which looked like a cleft scrotum. The case of the German hermaphrodite who was exhibited throughout the country is familiar to most medical men. An interesting case of hermaphroditism in the male, the patient believing itself to be a woman, and being married to a man, is recorded by W. E. Wheelock, M.D.” Calculous Nephralgia.-In this disease there is the passage of a calculus down the ureter. Many of the symptoms are similar to those of nephritis, with the exception of fever. The diagnosis is made by the suddenness of the attack, the comparatively healthy condition of the urine, the absence of fever already noted, and the instantaneous relief afforded, as the stone passes into the bladder. The pain is of excruciating character, and shoots down the loins into the scrotum ; there is vomiting and retraction of the testicle. * Medical Record, June 8th, 1878. UNSTABLE KIDNEYS. 923 Treatment.—I have never known though I have heard of cases relieved by homoeopathic medication ; I have listened to long discussions in which the enthusiastic have asserted, that in every case of nephritic colic, simple and pure homoeopathic medicines, in attenuated doses, should be employed; but I must say, that the hot bath, hot fomentations to the part, and the inhalation of chloroform, have been most serviceable in my hands. Morphia must be used, either hypodermically or otherwise, in most cases, and has to be given in full doses until the agony subsides. The suffering is occasioned by a mechanical cause, and until it is removed the pain will continue. Unstable Kidneys.--—I have given this name to kidneys which are not fixed, in order to mark the difference between the floating kidney and the movable kidney. By the former is understood a kidney which has a mesentery, and which moves within the cavity of the peritoneum, whereas the latter indi- cates that the kidney is capable of restricted movement within its capsule of fat, or in a sac made between the peritoneum and the abdominal wall. The former is more rare than the latter, and there is always some difficulty in making out the diagnosis. Mr. Lawson Tait is of opinion that the “floating kidney ’’ is a myth. In general terms, it may be said that the degree of mobility indicates the different conditions. In a case of floating kidney which I exhibited to the Medico-Chirurgical Society of New York, the evidences of unstability were sufficiently obvious to convince the most skeptical. The patient was a young woman, aged twenty-three years. Her general health was good, but she occasionally had severe shooting pains in the right lumbar region, which were worse upon motion. When lying on her right side, and rising suddenly and leaning a little forward, the members of the Society detected the kidney (by its shape) in the right latero-lumbar region, and sometimes also a little toward the front of the abdomen. This tumor could be readily moved in all directions, and when the patient assumed the recumbent position, the kidney immediately disappeared. I could not (and according to my judgment, it must take a superlative “tactus eruditus” to accomplish the feat) tell whether the kidney was attached by a pedicle, long or short, as Henderson says can be done. Symptoms of dyspepsia, with occasional diarrhoea, were present, and there was at times sudden stoppage of the urine. The treatment I recommended was the wearing of a bandage. According to Newman,” who quotes Skorczewsky, out of 1422 patients, 32 females out of 1030, and 3 males out of 392, were affected with floating or movable kidney. The reasons that females are more liable than males to be afflicted, is supposed to be the congestions and pressure which are known to result from menstruation, conception, gestation, and child-bearing. M. Oser, of Vienna, quoted by Newman, “considers that pregnancy is one of the most common causes of movable kidney, and states that among the poor of Austria, 10 per cent. of the women who have borne children suffer from it, and Professor Bartels, of Kiel, has found it frequent among working women, but attributes it to the habit of wearing tight waist strings to hold up heavy clothing.” - - The right kidney is more subject to displacement than the left, and hydronephrosis is a frequent accompaniment of the affection. As might be anticipated, the great vessels, from the constant traction upon them, are fre- quently elongated, and from the twisting of the ureter as well as the vessels the urine is prevented from passing into the bladder. In another case that was under my care the bladder was affected sympathetically, and severe urinary tenesmus was present. This patient, who had borne three children, while feeling apparently * New York Medical Abstract, January, 1884, p. 16. 924 A SYSTEM OF SURGERY. well, would be seized with great prostration and fainting, would pass into a Comatose state, accompanied with complete suppression of urine, at which times a strong urinous odor could i. perceived upon the breath. This “fainting turn " would occur at irregular intervals, and last from thirty minutes to three or four hours, and on one or two occasions collapse and death were imminent. t Treatment.—It is important that the diagnosis, as to which kidney is affected, be made, if any operation, either nephrorraphy or nephrotomy, is to be performed, and in the section upon the latter, the directions are given by which a somewhat definite conclusion may be arrived at. If the kidney is movable, and can be felt and seen to change its position, the diagnosis is not difficult, but if the case is one in which hydronephrosis or pyonephrosis is present, the question which is the kidney to be operated upon, is the sine qua mom. If the patient does not suffer inconvenience from movable kidney, the best and only treatment is the application of a well-fitting elastic bandage, * should be worn night and day. This will generally give the patient Tel1621. The operation for fixing the kidney is as follows: The patient is placed on the left side; an incision, about sixteen or eighteen centimeters long, is made in the lumbar region along the external border of the sacro-lumbar muscular mass, extending from the last inter- costal space to the crest of the ilium. The surgeon must cut carefully through the parietes, until the circumrenal fatty connective tissue is reached. The kidney must be pushed up with the hand and kept in position, while the operator, breaking through the fatty connective tissue, discovers the convex border and the greater part of the posterior surface. The first suture must be put in the convex border; the needle traversing the fibrous capsule of the kidney. The circumrenal fatty connective tissue is then raised and drawn into the wound, through the tissues directly under the lower edge of the last rib, and again through the circumrenal con- nective tissue. A second suture is applied on the posterior surface of the kidney, and in the deep tissues of the posterior lip of the wound. A third suture is placed in the same way in the anterior surface of the kidney, at the convex border and the deep structures of the anterior margin of the wound. With these three sutures the kidney is held in position. For greater security, the circumrenal fatty connective tissue of the lower half of the kidney may be united by four sutures to the tissues of the wound. Catgut sutures are used. A large drainage-tube is applied deeply, and a Small one superficially, and the wound sewed up with seven points of deep sutures and twelve superficial. . Nephrectomy.—According to Weir,” Simon first intentionally performed nephrectomy in 1869, and since then the operation has been resorted to 152 times, about half the patients dying. Weir states, with good sense, “Nor has the mortality decreased in the last fifty cases as might have been expected.” He then gives the following interesting summary : - Disease. Cases. Deaths. Mortality. Wounds, wº • tº * * ſº . 5 2 40 Per cent. Urinary fistula, . º O © º . 9 3# 33.32 “ Floating kidney, . e * > e º . 16 6 37.5 {{ Hydronephrosis, . & e º t . 21 12 57.14 “ Tumors, * e g º º * > . 32 22 68.75 “ Suppuration, . e tº tº g te . 58 27 46.5 & * Medical News, December 27th, 1884. f Weir has two deaths, but is corrected by an editorial in Medical News, January 3d, 1885, from which this table has been made, NEPHRECTOMY. 925 Thus making a mortality of about 50 per cent. Gross,” however, makes the death rate somewhat less, out of 233 cases 129 recovered, and 104 died, making a mortality of 44.63 per cent. Of these oper- ations 111 were by the lumbar incision, and 120 by the abdominal, and 2 un- certain. Of the first the percentage was 36.93; of the second, 50.83 per cent. The diseases for which the operation should be performed are chiefly, suppuration and hydronephrosis and various neoplasms. The great point is to ascertain which kidney is affected, and whether there are two kidneys. Instances are upon record where the operation has been performed and one kidney found. These are rare. If the reader will refer to the section of this Chapter on Exstrophy of the Bladder, he will find a record of a remarkable case, in which but one kidney existed, which was nineteen inches and a half in circumference. It is said by Dr. Weir that such an anomalous condition need scarcely be tººd as “the single kidney is found about once in five thousand OCI16S. ' ' In a case of tumor or of hydronephrosis (cystic disease) the affected kid- ney can readily be ascertained, but it is difficult to discover which organ is secreting the pus casts, and cellular elements after they have passed into the bladder or through the urethra. Several methods have been devised for this purpose, all of them save one being difficult and uncertain. The idea has been, either by catheterization of the ureters, compression with the hand in the rectum, or with the rectal rod of Davy, to temporarily obliterate one ureter and to collect the urine and ascertain its character and thereby judge which of the kidneys is diseased. The methods which pre- sent the best chances of success are the introduction of the hand into the rectum, the exploratory incision of Lange, or the method of Dr. Polk. The hand may be allowed to compress the ureter for a time, to collect urine enough for examination. Broad compression of the artery will generally be sufficient to obstruct the ureter. Dr. Polk proceeds as follows: “The method I have to suggest is to compress the ureter. It is easier of performance in the female than in the male, but I believe it can be accom- plished in both. Take a large catheter, made of some substance like block- tin, bend it to the shape of a Sims' sigmoid catheter, let the curve that passes into the bladder be as decided as it can be made, and yet not so great as to interfere with the ready passage of the instrument into the bladder. Suppose it to be the right ureter you desire to close : “Introduce the instrument, then place the patient in the lithotomy posi- tion. Now carry the fingers as far into the rectum as possible. Now place the catheter so that its curve in the bladder hugs the right pelvic wall; the end of the curve will pass directly across the line of the right ureter. Now press the fingers against the catheter, and the ureter will be sufficiently oc- cluded to prevent all escape of urine. By means of the catheter in position (it may be double) you thoroughly cleanse and empty the bladder. As fresh urine flows in from the other ureter, it can be withdrawn and tested. As urine from a sound kidney is secreted at about the rate of a minim in four or five seconds, it will not require long-continued pressure to secure the amount of urine necessary for satisfactory examination. In the female the procedure is more certain of accomplishment than in the male, because we can, in a measure, fix the base of the bladder by traction upon the an- terior vaginal wall by means of a tenaculum hooked into it just below the cervix, or, better, well to the right of the cervix on the lateral wall, the traction being downward and to the patient's left.”f * American Journal of the Medical Sciences, July, 1885, p. 79. f New York Medical Abstract, vol. iv., No. 1, page 19. 926 A SYSTEM OF SURGERY. The Operation.—There are two methods of performing nephrectomy, one through the abdomen, the other through the loin. For tumors of any magnitude or hydronephrosis (when nephrotomy is not applicable), the abdominal incision ought to be preferred, although, even in these cases, the mortality is large. For the removal of smaller growths and pyonephrosis the lumbar incision is best. Abdominal Method.—There are two incisions by which the kidney can be reached through the abdomen, one, when the tumor is large, being made in the linea alba, about four inches below and three inches above the umbilicus, the other as recommended by Langenbach in the lineae semilu- nares. The peritoneum then comes to view, and is carefully divided, and the intestines turned over until the kidney is found, when the large vessels forming the pedicle are exposed, if it be possible, they should, as recom- mended by Agnew, be tied separately. In all masses of tissue in which large bloodvessels ramify, it has been my custom before applying the ligature, to put on some sort of a clamp, not so much for the arrest of hamorrhage, but to keep the parts from slipping away when the ligatures are being tightened. Even through the blades of a tightly-screwed clamp, I have known just enough tissue escape to give rise to great haemorrhage. After the vessels have been secured, and an additional ligature tied with a Staffordshire knot has embraced the pedicle, then the operator may enucleate the kidney from its capsule, if so desired, or cut away the organ; after this, he should cauterize the stump thoroughly with a Paque- lin, or ordinary iron, then remove the clamp, still having hold, however, of the stump with a pair of forceps as the clamp is unscrewed, to be sure that there is no hamorrhage. The cavity may then be thoroughly washed with bichloride solution 1 to 2500, and the wound brought together with silver or catgut; all this must be done with the strictest antiseptic precau- tions. - - Lumbar Method.—In this the patient is placed on the sound side, three- quarters or more face over, with the body somewhat bent. The incision is made along the border of the quadratus lumborum, beginning below the twelfth rib, three inches from the vertebrae, and carried almost or (if occasion require) to the iliac crest. This cut includes integument and cellulo-adipose tissue, and exposes the conjoined tendons or portions of the internal oblique and transversalis muscles. These must be divided upon a director, when the full border of the quadratus comes in view, and, under this, the fat in which the kidney is embedded. This adipose tissue is soft and may be separated easily with the finger, until the kidney is seen. The organ may then be cut into or aspirated as may be deemed proper; and an incision made in the capsule and the kidney removed, as in the preceding method. It will be found sometimes difficult to clamp the pedicle in this operation, but the ligature thrown about the vessels should be strong and tied tightly. - Dr. Gross, says at the end of his elaborate paper, already referred to : “From a careful analysis of all the facts pertaining to the surgery of the kidney contained in this paper, based as it is upon a study of nearly four hundred and fifty cases of different operations, I believe that I am justified in formulating the following propositions for discussion: “1. That lumbar nephrectomy is a safer operation than abdominal ne- phrectomy. “2. That primary extirpation of the kidney is indicated, first, in sarcoma of adult subjects; secondly, in benign neoplasm at any age ; thirdly, in the early stages of tubercular disease; fourthly, in rupture of the ureter; and, lastly, in urethral fistula. “3. That nephrectomy should not be resorted to until after the failure of NEPHROTOMY-NEPHERORRAPHY. 927 other measures, first, in subcutaneous laceration of the kidney; secondly, in protrusion of the kidney through a wound in the loin ; thirdly, in re- cent wounds of the kidney or the ureter, inflicted in the performance of ovariotomy, hysterectomy, or other operations; fourthly, in suppurative lesions; fifthly; in hydronephrosis and cysts; sixthly, in calculus of an otherwise healthy kidney; and, finally, in painful floating kidney. “4. That nephrectomy is absolutely contraindicated, first, in sarcoma of children; secondly, in carcinoma at any age, unless, perhaps, the disease can be diagnosticated and removed at an early stage; and; thirdly, in the advanced period of tubercular disease.” Dr. I. H. McClelland, of Pittsburgh, published the account of an interest- ing nephrectomy in November, 1880.* Mr. Christopher Heathi reports also a nephrectomy for sarcoma of the kidney performed upon a young child, the patient surviving eighteen hours. Mr. F. B. Archerſ gives an account of an abdominal nephrectomy per- formed by himself on a widow, aged 50 years. The case was remarkable because of the size of the cyst, which contained eighteen pints of fluid. There was collapse, but the patient ultimately recovered. Dr. John E. James and Dr. George A. Hall have successfully performed this operation. Nephrotomy—Nephrorraphy.—By this is understood an opening made in the groin or in the abdomen according to the directions given for nephrec- tomy, and either aspirating or opening the kidney for the evacuation of water (hydronephrosis) or pus (pyonephrosis) or for fixing a movable kidney. This operation should be done, if practicable, in preference to nephrectomy, and should be tried before the performance of so serious a procedure. - The incisions are made in a similar manner to those mentioned in the last section, for the performance of lumbar nephrectomy; when the kidney is reached, the organ is to be pushed into the wound. The Surgeon must hold the kidney in the opening, and pass a stout needle, threaded with a strong antiseptic catgut ligature, through the cortical substance of the upper portion of the organ from its anterior to its posterior aspect, about half an inch from its convex margin. A second thread of similar calibre and preparation, must be passed through the lower portion of the kidney in the same manner. The kidney must now be al- lowed to slip back into its capsule of fat, and the cut surfaces of it (the capsule) carefully stitched to the muscular tissue at the deep portion of the wound. The kidney sutures must be passed through the muscle, cel- lular tissue and skin, but not tied, a drainage tube must be inserted, and, traction being made upon the ligatures passing through the kidney, it is to be drawn into its place, filling the bottom of the wound. Then the integument must be stitched together and the kidney sutures either clamped or tied over a piece of bougie. Prof. Franzatime performed nephrorraphy by fixing the floating kidney to the wall of the lumbar region, according to the directions already given. The operation was made through the abdominal incision, and the lapa- rotomy and fixation together, only occupied one hour and thirty minutes. It may be well to remark that the abdomen was opened for a suspected tumor of the mesentery.S Dr. George A. Hall, of Chicago, made a successful nephrotomy in a case of nephrolithiasis. * Hahnemannian Monthly, November, 1880. + British Medical Journal, July 15th, 1882. † London Lancet, July 1st, 1882. 3 Medical News, July 4th, 1885. | Medical Investigator, May 15th, 1880. 928 A SYSTEM OF SURGERY. Cystitis.-The urinary bladder may take on inflammation, to which the names cystitis, inflammatio vesicae are given. The inflammation may attack any of the coats, but generally affects the mucous one, and the secretion of mucus, which in an acute form of the disease is diminished, in the chronic stage becomes increased and altered, constituting the disease known as catarrhus vesicae, dysuria, mucosa, catarrhal inflammation of the bladder. The general symptoms are, acute pain, tension, and tumor in the region of the bladder, with fever; pressure above the pubes causes pain and Soreness, and when made on the perinaeum produces micturition, the urine being dis- charged in small quantities and with suffering, or there is complete inability to pass it; it is of a dark-red color and is frequently discolored with blood; there are also tenesmus and vomiting. The pains are burning, lancinating, or throbbing, and extend to the perinaeum, sometimes to the testicles and upper part of the thighs. In some cases there is confirmed suppression, with skin hot and dry, pulse frequent, hard, and full; tongue whitish, thin, red, and dry. Should the disease not be arrested, swelling in the hypogas- tric region takes place, with increase of sensibility in the perinaeum and hypogastrium. If the neck of the bladder especially be affected, pain is felt in the perinaeum, and there is complete retention of urine, or the patient has dysuria (difficulty in passing urine), or strangury (issuing drop by drop). In this condition the introduction of a bougie is painful. Tenesmus takes place if the posterior part of the bladder be chiefly affected, in consequence of its proximity to the rectum. If the inflammation be about the mouths of the ureters, and extend along their course, complete retention takes place, and there is more or less tenderness on pressing upon the hypogastrium. The disease may terminate in resolution, suppuration, and as in other inflamed mucous surfaces by the deposits of false membrane (Pseudo-mem- bramous Cystitis), gangrene, or induration and thickening of the coats of the bladder. Resolution is known by the gradual disappearance of symptoms; suppuration if chills or rigors accompany the abatement of the pain and fever, with deposit of a white matter in the urine. If suppuration take place in the mucous membrane, or an abscess form between the coats of the bladder, and the pus break into that viscus, it will be discharged with the urine; or it may open into the vagina or rectum, infiltrating cellular tissue of the pelvis; or it may burst into the peritoneum, labia pudendi, or scrotum. In the majority of cases which have an unfavorable termination within seven days, gangrene follows, which is known by the sudden subsidence of pain, cold, clammy perspiration, cold extremities, prostration, confusion of intellect, weak, frequent pulse, deathlike countenance, and hiccough. The causes are, acrid substances irritating the bladder; injections of can- tharides or turpentine thrown into the bladder; metastasis of other diseases, as rheumatism and gout; gonorrhoea; the introduction of a catheter or bougie ; suppressed sweat and hamorrhoids; injury in parturition, or by the use of obstetrical instruments; the application of cold to the feet or lower portion of the abdomen; retained urine; external . in the hypogastric region; retroverted womb; frequent use of stimulating drinks. When complete suppression of urine exists and the inflammation is high, the danger is imminent. - Treatment.—The medicines are, acon., canth., equiset, hyem., nux, bell., merc., scill., phosph., apis, sulph., lycop., Sandalwood oil, uva ursi, copaiba, cubebs, puls. With this treatment the bladder should be washed (see further in this chapter), hot sitz baths taken in the chronic form of the disease every night and morning, and in the acute every three or four hours will give comfort to the patient. If there should be urinary tenesmus, hyoscyamus in ten-drop doses, given in a small quantity of hot water and repeated every four hours, has in my hands been more effectual than any CYSTITIS. 929 other medicine. In both the acute and chronic forms I have insisted upon two things: one the complete abstinence from all—even the mildest— stimulants, and the taking freely of demulcent drinks, especially a decoc- tion of triticum repens or buchu, of which the patient should take at least ten ounces daily. Small doses of the liquor potassa are frequently of signal Service. In chronic cystitis I have been successful, especially in women, in dilating the urethra. This is effected by the instruments constructed for the purpose. In men a gradual dilatation may be made with sounds, followed by the use of Sir Henry Thompson's dilator, and in women I have used Goodell's cervix dilator with excellent results. If these means fail, then the surgeon must consider the propriety of either a supra-pubic or vaginal opening. The latter process of establishing a new outlet for the urine, thus allowing the irritable parts complete rest, is gaining favor among specialists. Washing out the bladder should be performed in all cases of cystitis whether acute or chronic; if the former, the water should be hot, in the latter it FIG. 577. tº sº tººs § d § l / / // Ž Ö % // A.WY NOWNYWS-CO. should be tepid, and this no matter what substances are employed to medi- cate the fluid. Irrigation is frequently done by the ordinarydouble catheter (Fig. 577). A more satisfactory instrument is that seen in Fig. 578, which is flexible. FIG. 578. º Flexible Double Catheter, The best apparatus is that devised by Dr. Keyes, and which I have employed and recommended for years. Especially is this a useful instru- ment in washing the bladder of those affected with enlarged prostate. Fig. 579 shows the apparatus with its description. The simplicity of the instrument as figured is obvious. To the fountain- syringe bag holding a pint, and a tube of variable length, so as to allow, if desirable, considerable pressure by elevating the bag, is attached a two-way stop-cock. Upon the tube is another stop-cock only useful when it is de- sired, having thrown a medicated solution into the bladder, to retain it there for a certain length of time without either allowing the bladder to become over full, or its contents to escape. The nozzle of the stop-cock is very large, and fits into the expanded conical mouth-piece. It fits so easily, that 69 930 A SYSTEM OF SURGERY. the most clumsy fingers can readily adjust it almost unaided by sight. Upon this catheter is fitted a thin piece of rubber tubing, covering its upper two-thirds, which allows the mouth-piece to be used with any metallic or other hard catheter, and prevents leakage. The fine conical point is to be FIG. 579. screwed into any soft catheter before introducing the latter. The other branch of the two-way stop-cock is fitted into a short piece of rubber tubing which conveys the urine and the washings into some convenient receptacle. Other medicines are adapted to this disease, and especially to the more chronic forms; each case which presents itself for treatment having its own peculiar symptoms, for which the materia medica must be consulted. Tubercular Cystitis.-This disease manifests itself in three ways, and in the majority of instances is secondary. 1. It may arise as secondary to tubercular nephritis; 2. From tubercular disease of the testicle; 3. It may begin primarily in the bladder. One of the first evidences is hamaturia, the blood coming from the mu- cous lining of the bladder; this symptom may continue for several years before the more severe manifestations take place. After a time, pain is felt in the region of the bladder, urination is increased in frequency, there is much vesical tenesmus, and pus is found in the urine which is more or less gelatinous in character. The pain may be diagnosed from that of calculus by the fact that there is no relief in any position and that the suffering pre- vents sleep. The position of the patient is often characteristic; he lies with his legs drawn up to relax the abdominal muscles and thus remove pressure from the bladder. The prognosis is bad, because in the majority of instances the kidneys become affected and the patient succumbs to uraemia. Relief is obtained by washing out the bladder with an iodine solution and bella- donna suppositories in the rectum. The medicines adapted internally are thuja and boracic acid, together with the adjuvants of rest, absence of stimu- lants, dilatation of the urethra, already mentioned in the treatment of ordi- nary inflammation of the bladder. - - CATHETERISM IN THE MALE. 931 Cystitis in Women.—This disease is divided into acute and chronic, and the inflammation may affect any of the investing coats of the bladder. It may begin at the peritoneal coat and extend inward, or it may begin with the mucous lining and extend outward. There are many causes which develop this affection; it arises from over- distension of the bladder; sometimes from the introduction of foreign sub- stances into the vagina, as used by hysterical women in masturbating, and sometimes from injuries. Peritoneal inflammation, gonorrhoea, vaginitis, too frequent application of the catheter or the rough use of the instrument, also produce the disease. The symptoms are so well marked that the diag- nosis is easy. There are painful and frequent emissions of urine accom- panied with tenesmus of the bladder; there are pains in the peritoneum which sometimes extend to the navel or even to the breast. The urine contains, upon examination, mucus, blood, or pus. At first the secretion is pale and the specific gravity low, becoming, after a time, high-colored. After the symptoms have continued for a length of time the inflammation may extend by continuity of surface along the ureters to the kidneys and secondary nephritis result. Treatment.—Besides the remedies mentioned, rest is an important factor, and a diet consisting of large quantities of skimmed milk may be em- ployed. When the tenesmus is excessive the tincture of hyoscyamus in five- to ten-drop doses, given in hot water, will be found useful. The blad- der must be carefully washed with a solution of boracic acid and warm water, twenty grains to the ounce. Rapid dilatation of the urethra is also effective, and can be employed without danger every other day. The in- strument which I have employed for this purpose is Goodell's dilator for the cervix uteri. The other medicines for the treatment of cystitis in women do not vary materially from those used for inflammation of the bladder in men. t Retention of Urine (Ischuria Vesicalis).-This affection differs from sup- pression of urine. In the latter the kidneys do not perform their usual function, while in ischuria, the urine is secreted and passes into the bladder, but cannot be ejected. There is more or less pain in the bladder, which, from distension, is perceptible above the pubes; there is urgent desire to void the urine, with pain and nausea, and but few drops are emitted. The disease is generally amenable to treatment, but in some cases it is of intract- able character. Treatment.—The medicines for this complaint are, acon., cann., canth., dulc., merc., nux vom., op., puls., stram. Others may be required in par- ticular cases. An empirically applied medicine, but one which relieves spasmodic retention of urine frequently in a short time, is buchu. The powerful action that this plant is known to exercise upon the urinary appa- ratus, should lead to its complete proving upon the healthy individual. The method of preparing it for administration is as follows: Place in a large-sized tumbler, or other vessel, a small handful of the leaves and pour thereon scalding water; allow this to remain until it becomes cold; of this infusion administer a dessertspoonful every quarter or half hour, until the patient is relieved. This mode of administration may be useful to the prac- titioner in urgent and peculiar cases, when other means have failed. When the patient is suffering intense pain from distension of the bladder, the catheter should be immediately used. Catheterism in the Male.—Every physician and surgeon is called upon to pass the catheter into the bladder of man. Those who have often essayed the operation are aware of the difficulties that attend its performance, and those who are seldom called upon are fre- 932 A SYSTEM OF SURGERY. quently, after repeated and unsuccessful trial, obliged to abandon the task, or hand the case over to more experienced manipulators. There is scarcely an operation which requires more dexterity and knowl- edge, more gentleness and steadiness, than the simple procedure of the in- troduction of a catheter, or, as it is technically termed, catheterism. A bungler may often pass an instrument through a healthy urethra and reach the bladder, while, on the other hand, experienced and renowned surgeons have been foiled in the attempt. I very well recollect, while I was a student, waiting in the amphitheatre of the old Pennsylvania Hospital for over an hour while two gentlemen of acknowledged surgical ability were endeavoring to relieve a patient of a bladder full of urine. I have heard the illustrious Mütter state to his attentive class that the most important operation which the general practitioner was called upon to perform was undoubtedly catheterism. Surgical Anatomy of the Deep Urethra.-If we draw a line across the perinaeum from one tuber ischii to the other, we form the base of two tri- angles, the upper one having an apex at the pubic arch, and being termed the urethro-perineal, the other having its point at the coccyx, and being designated the perineo-anal triangle. It is the upper of these spaces that we propose to consider, as bearing upon the point we have in view. The line aforesaid from the tuberosities of the ischia would pass above the verge of the anus, and must therefore be some distance below the transverse perineal muscles. The sides are very nearly equal, and measure from three inches to three inches and a quarter. In the centre of this triangle, and dividing it into two halves, passes the raphé of the perinaeum, which is of considerable importance in a surgical point of view, but of little consequence anatomically. . - - Underneath the skin, which is counted as the first covering of the parts, and which is thin, elastic, and very movable, indeed to such a degree as to render it not easily divisible without being put upon the stretch and firmly held by the finger and thumb, we have the second layer, which is a cellulo-adipose structure, varying considerably in thickness; this fascia does not lie in contact with the pelvic bones, but is continuous with a similar structure upon the thighs and scrotum. After we remove this layer we come upon the true superficial fascia of the perinaeum, which is attached in a peculiar manner, an appreciation of which serves to explain the course taken by the urine in extravasation, either from rupture of the urethra or after surgical operations in the perinaeum. To the outer border of the pubic and ischiatic bones it is firmly attached, and also to the triangular ligament, of which I desire to speak more particularly hereafter, whereas in front it is continuous with the dartos of the scrotum. Therefore in cases of urinary infiltration, unless this fascia is ruptured, the renal Secretion cannot gravi- tate either downward or backward, as would be supposed, but passes for- ward into the scrotum and upward into the groin. Dr. Buck, of the New York Hospital, demonstrated by careful dissections that this fascia also envelops the perineal muscles, the spongy structure of the urethra, and the corpora cavernosa penis. : Underneath the superficial fascia we come upon the fourth layer of the perinaeum, which is composed of five muscles, two in pairs and one single muscle, which, together with the anterior portion of the sphincter ani, are connected at a point called the central tendon. The transverse muscles are situate in front of the anus, are irregular and somewhat triangular in shape, arise from the inner side of the tuberischii, and are inserted into the already mentioned central tendon. The erectors also arise from the tuberosities of the ischium, and are in- serted into the cavernous body of the penis; while the accelerator muscle, SURGICAL ANATOMY OF THE DEEP URETHRA. 933 with a bipenniform arrangement of the fibres, surrounds the bulb of the urethra and is inserted into the triangular ligament and into the cavernous body of the penis. I have passed hastily over these muscles, which are possessed of great interest, that we may come to the structure which we wish to consider, viz., the triangular ligament. Before proceeding to describe it, let me premise that it is called by many names, each anatomist and sur- geon giving it what he deems its most appropriate signification, which often leads to considerable confusion. Thus it is called the deep perineal fascia, Cowper's ligament, the recto-urethral aponeurosis, and the ischio-pubic fascia. It would be far better to designate it by the term triangular ligament of the urethra, which would abundantly suffice for all practical purposes. The triangular ligament then closes up a greater part of the space between the pubic and ischiatic bones, excepting superiorly or immediately under the arch of the pubis, which space is filled by an expansion of fibrous tissue called the subpubic ligament. It is attached to the inner border of the pubic and ischial bones, and extends from the ligament above—the subpubic—to the rectum and anal aponeurosis. It is composed of two layers, an anterior and a posterior; the former, which is comparatively dense, is prolonged forward around the urethra, while the latter is connected with the fibrous investment of the prostate gland. It contains foramina, superiorly for the passage of the dorsal veins of the penis, and about an inch below the pubic symphysis and directly opposite the raphé of the perinaeum, an opening of considerable size for the passage of the membranous portion of the urethra. The urethra, being movable along the most of its extent, becomes fixed and stationary after it passes the triangular ligament, making therefore a fixed curve, which varies but little, excepting in disease of the prostate gland. Besides this triangular fascia, the suspensory ligament of the penis and the anterior true ligaments of the urinary bladder assist in keeping the urethra tn situ, and necessarily fia: the curve at this point of the canal. It is at this point that, from the wrong direction of the curve of catheters, which are often constructed merely as the fancy of the cutler may dictate, or some ill- defined conception on the part of the surgeon, often great difficulty in the introduction of the catheter is experienced. Having in mind the ligaments already mentioned; by finding the distance from the pubic symphysis to the opening in the triangular ligament, we can discover the lowest portion of the curve which the urethra makes as it passes beneath the subpubic arch. This point Sir Henry Thompson has found, by careful and oft-repeated measurements, to be distant from the pubic symphysis from seven-eighths of an inch to one inch and one-eighth, the variations not exceeding one- quarter of an inch, thus explaining why the urethral curve varies so little. Dr. Van Buren thus wrote: “By these firm attachments the curve of the urethra is maintained in a fixed relation to the symphysis pubis, a relation which is unchangeable except by disease or injury to the parts. By taking its centre from the surface of a vertical section through the symphysis, the mathematical elements of the curve can be readily determined. It consti- tutes three-tenths of a circle, three inches and a quarter in diameter.” Or, as Sir Henry Thompson says, the subpubic curve may be considered as an arc of a circle, three and three-quarters inches in diameter, thus making a circle described by a radius of one and five-eighths of an inch in length, the chord of whose arc is two and three-quarters inches. Fig. 580 shows a catheter and sound bent according to measurement. A B, the arc of a circle, three and three-fourths inches in diameter, having a radius of one and five-eighths inches; A B E, a catheter, corresponding to this curve; F B E, a sound, with same curve, though shorter; C B D, Benique's sound, following same curve, though with a larger arc of circle. I would have it understood that these remarks apply to simple stricture, 934 A SYSTEM OF SURGERY. or the passage of the catheter in retention of urine. . It is a different matter in treating cases of enlarged prostate, because in this disease the prostatiº portion of the urethra may be double its natural size, because the increased thickness in the diameter of it may be so great as to form a projection into the canal, and therefore the entrance into the bladder may be pushed so far backward, as to occupy a position almost behind the symphysis pubis. In such cases the catheter must be at least four to six inches longer than usual, have a greater curve, and be somewhat elevated at the point, or otherwise represent more of the arc of a complete circle. FIG. 580. \| # * * * * ,' & w ,’ e’ e : It is always better to have a good-sized catheter, with a curve corre- sponding to the measurements to which attention has been called, if we wish to remove many difficulties in the performance of the delicate ppera- tion of catheterism. Catheters and bougies are made of various sizes, but according to a regular scale. The Nos. 10 to 16 of the English scale are most frequently called for in general practice, although every physician should have eight or ten CATHETERISM IN THE MALE. 935 catheters on hand. Fig. 581 shows Parker's compound catheter, a useful and convenient instrument. FIG. 581. Parker's Compound Catheter and Caustic-holder. The French scale is much used, and by some preferred, because there are smaller, more regular intervals between each number. Thus No. 1 is one FIG. 582. zºº. 20 21 22 23 24 as 26 - º - - 13 la is is is FNG 11 12 Fºc. 19 18 ºwg iſ lo - º s the wann- sº sº. French and English Catheter Gauge compared. millimeter in circumference, No. 2 is two millimeters, and so on to 30. The diagram shows the comparison between the FIG. 583 sizes of the instruments (Fig. 582). --- In introducing the catheter, the patient may be placed in the horizontal or in the upright position, the former being that pre- ferred. The head should rest upon a pillow, and the thighs be slightly bent upon the abdomen. The catheter (of the proper size and curve), well oiled, should be held with the thumb and forefinger of the right hand, while the surgeon, on the left side of the patient, takes the glans penis between his thumb and finger, retracting the prepuce and allowing the orifice to gape. The in- strument is entered with gentle pressure of the right hand, and the penis drawn up almost on a line with the abdomen, with the left, the object is to put the movable portions of the urethra on the stretch, and to draw out the folds º the . lining (see Fig. 583). The catheter is carried alon - - the º until it reaches the arch of º Catheterism pubis, at which point, as has been shown, the urethra perforates the tri- 936 A SYSTEM OF SURGERY. angular ligament. When the instrument reaches this point, it should be brought parallel with the linea alba. Then, still drawing the penis well up on the catheter, compressing it with finger and thumb of left hand, the han- dle should be depressed, or, in other words, made to describe a part of a circle, of which the straight portion of the catheter is the radius, and it will, With a little additional pressure, glide into the bladder. , , Dr. Squire, of Elmira, New York, devised a “vertebrated catheter,” espe- cially for prostatic enlargement. Its curve is formed of sections, as seen in the figure, and it is designed for passing tortuous canals. So soon as it enters the viscus, by turning the screw at the handle the sections are tightened. This improvement has again been somewhat modified by Dr. Caro, of New York (Fig. 584). FIG. 584. gº ºf Essºs - º: S. - e= - c. -E =sº # = Fºº F =s Caro's Modification of Squire's Vertebrated Catheter. a, Is a regulating screw, by which the links can be made firm or slack to any degree, b, Is a stopcock, with nozzle for the escape of urine, as indicated § the dart. Whenever the two buttons (c) stand parallel, the stopcock is then open for the evacuation of urine; but when the nozzle of the stopcock is turned up, or to either side, the escape of urine is entirely prevented. - - - The best ordinary instrument that can be used for entering the bladder is the soft rubber catheter, Fig. 585; it has the advantage of having the edges of the eye sunken. With this catheter a patient may readily be taught to relieve himself, as no danger can result from its application. FIG. 585. Tiemann's Soft Rubber Catheter. In some cases, however, especially of enlarged prostate, the difficulties of entering the bladder seem almost insurmountable; none but those who have had experience in these matters can appreciate the patience, gentle- A --—O G. 7/EMA/W/W & CO Otis's Prostatic Guide. A, Small rod. B, Spiral riband to accommodate itself to the urethra. º FIG. 586. ness, tact, delicacy, and perseverance that are required. Dr. F. N. Otis has invented an ingenious instrument, Fig. 586, for the purpose of aiding the introduction of the soft rubber catheter in cases of enlarged prostate. ABSCESS AND FISTULA IN PERINEO. 937 Figs. 587 and 588 represent the elbow catheter of Mercier, which is said to be useful. If all these means fail, or if there be much difficulty in the introduction of instruments, the aspirator may be used without fear. The capillary punctures heal readily, and the operation may be repeated without danger. It is a question whether, after a careful trial of the catheter, the surgeon FIG. 587. FIG. 588. *- :- - T. T. T_--~ * Mercier's Elbowed Catheter. Mercier's Double-Elbowed Catheter. should not resort immediately to aspiration, rather than continue his efforts with other instruments, thereby necessarily bruising or injuring the parts, and running the risk of making false passages. Catheterism in the Female.—The following is the method of passing the female catheter: The forefinger of the left hand should be introduced between the nym- phae, and passed down to the urethral orifice, which is known by a depres- sion, with an elevation on its vaginal aspect. The catheter should be taken in the right hand, and introduced along the finger which is at the urethral orifice, into which it should be inserted, and thence it easily passes within the bladder. Abscess and Fistula in Perineo.—Urinary fistulae, or perineal fistulae, may arise from a variety of causes, one of the most frequent of which is abscess in the perinaeum. Wounds, bruises, tight strictures, etc., give rise to this distressing complaint. We must remember the manner in which the perinaeum is bound down; that the deep layer of the superficial fascia is firmly attached on each side to the rami of the pubes and ischia, and that it curves behind the transverse muscles of the perinaeum to join the lower margin of the triangular ligament, or deep perineal fascia. It will then be understood why we should endeavor to assist nature in making an outlet for discharges at as early a moment as possible after we have detected the symptoms of a urinary abscess. The constitutional symptoms are often more troublesome than the local. The shivering, nausea, febrile paroxysms, and the furred tongue, are well marked; and, in connection with these— especially if the patient has been afflicted with tight stricture—there is heaviness in the loins, and uneasy sensation in the neck of the bladder, with the stream of urine rapidly diminishing in size, and a slight puffiness about the parts. In proportion as a stricture increases, the urethra at the diseased part is diminished, while that portion of the canal immediately behind the obstruction is enlarged by the continued propulsion of the urine. The irritation thereby induced, engenders the inflammatory process, which terminates in ulceration; an opening is formed through the urethra, and communicates with the cellular membrane surrounding it; the presence of the urine excites additional irritation; suppuration results, the pus is discharged, and there remains a fistulous opening, through which the urine constantly dribbles. . Fistula in the perinaeum may sometimes proceed from rupture of the ure- thra; then the urine is instantly diffused into the loose cellular membrane of the perinaeum and scrotum, where it occasions much distension, and excites inflammation so intense, that in a few hours gangrene and sloughing of the scrotum may take place, leaving the testicles and urethra bare, and endangering life. 938 A SYSTEM OF SURGERY. There is seldom more than one fistulous opening communicating imme- diately with the urethra, but from it numerous sinuses extend in various directions; and in cases of long standing it is not unusual to find the cellu- lar membrane of the scrotum, and all the other parts through which the urine meanders, condensed and converted into indurated tumors, upon the surface of which may be found innumerable small holes, that discharge offensive urine and pus, rendering the patient disagreeable to himself and his neighbors. Treatment.—When a fistula in perineo depends upon a stricture of the urethra, the first care must be to get rid of the obstruction, by means to be mentioned farther on ; after which the appropriate medicines should be administered. Among these are, ars., calc., . an., silic., and sulph. By such means it will be found that as soon as a natural outlet is established the sinuses heal. The safe practice in perineal abscess is to incise the perinaeum in the raphé down through the triangular ligament. This cut may be from an inch to an inch and a half in depth. Even if the pus does not escape, the incision relieves the tension and establishes an opening through tissues which, from their unyielding nature, form such a barrier to the exit of pus that infiltration of the surrounding tissues would be the inevitable result. If the perineal incision be not resorted to at an early day, a ure- thral communication is formed, and we have a true urinary fistula, through which, at every act of micturition, more or less urine escapes. These peri- neal fistulae are divided into the simple and the indurated, Scrotal and ante- Scrotal, the terms explaining themselves. Of these, the latter are most º to heal on account of the small quantity of tissue surrounding the urethra. In speaking of the treatment, Sir Henry Thompson, in his Sixth Lecture, published in the Lancet, says: “It was sometimes attempted to cure such fistulae by tying in a gum catheter for weeks or even for months; but this always fails, and for this reason, that urine always finds its way from the bladder by the side of the catheter, along the urethra, and so into the fistula, by the force of capillary attraction, and thus the object supposed to be attain- able, in reality never was and never could be accomplished. The practical surgeon soon discovers that tying in an instrument never insures the transit of all the urine through it; some will always pass by the side and defeat your purpose.” If the fistula is small, the application of tincture of cantharides to the opening sometimes produces a good result. The patient's urine must be drawn off twice or thrice during the day with an elastic catheter. Free in- cisions may be made to the bottom of the fistulae or nearly so, and the parts washed with carbolic acid water. Galvanism has been tried, and with good results. In the ante-scrotal variety, plastic operations may be devised and are sometimes successful. As a rule the treatment is unsatisfactory. Laceration of the Urethra.-This untoward accident is generally occasioned by falls, kicks, or bruises in the perinaeum; whenever it occurs it always requires immediate and decisive means for its relief. The symptoms are (besides the immediate pain and sensation of sickness) those that belong to extravasation of the urine. The scrotum becoming infiltrated and oede- matous, no water being passed through the urethra, vesical tenesmus and excessive pain, spasm of the bladder accompany the accident. In some cases, when the rent has extended far back, the urine is discharged per rectum. - - The treatment must be prompt. So soon as the first appearance of infil- tration is present, the surgeon should lay open the scrotum or the perinaeum to allow of drainage and endeavor to pass a catheter into the bladder, which, CYSTOTOMY-PARACENTESIS VESICAE. 939 if the entrance is accomplished, should be allowed to remain in the viscus. In the majority of instances, however, the introduction of the instrument is prevented by the swelling around the laceration, or by the catheter passing into the rent. If free outlet has been given to the urine, by the requisite incision, much suffering and danger is prevented. In many instances, as the wounds heal, extensive sloughing of the scrotum takes place, which must be treated on general principles, antiseptics being used to rectify the odor, which is intensely º Though lacerations of the urethra are always serious and the prognosis doubtful, yet in young persons it is astonishing how these most serious acci- dents are followed by recovery. - Cystotomy—Paracentesis Vesicae.-Occasionally cases happen which re- quire paracentesis of the bladder. These are generally caused by stricture, traumatic or other, chronic enlargement of the prostate gland, and chronic FIG. 589. "Ooº M/V//w3/1-0 Rectum Trocar. cystitis. Cystotomy for the latter disease is comparatively recent, but from the reports of its success, it should be tried should the case appear to resist all other methods of treatment. Dr. E. F. Ingals” states that as Fig. 590. Cystotomy through the Rectum. long ago as 1866, Prof. Powell, of Rush Medical College, resorted to the operation for obstinate cystitis, and considers it as one of the legitimate operations in surgery, and not a dernier ressort. * Medical Record, December 2d, 1872, p. 549. 940 A SYSTEM OF SURGERY. There are several methods of performing cystotomy. The perforation may be made either through the rectum, through the perinaeum, or above the pubis. - The patient is placed on his back and the limbs drawn up. The surgeon introduces the forefinger of the left hand, well oiled, into the rectum, and determines the situation of the prostate gland and the trigone vesicae. Keeping the ball of the finger in the position aforesaid, a long curved trocar (Fig. 589), the point withdrawn within the canula, is passed into the rectum upon the finger already introduced, and pressed firmly upon the bladder from half to an inch above the prostate gland; the point of the trocar is then thrust into the bladder, and the instrument with- drawn, leaving the canula within the bladder. In some cases, a tube may be allowed to remain, but usually this is not necessary. Fig. 590 represents the operation. - Cystotomy through the perinaeum is the same operation as perineal section, which will be considered further on. Cystotomy through the hypogastrium is performed as follows: An incision is made just above the symphysis pubis, between the recti and pyramidales muscles; the bladder is thus brought to view, and the trocar and canula are used as before. An instrument having a side opening connected with india-rubber tubing is better than the ordinary trocar. For more minute directions the student is referred to the article on supra-pubic lithotomy in this chapter. These operations, however, unless performed with some other especial purpose than relieving the bladder, are all superseded by the aspirator. The puncture should be made above the symphysis pubis, the needle looking downward and backward. The operation may be repeated often without danger. I have performed it without hesitation twice a day for ten days, and not a single untoward symptom presented. Foreign Bodies in the Urethra.-A stone may have escaped from the bladder and become lodged in the urethra, or by some accident, a foreign Substance may have found its way into the canal. In such cases the irri- tability of that organ must be allayed by the administration of acon., canth., Scill., or calc. carb., nux vom., opium, puls., kali carb., and the patient should be made to drink freely of decoction of buchu, or water- melon seed. When the desire to urinate comes on, it should be restrained as long as possible; when it becomes very great the patient should lie on the belly, grasp the penis and draw it outward and downward, and then with a sudden forced tenesmus endeavor to propel the urine forward. If this plan does not succeed a small and delicate forceps (Fig. 591) should FIG. 591. G. 7/5/MA/VW & CO, Urethral Forceps. be introduced into the urethra. A better instrument, and one which can be procured easily for an emergency, can be made as follows: Take a flexible catheter, about No. 9 of the English scale, and cut off its end, in order to convert it into a hollow tube; insert into this a loop of silver wire. Then having it well oiled, introduce the instrument until the end touches the foreign material, when the wire is pushed down and twisted a little, in order to make it encircle the foreign substance in the manner familiar to all in withdrawing a cork which has fallen within the body of a bottle. If this does not remove the obstruction, the effort may be made to push it into the STRICTURE OF THE URETHRA. 941 bladder and then perform one of the operations described for lithotomy, or to resort to external perineal urethrotomy. Stricture of the Urethra.--Stricture may be defined, “An abnormal con- traction of some part of the urethral canal.” Sir Charles Bell, however, regarding the normal condition of the urethra to be that of approximation, defines it as a canal that has lost the power of dilating. These constrictions have been regarded as of two kinds, permanent and transitory, the former being due to organic deposit about the walls of the urethra, the latter to the spasmodic action of the muscular fibres; the latter may be cured by the in- ternal administration of medicine alone. The permanent is that to which the greatest importance is attached. John Hunter classifies strictures as the permanent, spasmodic, and inflammatory, while Thompson makes use of the terms linear, annular, irregular, or tortuous. By linear stricture we un- derstand, an obstruction of the canal by a membranous diaphragm; by the annular, that in which the contracted part is thicker than the linear; whilst the irregular include such varieties as cannot be classified under either of the above heads. Dr. Otis contends that “a true stricture always and of necessity surrounds the urethra.” Independent strictures may be found in the same urethra. Hunter records six. Leroy D'Etiolles mentions a case of eleven. Seldom do we find the tube entirely obstructed. The urethra may be long or short, according to provocation; it may be bent like the italic “s, with the external meatus looking downwards, or, with a single curve, it may point directly upward. It passes from the neck of the bladder to the end of the penis, and, generally, is nine inches in length and is divided into four portions. First, the prostatic, which passes through the prostate gland, about twelve to eighteen lines in length. Second, the membranous, ten to twelve lines. Third, the bulbous, which occupies an inch of its extent; and fourth, the spongy, which is four to four and one-half inches in length. A man with a small penis may have a large urethra, and the tube may be of Small calibre in an organ of good size. This is peculiar, but never- theless true. This is in direct opposition to the opinion published by Dr. Otis, who contends that there always exists a constant relation between the size of the flaccid penis and the capacity of the urethra, but experiment will prove the truth of my assertion. The urethra is subject, during its whole extent, to these abnormal con- tractions, but some portions of it seem to specially favor its location. John Hunter says the bulbous portion is most liable. Sir E. Home writes: “Next to the bulbous portion, the most frequent place is four and one-half inches from the orifice of the glans.” Says Mr. Liston: “Stricture is found most frequently about four inches from the meatus.” Mr. Shaw, in more than one hundred dissections, has never found a stricture posterior to the ligament of the bulb. Vidal observed stricture to be most frequent at the junction of the membranous and bulbous parts. However much they differ in other respects, anatomists generally agree in assigning the most frequent point to be at the subpubic curvature. Mr. A. Pearce Gould,” in reply to “Why is organic stricture most com- mon in the bulbous portion of the urethra,” speaks thus: The causes of stricture in this part of the urethra, are two: injury and chronic urethritis. 1. Traumatic Stricture.—The commonest stricture-producing injuries are falls astride beams, or kicks. Sometimes the cause is a punctured wound, or the urethra may be lacerated. 2. Stricture from Chronic Urethritis, which almost invariably begins at the º * Braithwaite's Retrospect of Pract. Med. and Surgery, July, 1878, Part 77. 942 A SYSTEM OF SURGERY. meatus externus, spreading towards the bladder, is more common in the penile urethra, yet the induration resulting from it is most commonly found at the bulb. This seeming paradox has been thus explained by Sir H. Thompson: “It is the prolonged existence of subacute inflammation . . . . which is to be regarded as the cause of that deposit, in and beneath the mucous membrane, which, by its subsequent contraction, so commonly produces stricture.” M. Guérin explains it by the greater size and vascu- larity of the corpus spongiosum at the bulb than further forwards, leading to increased plastic effusion. Injections to be useful must be frequent and efficient, as they secure cleanliness and free the canal from secretions. It is remarkable that stricture is said to occur more frequently in hot than in cold climates—may not this depend on less frequent micturition, and more concentrated irritating urine in the former ? From all these authorities Dr. Otis” differs materially. He states that out of 258 strictures, 52 were in the first quarter inch of the urethra, 63 in the following inch; 48 from 14 to 24; 48 from 24 to 34 ; 19 from 34 to 44; 14 from 44 to 54; 8 from 54 to 64; 6 from 6% to 7+. It must be borne in mind, however, that Dr. Otis's method of examination is by very large sounds, and that thereby inequalities of surface unnoticed by the ordinary instru- ments would be designated. - The earliest symptom premonitory of this affection, is a constant desire to urinate, often causing great pain; uneasiness is also experienced along the canal. As the disease progresses there is a slight discharge of urine, not unfrequently containing mucous shreds. The presence of long-lasting “gleet ’’ should alone arouse the suspicions of the watchful surgeon as to the probable existence of stricture. Then the discharge of urine is no longer subject to the will; there is a sense of heat and soreness of the parts about the bladder, pain during coitus, and retention of urine, followed by engorge- ment. At this stage we have a condition simulating incontinence, the urine dribbling away drop by drop. The changes effected by stricture will be apparent in the whole genito- urinary apparatus. Sacculi of the bladder are frequent; some have been found capable of holding from two to three ounces. Nor is this dilatation limited to the bladder alone; cases are on record of its extending through the ureters to the pelvis and calices of the kidneys; especially do we find it in the urethra just posterior to the stricture, and often of sufficient size to admit the passage of a man's finger. Constant contact of the walls of the urethra with urine will often result in ulceration of that membrane. Abscess and fistula form from urinary infiltration, and extravasation of urine takes place from breaking down of the urethra, consequent upon pro- longed retention. Treatment.—The spasmodic variety of stricture is amenable to treatment; applications of hot water, the warm sitz bath, and injections of warm oil often relieve the patient in a short space. Of the latter injection I can speak with much confidence. I have relieved patients by this method when the catheter has been tried in vain for hours. My plan is to have four to six ounces of olive oil heated, and slowly inject into the urethra, by means of a two-ounce syringe, a quantity of the lubricating fluid. If this does not relieve the patient in itself, it much facilitates the passage of the bougie or catheter. Aconite is useful for the inflammatory symptoms, belladonna for frequent urging and tendency to congestion, cantharides for priapism and discharge of blood, and camphor when the urine is very acrid. Other medicines are, agaricus, clematis, iodine, kali iod., acid. nitric., * Stricture of the Urethra, its Radical Cure, by Fessenden N. Otis, M.D. New York, 1875. STRICTURE OF THE URETEIRA. 943 ºnium, digitalis, nitrate of silver, opium, eupatorium purpureum, and thuja. Dr. Bagley* reported a case of a man aged thirty-nine, attacked with cystitis. All efforts to empty the bladder by use of the catheter had been ineffectual, although attempted by a number of surgeons. The patient called on Dr. Bagley, stating he had stone in the bladder, and was troubled with incontinence of urine. On examination, a false passage from the urethra, an enlargement and induration of the prostate, a stricture of the membranous portion, and constant dribbling of urine were found. There was capability of performing the generative act, but not ejaculation of semen, it passing back into the bladder on account of stricture. The false passage was irritated with a roughened bougie, and then adhesion secured by pressure; the stricture was readily relieved by use of bougies. Mer- curius iodatus acted on the prostate promptly, discussing the chronic in- flammation and induration. Eupatorium purpureum restored the nervous FIG. 592. Gº- €º- 5:T tº Ti ENHAN # tº tone and energy of the bladder and relieved.the irritation at its neck, re- storing also integrity of the mucous surface from the kidneys to the glans. The patient could again void urine and ejaculate semen. The first great point, in the treatment of stricture, is to understand the normal calibre of the urethra we are to treat. That this can be accurately determined by the circumference of the flaccid penis, a point which is dé- clared by Otis to be demonstrable, and as stoutly denied by Sands and others, must at present be left an open question. The difficulty in deter- mining the point, must be that the urethra is, in its natural condition, en- tirely closed, and because it can be enormously distended by instruments is no reason why its overdistension should be considered as its normal size. FIG. 593. ©º-tº- B <=06 2-ºl * ===zº- The Vagina is expanded and not ruptured by the passage of the foetus, and yet, its normal capacity could not be said to be that of its distensibility. Following a law of nature, the size of the urethra may be said to be that of the volume of the ordinary stream of water that passes through it, and that the passage of very large instruments is not necessary for the perma- nent cure of stricture. To find the locality of the stricture, the bougie à boule, or the metallic bulbous sounds, Fig. 592, are fair instruments; they are not, however, so * American Homoeopathic Observer, Detroit, July, 1867, p. 280. 944 A SYSTEM OF SURGERY. good as the urethra-meter, Fig. 593, of Otis. The dial indicates in milli- meters the amount of expansion at the bulb. It is introduced closed, and having passed it carefully down to the membranous portion of the urethra, the Screw in the handle is turned until a sensation of fulness is experienced; it is then withdrawn. As it reaches the narrowed part of the canal it will meet with opposition. The screw must be again turned until the instru- ment can be withdrawn. The hand on the dial will mark the size of the stricture. Dr. Otis has also invented an endoscopic tube for the urethra. (Fig. 594.) It is six inches in length, and from No. 17 to No. 19 of the English scale. By this instrument a partial view may be obtained of the canal. It is used also to repress hamorrhage. In the treatment of organic stricture the main consideration is the res- toration of the canal to its normal calibre, and its maintenance in that con- dition. To accomplish this, introduce from day to day, bou- FIG. 594, gies of increasing diameter, until the contraction is overcome, º or forcibly separate the adhesions at once. I am in favor of the treatment of stricture by dilatation, and from it I have obtained excellent results, and though from time to time instruments must be used, the same objection, either in a greater or lesser degree, holds good with other methods. Incisions have to be repeated in some cases a number of times. The value of ascertaining where the stricture is located, its measurement, and the internal urethrotomy treatment, are points for the proper explanation of which credit must be given to Dr. Otis, of New York, and whether or not we agree with him in reference to his theory of gleet, or his ideas regarding the slitting of the meatus, we must allow that his accurate observations, careful experiments, and manly defence of his doctrines have opened a new field of inquiry and ex- perimentation. In adopting the method by gradual dilatation, bougies may be used of wax, plaster, softened ivory, gum-elastic, whalebone, or metal. The treatment of a complicated case requires care, patience, and skill. It may be days before we introduce the slenderest instrument, and in such, the “guides’ of Dr. Gou- ley (Fig. 595) should be used. The twisted bougies of Leroy D'Etiolles, which are made of whalebone or gum-elastic, are useful to discover the smallest cavities and tortuous canals. The English filiform bougie (Fig. 596) is also used. It is well to remember that false passages may exist, which often mislead in the endeavor to pass instruments, particularly when ex- loring. The best method, after having selected a proper bougie, is to place the patient in a standing position, grasp the glans penis with the ring and little finger of the left hand, and, by ºWſ, ºft gentle traction, place the penis in a horizontal position; then, § having smeared the instrument with oil, and holding the bou- | gie as a pen, gently introduce it by a slight rotary motion un- (º, A til it reaches the stricture, when a sensation will be communi- tº cated to the hand, which should be a warning to proceed with Oº increased, gentleness. There are several obstacles which may §:#. impede the course of a bougie; it may become entangled in one of the lacunae, or in an accidental fold of the urethra. A small and soft instrument may bend when pressed against the lower por- tion of the canal, or its onward course may be arrested by a spasmodic | STRICTURE OF THE URETHRA. 945 (spasmodic stricture) contraction. It is always the better plan to com- mence with small and soft bougies, for the stricture may be old, narrow and tortuous, and additional suffering and danger be avoided. Some surgeons recommend a fine catgut bougie; others a FIG. 595. gum catheter, curved and without wire. There is some disadvantage in using these pliable instruments, because, on pressure being exerted, they yield easily; but a skilful hand can readily distinguish between the bending of the bougie and the narrowing of the canal. If a soft instrument cannot be introduced, recourse must be had to a metallic one. Frequently the obstacle preventing the passage of the bougie arises from the vital action of the part, but this may be overcome by steady pressure, using care, as it passes down the urethra, that nothing is lacerated. We can tell whether the bougie has en- tered the stricture by endeavoring to withdraw the instrument. If it has passed the contraction there will be a resisting force. e Many surgeons object to the term “dilatation,” as applied to strictures. It is argued, and justly, that, if a stricture were merely a muscular contrac- | FIG. 596. E=E *=_-- * Iſ M.A. N. N. . ſº . NY tion, the term would be correct, but this is not the case, for organic changes have taken place. The passage of the instrument modifies the vital proper- ties of the canal, while the pressure which it exercises on the newly-organ- ized parts, induces a tendency to absorption, and gives a stimulus which enables nature to complete the cure. The effect of the bougie, or, as it has been well termed, the “vital action,” is visible from the commencement of the treatment. Haemorrhage is often present, and there is always a slight discharge. Whatever be the kind of instrument employed, experience has demonstrated that, with certain ex- ceptions, the so-called dilatation is the safest and most effectual method for relieving the distressing symptoms which attend stricture of the ure- thra. The mode of dilatation is not to be disregarded. It may be con- ducted on different principles: it may be temporary or permanent; or gradual or rapid. The size of the instrument, whether it be a plastic bougie or metallic sound, must be regulated by the presumed diameter of the FIG. 597. contraction; and after having been selected and introduced in the manner described, it must be allowed to remain for a certain time, and withdrawn at stated intervals. The object is to effect a regular and progressive dila- tation of the strictured part, without inflicting injury on the tissues or ex- citing severe irritation in the urethra. On the first introduction of the instrument it ought not to remain more than a few minutes. If it has been tolerated, it may be repeated on the following day, and so on; but the best 60 946 A SYSTEM OF SURGERY. practice is to introduce the bougie every third day at first, and then gradu- ally shorten the intervals, at the same time increasing the size of the instru- FIG. 598. Holt's Dilator, Bumstead's Modification. External Urethrotomy. ment. All this must be regulated by the effect produced upon the stream of urine, which indi- cates the progress of improvement. Though dila- tation is the safest and most certain, it is never- theless a tedious method; and hence many sur- geons have attempted to procure the same result in a more speedy manner. This is done by first introducing a bougie of small calibre, quickly withdrawing it, and then passing others of larger size, until the patient complains of uneasiness or pain. The same operation is repeated every day or two, larger instruments being gradually em- ployed. By the adoption of this method obstinate strictures have been cured in five or six days. Permanent dilatation, as its name implies, is effected by leaving the instrument permanently in the bladder. The treatment should commence by using a metallic bougie, which should be allowed to remain in the urethra from twenty-four to forty- eight hours, and then withdrawn. Temporary di- latation is the method most frequently employed, because it is the safest and best. Rapid and forci- ble dilatation may be attempted when the stricture yields readily, or when it is a matter of moment to the patient to be speedily relieved. Indeed, some surgeons prefer this method to any other, and in the worst forms of stricture it has been effectual in my hands. Several instruments are used for the purpose. Among the best is that of Sir Henry Thompson (Fig. 597), and Holt's (Fig. 598) as modified by Bumstead. In the latter the “guide” is first introduced, and upon this the closed instrument is passed into the stricture. The screw is turned, which separates the sides of the dilator; into this the solid rod is driven home. As a general rule, no untoward results follow the apparently summary proceeding. Dr. Thebaud's stricture- dilator works with a screw in the handle, as does Sir Henry Thompson's (Fig. 597), the difference being that in the former the jaws separate by the motion of the thumbscrew, while in the latter the expansion takes place higher up in the body of the instrument. In the treatment of permanent stric- . ture, any disorder of the general health or of the genital organs must be corrected by the adminis- tration of appropriate medicines, after which dila- tation must be employed. Subcutaneous division of the stricture by means of a delicate tenotome has proved successful in the hands of Dr. C. H. Mastin,” who resorts to it when neither catheter nor guide can be made to traverse the urethra. —In obstinate cases of rupture of the urethra and * Medical News, September, 1886. URETHROTOMY. 947 extravasation of urine, or in impassable and traumatic stricture, the oper- ation of opening the urethra from the perinaeum is necessary. This has received the sanction of many eminent surgeons, and is growing in repute. Prof. Syme stated that perimeal urethrotomy was the only safe and sure means for the radical cure of traumatic or impervious stricture. Prof. Van Buren says the same ; and in a lecture styled “Then and Now,” in which the great improvements in medicine and surgery are noted, the late Prof. Gross gives the same idea. The patient should be placed in a position similar to that for lithotomy, a director passed into the stricture, the left forefinger introduced into the rectum in order to feel for the urethra and serve as a guide to the incisions. A straight bistoury is plunged into the perinaeum to the depth of an inch, and carried backward on the director until the stricture is divided. An- other method is as follows: The perinaeum having been shaved, a capillary probe-pointed whalebone bougie is introduced into the urethra. If the guide in passing catches in the lacunae of the canal, it must be withdrawn and again introduced until it enters the bladder. A No. 8 grooved metallic sound is then introduced by passing through its eye the free end of the guide. The instrument is known as Gouley's staff and director, a descrip- tion of which is seen further on. An assistant takes charge of the staff and guide, while the surgeon, after an examination per rectum, makes a free in- cision in the median line of the perinaeum, which extends from the base of the scrotum to within half an inch of the anus. This, however, only involves the skin and superficial fascia. By dissection the urethra is brought in view, and the canal opened on the groove of the staff. The edges of the urethral incision are kept apart by loops of silk. After withdrawing the sound, the stricture and about half an inch of the urethra are divided with FIG. 599. c. raataav-ºfflº * a modified canalicula knife (Fig. 599). By passing a catheter into the blad- der it will be known that the stricture is divided. Internal Urethrotomy.—All operations for internal urethrotomy may be per- formed in one or two ways; either the stricture is divided from the vesical side, or that nearest the meatus, the former being by far the best. Many modifications have been made and plans proposed for dividing the obstruc- tion within the urethra, but they consist of essentially the same steps. A con- ducting rod or bougie is passed into the bladder, and upon this as a guide the knife is carried, dividing the stricture. In some of the instruments a blade is concealed in a canal, as proposed by Civiale, which being made to pass the obstruction, the blade is released by a spring and cuts into the stricture from the vesical side, then the instrument is withdrawn. Fig. 600 shows Bumstead's modification of Maisonneuve's stricture-cutter. Char- riere's instrument combines both methods. The following is a description of Prof. Gouley's catheter and its use in stricture (Fig. 601). The catheter is three millimeters in diameter. A groove on its convex side extends four inches, and is bridged over in its last twelfth of an inch, to form a canal for the reception of a delicate whale- bone guide. The catheter eye is on the concave side, about three-fourths of an inch from its point, and is kept close to a well-fitting stylet. Its curve is equal to one-fifth of the circumference of a circle three inches and a quarter in diameter. The manner of using is as follows: With a small syringe the urethra is to 948 A SYSTEM OF SURGERY. be filled with olive oil, and an attempt made to introduce a probe-pointed whalebone guide, half a millimeter in diameter, and the length of an ordi- nary bougie, the point of which may be made temporarily spiral by immer- Sion in boiling water, then twisting around a small staff, and suddenly cool- ing it. If its point becomes engaged in a lacuna, it is to be withdrawn a little, and carried onward with a rotating movement. If it enter a false FIG. 600. FIG, 601. jº º: gº sº W;| | | | | | # Maisonneuve's Stricture-Cutter. Gouley's Staff and Guide. passage, it is to be retained in situ with the left hand, while another is passed by its side. If this second guide makes its way into the false passage, it is to be treated precisely as the first, and the operation repeated till one be made to pass the obstruction and enter the bladder. Sometimes five or six guides are thus caught before the false passage is filled and the natural INTERNAL UEETHROTOMY. 949 route discovered. As soon as the bladder is entered, which is known by the instrument being easily moved in and out, the outer ones are to be with- drawn, the free end of the retained guide passed through the canal at the end of the catheter, and this instrument carried down the urethra until its point reaches the stricture. Generally with slight pressure in the right di- rection, the catheter may be made to enter the stricture and finally pass into the bladder. The guide may be kept in position after the withdrawal of the catheter, and dilatation carried on by the successive introduction of the instruments already mentioned. Dr. Otis, who is a strong advocate for internal urethrotomy, believing in the largest expansion of the urethra and the thorough division of all stricture, to effect a permanent cure, thus writes: “To warrant the reasonable expectation of cure, the stric- FIG. 602. ture must be completely divided at some one point, and Bº . this cannot be with certainty accomplished without a \º knowledge of the normal urethral calibre. The normal calibre once ascertained by means of the urethrameter, or by measurement of the flaccid penis, the method by which the sundering of the stricture at some one point is accomplished, may vary and rest in the judgment of the operator. If dilatation or divulsion be selected as the medium through which to effect this result, the pro- cedure must be carried far enough to completely rupture every fibre of the contraction; if division, every fibre must be completely severed, or subsequent recontraction is certain. Neither divulsion alone, nor simple urethrot- omy, is capable of effecting this with any certainty. It requires a combination of these two methods to accomplish the desired result.” To effect this purpose he has devised several instruments (Fig. 602), which combine the properties of thoroughly expanding and then dividing the stricture. Of his ordinary dilating urethrotome, he says: “It should measure 18f when closed, and be capable of expansion to 45. It is curved so as to pass readily through the curved portion of the urethra when this is necessary. It is thus well adapted for the division of deep strictures. The blade is guarded at the top like that of M. Maisonneuve's, for the purpose T i of avoiding incision of the healthy portions of the canal in introduction; in the same way it limits the incision on withdrawal. This instrument is introduced closed, and without the knife, unless the stricture is very large. The knife is then carried down, the screw at the handle 2. turned until the hand on the dial indicates two or three 2 millimeters beyond the previously determined normal l | calibre of the canal, and the blade is drawn through the stricture or strictures. The instrument is then closed to 25f and withdrawn. Partial closure prevents pinching . the mucous membrane. The results are ascertained by examination with the full-sized bulbous sound. If a trace of stricture is left, the operation should at once be repeated, either using a wider blade or dilating two or three more millimeters. In very resilient strictures, two or more attempts are sometimes unavoidable before complete sundering of the strictures is effected, nothing short of which can produce permanent beneficial results. “The guarded blades of this instrument should not project more than four millimeters, nor less than three, above the shaft; and the guard should 950 A SYSTEM OF SURGERY. not exceed 3 m, in breadth, as more than this will hold behind the stricture and prevent easy division. In case of very dense and resilient stricture, a perfectly plain blade may be used, always in such event turning the instru- ment down as soon as the blade has passed through the stricture.” He then gives us the following table: OTIS's TABLE. No. No. Of º - No. No. of Time after operation. of cases. strictures. Time after operation. of cases. strictures. 3 years............................ 1 4 5 months..... ........... ....... 1 7 2% years......................... 1. 7 4 “ ............... 1 3 1% year. ......................... 2 8 & 4 4 15 13 months....................... 3 14 2% “ 1 10 1 year. tº e º 'º e - 4 7 2 “ ......................... 4 11 10 months 1 2 1 month.......................... 1 1 9 “ 1 1 8 weeks........................... 1 5 8 “ 1 1 2 “ tº ſº tº ſº tº in º º 1 1. 7 “ 2 10 6 “ 7 21 37 .128 In thirty-one cases none of the strictures had recontracted. In six cases most of them had been absorbed, while some remained. RESULTS. CASES. Cures. Re-examined. No recontraction, . e o e º 31 Cure. Patient perfectly well when last heard from. No re-examination, .. 52 Perfect relief for a long time. Return of symptoms. Re-examination. Stricture found to have recontracted, e º º e o ... 4 Perfect relief for a length of time. Return of symptoms. No re-exami- nation, . e º e º & e e º o e e ... 5 Relief of most symptoms. Some remaining. Patient still under treatment, 4 Partial relief, o º e o o e º 3 Result not known, 1 Dr. Thomas R. Brown” gives the following summary of varied profes- sional views in regard to the treatment of stricture, and they are important as embodying the experience of eminent gentlemen. In answer to the question proposed by Dr. Brown: “What is your opinion as to there being such a condition as spasmodic urethral stricture?” the re- plies were about equal in number. In answer to the question, “What means of relief should be employed when renal disease is detected ?” the majority preferred gradual, continuous dilatation or divulsion, rather condemning operative procedure except when clearly necessary. The after-introduction of the sound, they thought, could not for an indefinite period be dispensed with in cases treated by the ordinary method; while as to the relation of the size of the urethra and the flaccid penis, the majority, having no expe- rience, had no answer. The views of all the respondents were that close strictures of the penile urethra should be treated by internal section, and all the rest by gradual dilatation or divulsion. T Electrolysis is, one of the best methods of treating urethral stricture. The rationale of its application can be found on pages 58–61. In stricture of the urethra the result desired is its absorption, and except in old, hard, cartilaginous formations, all cauterizing effects must be sedu- lously avoided. The modus operandi is to introduce into the urethra an electrode, about a size larger than the stricture will admit (insulated to the tip) down to the stricture. The electrode in this case must be soaped, not * The Medical Record, October 12th, 1878, No. 414. URINARY DEPOSITS AND URINARY CALCULI. 951 oiled (oil being a non-conductor), for the purpose of lubrication, and to facilitate its introduction. This electrode is to be attached to the negative pole of the battery. The circuit is completed by the broad sponge rheo- phore, moistened with salt and water, and either held in the hand of the patient or placed upon some convenient part. The patient may be operated upon either standing or lying, as is most convenient. As regards the amount of current to be used, the first point is here, as elsewhere, to use as little as will produce the desired effect, and that is best judged by consulting the sen- sation of the patient. We must avoid the production of pain. As soon as the patient feels the current, the intensity is sufficient, and should not be increased beyond this point. I prefer the use of some modification of Daniell's elements, and perhaps I may state as an average, that a current from six to twenty of these cells is all that is needed. Keeping the elec- trode pressed in contact with the stricture, but not forced, in a few minutes it slips through with facility. If a second stricture is present, it must be treated in the same way. This completes the operation, which may be repeated as many times as necessary at intervals of a few days. It will be noticed that I have laid stress upon the use of the negative pole. This is quite necessary, as the use of the positive easily produces an eschar, which heals by contraction, and thus, instead of curing a stricture, will actually C8, U1S6 OIlê. Dr. Robert Newmann” gives the following tabulated statement of one hundred cases treated in this manner without a relapse: “These one hundred patients had one hundred and eighty-nine strictures together, which were situated in all parts of the urethra, from close to the meatus to within eight inches from the meatus. The exact location of these strictures was as follows: “Eight strictures were found at one inch or less from the meatus. “Twelve strictures were found from one to two inches from the meatus. “Thirty-one strictures were found from two to three inches from the meatus. “Twenty-five strictures were found from three to four inches from the meatus. “Forty-two strictures were from four to five inches from the meatus. “Thirty-seven strictures were from five to six inches from the meatus. “Twenty-four strictures were from six to seven inches from the meatus. “Ten strictures were from eight to nine inches from the meatus. “Séances.—From one to ten operations, in some cases even more, were necessary for a cure, from which one may draw the conclusion that the average number of séances was five to six for each case. “Time.—The treatment in each case averaged two to three months. Long intervals between the séances, and weak currents, are rules to which I still ad- here, and which I cannot impress too strongly upon operators, as most important points in these operations.” Urinary Deposits and Urinary Calculi—Urinary calculi may be found in the kidney, in the bladder, or in the passages leading from these organs, but in all cases they give rise to symptoms of grave import. To arrive at a proper understanding of this subject it will be necessary to consider the appearances of urine in health, and also its deviations from that condition. It is known that the ingredients of the urine are modified by the diet, the time of day, and the habits of the individual. In health, urine is of clear amber color, gives an acid reaction, and has a specific gravity of 1020 to 1030. In 1000 parts, 954.81 are water and 45.19 solid matters. For analysis, it is best to obtain a quantity passed shortly after the midday * Reprint from the New England Medical Monthly, June, 1885. 952 - . A SYSTEM OF SURGERY. meal. When the urine contains any ingredient in excess, there is reason to suspect some important change in the system. If there is excess of any of the constituents, a deposit takes place, which, if not easily soluble, as the Salts of lime and magnesia, and also uric acid, a nucleus is afforded for the formation of a calculus. Urinary deposits may be classed under two heads, organic and inorganic. Of the former are urea, which is found in the proportion of from 15 to 35 parts in 1000 parts of urine; and uric acid, which exists only in very small quantities—one-half or one grain in 1000 grains of urine. The inorganic deposits are saline, consisting of sulphuric, phosphoric, and hydrochloric acids, combined with bases of potash and soda; and mineral, comprising phosphoric and sometimes carbonic acid in combination with lime, magnesia, and occasionally alumina; silica is sometimes found. Of these ingredients, the phosphates are most often deposited. For the sake of distinction, the deposits are called “sediments” when consisting of amorphous matter; when they are composed of small crys- tals, they receive the name of “gravel;” and when these by concretion form larger masses, they are known as “calculi” or “stones”—being de- nominated “renal’’ or “vesical,” according as they are located in the pelvis of the kidney or in the bladder. Other deposits take place, such as blood, FIG. 603. - FIG. 604. Epithelium from Urinary Passages. Spermatozoa and Vaginal Epithelium. BRYANT. BRYANT. pus, mucus, epithelium (Fig. 603), spermatozoa (Fig. 604), fatty matter, etc., the presence of which is determined by chemical tests or the microscope. We find renal casts, which are sometimes “waxy,” at others “oily,” some- times “granular,” and “epithelial.” (Fig. 605.) . Uric acid deposits (Fig. 606) are common, appearing in variously formed crystals of a yellow or yellowish-red color, generally rhomboid, with the angles rounded, or lozenge-shaped. By aggregation these crystals may form gravel, and finally result in calculus. They are soluble in soda or potash, but not in the mineral acids. Urates of ammonia are common (Fig. 607), but rarely result in calculus. The ammoniacal odor will be apparent by the application of heat. The presence of uric acid may be detected in a deposit by treating it with nitric acid, and applying heat until the mass is a #. powder. Add a drop of ammonia and a bright-violet color will be pro- uced. - The oxalate of lime, which is the origin of the mulberry calculus, usually is of a dark-brown color, and the crystals are either octahedral or dumb-bell- PHOSPHATIC DEPOSITS. 953 shaped bodies (Fig. 608). The diathesis which specially favors this deposit, is found in persons suffering from nervous exhaustion and impaired diges- tion. The oxalates are not soluble in alkalies, but the mineral acids will dissolve them without effervescence. If they are subjected to the heat of a blowpipe, FIG. 605. FIG. 606. Caré and the white ash which remains be placed upon moist red litmus-paper, an intense blue color will result. Phosphatic Deposits.-These are of two varieties, the alkaline and the earthy. The former include phosphate of soda, the acid phosphate of soda, and the phosphates of Soda and ammonia, and seldom form concretions. FIG. 607. FIG. 608. The earthy phosphates comprise: 1. The ammonio-magnesian phosphates (the triple phosphates), which appear as beautiful, colorless, transparent crystals, forming an iridescent pellicle on the surface of the urine. They are supposed to arise from a decomposition of urea; are soluble in acetic acid, but not by heat. & º 2. The phosphate of lime and the phosphate of magnesia, which occur gen- erally in the form of a white amorphous deposit, sometimes assume a crys- talline form. If it exists in solution, or is precipitated by heat, it may be 954 • A SYSTEM OF SURGERY. mistaken for albumen; and when it forms the greater part of a deposit, may be erroneously called pus or purulent mucus; especially as it is most fre- quently found in alkaline urine mixed with pus or mucus. These phos- phates are insoluble by heat, but soluble in acetic and the mineral acids. According to Sir Henry Thompson, who has experimented on this sub- ject, an atonic bladder may retain urine unexpelled for a long time, without undergoing decomposition. When, however, crystals are developed, “the urea is broken up and ammonia is formed. The phosphates of lime and magnesia decompose, their earthy bases being precipitated, and from these actions are produced the ammoniaco-magnesian or triple phosphate, as well as some bibasic salts.” Pus also will be formed, and the plastic inflam- . matory exudation being mixed with these phosphates is with difficulty expelled. Thus portions remain and form a nidus for the formation of calculus. Sir Henry arrives at the following important conclusions: 1. That in its healthy condition the bladder rarely if ever retains, but on the contrary expels all phosphatic deposits. 2. That when the bladder is not healthy, but affected by chronic inflam- mation, provided it is not considerable or very prolonged in duration, the power of expulsion is still almost as great as in the healthy organ. 3. That there is a diseased condition of the inner coat of the bladder, in which the ability to expel phosphatic deposits is almost lost, and in which the formation of concretions—and, if these are neglected, of stone—is certain to occur.” The mixed or fusible phosphates, which are a combination of the two already described, and frequently form the crust of calculi, are made up of urates or oxalates, or have their nuclei in some foreign body introduced into the bladder. At other times the stone may consist entirely of phosphates and may reach a considerable size. They are not soluble in alkalies, readily in acids, and by the blowpipe may be fused into a hard enamel. There are also deposits known as wric oſcides, also called æanthic orides or acanthin ; cystic 03:ides or cystin ; carbonate of lime calculus; fibrinous calculus ; tyrosin, haematin and wrostealith, which are all pseudo-deposits, and for a description of which the reader is referred to the many works on urine and its deposits. It may be said in review, that the wrates alone are dissolved by heat; potash renders soluble all except the phosphates and the oxalate of lime; while uric acid only is insoluble in hydrochloric acid. -- When any of these organic substances combine, or when they attach themselves to some organic matter or foreign body, they form a calculus. These may arise as follows: 1. A precipitation of the salts may take place in the secreting cells of the kidneys, as occurs naturally in the kidneys of reptiles and birds. 2. A precipitation of some of the ingredients of the urine may take place in the bladder, in consequence of stagnation of its contents. 3. The presence of anything which acts as a foreign body in the bladder causes decomposition of urine, leading to abundant precipitation. Urinary Calculi may be divided into three classes, viz.: Those formed of uric acid and the urates; together with the oxalates; those derived from the phosphates; and, lastly, those exceptional concretions already men- tioned under urinary deposits. The uric acid calculus is found most frequently. It usually originates in the kidney, is carried into the bladder, and there becomes an oval-shaped stone of a yellowish or yellowish-brown color. It is generally composed of * Medical Record, April, 1878, p. 270. TREATMENT FOR URINARY DEPOSITS. 955 layers, which are crystalline and fibrous, the fibres radiating from a centre. It is often found in gouty subjects, associated with acid urine. The urate of ammonia calculus is rarely seen, and generally occurs in chil- dren. It is ovoid, smooth, and not above an inch in diameter. Its color is characteristic, being grayish or clay-tinted, sometimes like pipe-clay, or has an earthy appearance. - The oxalate of lime forms the mulberry calculus, which after the uric acid stone is the most frequent form. The surface presents a tubercular, angu- lar or spinous appearance, being rarely smooth. In color it varies from brown to almost black, from which it derives its name. A section shows an imperfectly lamellated structure with waving lines, simulating the knotted heart of oak. These stones are said to produce less irritation than the smooth varieties, perhaps because they are more stationary. The phosphate of lime calculus is generally found combined with other salts. Those of renal origin are of a pale brown color, with a smooth pol- ished surface, and contain considerable animal matter. The variety which begins in the bladder, and is most frequent, resembles irregular pieces of mortar, or is a granular powder covered by mucus, and is often termed “bone-earth calculus.” The triple phosphate calculus, or ammonia.co-magnesian phosphate, is uncommon. It has been seen a few times with some foreign body as its nucleus. The fusible or mixed calculus is the most common of the phosphatic con- cretions. It is found of large size and of different shapes, often moulding itself to the form of the place in which it rests. It is of a whitish gray or dull yellow color and more friable than any other, sometimes resembling moist chalk. The character of the urine will sometimes give a correct idea of the nature of the calculus. If it be acid, the stone probably is uric acid or oſcalate of lime, or a combination of both. If the urine is fixed alkaline, the deposition probably consists of earthy phosphate or the carbonate of lime. Fº regard to the frequency of calculus in the two sexes, it is said to be found twenty times in men to one in women. This probably is due to the fact that in the female the urethra is much shorter and more dilata- ble than in the male, and permits the natural discharge of these concretions while they are yet small. Treatment.—The medical treatment for the different urinary deposits can scarcely be laid down here, inasmuch as they are so numerous, and are but symptoms of other diseases, which require constitutional treatment. When a calculus has formed of any size, the only means of relief is one of the operations about to be recorded. For the smaller varieties, the best medi- cines that I know of, are scilla, nitric acid in full doses, phosph. acid, car- bonate of lithia, and Poland or Gettysburg water. From the latter I have received unmistakable results; in one instance nearly two hundred calculi, varying in size from a shot to a large pea, were passed in a space of two months, while the patient drank this water. A coincidence was observed, in the fact that these calculi were dissolved after being immersed in this water, while they withstood the action of hydrochloric acid. The following medicines may be found serviceable according to their symptoms: apis, can. Sat., canth., alnus rubra, digital, chimaphila, erigeron, caust., eupato- rium purpureum. Speaking of the latter, Rafinesque says that it is a spe- cific among the country people, who give it the name of “gravel root.” Galium aperinum and the fluid extract of hydrangea are also extolled by the eclectics, among whom are Beach, Scudder, and Smith. My experience (being generally called to see these cases after the calculi have formed) is, that those medicines which I have first named will give 956 A SYSTEM OF SURGERY. more favorable results than any others. According to Dr. Coe, corydalis formosa is a good medicine in this affection. • Stone in the Bladder.—Although the physical signs of stone (chiefly elicited by “sounding ”) are the real means by which we can unhesitatingly give a correct diagnosis, yet there are certain subjective symptoms which always lead to the suspicion that a calculus may exist, and these are often so well defined, that the presumptive evidence is in favor of the presence of stone in the bladder. Among these we find pain, which, however, varies greatly in different patients. It generally occurs in paroxysms, especially in the early stages; after a time, however, it becomes more constant, and the patients, especially children, lie on their bellies or draw at the prepuce. Together with the pain there is frequent desire to urinate and often urinary tenesmus. During micturition, the stream is suddenly arrested by the stone falling toward the neck of the bladder. There is hapmaturia, coldness of the glans penis and aching in the testicles; there is in some cases severe priapism. The symptoms of stone vary in severity according to its size and rough- ness, the state of the urine, and the condition of the bladder, whether healthy or inflamed. The manifestations may be slight for years; indeed, a little pain and bloody urine when micturating after exercise, may be FIG. 609. the only inconvenience experienced. After a time the bladder suffers as it does from any other irritation; the urine deposits a slight cloud of mucus; the bladder becomes more irritable, and finally inflames; the urine be- comes alkaline, loaded with viscid mucus and with the triple phosphates and phos- phate of lime; the strength fails, and, after years of suffering, the patient sinks. Sir B. Brodie remarks, “That if the prostate be- comes enlarged, the sufferings from stone are mitigated; because it is prevented from fall- ing on the neck of the bladder.” ounding for Stone.—To perform this por- tion of the operation, upon which alone the diagnosis of the case is to be made out, one should possess a thorough knowledge of the anatomy of the urethra and the curves that it makes in different parts of the canal, other- wise not only will the patient be subjected to much additional pain, but dangerous results may follow the improper management of the instrument. . To sound a person properly the bladder should contain urine, or should have fluid injected therein. The instrument must pos- sess a proper shape, the curve being the arc of a circle described by a radius of 18 inches. It should be constructed of solid steel, highly polished, with a broad, flat and rather thin handle, that any impression made at one extremity may be distinctly appreciated at . . the other, while that portion which enters the bladder should be of larger calibre. than that which remains in the urethra. Fig. 609 shows Van Buren's Sound, and Fig. 610 that of Benique. Grasp the penis in the left hand and retract the prepuce ; put the organ Van Buren's Sound or Bougie. SOUNDING FOR STONE. . 957 upon the stretch and direct its extremity at about an angle of forty-five degrees from the body. Taking the sound, well oiled, between the thumb and forefinger of the right hand, held close to the body of the patient, introduce its point into the meatus urinarius, and allow it to glide along the urethra until the curve reaches the perinaeum; then holding the sound and penis in the left hand, gradually depress them or turn them toward the feet of the patient, whereby the point of the instrument is raised, and then with gentle pressure of the right hand cause the curve to pass over the bulb of the urethra, and into the bladder. - This is not “sounding” properly so called: it is merely the introduction of the sound; the more delicate portion of the proceeding remains to be accomplished. The sound must now be held lightly, and must be moved about in all portions of the bladder until the peculiar click is heard or felt. Fig. 610. --- S. … tº. 7/4 AM/, /VAV & C O Benique's Sound. As soon as the operator has satisfied himself that the steel instrument has touched the stone, he should pass it to other professional friends, that it may be demonstrated beyond the possibility of a doubt that the calculus is present. This rule should always be followed, nor should the opera- tion be commenced until several surgeons have detected the offending mate- rial. - - Sometimes the stone cannot be found; in such cases by introducing a finger into the rectum, and pressing the lower part of the bladder upwards, the calculus may be made to touch the sound. When these means proved unsuccessful, Dr. Physick, whose experience in lithotomy was extensive, was in the habit of placing the patient nearly upon his head, by FIG. 611. which position the stone was dis- lodged from the fundus of the bladder and thrown against the sound. - In sounding, care must be taken lest the student mistake a stone in the urethra or prostate gland for a calculus within the bladder. It will, therefore, be seen that this operation is difficult and deli- cate; and when men who have devoted their attention to the con- sideration of stone in the bladder say of “sounding,” “that to per- form it well requires great tact in the use of instruments, a perfect knowledge of the anatomy of the Position of the patient for Lithotomy (Cheselden's urinary apparatus, and a degree Operation). of experience which multiplied - © observation can alone supply,” and that “the want of success in the opera- tion is not confined exclusively to the young, the ignorant, or the unskilful, but that men of most consummate dexterity have occasionally failed in 958 A SYSTEM OF SURGERY. detecting a stone where stone really existed; ” the procedure must be looked upon as all-important in the operation. The Preparation of the Patient.—Having had the bowels evacuated by a full dose of castor oil, which serves the double purpose of relieving the bowels and inducing thereafter constipation, he must be brought to the edge of the bed, over which an oil cloth or india-rubber blanket has been laid, and the wrists and ankles are to be firmly secured as seen in Fig. 611, or “the leg braces” of Comstock or Peters applied. An assistant must stand on either side, and with his hands upon the knees of the patient, must separate the thighs as widely as possible. Anaesthesia should now be complete, and an instrument resembling in shape a catheter, constructed of solid steel, with a groove a little to the left side, with a rounded extremity, and which is called a staff, Fig. 612, must be passed into the bladder, drawn up against the pubes and placed in the hand of a steady assistant. Gross says: “A poor staff-holder is a great curse,” and so he is, for a change in the direction of this instrument, its depression in a sidewise position, may not only embarrass the operator, but may cause the death of the patient, by a division of wrong structures. Lateral Lithotomy.—Having now all things prepared, the patient anaes- thetized and well secured, the staff-holder steady, and the staff in position, sponges, etc., at hand, the instruments beside him in convenient position, and a good light falling upon the perinaeum (which, if the patient be an adult, must be carefully shaved) and thoroughly disinfected, the surgeon seats himself in front of the patient, takes an ordinary scalpel in his right hand, and with the thumb and forefinger of the left, puts the skin upon the stretch, and enters the point of the knife on the left side of the peri- naeum about an inch and a half above the margin of the anus, and carries it downward and outward to a little distance below the tuber ischii of the left side (Fig. 611, page 957, shows line of this incision). In a child there is not much subcellular tissue, and therefore not a very deep incision is required, but in some instances, where the patient is fat, this cut must be fully an inch in depth. There is an important point to be remembered in this part of the operation, viz., the incision from the external surface of the perinaeum to the point where the knife enters the groove in the staff, must FIG. 612. G.7/EMA WN 8, CO Lithotomy Staff. be either conical or triangular, with the apex at the membranous portion of the urethra, a little in front of the prostate gland; by bearing this in mind it will be perceived that the nearer we approach the staff the less extended will be the incisions. Placing the index finger in the upper angle of the wound, the transverse muscles and triangular ligament are successively divided until the staff is clearly felt within the canal at its membranous portion. Keeping the finger in the wound, and with the nail for a guide, LATERAL LITHOTOMY. 959 introduce the Fº of the scalpel into the urethra, and then withdrawing it, substitute for it a knife which has a long blade, a long handle, and a short cutting edge, with a buttonlike extremity which fits into the groove Fig. 613. Lithotomy Forceps. in the staff. At this stage it is well to pause a moment, and have the staff drawn up under the pubes and ascertain if it is in the proper position, and finding it in place, push forward the knife; it readily enters the bladder, which is indicated by the gush of urine which generally follows. Let me impress upon the student the direction in which the knife is to be pushed. It should be carried straight along into the bladder, keeping the probe-point well into the groove, care being taken not to elevate the hand or allow the blade of the knife to look downwards, for if this be done it will slip from the groove in the staff and be plunged into the rectum instead of the bladder, and the operation spoiled. Another º º caution is necessary, lest too much of the pros- tate be cut; the knife must be withdrawn as * soon as there has been an opening made into º the bladder, and the forefinger of the right * hand gradually inserted to enlarge the open- º in - | jº s - frequently the stone can be felt at the open- || ing of the bladder, and by introducing a pair ºš of forceps with broad serrated jaws (Fig. º º tº s the stone can be removed with the assistance of ãº% ANA s the finger (Fig. 614). If it be impossible, from the size of the offending mass, to accomplish its - removal, the wound must be carefully enlarged º to its utmost extent. If still the calculus can- not be withdrawn, it must be broken in pieces *fººl” with a crusher (Fig. 615). The bladder must - now be thoroughly washed out with carbolized water by means of a good- sized syringe, and the finger again introduced to ascertain if other calculi be resent. If there be none, release the patient from his bands, place him in ed on his left side, with an india-rubber cloth covered with absorbent cotton under the buttocks to catch the urine, and the operation is complete. employ neither compress, straps, bandage, nor catheter. To enlarge the in- ternal opening and facilitate the passage of the crusher or forceps, without ºnºment of tissues, an instrument has been devised, as seen in ig. 616. Key's Operation.—Lateral lithotomy was modified by Aston Key, of Guy’s Hospital; he used a staff nearly straight, instead of the ordinary curved I 960 º A SYSTEM OF SURGERY. director of Fergusson. When the groove in the staff has been exposed, “the point of the knife being kept steadily against the groove, the operator with the left hand takes the handle of the director and depresses it to an angle of 65° or 70°, at the same time keeping the right hand fixed. Next, FIG, 615. Stone-crushing Forceps. by moving both hands simultaneously, the groove of the director, with the edge of the knife, are turned obliquely toward the left side, and the knife has now the correct bearing for the section of the prostate; which may be accomplished by carrying the knife slowly forward in an exact line with the director.” - . Besides these methods of procedure, other operations have been adopted by eminent surgeons, as improvements. Allarton's Operation.—The median section is an ancient method, also known FIG. 616. G. 7/8/WA/W/V. CO. Guide for the Forceps through the Perineal Opening. as the Marian or Italian operation. It either adopts the plan of making a vertical incision through the prostate, as practiced by Vacca, or follows the method revived by Allarton, in which only the apex of the gland is incised. * - In this the common grooved staff is passed into the bladder, and its handle intrusted to an assistant. The surgeon introduces his finger into the FIG. 617. - Q Tºsº, |NN-CQ, Little’s Director. rectum as far as the apex of the gland, and there retains it as a guide to the next part of the proceeding, which consists in entering a long straight bis- toury with its edge uppermost, about a half inch in front of the anus, in the median line; cutting down to the membranous portion of the urethra until BILATERAL SECTION. 961 the groove in the staff is reached, and pressing it toward the bladder for about half an inch; then carrying the incision upward, the membranous portion of the urethra is freely divided, and the soft tissue of the perinaeum. A long ball-pointed probe, or, what is better, the director of Dr. Little (Fig. 617), is now carried through the groove into the bladder, and the staff is re- moved. By passing the finger along this probe into the bladder the orifice is dilated; it also serves as a guide to the forceps in seizing and removing the stone. In cases where the calculus is of small size this method may be success- fully employed; but in general, experience has failed to give much support to this mode of operation. Bilateral Section.—Dupuytren recommended a bilateral incision through the prostate gland, making a semilunar cut transversely through the peri- naeum. He considered this a superior method for the removal of large cal- culi, but the operation now finds few advocates. The first incision having reached the staff, a double-bladed curved lithotome is pushed close along its convexity into the bladder. The blades are now opened transversely, Wood's Lithotomy Staff and Knife. and by withdrawing the instrument, the neck of the bladder and the pros- tate gland are divided. The late Dr. James R. Wood was partial to the bilateral section, and to facilitate the operation devised a bisector, with fixed open blades, as seen in Fig. 618. - Civiale's Medio-bilateral Operation differed from the above only in that the first incision was made in the median line. Buchanan's Operation.—In this a staff bent at right angles three inches from its point, with a deep lateral groove and a posterior opening, is intro- duced into the bladder, and, guided by the finger in the rectum, its angle is made to correspond to the apex of the prostate gland. With the finger still retained in the rectum and the staff in the hands of an assistant, the peri- naum is entered by a long straight bistoury held horizontally, with the edge turned to the left, directly opposite the angle of the staff. When it enters the groove it is pushed toward the bladder until it reaches the stop at the end of the staff. On withdrawing the knife, a curved incision is made through the soft tissues to the left of the rectum, about 14 inch in length. The cut can be made with a lithotome caché (Fig. 619). The author claims several advantages over the ordinary method, viz.: The prostate gland is reached more easily and rapidly, the membranous portion of the urethra is avoided, all bloodvessels of any importance are out of danger, there is less liability of the rectum being injured, and not so much risk of deep-seated urinary infiltration. Recto-vesical Lithotomy, or lithotomy through the rectum, was at one time frequently resorted to, but at present has fallen into disuse, so that it 61 962 A SYSTEM OF SURGERY. has been omitted from some modern works on surgery. The grooved curved staff being in position, a straight bistoury laid flat on the palmar surface of the finger is carried into the rectum about one inch. With the other hand, the edge is turned up and the knife thrust through the wall of the rectum - until it reaches the groove of the staff, when by withdrawing it, the rectum, external sphincter, and sur- rounding tissues are divided about one inch in the median line. Insert the left index into the wound, guid- ing the knife, with its edge turned downward, to the groove, and then push the instrument forward into the bladder, making the incision to correspond to the supposed size of the stone. The finger is now car- ried into the bladder, the sound withdrawn, the forceps introduced, and the stone extracted. The important objections to this operation are the danger of wound- ing the peritoneum and vesiculae seminales, the subsequent infiltra- tion of urine, or recto-vesical fistula. The Suprapubic or High Opera- tion, Epicystotomy, Hypogastric Sec- º tion-This operation was first per- º formed by Pierre Franco, who, in he Lithotome Caché. 1561, according to Belmas” and Vel- peau, and in 1560, according to Heister, operated successfully upon a boy. Hypogastric section gained favor for a time, Cheselden, Proby, tº and others lauding it highly. It fell into disrepute for a time, until the French surgeons, notably Sou- berbeille, brought it into notice. Soon it lapsed into oblivion again, to be resurrected, attacked, and defended, until to-day its merits are being dis- cussed by the greatest men of the age. Elsewhere, $ as well as in the last edition of this work, I have expressed the opinion that it is the best method of cutting for stone. The following description, with some modifications, I have taken from my work on this subject. It makes little difference whether the incision be made with a bistoury or scalpel, whetherit goes from above downward or below upward, whether the bladder be held up with a tenaculum, or a hooked finger, or a loop of catgut, provided it be held up. A surgeon will have his favorite instru- ments, which, in his hands, have been best adapted for making the appro- priate incisions. Several days before the operation, if the urine has been putrid, or there has been atony of the bladder, that viscus should be washed out carefully with a saturated aqueous solution of the biborate of soda, and the best apparatus for the purpose is that of Dr. Keyes. The injection of the bladder and rectum before the operation is begun, is an important feature in the performance. According to Fehleisen the rec- tum i. hold more fluid than the bladder–14 or 15 ounces in the former and 10 or 12 in the latter. In my last operation I used a good-sized colpeu- § -º - § - * Traité de la Cystotomie Suspubenne. Paris, 1827. + Velpeau, Operative Surgery. † Institutiones Chirurgicae, tom. ii., p. 927. & Suprapubic Lithotomy, 4to, p. 99, Boericke & Tafel, 1882. THE SUPRAPUBIC OR HIGH OPERATION. 963 rynter, introduced well up in the rectum, to the tube of which a stopcock was attached; they should be distended as much as possible to elevate the peritoneum. The sonde-à-dard is not an essential; a catheter or ordinary sound will mark the point where the bladder incision should terminate if begun at the pelvis, or where it should be begun if it terminates at the pubes. It, however, gives a sure guide to a free, bold, and smooth incision into the bladder, and should be used if practicable. Besides this, in the modification which I have devised, it prevents the frequent passage of in- struments through the urethra, which, in some cases, is not desirable. Every instrument must be “listered,” every particle of the bedclothing, #: clothing, atmosphere, and apparatus, should be prepared with care; then, $, (1.) Place the patient in a comfortable position, supine, on a table of proper height, and administer the anaesthetic. (2.) The patient being etherized, a small rubber bag is rolled up in the shape of the letter V, upside down (A), and gently pushed into the rectum, care being taken to have it clear of the sphincter. It is then slowly filled with water, the surgeon using his judgment as to the amount, about 12 to 14 ounces being required. The bladder is in its turn filled until its promi- nence over the pubis is both seen and felt. The distension of the bladder is º as important as that of the rectum, but in either case force must be UlSéCi. (3.) Introduce the sonde-à-dard (Fig. 620) without the stilet, and inject the bladder (with stopcock B open) with a solution of calendula 1 : 100, at a FIG. 620. * * • *...** SAVV *º-º: Nº-Nºseys The Author's Sonde-à-dard. temperature of 100°. So soon as the slightest resistance to the passage of liquid is observed, draw the plug from the mouth of the flange C, and, as the water passes out, inject more until the bladder is thoroughly cleaned. (4.) Insert the plug D firmly into its place, and inject the bladder with as much as it will hold, and, having done this, turn the stopcock to retain the water. It will be seen that the sonde may be used not only as a searcher for the stone, but for injecting and washing out the bladder, and that if it be made the proper size, equal to a No. 16 English bougie, there will be little, if any, water escape by its side. By using one instrument a great advantage is gained, especially in cases of sensitive urethrae, where 964 A SYSTEM OF SURGERY. the frequent introduction and withdrawal of tubes may greatly complicate the case. The instrument used to inject is the ordinary rubber 12-ounce syringe fitted with a stopcock. (5.) The surgeon, with a scalpel, makes an incision from a point about two inches and a half above the linea alba, down to the top of the pubis, and about half an inch over the top of the pubic arch, almost to the root of the penis. This extension of incision is of importance, for it gives room to manipulate instruments, and in persons in whom there is much adipose tissue, this latter part of the cut assists materially in widening the mouth of the pit. While making this cut, by holding a small sponge with the middle, ring, and little fingers (after the manner in which an apothecary holds the cork of a vial which he is decanting into another bottle), and rendering the integument tense with the thumb and finger of the same hand, the surgeon may do his own sponging, and keep the cut clean as he goes through the tissues. (6.) When the linea alba is reached, the parts are examined to see if there be any bleeding points; if there are, the vessels may be twisted, or small catch forceps, as recommended by Spencer Wells, may be applied, or Vidal's forceps employed. The lips of the wound may be more widely separated by pushing them apart with the fingers. (7.) The tendinous expansion must be snipped above the pubes, a di- rector inserted, and the abdomen opened from below upwards for at least two inches. I generally do this with the scissors, although a knife with a probe point, or a sharp-pointed curved bistoury, will do as well. This brings the fat, which is usually found above the fundus of the bladder, in view, and, as in my first case it gave me much perplexity on account of its quantity, it is well to remember that it is often found of considerable thickness. If the cut is extended higher towards the umbilicus, the peri- toneum is exposed, but, as a rule, this is not necessary. (8.) At this stage the handle of the sonde-à-dard must gradually be de- pressed between the legs of the patient, to bring its beak at the fundus of the bladder, just below the point of attachment of the peritoneum ; thus the surgeon has a guide to this important point in the anatomy of the operation. (9.) The assistant holding the instrument as above, the surgeon takes a round curved needle, threaded with strong carbolized catgut, passes it through the bladder-wall, and draws it through, ties a knot in the catgut, making a loop of about an inch and a half, cuts off the needle, and places the loop over the bent finger of an assistant, or fenestrated catch-forceps may be used. (10.) The stopcock (B) of the sonde is turned, and a portion of the fluid allowed to escape. This is done to prevent any water flowing into the cavity of the abdomen, as the stilet is passed through the bladder. (11.) The stilet (C) is pushed into the canula and passed directly through the bladder. FIG. 621. m=miº % §:#################|- Gji=E-2 (12.) The sharp point of a pair of scissors, or the point of a curved bistoury, or the curved probe-pointed aponeurotome (Fig. 621) (I prefer the former), is introduced into the groove of the stilet, and the incision enlarged to obtain a fair opening into the bladder. The stilet is then THE SUPRAPUBIC OR HIGH OPERATION. : 965 withdrawn into the sonde, which is removed from the bladder, that organ being kept up by the loop of gut on the finger of the assistant. (13.) The finger is gently introduced into the bladder, the stone or stones are at once perceived, and in the majority of instances the fingers are the instruments which remove the calculi. When the concretions are large, or the patient very fat, as in my first case, forceps must be employed, and used with the utmost gentleness, until the calculus is grasped and removed. (14.) Search must be made to ascertain that the bladder is entirely free from stones, and then the bladder wound must be sewn up. (15.) In sewing the bladder (whether indeed it should be sewn or not, has been a matter of discussion), care should be used, and fine needles threaded with catgut employed. In my cases, and in those of Dr. Doughty, in every instance, the bladder-wound was closed with carbolized sutures of catgut. To do this effectually, a fine piece of the gut should be threaded upon a small-sized curved needle, and a small knot tied at the end ; beginning at the top of the wound, just below the point of suspension of the bladder by the loop of catgut already mentioned, a glover’s or continued suture should be carried the length of the wound, a reverse stitch taken, and the needle cut away. Günther does not apply any stitches, but Starr sews the walls of the abdomen and the bladder-wound with a peculiar stitch, which in- cludes both the bladder and the walls of the abdomen. He says of it: “I passed a silver suture down through the walls of the abdomen into the cavity of the bladder, included a part of this, and brought the wire back through the bladder and abdominal wall on the same side, then I carried it across the incision, passed it down through the abdominal wall and blad- der on this side, included a segment here, and brought it out as before, and just opposite where it had first entered the tissues; now when the ends of the suture were drawn upon, the sides of the wound were approximated, but the edges of the incision in the bladder were inverted and their outer surfaces brought into contact, while the mucous surfaces were turned in- ward, thus promoting union.” - (16.) After the bladder-wound has been sewn (that is, if it be not included with the abdominal walls after the manner of Dr. Starr), a sponge-holder containing antiseptic absorbent cotton must be gently pressed within the wound to remove all clots and moisture, but sufficient force must not be used to separate any of the paravesical connective tissue. (17.) The loop of catgut must be drawn to the top of the wound, where it generally remains, and held there while the tegumentary cut is closed. In my last case, instead of using the catgut loop, I held the bladder with º of forceps with a spring-catch on the handles and broad fenestrated 3,Ol€S. - (18.) In sewing the abdominal wound, either one of two methods will be found serviceable : a large-sized round needle should be threaded with waxed-silk, which should be cut to leave ends about four inches long; these should be sewn together with fine thread, or be spliced to make a loop. This method, which I have used for many years, is better than tying the half knot. The loop must again be waxed; upon this the silver wire, No. 26, must be bent, and squeezed together with a pair of forceps. By this means the flexibility of the silk allows the needle to be inserted and withdrawn through the abdominal walls without kinking the wire. The best of all needle-holders, especially where the tissues are thick, is that known as the Russian (page 35). -- The needle is introduced half an inch from the margin of the cut at the upper angle of the wound, passed through the entire thickness of the * American Journal of the Medical Sciences, July, 1877, p. 113. 966 A SYSTEM OF SURGERY. abdominal wall, and drawn through; again it is grasped by the needle- holder, inserted in the opposite side under the tissues, and brought out at the integument at a point opposite to where it has been entered on the other margin of the cut. The wire is drawn gently through and cut to leave about an inch and a half projecting from each side of the incision. These two ends are taken in charge by an assistant, who turns them over on the abdomen towards the head of the patient. A second suture is introduced in like manner a quarter of an inch from the first, and so on; the lips of the wound are brought in proximity, leaving, however, about half an inch at the lower angle for the admission of the drainage-tube. The second method for the introduction of the wires is to take a needle with an eye in its point (page 40), thread it with waxed silk about four inches long, introduce it from within outward, and when the eye with the thread in it appears at the integument, draw it (the thread) forward with a small tenaculum, until the loop is sufficiently large to hook upon it the wire, which is bent over the thread. The needle is withdrawn, the operator taking care to hold in his grasp, with the handle of the instrument, the distal extremity of the silk. The operation is repeated in a similar manner on the opposite side. As each wire is introduced, the assistant turns the ends upward, as in the first instance, and holds them out of the way until a sufficient number are introduced. (19.) Before the parts are approximated, the surface is washed with an antiseptic solution, and again the sponge-holder, charged with fresh anti- septic cotton, is used to remove any blood that may have oozed from the needle puncture. (20.) A small-sized glass drainage-tube, having a flange, to which is attached a piece of new india-rubber tubing, is inserted into the lower angle of the wound, and the wires twisted with the usual instrument. A new cork must be placed in the drainage-tube, and the india-rubber tube carried over the thigh into a vessel containing carbolized water, on the floor, or upon a stool by the edge of the bed. A narrow strip of plaster must then be laid along one side of the wound and the ends of the wire bent over the point of a tenaculum. Over the whole wound a covering of marine lint should be placed, and secured by carbolized india-rubber plaster. The loop of catgut must be lowered a little, and fastened by placing a bit of bougie through the loop transversely over the incision, and holding the bougie in the abdomen by adhesive strips. I use this as an additional preventive for extravasation; the idea being to keep the bladder-walls some- what apart, thus making a deeper trough for the accumulation of urine. Whether this has accomplished its purpose I cannot say, for I have been careful to keep the bladder empty by the presence of the catheter, or its frequent application. Dr. Doughty has invented an ingenious, and, in his hand, satisfactory apparatus to prevent excoriation from overflowing urine, which should be applied as the urine shows itself at the abdominal opening. It consists (Fig. 622) of a glass bell similar to a nipple-shield, which, for illustration, we divide as follows: A, bell; B, flange; C, rest. At the junction of A and B is an aperture for the passage of the drainage- tube. This must fit snugly, and be of sufficient length to pass from a bottle, between the thighs, over the scrotum by the side of the penis, through the aperture of the bell, and well into the wound. The end of the drainage- tube in the bottle must be lower than the bladder, that it may act as a siphon. The tube must have openings at intervals, in that part of it within the wound, and one at its upper side within the bell where it has passed the aperture. Let the pubes be shaved, the drainage-tube introduced, and the wound, unless there has been primary union, brought together with adhe- sive strips (as applied to an ordinary indolent ulcer), leaving the lower inch THE SUPRAPUBIC OR HIGH OPERATION. 967 of it exposed. In applying the instrument, let the centre of the bell cor- respond with the lower extremity of the incision, to admit of easy intro- duction into the wound. To secure it, let a strip of adhesive plaster, six inches in length by one inch in width, with a semicircular piece cut from one edge in the middle to receive the bell, be applied across the wound and over the flange. FIG. 622. Next let a piece of roller bandage be passed under the patient, and the ends brought up over the thighs above the great trochanters, leaving the space across the abdomen for the attachment (by pinning or sewing) of a piece of elastic * to # of an inch in width, and without tension raise the elastic from its centre to the rest C. The roller bandage and the elastic being prop- :-- ºr ; erly adjusted, no urine can escape on the person, . A. nor can any suffering be experienced by the º Ø patient; therefore skill and precision in the º º application of the apparatus is indispensable. 6. If the pubes be unequally impressed by the Ó entire flange, so that pain results from too severe § pressure, the application is a failure. The reasons 6 and the remedies are obvious. If the failure is | due to the roller bandage (causing tipping of the bell, and so unequal pressure of the flange), it must be newly adjusted by removing it, either ji Hº a trifle higher or lower; if the fault is due to ºn the elastic, its tension must be increased or di- ºf i. iº minished. Stoppage of the tube, external to the º:Hºe bell, will be readily detected by the rising of the º i. *::::=: urine within it (the bell), and can be relieved by ſº ºl º aspiration, by means of a small penis syringe. " º * If the obstruction is in the part within the wound, the whole apparatus must be removed, for reasons readily appreciable. It is a question with some surgeons regarding drainage. Dr. Stimson says that Dr. Keyes recommended drainage per rectum ; others draw the water every few hours, as recommended by Dulles. I have seen excellent results from fixing a Nélaton flexible catheter in the bladder, only remov- ing it sufficiently to cleanse it, recollecting that so soon as its bladder-end shows a tendency to becoming rough, a new one must be substituted. (21.) The position the patient assumes makes but little difference, but for the first few days the recumbent is that most desired, because it is more comfortable. As far as the renewal of the old practice of turning the patient on the face, as lately practiced by Trendelenberg, I should think it both undesirable and tiresome, and above all, the position would be likely to force the urine from the wound, simply by attraction of gravita- tion, a circumstance which is much to be deprecated in the after-treatment of the operation. After-Treatment.—The chief danger in “the high operation ” for stone, consists in the liability to urinary infiltration, and, perhaps, phlegmonous inflammation of the paravesical tissues. The wounding of the peritoneum need not occur, excepting in cases in which the enormous size of a cal- culus necessitates a corresponding wound in the bladder, and in such it would be preferable to crush the stone and remove it by fragments; that is, if it can be broken. The evil results of urinary extravasation can be much reduced by the methods I have lately practiced. The morning after the operation the 968 A SYSTEM OF SURGERY. patient should be dressed as follows: All the bandages should be removed and the parts carefully washed and dried, then a coating of flexible collo- dion should be placed over the wound and around it, for the distance of three or four inches on each side, and down on the inside of the thighs. The drainage-tube should be removed; if glass, it must be cleansed and allowed to lie in a solution of carbolic acid 1:60 until it is wanted; if india-rubber, it is to be burned and a new one employed. A flexible Néla- ton catheter, with a countersunk eye, is to be attached to the tube of a fountain-syringe, and carbolized water 1: 200, at a temperature of 100°, is allowed to run into the wound; this should be continued until a quart of the solution has been so used. The dresser, taking his probe, wraps the end of it with borated cotton, introduces it to the depth of the in- cision, and wipes out the wound; he then removes the cotton, reapplies another piece, uses it in a like manner, and so on until the whole cavity is dry. This may take half an hour or even more. The catheter is re- moved from the bladder, washed and carbolized, and is ready for readjust- ment. The surface of the abdomen must be covered with a large wad of borated absorbent cotton, and a muslin binder applied over it, and fastened with safety-pins. The catheter for the first few days must be permanently retained in the bladder, which is accomplished as follows: Take six or eight hooks, such as are used in fastening ladies' dresses (hooks and eyes), secure three of them just below the glans penis, by wrapping around the organ a strap of india- rubber salicylated adhesive plaster, apply a corresponding number to the flexible catheter at a point about an inch from the meatus; the catheter is inserted, and by slipping over the corresponding hooks small india-rubber bands, which, from their elasticity, will allow sufficient expansion of the penis, when it has a tendency to erect, or at least enlarge, the instrument will be comfortably kept in position. After the first week, the permanent use of the catheter should be dispensed with, and the urine drawn every two or three hours. - Dangers.-As to the relative danger attending these several methods of operation, it may be stated as follows: In 1827 cases, of all ages, in the various metropolitan and provincial hospitals, upon whom the lateral operation was performed, the ratio of mor- tality was about one to eight. - The recto-vesical operations show the proportion of fatal cases to be about one in five and one-fourth. In suprapubic lithotomy a death ratio has been found of one in four. This is hardly a fair estimate, because of the character of the cases which have heretofore been subjected to the suprapubic. According to Dulles,” the mortality is shown to be 1 in 10 in the table he collected for ten years, and from the tables in my work the true mortality is about the same. Under twelve years of age the lateral operation is said to be the safest, and most successful. After that age the various modes of procedure have been instituted, hoping to diminish the mortality, but the results thus far are by no means flattering. * * * The causes of death, after the operation of lithotomy, may be briefly stated —1. Disease of the kidneys, which is generally present if the calculus has existed a long time; indeed, if the source of irritation remain in the blad- der, death will probably result from the cause above mentioned ; and where there exists any serious lesions of the kidneys, the operation is much less * Suprapubic Lithotomy, by C. W. Dulles, M.D. American Journal of the Medical Sciences, April, 1878. STONE IN THE FEMALE BLADDER. 969 likely to prove successful. 2. Deaths from shock, so called, are undoubtedly often dependent on the same condition. 3. Haemorrhage may be one of the causes, but is rare. 4. Pelvic cellulitis is a common cause of mortality in adults, and generally arises from urinary infiltration. 5. Peritonitis is less common. 6. Cystitis has sometimes given rise to fatal results. Other causes are phlebitis, pyelitis, and uraemia. Stone in the Female Bladder.—It is probable that calculi are formed in the kidneys of the female as often as in the male, but having once passed into the bladder, the anatomical relations of the urethra to that organ are such as to render the escape of small concretions comparatively easy. No pros- tate gland obstructs the passage, the urethral canal is short, straight, and largely dilatable, so that calculi of nearly an inch in diameter have, by nat- ural efforts, been expelled with little pain. The above reasons will explain why vesical calculi in the female so rarely require surgical interference. - The symptoms are similar to those already detailed as occurring in the male; but the special ones are bearing-down pains, pains in the urethra, and incontinence of urine, and these may so simulate the symptoms of uterine disease that a correct diagnosis can only be attained by a vaginal examina- tion and the use of the sound. Sometimes nature adopts a method for the removal of stone, in which ulceration of the bladder takes place, and the mass is discharged into the vagina, leaving a vesico-vaginal fistula, an acci- dent much to be deplored. Urinary calculi in the female are more easily removed than in the male, as the operation generally consists of dilatation of the urethra, followed by extraction; or of lithotrity. By the former process, stones three-fourths of an inch in diameter may be removed from children, while from adults, cal- . one-fourth to one-half inch larger in diameter may be extracted with safety. There are two methods of dilatation,-the slow, performed gradually by means of tents, bougies, or dilators, until the urethra is sufficiently en- larged to introduce the forceps; and the rapid, which is accomplished while the patient is under chloroform, by the use of the urethral dilator, and the whole operation completed at one sitting. The first method is more liable to be followed by incontinence of urine than the second. If the stone prove too large to be removed by these means, it should be broken up by the lithotrite, and the pieces extracted, which may be done with little danger. If the bladder is so much diseased as to render lithotrity impracticable, an incision must be made through the Septum of the vagina into the bladder—avoiding the urethra—by means of a director passed into it, which will serve as a guide. The wound is to be closed by sutures, as in vesico-vaginal fistula. Experience has taught that any incision into the neck of the female bladder is reprehensible, as it is liable to be followed by incontinence of urine. The Suprapubic operation is by far the better method of removing stones from the female bladder when a cutting operation is necessary. Other foreign bodies are found in the bladders of both males and females, and their extraction will be effected by the same general means as those for the extraction of stone. Lithotrity.—As early as 1626, the idea of crushing stones within the blad- der and passing the fragments through the urethra, was conceived by Santorio, an Italian, and one Ciucci, of the same nationality, projected a similar method of dealing with urinary calculi. But to Civiale must be awarded priority in conceiving the idea and accomplishing the result. His instrument, as first constructed, consisted of a straight canula, containing three claws and a drill, with the claws concealed; the instrument was passed 970 A SYSTEM OF SURGERY. into the bladder, the claws opened, the stone seized, and the drill put in motion, until the stone was broken. Civiale, however, soon modified his apparatus, and finally produced an instrument as seen in FIG. 623, Fig. 623, and which I used some years ago, with fair results. sº In 1824, the London cutler, Mr. Weiss, devised and con- structed a lithotrite with two blades bent at a right angle with the shaft, one working upon the other, by a set screw in the handle, and since that period all lithotrites have been modifications of that principle. It is scarcely necessary, except as matters of historical in- terest, to allude to the old operations of lithotripsy. The instrument of Heurteleup consisted of two blades, which were made to slide one upon the other. It was intro- duced into the bladder as a simple sound or catheter, and the blades were afterwards expanded, for grasping the stone. In its original form, the male blade was struck with a hammer; later, however, the crushing force was exerted by means of a peculiarly adapted screw. The extremities of the instrument were fitted with teeth, for the retention of the stone after it had been grasped, and fenestrae, or perforations, to allow the escape of the powdered stone or sand. Previous to the operation, the urethra was dilated, and the urine retained in order that the bladder might not be in a collapsed condition, and thus endanger its coats being caught by the instrument. The patient was laid on a convenient bed or table, with the pelvis elevated in such manner as to throw the stone into the fundus of the bladder. The instrument, having been oiled and warmed, was introduced, and, after encoun- tering the stone and fairly grasping it—an operation which required skilful manipulation—the calculus was crushed by slowly and gradually turning the screw. The methods of Thompson and others were similar to that of Civiale, except that the instruments were better adapted for crushing the stone; Fig. 624 shows the entire lithotrite of Sir Henry Thompson; Fig. 625 represents the handle; and Fig. 626 the jaws. In these operations as much of the stone was crushed as the skill and dexterity of the surgeon could accomplish in a few moments, and the debris removed either immediately through the urethra or a catheter, or allowed to remain some time in the bladder that the sharp ends of the frag- ments might be worn off. There can be no doubt (notwithstanding the usual oppo- sition offered % the characteristic º of our transatlantic Civiale's Litho brethren) that Bigelow's American Method of Lithotrity, or §Wei." Litholapaxy, as it is denominated by its author, has taken the place of all the older proceedings for crushing stone in the bladder, has reduced a prolonged series of suffering sittings to a single painless operation, and has demonstrated beyond cavil, the toleration of the bladder and urethra for very large surgical instruments. Of course the single séance, the large instruments, and the washing bottle, when first introduced, were critically scrutinized, for the old teachin was small instruments—the smaller the better, from two to six sittings an two or three minutes at a sitting. If a stone was thought to require more than this, the patient was subjected to lithotomy. In reviewing the opera- LITHOTRITY. 971 tion, Sir Henry Thompson thought the instruments too big and the time of the operation too long; but only so short a time ago as 1882 he wrote in the Lancet:” “In order to remove two or three hundred grains of calculous material from the bladder—many calculi weigh less than a hundred grains, FIG. 624. Thompson's Lithotrite. while all ought to be found before they attain that weight—it is wholly un- necessary, I will even say that it is unwarrantable, to introduce lithotrites and evacuators with the diameter of No. 18 or 20 English scale into the bladder.” But soon the experiences of Trevan, Van Buren,f Keyes,S FIG. 625. ==== ºſ. š.: “jififiºsº, ſº Cº-ºlllllllllllº- --- sºlſ|{{ſº :*:::: **** -------- "$º: ::m:º:# , ºº::=== sº 8. --- - - - - - - - - - - - - - - - - - - - - - w --- --- Tºtº citemann-co. Handle of Thompson's Lithotrite. Sands, Otis," and other distinguished surgeons removed these objections, the operation was accepted, and they have proven that, not only is the operation adapted for most cases of stone, but that it may be accomplished with success in spite of serious constitutional disorders. Mr. W. F. Trevan, FIG. 626. Jaws of Thompson's Lithotrite. F.R.C.S., prefaces the publication of some cases of lithotrity by these Words: “The cases I relate prove what Bigelow's operation can accomplish even when the presence of stone is complicated by the existence of grave constitutional disease. The calculi were, I believe, the largest single ones ever removed, in this country, from the bladder at one sitting. One of the patients was suffering from diabetes, the other from paralysis. Youngest, fifty-six, eldest, seventy-seven.” * London Lancet, May, 1881. f Medical Record, March 22d, 1879. i American Journal of the Medical Sciences. Medical Record, March 22d, 1879. | American Journal of the Medical Sciences, January, 1880. Medical Record, November 3d, 1883. * London Lancet, May, 1881. 972 A SYSTEM OF SURGERY. Specialists in this department have proved the value of the operation and accorded the credit to Bigelow. On this point Dr. Otis says, in his remarks regarding the fact that other surgeons besides himself Fig. 2. had crushed stones at a single sitting before Bigelow: º “I am sure that many surgeons have experiences, prac- |s tically equivalent to the foregoing, antedating the opera- tion of litholapaxy by many years. And thus I claim that Professor Bigelow did not discover the tolerance of the human bladder to prolonged instrumental inter- ference. He did much more—he utilized the knowledge which he in common with other surgeons possessed. He had the inspiration to conceive of its value as a factor in a great life-saving operation. He seized the demonstration of an average urethral calibre of 32 mm. in circumference. He joined it with his knowledge of the toleration of the bladder to legitimate surgical procedures, and litholapaay was born. He had the courage, the surgical knowledge, the skill, the inventive mechanical genius, and the perse- verance to carry it, vi et armis, to a successful maturity, thus finally achieving one of the most brilliant surgical triumphs of modern times.”* There is a point here worthy of mention regarding the gentleman who has just been quoted in according to Dr. Bigelow his meed of praise—I refer to Dr. Otis. That however surgeons may differ from him regarding the rela- tive size of the urethra with the circumference of the penis, to him unquestionably belongs the credit of demon- strating the extreme toleration of the urethra, for instru- ments at least 22 mm. in circumference, which fact, no doubt, assisted Dr. Bigelow in the construction of his evacuating tubes, the proper calibre of which is an essen- tial feature in successful litholapaxy. For the satisfactory performance of this operation, it is requisite, first that the lithotrite should be of sufficient size and strength, and that the blades, being opened and closed so frequently within the bladder, do not become clogged with the débris; and second, that the evacuator should have sufficient power, that the evacuating tubes —as before remarked—should be of sufficient size, and that as little air as possible be allowed to enter the blad- der. To accomplish these results, endless modifications of the lithotrite and washing-bottle have been devised. Dr. Bigelow's instrument, Fig. 627, works with a round handle, a, which can set the jaws by a turn of the wrist, and a circular grooved hand-piece, b, to force the blades together; c represents the handle proper; d the shank; e the male blade with large triangular notches, the better to grind the stone, and to allow the escape of a portion of the débris laterally, and furnished with an additional projection at the heel to fit into the slot in the female blade f. The female blade should be very smooth and the floor nearly level with its rim. Dr. Bigelow has made other modifications of his instrument both in the handle and blades, which will readily be seen by referring to the cuts. * Medical Record, November 3d, 1883. LITHOTRITY. 973 The lithotrite which I now use is the one modified by Dr. Keyes; it has the fenestrated blade with the male blade angular and with a flat heel, the FIG. 628. : | º-º - | ſºBºº :-- :º - -* | Bigelow's Lithotrite. female blade being smooth, tapering, and curved with serrated sides. Fig. 629 shows the lithotrite; the strong shaft, 2, on which are the measurements FIG. 629. wº* * W* E Www. w W . E. Hº - * =#EP to register the size of the stone; i, the screw; m, handles for locking; d, the female curved and serrated blade; p, the male blade, grooved and notched for completion of the crushing. 974 A SYSTEM OF SURGERY. Fig. 630 represents the modifications of Keyes' instrument, with the groove in the male blade, and the arrangement of the female blade. - I have used Keyes’ first instrument many times and have found it satis- factory, occasionally inclined to clog and once in a while catching in the walls of the bladder—more, perhaps, because, as Dr. Keyes, in the early FIG. 630. Jaws of Keyes' Lithotrite, days of the operation, himself wrote: “There is no royal road to lithola- paxy,” than from fault in the lithotrite. The objections urged against the fenestrated instruments are chiefly, that as the crushing process goes on, sharp splinters are forced against the bladder-wall, and thus become sources of serious irritation; and that the process is delayed, because the same fragments are liable to be caught again, and thus delay the operation. FIG. 631. Jaws of Fenestrated Lithotrite. Each surgeon has his preference and can do the best work with that instru- ment with which he is most familiar. Fig. 631 shows the jaws of fenestrated. lithotrites. - So much for the crushing apparatus; the next step is the evacuation of the débris. In one of his earlier articles upon litholapaxy, Dr. Bigelow laid down axioms regarding the washing apparatus which are still true. He stated them” it is essential that the shape of the tubes and the shape of the * American Journal of the Medical Sciences, January, 1878. LITEIOTRITY. 975 receiving extremities of the tubes, their large capacity, the assemblage of FIG. 632. Sir Philip Crampton's Evacuator. fragments around their ends, the immediate recognition of these fragments, - FIG. 633. Mr. Clover's First Evacuator are conditions for the successful withdrawal of the débris. As Weiss, the FIG. 634. FIG. 635. - |||}| 1. |) || t | | . ſ Stand for Bigelow's Evacuating Apparatus. W | º Bigelow's Evacuating Apparatus. instrument-maker, arranged a model upon which most of the lithotrites 976 A SYSTEM OF SURGERY, have been made, So Clover invented an aspirator which was a modification - of Sir Philip Crampton's. Fig. 632 shows the original instrument, and Fig. FIG. 636. 3A Sir Henry Thompson's Original Evacuator. 633 Mr. Clover's modification. So late as January, 1882; Sir Henry Thomp- Son* states that “the instrument of Clover is still a useful one.” Bigelow's FIG. 637. Sir Henry Thompson's latest Evacuator, modified by Weiss. original washing-bottle is the only one I have employed, though I have been present on several occasions where the modifications have been used, * London Lancet, January, 1882. LITEIOTRITY. 977 and I am of opinion that up to this time the old will bear comparison with any of the newer models, because it is much more simple; sometimes, it is true, a bit of stone may be returned into the tube, and perhaps some air be forced into the bladder, but this is liable to occur with any of the bottles. FIG. 638. Bigelow's Evacuator. As a rule, I have had better success with the straight than the curved tube. Fig. 634 shows the original apparatus of Bigelow; Fig. 635 its stand. Sir Henry Thompson's original evacuator, Fig. 636, was on the same principle as that of Bigelow. He says of it, that it should be light, easily FIG. 639. mº lºgº Walker's Washing Bottle. grasped with one hand, A, have its opening at the top for filling, F, regu- lated by the screw, H, the catheter, B, should be attached to its lower part, E, governed by the screw, D, and that its trap should be at the bottom, G. This instrument I have never seen used, but it was said to be open to several objections, mainly that the fragments mounted again into the reser- voir. Later Mr. Weiss modified the apparatus by putting the trap forward, Fig. 637, which I should consider a great improvement. It were useless to endeavor to portray the various modifications of Prof. Bigelow's washing apparatus. Fig. 638 represents the most recent, which 62 978 A SYSTEM OF SURGERY. is perhaps the best, making the route to and from the bladder short, and being easily filled, refilled and readily worked. It has an elastic bulb, glass receiver, and stopcocks. , Below there is a metal brace between the collar of the glass receiver and that of the catheter to steady the latter. Within the bulb, and open at the end, is a tube strainer to prevent the return of debris. The bulb forms a concentric handle to the catheter. - The efforts that have been made to produce an evacuator which shall combine efficiency with lightness have resulted in many good contrivances; of these, that by Prof. H. C. Walker* appears to be one of the best. The cut will explain itself, and further description may be found in the journal referred to. - Dr. F. N. Otisf has invented and modified probably the most easily worked and efficient aspirator, of which he says: “The instrument may be filled, preparatory to using, by means of an or- dinary Davidson's syringe attached to the stop-cock. The readiest and best way of filling the instrument, is to plunge the evacuating end into a vessel of water, of a temperature of 98°, and by one or two firm compressions of the rubber bulb, the filling is complete, and the evacuator is ready for use. If, during the operation, it is found desirable to introduce additional water into the bladder, this is done with great ease, by attaching the discharge pipe of the Davidson's syringe to the stop-cock (at L), while the supply end is immersed in a vessel (preferably a large glass graduate), filled with water FIG. 640. G, T, Otis's Evacuator. of a proper temperature. The easy attachment and detachment of the Davidson's syringe, allows any desired amount of fluid to be introduced into the bladder without delay or inconvenience.” With this understanding of the instruments, a few explicit directions for performing the operation is all that will be necessary. I should advise those who undertake litholapaxy for the first time, to make experiments with the lithotrite, in order to gain experience in using the instrument. The method by which I instructed myself, was by taking the fresh bladder of an ox, putting therein a few pieces of coal cinder and fixing at the neck of the bladder a flat cork of about two inches in diam- eter, with a hole in the centre of sufficient size to admit the lithotrite. The bladder was then partially filled with water and the lithotripter applied, * Medical News, January 10th, 1885. f A Simplified Evacuator, etc., Pamphlet, February 4th, 1885. LITHOTRITY. 979 In performing the operation on the patient, he may be etherized or not according to #. desire, the sensitiveness of his urethra, or the magnitude and hardness of the stone. Some who have a canal of large calibre and been accustomed to the use of the sound and catheter, prefer to be operated upon without anaesthesia, but I prefer in all cases the use of an anaesthetic, save when there is a suspicion of kidney disease, and then it should be prohibited entirely. The i. should º washed with tepid water, either through a large soft catheter, 18-English, or one of the washing apparatuses already depicted. In the majority of instances, the surgeon will find it good practice to di- vide the mouth of the urethra with the urethrotome. Of course this addi- tional operation need not be made if the meatus is of sufficientsize to readily admit the lithotrite. The bladder must be filled with warm water, generally from eight to ten ounces. This must be gradually done, for sometimes the sensitive bladder reacts slowly, and its walls are so thickened that its capacity is much dimin- ished. The operator, standing on the side of the patient most convenient, takes the penis in his left hand, separates the meatus by pressure with the forefinger and thumb, and enters the point of the lithotrite, held in the right hand, within the urethra until its point reaches the fossa navicularis. The penis being steadied by the left hand, the handle of the lithotrite is made to ascend the arc of a circle, by raising the handle; after it has been a little elevated the lithotrite, in many instances from its own weight, and in all instances where there is no stricture, with gentle pressure, drops down to the triangular ligament. By drawing the penis upward upon the shank of the lithotrite, with the left hand, while at the same time the right hand finishes the arc of the circle, by depressing the handle between the legs of the patient the closed jaws enter the bladder. During these manipulations, in most instances, there are spasmodic gushes of water through the urethra, and I am in the habit of tying a broad tape around the root of the penis to prevent the escape of all the fluid. Some- times the beak of the lithotrite touches the stone immediately it enters the bladder, in others it does not; then the lithotrite must be slowly turned to the right side, sometimes to the left, sometimes to the base, in search of the Fig. 641. FIG, 642. Lithotrite Grasping the Stone. Eye of Evacuating Tube. calculus. When the stone is found, the blades are opened, not too slowly, but with steadiness, and it falls (sometimes at once) into the jaws of the lithotrite. This manoeuvre may have to be done many times before the stone is rasped. When the jaws are fixed upon the calculus, the instrumentshould É. rotated each way to see that the mucous membrane is not caught in the blades, and, if free, the blades should be turned directly upward as seen in Fig. 641; the catch fixed, the screw turned, and the stone broken. 980 A SYSTEM OF SURGERY. This crushing should be performed several times without the withdrawal of the lithotrite, the surgeon being careful every time that the bladder walls are not entangled in the jaws of the instrument. When the operator is sat- isfied that there is sufficient debris made (and it must be borne in mind, that the detritus may, after a time, prevent the further crushing of larger fragments), the lithotrite is to be withdrawn, and the washing bottle, with its reservoir filled, brought by the side of the patient, or placed upon the abdomen. The evacuating catheter with its large eye, Fig. 642, is introduced into the bladder and affixed to its tube, the stopcocks arranged as already described, and the pressure made upon the bulb. This pressure ought also to be steady, not too sudden, and the bulb allowed to slowly expand. The bits of calculus fall into the trap and the bulb fills again with the recurrent water. This operation is to be repeated until there appears to be no more debris. The bladder is filled again with water, the lithotrite put in action, and the process of crushing and evacuating continued until the operator is certain that nothing remains behind. The bladder then should be carefully washed with warm calendula and water, 1 to 4 or 6, the patient put to bed with warm bottles at the feet, and aconite administered every half hour for a few hours, to allay any urinary irritation. If bladder tenesmus should be present, I have found tinct. hyoscyami in 8 to 10 drop doses, given every hour or two, productive of much relief. If the urine be .# a drink of potash water, made palatable, may be given. . There is in some cases a secondary cystitis set up, after the third or fourth day, which demands attention, and which should be checked at its onset, lest it become chronic. This condition is especially controllable by the equisetum and sandal wood oil. The conclusions of Dr. Bigelow regarding his operation as first given remain essentially the same, though the instruments have undergone vari- OllS modifications. I give them as authority on this subject, in his own WOTCIS. “1. The calculus, although not necessarily pulverized, is crushed as rapidly and completely as is practicable. The dust and fragments are im- mediately evacuated, and a serious source of irritation is thus removed. “2. This can be generally effected in a single operation. • “3. The operation—performed of course under ether—may be, if neces- sary, of one or two hours’ duration, or even longer. - “4. The method applies to larger stones than have been hitherto consid- ered to lie within the province of the lithotrites. It also applies to small stones, nuclei, phosphatic deposits, and foreign substances. - - “5. Evacuation is best accomplished by a large tube, preferably straight, with a distal orifice, the extremity of which is shaped to facilitate its intro- duction, and, during suction, to repel the bladder wall—and by an elastic exhausting bulb, which acts partly as a siphon. Below the latter is a glass receptacle for debris. - - “6. The best size for the tube is the largest the urethra will admit. “7. Such a tube is usually introduced with facility, if passed vertically as far as it will go toward the anus before changing its direction, and after- ward directed almost horizontally, and passed by rotation through the tri- angular ligament. The first part of this rule applies also to the introduction of a lithotrite, and even a curved catheter. A free injection of oil is impor- tant. “8. A small meatus should be enlarged, or a stricture divulsed, to allow the passage of a large tube. - “9. If the bladder be not small, a large and powerful lithotrite is always better than a small one. * “10. That this may have room for action, the escaping water should be LITHOLAPAXY IN CHILDREN. 981 replaced occasionally, through a tube inserted a few inches into the urethra by the side of the lithotrite. But the bladder should not be over-distended. “11. To save time, and also to prevent undue dilatation of the vesical neck, a non-impacting lithotrite is desirable. The jaws of a non-fenestrated instrument will not impact, if the male blade is furnished with alternate triangular notches by which the debris is discharged laterally, and also with a long thin spur at the heel fitted to a corresponding slot in the female blade, —provided the floor of the female blade, especially at the heel, be made nearly on a level with its rim. To repel the bladder, the female blade should be longer and a little wider than is usual. It should have also low sides easily accessible to fragments, relying for strength less upon these than upon a central ridge below the heel. In the male blade of such a lithotrite the apices of the triangle should be a little blunted. Lastly, a non- fenestrated female blade protects the floor of the bladder, during a long sit- ting. A fenestrated instrument directs sharp splinters against it. The latter also delays the process of disintegration, by delivering through its opening the same fragments many times. - “12. In locking and unlocking a lithotrite repeatedly in a long operation, it takes less time and is easier to turn the right wrist, as in my instrument, than to displace the thumb of either hand in search of a button or lever, as in previous instruments.” Sir Henry Thompson* says that, after lithotrity, the appearance of muco- pººn matter in the urine indicates cystitis from irritation of the bladder y the remaining fragments, and advises further crushing without delay. He points out the necessity of drawing the residual urine by means of the catheter as soon as the slightest inability to evacuate the bladder, even to the extent of a drachm or two, comes on after lithotrity. In this way alone can the formation of subsequent phosphatic calculi be prevented. When the urine becomes ammoniacal and the earthy phosphates are deposited, he washes out the bladder with weak nitric acid. He has found one admirable remedy for that low chronic cystitis, associated with the production of phos- phatic calculi, viz., the injection every other day of a solution of silver nitrate, one-half grain to four or six ounces of distilled water. The results of litholapaxy are very favorable, the mortality being a little over five per cent.: Freyer having 76 cases, with 3 deaths; Sir Henry Thompson 194 cases, and 10 deaths; Von Dittle 80 cases, with 5 deaths. Litholapaxy in Children.—It has been generally considered that children under fifteen must always be subjected to the cutting operations for stone, and the suprapubic method has been so successfully employed in such patients, that other methods need not be tried. Of late, however, litho- lapaxy has been successfully employed in children, especially by Surgeon- major Keegan, of Indore. He reportsi the successful use of the lithotrite in twenty-three cases. The lithotrites were small, being équal in calibre to Nos. 5, 6, 7, and 8 of the English scale. The diameter of the evacuatory tube was equal to the English No. 9. The ages of the patients varied very much, the youngest being only twenty months, the eldest twelve years; five of them were five years old, and three of them were aged eight. The largest stone weighed two hundred and forty grains, while seven grains was the heft of the smallest. The aver- age time consumed in the operation was about thirty-nine minutes, the shortest time being four minutes, the longest about seventy. In seven cases the evacuator was not used, the stones being thoroughly pulverized, the debris being passed per vias maturales. * Monthly Abstract of Medical Sciences, October, 1876; Lancet, January 8th, 1876. f India Medical Gazette, May, 1884. 982 A SYSTEM OF SURGERY. Tumors of the Bladder.—These neoplasms are difficult to diagnose, espe- cially as to their clinical characters. They may be either malignant, semi- malignant, or non-malignant, and are often obstinate as to treatment and fatal as to their results. They occur generally after adult life, although they have occasionally been discovered in the young; in character they are generally fibrous, myxomatous, villous, papillomatous, or carcinomatous— perhaps, in the majority of instances, the latter being the case. If there be much haemorrhage and little cachexia, the inference would be that the growth was innocent, especially if the hamaturia was a late symptom ; if, on the contrary, pain was an early symptom, and the haemorrhage a sec- ondary appearance, with cachexia and heredity, then the malignancy of the tumor could be pronounced with some degree of certainty. In some instances, calculi and growths have been found at the same time, giving rise to the supposition that the irritation of the former may produce the latter. In a late case, wherein the patient had every symptom of stone, with profuse hamorrhages, I ºisi the patient twice, once when he was thoroughly anaesthetized, and though I could find readily enough a soft, villous, nay, even trabeculated growth, could discover no calculus; yet in a few weeks after, a couple of calculi were voided per wrethram. Looking at the formation of the bladder, with its muscular, mucous, and epithelial coats, it will be perceived that there can be no valid reason why tumors of all varieties may not arise within it, that is, if there be any truth in the blasto-dermic theory. The epithelia may develop into epithelioma, or the gland-structure into carcinoma, while the ordinary growths of the connec- tive-tissue series may arise from the muscular walls and its connective tissue. These would include fibromata, myxomata, sarcomata, etc. These tumors arise probably from the chorionic villi of the bladder, and are necessarily (if we recollect the origin of this structure from the alantois) very well supplied with bloodvessels. This variety are generally small, are often pedunculated, though I have seen them sessile; they are reddish in color, though sometimes purplish, resembling a mass of placenta. The microscope, however, is the most valuable assistant in diagnosing these tumors. The history of these cases of bladder-tumors is well described by Sir Henry Thompson.* “They come,” he says, “first under the care of a physician for haematuria, then pain follows, a surgeon is called, the sound used, and no stone found; another surgeon is called, and the operation is repeated with the same result. The hamorrhage is then supposed to be renal, and the patient is allowed to die slowly from chronic hamaturia.” Treatment.—In the early part of the disease, the medicines which have already been given for the treatment of chronic cystitis may be employed (acon., hyos., canth., cann., merc., nux wom., equisetum, etc.). Infusions of uva-ursi, pareira brava, buchu, and alchemilla, the latter having often a salutary effect, may be used, together with the hot sitz-bath, twice during the day. I have also employed the triticum repens, in the proportion of an ounce of the root and stems to a pint of water, a half a tumblerful being taken three times a day. The “back water” must be removed and the viscus washed out, as already noted. If all medical means fail, then first make the diagnosis certain, and an operation is justifiable. If the patient appear perishing before the eyes of the surgeon, an exploratory incision may be made. Sir Henry Thompson frankly states that he has opened twenty-seven bladders and has found but twelve tumors, and I note this fact that the down-sinking heart of the surgeon performing his first cyst- otomy may be relieved if no tumor or stone be found. It may be neces- sary in some cases to perform a second operation. As usually performed, * British Medical Journal, June 16th, 1883. TUMORS OF THE BLADDER, 983 the patient is placed in the lithotomy position, and the lateral or median cut made, and the director (Fig. 643) inserted. Then the operation is completed as follows: “Insert the forefinger first through the urethral incision, and make a complete examination of the interior of the blad- der, so as to feel familiar with the exact position and size of any tumor FIG. 643. e Sir Henry Thompson's Director for Digital Exploration. present. Then quietly withdraw the finger and insert the forceps, as seen in Fig. 644, guided only by the knowledge he has acquired, and make a decided nip with it with little or no traction; withdraw the forceps, re- insert the finger, and remove, if necessary, with the finger-nail anything FIG. 644. gº-- |Hiſſºs Forceps for removing growths in bladder, with separation of the blades to avoid nipping the neck of the bladder, that the forceps left incompletely divided. It is often best to leave the detached pieces of the tumor in the bladder for the moment and remove them all at the end of the operation by the lithotomy scoop.” Care must be taken to hold up the bladder wall by means of a ball probe alongside 984 A SYSTEM OF SURGERY. the forceps, otherwise the depressed bladder may be mistaken for a tumor, and as in one case the wall gave way after the operation from bruising with the forceps; this accident is to be deplored, I have given the manner of performing this operation in the words of its distinguished author, but it would be under very peculiar circumstances that I should ever resort to its performance, when there remained the supra-pubic method of opening the bladder, Seeing the growth, removing it in toto, either by the scoop, the for- . or the ligature, and washing the viscus readily and perfectly twice a day. Tumors in the Female Bladder.—Growths. of the same character as those affecting the male bladder are found in the female, the symptoms being haºmorrhage and pain. The existence of the growth is somewhat difficult to diagnose, and the exploration of the bladder with the finger and the endoscope can alone be relied upon. As a rule, the catheter and the sound are of little use. The plan is first to gradually dilate the urethra with a urethral or two-bladed uterine dilator, and finally insert the finger. The Scoop, or the wire of an écraseur may then be inserted and the growth Scooped or scraped away. If this method is not successful, that of Simon, which consists of making a T-shaped opening into the bladder through the vagina, and thus exposing the cavity, may be performed, or if the growth be large, suprapubic cystotomy may be employed. Acute and ãº. Prostatitis.-The prostate gland is liable to inflam- mation, which is always serious in character because of the difficulty in management, and because of the close intimacy which exists between it and the surrounding structures. It is a difficult thing to define exactly or dis- sect minutely the prostate so that we may actually detect its boundaries. It appears to submerge itself into the surrounding structures, and can only with difficulty be separated from them. The gland receives its name from “standing before ” the neck of the bladder, and thus forming or blending with the structure. For these reasons an acute attack of prostatitis per Se is a rare disorder, but its inflammation from an extension of disease from bladder, urethra, or rectum is not so uncommon. The causes of the affection are extension of urethral inflammation, strict- ures of the urethra, particularly those of old standing, which are tight and contracted, cystitis, calculi in the bladder, wounds or bruises in the peri- naeum, long-continued and drastic purgative medicines; diseases of the rectum, as haemorrhoids, fissures, etc., constant straining at stool, and some- times violent horseback exercise. The symptoms are pain, weight, and fulness in the perinaeum, weight and heaviness in the loins, a fulness in the rectum, pressing at the cervix vesica”. These pains are particularly aggravated by straining at stool and by pass- ing water. The attempt to introduce the catheter gives great pain to the patient. With these symptoms there is fever, thirst, and more or less vas- cular excitement throughout the system. If the finger is introduced into the rectum, the gland is found hardened and enlarged, the anterior wall of the rectum is also indurated, and together with these, there is a constant desire to go to stool, with pains extending down the thighs and along the penis. If these symptoms be not subdued, the inflammatory process may end in suppuration, thus producing abscess of the prostate. Such a condition may be feared, if the inflammation has not yielded to the appropriate treatment, and the difficulty of micturition and defecation either continue or increase in severity. The usual symptoms of the formation of pus are then noticed, and fluctuation may be perceived in the perinaeum or in the rectum. There is a variety of abscess known as periprostatic, in which suppuration takes place external to the gland. Such abscesses are not as troublesome or dangerous as those previously named. PROSTATITIS. 985 An abscess of the prostate may discharge itself into the urethra or the rectum, the former being generally the locality at which the pus finds exit. The chief trouble in this disease is the long-continued suppuration which generally follows the acute abscess, and this continues for such a length of time, that the entire gland is destroyed; then the bladder and other organs sympathize, until finally emaciation, hectic, and death result. If entire resolution does not take place, and the more violent inflam- matory symptoms subside, then there remain those symptoms which point to chronic inflammation of the prostate. These are weight and fulness in the perinaeum, extending to the anus; pain in passing water, with diminished power in propelling the stream; the urine is cloudy; a gleety discharge often exists; there is pain in coitus and defecation, and sometimes spermatorrhoea. Treatment.—It is scarcely necessary to repeat what has been so often mentioned throughout the volume, viz., the indications of aconite and bel- ladonna for the feverish conditions belonging to the commencement of all inflammations. Besides these, cannabis, merc., prot., pulsatilla, and thuja are medicines that may be called for; and hepar, silic, and sulphur, with calendula for abscess. For the chronic inflammation, the medicines which are best are thuja, kali hydriod., calc. carb., conium mac., pulsatilla, and sulph. A useful application to the perinaeum I have found to be a compress saturated with the tincture of cantharides. Dr. T. G. Comstock, of St. Louis, speaks highly of the spiroea ulmaria in the treatment of prostatitis. He has employed it in both acute and chronic cases, and regards it “in a measure specific.” Dr. M. O. Terry, f of Utica, N.Y., thus writes: - “My success in the treatment of chronic inflammation and in hyper- trophy of the prostate, was not satisfactory until I had tested the efficacy of the muriate of ammonia. I generally prescribe it in the following formula: “B. Ammonii chloridi, . tº gº tº • • {} tº ū • 35s. Syr. Aurantii cort., . © tº & * • ... • te e . 3iv. Sig. One teaspoonful taken in water three times a day.” Dr. Terry quotes M. Fischer, of Dresden (1821), as recommending it, and states that several German practitioners have spoken highly of its value. Dr. Magendie, of Paris, believed that muriate of ammonia had a decided effect in reducing the hypertrophied gland. Dr. Gross says: “The treat- ment of hypertrophy of the gland seldom fulfils the expectation of the sur- geon,” but he mentions hydrochlorate of ammonia incidentally. Dr. Terry, in conjunction with Drs. Hill and Laird, of Utica, reports ten cases, representing various forms of prostatic disorders, but especially hyper- trophy of old men, speedily cured. & ypertrophy of the Prostate.—This serious affection, which is encountered among the aged, and receives the name Senile hypertrophy of the prostate, has been denominated “the common inheritance of mankind.” Although many old people pass away without suffering from it, Mr. Thompson states: “I have never seen or heard of a true example of it before the age of fifty- four years.” The tissues constituting the enlargement are: “First, unstriped muscular fibres and the connective tissue are always associated; they form at least three-fourths of the prostate body. Second, interspersed among this struc- ture are numerous branching glandular tubes and their accompanying ducts.” - * Personal letter to the author. f Transactions of the Homoeopathic Medical Society of the State of New York, 1883. 986 A SYSTEM OF SURGERY. The first symptom of the disease is merely a diminution in the force of the urinary stream, which may exist without giving inconvenience or ex- citing particular attention. After a time, however, the desire to urinate increases, but the patient feels less ability to accomplish the act. During these periods there is a sense of weight, heaviness, and dull pain in the perinaeum. There exists a degree of irritation about the rectum, which may increase to such a degree that faeces pass with the efforts to urinate. The faces are flattened, and hamorrhoidal tumors result. Then inflamma- tion of the neck of the bladder develops, which adds to the discomfort and uneasiness of the patient. As the hypertrophy increases, the urethral canal becomes more and more closed, and consequently micturition more incom- plete, while urinary tenesmus is also aggravated. At this stage, inconti- nence of urine takes place during the night. . While these symptoms are gradually developing, the constitutional symp- toms are more and more marked; there are frequent attacks of fever, sweats, emaciation from loss of sleep, constant urinary irritation; and paroxysms of complete retention occur, which are distressing in character. The obstruction thus offered to the natural outlet for the renal secretion, combined with the irritation of the urinary apparatus, are sufficient to cause changes in the chemical characters of the urine. There is a large amount of glairy and slimy matter deposited; the chemical reaction is alkaline, the odor is fetid or ammoniacal, and the color often altered by the admixture of blood. From these changes it is not surprising that after a time, calcareous for- mations take place, which, of course, add materially to the suffering. In Such cases there is constant and often agonizing pain at the neck of the bladder, and at the end of the penis, with purulent or bloody discharges. If, in addition to these symptoms, portions of the calculus can be detected in the urine, the diagnosis may be made; otherwise, in the absence of the . symptom, the true nature of the affection may not be readily discov- €r€Ol. Assistance may be rendered in making a diagnosis, when senile enlarge- ment of the prostate is apprehended, by physical examination. The fore- finger of the left hand should be introduced within the rectum, and the size, position and relations of the prostate ascertained; by passing a catheter into the bladder and (keeping the left forefinger still in the rectum) moving it gradually and gently from side to side, the dimensions and relations may be determined. If the ordinary catheter does not pass through the increased length of the gland, the prostatic catheter must be used. This is from two to four inches longer, and possesses a larger curve than the ordinary instrument. If, in its introduction, the handle appears to turn to one side or to the other, the enlargement may be expected to be found on that side toward which the handle is deflected. Sometimes a sound with a short curve may be used as an explorer. Treatment.—The wrine, if possible, must all be removed from the bladder several times a day. This may be accomplished either by the prostatic catheter, or by the use of Squire's vertebrated prostatic catheter, a cut and de- scription of which are found in the first part of this chapter. By a little in- struction, patients soon learn how to manage the instrument, and after a time become dexterous in its application. I have known several who could surpass their professional attendant in the introduction of the catheter. The medical treatment is professedly weak. The medicines which have effect are mercury, the iodide of potash, iodine, pulsatilla, calc. carb., thuja, and sulphur. Long-continued treatment with medicines will often produce amelioration, the main secret, however, being the continuous use of the drug. The muriate of ammonia, as recommended by Dr. Terry, in the pre- ORCHITIS. 987 vious pages, with faradization within the rectum, together with baths, etc., can all be tried, and sometimes give great relief. Galvano-Cautery.—The use of this instrument in this affection is at present attracting considerable attention. Dr. Robert Newman thus describes his method:* The instrument consists of a smooth metal catheter with a fenes- trum at the end of the curve in which is placed a platinum wire. In the interior of the instrument is the mechanism for treatment. The catheter is introduced into the urethra so that the fenestrum is held against the enlarged prostate, which is then instantaneously cauterized. The catheter is equal to No. 18, French scale. The instrument must be regulated by a fixed potential, and can be so adjusted that failure is impossible. These applications are repeated at short intervals until the cure is effected by shrinkage of tissue. The objections are said to be, that after the operation has been performed several times, a cicatrix forms which increases the denseness of the gland. The advantages consist in the absence of pain and haemorrhage, and in that patients are not detained from their business by the treatment. Dr. Lippet has given the indications for the following medicines: º pulsatilla, digitalis, cyclamen, Selenium, causticum, lycopodium, Secale, copaiba, zinc, agnus castus, alumina, hepar, apis, and sulphuric acid. The student may refer, for further information, to the article, or to Raue's Path- ology. CHAPTER XLVI. DISEASES OF THE MALE GENITAL ORGANS. MALFORMATIONS—ACUTE AND CHRONIC ORCHITIs—FUNGOID GROWTHS OF THE TESTICLE —CYSTIC DISEASE—CARCINOMA—CASTRATION.—CARCINOMA OF THE SCROTUM-HY- DROCELE–HAEMATOCELE—VARICOCELE—ELEPHANTIASIS SCROTI—AMPUTATION OF THE SCROTUM–PHIMOSIS-PARAPHIMoSIs—EPITHELIoMA PENIs—AMPUTATION of THE PENIS—SPERMATORRHOEA. Malformations.—There may be a failure in the development of the testi- cle, or in the formation of either of its parts. It is well known that the body of the testicle is produced, in foetal life, in front and independent of the Wolffian body, and that the epididymis comes apparently from the lower part of that body itself. Either of these may be absent in imper- fect development of the testes. The vas deferens is sometimes wanting, º the virile power may be unimpaired, the person being necessarily sterile. When speaking of the diagnosis of hernia, mention was made of the re- tained testicle, which retardation, according to Sir Astley Cooper, takes place in one out of five infants. Orchitis.-Inflammation of the testicle proper is denominated orchitis; epididymitis being the term used when the epididymis is involved. Often both testicle and epididymis are implicated, and the cause is generally a * Paper read before the American Medical Association, St. Louis, 1886. f American Homoeopathic Review, vol. iii., p. 150. 988 A SYSTEM OF SURGERY. badly managed gonorrhoea—a sudden suppression of the discharge, either from cold or strongly astringent injections. The pain is severe, the parts enlarge, are redder than usual, the rugae of the scrotum are lost, and there is exquisite sensitiveness to both touch and pressure. High fever, and often delirium, accompany the disease. The urethral discharge abates, but the patient may be troubled with nocturnal emissions. Pain in the back and loins, sometimes extending down the thighs and into the perinaeum, is often present, and the attacks are frequently accom- panied with nausea and vomiting. - Abscess of the Testicle.—If the inflammatory process be not arrested it passes on to the suppurative stage, and abscess of the testicle results. If such condition takes place the fever increases, the pulsation, redness, and pain are deep-seated, and shiverings are present. Touch—even the pressure of the bedclothes—is insupportable, and the pus when formed is mostly ill- conditioned. Fluctuation appears at different points, and the abscess dis- charges at several places. - I have noticed a particular feature in cases—especially neglected ones— of suppuration of the testicle, and that is the apparent unwillingness of the openings to heal, through which the pus has been discharged. Very often through these openings a fungous growth protrudes, of which more will be mentioned in the following portions of this chapter. - Treatment.—It is astonishing how rapidly the proper medicines, if admin- istered early in this affection, arrest the disease. I use neither ice-bags, hot formentations, nor any applications save a compress wet with water laid Over the part, and begin the treatment with aconite, which I administer always in a low potency, even a few drops of the mother tincture in water. Belladonna is excellent in plethoric persons, with tendency to delirium, and congestion to the head and face. Gelsemium is a superior medicine when the disease arises from a sup- pressed gonorrhoeal discharge, from exposure to sudden cold or wet, when there are also indications of biliary disorder and congestion. After the inflammatory symptoms have in a measure subsided, clematis erecta is an admirable medicine, especially if the epididymis is particu- |. involved, and there appears to be a tendency to assume a chronic OTO]. Pulsatilla is applicable to mild and rather delicate men, when the gland is more involved than the surrounding structure, when the pain shoots down the back, or into the thigh, and changes place, with but little or no thirst during the fever. Mercurius after the inflammatory symptoms have subsided, and there appears to be a tendency to the formation of pus, with shiverings and per- spiration. The gland is hard and sensitive, but not in such a degree as would indicate clematis, which is a reliable medicine for the disease. Hepar is called for in abscess of the testicle. When the pus has formed the fluid should be evacuated with a simple puncture, and the wound closed with a piece of adhesive plaster. After the evacuation of pus, silicea and phosphorus are generally sufficient to complete the cure. The patient must wear a suspensory bandage, and must keep the recumbent posture. During the treatment if there be priapism or burning during the act of mic- turition, cantharides or cannabis are necessary as intercurrent medicines. Dr. Ludlam speaks of hamamelis, Dr. Hale * of phytolacca dec. and pul- satilla nut., and Dr. Osgood of veratrum viride, in the treatment of this dis- €a,Se. * Hale's New Remedies, vide pp. 509, 792, 866, and 1059. CHRONIC ORCHITIS. 989 Chronic Orchitis.-Chronic inflammation of the testicle, or, as it is termed by some, sarcocele, may result from acute orchitis imperfectly resolved, or the action may be chronic from the commencement. It may be either primary or secondary, that is, it may occur as an independent affection, or as a concomitant result of gonorrhoea; it not unfrequently results from disease of the urethra, and in some instances may be traced to syphilis. The tume- faction extends from the epididymis, which is usually the primary seat of the disorder, and gradually involves the whole testicle, which presents the appearance of an inelastic, uniform tumor, which is oval, and seldom ex- ceeds two or three times the bulk of the healthy gland. The accompany- ing uneasiness is slight, is more severe at night than during the day, and, as the disease advances, the characteristic sensibility of the organ to pressure is lost. Occasionally the disease, in its later stages, is accompanied with a degree of effusion within the tunica vaginalis, constituting what is termed hydrosarcocele. Upon examination more or less yellow solid lymph is found interspersed throughout the substance of the testicle, extending into the was deferens, and, according to Mr. Curling, deposited in the tubuli seminiferi. By the smoothness and uniformity of the swelling, its gradual progress, and the absence of glandular enlargement, the affection may be distinguished from malignant disease. Treatment.—Rest and a recumbent posture are necessary in the first in- stance, and in the milder forms, or at its commencement, resolution may be effected by the following medicines: aurum, clematis, lycopodium, agnus castus, graphites, rhododendron, and sulphur. When the disease has a syphilitic origin, a careful investigation, and a knowledge of the character of the syphilitic affection from its commence- ment, are required. Calc. carb., carbo veg., aurum, kali carb., lycopodium, spongia, merc. Sol., acid. nit., clematis, mezereum, etc., may be required. Graphites, lycopodium, oleander, and belladonna are recommended if the disease is complicated with a scrofulous condition, chronic eruptions, or glandular enlargements. Where the tumor, in an advanced stage, gives evidence of the superven- tion of a malignant condition, arsenicum, clematis, diadema, carbo veg., and thuja, may arrest the progress of the disorder, though in the majority, the FIG. 645. use of the knife can scarcely be avoided. In chronic cases, especially in syph- ilitic patients, I have succeeded by the internal administration of the iodide of potassium, five grains three times a day. Strapping the testicle with adhesive plaster sometimes is necessary; in all, the suspensory Strapping the Testicle.—BRYANT. bandage must be used. - Bryant says: “To strap a testicle requires some skill. The patient should be made to stand against the edge of a table and separate his legs. The surgeon should then with his left hand grasp the organ from behind, and press it down to the bottom of the scrotal sac, making the Scrotum tense over its surface, the thumb and index finger of his left hand holding its neck. A piece of elastic strapping, spread on leather half an inch or more wide, is next to be wound around the neck of the tumor once, twice, or even thrice, to hold it in position, for if this point be not attended to, all the subsequent steps will be useless.” (Fig. 645.) This process requires some time, to save which, and insure equal com- pression, Dr. A. L. Carroll has devised an excellent compression. (Wide Fig. 990 A SYSTEM OF SURGERY. 646.) It is constructed of ordinary web, with a strip of flexible metal to isolate and control the gland. Fig. 647 represents Holmes's orchitis com- pressor. The following remarks of Professor Thiry, in a lecture on a well-marked case of acute blenorrhagic orchitis, deserve consideration. He says: Al- though there must be some pain occasioned by the application of the bandage, compression should not be lost sight of; in fact, it is of more benefit in acute than in chronic cases. The orchitis will often subside with rapid- ity in proportion to its acuteness. By applying the compressive bandage success may be made certain if we remember the objects in view: 1. Benumbing the local, the general sensibility becomes less, as seen just after the application; 2. Diminishing the afflux of blood into the affected organ by compressing the vascular parietes—the arterial afflux being in proportion to the intensity of the pain; 3. Repelling the venous blood and the products of exudation; and 4. The immobilization of the testes, and their safety from injury. Compression of the testis by the starch bandage was applied, and brought to bear on the cord by means of graduated compresses. Though the patient suffered much, he at once became calm, and expressed himself free from FIG. 646. FIG. 647. º Carroll's and Holmes's Orchitis Compressors. pain. A pill had been previously prescribed, composed of a small quantity of bromide of potassium and opium, every three hours, to aid the anaes- thetic effect of the bandage. Of all the trials of various modes of treatment, he has invariably come to the conclusion that compression is the most simple, expeditious, and efficacious procedure. Fungoid Growths of the Testicle.—Fungoid growths from the testicle after chronic orchitis are not uncommon, and are often troublesome to manage. They are of two varieties, the benign and malignant. This distinction, how- ever, was unknown to the older writers, who believed that every growth presenting the well-known objective symptoms of fungoid tumors, was of malignant character. The benign has received the names of hernia testis and granular swelling. The symptoms which render the diagnosis more certain are: in the malignant disease there is frequent haemorrhage, and liability to bleed upon slight irritation. This condition is rarely noticed in the benign growth. In the latter the protruding mass presents a granu- CYSTIC or ADENOID DISEASE OF THE TESTICLE. 991 lating appearance, while in the former it is soft and spongy. In the benign the color is paler than in the malignant, the growth is more consistent, and pressure on the tumor causes that peculiar sickening sensation which attends the compression of the healthy testicle, while in the other variety no such sensation is experienced. To make the diagnosis certain, the microscope should be employed. The following may illustrate the course and history of a fungus, when proceeding, as it often does, from chronic orchitis. The patient, a young man, was a conductor on a sleeping car. He fell astride a large iron bar, causing a severe contusion of the right testicle. The pain was intense, the swelling enormous, the testicle hard and extremely sensitive; there was weight and dragging in the loins; the spermatic cord was tumefied ; and all the symptoms of severe acute orchitis followed. The patient was treated Secundum artem, and after a considerable period, a sensation of fluctuation being apparent, the scrotum was lanced. In a short time a fungoid-looking substance, presenting an ashy or yellowish-white appearance, protruded from the opening. The whole tissue of the scrotum was much thickened and indurated, the color of the integument being purplish. The epididymis was pushed up- ward, and the cord much thickened. Castration radically cured him. Treatment.-If mercurius, thuja, phosph., or those medicines already mentioned for the treatment of acute and chronic orchitis, are not avail- able, one of two operations may be selected. The one proposed by Mr. Syme, of Edinburgh, consists in carefully loosening the fungoid testicle from the scrotum, pressing it within the cavity and stitching the walls over the growth, thus producing a certain amount of steady pressure. “The surface of the fungus,” says Mr. Syme, “being coated with granulations becomes incrusted with effused lymph, and in order to facilitate the healing process, the hard ring of skin through which the fungus protrudes must be also removed.” The other operation is castration, which must be performed in the malig- nant disease. The methods of operation are noticed on the next page of this chapter. Cystic or Adenoid Disease of the Testicle.—This is a rare affection, and the growth is so insidious and slow that, in its early stages, it gives rise to Scarcely any inconvenience to the patient. The tumor is oval in shape, somewhat elastic, and can be handled without much pain. The swelling is smooth in the majority of instances, but in others it may be lobulated or slightly irregular. Generally at its upper portion, there may be fluctua- tion, which may resemble hydrocele of the cord. The usual symptoms of weight, heaviness, and dragging are experienced in the groin, and there is aching numbness of the part. - The chief trouble is the correct diagnosis of the case, Distinguished Surgeons have been misled, and Sir Astley Cooper confesses to have seve- ral times plunged a lancet into a tumor of the scrotum expecting fluid to pass, when nothing but blood flowed from the wound. The disease may be diagnosed from hydrocele by the following symptoms: In hydro- cele we have translucency. In cystic disease none. In hydrocele the tumor is pyriform. In cystic disease the tumor is oval. In hydrocele pressure on the part usually occupied by the testicle produces no pain. In cystic disease there is slight pain, but as a rule, the swellings are painless. Hydrocele is occasionally double ; cystic disease is always single. Treatment.—The remedy is complete removal. Upon examination of the testicle after removal, it will be found enlarged and situated within the tumor; it is somewhat harder than natural, and here and there a cyst con- taining a small quantity of straw-colored fluid is found. 992 A SYSTEM OF SURGERY. Carcinoma of the Testicle.—The testicle is affected with medullary cancer, as well as Scirrhus. According to recent authority we find that the majority of cancerous affections attacking the testes are of the soft, encephaloid or fungoid variety. (For the differential diagnosis the student must refer to the preceding page.) There are two especial forms of cancer—one being the tuberous, the other the infiltrating. In the substance of the glands cysts are generated, which become filled with blood-stained glairy fluid, Containing cancer-cells in profusion. The swelling is tense, firm, and elastic ; some parts of it being firm, others presenting appearances of fluc- tuation. The peculiar feeling, known by some as “testicular sensation,” is soon lost, and the parts growing rapidly acquire large bulk. The pain is not great, although sometimes a sharp shooting one is felt; the veins are full and enlarged. The infiltrating form may be complicated with cancer in other portions of the body, and is characterized by smoothness and infil- tration. - - Treatment.—By referring to the Chapter upon Cancer, those medicines will be found which are adapted to the treatment of the disease. Conium mac., phosph., the protoiodide of mercury, iodine, the iodide of potash, arsen., iodide of arsenic, hydrastis, phytolacca, scutellaria, may be of Ser- vice, but, as a general rule, time is lost by internal medication, and operative measures must be employed. - Castration.—This operation is demanded in several varieties of affections of the testicle, sometimes by men in the full enjoyment of their health and faculties. I was once requested to castrate a young and healthy man (a patient of Dr. J. F. Talmage, of Brooklyn), who desired to preserve his voice as a falsetto in an opera troupe. It is needless to say that the request came from the patient himself, who preferred to be a eunuch with a good voice than a man with procreative powers. I declined to perform the oper- ation. The following methods may be resorted to: The scrotum and groin having been carefully shaved, and the patient placed in a recumbent posi- tion, the surgeon grasps the tumor behind in order to render the skin tense. An incision is made from the external abdominal ring, reaching to the bottom of the scrotum ; or the scrotum may be gathered into a fold by the fingers, and transfixed at its base, when a suitable incision will be made by cutting directly outwards. The cord, having been exposed, is separated from the surrounding textures, and intrusted to the firm grasp of an assist- ant to prevent retraction within the abdominal aperture when divided; the bistoury is carried behind the cord, which is cut across, and the operator seizing its lower portion draws it forward, and proceeds to dissect out the testicle—a dissection rendered comparatively painless and bloodless, by early section of the cord. The arteries should be tied, and the wound kept open until the bleeding has ceased; the lower portion, seldom healing other- wise than by granulation, need not be closely approximated. Care should be taken during the operation not to wound the septum, and thus expose the sound testicle. The operation also may be performed by first separating the testicle from its integuments, before dividing the cord; all fear of irrepressible haemor- rhage by retraction of the vessels may be avoided, by dissecting up their cremaster envelope for a considerable distance towards the abdominal ring, and passing a ligature around them before severing the cord. Where, how- ever, there is but a small portion of the cord to be found, where there may be tedious dissection required to separate the diseased tissues from the healthy, and where the walls of the scrotum are much distended, then the dangers are more apparent, and an operation which, under most circum- HYDROCELE. 993 stances, is simple, becomes one which may not only prove embarrassing to the operator, but fatal to the patient. For instance, where the cord is short, and has to be divided close to the ring, a retraction may take place, which renders the condition alarming. “In a case which came under the obser- vation of Sir. A. Cooper,” says Mr. Curling, “the bleeding from the vessels of the retracted cord was so profuse that the operator was convinced that he had wounded the iliac artery, and unfortunately proceeded to place a ligature on that vessel. The patient died the day after the separation of the ligature. The iliac artery, though not wounded, had been tied securely enough ; but the vessels of the cord, the source of the hamorrhage, had been neglected.” The same author records two instances which came under the observation of Mr. Benjamin Bell, in which two patients died from hamor- rhage from retraction of the cord, before the vessels could be secured. Sec- ondary hamorrhage is a serious complication, which is apt to occur after the operation, chiefly from the vessels of the scrotum. Taking these circumstances into consideration, I prefer a mode of opera- tion which I have not seen anywhere recorded, and which may be recom- mended for the ease with which it may be performed, and the safety of its results. Having placed the patient under the influence of an anaesthetic, take the cord between the thumb and finger of the left hand, just at its exit from the external abdominal ring; having rendered the integument tense by firm pressure, enter an acupressure pin at right angles with the cord, and having depressed the head, bring out the point on the opposite side. To make it still safer, another pin may be placed about half an inch below; over these draw two slight rings of india-rubber. Make an incision upon the tumor and dissect out the gland. Divide the cord with a single stroke of the knife, and neither will a drop of blood exude, nor a particle of retraction take place. Thus, by pins properly applied, two serious difficulties are re- moved. The acupressure prevents the hamorrhage from all the vessels of the cord, and does not allow it to retract. Hydrocele.—The tunica vaginalis testis secretes, in its natural state, a limpid fluid, which lubricates its internal surface and that of the tunica albuginea; and whenever this fluid, from any cause, is secreted in undue proportion, it distends the tunica vaginalis, giving rise to a tumor of the scrotum, which is termed hydrocele. - It is probable that the accumulation is the result of excited action in the parts, for its origin is frequently attributable to external injury, followed by swelling, which after a time subsides, leaving some enlargement of the testicle, or of the more superficial tissues, and succeeded by the gradual appearance of the disease. It is also caused by inflammation of the testes, and is frequently combined with stricture of the urethra, or local irritation along its course. Dr. Physick succeeded in curing a case by dilating the stricture with a bougie. Congenital Hydrocele.—When the communication between the cavity of the abdomen and the tunica vaginalis is not closed as it should be at the usual period, the fluid descends from the cavity of the abdomen into the cavity of the tunic, forming what is denominated a congenital hydro- cele. This affection is sometimes conjoined with sarcocele, or chronic enlarge- ment; when it is termed hydro-sarcocele. It is important to distinguish between these two diseases. In sarcocele, the tumor is oval and flattened ; it may attain a considerable size, without ascending so near to the ex- ternal abdominal ring as does a large hydrocele. In sarcocele there is a space between the tumor and the abdominal ring, whereas there is none in a large hydrocele. The tumor may be known by its weight and opacity. In hydrocele the swelling commences at the bottom, and is confined to one 63 994 A SYSTEM OF SURGERY. side. At first the tumor is flaccid, and the testicle may readily be distin- guished; but as it increases, it becomes firm and incompressible, and the testicle can scarcely be felt. The swelling assumes a pyriform shape, the corrugations of the scrotum disappear, and the raphé is displaced to the opposite side; there is little or no pain or inflammation, and no alteration of color. When inflammation, however, precedes this disease, there is pain, swelling, and hardness. The swelling is translucent, and, on placing a lighted candle on one side of the scrotum, the light can be discerned through it. In some cases the tunica vaginalis becomes thicker and harder, the flºº ºpaque and dark-colored, thereby obstructing the passage of the raws of light. Enº Hydrocele of the Cord.--Sometimes an accumulation of fluid takes place in the tunica vaginalis of the spermatic cord, forming an encysted hydrocele of the cord. This variety occurs more frequently in children than in adults. The fluid is thin, clear, and contained in a distinct cyst, of a smooth, shining, serous appearance; this cyst may be either an unoblit- erated portion of the congenital spermatic structure, or composed of thick- ened and condensed cellular tissue, strengthened exteriorly by the expan- sion of the cremaster muscle. This variety may be confounded with hernia, from which it is necessary to distinguish it. In hydrocele of the cord the accumulation takes place gradually, unattended with pain, and is always below the external abdominal ring. When the patient coughs, there is no impulse communicated to the finger, and the tumor is not capable of being returned into the cavity of the abdomen; whilst in hernia, the swelling takes place suddenly, attended with pain ; and a peculiar impetus is com- municated to the tumor when the patient coughs, and it may generally be returned by pressure into the abdomen. It sometimes happens that both these affections coexist in the same individual, and in such cases the diag- nosis is difficult. If, in the withdrawal of the fluid with the hypodermic needle, it is found to be whitish, the diagnosis of spermatozoa in a cyst may be arrived at, and spermatozoa may be said to be pathognomonic of encysted hydrocele of the cord, although in some instances the disease may exist without them. Diffuse Hydrocele of the Cord.—Accumulations occur in the meshes of the cellular tissue of the cord; the cells expand and form receptacles for the fluid ; these vary from the FIG. 648, size of a pea to that of an almond. -º-º: We then have the affection known as “ diffuse hydrocele of the cord” (Fig. 648). In this disease the swelling is uniform, has a defined shape, grows slowly, and is productive of little pain. By careful manipulation the swelling may be separated from the vaginal tunic. . Of itself, hydrocele is not a dangerous disease. Persons may have it for years, and be free from pain; but, if the swell- ing increase to a great size, pains in the spermatic cord and renal region are ex- perienced. On account of the enormous - * size of the effusion, the penis becomes Diffuse Hydrocele of the Cord. much retracted, and sexual intercourse is rendered impossible. The discharge of urine may be interfered with, and the emission of semen is likewise im- peded. -- HYDROCELE. 995 The diagnostic symptoms may be arranged as follows: Increase of the tumor from below upwards. Fluctuation, or want of solidity. Translucency. Lightness as compared to solid growth. Sickening sensation experienced when pressure is made in the region of the testicle. Smoothness of sur- face. Absence of cough-impulse. Absence of pain. The history of the Ca,S62. - - By examining these symptoms, we find that separately they are equivocal in complicated or old cases. In such, how must we proceed? First. By a careful comparison of the tout ensemble. Second. Especially by the use of the exploring needle or aspirator. Third. If the diagnosis be obscure, by carefully cutting down upon the Sac with a scalpel, instead of puncturing with a trocar. There are peculiar cases, in which the symptoms may be rendered more obscure by the formation of one or more partitions in the sac, forming multilocular hydrocele. This may give rise to unevenness of surface, and may perplex the surgeon during an operation, in which the ordinary trocar or acupuncture-needle is only thrust into one of the compartments. In such there is a flow of serum and suddenly a stoppage of the fluid, and but a partial diminution in the size of the sac. These cases are rare. he Quantity of Fluid.--Sometimes the quantity of fluid is so great that the records appear almost incredible; yet, when it is remembered how much serum may collect in those cavities of the body, the walls of which are extensible, we will not be astonished at the quantity that may accumu- late in the scrotum. Who does not recollect the famous epitaph recorded by Watson of Dame Gregory Page, who in sixty-seven months, was tapped sixty-six times, and had taken from her two hundred and forty gallons of Water 2 Gibbon, the historian, is said to have had removed from his scrotum six quarts of water. In the tables of hydrocele prepared by Dr. Duyat, at Calcutta, the quantity of serum varied from ten to one hundred ounces. Analysis of the Fluid.—The following analysis of the fluid, made by Dr. Bostock, of 100 parts, of the specific gravity of 1024, were found to contain : -- Water, . g e e e o o © e º ſº º . 91.25 Albumen, g e e e ſº º g © e º * . 6.85 Uncoagulable matter, 1.1 Salt, e s .8 100.00 The fluid, as has been mentioned, in old cases, is of a thickish, dark color, and may contain cartilage and Osseous deposit. Albuminous sedi- ment is present. Treatment.—Hydrocele may be divided into medical and surgical, and the latter into palliative and radical. Let it be remarked that hydrocele, especially in infants and young chil- dren, often disappears spontaneously; and, indeed, in adults, such cures have been recorded. Mr. Pott describes two cases of confirmed hydrocele, which disappeared without any treatment. The small accumulations that are often noticed in very young children need no treatment, except, perhaps, a suspensory bandage, which latter, in the majority of instances, is rendered unnecessary, because a certain degree of pressure is exerted by the diaper. 996 A SYSTEM OF SURGERY. Humphrey” records a case cured by pulsatilla, in which there was swell- ing of the scrotum on one side, and of the left spermatic cord; also, a suc- cessful one, in which arnica was externally applied, and conium internally, together with sulphur, nux vomica, puls., and graph. Dr. Blackt gives an interesting account of hydrocele successfully treated % medicines, and records, especially, the action of graphites in the dis- OTC16ºr. - Hastingsi records a remarkable cure of hydrocele by rhododendron. Ozanam Š cites a number of cases, where he employed rhododendron. A boy, aged 13 years, suffered from hydrocele; rhodo. internally and locally administered, and compresses saturated with a solution of the same medi- cine, removed the difficulty in one month. After ten days’ treatment a marked diminution was observed. - “A boy six years of age had had two attacks of hydrocele, the first about two years ago. This patient was cured with rhodo. in one month. A year and a half after, he had another attack, caused by a long ride upon a donkey. The parents did not call for advice until three months after the attack; rhodo. internally and locally produced a speedy cure.” In several cases of long standing, one of forty years’ duration, the im- provement was more tardy, yet the enlargement was reduced to half its former size. Ozanam’s observations led him to the conclusion that rhodo. not alone manifests positive action upon the tunics of the testicles in the male, but also upon the ovaries of the female, and, perhaps, also upon the fibrous and muscular tissues of these organs. + Raue|| says: “Those hydroceles which are dependent upon a general hy- dramic state of the blood, must be treated with reference to this whole gen- eral state and its symptoms. Hydrocele in consequence of a blow, requires arnica and pulsatilla ; those of unknown causes, aurum, graphites, iod., psoricum, rhodo., silic.” The medicines which have proved most effectual in my hands are calc. carb., conium, dig., dulc., graphites, iodium, merc. Sol., puls., rhod., sil., sulph. #. palliative treatment of hydrocele consists in evacuating the sac either by the aspirator or the trocar; while the radical cure is effected by exciting inflammation in the sac after the withdrawal of the fluid, thus preventing its return. Some persons, especially those in the upper walks of life, prefer the pal- liative treatment; but, if the patient be healthy, it is always better to per- suade him to have the operation thoroughly performed, to prevent further accumulation in the tunica vaginalis. There are circumstances where only palliative treatment is required. Treatment by Acupuncture.—The method of acupuncturing is simple, and, if properly performed, causes so little suffering, that I prefer it where mere palliation is required. The needles, which should be of different sizes, are very sharp; one of these is set in a handle by means of a small thumbscrew ; its point is applied to the most dependent portion of the tumor; the handle is twirled rapidly between the thumb and fingers, gentle pressure being exerted at the same time. The sac must be punctured in several places. * Humphrey's Ruoff, p. 121. f British Journal of Homoeopathy, vol. iii., p. 525. † B. J. M., vol. xviii. p. 351. 3 Bulletin de la Soc. Med., April 15th, 1869. | Raue's Pathology, p. 402. HYDROCELE. 997 Dr. Lanyin, in the London Lancet, speaking of the palliative treatment, States that he has met with several cases where the introduction of a com- mon needle of large size has invariably caused the removal of the fluid, after an interval of twenty-four hours. The Palliative Treatment by the Trocar.—When this is employed, a round trocar and canula are to be used. The patient is placed in the erect pos- ture, with the thighs separated; the Surgeon takes the scrotum and posterior part of the tumor in his left hand, ren- dering it tense and prominent in front; the instrument is entered at the lower and anterior part of the tumor, pass- ing obliquely upwards and backwards (see Fig. 649), so as to avoid wounding 6. A )*, the testicle, yet at the same time taking tº ; /\,\\ care that the obliquity is not such as ſº | f | endangers separation of the coverings º Å of the sac, and non-entrance into the sac itself. The trocar being withdrawn, the ca- nula remains, and the fluid is allowed to pass. - The Hypodermic Injection of 10 drops of compound tincture of iodine into the hydrocele, without any attempt to draw off the fluid, should always be tried first. In some instances one in- jection cures, in others several are neces- Sary, and again the relief is but tempo- Tapping the Scrotum. rary. I have cured some patients, but by far the greater number have only been relieved. The operation is so simple, and so free from pain or danger, that it may be tried before more severe measures are resorted to. The Radical Methods of Cure are the withdrawal of the fluid, and estab- lishing adhesion within the scrotum. This is accomplished in a variety of ways. Mr. Miller speaks of the radical cure being effected by injections; and remarks, “that the operations of seton, caustic, and incision, are fallen into complete disrepute.” It is to this latter statement I must dissent. There are cases in which injection treatment has failed; indeed, this method is not resorted to by surgeons of considerable experience and skill. John Mason Warren,* after an extended term of years at the Massachu- setts General Hospital, speaking of injections, says: “This treatment is, at best, very uncertain.” Dr. Grossi prefers the seton, on account of its simplicity, its freedom from danger, and its never-failing certainty. He describes the method of oper- ating (which will be mentioned towards the close of this section), and refers to incision as consisting of simply opening the tunica vaginalis with the knife, and dressing the wound with lint, or irritating substances. Simple incision has cured hydrocele. Mr. Cooper has related several instances of the kind, and Mr. Cook states that, after such operations the whole fibrous tunic was thrown off by the sloughing process. e * Surgical Observations, p. 251. f Gross, Surgery, vol. ii., p. 946. 998 A SYSTEM OF SURGERY. ... A case is related by Paul F. Eve,” in which a large hydrocele was cured by a stab inflicted with a bayonet. Erichsen, f speaking of the caustic treatment by injections of iodine as that commonly employed, says: “when the injection fails, the seton will, ...} be found to be the most certain means of accomplishing our object. º injection treatment is most common, and, in ordinary cases, is suc- CôSSIUll. - The operation is simple: the surgeon ascertains, first, the position of the testicle ; avoiding it, he inserts a trocar and evacuates the fluid. Through the canula he injects the tincture of iodine, which in some cases may be allowed to remain, and in others, to escape from the scrotum after a few minutes. Some surgeons use the dilute tincture of iodine, and others the pure article; my preference is for the compound tincture of iodine in small quantities. It should be retained in the tunica vaginalis. Dr. Bellingham is averse to the employment of the ordinary preparations, and prefers the following: R. Iodidi potass., . • * gº e g & º º © . 3ij. Aquge dest., . . . . tº º ſº º º ſº e . 3ss. Adde, - - Tinct. iod., . * © & dº ge we g º tº tº . 3iv. He states that, in using this formula, there need be no fear if the injection does not return, as it will be taken up by the absorbents. . It would be useless to give, in detail, successfully treated cases of ordinary hydrocele of the tunica vaginalis with iodine injections. Every practitioner * either used the treatment, or known of cures being accomplished y it. -- . Professor Syme stated that he used the timeture of iodine alone, and with- out a single case of failure, either in private or public practice. The quan- tity he employed was about one teaspoonful. Bransby Cooper employed the iodine injections in about thirty cases, and in all, the cure was effected. He stated that the compound tincture must be used, in preference to the ordinary preparation. He injected 3ij of a mixture composed of one part tr. iod. comp. to three of water, and allowed it to remain. The injection treatment fails sometimes, oftener, perhaps, than is sup- posed, especially in those obscure and difficult cases already considered ; then recourse must be had to other methods. - The proportion in which iodine injections fail has been variously esti- mated. Mr. Martin affirms that in India the failures scarcely amount to one per centum. Velpeau calculates them at about three per cent., and Mr. Erichsen says: “I have, during the last few years, seen a considerable number of cases of hydrocele of the tunica vaginalis, both in hospital and private practice, in which a radical cure has not been effected, although the iodine injections had been had recourse to by some of the most careful and skilful surgeons of the day.” In such he prefers the seton, which is introduced by a large needle, and the fluid allowed to drain away through the puncture, or the method recommended by Mr. Green, and lauded and practiced by the late Dr. Gross. - - Dr. Keyes, of New York, prefers the injection of pure carbolic acid into the sac, the quantity being a drachm, and speaks highly of his success. * Remarkable Cases in Surgery, p. 371. f Science and Art of Surgery, vol. ii., p. 1110, 1885. HYDROCELE. 999 Dr. Keyes uses a glass syringe holding 100 minims. The needle is intro- duced, the cyst emptied, the point unscrewed from the barrel and allowed to remain in the cyst, the syringe is then filled with pure carbolic acid deli- ºwth a little glycerine, and from thirty to sixty minims thrown into the sac. Treatment by Seton.—Having drawn off the fluid through the canula, insert the trocar again, and push it up until its point emerges from the upper part of the scrotum. Having withdrawn the trocar, pass through the canula either a probe or long needle, armed with a ligature, which is drawn out at the upper orifice made by the reintroduction of the trocar; this done, remove the canula and make fast the ligature, which is allowed to remain until suppuration is established. The Treatment § Incision.—This treatment was employed by John Hunter. He opened the scrotum, allowed the fluid to escape, and then sprinkled flour on the surface of the tunica vaginalis, to excite inflamma- tion. Pott repudiates such proceeding, because of the frequency of slough- ing. Where there is difficulty in diagnosis, or where other methods have failed, incision may be º: Chelius prefers incision, because com- plications are more readily made out, and existing intestinal rupture can be properly treated; whereas, he is of opinion that the injections, especially of iodine, act violently on the testicles, or the fluid may be poured into the cellular tissue, which has been known to produce mortification and death, and also, because the disease is likely to return. It is singular that the objections urged here are said to be provocative of cure by other surgeons; thus Mr. Stanley, F.R.S., recommends the fluid to be evacuated into the cellular tissue of the scrotum, and records cases where the fluid was absorbed in forty- eight hours. German surgeons prefer treatment by incision. In one of my cases the injection method with compound tincture of iodine had been tried, and the fluid had re- accumulated. Imade an incision into the sac, and having introduced a grooved director, opened the scrotum about an inch and a half; into the cavity were passed strips of lint, until the scrotum was packed. This dressing was allowed to remain three days, when it was removed, and others applied. The pain was severe, but the cure complete. Some surgeons, after the opening is made, sprinkle the parts with mercurial powder. Mr. Lloyd, of St. Bartholomew's, introduces into the sac, finely levigated, the powder of hydrarg. nitr. oxidum, and has employed it with complete success. Treatment by Incision and Removal of a T t by Excision of the Tunica Portion of the Vaginal Tunic.—Having placed **ś. the patient in the usual position, the walls - - of the scrotum are divided with a scalpel, and a fold of the tunica vagi- nalis taken up with the forceps, and a portion thereof cut away. (See Fig. 650). The wound may then be closed with carbolized gut sutures. Treatment by Electrolysis.-Two acupuncture-needles are introduced, the one in the upper, the other in the lower part of the tumor, and the free extremities of the needles are connected with the poles of the induction * Medical Record, February 20th, 1886. 1000 1 A SYSTEM OF SURGERY. machine. Care should be taken that the points of the needles project into the fluid, and the current passed through them should be mild, and grad- ually increased until the patient complains of pain. The operation should continue twenty minutes. At first, the scrotum appears puffed, but soon diminishes in size. Cases are known in which hydrocele has diappeared in twenty-four hours after one application of the battery. In conclusion, I may allude to the treatment by alcoholic fomentation, as introduced by M. Pleindoux, who has been successful in several instances, and which was accidentally introduced to his notice. A wine merchant of Nismes had been affected for a length of time with a considerable hydro- cele of the left side of the scrotum, and, for private reasons, desired the palliative treatment. A puncture was made, and more than a pint of water drawn off. Nine months after, a second puncture was made to evacuate the fluid ; it then occurred to the patient to envelop the scrotum with a large compress, steeped in alcohol at 30°. The application was renewed every evening, and was kept in place by a suspensory bandage. The first effect was great contraction of the scrotum. These fomentations were continued forty days, and the patient was completely freed from his hydrocele, which had not returned in eighteen months. Haºmatocele.—By this term is understood an accumulation of blood in one of three localities, the areolar tissue of the scrotum, the areolar tissue of the cord, or the tunica vaginalis. It may be of spontaneous occurrence, or the consequence of external injury. * When it attacks the scrotum it is the result of a bruise or oblique wound ; the scrotum becomes swollen, and assumes a blackish hue, like urinous infiltration; the swelling has a doughy feel, and at one or more points, where the cells are broken down and blood has collected, fluctuation is per- ceived more or less distinctly. Haematocele of the cord arises from the giving way of a spermatic vein, from external injury, or great bodily ex- ertion, when extravasation into the areolar tissue will result, forming a tense, discolored tumor. Haematocele of the tunica vaginalis is the most common variety; and to it, in strict accuracy, the term may be limited. The blood is extravasated into the cavity of the tunica; it may be associated with hydrocele, from a wound of the testicle in tapping, by a blow or other external injury, or by the spontaneous giving way of a blood vessel. A hydrocele may be converted into ha-matocele, the diagnostic marks of hydrocele thereby being lost. The tumor suddenly increases in size, and is the seat of pain; and when handled is found heavier and less fluctu- ating than before. The blood, if in small quantity, becomes diffused in the serous fluid ; when copious, a portion coagulates, and assumes the fibrinous arrangement. This, acting as a foreign substance, may excite inflamma- tory action; and suppuration may take place, with increase of swelling and 2,111. p Treatment.—When the accompanying inflammation assumes a high grade, aconite should be administered ; when it results from contusion, or other mechanical injury, arnica or conium should be given and applied to the affected parts as a lotion ; pulsatilla may avail in such cases; and nux vom., rhus, sulph., or zinc. may be found efficient. The use of the knife is not necessary unless suppuration has occurred. When extravasation super- venes on hydrocele, and the medicines prove unavailing, simple tapping is to be employed. To inject then, would be productive of evil rather than good. The fluid is allowed to collect again, and tapping is repeated, and when, after several withdrawals, the fluid is found to be of the same char- acter as in simple hydrocele, then injection may be resorted to with safety, and with probability of success—provided the testicle be sound. In con- VARICOCEILE. 1001 firmed cases, and especially when suppuration is threatened, the only means for a radical cure is free incision; laying the cavity open, turning out the coagula, and obtaining closure of the wound by granulation; care being taken to avoid wounding the testicle. Varicocele.— Varicocele, circocele, or spermatocele, expresses a varicose condi- tion of the veins of the scrotum or spermatic cord. Usually the latter is affected. It commonly commences close to the testes, and extends upwards towards the abdominal ring. It is caused by obstruction to the return of blood, the dependent nature of the part predisposing to the affection. Laborious .# constant exercise in the upright position, constipation, cor- pulence, the wearing of tight belts, trusses, tumors, or whatever affects the upward flow of blood, give rise to the disease. It is more frequently ob- served on the left than on the right side, in consequence of the spermatic vein of that side having a longer and more tortuous course, and having to support a greater column of blood, and by its being more liable to com- pression, by accumulation of fecal matter in the sigmoid flexure of the colon. The affection is chiefly met with amongst young, vigorous, un- married men, who have led exemplary lives. The whole of the cord ap- pears to consist of knotty and tortuous veins, which feel like a bundle or congeries of earthworms twisted upon each other; it is sensitive to the touch, creates a feeling of weight in the scrotum and loins, and often a degree of numbness in the thighs. It may be distinguished from hernia in the fol- lowing manner: After the patient has been placed in a recumbent posture, and the swelling reduced by compression of the scrotum, the fingers are pressed on the upper part of the abdominal ring, and the patient is directed to rise; if it be circocele, the swelling will reappear in increased size, from the obstruction offered by the pressure to the return of blood; but if hernia be present, the recurrence of the tumor cannot take place so long as the pressure is continued. Treatment.—The radical cure of this affection by means of medicine is attended with difficulty, and in many instances palliative relief is all that can be obtained. Pulsatilla and hamamelis are useful medicines; the treatment may be commenced with puls., and the testes should be sup- ported by means of a suspensory bandage, or bag truss, made of silk net- work. When the affection has been occasioned by a blow or other external injury, or by pressure from the pad of a truss, arnica should be applied in the form of a lotion. As a constant application, hamamelis, one part of the tincture to three of water, is excellent as a palliative, while the same medi- cine administered internally has relieved the pain and dragging of the cord. When the symptoms do not yield to medicines, and the tumor is large and painful, and there is danger of the testicle becoming atrophied in conse- quence of the pressure, the varicose veins should be obliterated. Several processes have been adopted (none of them, however, being free from dan- ger) for this purpose. It must be recollected that the cord is composed of the spermatic arteries, which arise directly from the aorta; of the veins, which constitute the pam- piniform plexus, coming from the back of the testes; and of the was def- erens, which is the excretory duct of the testicle and a continuation of the epididymis. The obliteration by pressure, suture, injection, or otherwise, of either the artery or the excretory duct, is equivalent to castration, and— setting aside the danger of phlebitis, which is of itself a disease of great danger and liable to occur in any operation of the kind—the proceeding is one which requires, not only a correct knowledge of the anatomy of the parts, but delicate manipulation. It was the elder Delpech, who had obtained an enviable position among 1002 A SYSTEM OF SURGERY. the first surgeons of the world, who operated upon both sides, and unfortu- nately included in the ligature the spermatic arteries; atrophy of the testicles occurred; the mind of the patient brooded over the terrible mishap, and his brain, crazed with sorrow and mortification, thirsted for revenge. He waylaid Delpech, and rushing upon him as he left his carriage, stabbed him to the heart. - - - There are many methods of treating this disease. * 1st. Compression. Breschet's method, consisting of applying to the en- larged veins two iron clamps, the jaws of which were tightened with thumb- screws. Curling uses a peculiar variety of truss. 2d. By Suture, as employed by Velpeau and others. 8d. By Ligature, as recommended by Reynaud of Turin, Gagnebe, Ricord, and others, 4th. By Roll- ing up the veins of the spermatic cord, as per- formed by Vidal. Dr. Packard, of Phila- ºhia. employs a double wire loop (Fig. 1). . - Dr. Gross passed a needle behind the veins, and applied a figure-of eight suture (Fig. 652), but stated that after losing one of his patients with phlebitis, he resorted to subcutaneous liga- tion. - A simple method is as follows: - The patient should rise early, take a light breakfast, leave off the suspen- sory bandage, and use as much exercise as possible. By these means the veins are enlarged for the operation. He should be seated upon the edge of a chair, and, with the forefinger and thumb of the left hand, the palmar surface being toward the anterior part of the scrotum, the was deferens and the spermatic artery are searched for. Those accustomed to anatomical manip- ulations are aware that the was deferens ascends behind, and may be distin- guished from the surrounding structures by its fibrous feel, or somewhat cartilaginous hardness. So soon as the duct is found, the ball of the index finger of the hand aforesaid is pressed between it and the veins, thereby making it lay against the nail or posterior surface of the finger, by which it can be pressed against the pubic bones; the artery is also felt by its pulsa- tion, and held aside with the thumb, thereby having nothing between the finger and thumb of the left hand but the bundle of veins. This is an import- ant step in the operation. The patient can be placed under the anaesthetic agent, while the veins are held by the surgeon. It is better to defer the ad- ministration of ether, because the patient can materially assist the surgeon by describing the sensations which are experienced when pressure is made upon the excretory duct of the testicle. Taking a strong piece of carbolized ovariotomy silk, and doubling it, the loop is passed through the eye of a large needle similar to that used by sailmakers, which is with the right hand introduced in front of the thumb of the left hand, and made to pass behind the veins and to emerge in front of the index finger, which holds behind it the was deferens. The ligature must be drawn through and the needle removed, and again inserted in the same opening, but this time directed in front of the veins and behind the skin of the scrotum. The point is then brought out at the same opening from which the loop pro- jects. By this means a double ligature is behind the veins, and the needle in front of them, where it is allowed to remain. The loop is then brought over the point of the needle, and by making traction on the ends of the ligature at the point of entrance, and tying them firmly over the shank of the needle, and again over a piece of cork, the veins are thoroughly compressed. To prevent irritation resulting from the point of the needle, FIG. 651. AMPUTATION OF THE REDUNDANT SCROTUM. 1003 it should be covered with a small cork. On the fifth day the knot is to be tightened, and on the eleventh day the whole may be removed. - This method is safe. In the first place, but two punctures are made in the scrotum ; in the second, should any of the important structures become entangled in the ligature, by withdrawing the needle the whole apparatus is removed. This is the method recommended and employed by the late Dr. Pancoast, of Philadelphia, and from its simplicity and safety should be borne in mind by the surgeon. I have employed a needle set in a handle with the eye in its point. By this means a single loop of cord may be drawn through instead of a double one. The injection of the persulphate of iron has been used with success. The solution should be weak and small in quantity. It may consist of from two to five drops of the following solution. B. Ferri persulph. (liquor), tº © © e § gtt. X. Aquae font., . e º e e © e gtt. XXX. The superficial veins are the first to be injected, and afterwards the deeper seated ones. A clot appears after the injection, which ulcerates and obliterates the veins. In double varicocele, by operating on one side, sometimes the disease disappears. Dr. Clark's Method.—In a Report on the Progress of Surgery, made to the St. Louis Medical Society, and afterwards published in pamphlet, Dr. Clark thus describes his operation: “It consists in excising a portion of the re- dundant scrotum, by taking up a fold of it between the blades of a forceps, or with Ricord's fenestrated forceps for phimosis, and thus exposing the cord with its vessels, so that they can be manipulated separately, and the veins be distinguished from both the artery and the vas deferens. This part of the operation was originally proposed by Sir Astley Cooper, who, after excising a portion of the scrotum, brought the wound together by sutures, relying upon this procedure to effect a cure. I, however, after a fold of the scrotum has been removed, and the vessels of the cord exposed, so that the vas deferens can be isolated, pass a needle around with a wire ligature beneath the cord, excluding the was deferens and including all the other contents of the cord. The needle is then disarmed, removed, and the two ends of the wire passed through a small tube about two inches in length, and wound over a cylinder fixed at the other end of the tube, so as to grasp the vessels as the écraseur does, and compress them sufficiently to arrest their circulation, and induce their complete obliteration. “After the lapse of thirty-six or forty-eight hours, the ‘ecraseur’ is re- moved and the wound closed by the ordinary interrupted suture or needles, the former being preferable. The operation is comparatively devoid of all danger, as any excessive inflammatory action may be controlled at once, by cutting the wire and withdrawing the écraseur.” Amputation of the Redundant Scrotum.—Dr. M. H. Henryº read an inter- esting paper before the New York Academy of Medicine, on the subject of amputation of the redundant scrotum for the cure of varicocele, which pro- cess I have now repeated some twenty-seven times with success. In this operation care and attention to details are necessary. After the usual shaving and antiseptic washings, the scrotum is to be expanded with both hands, the testicles thrust up to the rings, and the clamp (Fig. 653) fitted to the ex- r- * Medical Record, May 28th, 1886. 1004 A SYSTEM OF SURGERY. panded scrotal wall. The curves of the clamp will be found to sufficiently correspond with the curve of the raphé to embrace the bag from the root of the penis to the anus. Care must be taken not to place the clamp too FIG. 653, !" | Al Henry's Clamp. far wip in front, or the cut will remove the skin from the under side of the penis, which should be pulled up over the abdomen out of the way. In screwing down the clamp the operator must make sure that both screws are turned evenly, and that the blades fit accurately; otherwise, so great is the contractility of the dartos, that upon incising the redundancy the lips of the wound may be drawn through the clamp. The shears (Fig. 654), are FIG. 654. Henry’s Shears. then applied, and the extra blade of the clamp removed. The entire wound should be overhanded, or closed with the “bagging-stitch;” the stitches made with whale-tendon carbolized, and about one-eighth of an inch apart. These ought to be drawn tightly. Then the clamp is to be removed and the whole track of the wound carefully looked after. If there is a single oozing point, a couple of extra stitches will arrest the bleeding. The entire scrotum is to be powdered with iodoform and covered with sublimated cotton, enclosed in borated gauze, held in position by an antiseptic band- age. I have been successful with Dr. Henry’s method, but it requires some experience in its performance. I have had a poorly fitting clamp allow the scrotum to slip away; severe hamorrhage in one case from not sufficiently attending to the sutures, and great extravasation and clots in the tunica vaginalis in another. I have had pins cut out and clamps cut in, when I employed them for closing the wound; but lately, with proper stitching and care, the parts have required but one dressing. Keyes's Method.*—After having the scrotum washed with a rººm solution of corrosive mercury, a few drops of a four per cent. Solution of cocaine are injected at the site of puncture. The patient is made to stand, and the was deferens and artery separated in the manner already described. A needle set in a handle and threaded either with catgut or whale tendon (the latter being preferable), is thrust through the scrotum from before backward, leaving the veins on its outer side (toward the thigh). A tenaculum catches the loop on the posterior face of the scrotum and pulls out one end of the * Medical Record, February 26th, 1886. AMPUTATION OF THE REDUNDANT SCROTUM. 1005 thread. The needle is carefully drawn back through the posterior puncture and into the scrotum, but not through the anterior puncture. The veins are freed from the fingers of the left hand and find their natural position. Thus far the thread is on the inner side of the veins, with its end extending through the posterior puncture, and the needle, still threaded, sticking in the anterior puncture. By gentle manipulation the needle is passed under the integument of the scrotum, external to the veins, and its point brought out at the same hole through which the single strand is protruding. A tenaculum is employed as before, and the loop drawn out. The single thread is then passed through the loop and the whole drawn through. The needle is removed, and the ends of the ligature tied in three knots. In a more recent paper,” Dr. Keyes has modified his needle by placing two eyes at its end a short distance apart. The front eye is to carry the ligature, and the loop passes through the other eye, and is held tense on one of the steel buttons at the handle. Dr. Keyes now uses silk instead of gut, thoroughly cleansed and made antiseptic. 0gston's Method.j-After disinfection, the left half of the scrotum is, by the usual manoeuvre, seized three-quarters of an inch above the testicle, between the forefinger and thumb of the left hand, and its contents allowed to slip back and escape until the cord-like was deferens slips out of grasp. At this point the finger and thumb squeezes the skin of the two sides of the scrotum together, to withdraw the veins from the was deferens, and a threaded needle is thrust through the scrotum at this spot. A handled needle, with a large eye at its point, is threaded with the strongest surgeon's silk, disin- fected either by having been boiled in five per cent. carbolic solution, or by Kocher's method of twenty-four hours soaking in German oil of juniper, the thread being afterwards kept in absolute alcohol. The needle should be disinfected. In thrusting the needle through the scrotum, care must be taken to avoid the tubular sebaceous scrotal glands from which hairs emerge. They are always full of bacteria and their disinfection is impos- sible. The needle is unthreaded and withdrawn, leaving the thread in its track. The skin of the front of the scrotum must be seized by the left forefinger and thumb and drawn forwards in a fold between them until , the punctures from which the thread emerged are drawn forward over the dilated veins to the base of the folds. They are there squeezed together and steadied by the finger and thumb, and the needle, this time without any thread, is once more passed through the scrotum, entering and emerging by the same points as before. The end of the thread emerging beside the needle-point, is threaded into its eye and the needle withdrawn, carrying the thread with it, so that both ends of the thread emerged by the same point, where the needle was first entered. The needle having been detached the long ends of the thread are tied by a surgical knot and tightened upon the veins and tissues they embrace with the utmost strength. A triple knot is made, the ends of the silk are cut off short, and the knot permitted to sink into the depth of the scrotum. The puckerings inward of the needle apertures, due to the first and second needle-tracks, sometimes do not quite coincide in the subcutaneous tissues, and can be freed by pulling the skin outwards at these spots until the included fibres give way and º the skin to fall into its natural position, entirely unconnected with the knot. Another exactly similar procedure is made an inch (or two finger breadths, as the case requires) higher up the veins, and the operation is then complete. * * Medical Record, September 18th, 1886. f Annals of Surgery, August, 1886. 1006 A SYSTEM OF SURGERY. The scrotum should be disinfected, surrounded by a sheet of salicylic wool, and the patient laid in bed with the testes elevated. r Carcinoma of the Scrotum.—This disease is, in the generality of instances, of the epithelial variety, and is formidable in its nature. It is called also chimney-sweepers' cancer. It is not common, but is intractable in its nature. A small excrescence forms at the base of the scrotum, which soon degen- erates into a malignant ulcer, which extends rapidly, consuming the neigh- boring integument, and involving the testicle and other subjacent parts. The induration often extends along the spermatic cord, and the lymphatics participate in the diseased action at an early period. The discharge is acrid, Sanious, and possessed of much fetor; sometimes fungi protrude, but more commonly the surface is excavated and smooth. Not unfrequently the skin surrounding the ulcer is studded, to a considerable extent, with numerous clusters of warts of an unhealthy and angry aspect. The general health is soon undermined, and the disease advances from bad to worse, with the usual certainty and rapidity of malignant action. “Other people besides chimney-sweepers,” says Pott, “have cancers of the same part; and so have others, besides lead-workers, the Poictou colic and the consequent paralysis; but it is, nevertheless, a disease to which they are peculiarly liable, and so are chimney-sweepers to the cancer of the scrotum and testicles.” It cannot be determined why a cancerous growth should arise in one locality rather than in another, but there appears to be conclusive evidence that the habitual handling of certain substances and direct violence are much concerned in the development of cancer in particular regions. Mr. Lawrence operated on a chimney-sweeper, who presented cancerous forma- tion anterior to the concha of the left ear. This patient appeared especially obnoxious to the action of soot, for previously a genuine chimney-sweepers’ cancer had been removed from the scrotum ; but it is probable that when the disease reappeared on the ear it was caused by the same substance, for the patient was in the habit, whilst engaged in his trade, of carrying bags of soot on his left shoulder, and it is likely that the ear on that side was often covered with the substance; thus the growth of the tumor may be accounted for.” Treatment.—Arsenicum appears to be serviceable in this affection, when there is inflammation and swelling of the scrotum, and the ulcer is painful in the morning, with burning in the circumference, and uneasiness when the part becomes cold ; when the ulcerative process consumes the adjoin- ing structures, and the constitution of the patient is in a debilitated and impoverished condition. It would seem that this medicine, together with carbo veg., is especially indicated by the habits and mode of life of that class of persons who are liable to the affection. The latter medicine should be administered when the parts surrounding the ulcer are bluish or purple, or when there are pressure and tension around the sore, which emits a cor- rosive humor. Thuja, secale, china, lachesis, rhus tox, clem. erect., hell., iod., mur. ac., merc., corr. sub., may also prove serviceable. If the disease appears to be spreading, complete excision should be prac- ticed. In this operation every bleeding orifice should be secured with fine ligatures, or secondary hamorrhage will result. Elephantiasis Scroti—The student, for a description and cut of this for- midable disease, is referred to page 419. In that chapter will be found a reference to the hydrocotyle asiatica in the treatment. Hamilton't gives an interesting account of Dr. Thebaud’s case—that of * London Lancet, November, 1850, p. 488. f Principles and Practice of Surgery, p. 884. AMPUTATION OF THE SCROTUM. 1007 Isaac Newton—as seen in Fig. 207 of this volume. During the operation, “nearly one hundred vessels, most of which were large and open-mouthed veins, were tied. His recovery was complete.” In describing this operation, I have given the rules of Dr. Allen Webb, a Calcutta surgeon. Amputation of the Scrotum.—Before the surgeon begins this operation, he will by examination ascertain : 1st. If there be hernia (best recognized by percussion if the tumor be large); 2d. If the glans penis be drawn near the external opening; 3d. If there have been abscesses in the perinaeum, drag- ging down the fascia; 4th. Whether or not hydrocele exists; 5th. The situation of the testicles; 6th. The consistence of the tumor and skin; 7th. If the patient is completely under the influence of the anaesthetic. While the operator is being satisfied on these points, the assistants, of whom there should be at least six, arrange the instruments, prepare the patient, and take their respective positions as follows: The first assistant provides the instruments for immediate use: bistouri-caché, double-edged catling, guarded with a nodule of wax, one small Liston knife, and one long knife of same pattern, a strong-handled scalpel, six forceps, six tenacula, many sponges, ligatures, chloroform, brandy and ammonia, bandages and split cloth, tow and lint; also a hospital cot, folded blanket, oilcloth, and pans of sand and water. Having placed the patient on the cot or table, he administers the anaesthetic, at the same time sees that the pubis is shaved. The second and third assistants separate the patient's legs, and having extended them, place them upon stools on a level with the trunk, which lies with the nates pro- jecting over the edge of the table. The business of the fourth assistant will be to support the tumor, moving it as required, and managing it throughout the operation ; he stands at the right of the patient. If the tumor is large, two assistants may support it on a cloth placed beneath. The fifth and sixth assistant, standing at the patient's hips, keep the sponges wrung out for immediate compression. The surgeon should be assured that each assistant is in his place, and fully competent to perform the part allotted to him, and that all the instruments are ready at his hand. He now seats himself on a low chair between the patient's legs, and directs the fourth assistant to raise and reverse the tumor that it may be drained ; he then endeavors to feel with the left index finger the reflexion of the pre- puce from the penis; if found, the tumor is depressed at the same time that the knife (guarded by wax at the end), aided by the weight of the tumor, is thrust through the point of reflexion till it cuts itself out, and the penis is fairly exposed up to its root on its dorsum. The fifth assistant now, keeping apart the edges of the incision, clears it with a sponge, and then grasps the penis firmly, raises it from the attachments and preserves the urethra from the knife. The surgeon then severs the franum and attach- ments of the under surface of the penis already drawn up. The fourth assistant now raises the tumor, rendering the integument lax, so that the operator may pinch it up over the right spermatic cord, and by thrusting the knife under the raised skin, cuts it through horizontally on a line with the root of the penis. The surgeon follows this by another incision bold and deep, from top to bottom of the tumor in the course of the cord—going less deep if any por- tion of the cord appear—as far as the testicle. If hydrocele exists, it will probably be opened and reveal the testicle at the back part of the sac. The fifth assistant instantly thrusts both thumbs into the incision, grasps the mass and compresses the vessels. Using his knuckles as a fulcrum, he turns out the bottom of the incision, revealing the attachment of the testicle and presenting it to the action of the knife. He lifts the testicle with a firm grasp up to the abdomen, and holding it there by the left hand, thrusts a 1008 A SYSTEM OF SURGERY. Sponge into the cavity with his right, compressing the vessels at the neck of the tumor. The testicle and cord being lifted they are rapidly dissected upwards toward the abdominal ring. The surgeon next proceeds with the left side, by pinching up the skin and cutting it through as with the right testicle. He cleaves the tumor by a firm and deep incision from top to bottom as before, and exposes the left testicle. If a large hydrocele pre- Sents, it is opened, and the testicles and cord are dissected from the mass, carrying them upward. The sixth assistant immediately thrusts in both thumbs and turns out the testicle, with his fingers placed behind the tumor; lifts the testicle, carries it up to the abdomen, and holds it there with his left hand, while with the right he presses a sponge on the vessels at the neck of the tumor. The fourth assistant now draws the tumor toward the oper- ator, rendering it tense like an apron spread out, if it is small, or if very large, supporting it upon his arm. Taking care that the penis and testes are well drawn up out of harm's way, the surgeon with a long catling * the remaining attachments of the tumor close to the perineal 3.SC18. The assistants now proceed to draw out and ligate all vessels of any im- portance, keeping them compressed with sponges, and exposing but one at a time. They will also raise the patient’s legs at right angles to the trunk, and administer restoratives if necessary. At the same time the operator examines the testes, castrates if they are diseased, cuts away portions of the hydrocelic sac if it be abundant, and removes any diseased blubber which may remain. As soon as these details have been properly attended to, the dressing of the wound will be accomplished by the first assistant securing a T Fºuge around the abdomen, and bringing the split-tails of it between the egS. g * At the same time the operator fixes each testicle at the root of the penis where he intends them to adhere, until the bandage is brought up by which they are secured, while the assistant applies strips of oiled lint over the wound, and over that some teased tow, to support the testicles and prevent them from slipping down from the fingers of the operator. Over this are brought the tails of the bandage, which cross under the penis, and are carried on either side and secured to the horizontal band. A water-dressing will be found serviceable, and the surgeon, having ordered the patient to be carefully watched in case of supervening hamorrhage, can now leave the wound until the discharge renders dressing necessary. Dr. D. W. Osgood, surgeon to the Medical Missionary Hospital, Foochow, China,” after remarking that about three-fourths of the patients treated at Foochow had the disease located in the legs, and the remainder in the scrotum, gives a description of his method of operating. This consisted: 1st. In the elevation of the scrotum for an hour or more before the opera- tion. 2d. The use of Fayrer's tourniquet, which was of prime impor- tance in the suppression of haemorrhage. 3d. Dissecting up lateral flaps, which should not include any of the diseased skin. 4th. Dissecting out the penis and testicles. 5th. Holding the genitals well out of the way, and removing the scrotum by a few well-directed strokes of the scalpel. 6th. Arresting the hamorrhage by pressing upon the wound and by ligating or twisting the arteries. When hydrocele existed the sac was opened with a free incision. In some cases the spermatic cords were much elongated, but they retracted soon after the operation, and in a few days the testicles were drawn up close to the inguinal ring. The parts were usually covered with granulations in two or three weeks, after which time skin-grafting was ad- * Medical Record, April 8th, 1876. PHIMOSIS. 1009 vantageously resorted to. The writer appends a table of fifty cases of ele- phantiasis scroti, operated upon in Southern China, all of which recovered. Thirty-three of these were known to have had ague; about one-half had hydrocele, which was frequently connected with atrophy of the testicle. The average age of the patients was 38 years, and the duration of the dis- ease eight years and a half. Phimosis.-Phimosis signifies a preternatural constriction of the edge of the prepuce in front of the orifice of the urethra. The prepuce occupies its natural relative situation, but difficulty is experienced in uncovering the glans, and frequently is impossible. There are two varieties of this affection, the natural or congenital, and the preternatural or acquired. The former exists at birth; the latter may occur at any period, and is frequently the result of an acute inflammatory pro- cess following external injury; the cicatrization of an ulcer or wound; or is sympathetic with gonorrhoea, balanitis, or venereal sore. * Congenital phimosis is not an uncommon affection, and will be found in two or three varieties. Sometimes, though rarely, the prepuce is imper- forate, and consequently the urine, not being emitted, collects between the glans and prepuce, forming a bag or tumor. Another variety is that in which an opening exists at the extremity of the prepuce, which is not sufficiently large to allow the urine to escape with the same rapidity as it issues from the urethra; consequently it collects under the prepuce, and distending the latter, is forced off gradually in a fine stream and to a distance. If the disease continues for several years, pus, and even calculi, may collect, keeping up a constant irritation. In the majority of instances, there is no impediment to the flow of urine, and no extraordinary elongation of the prepuce, yet it is so con- tracted at its orifice as to prevent the exposure of the glans. A whitish Sebaceous matter collects in quantity between the glans and prepuce, ex- citing irritation; and inflammation ensuing, adhesion takes place between the glans and prepuce, only to be relieved by dissection. In after-life the preputial contraction may have the same effect as a tight stricture of the urethra; causing irritability of the genito-urinary system, organic change, stricture of the urethra, alteration of the coats of the blad- der, dilatation of the urethra, and finally renal disease. Should the patient have escaped these dangers, ulceration is apt to take place at the contracted i. or a cancerous condition may ensue, which, involving the glans and ody of the penis, demands amputation; for in nine cases out of twelve in which Mr. Hey* had occasion to amputate the penis for cancerous disease, the patients were affected with natural phimosis. Preternatural or acquired phimosis may be either acute or chronic. In the acute variety the areolar tissue becomes infiltrated with serum; the swelling thus caused prevents the glans from being uncovered in the usual way, and secretion accumulating, aggravates the disorder. The chronic form may result from gradual increase of original malformation, or may be occasioned by the cicatrization of a wound or ulcer. The neuroses which are developed by this disorder are numerous. They are all affections of the nervous system, and vary from ordinary sleepless- ness and nervous jactitations, to complete incoördination of movements and loss of equilibriating power. Sometimes the affections simulate hip disease, sometimes locomotor ataxia is present. A typical case, as exhibiting to what degree these symptoms may be present, was reported by E. P. Hurd, M.D.f “A lad of seven years had for several months been losing strength, * Practical Observations in Surgery. - f Boston Medical and Surgical Journal, January 18th, 1877. 64 1010 A SYSTEM OF SURGERY. appetite, and flesh, was restless and nervous. Locomotor ataxia was a marked symptom ; he could not coördinate his members in any act; could not walk across the room without staggering and pitching headlong. The same want of coördination was manifested when he attempted to feed himself. It seemed impossible for the will to guide the hand to the mouth. Intellect not disturbed, only the hebetude before mentioned was marked. Responded to questions in monosyllables, and speech was not distinct. Pupils dilated; at times an outward and slightly upward squint of both eyeballs, from paresis, as was supposed, of the third pair of nerves. Marked dulness of hearing. No febrile heat; pulse normal. No pain. Could not elicit from him whether he experienced any abnormal sensations on attempting to put his feet to the floor, or whether the tactile or mus- cular sense was perverted. Hyperaesthesia of general surface. Shortly after coming under treatment, had a fit of epileptiform type. There was no con- stipation or difficulty of micturition. “For upwards of a week he was treated with sedatives to quiet the excessive nervous irritability manifested during the night, with only par- tial benefit. One day the patient lay naked in his mother's arms, when a glance revealed phimosis, the prepuce was greatly elongated, strangulating the glans, and the urinary punctum was minute. Circumcision was per- formed, and from that time steady improvement set in.” Dr. John Thomp- son, of Albany,” reported a case of epileptiform convulsions produced by phimosis, and I have relieved intense nervousness, jactitations, and vomit- ing by circumcision. An interesting monograph on the reflex neuroses of phimosis, by Dr. T. G. Comstock, of St. Louis, will repay perusal. Treatment.—When the inflammation has been produced by friction, or other mechanical cause, arnica should be employed both internally and as a lotion. If the inflammatory action be violent, aconite is advisable. If no beneficial effect appears to result from the use of the latter remedy, calend., rhus, or puls. may be administered. When the affection is accom- panied with suppuration, merc., caps, or hepar may alleviate; and when induration of the affected part and surrounding integument supervenes, sepia and sulphur are appropriate medicines. When gangrene threatens, or has commenced, particularly if the disease is associated with gonorrhoea, ars. is recommended.t. When young children are affected, acon., merc., calc., and sulph. are suitable. When this difficulty arises from syphilitic causes, the remedies are, merc. Sol., rhus t, thuja, cinnab., Sulph., viola tric., and kali hydriod. Balanorrhoea generally accompanies this variety of phimosis; some authors state this to be always the case; and when the above-mentioned remedies are insufficient, it may be necessary to make incisions into the prepuce, and allow the secreted pus to escape. The congenital and chronic variety of acquired phimosis, can Seldom be relieved without an operation. When natural phimosis existing at birth is complete, an immediate opera- tion is required; generally puncture with an ordinary lancet in the promi- nent portion of the tumor, will be sufficient, as the stream of urine will prevent the closure of the wound. wº. When the orifice of the prepuce is not entirely closed, but merely con- tracted, a simple method is that recommended by Mr. Liston; $ which con- * New York Medical Journal, July, 1875. # For an interesting account of several cases of this nature, effectually treated by arseni- cum, vide British Journal of Homoeopathy, vol. iv., p. 265. f Gollmann's Diseases of Urinary and Sexual Organs, p. 64. & Elements of Surgery, p. 410. TREATMENT OF PHIMOSIS. 1011 sists in passing a grooved director, open at the end and well oiled, under the prepuce, alongside of the franum, taking care that it is not passed into the urethra. A sharp-pointed knife is slid along the groove, and emerges at its extremity, when with one sweep the prepuce is divided. If the edge of the prepuce is thickened, it should be seized between the blades of the forceps, and shaved off. Several fine sutures will be necessary to prevent the separation of the integument and mucous membrane, that they may unite by adhesion. In phimosis the stricture is caused by contraction and rigidity of the internal membrane of the prepuce, the external portion consisting of cel- lular tissue and skin, remaining generally sufficiently loose and yielding. Hence the constriction may be relieved by dividing the internal lamina. This may be effected, where the phimosis is not complete and rigid, by drawing back the external portion of the prepuce as far as practicable, until the tense ring of the inner prepuce, which forms the stricture, is ex- posed, and dividing the latter with a bistoury or a pair of scissors, at one or more points, sufficiently to permit of the free motion of the prepuce over the glans. Another operation is that of Cullerier. It is applicable to those cases in which the integuments appear to be not condensed or indurated, but in which the stricture is due to the more unyielding mucous membrane. The instrument employed is a pair of small straight scissors, of which one of the blades is terminated by a button, like a probe-pointed bistoury. This is passed between the glans and prepuce, while the sharp-pointed blade is thrust into the substance of the prepuce, being separated from the other by the mucous membrane; the latter is then divided a sufficient length to allow the prepuce to be drawn back.” The operation which I prefer is as follows: Make the first incision as that directed by Mr. Liston, and then with the scissors trim the mucous mem- brane and integument around to the franum praeputii, unite the mucous and integumentary surfaces; or, having drawn the integument well forward with a pair of “bull-dog’ forceps, it is given to an assistant. With a pair of narrow-bladed forceps, held at right angles with the first, the prepuce is grasped transversely. With a sweep of the knife or scissors all the part anterior to the forceps held transversely is divided; both pairs of forceps are removed, and it will be found that scarcely any of the mucous surface has been cut through ; this must be lifted up with the forceps and trimmed with the scissors, after which the sutures are applied. Some surgeons prefer introducing the stitches first, and forceps with fenestrated blades (Vidal's) have been invented for that purpose. The pre- puce is drawn out, the fenestrated blades (held perpendicularly to the penis) grasp the prepuce (Fig. 655), the ligatures are passed through the open- ings in the blades, two being sufficient; the prepuce is removed, and through the preputial orifice the threads are drawn forward and cut, thus making four ligatures, which, being tied, unite the mucous and integumentary surfaces (Fig. 656). Dr. Hutchinson, of the Brooklyn City Hospital, has devised a pair of forceps “for rupturing the mucous membrane in accidental phimosis” (Fig. 657). The doctor says: “The operation consists in introducing the blades of the forceps closed, through the preputial opening and along the dorsum of the glans penis as far as the corona. They are then suddenly expanded, and withdrawn fully dilated. The prepuce can at once be retracted behind the corona glandis, when it will be found that the mucous membrane has * South's Chelius, vol. ii. * 1012 A SYSTEM OF SURGERY. been split at the seat of stricture, the skin being uninjured unless the phimosis has been produced by a cicatrix at the preputial orifice, which existed in one of my cases, and was ruptured. The patient is now directed to retract the prepuce behind the glans several times a day, especially during micturition, both in order to prevent the contact of urine with the wound, and also the too rapid union of the ruptured edges, which would re- Fig. 655. º TT|{ º Thiſ º Dividing the Prepuce. Ligatures in Position. roduce the disease. The patient should be cautioned not to leave the oreskin retracted behind the glans, for swelling might occur to such a degree as to cause paraphimosis. This indeed happened in one case at the Brooklyn City Hospital, which was operated upon by house surgeon H.T. Pierce. The prepuce was drawn forward by the usual manipulations, aided by ether spray thrown upon the glans by Richardson's atomizer, to diminish FIG. 657, Hutchinson's Prepuce Dilator, the size of the organ. This operation should not be practiced when chan- croids are present, for fear of inoculation, nor until sufficient time has elapsed for the phimosis to disappear spontaneously. “The above operation has now been repeated nine times by myself and house surgeon H. T. Pierce with the most satisfactory results. It will be found, I think, to possess the following advantages over the methods of treat- ment ordinarily practiced: * 1st. It is ... to circumcision, or slitting up the prepuce, because it is simpler, is done more quickly, and there is no haemorrhage requiring PARAPHIMOSIS. 1013 the use of haemostatic agents. But when the prepuce is much diseased, circumcision should be preferred. “2d. It is better than simple dilatation by means of Thompson's urethral dilator, as suggested by Mr. Erichsen, because the contraction is less likely to recur after rupture than after dilatation. “3d. It is preferable to simple division of the mucous layer of the pre- E. which is done by thrusting one blade of a sharp pair of scissors etween the layers of the prepuce, while the other is carried along the dor- sum of the glans penis, so as to divide the mucous membrane to the corona glandis, because there is less danger of a reproduction of the disease after a rupture than after an incised wound.” araphimosis.-Paraphimosis is the reverse of phimosis—the prepuce becoming retracted behind the coronaglandis, leaving the glans uncovered; the body of the organ is constricted by the tight preputial orifice, and gives rise to unpleasant and sometimes dangerous consequences. The superficial areolar tissue becomes swollen on either side of the stricture, the glans being involved in the tumefaction, and an acute inflammatory process is estab- lished under adverse circumstances, the strangulated parts being obviously ill-provided with the power of resistance or control. The disease may be either congenital or acquired, though the latter is more common. It may be the result of a retraction of the prepuce, when the patient had previously been affected with phimosis; but it generally proceeds from inflammation, induced by a syphilitic or gonorrhoeal disease. In some instances the swelling and constriction are so great that mortifica- tion ensues, and the glans, or even the whole penis, may be lost; this, how- ever, must be considered a rare termination. In neglected cases, ulceration of the body of the penis may take place, perforating the urethra, and pro- ducing urinary fistula. Treatment.—In recent cases, before the swelling has attained any consid- erable size, reduction is practicable. The patient having been placed in a suitable position, and the parts well oiled, the surgeon grasps the glans with the fingers of the right hand and makes pressure thereon, at the same time E.; it steadily from him; with the fingers of the left hand he draws orward the constricting portion—the object being to push the glans, when diminished by pressure, through the narrow preputial orifice. If it should fail, and there be no marked urgency, the penis should be placed in an erect position and a stream of cold water poured on it. This may have a happy effect in diminishing the bulk of the formerly turgid part, and FIG. 658. it may be replaced within the prepuce without much diffi- culty. - For many of the symptoms connected with paraphimosis, aconite, cannabis, sabima, and mercurius are the appropriate medicines; but should these fail, resort must be had to an operation. The tumefied parts are to be separated by the fingers, and the strictured band cut through Method of making Incision in Paraphimosis.-BRYANT. with the sharp point of a knife, when the prepuce should be drawn forward so as to occupy its normal position: this operation is recommended by Mr. Hunter. That of Richter consists in raising a fold of the skin, and cutting through it; a director is 1014 A SYSTEM OF SURGERY. Fººth the stricture, and the latter is divided by a sharp bistoury. 1g. boč. } Epithelioma of the Penis.-Cancer of the penis is generally of the epithe- lial, and rarely of the encephaloid variety. The disease commences with the appearance of a small watery excrescence or pimple on the prepuce or glans. It often occurs in old persons, and may be traced to the irritation Consequent upon phimosis, commencing by ulceration at the preputial orifice, and thence extending to the body of the penis. The glans becomes hardened and enlarged, ulcers of an irritable appearance penetrate it, the lymphatics on the dorsum of the penis become swollen and indurated, the glands of the groin are involved, and the discharge from the sore is fetid and irritating. The disease follows the ordinary course of cancer. Treatment.—Medicines which have been mentioned for cancer in other parts of the body, may be used; in a majority of instances amputation is the only resort; and this is not always successful, as the disease reappears in the stump, or exhibits itself in the inguinal glands. Amputation of the Penis-Ricord's method of amputating is good, being calculated to obviate the difficulty attendant upon the operation—namely, tendency to contraction in the orifice of the urethra. The penis is put upon the stretch by the left hand, and removed with one cut, care being taken to leave sufficient integument to cover the corpora Cavernosa; the surgeon, seizing the mucous membrane of the urethra by means of forceps, with a pair of scissors makes four slight incisions, to form four equal flaps; then using a fine needle armed with a silk ligature, he unites each flap of membrane to the skin by a suture. The wound heals by the first intention, adhesions form between the skin and mucous mem- brane (these textures becoming continuous), and the cicatrix contracting, tends to open the urethra. When micturition is difficult of accomplish- ment, in consequence of the shortness of the penis, the inconvenience may be ºiated by allowing the patient to urinate through a funnel-shaped C8, Ill] 18,. During the operation fine ligatures are required. If the penis has to be amputated close to the body, a stout cord or wire may be passed through the base of the organ to draw it downward in cases of retraction and sec- ondary hamorrhage. Many surgeons use the écraseur or the galvano-cautery, and thus prevent danger of haemorrhage. The integument may first be divided to form a track for the chain of the instrument. g Spermatorrhoea.—The symptoms of this affection are well known. It is a mistake to suppose, because a young person in all the vigor of man- hood has an occasional nocturnal emission, that the disease exists. It is a Question whether certain emissions of semen without copulation are not necessary to the preservation of virility. This fact is not sufficiently under- stood, and young persons having had an emission or two become alarmed, apply to the physician, and are “put through ' a disastrous surgical and medical treatment. Cases of spermatorrhoea are occasioned by masturba- tion, and this must be controlled by the will and proper, medication. The symptoms are emissions of semen, at night or towards morning, gradually increasing, until they recur with great frequency. The patient does not feel the loss at first, but, as the pollutions increase, there is depression of the mental powers, ringing in the ears, loss of strength, emaciation, and great bodily disturbance, dyspepsia, constipation or diar- rhoea, and flatulence, until the mind itself shows symptoms of decay. Treatment.—Some years since I frequently made use of the instrument of Lallemand, and cauterized the seminal ducts. I have never known an instance of its curing, or even benefiting the patient, while I have known EXAMINATION OF THE UTERUS. 1015 it to produce bad results from tampering with a sensitive urethra. I have also tried the perineal pad, perhaps with benefit. With gelseminum, platina, agnus castus, and nux vom., together with cold sitz-baths, proper exercise and ventilation, I have cured many cases. Patient and persevering application of the means will accomplish the de- sired end. Kafka” remarks that nux vomica takes high rank in the treatment of onanism and pollutions. Its characteristics are; nervous erethism all over, and especially in the sexual sphere; frequent pollutions, with lascivious dreams; sleeplessness in the forepart of the night, and sleep with pollutions toward morning; ejaculation of semen from the slightest cause without erection, and coldness and weakness of the lower extremities after it: hypo- chondriasis, dyspepsia, and constipation. Nux vom. or calcarea will be indicated, especially for pressing pains in the head, neck, and back, after the pollutions; lassitude and weakness in the lower extremities. - Dr. Lilienthal recommends sulphur, merc., staphisagria, phosphorus and phosphoric acid, acidum sulphuricum, anacardium, bufo, cobaltum, dioS- Corea, eryngium aquaticum, gelseminum, graphites, iris versicolor, hama- melis virg., kali brom., lycopodium, naja tripudians, natrum mur., nuphar lutea, selenium, sepia, thuja, ustilago maidis, zincum oxidatum. Circumcision ought to be performed early if there is a redundant or con- tracted prepuce. - CHAPTER XLVII. INJURIES AND DISEASES OF THE FEMALE GENITAL ORGANS. ExAMINATION OF UTERUS—CARCINoMA—SCIRRHUs—EPITHELIoMA, VEGETATING AND ULCERATING—AMPUTATION OF THE CERVIx—UTERINE TUMoRs—FIBRO-MYoMATA —VAGINAL REMOVAL, AND LAPAROTOMY-HYSTERECTOMY-VAGINAL ExTIRPATION of THE UTERUs—OöPHoRECTOMY-LACERATION OF THE PERINAEUM–VAGINISMUS— ELEPHANTIASIS OF THE LABIA. IT is not to be expected, in a work on General Surgery, that much space can be devoted to gynaecology: that department already covers so wide a field, that a series of volumes can scarcely contain all that is known con- cerning the varied diseases of the uterus and appendages. There are, however, some diseases and operations that fall within the province of every physician, and to these allusion may be made. These are tumors of various kinds, including ovarian cysts and Ovariotomy; oöphorectomy, cancer of the uterus, vaginismus, fistulae, lacerated peri- naum, cervix, and atresia vaginae. - Examination of the Uterus.-Position is a matter of import in the exami- nation of a patient, and may vary with the kinds of instruments to be em- ployed, and the operations to be performed. If the examination be made by touch, the patient should recline on her * Hom. Therapie, i., 942. 1016 A SYSTEM OF SURGERY. back, with the hips elevated and the head resting on a single pillow. She should be close to the edge of the bed (the right side, if the surgeon is to use his right hand, and vice versa), and the sheet and coverlet should fall over the side of the couch to prevent any exposure of person, when the hand is introduced. If the patient is to be examined with her clothing on, the covering should be placed over the lower parts of the body. The knees should be slightly raised, and the operator, sitting on a chair facing the patient, having lubricated the fore-finger of his right hand with oil, glycerin, or Soap, raises the covering slightly with his left hand, and introduces the FIG. 659. -:::::::::: Fergusson's Speculum. oiled finger into the vagina at the posterior fourchette. If the speculum be used, the patient should face the light; the thighs be flexed on the abdo- men, and the legs on the thighs, and the knees separated. A sheet should be thrown over the lower portion of the person, and each end of the linen wrapped around the legs, as the thighs are open. By such a manoeuvre carefully performed, there need be no exposure. A great variety of specula have been and are now being introduced to the profession. The old- fashioned one of Fergusson (Fig. 659) is preferred by some operators. It is made of glass, coated with india-rubber FIG. 660. on the outside, and lined with quicksilver. E-º Q: , Most of the specula are more or less modi- fications of the instrument of Dr. Sims,” and to him belongs the credit of allow- ing atmospheric air to enter the vagina and dilate the canal. Fig. 660 shows the speculum which now receives the name of the inventor. The patient for the intro- duction of this instrument must lie in a semiprone position. The right thigh must be flexed, so that the right knee will be above the left, and the left arm must be drawn well behind the patient, that the left side of the thorax will come closely in contact with the couch. When the specu- lum is introduced, it must be drawn up well to put the perinaeum on the stretch ; provided the posterior wall of the vagina is to be viewed, it may be drawn under the Sims's Speculum. pubes, its position being reversed if the vagino-rectal septum is to be brought under observation. Fig. 661 represents Nott's speculum open. It is self-retain- ing, and has two short arms, which depress the anterior wall of the vagina. | * Silver Sutures in Surgery. CARCINOMA OF THE UTERUS. 1017 Dr. William O. McDonald's modification of Sims' speculum, one flange being much shorter and broader than the other, is now used almost entirely FIG. 661. Nott's Speculum. at the Hahnemann Hospital. Its advantages are additional expansion of the posterior vaginal wall, and the increased facility with which any ma- nipulation of the cervix can be accomplished. Comstock’s “Gynepod '' is seen further on in this section. Uterine probes and sounds (Fig. 662) are necessary in ascertaining the internal condition of the uterus. FIG. 662. G, T/E/MA /VW & CO Uterine Probes and Sounds. Carcinoma of the Uterus.-The uterus is frequently the seat of carcinoma, but there are other diseases which may simulate one or other of the varieties of cancer and render the diagnosis difficult. Venereal ulcerations, polypus, and even prolapsus, have been mistaken for carcinoma, and have been treated accordingly, the error not being discovered until the disease was too far advanced to admit of successful treatment of any kind. A minute examination and inquiry must, therefore, be instituted, and the microscope employed in the examination of the discharges, before venturing to offer any decided opinion concerning the character or termination of the affec- tion. Scirrhus of the Uterus.-In scirrhus, the cervix and mouth of the uterus become heavier than usual; there is likewise inequality of surface with hardness. The organ appears situated lower down in the vagina than natu- ral. There is pain during coitus, and the lancinations which are experi- enced are often severe. As ulceration progresses, pain is experienced when touching the part; ulcers appear with spongy bottoms and callous edges, and frequently fungi sprout from the surface of the wound. In most cases the vagina participates, losing its natural rugosity and becoming contracted, nodulated, and finally the whole cavity of the matrix becomes filled with 1018 & A SYSTEM OF SURGERY. degenerate tissue, with frequent bleedings and offensive discharges. Some- times the bladder, at others the rectum, is perforated by the ulceration. Epithelioma-In the incipent stages of epithelioma, the disease is fre- quently mistaken for irregularity of the menstrual function; for leucorrhoea or chronic metritis. The first symptoms are cessation or too frequent return of the menses, irregular discharges of blood in place of the catamenia, to- gether with fluor albus. The patient complains of a sensation of heaviness or drawing within the pelvis, and pressing towards the external organs, being aggravated or excited by various circumstances, such as lifting, fatigue, etc. Upon examination, the vaginal portion of the uterus is found to be preternaturally indurated, bleeding readily, of irregular consistence, Swollen, misshaped, tuberculous, and sensitive to pressure; the lips of the OS uteri are interstitially infiltrated, indented, and elevated, and the orifice is distended. The pains become violent, particularly at night, and are press- ing, stitching, shooting, and burning, not only in the pelvis, but extending into the lumbar region and along the thighs, with swelling and tension of the inguinal glands; frequently there is a continual burning pain in the lower part of the pelvis, accompanied with shooting pains in the uterus. A pungent acridichor, of a reddish-brown or claret color, exhaling a deleterious effluvium, is discharged from the vagina, excoriating the surrounding in- tegument, and giving rise to painful itching of the external organs. Copious discharges of blood, containing coagulated and fibrinous substances, are fre- quent, and Sometimes cause great exhaustion. The cancer has now changed to an open, irregular ulcer, which is readily recognized by the touch. The neck of the uterus feels rugged, and is studded with soft, readily-bleeding excrescences, which are narrow at their base, as though a ligature had been placed around them ; these fill up the whole vagina, the walls of which are indurated or disorganized, conveying to the finger the sensation as of a hard, contracted ring. As the disease advances, the symptoms of the cancer- ous dyscrasia become more apparent; the skin is of a pale straw color; the features exhibit an expression of suffering; the digestive functions are im- paired; sleep is almost impossible, the patient emaciates, and hectic fever supervenes. The affection frequently occurs between the ages of forty and fifty, and as it proceeds it may partake of one of the two varieties, vege- tating or ulcerating. Vegetating Epithelioma-This affection was formerly called “cancroid,” but belongs to the cancer family, differing chiefly from other forms in the depth of parenchymatous involvement. The name epithelioma was given to it in 1852, by Hannover. The cauliflower or strawberry-shaped excrescence of the ostincae is seated generally on one of its lips, or in some instances proceeds from the whole circumference. This fungus grows from a broad base, is soft, of a bright flesh-color, presents a granular or strawberry-shaped surface, and to the touch conveys somewhat the same sensation as that of the uterine surface of a placenta. It is formed of large papillae with a central stroma covered with epithelium, which grows in nests. The ulceration is superficial, the walls and floor of which are infiltrated with round cells. This disease has been considered as a local affection, and progresses slowly, the latter feature serving as one of the diagnostic marks between it and cancer. There is another variety of epithelioma, which ulcerates instead of propagating a fungus. To this the term ulcerating epithelioma is given. Ulcerating Epithelioma was formerly called phagedemic uterine ulcer; this is preceded by a pseudo-plastic formation, or infiltration of the surrounding textures. The uterus around the ulcer may be almost in a normal condi- tion, but in the generality of instances the sore is surrounded by a diseased mass, which is soft and yellow, or of a reddish-brown color. If the un- EPITHELIOMA OF THE UTERUS. 1019 healthy action be not arrested, the destruction may extend to the wall of the uterus, to the vagina, rectum, and perinaeum. Treatment.—When the disease is established, the physician can do little else than palliate the sufferings of the patient, though in the incipient stages benefit may be had from treatment. In the later stages the uterus feels like a hard body lying above the pubic bones, and presents the follow- ing symptoms, which correspond to belladonna. Pressing and fulness of the inner parts, rendering it difficult for the patient to stand, accompanied with pain in the sacral region. Likewise when a sanguineous ichor is dis- charged from the uterus, either continually or at intervals. Platina is indi- cated by spasmodic, or pressing colicky pains, accompanied with a dis- charge of thick, viscid, venous blood, especially if the patient previously suffered with profuse menstruation. If constipation, nervousness, and a long-lasting, though regularly occurring discharge of acrid blood, with burn- ing, Smarting, and itching be present, nux vom. should be administered. The debility which supervenes in consequence of the pain and loss of blood, is relieved by china. Arsenic, sepia, creasote, iodine, conium, and thuja may be used with advantage. - - The treatment which has given me most satisfaction is the early applica- tion of Marsden & McLement's paste (vide page 183) and the hypodermic use of Déclat's nascent phenic acid—60 to 80 minims being injected into the skin of the abdomen or upper portions of the thigh every night and morning. In addition to this a granule of arsenic, 1–100 of a grain, should be given after dinner. The paste is to be applied upon cotton, through a cylindrical speculum, and the wad pressed firmly upon the cervix. It should be allowed to remain three hours, be then withdrawn, and the parts carefully syringed with hot water. The application may have to be re- peated six or eight times. Dr. Wahle, of Rome, Italy, prescribed graphites for the following symp- toms: The vagina hot and painful; swelling of the lymphatic vessels and mucous glands, some of which are of the size of a filbert; the cervia, uteri hard and swollen, and on its left side three large and painful tubercles of various sizes, each consisting of several smaller ones, which threaten to change to a bleeding excrescence; upon rising a sensation as of great weight is experienced deep in the abdomen; with increase of pain, debility and tremor of the lower extremities; the sufferings are most acute shortly before and during the period of menstruation; the discharged blood is black, coagulated, and emits a disagreeable odor; a sensation of heaviness is experienced in the abdomen, with violent lancinations in the uterus, ex- tending down the thighs, somewhat resembling the passage of an electric current; the pains are burning and lancinating; little appetite, constipa- tion, frequent chilliness, without subsequent heat and sweat; the patient is sad, anxious, and sometimes desperate; complexion livid; pulse frequent and rather hard. It is necessary that injections of disinfecting substances be made use of, and for this I employ Platt's chlorides or Labarraque’s solution. The reader may refer to Disinfectants for information on this subject." It may be considered necessary, under certain circumstances, to extir- pate the cervix uteri or the entire uterus, which subjects will be treated in this chapter. - Amputation of the Cervix.-Prof. Osiander, of Göttingen, was the first to conceive and execute excision of the cervix uteri, and his example was fol- lowed by Dupuytren and other distinguished surgeons. The first operation was performed by Osiander in 1801, on a widow, whose vagina was filled by a vascular fetid fungus from the orifice of the womb, as large as a child’s 1020 A SYSTEM OF SURGERY. head. By means of Smellie's forceps the fungus was brought down low in the vagina, but being accidentally broken, haemorrhage ensued; undis- mayed, the operator determined to proceed, and immediately pushed a number of crooked needles, armed with strong ligatures, through the bot- tom of the vagina and body of the uterus, until they emerged at the inner orifice. These ligatures served to draw down the uterus, and retain it in the vagina near the external orifice. The surgeon then introduced a strong bistoury above the scirrhous portion, and divided the womb completely in a horizontal direction. The haemorrhage, though profuse for an instant, was speedily suppressed, and the patient recovered in three or four weeks. Osiander afterwards performed eight similar operations upon different pa- tients, all of whom recovered. * - Dupuytren operated eight times; but, instead of employing the ligatures and bistoury recommended by Osiander, he drew down the uterus with forceps, and divided it above the scirrhus by knives and scissors. This pro- cedure is recommended at the present time. The operations of to-day may be made either with scissors and knives, with the écraseur, or by the galvano-caustic wire. The patient should be placed in the position of Sims—see p. 1016—and FIG. 663. Scissors Curved on the Flat. the cervix divided bilaterally; the lips are then seized, drawn downward, and removed with the scissors; these should be curved on the flat, as seen in Fig. 663, or have long handles, with the cutting edge at right angles (Fig. 664). Sims, after the amputation, drew down the mucous membrane FIG. 664. G. ºr waſ ſº dº nºt * tº Long Uterine Scissors, and stitched it over the raw surface. If the écraseur be used, the chain is applied as high up as possible, and the screw worked slowly. By referring to page 259 et sequentes, the student will understand the method of using the instrument. If the galvano-caustic is used, the wire instead of the chain is FIG. 665. : º, .<=> É §§: * s E. , a.º. fººt Electro-cautery Sling and Platina Wire. applied. Fig. 665 represents the looped platina wire and the sling for its application. This method is the safest of the three, and I have had satis- faction in witnessing its thoroughness and efficiency in numerous cases. UTERINE TUMCRS. 1021 Uterine Tumors—Fibroids—Fibro-Myomata—Myomata.-There is a dis- crepancy among writers concerning tumors of the uterus. They are called fibroid, fibro-cystic, and polypoid. Some classify them according to their seat, others according to the texture of the parenchyma. Virchow denomi- nates them myoma, to which term Billroth objects, and declares that myo- fibroma shoufd be the name, because there is a mixture of fibrous and mus- cular substances. The latter is the term generally in use. A fibroid tumor consists chiefly of connective tissue and unstriped mus- cular fibres. It is probable that the preponderance of the latter element caused Virchow to classify these tumors as myoma. The connective tissue is hard and firm in the majority of cases, in others it is loose, but in either case generally formed in concentric layers. Rokitansky makes three varieties of fibroid tumors of the uterus. . The first variety is distinguishable: 1st. By its smallness. 2d. By its spherical shape. 3d. By its density. 4th. By its hardness. 5th. By its poverty of vessels. This latter is common in married women. The second variety, which is the true fibro-cystic tumor, is distinguished: 1st. By a concentric arrangement of fibres, which is more discernible before their immersion in spirits. - 2d. By an accumulation of softer tissue in the interstices, and their re- ºnce either to a coarse-grained salivary gland or to a soft mammary gland. º 3d. By a peculiar soft, doughy, elastic “feel,” and the fluctuation of the fluid in the cysts. 4th. By a somewhat rounded and nodulated exterior. It is this variety that attains the largest size. - These tumors become more cystic as they advance in age, and the bes explanation of the transformation is that of Coe,” who has given a great deal of study to the subject. In his sixth conclusion he states: “such cysts probably arise from the so-called ‘geodes’ or gelatinous patches,” and in his eighth conclusion he affirms: “The geodes are probably dilated lymph spaces, which expand by reason of the accumulated fluid in their interior, a condition due to a general stasis.” The third variety, or true fibroid polypus fibro-cystic, is distinguished: 1st. By its distinctly lobulated surface. 2d. Its expansion of fibres, making, 3d. Internal cavities of considerable size. 4th. Its flattened shape. 5th. Its close adherence to the uterine parenchyma. 6th. Its great vascularity. 7th. Its congested and reddened appearance. By bearing in mind these peculiar characteristic appearances, it will not be a difficult matter to diagnose the variety of uterine tumor that may be encountered by the physician. The most common classification of the present day of these tumors is into submucous, subperitoneal, and interstitial, according to their seat and the manner of their development. M. Malgaignet makes five divisions of the polypus: 1st. The vascular. 2d. The cellulo-vascular. 3d. The polypus from hyper- trophy. 4th. The moliform. 5th. The fibrous polypus. * American Journal of Obstetrics, 1882, p. 877. i Colombat, “On Females,” p. 390. 1022 A SYSTEM OF SURGERY. Colombat appears to divide them into pedunculated and non-pedunculated, the former being the true polypus, the latter the fibroid tumor. Other phy- sicians recognize the glandular, the cellular, and the fibrous polypus. Thomas defines uterine polypus “as a tumor covered by the mucous membrane of the uterus and attached to that organ by a pedicle or stem ’’ (p. 508). It is a well-known fact that submucous fibroids become pedicellated; they would then be classified as polypi. Fibroid is as good a term for these growths as can be applied. But the best and most simple classification is that of Rokitansky, of which I have condensed the main features. With refer- ence to the frequency of their appearance, we quote a single passage from Colombat: - - “The fibrous tumors, properly so called, that are developed under the same influences as those that produce the pedicellated sort (polypi), are far more frequent than the latter. Boyle estimates that in one-fifth the number of women beyond thirty-five years of age, he met with samples of one or more fibrous tumors. Patal found a still larger proportion, since in twenty wombs he examined in 1770 there were thirteen exhibiting the fibrous ex- crescence. Lastly, according to Dupuytren, there are but few specimens of the womb in aged women that are unaffected with tumors.” These statistics are somewhat modified by Dr. Orrum, who, in 1002 post- mortem examinations for six years, found but 53 individuals who showed the appearances of fibroids. Under 20 none were discovered; after 40 they occurred in 12 per cent. of the bodies examined.* A fibro-myoma of the uterus may attain considerable size before any special symptoms are noted. I had under treatment a lady, who for two years had projecting from the os uteri a fibroid tumor of the second variety, which gave little inconvenience excepting by the occasional discharge, which was mucous and bloody in character. In general, the patient experiences a sense of weight and fulness about the uterus, often accompanied with frequent desire to urinate, which disagreeable sensations are aggravated at the menstrual period. In many cases a reflex nervous action upon the stomach causes constant nausea. The discharges are not always bloody, although the hamorrhage may be so exhausting as to endanger life. Were it not for the bleeding and constant anaemia and exhaustion following every menstrual period, a patient might pass through life with but little disturb- ance, for it is an acknowledged fact that the organs of the human body, and the uterus in particular, tolerate these growths with remarkable facility; indeed, they may last for years, and the only unpleasant symptoms be those of pressure. On the other hand, as already stated, the distressing and alarm- ing hamorrhages often bring the patient to the verge of the grave. When the growth is subperitoneal, it can generally be recognized by the eye and by palpation ; when submucoid, the uterine sound gives evidence of the neoplasm ; and when the interstitial growths are present, the fre- quent and prolonged hamorrhages, if they are not pathognomonic, are sufficient to place the surgeon on his guard. It must be remembered, in making a diagnosis, that large fibro-cysts (second variety) iſ may exist with- out haemorrhage, and that women of full habit, of complaining and hys- terical temperaments, while passing through the climacteric, suffer from profuse bleeding, at irregular (often very short), intervals. The abdomen, in such persons, often enlarges, and the abdominal muscles, from hysteri- cal contractions, become irregularly rigid. I have known a myo-fibroma coexist with a distinct carcinoma. I repeat, that the presence of profuse and protracted haemorrhage de- * Howitz, Gynaecological and Obstetrical Transactions, vol. ii., 1878, No. 1. f Wide Goodell, Am. Journ. of Obstet, vol. xiii., p. 146. TJTERINE TUMCRS. 1023 mands immediate and thorough examination with the sound, and by pal- pation, both single and bimanual, and that such examinations should be often instituted. $ It may be difficult to diagnose between fibro-myoma and distension of the Fallopian tubes. I, therefore, give the following differential diagnosis between these two diseases, taken from Dr. P. Horrocks' article in the British Medical Journal:” - “1. Fibro-myomata are usually accompanied by menorrhagia, and disten- sions of the tube are not. 2. Fibro-myomata, especially when intramural, cause uterine enlargement; while in distension of the Fallopian tube the uterus is not enlarged, or only slightly, unless complicated by some other condition. 3. Fibro-myomata are usually painless, except that there is often dysmenorrhoea, and, if large, a bearing-down pain, or sense of weight: while in distension of the tube the pain is constant throughout the inter- menstrual period, aching in character, and aggravated by the menstrual period. 4. Nutrition is not much affected in fibro-myomata, while it is in distension of the tube, especially when the distension is caused by pus; hence, wasting or loss of flesh is a valuable distinction. 5. The temperature is normal in fibro-myomata, raised more or less according to nature and amount in distensions of the tube. 6. Fibro-myomata, when intramural, move much more rigidly with the uterus than distensions of the Fallopian tube. 7. Fibro-myomata are much less painful, on pressure, than distensions of the tube. 8. Fibro-myomata are usually much firmer in consistence than distensions of the tube. 9. Intermenstrual discharges, usually yellow, are much commoner in distension of the Fallopian tube than in fibro- myomata. 10. The position and direction of the uterine cavity is much more affected by fibro-myomata than by distensions of the tube. 11. Fibro- myomata are usually more or less spherical, distensions of the Fallopian tube cylindrical. 12. Aspiration yields serum or pus in hydrosalpinx or pyosalpinx, and blood in fibro-myomata and haematosalpinx. 13. Disten- sions of the Fallopian tube are accompanied by pelvic inflammation much more frequently than fibro-myomata.” Treatment.—The question arises, Can such tumors be removed by the administration of internal medicine? From my experience I would say that in the earlier stages of the disease, when the outgrowths are small, it may be possible to remove them by the exhibition of drugs. In the ma- i. of cases, it is an absolute waste of time to attempt to remove the arger growths by any other means than operative procedure. The muriate of ammonia is highly spoken of in the treatment of the fibro- cystic form of tumor. Dr. Minori records a case, in which the muriate was given in from three to six-grain doses, three times a day, dissolved in a large quantity of water. The patient was kept under the treatment ten months, “at the end of that time the tumor was decreased to such small dimensions that it could only be detected with difficulty. . . . She is now apparently restored to perfect health.” Dr. John H. Thompson furnishes me the following: Mrs. G. W. M., age 42; married; has had four children; the youngest, seven years ago. May 19th. Has been treated for a tumor by several physicians, without deriving any benefit. On examination, a subperitoneal fibroid discovered in the left hypogastric region, about the size of a small orange. B. Ammon. mur., gr. v ter die in aqua q. S. f. haustus. July 22d. Patient returned, complaining of tenderness of left ovary; ex- * Medical Record, July 3d, 1886. f The Medical Union. 1024 A SYSTEM OF SURGERY. amination failed to detect any trace of a tumor. Several examinations, made to October, show no reappearance. Dr. Kiddº states that, though sabina, ferrum mur., and secale may be homoeopathic to the symptoms produced by these tumors, “yet that their use is only palliative, and in no way curative to the disease.” He relates four cases, one of which is reported as successful, the others not at all so. Dr. Sampson't reports in like manner. That the proper administration of medicine will alleviate the symptoms produced by such abnormal forma- tions there can be no doubt. For the expulsion, or to cause the resorption of the submucous tumors, calc. c., kali hydriod., merc. corr. Sub., and silic. may be tried ; but if after their employment for a number of weeks no diminution in the size of the growth is discovered, the sooner it is removed by mechanical means the better. For the haemorrhages which supervene I have been better satisfied with the action of secale and ferrum in low potencies than with any other remedies; ham., virg., cinnamon, crocus, and Sabina have been employed; but the two first mentioned are generally efficacious. The topical application of the preparations of iron, particularly the perchloride and persulphate, are serviceable. It is well known that the third variety of fibroid tumors, according to Rokitansky, viz., the fibrous polypus, is frequently spontaneously expelled. Quite a number of cases are upon record, but those in which the growth returned are not so numer- ous. While we are disposed to believe in the action of medicines admin- istered to arrest haemorrhage, alleviate concomitant symptoms, and to assist in the expulsion of the foreign body, we must remember that patients have been relieved by nature, and recovered without the use of any medication. Dr. Meigs relates a case of this kind in his edition of Colombat, and most Surgeons are familiar with them. Removal Through the Wagina.-The best instrument for the eradication of polypi is the écraseur; care must be taken to place the chain as high up as possible, and, to prevent undue hamorrhage, to turn the screw very 1 G.IIEMANN & Co., slowly, frequently allowing it to remain at rest for a moment or two during the course of the operation. There have been invented a great variety of canula, knot-tyers, polypi forceps, etc., for the strangulation of the base or pedicle of uterine tumors; the écraseur does away with all these. There is often considerable difficulty in passing the wire around the pedicle of the tumor; in such, a canula, or the instrument of Van Buren (Fig. 666), should be used: r represents a growth to be removed, t t are two hollow tubes through which the wire is slipped; and thus, holding one in each hand, and with the use of the hook, u, the wire is readily manipu- * British Journal of Homoeopathy; Fibroid Tumors of the Uterus, No. lxxix., p. 52. + United States Journal of Homoeopathy, No. vi., p. 255. | Pathological Anatomy, vol. ii., p. 211. UTERINE TUMCRS. 1025 lated. The two cylinders are then passed into the écraseur. The screw is tightened, and the instrument gradually screwed up. FIG. 667. Braxton Hicks's Wire Écraseur. Fig.667 represents Hicks's wire rope écraseur, with three wire leaders, and Fig. 668 exhibits the instrument of Emmet. Many authors have recommended the gradual strangulation of the poly- pus by tightening the ligature each day; but if the ligature is used, we FIG. 668. •r 3-A/Mytynºa Z *** * Emmet's Écraseur. agree with Mr. Brown” that it is better to draw the thread or the wire closely around the pedicle, and divide it with a sharp curved bistoury. Enucleation.—If the tumor is of the submucous variety, enucleation should be performed, as directed by Dr. Thomas:f “The cervix should be fully dilated with tents or freely incised in two or three places, as practiced by Dupuytren, Amussat, and Baker Brown. After checking hamorrhage, if any be created by incision (should this have been resorted to), the vagina being dilated by Sims's speculum, and the tumor held firmly by toothed forceps, an incision is made over its surface and through its capsule. This may be either straight or crucial. Thomas's scoop may then be introduced and the mass gouged away. In some instances profuse haemorrhage follows, but in others, and I think in the majority, though there is considerable bleeding, it is readily checked by hot water and styptics. If the mass be removed, all clots should be washed out of the uterus by a stream of water, and the patient quieted by a full dose of opium. “Sometimes a middle course may be followed with advantage: the os being dilated or incised, a long crucial incision is made over the presenting part of the tumor, and the lips of the capsule separated by the finger, in the hope that the body of the tumor may present through this species of Os and be expelled by uterine effort.” I have had a fair share of these cases, both pedunculated and sessile, and as yet have not found any covered with a capsule. Dr. Emmet says: “It is my conviction that fibroids become pedunculated only when influenced by the force of gravitation, which causes uterine contraction. I do not * On Some Diseases of Women Admitting Surgical Treatment. # A Practical Treatise on Diseases of Women, page 498, 65 1026 A SYSTEM OF SURGERY. believe they have a capsule proper, the only capsule being the mucous mem- brane of the uterus, covering their projection; the only line of demarcation between them and the uterine wall, being the difference in the density of the respective tissues.” The author states, that by traction alone these tumors may be brought without the cavity of the womb, and that he discovered the fact fourteen years ago. He remarks, that when the tumor is larger than a pigeon's egg, the best method is to control haemorrhage, and assist the uterus in forcing the tumor into the cavity, and remove the same by traction. After the thorough removal of the débris, the application of Churchill's tincture of iodine is said to act beneficially. There is no mention of any internal treatment, and I must acknowledge that, excepting for arrest of haemor- rhage, medicines are of no avail, and surgical treatment is the only reliable cure. Large doses of ergot have a tendency to force the intra-uterine tumors into the vagina, and Dr. O. Stroinski, of Chicago,” in speaking of the treatment of intra-mural uterine tumors, states that continued intra- uterine injections of dilute subsulphate or sesquichloride of iron, will cause the growth to be forced into the uterine cavity, from which it may be more readily extracted. - Hypodermic Injection of Ergot.—The cases suitable for these injections are intra-mural tumors accompanied with profuse hamorrhages. The fibroid polypus is not at all affected by this treatment so far as my experience leads, excepting as it may be expelled from the cavity of the uterus into the vagina by its use. It has been advocated strongly by Hildebrant, who uses the following: Aqueous extract of ergot, forty-six grains; glycerin and dis- tilled water, each two drachms.f. The preparation which I have made is the following: ſº B. Extracti ergotae aquosae (Squibb), . . . . . . . grs. 200 Aquae, . * e tº e g tº & e tº Trl 250 Stir, filter, and add Aquam, . e tº tº e * e tº & e . ad Trl 300 In this each minim represents six grains of powdered ergot. I also em- ploy Squibb's solid extract, so reduced that each minim represents four grains of the powdered substance. The action of ergot appears to depend upon the contractility of the mus- cular tissue, and therefore those tumors partaking of the nature of myomata, are especially adapted for the use of the secale. If the muscular fibrillae have not undergone fatty degeneration, or been broken up by the appear- ance of other growths, we may have a reasonable hope of success. I cannot agree with Schroeder that the injections are painful; in my cases, excepting in one or two instances, the pain passed away soon after the injection. Sometimes suppuration, which often follows the use of the hypodermic syringe, has been set up, but no bad results have followed. On one or two occasions, when I have injected through the abdominal parietes, some symptoms of peritonitis have developed, which were speedily arrested by aconite or belladonna. In several cases a chill has followed the injec- tion, and in one alarming symptoms of collapse followed. Latterly, I have inserted the needle into the side of the buttock, a process, I think, also recommended by Hildebrant. I can count about one-third cured; in all alleviation of bad symptoms, and in the majority a diminution of the tumor. I have had cases under * Medical Record, July 19th, 1886. f Ziemssen, Diseases of Female Sexual Organs, p. 250. DTERINE TUMC).R.S. 1027 treatment for years, taking an injection every week, or once in ten days, according to circumstances, and always ceasing during the menstrual pe- riod. & The secale was administered both by the mouth and hypodermic syringe, the latter being sometimes inserted into the cervic, or indeed into the tumor itself. The substance used was Squibb's solid extract, reduced with water, So that each minim of the solution contained about four grains of ergot in powder. Internally, a gelatin-coated pill of five grains was administered twice or three times during twenty-four hours. . In these cases we have not only the wonderful emmenagogue properties of the spurred rye fully developed, but also its haemostatic powers brought into play. The question may be mooted, as to whether this method of treatment would not assist “the traction method,” as recommended by Dr. Emmet, and whether the physiological action of the drug itself would not allay many of the disagreeable and alarming symptoms of pain, haemor- rhage, and contractions, during the progress of the manipulations. Dr. J. H. Thompson has been successful in many cases of uterine fibroids. Dr. William H. Byford,” in a résumé of 101 cases of fibrous tumors treated by ergot and reported by various observers, reports twenty-two cured, thirty-nine diminished in size with removal of disagreeable symp- toms and haemorrhage, nineteen benefited without diminution in size, and twenty-one unaffected. In twenty-one of these cases the treatment was Suspended. He presents the following general conclusions: 1. Ergot may cause the tumor to be gradually disintegrated and absorbed without any disagreeable symptoms. 2. Ergot may so interrupt nutrition as to produce rapid destruction, with consequent decomposition within the capsule, and later expulsion of the semi-putrid mass, accompanied by inflammation of the uterus and toxaemia more or less grave. 3. It may cause the tumor inclosed in its capsule to be totally or par- tially expelled from the cavity of the uterus, with more or less inversion of the organ. He calls attention to the fact that ergot may have a cumulative action, and recites how in one case, after two months’ persistent use of the drug without any observed effect, “terrific uterine contractions” set in with “explosive suddenness.” Dr. Byford concludes that “ergot, in the treatment of fibrous tumors of the uterus, is a prompt and powerful agent, not to be recklessly used with- Out great danger;” and that “the circumstances under which its adminis- tration will be safe and effective” have not yet been determined. M. Delore made injections into the tissues of the uterus itself. He em- ployed one part of ergotin to two of distilled water, using a speculum and piercing the cervix uteri. In these patients he observed phenomena of different kinds: chills, trembling, bilious vomiting, fainting, troubles of vision, diarrhoea, pain in the kidneys, thighs, legs, abdomen, or head. In two cases he has seen abscesses produced. The cases had all been relieved; the haemorrhages had been arrested; in fine, the results had been encouraging. M. Duplay has employed the method several times, and, while he has not obtained curative effects, has obtained satisfactory results as to the relief given. He has never seen any accidents. M. Terrier has made a number of injections into the skin of the ab- domen without accident; frequently they were made by the husbands of * Month. Abs. Med. Science, May, 1876; American Medical Association, 1875. 1028 A SYSTEM OF SURGERY. the patients; in these cases the injections had been made not into the sub- cutaneous cellular tissue, but in the skin itself, and were followed by small foci of sloughing. The treatment had given good results in haemorrhages, but in one case there was violent contraction of the uterus, and the metror- rhagia was augmented. Probably the most satisfactory method of treating fibro-myomata is the removal of the ovaries and tubes. The method of operating will be detailed in the section on oëphorectomy. The Removal of the Tumor by Laparotomy.—In this operation, which can be accomplished with good results, two methods may be employed: the one being the removal of the pedunculated tumor per se, the other the re- moval of the tumor with portions of the uterus attached. The abdominal cavity is to be opened as usual (see Ovariotomy, Sutur- ing Intestines, Hysterectomy, etc.), and, if possible, the tumor should be raised and pushed through the incision; if the neoplasm is larger, a long cut is required, particularly if the tumor is solid. If the size of the growth can be diminished, either by puncturing the cysts or cutting away parts of the tumor, it may be done, but it is better to get it in its entirety through the abdominal wall. Even after this is accomplished it is sometimes neces- Sary to gouge out portions of the growth to get access to the pedicle. If portions of the womb are taken away, and the patient not have passed her climateric, the ovaries and tubes ought to be removed also, else fatal hamorrhage might occur, and cases of abdominal conception have been recorded, from neglect of this precaution. The treatment of the stump should be extra-peritoneal in all cases. The method of performing this important portion of the operation will be de- Scribed when treating of supra-vaginal hysterectomy. Hysterectomy—The removal of the uterus and its appendages is an oper- ation of magnitude and danger, but is justifiable in certain cases of myo- fibromata of the womb, but whether it can be considered useful in malignant disease of the organ, is a question which has not yet been decided. The certainty of recurrence of cancer and the severity of the operation, render its performance doubtful. Many surgeons, therefore, wholly con- demn hysterectomy for malignant disease. My opinion is, from the great mortality that attends it, the operation ought not to be undertaken. Dr. A. Reeves Jackson,” in an admirable paper on this subject, declares that “extirpation of the cancerous uterus does not lessen suffering, and it shortens the aggregate of life,” and that “other methods of treatment less dangerous than extirpation of the uterus are equally or even more useful.” He bases his opinion on the fact that diagnoses of carcinoma cannot be made out early enough to insure a non-return after extirpation ; and that even if the operation be performed there is no reasonable hope of a radical cure, and the operator neither ameliorates suffering “except in those whom it kills.” Dr. Paul F. Mundéï takes different ground, showing that the results are more favorable than ordinary operations for the removal of the cancerous cervix. He says, “that 39.2 per cent. of the cases in which the operation was performed at a sufficiently early period to permit the incisions to be carried through still healthy parametrium, remained free from recurrence two years after the operation,” and, “compared with the results reported by Paeolik, of 25 per cent. after the removal of the cancerous cervix only, and of Schroeder of 21.8 per cent. after different methods of operation,” the average can scarcely be considered unfavorable. These arguments, it must be said, were chiefly concerning the vaginal extirpation of the womb. * Gynaecological Transactions, 1883, p. 173. f Gynaecological Transactions, vol. ix., 1884. PIYSTERECTOMY. 1029 Hysterectomy is performed in two ways, one being known as the “vaginal extirpation,” the other as laparo-hysterectomy. Laparo-Hysterectomy.—The patient should be thoroughly etherized, placed upon the table, and a large pillow laid under the nates, to allow the intes- tines to gravitate toward the diaphragm. The incision is commenced just below the umbilicus, and extends downward upon the pubic bones. The peritoneum should be opened, and as the omentum and intestines pro- trude, they should not be drawn out, as first recommended by Freund (who now has a netting to inclose them), but held within the cavity with soft flannels, wrung out of hot water. The fundus of the uterus now comes in view just about on a level with the pubic symphysis. Hanks's hooks can be used to draw up the organ, which should be steadied and elevated by an assistant, with his fingers in the rectum. The right broad ligament may then be drawn forward, and the upper two-thirds of it ligated in two sec- tions, and divided close to the uterus. The left ligament is to be treated in like manner. Haemorrhage on both sides may occur which requires ligatures. After bleeding has ceased the finger is placed in the vagina and carried over the anterior lip of the cervix, kept as a guide, firmly pressed upon the cervico-vaginal junction. A sharp-pointed knife is then passed through the mucous membrane. Into this opening, and keeping close to the cervix, a Stohlmann's hysterotome is passed, the blades opened and withdrawn, thus making a clean cut in front of the cervix. A similar method is adopted posteriorly, the hysterotome being entered at the centre of Douglas's pouch ; thus, the anterior and posterior junctions of the vagina are cleanly divided, leaving the lateral connections containing the uterine arteries intact. These incisions are made as close to the body of the uterus as possible, to avoid inclosing the ureters when the ligatures are applied. Simple as this procedure is to write, it is by no means so facile in its accomplishment generally, on account of the enlarged cervix, which projects into the vagina, as a champagne cork does into the neck of the bottle, tightly constricted at the mouth, but expanding in the neck. In attempting to puncture the cul-de-sac posteriorly, care should be taken not to pass the instrument through instead of behind the cancerous mass. Passing the finger of the left hand into the anterior opening in front of the cervix, the right hand should be introduced through the abdominal wound, and the bladder separated from the uterus. This is accomplished Hº with the fingers and partly with a blunt-pointed scissors curved on the flat. This is said to be easy of accomplishment. I do not find it so. The rectum should be separated in like manner, the uterus being drawn forward by an assistant. A ligature must be carried on the right side through the openings made anteriorly and posteriorly, and, drawing the bladder away, tied tightly; this lower segment of the broad ligament must be cut through. The mass is now so movable that it can be drawn far out of the pelvis, and a ligature applied to the lower segment of the left broad ligament, which is cut through and the uterus removed with a few applications of the scissors. All the ligatures should be left with long ends, drawn through the vaginal opening, which is left open for drainage. In considering the different methods adopted in securing the uterine arteries, I give preference to the one already described, for unless the needle, after it has been passed in front of the broad ligament and threaded, is brought down and re-introduced at its point of entrance (a difficult manoeuvre), the result will not be attained. Freund has modified his method of late on account of this difficulty. The abdomen is to be carefully cleansed, and the wound closed with silver sutures, including the peritoneum. I give below the method used by Freund in ligating the broad ligament, 1030 . A SYSTEM OF SURGERY. illustrating the same vertical section through base of right broad ligament to show the position of the ligatures in Freund's extirpation of the uterus. The posterior aspect of the broad ligament is to the right. A, Fallopian tube; B, ovarian ligament; C, round ligament. A Peaslee's needle, threaded with a loop of silk, is carried behind the ovarian ligament, B, and the loop held in place while the needle is brought back. One end of this thread, b, is passed through the margin of broad ligament, c.; the lower loop, d, is IFIG. 669, passed behind the round ligament, C, and cut off at e. The loop, a, is cut, and the ends being drawn tightly, the ovarian artery is entirely occluded. The loop, d, when tied, controls the pampiniform plexus. The ligature, e, f, g, is passed from the vagina and made to pass the lateral fornix at 6, and to emerge behind it, leaving e the free end. The needle is slid along and the thread passed through the lateral fornix, K, on the opposite side. The end, g, is then passed through the round ligament. The two ends of this thread being tied, the uterine artery is occluded. Waginal Extirpation of the Uterus. The uterus must be drawn carefully down to the vulva and the cervix separated from the bladder partly with the knife and scissors together with the aid of the fingers, The entire cervix must be liberated all around, and Douglas's pouch cut into. Two fingers of the left hand are carefully introduced into the cut, passed over the fundus into the space between the bladder and the uterus (vesico-uterine pouch). The fingers being held in this position, they are felt for with the fingers of the right hand within the cut already made in the front of the cervix. The surgeon now withdraws the right hand, and, with the scissors or knife, cuts carefully upon the fingers of the left until the peritoneum is thoroughly divided. These incisions free the uterus both in front and behind. The womb must then be retroflexed and forced through the cut in the posterior fornix. If this can be executed with the hand it is better so to do, if not, a forceps may be used. A Peaslee's needle, armed with very stout, waxed, antiseptic silk, is passed through the centre of the broad ligament, cut, and the ligature tied above and below. It is often advisable to use Thomas's large clamp temporarily while applying these ligatures, and to remove it afterwards before tying them. This is done to both ligaments, and as a matter of security a bit of india rubber ligature may be clasped around the stumps. The uterus can SUPRA-VAGINAL HYSTERECTOMY. 1031 then be readily removed. The stumps must be brought into the roof of the vagina and both pedicles secured by a strong ligature passing first through the cut surface of the posterior formix, then through the pedicles and, finally, through the anterior fornix. It will be seen that when the ends of such a suture are brought together, the wound in the roof of the vagina is also closed, a drainage tube should be passed between the stumps into the peritoneal cavity, the vagina packed (around the drainage tube) with antiseptic cotton, which must be removed as soon as any odor is man- ifested, and the parts washed with a solution of the bichloride of mercury 1 to 3000. It is said that by this method the mortality is 27 per cent. Supra-vaginal Hysterectomy.—This operation is resorted to for the re- moval of fibroid tumors, especially the intramural, and in my hands has been so successful that I can recommend it, even in cases in which the patients are exhausted from profuse haemorrhage, and are suffering from FIG. 670. WºWWENNPANN & W.W. Wilcox's Pins. aggravated pressure symptoms. The surface of the abdomen is washed with a bichloride solution 1 to 2000, and an etherial solution of iodoform is poured over the belly below the umbilicus. The incision is made in accordance with the size of the tumor. It is better to begin the cut just below the umbilicus and extend it to the pubis; if necessary, it may be enlarged toward the sternum. The peritoneum is divided, and the tumor exposed. If there are many adhesions, they are tied with catgut and FIG. 671. Tait's Clamp. divided. The hand is insinuated into the cavity behind the tumor and the mass lifted forward. If the tumor be large the ovaries and tubes are drawn upward close to its sides and the broad ligaments may all be in- cluded in the clamp. Two large steel pins, devised by Dr. Wilcox, are then thrust diagonally through the pedicle and a stout elastic ligature, stretched sufficiently to reduce it to half its calibre, is twisted six or eight times around the pedicle below the pins. The ligature is secured by means of a leaden clamp, and for the sake of security a second one may be em: ployed. I have used the clamp of Lawson Tait, Fig. 671, and have had excellent success with Dr. Thomas's large instrument, Fig. 672. In some cases I have employed the clamp and the ligature combined, with 1032 A SYSTEM OF SURGERY. surprising results. The uterus is cut away; of course the stump remains outside the abdomen and is powdered with iodoform. The cavity is cleansed by means of sponges on holders, and the wound dressed after the manner described in the Chapter on Ovariotomy. If the operation is care- º performed, the dressings need not be removed for eighteen or twenty ayS. Martin's operations for the removal of the uterus are peculiar. He treats the pedicle by the intra-peritoneal method. The tumor is lifted up and the elastic ligature applied as low down as possible. Deep lateral ligatures are FIG. 672. , sº º gº a - . . Faº º: º Fasº * - * . Aſ º' * : º .º.º. Thomas's Clamp. applied to the uterine arteries. The tumor is turned out and the uterus split to within a short distance of the cervix. The two sides are cut ob- liquely in such manner as to make a funnel of the cervix, which can thus be more readily scraped. The pedicle is then dropped into the abdomen. If bleeding occurs the pelvis is packed with sponges, until the operation is completed, when the separate points are tied.* - Oophorectomy.—This method may be either called “Battey's,” when the ovaries are removed, or “Tait's,” when the procedure includes the exsection of both ovaries and tubes for disease. - In the year 1823, James Blundell, of London, suggested the operation as pointed out by Aveling, and in 1865, Dr. Battey, of Georgia, conceived the idea of producing an artificial menopause by double ovariotomy. In 1872 Hegar operated with fatal results. A month later, in the same year, Mr. Lawson Tait performed the operation, but the patient died shortly after, and there was no publication made of the case. Seventeen days after Mr. Tait's failure, Battey was successful at Rome, Georgia; two years after, he again cured two cases following closely the one on the other. Since then the operation has been frequently performed with varying success. The removal of both ovaries has been variously christened. It has been called normal ovariotomy in contra-distinction to the usual term ovariotomy, as belonging to the diseased condition of these organs; or öophorectomy, which is approved by some but rejected by others, on account of its being used as a synonym for ordinary ovariotomy by Peaslee. It has been desig- * Medical News, September 11th, 1886. ÖOPHORECTOMY. 1033 nated “spaying,” “the castration of women,” and finally, at the suggestion of the late Dr. J. Marion Sims, has received the name of Battey's operation, which I think is the appellation by which it will hereafter be known. It is well to determine what are the conditions that justify the operation; what is the best method of removing the ovaries; what are the results and what the objections to the procedure. It must be remembered that the operation is not to remove diseased ovaries, although in many cases these organs are found so to be, the object being to prevent the function of ovulation, or establish an artificial meno- pause, and by so doing to arrest and cure the many complex and painful maladies dependent on that process. At the last meeting of the International Medical Congress, Dr. Battey thus spoke: “No safer rule can be laid down to-day than is embodied in the three questions: Is this a grave disease? Is it incurable by any of the re- Sources of art short of the change of life? Is it curable by the change of life? If all of these questions can be answered affirmatively the case is a proper one, but if not, the operation is not to be thought of.” . The following disorders are enumerated as those which demand the re- moval of the ovaries*: 1. Congenital disease of the uterus, with functional activity of the ovaries resulting in fatal heart disease by reason of a men- strual molimen, unrelieved by a menstrual flux. 2. Where there is an occlusion of the entire genital tract, as a sequence of labor where restoration of the outlet has been found impossible. 3. Cases of menstromania, where all other remedies have failed. 4. Ovarian epilepsy in which the convulsive action is evidently due to a disease of the ovaries, or to some abnormal condition of ovular action. 5. Certain forms of chronic inflammation of the ovaries, attendant upon severe pains, and nerve disturbances, at the men- strual period. 6. Amenorrhoea with grave disturbances of the nervous system, unrelieved by the menstrual function or by medical treatment. 7. Hernia of the ovaries into the inguinal canal, or into the labia, disabling the woman by excessive sensitiveness to pain and suffering. 8. Large sub- mucous and interstitial fibroids, accompanied by dangerous haemorrhages. 9. Certain incurable flexions of the uterus, attended with grave consequences requiring relief. 10. Deformities of the pelvis endangering a necessity for the Caesarian section. Dr. Thomas Savage, of Birmingham, England, records thirty cases, ten of which were protracted and painful ovary-prolapses, and four of myomata; and for these two especial conditions he thinks the operation applicable. Dr. Sutherland has arranged a table of the history of over five hundred inmates of the Wakefield Lunatic Asylum, and says “that in epileptic in- sanity the fits are generally increased in number, and that the patient fre- quently becomes excited at the catamenial period; that in mania, exacer- bations of excitement usually occur at the menstrual period, and that a state of intense excitement is almost continuous in patients suffering from metrorrhagia, and also that Esquirol and Morel have estimated the derange- ments of menstruation as the source of origin of one-sixth of the cases of insanity due to physical causes. In such cases as these the operation should always be considered, indeed Dr. Goodell advocates the removal of the ovaries in all insane women.f There are two methods employed for the removal of the ovaries, one by abdominal incision, the other through the vagina. At first some distin- guished gynaecologists in this country gave preference to the latter method, but later experience has proven, that in the majority of cases incision through * Transactions of the American Gynaecological Society, Vol. x., 1881. - # The American Journal of Obstetrics, October, 1881, p. 923. 1034 A SYSTEM OF SURGERY. the abdominal walls is the better. The vaginal removal, however, is always to be considered when the ovaries are prolapsed, can readily be felt through the canal, and appear to be movable. In one case in which I resorted to this method, great difficulty was experienced in drawing down the left ovary, as it appeared to be surrounded by dense fibrinous connection with the periuterine connective tissue, as well as to the broad ligaments which were themselves hard and inelastic. The operation through the vagina is as fol- lows: The patient may be placed on the left side, or in the lithotomy posi- tion; the latter, I believe, being preferred by Dr. Goodell, the former by Drs. Emmet and Sims. At all events the perinaeum must be retracted and the cervix caught by a stout tenaculum and drawn down to the outlet. The Douglas’ cul-de-sac is then snipped with the scissors, making a sufficient opening to admit the finger which is introduced and hooked over the ovary to hold it steadily, a pair of forceps with concealed hooks is made to grasp the ovary which is drawn through the incision. The pedicle is ligated with a double silk ligature, and the organ removed with the scissors. The stump is then returned into the abdominal cavity, and a suture or two applied. In some cases the stitch is not necessary. The abdominal section, now most in vogue, will probably supersede the former. In this operation the incision is made in the median line, four or five inches in length; the hand inserted and the ovary found. This is not easy of accomplishment. In several instances I have been obliged to lift myomatous tumors without the cavity to find a compressed and shrivelled ovary pressed behind the growth. When the organ is not bound in the pelvis by adhesions, the finger and thumb can readily grasp and withdraw it into the incision. If, on the other hand, it is firmly impacted in the pelvis, the adhesions are to be separated with the finger and scissors, until it is suffi- ciently free to allow the ligature to be passed around it. It is then readily removed. With reference to the selection of the method of “spaying,” I agree with Dr. Sims, who wrote: “As a rule operate by abdominal section, because if the ovaries are bound down by adhesions, it is possible to remove them entire, whereas by the vaginal incision it is impossible. “If we are sure that there has been no pelvic inflammation, no cellulitis, no hamatocele, no adhesions of the ovaries to the neighboring parts, then the operation may be made by the vagina, but not otherwise.”* The results of this operation are thus far very encouraging, but that it is one which could be much abused, is a foregone conclusion. It has been argued by some, that it may open the door to an increased immorality, by depriving woman of the power of conception, but I can scarcely believe this will be the case, for two reasons: first, because a woman would scarcely be sufficiently a slave to her passions to undergo such a critical operation, and second, because I have confidence enough in the profession to believe that no one will resort to it, without having duly weighed all the circum- stances by which the patient is surrounded, and the character and kind of suffering to which she has been subjected. It might be supposed that the removal of the ovaries always arrested menstruation, but this is not the case. In Mr. Tait's article, published in the American Journal of the Medical Sciences, for January, 1882, and in which he gives a record of thirty-one operations, he states distinctly that the removal of the ovaries alone is not always effectual in arresting menstruation, while the exsection of the uterime appendages is found to be so. Dr. Goodell, f in his excellent treatise, gives two tables, one of twenty- * British Medical Journal, December, 1877, quoted by Emmet, p. 756. f Lessons in Gynaecology, p. 340. . LACERATED PERINAEUM. 1035 six cases, in which both ovaries were removed, with the following results bearing upon the return of the menses. In nine cases the menstrual flux continued uninterruptedly after the operation, and in the balance it was ir- regular. In some there was an amenorrhoeal period of six months, and a return of the discharge for the six following months, while in others the flow appeared at intervals of from three to seven months, and again in others, small quantities of the fluid were irregularly noticed. In his second table we find thirty-one cases in which the removal of both ovaries during menstrual life was followed by an arrest of the flux. In eighteen of these there was no menstruation whatsoever, in several there appeared a sangui- neous discharge. In a few there was a metro-staxis, which soon ceased, and in one there was a white discharge, which soon disappeared. In the discussion upon this subject, at the International Medical Con- gress, Mr. Tait gave the following analysis of seventy cases: Incomplete Total. operation. Deaths. First: Those Operated upon for Pain. Recurrent haematocele.......................................... 1 1 0 Abscess of the ovary............................................ 2 () 0 Hydro-salpinx................................................... 2 0. 0 Pyo-salpinx...................................... *e e º e s e s e e s e º e s is e e 8 0 0 Chronic ovaritis.................................................. 8 2 1 Cirrhosis of the ovaries........................................ 11 1 0 Second: Cases Operated on for Haemorrhage. Hydro-salpinx.........................* * * * * * * * * * * * * * * * * * * * * * * * * * * 1 0. 0 Chronic ovaritis.................................................. 2 0 O Small cystic ovaries............................................. 5 0 0 YOIna • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1 5 n Third. Cases Operated on for Reflex Symptoms. - Menstrual epilepsy...................................... • e º e º s s e 3 0 O Deformity......................................................... 1 0 O 70 5 6 Lacerated Perinaeum.—This accident, which is well known to all ac- coucheurs, and which often produces much misery, is occasioned either by traumatic lesion, instrumental delivery, pressure of tumors, or parturi- tion, by far the greater number of cases being caused by the latter. If the rupture is incomplete, the inconvenience may be borne; if, however, both sphincters are torn through, there is perhaps no affection which renders life more miserable. Displacements of the uterus and vagina, incontinence of flatus and faeces, prolapsus of the rectum, and inflammation of the uterus itself are often engendered by this troublesome accident. The patient is unable to perform her usual duties, cannot go out for fear, and becomes disgusting to herself and to all around her. The operations which have been devised for the relief of this accident are sometimes successful and sometimes the reverse; the great difficulty being in bringing into apposition the torn muscular fibre. On this subject Dr. Emmet (than whom there is no better authority) says:* “In a large number of cases not a fibre of the * Medical Record, March 15th, 1873, p. 121. 1036 A SYSTEM OF SURGERY. muscle is united, although the perinaeum may have been restored and the laceration through the recto-vaginal septum closed by the operation. To unravel the cause of failure, and to devise means of obviating it, has occu- pied my attention for years. To appreciate so simple an explanation has cost me more thought than any other point in the whole field of the branch of surgery to which I have devoted myself.” Time of Operating.—A good deal has been said and written about the proper period of operating. The majority of surgeons are of opinion that the operation should be immediate. In those cases in which I have per- formed it at that time, the results have been favorable. If, however, this is not done, the interference must be deferred until the parts have cicatrized, and the patient regains her ordinary strength, that is, if she is not nursing. If she nourishes her own child, operative measures must be deferred until FIG. 673. Comstock's Modification of Fritsch's Leg Brace. the offspring can be safely weaned. The welfare of the child would appear to demand such procrastination. The employment of the leg braces of Fritsch as improved by Dr. T. G. Comstock, of St. Louis, much facilitates the performance of the operation. Fig. 673 represents the apparatus. Peters has also an excellent leg brace, Fig. 674, which I have used with satisfaction. The operation of Baker Brown, which is often quoted, and in the per- formance of which he and others, as well as myself, have been successful, is not as delicate as others to be mentioned. There is too much cutting about it. In this method the patient is placed on the table and fully etherized; the fissure is rendered tense by an assistant, and with a bistoury the surgeon removes all the cicatricial tissue on either side; after this the Sphincter ani (external) is divided. The directions are to cut the muscle on both sides about a quarter of an inch in front of its attachments to the coccyx, by two incisions carried outward and backward. These are made LACERATED PERINAEUM. 1037 by a blunt-pointed instrument, which is introduced into the rectum (guided by the forefinger of the left hand), and carried an inch within the gut; by drawing out the knife a cut an inch or thereabouts is made, extending outward from the anus, between the coccyx and the tuberosity of the ischium. º When the cutting has been accomplished, which, however, many operators consider unnecessary, the sutures are introduced as follows: With the fore- finger and thumb of the left hand, the left edge of the fissure is taken up, a needle threaded with a double cord is inserted one inch from the refreshed margin, and its point being directed downward and inward is made to emerge at the bottom of the pared margin of the fissure. It is then inserted at a point opposite on the denuded surface and brought out an inch there- from through the integument. This suture is passed at the upper end of the fissure. A second suture is made as before, going as deep as the sep- tum, and a third is entered at a low angle of the cleft. The ordinary method of making the quilled suture is then practiced, pieces of bougie answer- ing the purpose, and the cleft is thus approximated. Several silver-wire sutures are passed into the integument, and the operation is completed. The bowels are to be constipated with opium, a grain being given night and morning for a day or two, and after that a grain once in twenty-four hours. The patient should be put to bed, and a light and unstimulating diet or- dered, the urine carefully drawn with the catheter twice a day, and the knees tied together. The deep sutures are removed from the third to the sixth day, and on the eighth or tenth the superficial ones may be taken out. The operations which I formerly performed with considerable success, are now known as the old operation of Dr. Emmet. I use for such curved scissors, with fine points, and clawed forceps for raising the mucous surface. It is only necessary to denude the fissure of its mucous covering. Having placed the patient in position, and having the fissure put on the stretch on both sides, the cicatricial lines can generally be discovered marking out the triangles. Just on the outside of these, and going only through the mucous 1038 A SYSTEM OF SURGERY. surface, I mark off the triangles. Taking up one of the angles (the upper and outer), with a pair of delicate forceps, with the curved scissors I snip away the membrane. In many instances I succeeded in removing the part entire. This generally happens on the left edge of the fissure; were I ambidextrous I am quite certain that both could be easily removed entire. Taking then a round needle threaded with a long piece of silk, and having the forefinger of my left hand well in the rectum, with the ball of the finger I press up the septum, and pass the needle about an eighth of an inch above and a quarter of an inch to one side of the anus and carry it through all the tissues up to the septum (which it may have been necessary also to refresh); I then turn it and bring it down on the other side of the fissure and out at a point equidistant from the anus at which it was entered. The next suture is passed about the eighth of an inch above, its terminus being the septum ; it is brought out like the first; the third and a fourth if neces- sary are introduced in like manner. It will be seen, that, when the ends of these sutures are twisted, the raw surfaces come in contact entire, not FIG. 675. A ( c D ) ) ( being pierced with the sutures, the sides of the wire (as it were) holding together the cleft. The patient's bowels are to be confined with opium, as above; the catheter used twice a day, and the same after-treatment as before adopted. The following is Dr. Emmet's description of the rationale of his opera- tion. The paper was read before the State Medical Society, on February 4th, 1873. gº *The success of the operation is due to the point at which the first suture FIG. 676. FIG. 677. is introduced in relation to the edges of the divided muscle. If the first suture be entered on the line and a little outside of A B, Fig. 675, at the point which would seem most appropriate, but a small portion of the mus- cle could be approximated, as shown in Fig. 676, and incontinence to some extent must be the consequence. LACERATED PERINAEUM. 1039 “Introduce the suture, however, at some distance behind the muscle, toward the coccyx, at the points CD, Fig. 675, and we see at a glance, by Fig. 677, that on securing the suture the divided edges of the sphincter must be turned up and brought in perfect apposition.” Since the above was written, Dr. Emmet has modified his procedure. I have, therefore, omitted the minute details of the former method and sub- stituted his last operation.* Perineorraphy–Emmet's Method.—The new method of Emmet is as fol- lows, and is probably the best. It must, however, be somewhat modified by the condition of the laceration, the extent of the rectocele and other points which vary considerably in certain cases, especially with reference to the extent of paring the sulci. I have made some drawings which I think will explain the method of performing this operation. he patient is placed in the lithotomy position, the leg brace (gynapod) if at hand is applied. The parts are shaven and thoroughly cleansed with soap and warm water. The operator should have on a shallow tray at his side Emmet's scissors, right and left (but with handles not too long, and made to work easily on Fig. 678. _ºf__ - their Fº at least four uterine tenacula; two small-sized and narrow- bladed scalpels; half a dozen artery compressors; a pair of long, slender catch forceps; half a dozen needles, round, slightly curved at the point, strong in the shaft, threaded with silk and silver wire or whale tendon (the former being º: several sponges set in sponge-holders; sponges, etc. . Seating himself at the foot of the table and introducing the forefinger of his left hand, bulb uppermost, into the rectum, he presses up the crest of the rectocele, a, Fig. 678, and with a tenaculum in his right hand enters * Transactions of the American Gynaecological Society, vol. viii., p. 206, 1884. 1040 A SYSTEM OF SURGERY. its point at a ; this is given to an assistant, who slightly puts the parts on the stretch. A second tenaculum is then entered at the lowest caruncle, Fig. 678, b, and a third at the posterior commissure of the vagina, Fig. 678, c. The finger in the rectum is now to be removed, and point a is to be drawn upward, point b outwards, point c downward, thus putting the entire tri- angle upon the stretch. With a pair of scissors, as preferred by most opera- tors, or with a small scalpel, which I always use, I mark out the triangle to be denuded, drawing first the line from a to c, then from a to b, and finally from b around the laceration to c. This cut is only down to the subjacent tissues, and, if the mucous membrane is entirely cut through, the gaps made by the retraction mark distinctly the triangle of mucous membrane to be removed. Taking up the angle at b, a strip of mucous surface is removed from around b to a, and so on the whole surface may be denuded. If the knife be used, after a little experience the mucous triangle may be taken off entire. - The parts are then irrigated with a weak, hot antiseptic solution, and all bleeding arrested. The tenacula may then be removed, and the denuded surface will present somewhat the appearances presented in Fig 679. The needle, threaded and held in a stout needle-holder, is introduced high up in the vagina just below point a, Fig. 679, and so the stitches are severally passed, as seen in the cut. A similar proceeding is adopted on the other side, and the sutures are all twisted. TÉ. will bring the points of the cres- cent in apposition, and consequently lift up the sides af the perinaeum. Sometimes, while these sutures are being tightened, I take a pair of haemo- static forceps and, catching the point b (formerly the crest of the rectocele), let the instrument hang; by its weight it draws downward the ununited part of the flap. The method of bringing together the apex of the flap is seen in Fig. º The needle is entered at the side of the labium b, carried through the crest of the rectocele, turned and brought out at bº. The su- LACERATED PERINAEUM. 1041 perficial wires are then placed as seen in ee', ff", and g g’, and twisted not too tightly together. FIG. 680. The late Prof. John T. Hodgen, of St. Louis, devised an excellent opera- tion for the closure of complete lacerations, which has given me satisfaction when other methods have failed. He says: “An incision is carried through the centre of the lower border of the Fig. 681. CC, transverse line through the centre of the septum. BB, first incision. B D and BD, lateral incisions carried from B B forward to D, the muco-cutaneous junction. imperfect septum, between the rectum and vagina, splitting it in the middle. The two ends of this incision are about one and a half inches from the median line, and about half an inch anterior to a transverse line drawn 66 1042 A SYSTEM OF SURGERY. through the centre of the septum. This incision is about one-third of an inch deep at its central point, with its lateral portions passing into the sub- cutaneous areolar tissue. Other incisions of equal depth and about an inch and a half long are carried from the ends of the first incision forward and toward the median line, until they reach the muco-cutaneous junction of the labia majora. (Fig. 681.) “These thick, triangular flaps being dissected from their posterior lateral angle, but left attached along the inner or muco-cutaneous border, are now drawn forward over the vulva by their free angles, with the cutaneous sur- faces toward the vagina and the cut surface externally. The borders which correspond to the line of the posterior or first incision are thus approxi- mated and held by interrupted sutures, beginning at the anus, made by passing a fine needle armed with silk through, first from the cutaneous to the cut surface, and then the other flap from cut to cutaneous surface, so that when tied the knot shall be on the cutaneous side of the flaps. This º should be repeated every quarter of an inch until the free angles are reached. “The usual deep sutures of silver wire are now placed, entering for the first one at a point on the buttock about an inch beyond the cut surface, and nearly opposite the outer posterior angle, and, traversing deeply the septum between the rectum and vagina, it emerges at a point (on the oppo- site buttock) corresponding to that of entrance. “The second suture is placed about half an inch anterior to the first, and enters about an inch from the margin of the cut surface, and, traversing the tissues, emerges from the cut surface near the attached line of the flap, and Fig. 582. E is at the free margins of the skin º: EA is a line of junction, by interrupted sutures, of margins ºf flapstaken from incision BB. The dotted lines represent the portions of the wire which are buried in the tissues, and the black and white portions are external to the tissues. passing across external to the flaps re-enters at a corresponding point near the attached line of the other flap, traversing the tissues of this side to emerge through the skin an inch from margin of cut surface, and half an inch anterior to similar point in first suture. A third, and if necessary a fourth suture may be used anterior to those above described, being placed about half an inch apart. (Fig. 682.) “The thighs are now brought together, pushing the flaps of loose skin forward toward the vagina, and holding them in apposition by tightening and twisting the wire. It will be seen that the flaps, which are usually cut off, are made to serve a double purpose. They double the extent of the surfaces approximated, which increases the strength of the new perinaeum, VESICO-VAGINAL FISTUL.A. - 1043 and their cutaneous surfaces are continuous with the vagina, thus furnish- ing an apron which prevents the vaginal discharge and urine from flowing into the cut. - “In these two points consist the advantages claimed for the modified Operation. “The margins of the flaps, which correspond to the outer borders of the denuded surfaces, are without sutures, leaving thus an opening for the dis- charge of pus from any part of the denuded surfaces which may not unite by first intention, and preventing the formation of openings for the dis- charge of pus along the line of the sutures.” Vesico-Vaginal Fistula.-By the above term is understood a commu- º established between the vagina and bladder or urethra in the €1018.16. The symptoms are unmistakable. There is a constant discharge of urine through the vagina, which the patient is unable to control; the parts be- come inflamed and excoriated, the thighs being much irritated. There is that constant odor of heated urine which is familiar to all, and disgusting to the patient. In olden times these fistulae were considered incurable, but at present the majority are amenable to surgical aid. The causes are chiefly inflammation and sloughing of the parts occasioned by the pressure of the head of the foetus; sometimes the forceps have made the rent, sometimes a lithotomy wound produces it. A sensitive vagina and a large hard pessary are also favorable for the formation of vesico-vaginal fistula. It was formerly supposed that these accidents were occasioned by instru- mental delivery, but the reverse is found to be true. Dr. Sims says: “From a careful analysis and from my own experience, I am well satisfied that for one case thus produced their (the forceps') judicious application has pre- vented it fifty times.” These fistulae appear in many parts of the vagina, and are often compli- cated. In one case there was a complete closure of the upper part of the vagina, thus shutting up the os uteri; a complete extroversion of the blad- der, which protruded like a large red cherry through the vulva. This patient menstruated vicariously through the rectum. In another case, with com- plete destruction of the urethra, there was prolapse of the bladder, and also a recto-vaginal opening. - These fistulae may be confined to the urethra, the neck or the base of the FIG. 683. Emmet's Curved Scissors, bladder, with its body or the cervix uteri. Many complications often exist, which space will not allow us to mention. The student may refer to the works of Thomas, Sims, and especially to the brochure on the subject by T. Addis Emmet. Sims's and Emmet's Operation.—The patient having been placed in what is known as Sims's position, a Sims's speculum is introduced, the perinaeum drawn back and the fistula brought into view; the edge is raised with a fine tenaculum with a long handle, and the parts either pared away with 1044 A SYSTEM OF SURGERY, scissors bent at right angles, or those of Dr. Emmet, which are made rights and lefts (Fig. 683), or with one of Sims's straight knives (Fig. 684), or, if the parts require, a knife with a right-angled blade, as seen in Fig. 685. FIG. 684. * -ºº::=- Ge. Ulf MAMA = G e : Sims's Straight Knife. During this portion of the operation, the sponge, held in an applicator, a sponge-holder, or with long uterine forceps (Fig. 686), should be in frequent l] Se. A good deal of time is required to refresh the edges, and the operator must continue until every portion of the fistula is denuded. Simpson tº FIG. 685. Aºy. & G.7/Aſ/M/7,4//V & C G. N Sims's Curved Knife. says, “Enter the point of your knife into the vaginal mucous membrane at some distance from the fistula; then transfix with your knife the edges of the fistula to the extent you intend to remove it, and bringing it out at FIG. 686. the vesical border, carry it right and left fairly around the opening, so as if possible to bring out a complete circle of tissue.” - The needles threaded with silk, to which annealed silver wire may be attached, must be fixed in the forceps. The needles used are short, and are held with Russian needle forceps, or the modification as seen on pages 35 and 248. The passage of the suture is a matter of great importance. The operator should select that part of the fistula most difficult to reach, and enter the FIG. 687. FIG. 688, Passage of Thread. Sims's Self-retaining Catheter. needle from a quarter to half an inch from the pared edge, and bring it out just anterior to the mucous membrane of the bladder. As its point emerges it is encircled with a small blunt hook, which presses the tissues around it, so that it may be caught with a seizing forceps and drawn through. The needle is then taken with the forceps, its point entered in the refreshed margin opposite that where it passed out and near the mucous vesical Sur- VESICO-WAGINAL FISTULA. 1045 face, and made to emerge about half an inch from the pared edge of the fistula on the vaginal side (Fig. 687). The tenaculum must be used durin this operation, to render the parts tense for the better passage of the needle. As the thread comes through, to prevent the tissues from tearing, the fork must be gently employed. When the silk is drawn through, the wire follows, and suture No 1 is ready for twisting, which, however, is not done until a sufficient number of sutures are passed. So soon as they are all entered and brought out, the ends of the wire of the first suture are seized by the forceps, the spoon is slipped up to the tissues and the wire twisted, as seen in Fig. 106, page 249. The sutures having been all twisted, their ends are clipped with the scissors, the bladder syringed, and Sims's self-retaining catheter (Fig. 688) inserted in the bladder. A small cup should be placed between the limbs to catch the urine, and the patient ordered a light and nutritious diet. The sutures may be allowed to remain from ten to fourteen days, and in certain cases even longer. Care is required in the removal of the sutures, as the wire has a tendency to become imbedded in the tissues. It may be accomplished by raising gently with the forceps the twisted ends of the sutures and inserting the FIG. 689, -------------- ºwneº-sº iſſº fºLE †† /*Iº ſº VF | H- |||| A- É * W. Bozeman's Chair. sharp end of a small pair of scissors beneath the loop as it is drawn up, and severing the wire. The forceps may be used with a slight rotary motion, which twists out the wire without traction on the parts. FIG. 690. & - FIG. 691. arlemann ăs Bozeman's Button. Passage of Wires. In the earlier days, Dr. Sims recommended clamps and perforated shot. These I used with good results, and am not sure whether the method of fastening by perforated shot is not accomplished with more facility than the twisting of the wires. 1046 A SYSTEM OF SURGERY. Dr. Bozeman's operation has met with high favor. Hamilton, in his work, says, the “distinctive characters of Bozeman's operation are: the button suture, the position of the patient, and the self-retaining speculum.” Dr. Bozeman first removes all obstructions from the vagina, in the shape of bands and adhesions; this is done by division and dilatation, and, to prevent contraction, bags made of oiled silk, and stuffed with Sponge, are inserted into the vagina. So soon as this is effected, the patient is placed in the knee-chest position, or in Bozeman's chair (Fig. 689), and his self-retaining speculum applied. The paring of the edges of the fistula is accomplished after the manner already described, and the next step is the insertion of the needles. Fig. 692 shows Bozeman's needle-holder, which is com- FIG. 692. posed of a flexible canula, which holds the needle at the required angle. The dotted lines show angles at which the needles may be set. The needle is entered about one-third to one-quarter of an inch “from the pared surface, passed along the tissues of the septum, and is made to emerge just below the vesical mucous mem- brane, where it is caught upon a blunt hook, seized by the forceps and drawn through. . . . . . Thus transfix- ing of the mucous membrane is avoided.” Fig. 691 shows bevelled tissues and threads in situ. The wires are adjusted by passing them through an instrument with an eye at its extremity, and the button pushed up to the cut surfaces. The button is made of lead, is one-twentieth of an inch thick and five-eighths of an inch in width, and must be cut of length and width to fit the part, and perforated in order to admit the wires. The holes should be about one-third of an inch apart. Fig. 690 shows the button. It must be moulded or arched, which is conveniently done by the plate- bending forceps of Dr. Bozeman. By this bending or arching of the button, the lips or edges of the fistula are prevented from being strained, while at the same time they are supported. The ends of each wire having been brought together, they are passed through the button, as seen in Fig. 693, which is pushed up to its É. as seen in Fig. 694; then perforated shot (No. 3 eing the best size) are placed upon the wires, as seen. in Fig. 695, and slipped up and adjusted by an instru- ment (Fig. 696); then with a pair of strong forceps, made somewhat after the fashion of bullet-moulds, the shots are compressed. The ends of the wires are cut off an eighth of an inch from the button and turned down. For complicated cases other forms of buttons are used. Dr. W. T. White” relates the spontaneous cure of vesico-vaginal fistula. The woman had been delivered by instruments six weeks previous to seeing her—urine escaping from some *...* false passage soon after the operation. A fistula near º the cervix on the left side was found. About ten days subsequent to menstruation, it was noticed that urine had ceased to escape, and it was discovered that the vesico-vaginal fistula was completely closed. —-º * Medical Record, January 25th, 1879, No. 429. ſ | º } ! i VAGINISMUS. 104.7 Waginismus.—This disease, which a few years ago was little understood and imperfectly described, has found but small space in surgical literature. Women of nervous temperament, of an emotional nature, are most likely to suffer from this affection, and it will be generally observed that with it are associated symptoms of spinal irritation. It consists of an involuntary spasmodic contraction of the ostium vaginae, attended with such hyper- sensitiveness of the vulva and outer extremity of the vagina, that the slightest contact may produce great pain, and marital intercourse be ren- dered impossible. There exists in most women the voluntary power of contracting portions of the vagina when excited during coition, and there FIG. 693. FIG. 694. FIG. 695. Application of Buttons and Clamps. can be no reason why such muscles may not suffer from spasm. Cases are upon record, where this contraction has been so powerful, that the penis has been retained within the vagina, notwithstanding the most forcible FIG. 696. G. Tiemannºco. efforts to effect its withdrawal. A case is recorded by Dr. E. G. Davis,* in which, before an amorous couple could be separated, chloroform had to be administered. In some instances, the sphincter ani is also implicated, and Severe suffering is experienced in the region of the anus. A single case will serve to present the characteristics of the affection, and the treatment necessary for its cure: A young lady who had been married about eight months, of a naturally strong constitution, was brought to me by her mother, who detailed the following symptoms: Shortly after her marriage, a peevish and fretful state of the nervous System was manifested, accompanied by loss of appetite and nausea; as these conditions were attributed to the new relations of life into which she had entered, no particular treatment was instituted for their relief. Constipation followed with such complete anorexia that medical aid was summoned, and the usual routine of cathartics and tonics administered, with no effect, save an aggravation of nearly all the symptoms. Emacia- tion and excessive nervous irritability followed, together with anaemia and great prostration, which the exhibition of cod-liver oil, wines, and other tonics, in conjunction with travelling, failed to relieve. Upon a careful ex- amination of all the symptoms arising since her marriage, I was led to sus- * Medical News, Philadelphia, December 18th, 1884. 1048 A SYSTEM OF SURGERY. pect that these manifestations were due to reflex nervous action, arising from an irritable sexual system. On further inquiry I learned that the menses had appeared regularly, and although somewhat less in quantity, still presented a natural appear- ance. An examination per vaginam was suggested, and upon attempting to introduce my finger into the vagina I found the orifice closed to such a degree, and the patient suffered such excruciating pain, that the attempt was abandoned. Thinking this remarkable sensitiveness might be due to the presence of one of those painful tubercles that sometimes are found at the orifice of the urethra, I proceeded to use the speculum; but although no such excres- cence existed, it was impossible to introduce the instrument on account of the severe pain. Her husband informed me that any attempt at sexual intercourse caused her such agony and produced such extreme nervous excitement that hours would elapse before she would become calm. I was satisfied that the patient before me was suffering from vaginismus, the de- scription and treatment of which had about that time been published by Dr. J. Marion Sims.” It is proper to say, that, although this disease was first presented to the profession by Dr. Sims, it was Dr. Tyler Smith, of London, who is said to have suggested the idea; and, according to Debrand, f it was Huguier, in 1834, who described the spasmodic condition of the Sphincter vaginae. The method employed by Dr. Sims places the patient on her back; the index and middle finger of the left hand are passed into the vagina, sepa- rating the labia laterally, opening the canal as widely as possible and drawing the fourchette very tense ; then with a common scalpel make an incision through the vaginal tissue, a little to the right side, bring it from above downward and terminating at the perineal raphé, making one side of a V; then insert the knife on the left side and cut obliquely toward the first in- cision, so as to join it at the raphé ; then follow the raphé itself until the incision resembles the letter Y. The amount of haemorrhage is generally unimportant and will be readily controlled by the pressure of a glass di- lator, which may be introduced immediately or twenty-fours after the operation, where, by an appropriate bandage, it is kept in situ for two hours in the morning, and two or three hours in the evening, according to the tolerance of the patient. - By this treatment I effected a perfect cure in my patient, and she has since become a mother. . Dr. E. Clark, of Portland, Me., f one of the oldest and most valued expo- nents of our school in that State, relates a perfectly successful cure similar to the above, by the same operation. Ludlam, speaking of this subject in his Diseases of Women, says: “Unless there is some special reason why the cure should be speedy, it is best to try the milder means,” before resorting to the knife. One of the plans recommended to overcome this spasm of the vagina is the gradual dilatation of the canal by bougies. These should be annointed with oil or a preparation of extract of belladonna, one part to six parts of lard or simple cerate. The process will be necessarily tedious, but a per- sistent use of these instruments, from a few minutes to an hour or two each day, with the administration of the remedy which seems indicated by the general condition of the patient, will often be rewarded by a per- manent Cure. * American Medical Times, May 31st, 1862. f Medical News, November 29th, 1884. † New England Medical Gazette, August, 1873. ATRESIA WAGINAE--ELEPHANTIASIS. 1049 Incidental or transient attacks of vaginismus may be relieved by the application of a mixture, consisting of chloroform one drachm, and olive oil and glycerin each one ounce. If the spasm is severe, the mixture may be thrown into the rectum, and treatment instituted most likely to remove the cause on which the paroxysms depend. - Atresia Vaginaº.—This closure of the canal may be either congenital or acquired, being often of the former variety. The nurse or mother discovers the fact. In such cases there is generally sufficient space for the passage of the urine. Sometimes the entire canal is occluded from ulceration in early life, and sometimes from imperforate hymen. The great difficulty in these cases is the diagnostication of the presence of the uterus; and this is the more difficult because sexual instinct may be present when the womb is absent. It depends more upon the ovaries than the uterus. In such cases the most careful examination must be made per rectum and over the abdo- men. If a tumor be found at the latter point, it may be assumed that it is formed of menstrual accumulation. - I have had fifteen cases of this affection, five congenital; two I saw and operated upon with Dr. Skiles, of Brooklyn; one aggravated case, a patient of Dr. Mandeville, of Newark. Several others came under my ob- servation in Missouri, and a most remarkable one I saw with Dr. Clark, of Troy. - Treatment.—Place the patient on the back, secure the legs with the gynapod, or other contrivance, thoroughly vaseline the parts, and as I be- lieve that mucous surfaces separate better by gently breaking up adhesions with the finger and blunt instruments, with here and there a touch of the knife to sever a fibrous or cartilaginous band, than when the knife is em- ployed exclusively, such means must be employed; moreover, union b the first intention is not nearly so likely to result. A catheter in the bladder, held by an assistant, the forefinger of the left hand in the rectum, to guide and draw away the parts, and the forefinger of the right hand in the vagina, worked steadily and carefully, now and then using the knife to free strong adhesions, will be productive of better results than the use of cutting in- Struments. The main trouble is the prevention of a recurrence of the contractions; therefore glass plugs, or those made of hard rubber, must be constantly worn, and the operation repeated if only a partial success occurs. Elephantiasis of the Labia.-The disease is classed by most authors (Til- bury Fox,” Rayer, and others) as one of the hypertrophies of the same genus as ichthyosis, keloid, and fibroma, and by Paget as cutaneous out- growths, which appears but another name for the same pathological state. He says: “The best examples of cutaneous outgrowths, of which, as I have said, a second division of the fibro-cellular outgrowths is composed, are those which occur in the scrotum, prepuce, labia, clitoris and its prepuce, and, not unfrequently, in the lower limb. These, which reach their maxi- mum of growth in the huge elephantiasis scroti of the tropical countries, con- sist mainly of overgrown fibro-cellular tissue, which, mingled with elastic tissue and more or less fat, imitate, in general structure, the outer, compact layer of the cutis. Their tissue is always closely woven and very tough and elastic ; in some cases it is compressible and succulent, and it yields on sec- tion a large quantity of serous-looking fluid.” He speaks also of the great enlargement of the veins, which he noticed in a specimen under examina- tion. I have given this brief quotation from Paget, because it covers exactly the appearances of the tumor after removal, which is accomplished only after a prolonged and very bloody operation. * Skin Diseases, p. 331. f Treatise on Diseases of the Skin, p. 401. 1050 A SYSTEM OF SURGERY. It is said that inflammation of the lymphatics constitutes the first stage in this affection. These being arrested in their function, the lymph re- mains to be appropriated by the tissues, thus rendering them hyper- trophic. . Another of the chief peculiarities is the enlargement of all the veins and the extremely patulous condition of their mouths, together with an enlargement of both arterial and venous capillaries. The bleeding is always profuse and often dangerous when these tumors are removed, and no one can read over Allan Webb's description of the amputation of the scrotum for elephantiasis arabum without seeing at once the great danger to be apprehended from ha-morrhage. Cases of elephantiasis scroti, and of “tropical big leg,” or “Barbadoes leg,” are frequently encountered, and scattered throughout the medical journals can be found the records of numerous cases. But although in many works the fact is mentioned that this form of hypertrophy can and does affect the labia, I can find but very meagre records of such an affection. - Thomas, in his Diseases of Women, merely says: “Elephantiasis of the labia differs in nothing from that of other parts. The affection is very rare. Kiwisch records one case, in which both labia increased in size to equal the head of a man, and to fall nearly to the knees. The parts affected by it are the labia majora and minora and the clitoris.” I find a case reported in an old number of Ranking, by Dr. O. Ferrall, to the Dublin Pathological Society, in which a species of cellular pendulous tumor, seven inches in circumference, was removed from the left labium. The haemorrhage was profuse. Dr. Eve, in his Remarkable Cases in Surgery, records a case of “ex- cision of the external labia pudendi for sarcoma.” This, no doubt, was similar to those now known as elephantiasis; indeed, the disease has been called, especially by Mr. Abernethy, “vascular sarcoma.” After relating the history of the patient, the surgeon (Simeon Bullen, Esq., of London), thus writes: “On removing the left labium, the discharge of blood was so rapid and profuse, and the vessels so numerous, that before I could succeed in securing them, fainting had taken place, and the effect on the system was so alarming that I was obliged to postpone for many days the opera- tion for removing the other, which was attended with similar loss of blood. The substance of each tumor was composed of adipose and fleshy tissue, numerously supplied with bloodvessels.” - Many works on Surgery do not mention this variety of hypertrophy as affecting the vulva, although they give descriptions of the disease as found in the leg and scrotum. Velpeau records the case of a girl, whose left labium was affected with an enlargement (hypertrophia). Bryant merely alludes to the fact of a case coming under his observation, and Holmes gives about a page to the consideration of the disorder—I mean as affecting the parts in question, for he has further on in the same volume an extended article on the subject of elephantiasis arabum, in which is given a table of one hundred cases, in which not one is recorded as affecting the labia. . Treatment.—I do not know of any other medicines for this disease, than those noted on page 419, and with regard to the methods of operating, I shall give a case of my own, in which the right labium measured one foot in length, and twenty inches in circumference. On February 7th, 1875, the patient, Mrs. X., was sent to the hospital by * At the college clinic, in 1874, I removed an hypertrophied clitoris, measuring in length five and a half inches, and in breadth nearly three inches. The operation was performed with the écraseur of Chassaignac. ELEPHANTIASIS OF THE LABIA. 1051 Dr. Wetmore for operation. Continuous with the right labium, there ap- peared a huge, fleshy mass, dark in color, sparsely covered with hair, ru- gous on the surface, with here and there a deep fissure. From the elastic nature of the tissues, and the infiltration of serum in some parts, there ap- peared to be distinct fluctuation, which, inded, I have even known in cer- tain varieties of fatty outgrowths. The doctor explored the tumor with a trocar, passing the instrument into the growth “up to the handle;” a pro- fuse stream of blood flowed through the canula. This operation was re- peated a second time with like result. When she came into the hospital, aspiration was resorted to, and about a tablespoonful of serum was with- drawn. A second puncture yielded no result. This serum, as I discovered afterward, found its bed between the meshes of the tissue, for the tumor was solid throughout, but when cut into, quite an amount of serum would immediately trickle away, though there was, apparently, no break in the substance of the tumor. Upon careful measurement, the growth was found to be twelve inches in length, and over twenty inches in circumference, globular in shape, and almost painless when handled. The patient had been unable to move about for a long period, nor could she retain her urine, the weight of the mass keeping the meatus continually OTO611. "ier due consultation, it was deemed advisable to attempt the removal of the mass. The best method of so doing was a question. To apply properly Esmarch's bandage to a globular tumor, is no easy matter; and as it is necessary, in using the elastic, to have each turn properly overlap the other, to drive all the blood back, I relinquished the idea, fearing the band- age might slip at a critical moment. I did not think the écraseur safe, where such profuse haemorrhage was to be apprehended; and although the heated wire presented some points for consideration, I finally adopted, as a preventive, Erichsen’s double thread, as used for navus. This was applied. Taking a stout needle, it was threaded with a strong hempen cord, about four feet in length ; one-half of this cord was blackened and allowed to dry ; then, having raised the tumor, the needle was passed upward through the pedicle (which was over six inches in length), and brought out on the upper side, and the thread drawn almost through. The needle was turned, entered on the upper side about half an inch from its place of exit, and drawn through on the lower side of the tumor, leaving a loop. This method of stitching was continued, until the whole pedicle was traversed. The pedicle was nothing more than the margin of the labium. The white loops were all cut at the top, and the black ones at the bottom ; the white ends of the thread tied tightly together above, and the black ones below. Not satisfied with this, and for a more thorough protection against sudden and exhausting haemorrhage, a second row of similar stitches was placed half an inch lower down. Having now the tumor held up, in order to take off all strain on the threads, with a large scalpel, I rapidly severed the growth. The bleeding, as the knife went through, and for a moment after, was terrific; the blood shot up in a stream which caused an exclamation from the bystanders. A good deal was venous, and had been held in the tumor by the superimposed ligatures. After this a steady flow with jets and spurts kept up. Thirty-two vessels were ligated, and, after having covered the wound with styptic cotton, placed over this a wad of tenax, and firmly applied a T-bandage, the patient was put to bed. The next morning she had scarcely begun to rally from the terrible shock of the operation, when, upon examination, I found she was bleeding again. The blood had soaked through the bandages and into the bed. All the dressings were removed, and eleven more ligatures applied. This effectually checked the haemorrhage. The patient reacted very slowly, had 1052 A SYSTEM OF SURGERY. constant nausea for several days, and could retain nothing on her stomach. Nº. anemas were given her, but she sank and died on the 23d day of €OI’U13.T.W. {{ tºtal Excrescences; Caruncles of the Urethra; Vascular Tumors of the Urethra.”—Patients who suffer from this affection have various urinary troubles, such as strangury and dysuria, with hypersensitiveness of the nervous system, which are especially noticeable during the menopause. There then appear, either within or around the urethra, these so-called caruncles. Most physicians have seen these exquisitely painful growths, rendering the patient miserable and nervous all the time, and giving acute agony during micturition or coition. They are generally solitary, but I have now under treatment a case in which there are three distinct lobules to one peduncle. These “urethral haemorrhoids,” as they are frequently called, from resem- blance to the vascular piles, are, as far as I have seen, situated on the lower border or floor of the urethra. - Treatment.—In the treatment of these painful tumors, I have never found internal medication of any avail so far as removal was concerned ; but the surgical treatment has been followed by the best results. I draw down the tumor, pass a fine needle, armed with a strong but fine double thread, deep down into the base of the growth (for, be it remembered, although these growths appear superficial, they often extend quite deeply into the tissues), and then, having ligated the tumor, cut it off outside the ligature, and apply either chromic acid, the acid nitrate of mercury, or the actual cautery to the pedicle. J. H. Woodbury” recommends highly the eucalyptus globulus. “With it,” he says, “I have been able to cure the patients.” Cures have been produced by the use of the eucalyptus, without a resort to any surgi- cal means. He applies a glycerole of the drug to the parts, and adminsters internally the first decimal trituration. - CHAPTER XLVIII.i. LACERATIONS OF THE CERVIX UTERI. THE first mention regarding this most important lesion, was made by Dr. James Henry Bennett, of London. In 1862 Dr. T. Addis Emmet acci- dentally recognized its importance, and originated the operation for its relief which has been styled by different authors “Emmet's operation,” “Hystero-trachelorraphy,” “Trachelorraphy,” and “Tracheloplasty.” In 1869 Dr. Emmet described the operation in a paper on “Lacerations of the Cervix Uteri,” read before the Medical Society of the County of New York. In 1871 he read a second paper before the same society upon the * New England Medical Gazette, June, 1876. # This chapter was prepared by Dr. F. S. Fulton, late house-surgeon to the Hahnemann Hospital, New York. LACERATIONS OF THE CERVIX UTERI. 1053 subject. This paper received a wide circulation, being translated by Dr. M. Vogel, and published in Berlin in 1875. To Dr. Emmet belongs the honor of introducing to the medical profession an operation which has probably done more to relieve the sufferings of women than any surgical procedure known to gynaecology. This lesion is apt to occur in primiparae, whose cervical tissues yield with difficulty to the dilating force of the head and amniotic fluid. In multiparae the os naturally is patulous; while in those who have not borne children, the inelasticity of the tissues resists the dilating force of the ute- rine contents during the latter months of gestation, and remains tightly drawn together until just preceding delivery, greatly favoring laceration. Dr. Emmet's statistics show that in his cases slow and tedious labor has been more frequently the cause, 20 per cent, being due to this cause alone. But, although contrary to the present evidence, he says he fully believes that more extended investigation will prove that rapid and difficult de- livery is more often responsible. Careless and needless instrumentation is another productive cause. Application of the obstetric forceps within or above the superior straits, is an operation attended with danger, even in the hands of experienced obstetricians, and should be avoided whenever ossible. . p Dr. T. A. Reamy, of Cincinnati, considers ergot, and the use of the fingers in hastily dilating the cervix, as of greater injury in the production of lacerations than are the forceps; and Dr. McDonald, in the New York Ob- stetrical Journal, says that “meddlesome application of obstetrical fingers in hurrying dilatation of a slow cervix, or in forcibly pushing the neck over the occiput during a pain, is the most frequent cause of cervical lacerations.” It is also a fact not always recognized, that abortion, even at an early period, is capable of producing a serious lesion of this character. Dr. Emmet says that in every case where criminal abortion is acknowledged or can be proven, laceration has resulted. Regarding the frequency of laceration of the cervix, Dr. Mundé says that out of 2500 parous women, he found that 25 per cent. suffered from this lesion, and 50 per cent. of these were serious enough to demand operative treatment, making, according to his statistics, only about 12% per cent. of all parous women requiring this operation. I have but little doubt that, as the operation assumes more and more its rightful place in surgery, and through more perfect knowledge the evil results of this lesion become better known, and its detection more frequent, this estimate will not be found too large. As a consequence of laceration, cellulitis is most apt to be established, entirely suppressing, at times, the Secretion of milk. It is claimed by Emmet that you can, not infrequently, ascertain at which delivery the laceration occurred, by finding out after which the mother had been unable to nurse her child. The cervix implicated in the laceration undergoes cystic hyperplasia, by which the parts are rendered prominent, boggy, and soft, as is indicated in Fig. 697. Nature endeavors to repair the damage and to again restore the normal outline of the cervix by filling in the bottom of the cleft with a large amount of cicatricial tissue, which is hard, and, at times, almost horny in consistency. For this reason, unless careful examination be made, an extensive laceration may be overlooked. It is this cicatrix which, by pres- sure upon the nerves of the cervix, causes so much reflex nervous disturb- ance. Great cystic degeneration and hyperplasia result, which may at times be so excessive as to be mistaken by even the best gynaecologists for a malignant neoplasm. Fig. 698 well represents this simulation of carci- DOH)3. 1054 A SYSTEM OF SURGERY. Regarding the tendency of these new formations to appear at the site of old lacerations, there can be but little doubt. Any portion of the cervix is liable to rupture during delivery. The lac- eration may be unilateral, bilateral, anterior, posterior, stellate, or internal. FIG, 697. Posterior and Bilateral Laceration, with Cystic Hyperplasia.-(MUNDE.) Cystic and Papillary Hyperplasia, Simulating Epithelioma-(MUNDE.) When unilateral, it involves only one side of the cervical tissue, which is usually the left. Emmet's statistics for the cases in which it is recorded as to what form of laceration existed, show the following results: Right side,. - - - - - - - Left side, . - - - - - - - Bilateral, . - - - - - - - Posterior, . - - - - . 157 per cent. ... -40.7 “ . . 39.5 “ - 4.0 “ From the large number of cases, however, in which it is not stated as to the variety of laceration, I cannot regard these results as correct, as in other statistics, as well as in my hospital experience, I found a much greater pro- portion of bilateral than recorded here. Dr. T. A. Reamy, of Cincinnati, in an article which appeared in the New York Medical Record, of May 10th, 1884, reported 223 cases of laceration, with the following results: Bilateral, . - - - - - - - - Unilateral, . - - - - - - - - Stellate, . - - - - - - - - Posterior, . - - - - - - - Anterior, - - - - - - - Extending into the cervico-vaginal junction, - With perineal laceration also, . - - - - Anal sphincter damaged, . - - - - Recto-vaginal septum opened, . - - - - Perineorrhaphy subsequently in, - - - - - 170 - - ... 30 - - . 16 - - - 5 - - 2 - - 15 167 - . 15 - - - 7 - - . 50 I believe that these statistics would more nearly represent the ratio exist- ing between the different forms of laceration. Fig. 699 represents a right unilateral laceration. (All the cervix cuts represent the appearance with the patient in Sims's position upon the left side.) According to the depth of the lacerations, they are arbitrarily clas- LACERATIONS OF THE CERVIX UTERI. 1055 sified as those of the first, second, and third degree; the first being merely a nick in the mucous membrane; the second a tear through the superficial Fig. 699. FIG. 700. Right Unilateral Laceration of the Bilateral Laceration of Cervix—Second Cervix.-(MUNDAE.) Degree.—CMUNDE.) muscular fibre; and the third extending to or beyond the cervico-vaginal }. Figs. 700 and 701 show the second and third degree of bilateral aceration. The stellate laceration, as shown in Fig. 702, is one in which the rents extend into the cervical tissue from the os uteri as a centre, it being not in- FIG. 701. Bilateral Laceration of Cervix–Third Degree. The two tenacula show the direction of approximation of the everted lips.-(MUNDE.) frequent to find as many as four or five different tears. These clefts can be discovered radiating in all directions from the os, some filled entirely with cicatricial tissue, others gaping, with exuberant granulations covering some of the everted surfaces, and hard nodosities disfiguring others; and all, to a greater or less extent, covered with erosions, from which is con- stantly poured a thick yellow or pearly leucorrhoea, which in time pro- duces a profound condition of anaemia. Theosis patulous, the lipseverted, and the whole cervix and uterine body hyperplastic and low down upon the floor of the pelvis. The average length of time in which symptoms be- come so distressing as to drive the sufferer to the physician for relief is about five years. It is not infrequent, however, for the patient to feel the bad effects of the 1056 A SYSTEM OF SURGERY. laceration from the time she leaves her bed until she submits to the opera- tion. In others, aside from the malaise from which they suffer, they may notice no inconvenience for several years, except the tendency to abort, After a time, symptoms begin to manifest themselves. The patient will be unable to undertake her usual amount of work or exercise. Slight exer- tion brings with it an amount of fatigue. Shaking and trembling for hours follows a walk of comparatively short distance. There is a dragging weight in the pelvis, and oftentimes a severe bearing down drives the patient nearly frantic. As the uterus becomes heavy from its condition of hyperplasia and subinvolution, the natural tendency is for it to become retroverted, in which FIG. 702. Stellate Laceration of Cervix.-(MUNDE.) case the heavy and enlarged fundus is thrown over against the sacrum and rectum, causing the dull dragging backache, with not infrequently tender- ness on the Sacral or lumber portion of the spine. It also produces a con- dition of partial stenosis of the rectum, obstructing the passage of the ex- crement and inducing an obstinate form of constipation. Both from the mechanical pressure upon the sacral nerves and the nervous disturbance produced by the laceration itself, there are developed all forms of neuralgia, and neuralgic pains in the limbs, more generally extending from the Small of the back through the pelvic structures and downwards over the anterior surface of the thighs, sometimes reaching to the calf of the leg, but more generally stopping at the knee. The spine is the seat of a dull dragging pain, or at times sharp neuralgic darts. The spine gives out easily on effort, seems scarcely to have strength enough to sustain the weight of the body, and if required to do so for any length of time, fails utterly, not infrequently prostrating the patient for days. The ovarian and hypogastric regions are usually more or less sensi- tive to pressure, and the seat of sharp darting pains frequently extending across the abdomen; or of a dull aching distress which is just as annoying. At other times a persistent form of sciatica is developed which resists all kinds of medical treatment. As a consequence of the laceration, cellulitis is usually developed, which is evidenced, if it occurs early, by the stoppage of the milk, fever, great pain, tenderness, and strong disinclination to move, on account of the pain occasioned. When the cellulitis results in bands of adhesion being formed, binding the uterus backward, as is most common, or laterally, it produces 8, ºplacement with its entire coterie of symptoms, which is most intrac- table. Every variety of menstrual disturbance known to women is produced by this lesion. In 17.80 per cent. of the cases recorded by Emmet, menstrua- LACERATIONS OF THE CERVIX UTERI. 1057 tion remained unchanged as at puberty; 44.74 per cent. had their flow either lessened or increased, or made irregular as to quantity without al- teration in the length of time of menstruation. In 82.17 per cent. the men- struation was altered as to quantity, the flow being increased, lessened or irregular; and of these, 62.8 per cent. had their menstruation increased. When the laceration first occurs, before the plugs of cicatricial tissue are deposited in the angles of the cleft, the woman is apt to be unusually pro- ductive, one impregnation following another with great rapidity, only to be aborted about the second or third month. This condition is especially liable to supervene after a large stellate laceration. The reason of this is plain when the large patulous os, the softness of the cervical tissues, and the great facility which is afforded the spermatozoa to enter the uterine cavity, are considered. This habit to abort generally persists till the cleft is filled with hardened tissue, and a heavy, thick, oftentimes, acrid leucor- rhoea is developed, which occludes the passage, when impregnations usually cease, and absolute sterility follows. Most distressing reflex nervous dis- turbances arise, as, for example, persistent headache usually in the Occiput, of a dull, heavy character, as if the patient had been struck with a club in that locality. The sufferer is exceedingly nervous and irritable, oftentimes semi-hysterical or melancholic, fears she is going crazy or about to die, The diagnosis of a laceration must be reached by means of both the finger and the eye. Neither alone is quite sufficient. When the finger is intro- duced it will generally find the uterus prolapsed, retroverted, and in a con- dition of subinvolution. The finger will detect the patulous os, the cleft angles of the laceration studded with little cysts presenting as hard nodular bodies above the cervical mucous membrane. The finger will also be able to detect the abrasion of the mucous membrane by the absence of the soft smooth feel of the healthy cervix. There will be usually more or less tenderness from existing cellulitis. The variety of the laceration is fre- quently detected by feeling the different clefts, or the hard stringy bands of cicatricial tissue which have filled them. In the use of the speculum, there is a great deal of choice. If the tubular one is used, the vaginal tissues are frequently pushed forcibly back, some- times carrying with them the posterior lip of the cervix, so that the appear- ance through the speculum is of a raw ulcerating surface. The natural ectropium is greatly increased, and no true idea can be gained of the pro- portionate amount of laceration and healthy tissue. The bivalvular specu. lum is much better and affords a truer view ; but even here the natural eversion of the parts is greatly increased, and it is usually very difficult, if not impossible, to successfully approximate in order to determine the amount of laceration. The Sims' removes the difficulty. With the patient in Sims's position, the vagina ballooned out, and the perinaeum retracted, there is nothing which offers any traction upon the cervical flap. It pre- sents itself to the eye exactly as it is. Having completed the diagnosis, the next question is when to operate, as statistics show that only about 50 per cent. of the cases of laceration require surgical treatment. If there is simply a slight laceration, without marked eversion of the lips, a slight amount of cicatricial tissue in the clefts, with a healthy mucous membrane, even if there be nervous symptoms and a certain degree of anaemia, there is no indication for an operation; and, if one were performed, it would probably be disappointing in its results. When, however, there is marked ectropium, more or less extensive erosions, deposit of cicatricial tissue in the cleft, cysts of the cervix, leucorrhoea with menstrual disturbances, anaemia, and reflex nervous trouble appearing as sciatica, ovaralgia, cephalalgia, neuralgia of various forms in different parts of the body, or some obscure neuroses for which no assignable cause can be 67 1058 - A SYSTEM OF SURGERY. found aside from that furnished by a well-marked laceration with the above distinctive marks, the probability is that an operation will be followed by brilliant results. No doubt exists of its being indicated in these cases. A marked degree of cellulitis or peritonitis is a contra-indication, unless the surgeon is satisfied that it is originated and perpetuated by the lacera- tion itself. An operation immediately after delivery would not be advisable on account of the softness, distension, and partial obliteration of the cer- vical tissues, rendering satisfactory coaptation well-nigh impossible, and endangering subsequent union. All gynaecologists consider preparatory treatment necessary. When there is the usual condition of subinvolution, hyperplasia, ectropium, cystic de- generation, erosion, leucorrhoea, and cellulitis with attendant pain and sore- ness on manipulation, hot-water douches night and morning, giving each time about a gallon of water as hot as can be endured, should be given. There is probably no agent which is of greater therapeutic value in treat- ment of uterine and pelvic inflammations than hot water used in large Quantities. Its astringent action on the bloodvessels and tissues of the pelvis is great, so much so, that when a douche has been properly given, the vaginal walls will be found thrown into additional rugae, narrowing the canal perceptibly, and reducing the size of the large congested cervix. The proper method of giving a douche is to place the patient in bed or on a douche-board, with the hips elevated sufficiently to retain a large amount of water in the vagina. The Davidson syringe should be used in place of the customary fountain bag, as there is a certain mechanical effect to be derived from the interrupted current of the former. Some patients cannot tolerate the pain which the more forcible jets of water occasion. If there be any cysts upon the cervix, they should be punctured, and their contents evacuated. It is not necessary to carefully select each cyst, but with a scarificator (Fig. 703) the cervix may be punctured over the entire surface. FIG. 703. ſe º Germas Aſafº - G ty's Buttle's Scarificator. This will empty the cysts, and relieve the congestion by allowing some of the additional blood to escape. After this the entire cervix, and, if there is much tenderness or congestion over the vaginal walls, they also should be painted with Churchill's iodine. Care should be exercised to introduce the iodine into any large cyst which may be punctured, to obliterate it. The iodine will check the bleeding and reduce the congestion. If, as is usually the case, extensive erosions are present, iodine may still be used or one of the following solutions: B. Glycerinae, . * 6 ſº & . . . . . . . 3i. Hydrastis (Fl. ext.), . º º © º º e º & . 3ij. B. Glycerinae, . & - . 3i. Iodini (Churchill's), . 3.j. B. Aquae, . & tº º & e e o te º º e . 3.j. Acidi Nitrici, . e e ſº º º sº & e tº • 3.j. B. Glyc., . • 3i. Alum., . º e º e e e º º º e • 3.J. B. Glyc., . . º tº e º º & * e e e . 3i. Acidi Tannici, . o & e • e te e e e . 3.j. Or any creamy mixture of iodoform and pure carbolic acid. One of the LACERATIONS OF THE CERVIX UTERI. 1059 most satisfactory, medicaments for local application is ominico, diluted about one-half, and applied as a douche night and morning. It is not neces- sary to use a large quantity, but enough to thoroughly wash the cervix. The peroxide of hydrogen, 15 volumes, diluted about 18 to 8 with water, makes a cleansing and stimulating application. In the New York Medical Journal, of October 10th, 1885, Dr. B. Brown, of Alexandria, Va., claims that by the use of the graduated solution of argentum nitricum, many cases, even of severe laceration, may be successfully cured. He first employs a solution of B. Arg. Nit. (cryst.), ë e e e o º e º e . 38S. Aquae dest., . e e e e º º o * e e . f.3j. Which he applies to the cervix and canal as far as the os internum. This he uses only in simple fissures of the cervix without deep laceration or ectropium. In deeper clefts, - B. Arg. Nit. (cryst.), . . . e & e e e e . Bijss. Aquae dest., . e º o s e o - e © º ... fl3.j. With this he washes the entire surface until a uniform white coating, con- sisting of albuminate of silver, is formed over the entire abraded surface of the cervix. This answers a double purpose of preventing septic infection and stimulating the formation of healthy tissue. After all applications to the uterine cervix, it is advisable to insert a tam- pon soaked in glycerin, or glycerin and alum, or in the glycerin, calendula, and tannic acid solution. These tampons should remain for about twenty- four hours. The room in which an operation for laceration of the cervix is performed must be scrupulously clean, and should, every little while, be disinfected FIG. 704, :::::::::- . . - - - -> S s 4- -- --~~ Dawson's Sims's Speculum. by the use of carbolic acid, sulphur, thymol, listerine, or some other dis- infectant. It is not necessary to adopt all the antiseptic precautions that are necessary in an abdominal section. As an operating speculum, Dr. McDonald's modification of Sims's is one of the best. Dr. Dawson has modified Sims's speculum by placing the blades on hinges for easy trans- portation. (Fig. 704.) Various needle-handles are used, such as Emmet's, Russian, Sims's, etc., all of which can be found in the chapter on Minor Surgery and Wounds. Skene has devised a holder for which he claims the special advantage of being able to better grasp and draw the needle through the cervical tissue. - 1060 A SYSTEM OF SURGERY. (Fig. 705.) For all purposes our preference is for the Russian forceps, as they grasp the needle firmly and are simple in construction. Three pairs of Scissors are necessary, unless some of the more modern revolving scissors are used. Those needed are Emmet's scissors, straight, curved on the right, curved on the left, and curved on the flat. If knives are used, and many operators are partial to them, on the ground that the deeper angles can be more easily reached and tissue divided FIG. 706. ºr -- E- E: º - --- Bozeman's Scalpels. more accurately; three, attached to long handles, will be necessary (Fig. 706); one straight, and two curved at the junction of the shaft and blade, FIG. 707. ( Emmet’s Tenacula. so as to allow cutting either to the right or left. Dr. Helmuth clings to the use of the knife, claiming for it far greater rapidity and nicety of operating. FIG. 708. º gºº Ž%.7% º, Yºº º' ºs- * - - º, Skene's Double Tenaculum. Two small Emmet's tenacula (Fig. 707) will be needed to raise the tissue as it is dissected away. A double tenaculum is often found serviceable for drawing down the cervix towards the vulval orifice. Fig. 708 is one devised by Dr. Skene. Generally no artery forceps are necessary. If the circular artery be cut, it can be secured by passing a thread of cutgut or whale tendon beneath it, and ligating through the tissues. If a tenaculum is not required, a pair of strong-bladed tissue forceps, with a serviceable catch, may be used. The style of needle varies with the operator. The majority of surgeons use either Emmet's (Fig. 709) or Sims's (Fig. 710). I prefer Emmet's latest needles, which are slightly curved at the point, and have three rather dull LACERATIONS OF THE CERVIX UTERI. 1061 cutting edges. Dr. Helmuth prefers, and generally uses, the large heavy Hel- muth needles, for the sake of greater rapidity and ease of placing the sutures. FIG. 709. FIG. 710. * Qºy tº www.wº yº ~ | ſ Prmmet's Needles. Sims's Needles. Dr. Van de Warker, of Syracuse, has devised a needle especially designed to overcome the difficulty of passing small or large needles through a very tough cervix, retracted, as it sometimes is, high up the pelvis. (Fig. 711.) FIG. 711. Van de Warker's Needle. These may be found useful, but, under most circumstances, no device is equal to the ordinary needle, placed at a proper angle in a serviceable pair of needle-holders. With these either a counter-pressure hook (Fig. 712) or Emmet's blunt hook will be required. FIG. 712. Hanks's Counter-pressure Hook. According to the preference of the operator, silver wire, whale tendon, silk or catgut will be needed. Each of these materials has its special advocates. The greater number of operators prefer wire. Dr. Skene uses silk and claims excellent results. Dr. Helmuth and some other surgeons use whale tendon almost exclusively. I believe that silver wire possesses great ad- vantages over the others. Dr. Sims first introduced silver wire, and it is now used extensively by many gynaecologists, among whom are Emmet, Hunter, and Mundé. * - On the night preceding the day of operating, the patient is given a ca- thartic sufficiently strong to insure a free movement of the bowels. About half an hour before the operation, the patient should receive a hot, copious, vaginal douche, also an enema if the bowels are not thoroughly evacuated. Some system of irrigation should be at hand by which a douche of hydrarg. bichlor. 1 to 2000 can be thrown into the vagina just before and at the com- 1062 A SYSTEM OF SURGERY. pletion of the operation. Large irrigating bottles are the best. A fountain syringe containing the solution will answer all purposes. The patient is placed upon her back, anaesthetized, after which she is turned upon her left side and placed in Sims's position, well down upon the table, the pillow removed to facilitate respiration, and towels and rubber sheeting placed under the buttocks and about the clothing to avoid soiling. Three assist- ants will be needed, one to give ether, one to hold the speculum and retract the buttocks, and One to manage the sponges and assist the operator. After the speculum, which should be warmed and well oiled, has been introduced, and the douche of hydrarg. bichlor. given, the cervix should be seized with a tenaculum and drawn carefully down toward the vaginal orifice. Care must be exercised not to exert too great traction, especially when old cellulitic bands of adhesion remain. The cervix can be drawn to within an inch of the vulva without danger. It should be retained in situ either by a double tenaculum or by a double thread passed through the an- terior lip, beyond the reach of the surfaces to be denuded. The tenaculum or double thread may be given to the assistant who holds the speculum. The lips are then brought together by tenacula, in order to ascertain the amount of surface to be denuded. The mucous membrane, which is to form the cervical canal, is mapped out with the eye, and should be slightly wedge- shaped, the broadest portion being at the extremity which is to form the os. FIG. 713. Surfaces denuded in Bilateral Trachelorraphy. Undenuded Strip for Cervical Canal in the centre.—(MUNDE.) The mucous membrane which is to be cut away is hooked up with a tenaculum and removed with the scissors or knife. . In a bilateral lacera- tion, it is well to denude the lower cleft first, to avoid the blood from an upper raw surface running over the portion upon which the operator is working; merely the mucous membrane and cicatricial tissue should be re- moved. The tissue in the angles of the cleft must be entirely cut away. It is advisable to continue the denudations well out upon the vaginal surface, to avoid subsequent puckering of the tissues. Fig. 713 represents the area of denudation, and the strip of mucous membrane left to form the cervical canal. - All the hardened tissue in the cleft must be dissected away, until the healthy muscular substance is reached and the lips can be easily approxi- mated. The extent of cicatricial tissue can be determined by the hard, gristly, resisting sensation imparted to the hand by the scissors on cutting, and by the fingers and nail which easily distinguish its nodular, hard, resisting character, from the soft yielding nature of the healthy cervical tissue. Unless this entire tissue is dissected out, the reflex neurosis and general mal-nutrition will probably not be benefited. It is a matter the importance of which cannot be overestimated. If, in making a deep dis- section, the circular artery is cut, it can be secured, as has been previously indicated. g - . LACERATIONS OF THE CERVIx UTERI. 1063 The opposite side is now denuded precisely as the first, leaving between them two symmetrical strips of mucous membrane, one on the posterior and one on the anterior lip, to form the cervical canal. Where the anterior lip is greatly hypertrophied, the whole lip may be denuded and the excess of tissue cut away, trusting to the mucous membrane left upon the posterior lip to insure the patency of the cervical canal. Any cysts remaining at the time of operation must be removed. If the laceration be stellate, with an enlarged cervical canal remaining, a V-shaped piece must be removed, including any hardened tissue. This may be done on either side and the whole treated as a bilateral laceration. If this is not practicable, the cervix must be freely laid open, the diseased portions dissected, the canal nar- rowed to its healthy calibre, and treated as bilateral laceration. A less radical course will be of no service. All unilateral lacerations are treated as above, it being necessary, however, to denude only one side. Everything is now ready for the sutures. If whale tendon, silk, or cat- gut are to be used, they can be threaded directly into the needle. If wire, for which I have a preference, the needles must be first threaded with double linen thread about fifteen inches long, the ends being drawn through the eye three or four inches, leaving the loop into which subsequently to hook the wire. Six or eight needles may be threaded, leaving the threads in the cervix until all the sutures have been placed, or only one needle may be used. This necessitates the placing of the wire as the sutures are introduced. I prefer the former method, as it assists the proper coaptation of the parts and the easy introduction of the stitches. The needle is now grasped with the forceps, the cervix steadied with a counter-pressure hook; and, introducing the needle at the outer angle, about one-quarter of an inch from the denuded surface, it is passed through the two lips. This can usually be done at the outer angles when the lips are not thick. Toward the cervical canal, especially if the lips be hypertrophied and hardened, it will be necessary to introduce the needles from without to the bottom of the denuded cleft, withdraw them, and reinsert them at the same point through the opposite lip, care being taken that they be reintroduced at a point exactly corresponding to the place of withdrawal. If catgut, silk, or whalebone be used, they can be drawn through, cut off at convenient length, handed to the assistant in charge of the speculum to hold, and, after the introduction of all, tied. If wire be employed the silk threads are left in situ until all the needles are introduced. The operator must see that the strips of mucous membrane, which are to form the cervical canal, are in exact apposition. The wire, bent over at the end, the loop being squeezed down as flat as possible, to facilitate its pas- Sage through the cervical tissue, is hooked into the loop of thread first in- troduced and drawn by a quick movement of the wrist through the tissue. It is then cut off at a convenient length, the ends merely twisted together and handed to an assistant to hold until all be placed. Fig. 714 illustrates #. sutures in situ, together with the triangular appearance of the denuded apS. . When all the sutures are in, those nearest the cervical canal are drawn down, unlooped at their extremity, carefully drawn over the cervix and line of incision, twisted once with the hands, the ends straightened out and grasped with the wire twister. The shield is then placed over the wire and the sutures twisted sufficiently to hold the parts in easy apposition, but without enough force to, in any way, strangulate the tissues. The wire is then bent over a tenaculum in the direction of the cervical canal, so as to lie close to the cervix, and cut off, leaving about three-eighths of an inch to be grasped when it is later removed. All the sutures are to be treated in the same way. When they are all twisted, properly bent, and cut away, a probe is introduced into the uterine cavity, to ascertain if the 1064 A SYSTEM OF SURGERY. canal, is pervious. The uterus is then replaced and rather strongly ante- verted, the cervix and vagina douched with the bichloride solution, the parts cleansed, all soiled linen removed, and the patient placed in bed. FIG. 714. Appearance of Raw Surfaces and Introduction of Sutures in Wedge-shaped Excision in Lacerated Cervix.—(MUNDE.) - The after treatment is in most cases simple, consisting mainly of douches of hot water, to which may be added carbolic acid making a strength of about 1 to 100, or boracic acid. These douches are to be given as soon as the discharge commences, and may be administered as often as two or three times a day. If the patient can pass urine unaided, it is best to let her do so; if she cannot, it must be drawn every six or eight hours, according to her individual requirements. She should not leave her bed until the stitches are removed, which can usually be done on the seventh or eighth day. No harm, however, results from their remaining in situ for a much longer time. If secondary hamorrhage should occur, which is not common, it can be controlled by injections of hot water, or hot water to which has been added Some astringent, as alum, tannic acid or iodine; or a tampon, soaked in glycerine and covered over with powdered alum, can be placed against the CeIV1}{. Cellulitis and peritonitis, should they arise, are best controlled by in- ternal medication, to which may be added the liberal use of hot water as a douche, or in the form of the coil, or applied to the abdomen by means of flannel wrung out in it and laid upon the hypogastric region and covered first with oiled silk and then with three or four thicknesses of dry flannel. These must be changed as often as they become cold. If the case progresses favorably, the stitches are to be removed on the seventh or eighth day. If perineorraphy has been performed at the same time as trachelorraphy, the perimeal stitches had best be removed about the tenth day, and the cervical sutures allowed to remain three or four weeks longer. No harm will occur from the presence of the stitches in the cervix. In removing the stitches, the twisted end of the wire is grasped with a pair of long dressing forceps and the sutures cut with the scissors or preferably with a wire-cutter having a hook-like projection at its end, which can be inserted into the loop. It is necessary to exercise care not to cut the twisted portion of the wire just above the loop, which is exceedingly easy to do, and causes great difficulty in subsequently finding the loop. If it be lost, it is best not to irritate the parts too greatly by searching for it, but to allow LACERATIONS OF THE CERVIX UTERI. 1065 it to remain until the cervix is somewhat reduced in size, when it can be more readily found. e If, on attempting to remove the stitches, the operator finds that union has not taken place, or still worse, that sloughing has occurred, he must freshen the surfaces with a probe, knife, or scissors, tighten the wire a trifle, if necessary, and allow it to remain quiet another week. If the parts have sloughed badly, so that there is no prospect of union, the stitches must be removed and the parts healed by the argentum nitricum solution, in strength of from 20 to 40 grains to the ounce. - The benefit to be derived from trachelorraphy is not always measured by the perfection of the union of the parts. If the cicatricial tissue be removed from the angles of the cleft and the parts healed without its redevelopment, the same good results usually follow. Nature smoothes down the project- ing lips, fills up the gap, and transforms sometimes apparent failure into a fair success. The beneficial results of trachelorraphy do not always immediately follow the operation. In certain cases, even of long standing, the tormenting head- ache or backache will disappear as if by magic as soon as the patient re- covers from the influence of the anaesthetic, and she will obtain the most refreshing sleep which has visited her for years. As a rule, however, there is gradual improvement, which must be measured by months; and it is not unusual for a year and a half or two years to elapse before the patient realizes the full benefit of the operation. Not infrequently, as the result of the mental excitement and the mechani- cal irritation of the parts, menstruation will appear. This ordinarily causes no disturbance, nor does it seem to exercise any prejudicial effect upon the healing process. It is well to omit the douches during the catamenia. Trachelorraphy is an operation remarkably free from surgical danger. A few fatal cases are reported, but it is unusual for the operation to imperil more than the immediate comfort of the individual. Failure to unite occurs in about eight per cent. of cases. After the operation, the uterus gradually returns to its normal size, the subinvolution and hyperplasia disappear, the cervix gradually resumes its conicity, and becomes covered with healthy mucous membrane. The endometritis and endotrachelitis, with their accompanying leucorrhoea, usually subside in from a few weeks to several months, and the menstrual flow becomes more free from pain, and gradually approaches its normal standard. - Dr. Van de Warker, in the American Journal of Obstetrics and Gynaecology, £i July, 1883, gives the result of thirty-one cases of trachelorraphy, as follows: - Uterine displacement unchanged in . tº e * > © e º . 16 Uterine displacement removed in © * ſº º * Q * . 11 Uterine catarrh unchanged in . e gº & to º e * - 10 Uterine catarrh removed in º e sº * tº ge {} * . 11 Subjective neuroses unchanged in e * º {} . e . . 3 Subjective neuroses improved or removed in . { } e tº . . 16 Nutrition improved in . e º e tº tº ſº te º tº . 18 Nutrition unchanged in tº º ſº & © & ſº ſº * > . 5 When the cervix is properly healed, there appears to be no more danger of a laceration at a subsequent pregnancy than existed prior to the opera- tion. - Drs. Goodell, Hunter, Skene, Lee, Emmet, and many others, have re- ported, through the medical journals, numerous cases of pregnancy follow- ing trachelorraphy with no impairment of the natural continuity of the 1066 A SYSTEM OF SURGERY. cervix. The subsequent history of the operation shows that laceration is no more apt to occur, casteris paribus, than in one whose cervix has never been torn. The effect of the operation upon sterility, which I cannot consider at any length, is uniformly good, except in those cases where for various reasons, such as the establishment of the menopause, the after effects of severe in- flammatory action, the advanced age of the patient which predisposes towards a failure to become pregnant, the patient is rendered incapable of impregnation. In the New York Medical Journal, of July, 1883, Dr. B. F. Baer reported six impregnations following out of what he regarded as a possible eight. It needs, however, great exclusive ability and propensity to justify this pro- portion. In the following number, Drs. Githens, Lee, Montgomery, and Goodell, reported numerous cases of pregnancy following the operation. Dr. Emmet remarks that the effect of trachelorraphy upon sterility is good providing the pelvic organs have not been too greatly injured by inflam- mation; that, after preparatory treatment, pregnancies are of very common occurrence without subsequent laceration. Under favorable circumstances there can be no doubt that trachelorraphy, properly performed, exercises a very beneficent action upon the sterility, as well as upon the symptoms, local and reflex, dependent upon a severe laceration of the cervix. CHAPTER XLIX. OVARIAN TUMCRS. ForMATION.—VARIETIES-ForMATION OF COLLOID—OF DERMoID—FIBROUs AND FIBRO- CYSTIC—DIAGNOSIs–PSEUDOCYESIS-PREGNANCY—PAROVARIAN CYSTs—ENCYSTED DROPSY OF THE PERITONEUM-ASCITEs—MICROSCOPICAL ExAMINATION OF THE FLUID—ALBUMINOID—MALIGNANT DISEASE—TREATMENT—THE PERFORMANCE OF OvARIOTOMY AND SUBSEQUENT MANAGEMENT. - IF it be true that each ovary contains 300,000 Graafian vesicles, the healthy function and anatomical peculiarities of which tend toward the production of cystic formations, it can readily be seen why certain morbid processes can induce a hypertrophic degeneration of some of the component parts of these vesicles and their surrounding stroma, and that cystic for- mations should result so frequently. Indeed, it has been well said by Mr. Tait,” “The function of the ovary is one of cyst-formation from its earliest existence to its latest, and in its pathology we need not go far away from its physiology.” * * Of course the majority of this immense number of Graafian vesicles are either atrophied, or lie latent in the ovary, and comparatively few of them develop and rupture, although this process is said to be going on in the body from the time of birth. It is affirmed that ovisacs are being con- stantly ruptured before puberty, the ovum being thrown into the peritoneal cavity, where it perishes. The sac then fills with blood, a portion of which also enters the abdomen, and there gives rise to little disturbance, being rapidly absorbed, or if a large extravasation be poured out, may produce and explain certain varieties of haematocele. From this it may be said that the first and simplest variety of ovarian cystoma arises from the dropsical * Diseases of the Ovaries, p. 140. OVARIAN TUMIORS. 1067 enlargement of the Graafian vesicle, and we can understand the rationale of the appearance of these tumors in the very young subject. Dr. T. G. Thomas” describes a case where, a month after birth, a tumor was developed in the iliac fossa, about as large as a hen’s egg. The child lived in an ex- hausted condition until it was three years and five months old, and then died. Post-mortem examination revealed an ovarian cyst filling the ab- domen. The probability is that this tumor was a parovarian cyst, for Dr. Thomas states that “the Fallopian tube and ovary '' were upon one side of the tumor. Dr. Basil, of Bonn, and Mr. Folker, of Hanley, f have per- formed ovariotomy, the first upon a child of two, the second upon a patient aged three years. Mr. Mills has operated upon a child of eight years, and in a contribution to the Medical News f it is related that Dr. Roemer actually performed ovariotomy upon a baby eighteen months old, the patient making a good recovery. From these facts it seems proper to deduce the opinion that many cases of ovarian cystomata are to be traced to the succes- sive enlargement of the Graafian vesicle until it finally becomes a patho- logical cyst. Indeed, up to the year 1848, the origin of all ovarian cysts was supposed to lie in these bodies, $ and even now, there is reason to believe that they alone give rise, either through one or another pathological pro- cess in the development of the vesicle, to cystic tumors. Dr. Emmet, as late as 1879, quotes Schroeder as follows: “ They (the cysts) occur singly, or the whole ovary becomes, through a repetition of the same process in numerous Graafian vesicles, converted into a tolerably large tumor, which presents, on Section, a multilocular cystic appearance.” Thomas'] quotes Rokitansky : “They are undoubtedly formed from the Graafian follicles, and it appears that an inflammatory process is particu- larly liable to give the first impulse to this metamorphosis. ... They are prob- ably, however, as often new formations from the beginning.” Thus, Courty, also quoted by Thomas: “In a word, these cysts are drop- sies, simple or complicated, of the Graafian follicles.” Rokitansky is of opinion that ovarian cystoma may arise from a corpus luteum, which Emmet substantiates, he having seen a cyst of the corpus luteum in the ovary of a woman who had died of a haemorrhage during miscarriage.* - Virchow at first, afterward Forrester, Rindfleisch, Maywig and others, have apparently demonstrated, that the proliferating cystomata have their origin in a colloid degeneration of the stroma of the ovary; that epithelium is not found in the smaller cysts, it only being developed in the larger and older formations. This doctrine appears to be at variance with that of de Sinéty and Melassez, Wills, Fox, Klob, Waldeyer, and others, who contend that the earlier cysts are developed by a dilatation of Pflüger's ducts, through the medium of the germinal epithelium. The ovary is composed of a cortical portion known as the germinal epithe- lium formed of cells rather columnar in arrangement, with granular nuclei, and an internal stroma also composed of epithelial cells in columns, be- tween which latter a vascular stroma of spindle-shaped cells is found ; in this tissue are small tubuli known as #. ducts. These lie chiefly at the base of the ovary, and it is said that through the pathological de- velopment of these germinal epithelia, ovarian cysts have their origin. * American Journal of Obstetrics, 1880, p. 110. f Wide Tait's Diseases of the Ovaries, p. 135; also Medical Record. i March 15th, 1884, p. 135. - 3 American Journal of Obstetrics, 1880, p. 2. | Principles and Practice of Gynaecology, p. 760. T Diseases of Women, p. 648. * Loc. cit., p. 760. 1068 A SYSTEM OF SURGERY. These “ovular chains " of Pflüger are, according to Heintzman,” nothing more than prolongations of the germinal epithelia “in the shape of tubules and Solid strings, which at first are connected, holding in their centres large rows of nucleated epithelia.” As these ducts, however, are considered as foetal structures, which are removed with advancing age, one of two facts must be deduced, either that certain ovarian cystomas begin their development during the embryonic existence, or that the tubes, in many instances, remain in adult life. , Tait, on the other hand, differs materially in his opinion regarding these ducts, saying that if they (Pflüger's ducts) are found they are but the re- mains of the Wolffian structures, and that he has never seen them “lined with epithelium,” and he does “not believe them capable of undergoing cystic degeneration.” An argument in favor of the development of cystoma from these tubes might be found in the appearance of cystoma ovarii in many young children. : Still another method of development has been advanced by Noeggerath.i. His idea is, that a certain number of cystic tumors of the ovary (adenoma cylindro-cellulare) arise from diseased bloodvessels of the gland. The in- tima of the vessel first becomes diseased and its lining membrane is de- stroyed, then the intima itself is broken up by migrating cells accumulat- ing about it, leaving tubules. He states further, “I have no longer any doubt, having seen all the stages of development from the beginning of the alteration to the very last determination, that a great deal of what has been described hitherto as corpora ablicantia and lutea are nothing but degen- erated blood vessels,”f and again at the end of his paper he says, “I, there- fore, conclude that in a certain number of instances, the epithelial tubes found in ovaries as precursors of ovarian cysts do not derive their origin from the germinative epithelium, but from the tissues composing the capil- lary bloodvessels.” Here we have three different opinions, all possessing weight from the character of those who have promulgated and developed them. The defenders and originators of the idea that the “proliferous cyst,” “ myxoid epithelial cyst,” “gelatinous or colloid cyst,” arises essentially from the distension and degeneration of the Graafian vesicles, are met by those espousing the origin of the formations to be originally in the enlargement of the tubes of Pflüger—with the remarkable fact that none of the cysts are found to contain ovules or proligerous disks, and as Cornil and Ranvier say, Ś neither is there found any trace of ovisacs or Graafian follicles, the ovary being completely transformed into cysts analogous to those we have de- scribed. Therefore, the hypothesis of a formation of the cysts by the dis- tension of pre-existing Graafian vesicles cannot be accepted. Mr. Tait, however, in his decided manner explains the non-appearance of ova. He says, “I am quite strengthened by my later researches, as well as by those before referred to, in the views I advanced eight years ago to the effect that ovarian cystomata are the result of follicular dropsy only,” and he goes on to state that in all his cases save two which he calls mul- tiple cystomata, he has failed to see anything like ova in any cysts of any tumors he has examined. He further explains this absence of ova as follows: “The aim and object of this cyst formation (healthy function of the ovary) is the production, maturation and discharge of the ovum. But if the ovum * Microscopical Morphology, p. 826. - + Am. Jour. of Obstet, 1880, p. 1; Diseases of the blood vessels of the ovary and their relations to ovarian cysts. - I Am. Jour. Obs., 1880, p. 9. ź Manual of Pathological Histology, p. 681. OVARIAN TUMCRS. 1069 be not formed, or if it be produced only in a rudimental extent, may it not happen that the cyst will not be ruptured, but go on aimlessly expanding?” There appears to be a great deal of common as well as of scientific sense in these remarks of Mr. Tait. The tumors of which he speaks are those which grow with rapidity, and may frequently take on malignant degenera- tion, whereas those neoplasms which he denominates “multiple cystomata” or “Rokitansky's tumors,” are of much smaller size, are rather rare in their occurrence, and within the cysts, ova are found ; in this variety also both ovaries are affected. - From this hasty sketch we perceive that ovarian cystomata may arise from the following conditions: - 1. Follicular distension of the Graafian vesicles. 2. Degeneration of the corpora lutea. 3. From colloid degeneration of ovarian stroma. 4. From the ovarian bloodvessels. 5. From the ducts of Pflüger. (Enclosed germ epithelium.) 6. From a retrograde metamorphosis of the Graafian vesicles and stroma (malignant formation). With all these theoretical explanations of the formation of ovarian tumors one is likely to “confound the categories,” as logicians say, and to get the matter much entangled. The tumors may all be classed generically as adenoma, because they arise from and absorb a gland; and I can see no reason for classifying a dropsically enlarged Graafian vesicle in one category, and the other varieties of formation as cystomata. There appears no very potent theory to oppose the proposition by Mr. Tait, that ovarian cystomata develop from Graafian follicles only, and this is the more plausible when we remember the powers of development residing in the area germinativa, and that in the centre of the Graafian vesicle there is a cavity containing albumen. These tumors, with all their high-sounding names, divisions, classifications, and microscopic revelations, are all epithelial in their begin- ning, nothing more, nothing less. We may say, for instance, that certain forms of these neoplasms originate in the glandular parenchyma. So they do, but what generates the glandular parenchyma but the epithelium ? We say that certain of these tumors arise from Pflüger's ducts; this may be also true, but what are these ducts but a division and transformation of epithe- lium ? We may state again that ovarian cystomata arise from the Graafian follicle, but what are the follicles derived from save Pflüger's ducts, which arise from modifications of epithelium ? We know one thing, that in whatever manner these growths arise, after they are mature they present varied appearances, and may be classified with more certainty, thus: - The simple dropsy of the Graafian vesicles. The myxomata embracing the two most noteworthy species. (A.) Glandular cysts (cystoma ovarii proliferum glandulare). (B.) Papillary cysts (cystoma ovarii proliferum papillare). Dermoid cysts. . Cancerous cysts (cystoma maligna). - Strictly speaking, there is no such thing as what is familiarly known as a unilocular cyst of the ovary. De Sinéty and Melassez say, “among all the cysts we have examined, we have not found one which was truly unilocular; all those sent to us as such, presented truly a large principal cyst, but on examining them with care, we have always found other cystic cavities, sometimes small enough, it is true, to pass unperceived on a first examination.” Tait says,” regarding this appearance: “This conclusion I can entirely substantiate.” He then gives a lucid explanation of the appearances.f “The formation,” he says, “ of a compound cystic tumor * Diseases of the Ovaries, p. 136. f Tait, Diseases of the Ovaries, p. 138. 1070 A SYSTEM OF surgery. in the ovary, whether it be of the multiple variety or of the less complete kind of which I am about to speak, may be very well illustrated by blowing Soap-bubbles in a basin. If the fluid be not viscid enough to enable the cells to retain their form, then the normal condition of the ovary is repre- sented, its cells bursting and disappearing. Let us suppose that the cell- growth is constantly going on, and that some alteration occurs in the state of matters which prevents the cell-walls bursting; the fluid in the basin is So viscid that the cells do not break, and bubble after bubble is formed, some larger, some smaller, until a large multicystic tumor is the result. The actual appearance of the cystic ovary may be very well imitated in the basin of soap-lees. A large cyst can be made with little ones crowding into it, looking like its offspring, and the walls between two or three may be broken down, making one larger multilocular—the remains of the interven- ing walls not being left in the instance of the soap-bubbles. Dropsy of the Graafian Vesicles.—The physiological performance of the follicle is to develop and burst; if, however, this metamorphosis does not take place, a retention cyst is formed, and as several of these coalesce the cell-walls may disappear, allowing the secretion to remain, and thus account for the production of the cyst. Cystoma Proliferum Glandulare.—In this a new formation takes place within the walls of the sac, originally arising (according to Waldeyer) from imperfectly formed Graafian follicles; in other words, Pflüger's ducts. The outlets of these glands are obstructed, the cyst enlarges by proliferation, each new group pouring out new cells to develop new formations, the pro- cess continuing until an innumerable number of cysts are produced. I have observed several such cases, one especially in which the operation was performed at the New York Surgical Hospital, while Dr. Dillow was the house surgeon, the count was made up to 118 cysts, and was then discon- tinued. These were of the larger size, but there were innumerable dimin- utive cysts scattered all over the cyst-wall, and budding out as the soap- bubbles already described.* The Cystoma Proliferum Papillare differs from the foregoing in that, in this variety, the connective tissue proliferation exceeds that of the adeno- matous. The connective tissue becomes hypertrophied from excessive nourishment, the epithelia are pushed forward into the cyst, and thus a papillary growth is produced. In some instances the pressure of the hypertrophied epithelia is too great for the cyst-wall and it ruptures. . I have frequently met these dendritic processes scattered irregularly over the cyst-wall, sometimes in patches and sometimes covering the entire surface. But I had two remarkable cases of complete papilloma of both ovaries, which were removed by me at the Hahnemann Hospital. A similar condition to that described is found in the testicle, the an- alogue of the ovary, arising from a proliferation of the epithelia from the tubuli semeniferi, and probably produced in the same manner. This fungoid growth has been mistaken for encephaloid or vegetating epithe- lioma, but is perfectly bland and receives the name of “benign fungus.” Formation of Colloid.—Colloid material is nearly allied to protein sub- stances, and mainly consists in the albuminous transformation of tissues varying much in consistency, sometimes being about the density of egg albumen and again presenting an almost solid appearance. These altered albuminates contain sometimes a certain proportion of mucin, a substance insoluble in acetic acid and soluble in alkalies, although as a rule this latter ingredient is absent in the colloid of ovarian cystoma. These myxomatous products arise not so much from a true metamorphosis of tissue, as from a * New England Medical Gazette, July, 1877. OVARIAN TUMIORS. 1071 modified secretion from or transformation of epithelial elements. In the young cyst the colloid material is more dense than in the larger and older ones, the fact being explained by some * as resulting “in a slow digestion of these crude substances” by the prolonged and constant action of the heat of the body. * It must be remembered that there is both an innocent and a malig- nant colloid material found in these cysts and which it is important to understand. I believe that a broad line cannot be drawn between the two, as myxomatous or mucoid formations are composed generally of imper- fectly formed cells which, instead of proceeding to a perfect and mature development, assume a retrograde metamorphosis, resembling in many respects the appearances presented by cancerous structures. This is proven by the fact that after an apparently successful ovariotomy, carcinomatous formations may speedily destroy life. I have had occasion to observe this in several cases. In one infiltration and cachexia commenced before the abdominal wound had entirely cicatrized, in another there was a large ascitical accumulation, the patient returned home apparently cured, but in eleven months reëntered the hospital with well-developed cancer of the omentum with large colloid accumulation. She was aged forty-seven, and had given birth to one child. According to Dr. Beyer, whose papert Heintzman gives in full, colloid cancer is not to be classed as a separate species, but as arising from secondary changes in the encephaloid or medul- lary cancer. He says: “In the same manner as cancer elements arise from medullary elements, so may fully developed epithelia under certain unknown conditions retrogress to medullary elements. Whenever this Occurs, medullary corpuscles are transformed into a reticulum, containing a jelly-like, homogeneous basis-substance, with interspersed remnants of epithelia.” - And again Pepper says i : “Colloid cancer is built upon the same struc- tural type as scirrhus and encephaloid. It bears a close resemblance to the latter in its clinical features, being rapid in growth and quickly fatal. . . . . The consistence of these tumors is subject to wide variations, but for the most part they are very soft, sometimes diffluent. When springing from the ovaries they may be mistaken for simple cystic formations. . . . . The de- generation commences in the cells; first a drop appears in the protoplasm, and as it enlarges the nucleus is thrust to the margin. Finally nuclei and cell capsules disappear, the change advances from the centre to the peri- phery, and the outside cells, prior to their destruction, become compressed and elongated and occupy a concentric position. The stroma undergoes a similar alteration, it softens and liquefies, so that the contiguous alveoli run together forming festooned cavities.” The Formation of Dermoid Cysts.-There have been many theories propa- gated regarding the origin of dermoid cysts, some indeed at the present day regarding them as foetal remains (foetus in foetu), or ovarian pregnancy. These conclusions have been proved erroneous. The argument against such hypotheses is the appearance of bone, hair, teeth, lime, etc., in other portions of the body and in both sexes. The majority of the profession appear to agree as to the congenital origin of these cysts. Waldeyer's views are generally accepted, although founded on no very recent experiments. He is of opinion that these tumors arise from the epithelial cells of the ovary, each of which is capable of becoming an ovular cell, and by some morbid process to proceed to incomplete embryonic development. * Peaslee, Ovarian Tumors, p. 33. i Medical Gazette, New York, April, 1880; Microscopical Morphology, p. 551. † Elements of Surgical Pathology, London, p. 482. 1072 A SYSTEM OF SURGERY. “Now it may very well be assumed that the epithelial cells of the ovary, in conformity with their significance of undeveloped ovular cells, furnish in their multiplication or division, and by budding, other products, and in fact such as are further advanced in the direction of an incomplete em- bryonic development than they themselves are.”* Tait supposes that during the developmental period of life a stimulus is given to a Graafian vesicle with its ovum, which, if it were not disturbed, might in time be carried into the uterus and there impregnated. On the contrary, if it remain in the ovisac and there “share alike with the rest of the economy in developmental activity, there could be only one result, and that would be the formation, in an incomplete degree, of those structures which it would evolve in perfection under more formidable conditions.”f I think the best solution of the question is that of the invagination of the blastodermic membrane, the external layer of which develops the organs of animal life. If, therefore, there should be an enclosure of any part of this membrane within any organ of the body, these epidermal formations would readily be produced. - In this variety, the wall is thickened, and consists of two layers. I have seen a cyst that could be separated into six laminae. The older the cyst- wall becomes, the more are these concentric layers of deposit arranged within it. * There are fat-globules and masses of fat on this layer, which may be mis- taken when opening the cavity for the appendices epiploicae of the omentum. The inner layer is skin, in which some observers have found not only the ordinary sebaceous glands, but also hair-follicles and sweat-glands. This skin presents the anatomical formation of the derma, and has often the papillary body and the chorium well developed. The contents of the cysts are various, -hair, bones of various and peculiar conformation, teeth, fatty or cheesy (vernix caseosa) matters, lime, and cholesterin crystals. I have seen several such tumors. One, in a patient aged twenty-seven years, weighed in all forty-three pounds, twenty pounds of which were contained in one large cyst, opening into which was a smaller one twelve inches in circumference, filled with sebaceous matter, hair, and lime; in another cyst were dark hair, bones, and teeth, and in one sac was a bone resembling the superior maxilla, containing perfectly formed teeth, with various other pieces of curiously formed bones. In another case there was some doubt as to the true nature of the tumor, but it proved to be a dermoid cyst, containing fourteen pounds of sebaceous material, first coming out like bullets, and then having to be scooped out with the hands. The substance was actually packed together, and was inter- mixed with a quantity of long, dark hair. My last case of the kind was in June, 1886. There were seventy-six bits of bone, with hair, lime, and much colloid material in the cysts. Parovarian Cysts.--It is necessary to say a few words regarding these, which have generally been called cysts of the broad ligament. They are peculiar both in diagnosis and treatment. As the testicle has an accessory—the epididymis, so has the ovary—the parovarium, which is the remains of foetal life, tubular in structure, and coming from the upper and outer surface of the ovary. It is also called the paraöorphoron. These bodies are really portions of corpora Wolffiana, which are tubular structures and are the primordial kidneys. When the kidney is formed some of these tubules remain undeveloped, and are con- nected with the ovary, as already noted, and are lined with epithelium. * Emmet, Gynaecology, p. 767. f Tait, Diseases of the Ovaries, p. 180. OVARIAN TUMQRS. 1073 These tubules vary in their number, from three to forty, always having cascal extremities, and generally showing a larger duct, known as that of Rosenmüller. It is from the lining membrane of these tubes that the cyst-formation develops. The duct of Rosenmüller can also be traced with clearness. Fibrous and Fibro-Cystic Tumors of the Ovary.—These neoplasms are of rare occurrence, and are generally small (about the size of a cocoanut), although they sometimes attain great magnitude. They are difficult, espe- cially when they have become cystic, to diagnose from the true ovarian cystoma, and operators have frequently been led, by the similarity of appearances in the two varieties of tumor, to mistake one for the other. It has been doubted whether the ovary ever develops a true fibroma, the idea being that the majority of such neoplasms have their origin in the uterine tissue. I think there can be no doubt regarding the existence of fibroma of the ovary. The solid fibroid by its deterioration may become cystic. I was called to Corning, New York, by Dr. Bryan, to operate upon an ab- dominal tumor. The abdomen was conical, fluctuation was perfect on the left side, but a solid tumor, smooth and elastic, extended above the umbilicus. The usual incision was made, and a white, shining, fibrous mass presented. There were no adhesions anteriorly, and upon introducing the hand, the uterus could be felt, but posteriorly the growth was everywhere adherent, it appeared perfectly immovable; upon introducing the hand into the left lumbar region the fluctuating part of the mass could be detected, but I could not bring it sufficiently up to the line of incision to introduce the trocar. I therefore deferred the tapping until a future occasion, and closed the wound. The patient recovered rapidly. Shortly after Dr. Bryan wrote me, “The fibrous portion of the tumor has diminished, the cystic has in- creased ;” and in a letter a year later, stated that he aspirated the patient, removing about thirteen pints of fluid, and that he could find no signs of the hard fibrous tumor. The best explanation of the transformation of the solid to the liquid tumor is made by Coe,” who has given a great deal of study to the subject. In his sixth conclusion he states, “such cysts probably arise from the so- called ‘geodes' or gelatinous patches,” and in his eighth conclusion he affirms: “The geodes are probably dilated lymph spaces, which expand by reason of the accumulated fluid in their interior, a condition due to a gen- eral stasis.” The original fibrous tumor (solid) develops from the stroma of the ovary itself, and its rareness may be accounted for by the fact, that the ovary is for the most part cystic in body and in function. Diagnosis.—In some instances this is easy and in others it is difficult. The latter fact is verified by the experience of those who have had extended opportunities for observation. Mr. Taiti thus writes, “I have more than once opened an abdomen under the complete belief that I should find an ovarian tumor, but have found only masses of cancer with an abundant ascitic effusion;” and again he refers to a case thus, “I diagnosed a parova- rian cyst, and in a few days I opened the abdomen to remove it; I found, however, that it was not a cyst of the broad ligament, but a dropsical dis- tension of the lesser cavity of the peritoneum, due to the occlusion of the communicating cavity by peritonitis.” I believe, if all the mistakes which have been made were to be recorded, an interesting volume could be written. It would profit both the surgeon * Am. Journal Obstetrics, 1882, p. 877. f Diseases of the Ovaries, p. 218. 68 1074 A SYSTEM OF SURGERY. and the patient. Dr. Atlee refers to such cases, and on one occasion diag- nosed a swelling of the abdomen as an ovarian cyst, and appointed a day for the operation. Shortly after, the birth of a healthy infant prevented the necessity of further interference. Goodell says:* “Once an enormously distended bag of water broke, just as a deservedly eminent British sur- geon had rolled up his sleeves, and was about to wheel his patient into an amphitheatre, crowded with spectators to witness an ovariotomy; and a surgeon, of whom Great Britain can well be proud, drove a trocar into the ºuis of a foetus under the idea that he was tapping one of these cysts. I was sent for to give an opinion in the case of a lady said to be preg- nant, and who had passed a month beyond her time. The nurse was at hand, the baby basket was furnished, the cord and scissors were arranged in their proper places, and a bureau full of clothes awaited the arrival of the stranger. The foetal heart was said to have been distinctly heard by a professor and another medical man of repute, and the family were anxious for the expected event. The introduction of the aspirating needle proved the fallacy of their expectations, and the removal of a tumor of forty pounds dispelled the illusion. - The characteristics for diagnosis are: 1. Prominence of the abdomen, it being conical in shape; lower ribs bulging. - - 2. Not much change in the shape of the belly when changing position. 3. Clear sound on percussion around flanks and high up on the tumor. Often the line of the cyst may be made out by this alone. - 4. No bulging or fluid between recti muscles when the patient rises from the dorsal decubitis. - 5. As the patient turns from the side to the back, there is but slight flat- tening of the abdomen. - 6. Enlargement of the abdominal veins. 7. Pulsations of the aorta generally felt through the abdominal walls. 8. Decided fluctuation all over the cyst, modified in some portions, espe- cially in multilocular cysts. 9. Fluctuation more distinct in the recumbent position than in the erect (the contrary the case in ascites). 10. The facies ovariana well marked in most cases, with emaciation about neck and shoulders. 11. The fluid contains the ovarian granules (Drysdale's corpuscles). 12. Fluid generally contains much albumen, though it does not coagulate spontaneously. - 13. The uterus is, in most cases, found behind the cyst. Tumors presenting these symptoms will be found to be true ovarian, either monocystic or polycystic, the latter being generally made out by the uneven surface of the abdomen. Pseudocyesis.--There is a condition known as phantom tumor (pseudo- cyesis). I have seen two cases, one in the practice of Professor Burdick, the other in that of Professor Danforth. I examined both of these patients, and in both there was certainly a bewildering resemblance to abdominal tumors. The abdomen was large and firm, and presented dulness on per- cussion in certain areas while resonance was distinctly noted in others; there was also that peculiar gurgling sound that leads one to the conclusion that the tumor is of the phantom variety. Complete anaesthesia rendered both the abdomens flat, with considerable relaxation of tissue. * Lessons in Gynecology, p. 352. # For further information refer to Thomas, pp. 655, 657, also to Emmet, p. 776. OVARIAN TUMIORS. 1075 Sterile women are more frequently affected with the disorder than the fruitful, and those suffering from it are generally hysterical and neur- asthenic, crave sympathy, and invariably grieve because offspring is denied them. Pregnancy.—Difficulty in diagnosis is sometimes experienced by the prac- titioner in cases of young unmarried women, whose abdomen has suddenly enlarged after suppression of the menses. Such a case was brought me in June, 1883. The patient was twenty-two years of age, had been living in a malarial region, her menses had ceased, she had experienced some sore- ness of the breasts, had failed in general health, and had steadily enlarged in the abdomen. Her sister suffered great anxiety concerning her, not knowing whether pregnancy existed. Upon examination I found the ab- domen conical, with dulness over its entire surface, no fluctuation percepti- ble, and the introduction of the aspirating needle drew no fluid. Knowing that, in such cases, the physician must be skeptical to the last (for women have stoutly denied their pregnancy with the head of the child protruding through the vulva), I questioned her closely, but she declared her innocence in such positive terms, that I was fain to believe her. However, I did not introduce the sound, and proposed an exploratory operation. She readily consented, and though she was suffering from malarial fever, with a pulse of 120 and temperature of 102°, yet she was failing so rapidly that I operated at once, removing a cyst weighing thirty-five pounds. An excellent rule in such cases (I mean those occurring in young unmarried women, in whom the menses have disappeared and the abdomen has steadily and symmetri- cally enlarged) is to delay a few months, listening from time to time for the foetal heart, and keeping such watch upon the patient as may facilitate diagnosis. When we find a tumor arising from the pelvis, it will be advisable to in- quire if it may not be a gravid uterus, and by assuming such to be the case until it is proved to the contrary, the mistake of attempting ovariotomy on a pregnant woman will be avoided. I give here the differential diagnosis from Peaslee. NORMAL PREGNANCY, FIVE AND A HALF OVARIAN CYST, SECOND OR THIRD MONTHS OR MORE. Enlargement sudden and rapid; symmetrical or slightly inclined to the right side. Features natural, healthy. Superficial veins of abdomen not enlarged. CEdema in ankles not uncommon after seven months. Chest not conical. Fluctuation indistinct, unless there is much liquor amnii. e Menstruation arrested. Vaginal touch detects softening and apparent shortening of the cervix and enlargement of the uterus. Ballottement feels impulse of foetus. Foetal heart-sounds heard. - Foetal movements felt. Enlargement of mammae. STAGE. Enlargement gradual; not symmetrical till the third stage. . Features emaciated, anxious. Veins are enlarged ; oadema in late stages; in exceptional cases one to two years after COmmencement. Chest conical, when there is great disten- SIOI). - Fluctuation very distinct, especially in mono- CyStS. Menstruation does not cease till third stage. No such change apparent, but uterus gener- ally displaced behind the cyst. Ballottement reveals nothing. No sound of foetal heart. No motion of foetus. Occurs but exceptionally. Parovarian Cysts are diagnosed from ovarian cysts by the character of the fluid. It is clear and limpid, like spring-water. It is, however, wrong to lay down as a rule that this fluid contains no albumen; in certain cases it does, and in large quantities. Another characteristic of this fluid is its * 1076 - A SYSTEM OF SURGERY. power of resisting decomposition. I have known it remain a week or ten days without showing signs of degeneration. Here the microscope aids the diagnosis. By referring to Dr. Atlee's work, it will be found that on several occasions an Ovarian tumor was diagnosed by skilful physicians, when a cyst of the broad ligament was found. In most cases, a first or second tapping will be sufficient to cure. These tumors generally occur in young females, and if a pregnancy exist may be cured by this alone. Dr. Terillan, after giving some important information regarding parova- rian cysts, arrives at the following conclusions:* - 1. Parovarian cysts, the fluid contents of which are limpid, not stringy and devoid of paralbumen, return after complete evacuation of their con- tents. 2. This return, though usually slow, and possibly occurring after an in- terval of three or four years or more, may occur within a few months. 3. The interval of time between tapping and the return of the fluid is such as to simulate complete cure, a.º. proved a source of error. 4. It is difficult to say in what proportion of cases the tumor returns, but it is more often the rule than the exception. 5. There are some well established cases, though few, in which a complete cure has been obtained after one or more tappings. 6. Ought tapping, therefore, always be practiced in supposed cases of par- ovarian cysts? 7. Removal, complete or incomplete, is indicated after relapse; the results are good, being below fifteen per cent. 8. Removal is preferable to the injection of iodine. Encysted Dropsy of the Peritoneum.—In the majority of cases of chronic pelvo-peritonitis, whether or not occasioned by tuberculosis, an effusion takes place in the lower space; of this I have seen an interesting case, asso- ciated with hard cancer of the uterus. The fluid collected in the cul-de-Sac of Douglas was evacuated readily by a small trocar, and the next night the patient died. This is contrary to the experience of Brickell,i but I am persuaded that in pelvic effusions, unaccompanied by cancerous or tuberculous disease, the result of the withdrawal of the fluid is satisfactory. Peasleef says of encysted dropsy: “This is an extremely rare patholog- ical condition ;” in his carefully prepared chapter on differential diagnosis, many symptoms are laid down, which I believe to be inaccurate. Ziemssen Š lays stress on the “sensitiveness” that presents, although he grants that it may be “exceedingly slight, or altogether wanting.” He says, also, “In cancer of the peritoneum and omentum, the cancerous modules may sometimes be felt in the exudation surrounding them, yet these very cases bear an extraordinary resemblance to irregular multilocular ovarian cysts, which lie in a copious ascites.” And again he says: “If, through the diagnostic points already given, it has been ascertained that the collec- tion of fluid in the abdomen is encysted, the presumption is in favor of its being an ovarian cyst, since other forms of encysted fluid are much less common.” Dr. Routh || records three cases of this peculiar condition, which were diag- nosed by the surgeons to the Samaritan Hospital as ovarian cystoma. In one of these, Mr. Wells diagnosed an extra-ovarian cyst. All were tapped, and all died. * American Journal of the Medical Sciences, April, 1886. # Ibid., April, 1877, p. 358. i Ovarian Tumors, p. 155. ź Vol. x., p. 385. | Obstetrical Journal of Great Britain, April, 1874. OVARIAN TUMCRS. 1077 He thus finishes his paper: “These three cases, although all unfortunate, illustrate this point in practice, that where you have adhesions of the colon, and especially if the induration is more marked on the one side than the other, it is extremely difficult, if not absolutely impossible, to diagnose the pseudo- cyst from a real ovarian or extra-ovarian cyst.” Morgagni” also recognizes this variety of dropsy. He says: “But others (dropsies) are of a different kind, as that described by the celebrated An- hoinius; an almost incredible quantity of fluid being confined between the peritoneum and the omentum, which had become very hard, in a woman whose face, considering her emaciated state of body, was of a pretty good color, and whose feet were free from swelling.” Atlee's f 15th, 16th, and 17th cases were instances of a similar character. If the nodules can be felt through the abdominal walls, the fluid floating over them, the surgeon may be upon his guard, but no clear diagnosis can be made without the withdrawal of the fluid and subjecting it to the micro- SCOTO €. Rºumulations of fat beneath the skin of the abdomen, which are often found in women between the ages of thirty and forty years, have sometimes been mistaken for pregnancy, and also for tumors of the ovary. But as the signs of ovarian tumor are absent, such a mistake would not be readily excused. - Ascites.—I give from Peaslee the differential diagnosis between ascites and ovarian cysts. - ASCITES. OVARIAN CYST. The patient has previously enjoyed good health. History shows previous ill health, as dis- ease of the liver, lungs, heart, or kidneys. Enlargement comparatively rapid. Face full, puffy, leaden hue. Patient lying on the back, the abdomen is flattened in front, but symmetrical. Patient on side, the sides are flattened. Patient rising suddenly from the back, the fluid bulges between and to the sides of the recti muscles. In sifting posture, lower part of abdomen bulges, Skin of abdomen smooth, tense, and shining. CEdema of extremities in all cases, and at last of abdomen also. There is no bulging of the floating ribs. Navel prominent and thinned. Fluctuation decided and clear; diffused through the abdomen, but avoids highest parts in all positions, and always has a hy- drostatic level. More distinct in erect position. Percussion gives a clear sound at highest portions of abdomen in all positions; is dull elsewhere, and changes with the posi- tion. - Aortic pulsation not felt through abdominal walls. Fluctuation immediately felt through vagina Or rectum. Gradual enlargement. Peculiar emaciation of face. The tumor is not generally symmetrical, is prominent in front. Patient on side, no change. Patient rising in same manner, may cause some bulging, if not adherent. In sitting, there is little, if any change in abdomen. Skin of abdomen appears natural or only thinned. CEdema only in exceptional cases. The chest is conical from bulging of the false ribs. Navel not thinned. Fluctuation less clear and decided, limited by the cyst, and may remain at the highest points; has no hydrostatic level. More distinct, in recumbent position. Clearness on percussion only at parts not corresponding to the cyst, and in both flanks. Dulness over cyst in all positions. Aortic pulsations transmitted through the cyst to abdominal walls. Fluctuation not so clear, or may not exist in case of polycyst. * Essay on Diseases of the Belly, vol. iii., book iii., p. 350. f Ovarian Tumors, pp. 72–78. 1078 A SYSTEM OF SURGERY. ASCITES, Uterus normal in size, mobility, and posi- tion; sometimes prolapsed. Fluid light-straw color, contains albumin and amoeboid corpuscles; coagulates spontaneously. Anaemia comes on early. Hydragogues and diuretics produce tempo- OVARIAN CYST. Uterus generally displaced behind the cyst. Fluid darker shade; abounds in albumin or colloid matter, but contains no amoe- boid corpuscles; never coagulates sponta- neously. Anaemia appears late. This treatment produces little if any effect. rary relief. Exceptions to the above rules are rare; but occasionally, if there be a very large de- posit of fluid, even the highest point of the abdominal cavity will present dulness when the patient lies on the back. Or the intestines may be glued down by adhesions, in which case deep percussion may bring tympanitic sounds. One or both flanks may give a clear sound, from gas in the colon. Exceptions.—There may be a tympanitic resonance if the cyst communicates with the intestine. One or both flanks may be dull from faeces in the colon. In addition to the above, the presence of ovarian granules and columnar epithelium in the fluid from a cystoma, their absence in ascites; while in the latter are found amoeboid lymph capsules, the diagnosis can be made. Withdrawal of a Portion of the Fluid.—Enough has been said regarding the difficulties which surround the diagnosis of some forms of abdominal tumors, to show that it requires experience and care to arrive at a correct conclusion regarding them. A patient is brought to the surgeon with an enlarged abdomen; thin face, with peculiar expression; emaciated, es- pecially about the neck; dulness on percussion over the anterior parietes of the tumor, with resonance of the flanks; conical abdomen in all posi- tions, with enlarged abdominal superficial veins; an absence of cardiac or hepatic disease; a smooth surface, without nodules or hardness; and the inference would be that an ovarian tumor was present. Is it ovarian or parovarian 2 Is it an encysted dropsy of the peritoneum, or is it a colloid cancer of the ovary 2 Or does a cancerous condition exist in conjunction with an ovarian cystoma 2 The best aid to diagnosis in these cases is chemical and microscopical examination of the contents of the tumor. To obtain the fluid, it must necessarily be drawn from the abdomen, and although I am aware that some high in authority have expressed them- selves averse to the use of abdominal puncture, I have never seen any bad results follow the method I have adopted. I employ a syringe capable of holding about eighty minims, with a needle four inches in length. The quantity thus taken is sufficient for microscopical purposes, the puncture and pain are nothing, and I have performed this little operation in my consulting-room, and sent the patient immediately either to the hospital or her own home, and never have known evil consequence. The adhesions from so small a puncture are of little import, and the slight modicum of risk appears a trivial offset to the unfortunate results that might ensue from an error in diagnosis. In this I differ from Dr. Garrigues.* There is no more danger of the remaining fluid leaking into the peritoneal cavity, if the puncture is made with the hypodermic needle, than there would be from the diagnostic puncture of the needle into the bladder, the pericardium, or the pleura, and if a small quantity did so exude, it would produce no effect save slight local irritation, as the peritoneum is tolerant of these fluids. Microscopic Examination.—While I decry the evacuation of the sac, by tapping (if a subsequent operation is to be performed), as being prejudicial * Am. Journ. Obstetrics, 1882, p. 679. OVARIAN TUMC)RS. - 1079 in many ways, I am so firm in my belief regarding the aid to diagnosis exhibited by the microscope, that I should consider myself derelict in my duty, if I performed ovariotomy without subjecting the fluid to careful examination.* I am not a microscopist, though I have somewhat versed myself in the appearances presented by these fluids; all my recent examina- tions have been made, with one or two exceptions, by Dr. Dillow. I am a believer in the appearance of what are known as “Drysdale's corpuscles" as being diagnostic of ovarian cystoma. I am bound to em- phasize this, as it is in accordance with my experience. In the only two cases wherein I have made an error in the diagnosis, and which have heretofore been stated as being encysted dropsy of the peritoneum, the examiners wrote in their reports in one case that the acetic acid test had not been applied, and in the other, the appearance of the granule was rather doubtful, and there were only few in the field. I am aware of the discussions which have taken place regarding this granular cell. I know that it has been stated that Drysdale's corpuscle is FIG. 715. G. Ovarian granules (Drysdale's corpuscles). P. Pus-corpuscles. I. Inflammatory corpuscles. O. Oil-globules. B. Blood-globules. - mot a cell, “but the nucleus of an epithelial cell in a state of fatty degenera- tion,”f and that the peculiar corpuscle had been discovered by Lebert, in 1846, and that these bodies, large and small, were also described by Dr. Bennett in 1852, and that they were frequently found in cysts in other parts of the body, Dr. Dillow having lately seen perfectly formed ones in the fluid from a mammary cyst and also from other tumors. It is also affirmed that Dr. Drysdale himself has made a serious mistake in the diagnosis of a cyst not ovarian, - These points in the discussion Dr. Drysdale denies. He declarest that the bodies described are original with him, neither Bennett nor Lebert hav- ing noticed them, and that they are true cells. He states that inexperienced * Both Drs. Atlee and Drysdale, and others of large experience, can corroborate this fact. Am. Journal Obstetrics, 1881, p. 956. # Am. Journ. Obstet., 1882, p. 681. † Ibid. 1080 A SYSTEM OF SURGERY. observers may mistake the pyoid cell of Lebert and the large cell of Bennett for his corpuscle, and he states positively that his test of acetic acid and ether will solve the problem. He writes, “The test which I recommend to distinguish the ovarian from Gluge's or Bennett's cells, is ether. If a small quantity of ovarian fluid be put upon a slide, and a few drops of ether added, and mingled with it by means of a tubular pipette, and the cover at once put on, the result will be that the pus-cells will be dissolved and the ovarian granule be made apparent.” FIG. 716. Microscopical Appearances Presented in Ovarian Fluid. a. Cells with granular appearance, and frequently with P". distinguishable fat-globules—Drys- dale's corpuscles. . b. Cholesterin crystals, c. Leucocytes, d. Fat-globules. e. Colloid concretions. f. Detritus in cysts which have repeatedly been punctured. g. Ciliated cells. h. Pavement epithelium. i. Red blood-corpuscles. Figs. 715 and 716 show the different appearances of bodies found in ovarian fluids. If the fluid, as it comes into the syringe, is colored brown, inky, or mahogany-color, and is rather difficult to be evacuated through the tube by the piston, and when it is removed is sticky, the tumor is ovarian. If, however, the fluid is amber colored, clear and limpid or bloody, then the surgeon must be upon his guard; he may have ascites, either general or peritoneal, a parovarian cyst, or a cancerous condition to look after. If nothing comes from the introduction of the needle, and yet the dulness on percussion and undoubted fluctuation are present, the chances will be that OVARIAN TUMC) RS. 1081 the contents of the cyst is colloid too thick to be drawn through so small an aperture, and other means should be resorted to, even if it may be necessary to make the exploratory incision. - A few drops of the fluid thus drawn should be placed in very clean drachm vials for microscopic examination, and the balance into a small test-tube to secure the process of coagulation. If the fluid be ovarian, there is no spontaneous coagulation, as a rule, or if there be any it is very slight, but upon the application of heat it rapidly coagulates; if the fluid be ascitical after a day, spontaneous coagulation results; and if in addition, the microscope shows, as pointed out by Garrigues, flat endo- thelium and amoeboid lymph-corpuscles, the diagnosis may be said to be certain. The twenty-fourth conclusion of Garrigues is essential to re- member. He thus writes: “The most important element in regard to diagnosis are columnar epithelial cells, seen in side view. Their presence excludes all other tumors than those of the ovary, Fallopian tube, or broad ligament.” According to Noeggerath, “if ciliated epithelium is found, it (the cyst) is probably parovarian, while if the epithelium is simply col- umnar, it is more likely from an ovarian cyst.” + For those who desire to enter fully into the chemistry of these fluids I would refer them to Hart and Barbour,f or to Ziemssen, where Eich- wald's experiemts are fully described. As a rule, the fluid drawn from a parovarian cyst is clear and limpid as spring water, contains no cell ele- ments, and is slightly saline. I think, however, that this character so much relied upon, viz., limpidity, is only characteristic of comparatively young parovarian cysts, and that as they increase in age, or have been frequently tapped, the color is likely to vary. On February 20th, 1874, having a patient in whom I was much interested, I sent her to Doctor Atlee, of Philadelphia, to confirm the diagnosis I had made of “cyst of the broad ligament,” as it was called in those days. After examination he confirmed the diagnosis, and I tapped her. The fluid was perfectly clear and limpid. She was pregnant then, and now has a fine boy nearly ten years of age. During this period I have tapped her four times, and on each occasion the fluid has changed its character; first, yellow, the second, brown, the third of an inky character, the fourth of a yellow hue. . On December 19th, 1880, a patient was sent to me by T. F. Allen, whom I aspirated and drew off the characteristic limpid fluid destitute of cell elements. About a year after I again evacuated the contents which were chocolate-colored. Neither of these patients would submit to any other operation. Albuminoids in the Fluid.—A word more is necessary regarding the pres- ence of the albuminoids found in these cysts. According to Waldeyer both paralbumin and metalbumin, especially the latter, are always found in ovarian tumors, which is also a i. aid in discriminating between these neoplasms and ascites. Scherer's test is said to be unreliable, and it gives me pleasure to insert a new method of testing for paralbumin in ovarian cysts by Dr. Clifford Mitchell, of Chicago.S He says: “The method I have devised for detecting paralbumin is much more simple and convenient than any test which involves boiling. Scherer found that paralbumin was coagulated by nitric acid and that the coagulum dis- solved in strong acetic acid. My method is based on this fact, and is as fol- * American Journal of Obstetrics, 1881, p. 678. f Manual of Gynaecology, vol. i., p. 213. † Cyclopaedia of Practical Medicine, vol. x., p. 368. 3 American Homoeopathist, vol. x., p. 99. 1082 A SYSTEM OF SURGERY. lows: Pour a fluid drachm of the ovarian fluid into a test-tube of small diameter (preferably not over one-half inch), then allow one or two drops of nitric acid to trickle slowly down the side of the test-tube into the ova- rian fluid. The acid slowly sinks through the fluid, coagulating the paral- bwmin as it goes, forming a well-defined clot. The tube may be shaken gently to accelerate the separation of this clot. When it has well settled to the bottom of the mixture, carefully pour off the supernatant fluid, and the clot remains. Now pour in some strong (glacial) acetic acid, filling the tube half full; the clot rises to the top of the acetic acid, and on placing the thumb over the mouth of the test-tube and shaking well, the clot is wholly or at least very perceptibly dissolved by the acid. The advantages of this method are that it does away wholly with boiling, and that it can be per- formed with a very small amount of ovarian fluid. Care must be taken not to use too much nitric acid or to form too large a clot, or some difficulty may be encountered in dissolving it with acetic acid. Moreover, only acetic acid having a specific gravity of 1065 at least, must be used. Commercial acid, having a specific gravity of about 1045 on the urinometer scale, failed to dissolve the clot. A slight turbidity remaining after shaking with the acetic º is of no significance, being due probably to proteids not soluble in this a CIOl. Malignant Disease.—The diagnosis of malignant disease of the ovary is Quite difficult. The main features are increased and increasing sensitive- ness of the abdomen over a rather small tumor, continued pain and general emaciation, a cancerous genealogy, and especially a rapid increase in asciti- cal fluid. The microscopical appearance presented by the fluid accumu- lating around cancers of the ovary, has been the subject of especial study, notably by Mr. Foulis, of Edinburgh, and is of the greatest importance in the formation of a diagnosis. The fluid should be sent to a specialist for examination. Tuberculosis of the peritoneum is often accompanied with increased peri- toneal exudation, but the unevenness of the abdominal walls will assist materially in the formation of the diagnosis. In some instances, however, the “knotty feel” is not present, and then the microscope or the exploratory incision must tell the story. Exploratory Incision.—Notwithstanding all that experience has thrown upon the diagnosis of ovarian cysts, there are yet cases so complicated that it is necessary to make an incision in the abdominal walls to discover the real nature of the disorder. There need be no hesitation in adding thereby to our acquaintance with the case, and any conscientious prac- titioner who has exhausted his means of diagnosis, should perform the operation. The incision should be cautiously made in the linea alba, and the peri- toneum carefully dealt with. Then if there be too many adhesions, with- out any attempt to break them up if they are very dense on the anterior face of the tumor, or if the tumor be any other than ovarian, the surgeon must decide what course to take. In encysted dropsy of the peritoneum such a proceeding is, it appears to me, absolutely necessary. In certain forms of cystic disease, and often in fibro-cystic tumors accompanied with ascites, the procedure is called for. This method is by no means free from danger. Wills reports four and Baker Brown three fatal cases. I have lost two, and am aware of several other deaths. Treatment of Ovarian Cysts.-There are cases of ovarian cysts which may be amenable to internal medication, and I have no doubt that if some cases were so treated ovariotomy might be dispensed with. I give the record of a number of such with the authorities from which they come. I TREATMENT OF OVARIAN CYSTS. * 1083 cite at least two undoubted ovarian cysts which were cured, one by apis mel. and arsen. ; the second by tapping, and the after-administration of proper medicines. Dr. Black * gives a remarkable cure with small doses of bromide of potassium. Dr. Neidhardt reports a case in which iodine and hepar in the first, third, and sixth dilution, together with a sponge Saturated with iodine water in- troduced into the vagina, was productive of happy results. Dr. Neidhardt regards ignat., graph., apis and platina as appropriate medicines,f and gives the following indications: - Ignatia for spasmodic pain in both ovaries, with contracted sensation at stomach. - Graphites—swelling of both ovaries as if they were in motion; pain on stooping and pressure ; enlargement caused by sexual excess. Apis mel. in the more acute form, pain increased by stooping and walk- ing, pressure on the bladder, frequent micturition. Platina—enlargement of ovaries; catamenial discharge coagulated and thick. Arsen., calc. carb., canth., china, iod. and lycop. are other medicines. It is probable that many cases of ovarian tumor which are reported as cured were parovarian cysts, which in many instances cannot be diagnosed from cystoma without a microscopic analysis of the fluid. The tumors are amenable to tapping and medicine. Vreith does not remove them with the knife on this account. Dr. D. A. Baldwin, of Englewood, was successful in the treatment of a case after several tappings. At the first he drew five and a half gallons; at the second, four and a half gallons; at the third, three and a half gallons; at the fourth, three and a half gallons; making in all seventeen gallons of fluid. The medicine was iodine in the third decimal solution given three or four times a day. In Dr. Peaslee's work we have a notice of cures by several remedial agents; two by Mr. Craig, by the administration of a saturated solution of chlorate of potassa, a tablespoonful three times a day; two cases by Prof. Courty, of Montpelier, with the oxide of gold, in doses varying from gº to # of a grain ; a case by Dr. J. Millar, with the bromide of potassium, five rains three times a day, increasing the dose to fifteen grains; Dr. Miller, of Chicago, three cases with bromide and iodide of potassium in alterna- tion. Dr. Peaslee employed with success the chlorate of potassa; the dose being half an ounce of the Saturated solution three times a day. Palliative Treatment consists in paracentesis abdominis. This should be effected with a large aspirating needle, and may be done often, though the operation is by no means free from danger. After the evacuation of the fluid, properly administered medicines may be of service toward effecting a cure. The trocar may be inserted at the linea alba, or if the tumor be polycystic, the operator may select the linea semilunaris or other points in the abdominal parietes. Other Curative Measures.—Tapping the sac and pressure, effected by means of compresses securely fastened with broad adhesive straps, so placed as to embrace the spine, “meeting and crossing in front and extending from the vertebral articulation of the eighth rib to the sacrum,” and secured by a broad flannel band, are recommended by Dr. J. Baker Brown. Tapping and the injection of iodine has cured, but appears only applicable * British Journal of Homoeopathy, January, 1869. f North American Journal of Homoeopathy, 1864, p. 17. † N. Y. Medical Journal, August 21st, 1886, p. 208. 1084 A SYSTEM OF SURGERY. to the monocystic tumor, as it would be a difficult matter to inject all the compartments of a polycyst; although several cases reported as the latter were cured. The following is the formula of Boinet: Distilled water, 100 parts, • • * g tº e . 3iij and 3.j. Tinc. iodine, 100 parts, . . . e tº e o tº . 3iij and 3.j. Iod. of potassium, 4 or 5 parts, º tº a e . . 3.j to 3.j}. Or tannic acid, 1 to 2 parts, . g & g g tº ... gr8. xv. to XXX. For the injection, a large trocar and canula is used, and the cyst is tapped in the ordinary manner. When most of the fluid is drawn off, a good-sized gum-elástic catheter, with several holes on either side, near the end, is passed through the canula to the bottom of the sac. The above quantity is injected and allowed to remain from five to ten minutes. The catheter may then be withdrawn. Electrolysis.—Dr. Danforth, of Chicago, and Dr. Franklin, of Ann Arbor, and Dr. Murphey, of New Orleans, have reported cures of ovarian cysts by electrolysis. This method is simple and effective, and is rapidly gaining favor; though I have seen it tried in several instances, it has never been productive of permanent good, and in two cases a sharp peritonitis fol- lowed the application of the needles. In a cyst of the broad ligament oper- ated upon by Dr. Butler, the tumor almost entirely disappeared, but soon after refilled. As yet, experience has not satisfactorily demonstrated the value of this method in the treatment of ovarian tumors. The Performance of Ovariotomy.—Before proceeding to details there is a point upon which I ought to dwell for a moment, and that is the priority of claim for the performance of ovariotomy, and to express the national pride that every one of us must entertain in pronouncing Ephraim McDowell, of Danville, Kentucky, the father of ovariotomy, not of American ovariotomy, but of ovariotomy the world over, and especially of ovariotomy in Great Britain. I am urged to this decisive declaration because the endeavor has been made in England to deprive America of the honor which belongs to it. - Dr. Ephraim McDowell was a student of John Bell, the anatomist of Edinburgh, who suggested and defended the removal of the ovaries for ovarian dropsy. Mr. McDowell espoused the idea of his preceptor, and in December, 1809, performed his first operation, which must have been a colloid cyst. In 1813 the second ovariotomy was made, and in May, 1816, his third, all of which were successful. In 1818 he prepared a report of these cases, and with justifiable pride sent a copy to his former preceptor. Mr. Bell was absent from London, and Mr. Lizars, having charge of his (Bell's) practice and correspondence, kept the record of Dr. McDowell’s cases for seven years before bringing them to light, and when he did, they appeared as an appendia, to a paper recording a case of his own, which proved to be not one of ovariotomy, as it had been diagnosed, but a simple accumulation of fat. With these well-known facts published time and again, no less a surgeon than the celebrated Mr. Christopher Heath, F.R.C.S., thus spoke to his class:* “Although ovariotomy was first performed by Dr. McDowell, of Kentucky, who was a pupil of John Bell, f the operation of modern times has been entirely of British cultivation. Mr. Lizars, of Edin- burgh, was the first to attempt ovariotomy in this country, and by the long incision, i.e., from the umbilicus to the pubes; his example was fol- * British Medical Journal, June 16th, 1877. + Of course the credit should, therefore, in the lecturer's estimation, be given to Mr. Bell, the Scotchman. OVARIOTOMY. 1085 lowed hy a few other surgeons and from time to time a success was ob- tained. The facts are these: Mr. Lizars perhaps would never have attempted the operation but for the seven years’ study of Dr. McDowell's cases, and it appears that when he did he actually mistook a mass of fat for an ova- rian tumor, examination revealing two healthy ovaries. In addition to this rather humiliating mistake, in 1825, Mr. Lizars again attempted ovari- otomy, but in two cases was unable to remove the tumors, and in the third mistook a subperitoneal uterine fibroid for a cystoma ovarii; indeed, such disastrous results followed “the father of ovariotomy in Great Britain.” that the operation was not repeated for twenty years in Scotland.* These facts are well known to every gynaecologist, and, though of interest to the general practitioner, would not have been mentioned had it not been that the effort has been again made in England, to give priority in the perform- ance of ovariotomy to a certain Robert Houston, of Glasgow. In Mr. Lawson Tait's latest work the endeavor of the author to procure for Great Britain the precedence in the performance of this operation is overdrawn. The operation described as an ovariotomy was performed in August, 1701, and is as follows: “I found this tumor grown to so monstrous a bulk, that it engrossed the whole left side from the umbilicus to the pubes, and stretched the abdomi- nal muscles to a great degree. It drew toward a point. From being obliged to lie continually on her back, she was grievously excoriated, which added much to her sufferings, which, together with a want of rest and appetite, had greatly emaciated her. “The operation of puncturing the abdomen being proposed, she con- sented ; accordingly with an imposthume lancet I laid open about an inch, but finding nothing issue I enlarged it two inches, and even then nothing came forth but a little thin, yellowish serum, so I ventured to lay it open about two inches more. I was not a little startled after so large an aperture to find only a glutinous substance bung up this orifice. The difficulty was how to remove it; I tried my probe and endeavored with my fingers, but it was all in vain; it was so slippery that it eluded every touch and the strongest hold I could take. “I wanted in this place everything necessary, but bethought of a very odd instrument, yet as good as the best in its consequences, because it answered the end proposed. I took a strong fir-splinter, such as the poor in that country use to burn instead of candles; I wrapped about the end of this splinter some loose lint, and thrust it into the wound, and by turn- ing and winding it I drew out above two yards in length of a substance thicker than jelly, or rather like glue fresh made and hung out to dry ; its breadth was above ten inches; this was followed by nine full quarts of such matter as is met with in steatomatous and atheromatous tumors, with several hydatids, of various sizes, containing a yellowish serum, with several large pieces of membrane, which seemed to be parts of a distended ovary. I then Squeezed out all I could, and Stitched up the wound in three places almost equi-distant.”f Can this be called an ovariotomy? Mr. Tait's reasoning is most pecu- liar; he says: “Although he (Houston) does not describe his division of the pedicle, or his having tied it, it is almost certain that he did both. He certainly must have seen and divided the pedicle, for he describes the disease as being of the left ovary, therefore he saw the pedicle.” How the latter * Peaslee, Ovarian Tumors, p. 270. f I have placed these words in italics to show that there is no mention made of a pedicle. 1086 A SYSTEM OF SURGERY. conclusion could be deduced from the former expression appears to me incredible. The disease was of the left ovary, “therefore he saw the pedi- cle.” Mr. Tait further continues: “Perhaps he tore it and it did not need tying. That he performed a complete ovariotomy is certain, from his hav- ing noticed secondary cysts, as well as from the recovery of his patient, and from the fact that she lived thirteen years afterward in perfect health.” From a careful reading, we may make deductions antagonistic to those of Mr. Tait, and may positively say that Houston did not perform a complete ovariotomy. It is not at all likely that a man like Houston, without previ- ous experience, or the example of others, could have turned out a cyst, ligated its pedicle and cut it off, without accurately describing the entire operation. . The precise manner in which the former steps of the operator are detailed forbids the idea, that so important a feature as ligating the pedi- cle and completely removing the sac, should be entirely overlooked. These deductions of Mr. Tait appear wholly without foundation, and cannot be allowed to stand in opposition to the complete performances of ovariotomy as furnished by Dr. Ephraim McDowell. It has been suggested by Dr. R. S. Sutton of Pittsburgh,” that Dr. Houston, without knowing, enucleated the cyst and directed no further attention to the pedicle. Peaslee simply says: “Dr. Houston did not perform ovariotomy. The fact appears to me to be that Dr. Houston cut down upon a colloid multilocular cyst, drew out its contents, with the rude instrument he describes, perhaps ruptured other cyst-walls within the mother cysts and dragged forth the torn-out particles; that he sewed up the abdominal wall, and left a small tent in the lower angle of the wound—‘ only this and nothing more.” With the under- standing of all these circumstances, it must be apparent to every one that Dr. McDowell holds priority of claim in the performance of this opera- tion, and we must still dignify him with the title of ‘the Father of Owari- Otomy. Every one who has performed a number of ovariotomies has some varia- tion in method, and, although the object to be attained, i.e., the removal of the tumor, is, of course, the ultimatum, there are different ways of arriving at it. Believing, as I do, that the atmosphere, in some undefined and unex- plained way, exerts an influence over the reactive power of a patient about to be subjected to ovariotomy, I select a perfectly bright and clear day for the operation, and in appointing a time for its performance state that if the day fixed be cloudy, or rainy, the operation will be postponed. This state- ment mollifies, in a measure, the disappointment which naturally would result from the change of time. Before the operation, if it be in the hospital, the ovariotomy room (an apartment about eighteen feet square, containing two beds and a chair, perfectly plain walls, destitute of ornament, pictures, or carpet) receives a thorough scrubbing, the walls are wiped down, and the windows opened to the sun for two days. The bed-clothing, mat- tresses, pillows, etc., are then aired, sunned, and brought into the room. If in a private house, the carpet is taken up, the furniture removed and the floors scrubbed. A kettle containing carbolic acid solution 1–20 is placed upon a small furnace, and the steam allowed to pass into the cham- ber for an entire day, and on the morning of the operation the windows are again opened to the sun and air. The sponges (which have been first allowed to soak in a strong soda solution, afterwards washed and immersed for a few hours in dilute hydrochloric acid, and then placed in jars contain- * A paper read at the meeting of the American Gynaecological Society, held at Boston, 1882. f Peaslee, Ovarian Tumors, p. 227. OVARIOTOMY. 1087 ing a small quantity of carbolic acid, 1–60) are taken from the jars and placed in a basin and exposed to the sun. The night before, the instru- ments, which I count myself, are placed in an earthenware pan containing carbolized oil 1 to 20, and the rubber coil and india rubber sheeting also washed off with carbolized solution. In the morning, the instruments are removed from the oil, wiped carefully and placed in shallow pans containing carbolized water 1 to 60. A list is made of every instrument and placed upon the wall, and the sponges (gen- erally one dozen, nine small, and three large and flat) are put into a basin holding a solution of bichloride of mercury 1–2000. The douche is hung up ready for use, and the thermometer suspended in a convenient place. The hypodermic syringe is charged with brandy, and the ether cone, pre- pared of an ordinary towel folded over newspaper and covered with an india-rubber cloth, is arranged beside the ether can. The carbolic steam is allowed to permeate the atmosphere of the room, and no one allowed to enter until near the time of the operation. No spray is used ; it makes the parts too cold. In an adjoining room, however, a steam spray apparatus is kept continually at work, and those who are to be present are requested by a written placard to disinfect their clothing before coming into the apart- ment. I always perform the operation at half past two o'clockin the afternoon, and at two o'clock the patient (having a small cup of beef-tea at eleven) receives a hypodermic injection containing one-sixth grain morphia and one one- hundredth of a grain of atropia. In about half an hour the medication is complete, the patient has slight dizziness, and a healthy flush upon the face; she is then brought into the operating room, and placed upon the table and the ether administered. This mixed method of anaesthesia has many advantages; much less ether is required to produce insensibility, and the capillary circulation is increased, not only throughout the operation, but for some time after. By this means also the coldness and collapse which often follow prolonged ovariotomies are scarcely perceptible, and the vomiting is less; often the patient slumbers tranquilly for one or two hours after she has been put to bed, which I regard as a great advantage. Before the anaesthesia is quite complete, the abdomen is washed carefully with warm water and corrosive sublimate solution 2 o'oo, and dried. The lower limbs are covered with blankets, the upper garments are tucked well up and shielded by india-rubber cloth. All the assistants wash their hands in soap and water and take their positions—that one in charge of the ether at the head of the table (which is on india-rubber wheels), the oper- ator on the right side, the first assistant on the left, and next to him the second assistant, who hands the instruments, and behind and a little to the left of the latter are stationed the nurses, who do nothing but clean sponges, which are beside them in two basins. Just before the incision is com- menced, I go to the list of instruments hung upon the wall, and call out the names of them in order, the chief assistant answering to the call. The nurse then counts the sponges, and the operation is proceeded with. The incision is made as usual, and the skin-vessels caught by catch forceps (Koeberlé's), the fascia is exposed and easily recognized, is caught and nicked and incised upon a director, or if the operator has experience, he may cut through it with the knife. The peritoneum is easily recogniza- ble by its rather bluish color, and membranous appearance, but sometimes it is very much thickened, and may be mistaken for the sac. I always divide this membrane upon the director with a pair of scissors, and am very particular to incise it carefully and sharply; often there may be the escape of ascitical fluid, or, perhaps, of some colloid material, and the Sac is brought into view. Anterior adhesions are now recognized by the passage 1088 A SYSTEM OF SURGERY. of a steel sound all over the parietes of the tumor; if there be many, they should not be ruptured with the instrument, but dealt with afterward. There are cases in which the peritoneum is not so easily recognized, espe- cially where a prolonged chronic peritonitis has been present, materially thickening and transforming the membrane, or, what is still worse, causing it to adhere to the cyst wall; nothing but cautiously cutting down upon FIG. 717. FIG. 718. is - - , , E} Wilcox's Forceps. Spencer Well's Ovariotomy Trocar. *** *-ºs is the presenting mass will decide the matter. I recollect a case in which such a complication existed, and I actually had separated a portion of the abdominal peritoneum before I discovered the mistake. I may state here, that after each instrument is used, it is not laid upon the table, but handed back to the second assistant, who wipes it and replaces it in the pan. This is the rule, and by following it there is not an accumu- OVARIOTOMY. - 1089 lation of bloody instruments lying around or upon the patient, and when it is necessary to employ the same instrument a second or third time, it comes to the operator's hand perfectly clean and carbolized. I now take a Wilcox’s forceps (Fig. 717) and give it to an assistant and introduce the trocar; immediately the cyst wall begins to relax from the escape of fluid it is grasped with the forceps and held firmly ; the patient is rolled three-quarter face over the edge of the table and the trocar with- drawn. I then take a knife or scissors and make a cut several inches long in the cyst, thus rapidly evacuating its contents, and allowing room for my hand to enter the cavity and rupture the child cysts through the parent wall. As a rule, I use the trocar very little, and have always found diffi- culty in catching the wall of the sac with the hooks on Wells's trocar. (Fig. 718.) Dr. Lungren, of Toledo, has devised a modification of this instrument, in which the hooks slide up upon the canula and are fixed by a set screw, which greatly enhances the value of the instrument. Occa- sionally the bladder is carried up by the tumor, or the urachus is much dilated, and these may be punctured by the trocar, Dr. Thomas and Dr. Noeggerath have each had one case of the kind, and I also have met with a most interesting one which has been reported elsewhere. The lady was brought to me by Dr. C. A. Bacon, and was operated upon in the Hahnemann Hospital. Dr. Emmet” also reports a remarkable instance in which the stomach and transverse colon were spread out over the surface of the tumor. In rolling the patient over some care must be exercised to keep the tumor well out, for I have read somewhere, that during this manoeuvre, the uterus and intestines forced their way into the opening, and the former was punctured to the depth of half an inch by the trocar. As the sac is being emptied the assistant draws it still further out to prevent the escape of intestines, and the patient is then turned supine again, and the adhesions treated. Each adhesion is tied with carbolized gut and then cut away, and if the attachments are broad, they are clamped with an instrument made for the purpose (of which I have two sizes). A needle armed with a double thread is passed through the centre, the loop is cut, and the ends tied on both sides. During this process, which takes con- siderable time, the flannels which are laid over the omentum are constantly changed, being wrung out in hot water, and gently laid over the parts. When the pedicle is reached I formerly applied the clamp, then ligated it (the pedicle) in two or more portions, cut it off and applied the Paquelin cautery at a dull heat and then removed the clamp. Lately, however, I use the Staffordshire knot, which is made easily, and can be tied very securely, and is not likely to slip. The knot is made by taking a Peaslee's needle, threaded with ovariotomy silk, made completely of silk fibre and very strong, and passing it through the centre of the pedicle; the loop is drawn through and the needle withdrawn, the loop is then passed over the tumor and the right hand free end of the silk is passed through the loop, the two free ends of the ligature are then tied tightly in a surgeon's knot, particu- larly if the pedicle is broad, and consequently a good deal of tissue, neces- sarily included; security is of paramount importance. I have often found, particularly if the tumor be colloid, that my fingers and the silk become so lubricated, that sufficient traction is sometimes difficult, even after the ends are carefully wiped; towels or napkins are cumbrous, and often in the way; I therefore have devised a pair of “pullers,” which answer my pur- pose. I place the free ends of the ligature within the blades, clamp them together, rotate the instrument several times upon itself, winding the thread * Am. Journ. Obstet. 69 1090 A SYSTEM OF SURGERY. around several times, and thus a powerful purchase can be exerted. When the knot is secured I give the ends in charge of the first assistant, and cut off the tumor, and sear the stump thoroughly with the Paquelin cautery. This done, I allow the stump to fall partially back into the abdominal cavity, but keep it in hand by the ends of the ligature. The abdomen is now thoroughly cleaned with large and small sponges, the latter being fixed on holders, and if there has been much escape of fluid or blood into the cavity, carbolized water 1–100, at a temperature of 100°, is allowed to run from the douche into the abdomen, until it passes away clear. The in- testines are all again thoroughly cleansed, and not until the sponges withdrawn are dry and clean is the wound closed. Before doing this, how- ever, the pedicle is drawn to the surface, examined, and if clean and dry, the ends of the knots are cut close and the stump allowed to find its way to its position. The omentum is carefully arranged, and a large flat hot Sponge is placed over it and the sewing begun. If I have reason to believe there will be much exudation, a glass drainage-tube, thoroughly clean and carbolized, is placed in a Douglas's pouch. The needle-holder I use is the large-sized Russian (vide pages 35 and 248) forceps; the needles stout round ones, with a good-sized eye and a slightly curved bayonet point. The loops of silk are spliced into the needles, and the silver wire bent upon the loop. The sutures are placed about the eighth of an inch apart, and pass through the peritoneum in each side of the cut; when the deep wires are all in, I place my two forefingers in the centre of the inci- sion and hook the two middle wires, one on each finger; one finger draws the sutures toward the upper, the other finger draws the sutures to the lower angle of the wound, and the flat sponge is withdrawn through the opening thus made. It is amazing to see in some cases how much blood has escaped from the needle punctures and has been received by the sponge. Before twisting the wires, the sponges are again counted, and the instruments also, and if they are “all right” the wires are fastened. A few superficial sutures of silk are sometimes required. A piece of salicylated india-rubber plaster is laid along the margin of the cut, and the ends of the twisted wire bent down upon it (the plaster). Another strip of the plaster is laid over the wire, and thus irritation is effectually prevented. The patient is made dry and clean, and the soiled materials removed. Over the track of the wound is laid a small strip of marine lint finely shredded, over this a large layer of cotton, which is enveloped in gauze, both having been pre- viously rendered antiseptic by the bichloride of mercury 1:2500. Over this an additional gauze is laid, and then a bandage, or, rather, a piece of prepared linen. This is kept in position by broad adhesive straps, three or four on each side, which are pinned with safety pins to the cloth. The patient is put to bed, warm bottles to the feet, and every article that has been used immediately removed from the room. If there are stains on the floor, it is cleaned with soap and water and wiped with a solution of carbolic acid 1–20. If the pulse has flagged during the operation, one, two, or more hypodermics of whiskey are given. Since I have been using the mixed method of anaesthesia, I have found that the patients sleep from one to three hours after the operation, a condition which I rarely met with when I used the simple ether narcosis. Of late I have had less occasion to employ morphine in the after treat- ment, for I have found that hypericum often relieves the immediate pain; I do not, however, fail to use the opium if the suffering and restless- ness are severe, giving five to eight minims of Magendie's Solution. Ice is allowed, though in small quantities, and if the patient vomits and is cold veratrum alb. is given. If there be much distension of the abdomen with flatus, the best medicine is the chlorate of potash. It is remarkable OVARIOTOMY. 1091 what an effect this drug will produce. As a rule, when a quantity of flatus passes by the anus, the patient will make a good recovery. At all events it is a signum salutis. When the temperature rises to 101° the cold coil is É. on and kept for several hours, and rarely fails to produce a decline in eat line. The diet on the second day is well-made cold rice water given every three hours, in small quantities; after the third day the patient is put upon peptonized milk. This milk is prepared as follows: a powder, composed of five grains of Fairchild’s ex. pancreatis and twenty grains bicarb. of soda, is dissolved in a gill of water and poured into a clean wine bottle, which is filled with a pint of milk. The bottle is placed in hot water for an hour, then removed and kept in a cool place. This is a won- derful preparation, and I have used it so frequently and in so many sur- gical and medical diseases, that I recommend it. If the patient is doing well the dressing is not removed for a week. The cork, however, is taken from the drainage tube on the second morn- ing and a small piece of absorbent cotton introduced; if it come back wet and bloody, the tube is cleansed with the douche until the water runs clear, and then it is wiped out. Serum in the drainage tube is of little conse- quence except it be present in large quantities. If I find nothing but simple serosity for two days, the tube is removed. If suppuration takes place the abdomen must be cleansed at least once a day with warm water, not with carbolized water (too much carbolic acid is worse than none all), and the parts and dressings kept remarkably clean. I do not allow my patients to See any one save the doctor and the nurse for two weeks after the opera- tion. The stitches, most of them, are removed on the ninth to the twelfth day, according to circumstances, and before the patient sits up a body bandage is put on, which she is enjoined to wear for at least two months after she gets about. The washing of the abdominal cavity may be con- tinued as long as there are any evidences of suppuration. Death occurs from shock—from a few hours to a couple of days after the operation—Or peritonitis from the second to the ninth, or septicæmia, from the seventh to the thirtieth, or even later. Dr. Ludlam * calls attention to a condition of auto-infection which may exist in old cases in which the idea of long postponement of operation has been held, and thus not only is there a drain of the vital fluids into the cysts, but the blood becomes cumulatively septic, thereby materially affecting the chances of recovery. Dr. Ludlam con- cludes his article with the following postulates: “1. That the absorption of a part of the cyst contents prior to the opera- tion is a not infrequent cause of fatality in ovariotomy. “2. That this condition is incident to old tumors, to compound cysts, and to cases that have been tapped. “3. That this insidious, pre-operative form of sepsis is most likely to de- clare itself through an irritable state of the gastro-alimentary mucous mem- brane, with repeated attacks of vomiting and purging, and to be confirmed at post-mortem by gastric or enteric ulceration. “4. That if the patient is predisposed to renal or hepatic disease, the kidneys or the liver may be the seat of serious lesions of function or of struc- ture, which really depend upon this auto-infection. “5. That the cardiac degeneration and involvement which are incident to this form of abdominal growths, as shown by Dr. Fenwick, i may be ascribed to a pernicious anaemia that is of septic origin, and which has its source in * The Clinique, July, 1886. f On Intra-abdominal Tumors as a Cause of Cardiac Degeneration. The British Gynae- cological Journal for May, 1886, p. 72. 1092 A SYSTEM OF SURGERY. absorption through and from the disintegrating tissues of the walls and partitions of the cyst, and not alone in the size and pressure of the sac. “6. That, when this septic infection has existed temporarily before the operation was made, the risk of its continuance and recurrence is very great, º º danger from it is due to the dyscrasia which it had insidiously de- Veloped. - “7. That these facts present a new and powerful argument for the early performance of ovariotomy, and indirectly explain the increasing exemption from fatal consequences.” IND EX. Abdomen, injuries and diseases of 832 wounds of, 832 Abdominal aneurism, 461 hernia, 857 varieties of 857 parietes, abscess of, 836 viscera, wounds of 832 Abscess, 113 of the abdominal parietes, 836 acute, 115 of the antrum highmorianum, 777 in bone, 512 chronic, sinuous, 512 cold, 115 consecutive, 388. dangers of, 115 diffuse, 115 hepatic, 841 hyperdistension with carbolic acid, 118 opening of 116 of the parotid gland, 793 in the perinaeum, 937 perityphlitic, 850 pointing of, 114 post-pharyngeal, 774 of the prostate gland, 984 psoas or lumbar, 691 residual, 115 of the testicle, 988 of the tongue, 750 Absorption of pus, 123 ulcerative, 129 Acetabulum, fracture of, 568 Acromion process, fracture of 565 Active haemorrhage, 316 hyperaemia, 91 Actual cautery in haemorrhage, 322 Acupressure, 329 methods of, 333 vs. ligature, table of 331 Acupuncture, treatment of hydrocele, 996 Acute mortification, 142 Adenitis, 233 Adenoma, 165 Adhesion, 100 Adhesive plaster, 251 Air in veins, 483 Albuminuria in hernia, 860. Allarton's operation of lithotomy, 960. Alopecia from syphilis, 237 Alveolar cancer, 178 Amputation, 352 bony tumors requiring, 356 of the cervix uteri, 1020 compound fractures requiring, 353 conical stump after, 392 Amputation, contused and lacerated wounds requiring, 354 definition of 352 diseases of joints requiring, 355 gangrene and mortification requiring, 354 immediate, 353 intermediate, 353 instruments for, 357 methods of, 358 mortality in, 360 neuralgia of the stump after, 391 other causes for, 356 primary, 353 protrusion of bones after, 392 question of, in wounds, 289–354 retraction of flaps, 392 secondary, 353 special, 365 of the breast, 832 cervix uteri, 1020 lower extremities, 365 at the ankle, lateral plantar flat, 378 Pirogoff’s method, 378 Syme’s method, 376 hip, 365 anterior and posterior flap, 367 lateral flap, 367 knee, 372 Carden's method, 374 circular, 374 leg, circular method, 376 flap method, 375. mixed method, 376 Teale's method, 376 sub-astragaloid, 380 through the tarsus, Chopart's method, 379 tarso-metatarsal articulation, 380 of the thigh, 369 anterior and posterior flap, 370 circular, 370 combination method, 370 lateral flap, 370 rectangular flap (Teale's), 371 through the condyles (Stokes), 371 toes, 381 penis, 1014 scrotum, 1007. tongue, 764 upper extremities, 382 arm, circular method, 384 flap method, 384 at the elbow, 386 of the fingers, 388 metacarpo-phalangeal, 388 1094 INDEX, Amputation of the index finger, 389 forearm, circular method, 385 flap method, 385 Teale's method, 386 through the metacarpus, 389 at the shoulder, 382 of the thumb, carpo-metacarpal, 390 in wounds, 289 at the wrist, 387 Amygdalitis, 767 Anaesthesia, 70 death from, 79 discovery of 71 local, 81 mixed, 78 primary anaesthesia, 79 sickness of, 79 Anaesthetic ether for local application, 84 mixtures for small operations, 85 Anatomy, microscopic, of cancer, 173 surgical, of the vessels, 463 Anchylosis, 615 of the inferior maxilla, 786 spurious, 615 Aneurism, 438 abdominal, 461 by amastomosis, 441 of the aorta, 456 arm, forearm, or hand, 460 arteria innouinata, 457 arterio-venous, 441 of the axillary artery, 460 in bone, 533 of the carotid artery, 458 catgut ligature in, 454 causes of, 443 3. cirsoid, 441 classification of, 439 compression in, 446 deformity in, 442 diagnosis of 444 diffuse, 440 by dilatation, 440 dissecting, 440 electrolysis in, 453 external, 439 false, 439 femoral, 461 fusiform, 440 galvano-puncture in, 453 general treatment of, 444 hernial, 439 inguinal, 439, 461 injection into, 452 internal, 439 introduction of foreign materials into sac, 456 of the leg or foot, 463 limited, 440 manipulation in, 448 medical treatment of, 445 oedema in, 442 old operation for, 449 pedunculated, 440 popliteal, 462 pulsation in, 442 rapid method of treating, 489 Aneurism, rest in the treatment of, 444 by rupture, 440 shape, 442 sounds in, 442 sphacelus after ligation, 455 special, 456 spontaneous cure of 443 of the subclavian artery, 459 symptoms of, 441 treatment by compression, 446 Esmarch's bandage, 449 galvano-puncture, 453 injection into the sac, 452 ligature, 453 manipulation, 448 medical, 445 placing foreign material into the sac, 456 rapid method of, 449 rest, 444 true, 439 Aneurismal varix, 441 Angeioma, 155 Angina maligna, 772 pharyngea, 772 Angular curvature of the spine, 686 Ankle, amputations at, 376 dislocation of, 667 excision of 709 weak, 639 Anthrax, 401 treatment of, 402 Antiseptic dressing of wounds, Lister's, 295 ligature, 338 method in gangrene, 147 Antiseptics, 61-66 and disinfectants in Surgery, 61. Antrum highmorianum, abscess of, 777 tumors of, 779 removal of, 779 Anus, artificial, 836 formation of 848 fissures of, 909 fistula of 901 prolapse of, 891 pruritus of, 910 and rectum, diseases of, 892 imperforate, 895 Aorta, aneurism of 456 Apnoea from drowning, 825 hanging, 826 Apparatus, movo-amobile of Suetin, 542 Arm, amputation of, 384 forearm or hand, aneurism of, 460 Arsenic in cancer, 190 Arterial haemorrhage, 316 Arteries, calcification or ossification of, 437 injuries and diseases of, 436 ligation of, 463 Arterio-venous aneurism, 441 Arteritis, adhesive,436 diffuse, 436 Artery forceps, 36 Arthritis, chronic, rheumatic, 621 Arthropyosis, 609 Articles for dressing, 40 Articular cartilages, ulceration of, 612 INDEX. 1095 Artificial anus, 836 formation of 848 haemostatics, 319 ischaemia, 339 respiration, 825 Ascites, 844 Aspirator, the, 52 Aspiration of intestine in strangulated hernia, 864 of pericardium, 824 of thorax, 821 Astragalus, dislocation of, 670 excision of, 708 Atheroma, 437 Atresia vaginae, 1049 Atrophy of bone, 528 muscular, 430 progressive, 430 reflex, 431 Autoplasty, 395 Axillary artery, aneurism of, 460 ligature of, 470 surgical anatomy of 470 Balanitis, 215 Ball, minié, 272 Bandage, the, 44 Bandages, India-rubber, 45 plaster-of-Paris, 46 starch, 542 Barton's fracture, 575 Battery for galvanic cautery, 57 Bed-sores, 423 Bending of bones, 544 Bismuth submitrate in wounds, 311 Bistouries, 37 Black cancer, 178 phagedaena, 146 Bladder, exstrophy of 914 female, stone in, 969 inflammation of 928 catarrhal, 928 paracentesis of 939 stone in, 956 tumors in, 982 Blenorrhagia, external, 215 Blood, buffy coat of 93 changes of, in inflammation, 93 effusion of, in inflammation, 93 transfusion of 346 Boil, 399 Bones, abscess in, 512 sinuous, 512 atrophy of 528. bending of, 544 cancer in, 531 cracked, 549 cysts in, 530 death of 519 excision of, 693 flexion or bending of, 544 fractured, non-union of, 545 hypertrophy of, 528 inflammation of, 511 injuries and diseases."of, 507 non-union of, 545 Bones, protrusion of, after amputation, 392 resection of, 698 sclerosis in, 512 suppuration in, 512 syphilis in, 517 tumors in, 528 innocent, 528 pulsating, 533 ulceration of, 515 scrofulous, 517 Bony tumors, 162 requiring amputation, 356 Bowels, intussusception of, 846 obstruction of, 846 Bozeman's operation for vesico-vaginal fistula, 1046 Brachial artery, ligature of, 472 surgical anatomy of, 472 Brain, compression of, 723 concussion of, 722 Breast, amputation of, 832 Broad ligament, serous cyst of, 1072 Bromide of ethyl, 78 Bromine as a disinfectant, 63 Bronchocele, 794 Bronchotomy, 807 Brood-cells, 173 Bubo, comparison of, in infectious and non- infectious chancre, 230 indurated, symptomatic of chancre, 228 non-syphilitic, 233 syphilitic, 233 Buchanan's operation of lithotomy, 961 Buck’s extension in fracture, 590 Buffy coat of blood, 93 Bunion, 431 Burns and scalds, 406 cicatrices after, 410 classification of, 407 treatment of, 408 Bursae, injuries and diseases of, 427 synovial, 195 Bursitis, 431 treatment of, 432 Calcis, caries of, 706 excision of, 706 Calculi fellei seu biliarii, 838 salivary, 766, 794 urinary, 951, 954 in veins, 484 Calculous nephralgia, 922 Calendula as a dressing, 112, 311 Cancellated exostosis, 529 Cancer, 171 alveolar, 178 arsenic as a prophylactic in, 190 black, 178 in bone, 531 cell, 173 chimney sweeper's, 100 colloid, 178 - encephaloid, 175 enucleation of, 183, 186 epithelial, 177 gelatiniform, 178 1096 INDEX, Cancer, gum. 178 hard, 174 hydrastis in, 181 . hypodermic injection in, 186 juice, 173 lapis albus in, 185 of mammae, 829 medullary, 175 melanotic, 178 mode of death in, 174 osteoid, 179 pigmental degeneration of, 178 of the rectum, 910 removal of, by the knife, 189 of the scrotum, 1006 testicles, 992 treatment of, 180 by Marsden and MacLimont, 183 of the uterus, 1018 varieties of, 171 villous, 180 Capillaries, diseases of, 484 Capillary tumors, 484 Carbolic acid, 66 Carbuncle, 401 Carcinoma, 171 melanodes, 178 Carden's amputation at the knee, 374 Caries, 515 of the calcis, 706 causes of, 517 dry, 519 varieties of, 517 Carotid artery, aneurism of, 458 common, ligature above the omo-hyoid, 465 below the omo-hyoid, 466 surgical anatomy of, 464 external, ligature of, 467 Carpus, dislocation upon radius and ulna, 677 Cartilages loose in joints, 631 Caruncles of the urethra, 1052 Castration, 992 - Catheterism in the female, 937 male, 931 Catheters, 933 Causes of inflammation, 104 Cautery, the actual, 322 Cells, cancer, 173 granulation, 102 wandering, 90 Cellular tissue, diseases and injuries of 396 Cerebral localization, 725 Cervix uteri, amputation of, 1020 Chancre, 228 differential diagnosis of, 229 soft, 221 treatment of 230 Chancroid, 221 character of, 221 definition of, 222 phagedaenic, 223 seat of, 223 treatment of, 224 of the urethra, 224 Charpie, 41 | Cheiloplasty, 739 Chemical constituents of pus, 110 Chest, injuries and diseases of 879 . Chilblain, 405 Chimney-sweeper's cancer, 1006 Chlorides, Platt's, 65 Chlorine as a disinfectant, 64 Chloroform, 76 method of administering, 77 symptoms of danger, 77 Cholecystotomy, 839 Chondroid tumors, 157, 159 Chondroma, 159 Chopart's amputation through the tarsus, 379 Chordee, 208 Chorion, cysts of 199 Chronic rheumatic arthritis, 621 Cicatrices, 410 r Cicatrization, 102 Circocele, 1001 Circumclusion, 334 Cirsoid aneurism, 441 Civiale's operation for stone, 961 Clap, 208 - - Clark’s splint, 593 Clavicle, dislocation of, 650 excision of 705 fracture of 558 Cleanliness in surgery, 33 Cleft palate, 751 spine, 682 Cloacae, 529 Club-foot, 633 hollow, 639 Cocaine as an anaesthetic, 85 Coffee as a disinfectant, 63 Cold abscess, 115 Cold, effects of, 404 Colles's fracture, 574 Colloid cancer, 178, 1070 cysts, 195 Colotomy, 848 Compact exostosis, 529 Compound fractures requiring amputation, 353 Compresses, 42 Compression in aneurism, 446 of the brain, 723 in haemorrhage, 324 permanent, in haemorrhage, 324 temporary, in haemorrhage, 325 Concussion of the brain, 722 of the nerves, 494 spine, 681 Condylomatous venereal disease, 220 Congenital cutaneous cysts, 194 hernia, 858 hydrocele, 993 , syphilis, 243 Congestion, local, 91 Connective tissue, 90 tumors, 165 Consecutive abscess, 125 Constitutional symptoms of syphilis, 234 Continued suture, 250 Contraction of the palmar fascia, 435 Contused wounds, 256 requiring amputation, 354 INDEX. 1097 Contusions, 256 Contusion of the spine, 681 Coracoid process, fracture of 565 Coronoid process, fracture of 580 Corpuscles, exudation, 90 migration, 90 pus, 109 white blood, 90 Costal cartilages, fracture of, 557 Cotton as a dressing, 41 Cough impulse in hernia, 860 Coxo-femoral dislocations, 656 Cracked bones, 549 Crassamentum, 93 Creasote as a disinfectant, 66 Crepitus in fracture, 535 Cruor, 93 Crural hernia, 886 Cryptorchism, 921 Cut-throat, 789 Cylindroma, 159 Cynanche tonsillaris, 767 Cystic or adenoid disease of testicles, 991 osteoma, 530 - tumors, classification of, 190 of the jaws, 780 of the lip, 751 Cystitis, 928 tubercular, 930 in women, 931 Cysto-sarcoma, 196 Cystotomy through the hypogastrium, 940 perinaeum, 940 rectum, 939 Cysts in bones, 194, 530 of chorion, 199 colloid, 195, 1070 compound proliferous, 196 congenital cutaneous, 194 dermoid, of ovary, 1071 with mixed contents, 201 from expansion, 193 exudation, 194 independent, 194 mucous, 193 ovarian, 199, 1060 parovarian, 1072 pultaceous, 192 retention, 199 sanguineous, 194 sebaceous, 199 serous, 191 of broad ligament, 1072 of orbit, 194 synovial, 195 thyroid, 194 Dangers of wounds, 246 Death of bone, 519 mode of, in cancer, 174 Degeneration of tissue, 109 Delitescence, 99 Demarcation, line of 141 Dendritic vegetation, 180 Dentigerous cysts, 780 | Derbyshire neck, 794 Desmoid tumors, 157 Diaphragmatic hernia, 890 Diathesis, haemorrhagic, 316 Differential diagnosis between concussion and compression of brain, 724 encephaloid and scirrhus, 176 endostitis and periostitis, 509 inguinal hernia and other dis- eases, 880, 887 intracapsular and extracapsular fractures of the femur, 585 ovarian cyst and ascites, 1077 'pregnancy, 1075 Diffuse abscess, 115 aneurism, 440 hydrocele of the cord, 994 - Dilatation of sphincter ani in treatment of fistula, 905 Directors, 34 Direct transfusion, 348 Disarticulation of the toes, 382 Diseases of the anus and rectum, 892 capillaries, 484 gall-bladder, 838 glands of the neck, 792 hip-joint, 623 lymphatics, 503 sacro-iliac synchondrosis, 645 tongue, 759 venereal, 205 Diseases and injuries of the abdomen, 832 arteries, 436 bones, 507 genital organs, female, 1016 male, 987 head, 718 jaw, 777 joints, 608 mouth and throat, 739 muscles, tendons, and bursae 427 - neck, 789 nose, 729 - skin and cellular tissues, 396 spine, 681 - thorax, 819 urinary organs, male, 914 veins, 479 Disinfectants, 61 and antiseptics in surgery, 61 Dislocations, 648 Dislocation, after treatment of, 680 of the astragalus, 670 extension and counter-extension in, 649 general diagnosis of, 648 treatment of, 649 lower extremities, 656 at the ankle, 667 - lower end of tibia backward, 669 forward, 669 inward, 668 outward, 668 of the foot, 667 at the hip, 656 head of femur downward into foramen ovale, 663 1098 INDEX. Dislocation at the head of femur forward upon the pubes, 664 upward and backward on dorsum of ilium, 658 into sciatic notch, knee, 666 head of fibula backward, 667 tibia backward, 666 forward, 666 inward, 667 outward, 667 of the patella, 665 * lower jaw, 652 manipulation in, 649 of muscles and tendons, 429 of the pelvic bones, 653 pubis, 653 ribs, 655 upper extremities, 671 carpal bones, 678 carpus upon radius and ulna, 677 clavicle, 650 at the elbow, 675 radius backward, 677 forward, 677 and ulna backward, 676 backward and outward, 676 backward and inward, 677 ulna backward, 677 of the fingers, 678 metacarpal bones, 678 at the shoulder, 671 head of humerus, backward, 674 downward, 671 forward, 674 of the thumb, 680 ulna from the radius, 678 varieties of 648 of the vertebrae, 656 Dissecting aneurism, 440 forceps, 35 Dissection wounds, 285 Dittel's elastic ligature, 345 Divulsion of the pylorus, 854 Doigt à ressort, 644 Dorsalis pedis artery, ligature of 479 * surgical anatomy of, 479 Drainage tubes, 43 Dressing of wounds, articles for, 40 methods of, 246 rules for, 44 Dropsy, encysted, of the peritoneum, 1076 Drowning, apnoea from, 825 Dry caries, 519 mortification, 143 suture, 250 Dupuytren's contraction, 435 Earth as a disinfectant, 62 in treatment of ulcers, 140 Ecraseur, the, in relation to haemorrhage, 328 treatment of haemorrhoids, 901 Effusion of blood in inflammation, 93 Elastic ligature, Dittel's, 345 Elbow-joint, amputation at, 386 dislocations at, 675 excision of 700 Electric light, 57 Electrolysis, 58 in aneurism, 453 in cysts, 200 Elephantiasis Arabum, 419 Graecorum, 420 of the labia, 1049 of the scrotum, 419, 1006 Elongation of the uvula, 775 Embolism, 437 Emphysema, 821 Empresma hepatitis, 837 Emprosthotonos, 491 Empyema, 820 Encephaloid cancer, 175 Enchondroma, 159 Encysted hernia infantilis, 858 hydrocele of the cord, 994 Endodontitis, 759 Endostitis and periostitis, differential diag- nosis between, 509 Enterectomy, 834, 854 in hernia, 870 Enucleation of cancer, 183, 186 of uterine tumors, 1026 Epicystotomy, 962 Epididymitis, 987 - Epilepsy, reflex, nerve-stretching in, 496 Epispadias, 919 Epistaxis, 730 Epithelioma, 177 of the lip, 748 penis, 1014 ulcerating, of the uterus, 1019 vegetating, of the uterus, 1019 Epulis, 157, 780 Equinia, 287 Erectile tumors, 484 Erysipelas, 396 bullosum, 396 contagion of 397 hospital, 397 phlegmonous, 396 Escape of white blood-corpuscles, 92 Esmarch's bandage in treatment of aneurism, 449 method of artificial ischaemia, 339 Ether, 71 anaesthetic for local application, 84 inhalers for, 74 Etherization by rectal method, 75 Examination of the rectum, 770 Exanthemata syphilitica, 235 Excisions of the bones and joints, 698 Excision of ankle-joint, 709 of astragalus, 708 of bones of hand, 698 forearm, 700 leg, 714 of clavicle, 705 of elbow-joint, 700 of hip-joint, 715 of humerus in its continuity, 703 of joint betweenos calcis and astragalus, 708 INDEX, 1099 Excision of knee-joint, 710 of lower jaw, 784 entire, 785 of olecranon process, 700 of os calcis, 706 of rectum, 910 of ribs, 706 of scapula, 705 of shoulder joint, 703 of toes, 710 of upper jaw, 781 of veins, 483 of wrist, 699 Exostosis, 162, 528 cancellated, 162, 528 eburnous, 529 medullary, 529 periosteal, 529 subungual, 426 varieties of, 528 Exstrophy of the bladder, 914 External aneurism, 439 urethrotomy, 946 Extirpation of the larynx, 818 parotid gland, 793 spleen, 854 Extracapsular fracture of neck of femur, 585 Extravasation, 316 Extremities, lower, amputations of 363 dislocations of, 656 fractures of, 584 upper, amputations of, 382 dislocations of, 671 fractures of 570 Exudation corpuscles, 90 Facial artery, ligature of, 467 surgical anatomy of, 467 Facial neuralgia, 501 False anchylosis, 615 aneurism, 439 joint from dislocations, 650 fracture, 545 Farcy, 287 treatment of, 288 Fatty tumors, 156 removal of, 156 Femoral aneurism, 461 traumatic, 462 treatment of, 462 artery, ligature of 476 surgical anatomy of, 476 hernia, 886 diagnosis of 887 strangulated, operation for, 888 Femur, fractures of, 584 Fever, hectic, 128 and inflammation, 98 inflammatory, 98 surgical, 120 syphilitic, 235 traumatic, 120 Fibro-calcareous tumor, 157 cellular tumor, 157 cystic tumor, 157 Fibro-cystic tumor of ovary, 1073 plastic tumor, 168 Fibroid or fibroma of the uterus, 1021 Fibrous polypi, 157 tumors, 157 Fibula, dislocation of, 667 fracture of, 603 Figure-of-eight suture, 248 Fingers, amputation of, 388 Fingers, amputation of, 389 dislocation of 678 metacarpo-phalangeal amputation of, 388 Fissures of the anus, 909 Fistula, 119 in ano, 901 lymphatic, 506 in perinaeum, 937 salivary, 767 vesico-vaginal, 1043 Flaps retracted after amputation, 392 Flat foot, 646 Flexion or bending of the bones, 544 forced, in haemorrhage, 323 Floating kidney, 923 Fluctuation, 111 Foot, dislocation of 670 backward, 669 forward, 669 inward, 668 outward, 667 or leg, aneurism of, 463 fractures of, 607 Forceps, 35 perforating ulcer, 426 Forearm, amputation of 385 arm, or hand, aneurism of, 460 excision of, 700 fractures of, 573 both bones, 582 Foreign bodies in the larynx and trachea, 806 in the nose, 729 Oesophagus, 800 rectum, 896 urethra, 940 Fractures, 534 causes of, 535 comminuted, 534 compound, 534, 607 crepitus in, 535 divisions of, 534 examination of patient in, 536 general consideration of 534 green-stick, 545 impacted, 534 incomplete, 549 diagnosis of 549 of the head and face, 549 hyoid bone, 551 inferior maxilla, 551 malar bones, 550 nasal bones, 549 skull, 719 superior maxilla, 550 lower extremities, 584 femur, 584 neck of femur, 584 extracapsular, of femur, 585 1100 INDEX. Fractures, lower extremities, impacted, 586 intracapsular, 584 shaft of femur in lower third, 589 in middle third, 589 in upper third, 588 fibula (Pott's),603 foot, 607 leg, both bones, 604 patella, 598 pelvis, 566 tibia, 602 medical treatment in, 543 mobility in, 536 mode of repair in, 537 simple, 534 splints for, 539 plaster-of-Paris, 540 symptoms of, 535 transverse, 535 of the trunk, 555 acetabulum, 568 clavicle, 558 acromial extremity, 559 costal cartilages, 557 os innominatum, 566 ribs, 557 scapula, 561 at acromion process, 565 at coracoid process, 565 at neck, 566 sternum, 557 vertebrae, 555 of the upper extremities, 570 forearm, 573 hand, 583 humerus, 570 at base of condyles, 571 at head and anatomical neck, 572 in the shaft, 570 at surgical neck, 572 through the tubercles, 572 phalanges, .583 radius at lower end (Barton's), 575 at lower end (Colles's), 574 at neck, 573 through shaft, 574 and ulna, 582 ulna, 579 at coronoid process, 580 at olecranon process, 580 Fraenum linguae, malformation of, 765 Fragilitas ossium, 527 Fumigation, nitrous, 65 Fungoid degeneration of joints, 613 growths of the testicle, 990 Fungus haematodes, 175 melanodes, 178 Furunculus, 399 Fusiform aneurism, 440 Gall-bladder, diseases of 838 Gall-stones, 838 Galvano-cautery battery, 57 moxa, 56 Galvano-puncture, 56 | Galvano-puncture in aneurism, 453 Ganglion, 432 diffuse, 432 treatment of, 433 Gangrene, 141 divisions of 142 hospital, 145 and mortification requiring amputation, 354 of the parotid gland, 793 senile, 143 Gangrenous pharyngitis, 772 Gastrotomy, 852 Gelatiniform cancer, 178 Gelatinous sarcoma, 158 Genital organs, female, injuries and diseases of 1016 male, diseases of 987 malformation of 987 Genuthrotomy, 615 Genu-valgum, 640 subcutaneous osteotomy for, 640 Giant-celled sarcoma, 168 Gingivitis, 758 Glanders, 287 treatment, 288 Glandular tumors, 165 - Gleet, 210 Glioma, 171 Globules, pus, 109 Glossitis, 759 Glottis, intubation of, 811 oedema of 776 spasm of 775 Glover's suture, 250 Goitre, 794 Gonalgia, 644 Gonorrhoea, 208 praeputialis, 215 treatment, 215 sicca, 209 spurious, 215 treatment of, 210 in women, 215 Gonorrhoeal ophthalmia, 218 rheumatism, 217 Grafting skin in ulcers, 136 Granulation, 102 Granulations, gray, 202 healthy, 102 Gravel, 951 Gray pultaceous phagedaena, 146 Greenstick fracture, 544 Growths, morbid, on the skin, 422 Gum-boil, 759 Gum cancer, 178 Gummatous products in syphilis, stage of, 236 Gunshot wounds, 270 delusions concerning, 278 diagnosis of 281 foreign bodies in, 279 of scalp, 719 shock of, 276 surgical prognosis of, 281 treatment of, 282 varieties of, 278 INDEX, 1101 Haematocele, 1000 Haematoma, 194 Haemophilia, 316 Haemorrhage, 315 active, 316 acupressure in, 329 arterial, 316 cautery in, 322 compression in, 324 definition of 316 elastic ligature in, 345 Esmarch's method of arresting, 339 forced flexion in, 323 intermediary, 316 internal, 316 internal medication, 319 ligature in, 336 method of arresting, 317 nasal, 730 other methods of arresting, 335 passive, 316 s percutaneous ligature in, 335 primary, 316 secondary, 316 styptics in, 320 torsion in, 327 venous, 316 Haemorrhagic diathesis, 316 Haemorrhoids, 898 treatment by écraseur, 901 by injection, 900 by ligation, 900 by nitric acid, 901 Haemostatics, 317 artificial, 319 natural, 317 Hand, arm, or forearm, aneurism of, 460 excision of 698 fracture of, 583 Hanging, apnoea from, 826 Hare-lip, 739 double, 747 Head and face, special fractures of 549 injuries and diseases of, 718 Healing of wounds, 245, 251 Healthy granulations, 102 ulcer, 131 Heat as a disinfectant, 63 in inflammation, 95 Hectic fever, 128 Hepatic abscess, 841 Hepatitis, 837 Hermaphroditism, 920 Hernia, 856 abdominal, 857 albuminuria in, 860 coffee in, 862 congenital, 858 cough impulse, 860 crural or femoral, 886 anatomy of 886 diagnosis of 887 diaphragmatic, 890 enterectomy, 870 epigastric artery in crural, 887 in inguinal, 879 frequency, 856 Hernia, funicular, 858 incarcerated, 860 infantile, encysted, 858 inguinal, congenital, in the female, 885 in the male, 876 interstitial, 858 irreducible, 859 ischiatic, 890 medical treatment of, 861 momenclature, 856 oblique inguinal, operation for strangula- tion of 883 obturator, 890 ovarian, 885 pudendal, 890 radical cure of 871 Heaton's method, 872 open method, 871 Wood's method, 875 reducible, 858 reduction by puncture of intestine, 864 by rubber bandage, 865 by taxis, 862 - simultaneous, 882 strangulated, 860 traction in taxis, 864 trusses for, 865 umbilical, 888 varieties of 857 Hernial aneurism, 439 | Herniotomy, 867 division of stricture external to sac, 867 Heteroplasty, 395 Heurteleup's operation of lithotrity, 970 High operation for stone, 962 Hip-joint, amputations at, 365 disease, 623 dislocations of, 656 excision of 715 iliac dislocation, 658 pubic dislocation, 664 sciatic dislocation, 662 thyroid dislocation, 663 History of syphilis, 205 Hodgens' splint, 592 Hodgkin's disease, 505 Horny tumors, 164 Hospital gangrene, 145 Housemaid’s knee, 431 Humerus, dislocation of head backward, 674 downward, 671 forward, 674 partial, 675 excision of, 703 fractures of 570 fracture at base of condyles, 571 of head and anatomical neck, 572 of the shaft, 570 surgical neck, 572 Humid gangrene, 142 Hydatid tumors, 199 Hydramyl as an anaesthetic, 85 Hydrocele, 993 congenital, 993 diffused, of the cord, 994 encysted, of the cord, 994 1102. INDEX. Hydrocele, medical treatment of 995 palliative treatment, 997 radical method of cure, 997 treatment by acupuncture, 996 by faradization, 999 by hypodermic injection, 997 by excision of tunica vaginalis, 999 by incision, 999 by injection, 997 by seton, 999 Hydrogen peroxide in wounds, 310 Hydrophobia, 261 symptomatic, 269 treatment of 267 Hydrops articuli, 609 Hydrosarcocele, 993 Hydrothorax, 820 Hygroma of the neck, 193 Hyoid bone, fracture of, 551 Hyperaemia, 91 Hypertrophic lupus, 414 Hypertrophy of the prostate gland, 985 tongue, 761 - Hypodermic medication, 50 Hypogastric lithotomy, 962 Hypospadias, 921 Hysterectomy, 1028 laparo, 1029 supra-vaginal, 1031 vaginal, 1030 Hysterical joints, 644 Ichorrhaemia, 121 Iliac artery, common, surgical anatomy of, 474 ligature of, 474 external, surgical anatomy of, 475 ligature of, 475 internal, ligature of, 475 Iliac dislocation of the femur, 658 Immediate union, 101 Impacted fracture of neck of femur, 586 Imperforate anus and rectum, 895 Incarcerated hernia, 860 Incised wounds, 252 Incisions, methods of making, 49 Incomplete fracture, 549 Index finger, amputation of, 389 India-rubber suture, 250 Indirect transfusion, 347 Indolent ulcer, 132 Infantile hernia, 858 syphilis, 243 Infarctions, 124 Infection, systemic, 121 Infiltration, Oedematous, 92 purulent, 115 Inflammation, 86 of the arteries, 436 bones, 511 bladder, 928 liver, 837 prostate gland, 984 results of, 104 symptoms of 95 theories of 91–93 treatment of, 105 Inflammation, varieties of, 103 of the veins, 480 Inflammatory fever, 98 gangrene, 141 new formations, 100 Ingrowing toe-nail, 424 Inguinal aneurism, 461 hernia, 876 anatomy of 877 congenital, in the male, 885 in the female, 885 diagnosis of 880 epigastric artery in, 879 oblique operation for strangulation of 883 Inhibitory nerves, 89 Injection of haemorrhoids, 900 Injuries and diseases of the abdomen, 832 - arteries, 436 bones, 507 head, 718 female genital organs, 101 jaws, 777 - joints, 608 larynx, 806 male urinary organs, 914 mouth and throat, 739 muscles, tendons, and bursae, 427 neck, 789 nose, 729 skin and cellular tissue, 396 spine, 681 thorax, 819 veins, 479 and operations, nervous system after, 488 Innocent tumors, 153 Innominata, fracture of, 566 Innominate artery, aneurism of, 457 ligature of, 470 - surgical anatomy of, 470 Insect wounds, 259 Instruments for excision of bones, 694 used in minor surgery, 34 Intention, first, healing by, 101 Internal aneurism, 439 haemorrhage, 316 malignant pustule, 421 medication in haemorrhage, 319 urethrotomy, 947 Interrupted suture, 247 Intestines, suturing the, 834 Intracapsular fracture of neck of femur, 584 Introduction of tubes into the oesophagus, 801 Intubation of the larynx, 811 Intussusception, 846 Involucrum in necrosis, 520 Iodine as a disinfectant, 63 Iodoform in wounds, 309 Iritis, syphilitic, 239 Irreducible hernia, 859 Irritable ulcer, 132 Ischaemia, artificial, Esmarch's method of, 339 •' Ischiatic dislocation of hip-joint, 662 hernia, 890 Ischuria vesicalis, 931 Ivory exostosis, 529 INDEX. 1103 Jaw, lower, anchyloses, 786 Jaws, cystic tumors of 780 dislocation of lower, 652 excision, lower, 784 injuries and diseases of 777 necrosis of, 781 phosphorus necrosis of, 781 Joints, diseases of requiring ampntation, 355 excisions of, 693 false, 545 fungoid degeneration of, 613 hip disease, 623 hysterical, 634 injuries and diseases of, 608 loose cartilages in, 630 wounds of, 608 Juice, cancer, 171 Keloid, 420 treatment of, 421 Relotomy, 867 Key's operation of lithotomy, 959 Kidney, floating, 923 King's evil, 201 Knee, amputation at, 372 chronic contraction of, 614 dislocations at, 666 excision of, 740 housemaid’s, 431 mixed amputations at (Carden's), 374 Knives, 37 Knock-knee, 640 Kyphosis, 691 Labia, elephantiasis, 1049 Labium leporinum, 739 Lacerated perinaeum, 1036 wounds, 257 Laceration of the urethra, 938 Laparo-hysterectomy, 1030 Laryngitis, syphilitic, 240, 806 Laryngoscopy, 813 Laryngotomy, 807 Laryngo-tracheotomy, 810 Larynx, adenoid growths in, 815 diseases of, 806 extirpation of, 818 intubation of 811 neoplasms in, 815 polypi in, 815 syphilis of, 240 tumors in, 815 warty growths in, 815 and trachea, foreign bodies in, 806 surgical affections of, 806 Lateral lithotomy, 958 Laudable pus, 109 Leg, amputations of 375 dislocations of, 666 excision of, 714 fracture of both bones, 604 or foot, aneurism of 463 Lepra tuberculeuse d’Alibert, 420 Leucocytes, 90 Lewis's metallic splints, 540 Ligation of arteries, 463 of haemorrhoids, 900 percutaneons, in haemorrhage, 335 Ligature, antiseptic, 338 in aneurism, 453 Dittel's elastic, 345 in fistula in ano, 904 in haemorrhage, 336 in naevi, 486 silk-worm gut, 39 thread, 39 whale tendon, 39 of the anterior tibial artery, 477 arteria innominata, 471 axillary artery, 470 brachial artery, 472 common carotid, above the omo- hyoid, 465 - below the omo-hyoid, 466 dorsalis pedis artery, 479 external carotid artery, 467 iliac artery, 475 facial artery, 467 femoral artery, 476 iliac artery, 474 internal iliac artery, 475 lingual artery, 467 popliteal artery, 477 posterior tibial artery, 477 radial artery, 472 subclavian artery, 468 superficial palmar arch, 474 superior thyroid artery, 471 ulnar artery, 473 Light, electric, 57 Limited aneurism, 440 Line of demarcation, 141 separation, 141 Linear rectotomy, 908 Lingual artery, ligature of 467 surgical anatomy of, 467 Lint, 40 Lip, cysts of 751 enlargement of mucous glands of 749 epithelioma of 748 lower, restoration of, 750 upper, restoration of, 747 Lipoma nasi, 731 Lipomata, 157 Lister's antiseptic dressing of wounds, 295 Litholapaxy, 970 in children, 981 Lithotomy, 957 Allarton's operation, 960 bilateral section, 961 Buchanan's operation, 961 Civiale's operation, 961 dangers of 968 Key's operation, 959 lateral, 958 preparation of the patient for, 958 recto-vesical operation, 961 suprapubic or hypogastric operation, 962 Lithotrity, 969 - American method of, 970 Heurteleup's method, 970 1104 INDEX. Little's artery forceps, 36 Liver, abscess of, 841 inflammation of 837 melanosis of, 837 Local anaesthesia, 81 mixtures for, 85 Localization, cerebral, 725 Lock-jaw, 491 Loose cartilages in joints, 630 Lordosis, 691 Lower extremities, amputation of 365 Lower jaw, dislocation of, 652 excision of 735 fracture of, 551 Lumbar abscess, 691 Lupus erythematodes, 416 exedens, 414 hypertrophic, 414 - microscopical appearances in, 415 non-exedens, 414 Luxations, 604 Lymphadenoma, 505 Lymphangitis, 504 mammary, 826 Lymphatic fistula, 506 Lymphatics, diseases of, 503 thrombosis of, 504 Lymphoma, 505 Lympho-sarcoma, 505 Maculae syphiliticae, 235 Maggots in wounds, 288 Malacosteon, 524 Malar bones, fracture of, 550 Malformation of the franum linguæ, 765 nose, 729 Malformations of the male genital organs, 987 urinary organs, 914 Malignant pustule, 421 internal, 421 tumors, 171 of the parotid gland, 793 Mammae, amputation of, 832 benign tumors of, 831 cancer of 829 - lymphangitis of, 826 • Marine lint, 40 Mastitis, 826 Maxilla, inferior, anchylosis of, 786 dislocation of 652 excision of, 784 entire, 785 fracture of, 551 superior, excision of, 781 fracture of, 550 Maxillary artery, external, ligature of, 467 surgical anatomy of, 467 Medication, hypodermic, 50 in hernia, 861 internal, in haemorrhage, 319 Melanosis, 178 of the liver, 837 Mercurial fumigation, in syphilis, 242 Mercury bichloride in wounds, 310 Metacarpus, amputation through, 389 Metastasis of tumors, 151 Methylene, bichloride of 81 Microscopic anatomy of cancer, 173 Migration corpuscles, 90 theory of Cohnheim, 91 Milk, transfusion of 350 Miner's elbow, 431 Minor surgery, 33 articles for dressing, 40 instruments, 34 Mode of death in cancer, 174 Moist mortification, 142 Mollities ossium, 524 Morbid growths on skin, 422 Morbus coxae senilis, 621 coxarius, 623 excision of hip in, 630 Mortality in amputations, 360 Mortification, 142 amputation in, 354 dry, 143 moist, 142 Mouth, injuries and diseases of 739 Moxa, galvanic, 56 Mucous cysts, 195 tumors, 157 Mumps, 792 Muscles, dislocations of, 429 injuries and diseases of, 427 and tendons, ruptures of, 429 treatment of, 429 Muscular atrophy, 430 progressive, 430 reflex, 431 Myeloid tumors, 168 Myomata of the uterus, 1021 Myxoma, 57 Naevus, 484 Nail, ingrowing toe, 424 Nasal bones, fractures of, 549 polypus, 732 Naso-pharyngeal polypus, 734 Natural haemostatics, 317 Neck, cystic tumors of 794 Derbyshire, 794 diseases of the glands, 792 injuries and diseases of 789 Neck of femur, extracapsular fracture of 585 impacted fracture of, 586 intracapsular fracture of, 584 of scapula, fracture of, 566 Necrosis, 519 causes of 521 of the jaw bones, 781 operative measures in, 523 periosteal, 520 peripheral, 520 of the skull, 510 Needles, 40, 246 Needle forceps, 35 Neoplasms, 150 laryngeal, 815 Nephralgia, calculous, 922 Nephrectomy, 924 * INDEX. 1105 Nephrorraphy, 927 Nephrotomy, 927 Nerves, concussion of 494 inhibitory, 89 stretching of, 495 wounds of, 495 Nerve suture, 499 secondary, 500 vaso-motor, 89 Nervous system after injuries and operations, 488 Neuralgia, 501 false, 502 - nerve-stretching in, 495 of the stump, 391 Neurectomy, 503 Neuroma, 154 Neuromatous tumors, 154 Neurotomy, 503 New formations, inflammatory, 100 Nitrous fumigation, 65 oxide, 81 Nodes, 509 Noli-me-tangere, 414 Nomenclature of hernia, 856 Nose, foreign bodies in, 729 haemorrhage from, 730 hypertrophy of 730 injuries and diseases of 729 lipoma of, 731 malformations of 729 polypus of, 731 ulceration of, 731 Obstruction of the bowels, 846 Obturator hernia, 890 : CEdema glottidis, 776 CEdematous infiltration, 92 CEsophagitis, 797 CEsophagotomy, 802 CEsophagus, foreign bodies in, 800 inflammation of 797 introduction of tubes into, 801 rupture of, 796 stricture of 797 electrolysis in, 800 Olecranon fracture, 580 Onychia, 425 Oöphorectomy, 1032 Ophthalmia, gonorrhoeal, 219 Opisthotonos, 491 Orchitis, 987 chronic, 989 Os calcis, excision of, 706 innominatum, fracture of 566 Ossium fragilitas, 527 Osteitis, 511 causes of, 511 symptoms of, 511 rarefying osteitis, 530 Osteo-chondroma, 159 Osteo-cystoma, 530 Osteoid cancer, 531 tumors, 528 Osteoma, 162 Osteo-malacia, 524 Osteo-malacia, and rickets, artificial produc- tion of 526 Osteo-myelitis, 513 idiopathic, symmetrical, 514 treatment of 514 Osteo-plastic amputation (Pirogoff's), 378 operation for removal of tumors from antrum highmorianum, 779 Osteo-sarcoma, 531 benign, 159 Osteotomy, subcutaneous, 526, 620, 640 supra-condyloid, 641 Ovarian fluid, examination of, 1078 peculiarities of, 1081. hernia, 885 tumors, 1066 diagnosis of, 1073 electrolysis in, 1084 formation of, 1067 medical treatment of, 1082 palliative treatment of, 1083 tapping and injection of 1083 and pressure of, 1083 Ovariotomy, 1084 treatment of pedicle, 1089 washing out abdominal cavity, 1091 Ovary, colloid cysts, 1070 dermoid cysts of, 1071 fibro-cysts of, 1073 Ozaena, 731 syphilitica, 731 Ozone as a disinfectant, 63 Pain in inflammation, 95 Painful subcutaneous tumor, 154 Palate, cleft, 751 Palmar arch, superficial, ligature of, 474 surgical anatomy of, 474 fascia, contraction of, 435 Paper as a dressing, 48 Papilloma, 164 Papulae syphiliticae, 236 Paracentesis abdominis, 845 vesicae, 939 Paraphimosis, 1013 Paronychia, 411 treatment of, 412 Parotid gland, abscess of 793 * diseases and injuries of its duct, 793 extirpation of, 795 gangrene of, 793 malignant tumors of 793 Parotitis, 792 Parovarian cysts, 1072 Parulis, 759 Passive haemorrhage, 316 Patella, dislocation of, 665 fracture of 598 wiring the, 602 Pedunculated aneurism, 440 Pelvis, dislocation of, 653 fractures of 566 Penis, amputation of, 1014 epithelioma of, 1014 Percutaneous ligation in haemorrhage, 335 70 1106 INDEX, Perforating ulcer of the foot, 426 Periangioma, 436 Pericardium, aspiration of 824 Perinaeum, abscess and fistula in, 937 lacerated, 1035. - Perineorraphy, 1035 Bozeman's method, 1046 Emmet's, 1039 Hodgen’s, 1041 Sims's, 1043 Periodontitis, 758 Periosteal exostosis, 529 Periostitis, 508 constitutional symptoms of, 508 and endostitis, differential diagnosis be- tween, 509 treatment of 510 secondary, 509 Peritoneal transfusion, 351 Peritoneum, encysted dropsy of, 1076 Perityphlitis, 850 Perityphlitic abscess, 850 Pernio, 405 Pes cavus, 639 valgus, 646 Phagedaena, black, 146 gray, 146 sloughing, 145 Phagedaenic chancroid, 223 diphtheritic, 223 Phalanges, fracture of, 583 Pharyngitis, 772 gangrenous, 772 Phimosis, 1009 Phlebitis, acute, 480 chronic, 481 Phlebolithes, 484 Phlegmonous erysipelas, 396 Phosphatic deposits in urine, 953 Piles, 900 Pirogoff’s operation at ankle, 378 Plaster, adhesive, 251 Plaster-of-Paris bandages, 46 splints, 540 Plasters, 42 Plastie operations, method of, 394 surgery, 392 Pleurosthotonos, 491 Pleurotomy, 823 Pneumocele, 819 Poisoned wounds, 259 Poisoning with rhus tox., 399 Polypus, fibrous, 157 fibro-cellular, 158, 732 nasi, 733 naso-pharyngeal, 734 soft, 157 uteri, 1022 Popliteal aneurism, 462 artery, ligature of, 477 surgical anatomy of, 477 Post-pharyngeal abscess, 774 Pott's disease, 686 Pott's fracture of fibula, 603 Pressure in abscess, 119 Primary haemorrhage, 316 Probes, 34 Process of inflammation, 89 scabbing, 102 Progressive muscular atrophy, 430 Prolapsus ani, 891 Prosopalgia, 502 Prostate gland, abscess of, 984 senile hypertrophy of 985 Prostatitis, acute and chronic, 984 Prothesis, 395 Pruritus ani, 910 Pseudo-arthrosis, 545 Psoas abscess, 691 Pubic dislocation of femur, 664 Pubis, dislocation of, 653 Pudendal hernia, 890 Pulsating malignant tumors, 533 tumors in bone, 533 Pultaceous cysts, 192 Punctured wounds, 255 Purulent infiltration, 115 Pus basin, 49 - chemical constituents of 110 corpuscles, 109 Pustule, malignant, 421 general or internal, 421 treatment of 422 syphilitic, 236 Pyaemia, 123 tables of cases, 125 Pylorectomy, 853 Pylorus, divulsion of 854 Question of amputation in wounds, 289, 354 Quilled suture, 250 Quinsy, 767 Rabid animals, wounds of, 261 Rabies canina, 261 in the dog, 262 Rachitis, 524 Radial artery, ligature of, 472 surgical anatomy of, 472 Radical cure of hernia, 871 Heaton's method, 872 open method, 871 Wood's method, 875 Radius, dislocation of head backwards, 677 forwards, 677 fracture of the neck of, 573 shaft, 574 Railway concussion, 681 spine, 681 Ranula, 766 Rectal method of etherization, 75 Rectotomy, linear, 908 Recto-vesical lithotomy, 961 Rectum and anus, diseases of 892 examination of, 892 cancer of, 910 excision of, 910 foreign bodies in, 896 imperforate, 895 prolapsus of, 897 stricture of 906 tumors within, 905 INDEX. 1107 Recurrent tumors, 165 Redness in inflammation, 97 Reducible hernia, 858 Reflex muscular atrophy, 431 Repair, 100 Resection of bones, in continuity, 698 of the pylorus, 853 Residual abscess, 115 Resolution, 99 Respiration, artificial, 825 Retention of urine, 931 Retracted flaps after amputation, 372 Retroclusion (acupressure), 334 Rheumatic arthritis, 621 Rheumatism, gonorrhoeal, 217 Rhinoplasty, 737 Rhinoscopy, 770 Rhus tox., poisoning with, 399 Ribs, dislocation of, 655 excision of, 706 fracture of, 557 Rickets, 524 Roller bandage, 44 Rotary, lateral curvature of spine, 684 Rules for dressing, 44 Rupture, 856 of muscles and tendons, 429 of the oesophagus, 796 Sacro-iliac disease, 645 dislocation, 654 Saddle-back, 691 Salines, transfusion of 351 Salivary calculus, 766, 794 fistula, 767 Sanguineous cysts, 194 Sarcoma, 149 alveolar, 171 cysto, 196 gelatinous, 158 giant-celled, 168 lympho, 505 round-celled, 171 spindle-celled, 165 Scabbing process, 102 Scalds and burns, 406 Scalp, gunshot wounds of, 719 wounds of 718 Scalpels, 37 Scapula, excision of, 705 fractures of 561 Sciatic dislocation of the femur, 662 Scirrhus, 174 of mammae, 830 Scissors, 34 Sclerosis in bone, 512 Scoliosis, 684 Scrofula, 201 in bone, 517 Scrofulous pus, 110 ulcer, 203 Scrotum, amputation of, 1007 carcinoma of 1006 elephantiasis of, 419, 1006 Sebaceous cysts, 199 Secondary haemorrhage, 316 Semi-malignant tumors, 165 Senile gangrene, 143 Separation, line of, 141 at sacro-iliac symphysis, 654 Septicaemia, 121 Sequestrum in necrosis, 520 Serous cysts, 191 congenital, 194 Shaft of femur, fracture of 588 Shock, 488 secondary, 489 symptoms of, 490 temperature during, 489 Shoulder-joint, amputation at, 382 dislocation of 671 excision of, 703 Simple ulcer, 131 Sims's and Emmet's operation for vesico-vagi- nal fistula, 1043 Sinus, 119 Skin-grafting, 136 Skin, injuries and diseases of 396 morbid growths upon, 422 Skull, fracture of, 719 with depression, 719 Slough, 131 Sloughing, 131 phagedaena, 145 ulcer, 145 - Smith's anterior splint, 592 Smoke.as a disinfectant, 62- Snakes, venemous, wounds of, 260 Soft chancre, 221 Sounding for stone, 956 Spasms of the glottis, 775 Special fractures of the head and face, 549 Specific pus, 110 Spermatocele, 1001 Spermatorrhoea, 1015 Sphacelus, 141 Spina bifida, 682 Spindle-celled sarconna, 165 Spine, angular curvature of, 686 cleft, 682 concussion of 681 injuries and diseases of, 681 rotary, lateral curvature of, 684 Splay foot, 646 Spleen, extirpation of 854 Splints, 539 plaster-of-Paris, 540 Spondylitis, 686 Sponge grafting, 138 Sprains, 433 Spurious talipes, 639 Squamae, syphilitic, 236 - Stage of gummatous products in syphilis, 236 Staphylorraphy, 751 Starch bandage, 542 Stasis, 91 Steatomata, 157 Steno's duct, diseases and injuries of, 793 Sternum, fracture of, 557 Stone in the bladder, 956 sounding for, 956 female bladder, 969 Strangulated hernia, 860 1108 INDEX. Strapping of ulcers, 134 Straps and plasters, 42, 251 Stricture of the oesophagus, 797 rectum, 906 urethra, 941 Struma, 201 Strumous synovitis, 613 Stump, neuralgia of, after amputation, 391 Styptics, 320 Subastragaloid amputation, 380 Subclavian artery, aneurism of, 459 ligature of, 468 surgical anatomy of, 468, 469 Subclavicular dislocation of humerus, 671 Subcoracoid dislocation of humerus, 674 Subcutaneous Osteotomy, 526, 620, 640 painful tumor, 154 Subglenoid dislocation of humerus, 671 Submaxillary gland, diseases of, 794 Subspinous dislocation of humerus, 674 Subungual exostosis, 426 Superior maxilla, fracture of, 550 Suppuration, 109 in bone, 512 Supra-pubic lithotomy, 962 Supra-vaginal hysterectomy, 1032 Surgery, minor, 33 plastic, 392 of special regions and tissues, 396 Surgical affections of trachea and larynx, 806 anatomy of vessels, and methods of ope- rating, 463 neck, 464 fever, 121 Sutures, 246 continued, 250 dry, 250 figure-of-eight, 248 glover's, 250 india-rubber, 250 interrupted, 247 nerve, 499 quilled, 250 silk, 38 silkworm-gut, 39 twisted, 248 whale tendon, 39 Suturing the intestines, 834 Swelling in inflammation, 96 Sycosis, 220 s treatment of, 220 Hahnemanni, 237 Syme’s operation at ankle-joint, 376 Synostosis, 615 Synovial cysts, 195 Synovitis, 609 strumous, 613 Syphilis, 205, 226 in bone, 237, 517 * congenital, 243 treatment of 244 constitutional symptoms of, 234 treatment, 238 history of 205 infantile, 243 Syphilitic alopecia, 237 bubo, 233 Syphilitic exanthemata, 235 fever, 235 iritis, 239 treatment of 240 laryngitis, 240, 806 maculae, 235 ozaena, 731 papulae, 236 pustules, 236 squamae, 236 tubercles, 236 Syphilization, 241 Systemic infection, 121 Talipes, 633 calcaneus, 634 equino-varus, 634 equinus, 634 spurious, 639 tenotomy in, 637 valgus, 634 varus, 634 Tapping the abdomen, 845 Tarso-metatarsal articulation, through, 380 Tarsus, Chopart's amputation through, 379 Taxis, 862 Telangiectasis, 485 Tendinous tumors, 157 Tendons, ham-string, division of, 614 injuries and diseases of, 427 and muscles, dislocation of, 429 rupture of, 429 Tenotomy, 637 Tents, 48 Terminations of inflammation, 99 Testicle, abscess of, 988 cancer of 992 chronic inflammation of 989 cystic or adenoid disease of 991 fungoid growths of 990 inflammation of 987 Tetanus, 491 causes of, 491 nerve-stretching in, 494 Thecitis, 427 Theories of inflammation, 88, 91, 93 Thermo-cautery, 55 for tracheotomy, 811 Thigh, amputations of, 370 fractures of, 584 Thoracentesis, 822 Thoracis, gradual drainage, 822 Thorax, aspiration of, 821 injuries and diseases of, 819 Thread, ligature, 39 Throat, injuries and diseases of, 789 Throbbing in inflammation, 97 Thrombosis, 479 Thumb, amputation of 390 dislocation of, 680 Thymol as a disinfectant, 69 Thyroid artery, superior, ligature of, 471 surgical anatomy of, 471 cysts, 194 dislocation of femur, 663 amputation INDEX. 1109 Tibia, dislocation of head, backward, 666 forward, 666 inward, 667 outward, 667 lower end, backward, 669 forward, 669 inward, 667 outward, 668 fractures of, 602 Tibial artery, anterior, ligature of 477 surgical anatomy of, 477 posterior, ligature of, 477 surgical anatomy of, 477 Tic douloureux, 502 Tissue, connective, 90 changes in inflammation, 92 degeneration of 109 metamorphosis, Stricker, 93 Toes, amputation of, 381 dislocation of 670 excision of, 710 Toe-nail, ingrowing, 424 treatment of, 424 Tongue, abscess of, 759 amputation of 762 diseases of, 759 entire removal of 764 hypertrophy of 761 partial amputation of 764 tumors of 760 Tonsillitis, 767 Tonsils, chronic hypertrophy of 768 Tooth wounds, 285 treatment of, 285 Torsion in haemorrhage, 327 Torsoclusion (acupressure), 334 Torticollis, 790 Trachea and larynx, foreign bodies in, 806 surgical affections of 806 Trachelorraphy, 1062 Tracheotomy, 807 with thermo-cautery, 811 Transfusion, 346 direct, 348 indirect, 347 of milk, 350 peritoneal, 351 of salines, 351 Traumatic fever, 120 gangrene, 142 tetanus, 491 Trephine, application of, 724 Trigger finger, 644 Trismus,491 treatment of, 492 True aneurism, 439 Trunk, fractures of, 555 Trusses, 865 Tubercle, syphilitic, 236 varieties of, 202 Tuberculosis, 201, 203 Tumors, 147 adenomatous, 165 in the antrum highmorianum, 777 in the bladder, 982 in bone, 528 bony, 162 Tumors, cancerous, 171 carcinomatous, 171 cartilaginous, 159 chondroid, 159 classification of 148 color, 151 condylomatous, 237 cystic, 190 desmoid, 157 differential diagnosis between innocent and malignant, 151 enchondromatous, 159 epitheliomatous, 177 erectile, 484 fatty, 156 fibro-calcareous, 157 fibro-cellular, 157 fibro-cystic, 190 fibrous, 157 fleshy, 157 forms of, 151 glandular, 165 growth, 152 histological formation, 152 homologous, 148 horny, 164 hydatid, 199 innocent, 153 lymphomatous, 162 malignant, 171 melanotic, 178 metastasis of, 151 mobility, 151 myeloid, 168 myomatous, 154, myxomatous, 157 neuromatous, 154 Osseous, 162 ovarian, 1066 papillomatous, 164 parotid, 793 pulsating, malignant, 533 in the rectum, 905 recurrent, 165 sarcomatous, 165 schirrous, 174 semi-malignant, 165 size of, 151 subcutaneous, 154 tendinous, 157 of the tongue, 760 of the uterus, 1021 vascular, 155 volume of, 151 Turf as a dressing, 310 Turgescence, vital, 91 Twisted suture, 248 Ulatrophia, 759 Ulceration, 129 of the articular cartilages, 612 of bone, 515, 517 of the nose, 731 Ulcerative absorption, 130 Ulcers, 131 classification of, 131 1110 INDEX. Ulcers, indolent, 132 irritable, 132 perforating, of the foot, 426 phagedaenic, 130 rodent, 414 scrofulous, 203 serpiginous, 414 simple, 131 sloughing, 131, 145 specific, 131 varicose, 133 Ulma, dislocation backward, 677 of from the radius, 678 fractures of 579 - coronoid process, 580 olecranon process, 580 Ulnar artery, ligature of, 473 surgical anatomy of, 473 Umbilical hernia, 888 Upper extremities, amputation of, 382 fracture of 570 jaw, excision of 781 fracture of, 550 Urethra, chancroid of, 224 foreign bodies in, 940 lacerations of 938 stricture of 941 electrolysis in, 950 Urethral excrescences, 1052 Urethrotomy, external, 946 internal, 947 Uric acid calculi, 952 Urinary deposits and urinary calculi, 951 fistula, 937 - - organs, male, injuries and diseases of, 914 malformations of 914 Urine, retention of, 931 Uterine tumors, 1021 enucleation of, 1025 injection of ergot, 1026 removal by hysterectomy, 1028 by laparotomy, 1028 through vagina, 1030 Uterus, cancer of, 1018 examination of, 1016 hard cancer of, 1018 lacerations of cervix, 1052 ulcerating epithelioma of, 1018 vegetating epithelioma of, 1019 |Uvula, elongation of, 775 Vagina, atresia of, 1049 Vaginal extirpation of the uterus, 1030 Vaginismus, 1047 Varicocele, 1000 Varicose ulcer, 133 veins, 481 Varied methods of dressing wounds, 291 Varieties of hernia, 857 of inflammation, 103 of pus, 110 Varix, 481 aneurismal, 441 Vascular tumors, 155 of the lip, 750 Vaso-motor nerves, 89 Vegetating epithelioma of uterus, 1019 Vegetations, dendritic, 180 sycotic, 220 treatment of 220 Veins, calculi in, 484 entrance of air into, 483 excision of, 483 inflammation of, 480 injuries and diseases of 479 varicose, 481 treatment of, 481 wounds of, 484 Venereal disease, 205 condylomatous, 220 warts, 220, 237 Venous haemorrhage, 316 Verrucae, 422 Vertebrae, dislocations of, 656 fractures of, 555 Vesico-vaginal fistulae, 1043 Bozeman's operation for, 1046 Sims's and Emmet's operation for, 1043 Villous cancer, 180 Vinegar as a disinfectant, 65 Vital turgescence, 91 Volvulus, 846 Wandering cells, 90 Warts, 422 venereal, 220, 237 Weak ankles, 639 Weaver's bottom, 431 Whale tendon ligature, 39 Whiskey as an anaesthetic, 76 White blood-corpuscles, 90 Whitlow, 411 Wiring the patella, 602 Wounds, 245 of the abdomen, 832 amputation in, 354 articles for dressing, 246 classification of 245 contused, 246 and lacerated, requiring amputa- tion, 289 danger of 246 dissection, 285 - dressing of, with adhesive plaster, 251 with gauze and collodion, 250 by sutures, 246 varied methods of 291 by alcohol, 294 antiseptic, 307 Lister's, 295 aseptic, 303 by compression, 293 occlusive, 293 open method, 293 gunshot, 270 healing of 245, 251 incised, 252 insect, 259 of the joints, 608 lacerated, 257 INDEX. - - 1111 Wounds, maggots in, 288 Wounds, by rabid animals, 261 methods of dressing, 291 of the scalp, 718 of muscles and tendons, 427 tooth, 285 pf the nerves, 494 of the veins, 484 poisoned, 259 of venomous snakes, 260: punctured, 255 Wrist-joint, amputation at, 387 treatment of, 256 excision of, 699 the question of amputation in, 289 Wry neck, 790 ¿§§§§§§ Ķº - };*/≡ ..--~~~~|~~~~~--~~~~ ~~~~）; | | ſo=rī į CP=（D |. ģĒ.· N5==< V·. . . 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