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INDICATIONS FOR OPERATION 
 In Disease of the Internal Organs. 
 
INDICATIONS 
 FOR OPERATION 
 
 IN DISEASE OF THE INTERNAL ORGANS. 
 
 BY 
 
 Prof. HERMANN SCHI.ESINGER, M.D., 
 
 Ext7aordi>iary Professor of Medicine in the University of Vienna. 
 
 Aiithorized English Translatioji 
 
 BY 
 
 KEITH W. MONSARRAT, M.B., F.R.C.S.Ed., 
 
 Surgeon to the Northern Hospital, Lizwi-pool. 
 
 K. R. TREAT & Co., 241-243, West 23rd Street. 
 1906. 
 
Vj 
 
) 
 
 TRANSLATOR'S PREFACE. 
 
 Professor Schlesinger's reputation as a clinician and 
 writer is in itself sufficient explanation for this translation. 
 The subject of his treatise is admittedly one of the first 
 importance. Now that the activities of surgery are so 
 far-reaching, the question of the indications for operation 
 is one which is constantly presenting itself to the prac- 
 titioner, and one which is often very difficult of decision. 
 The object of this volume is to aid in the settlement of 
 such problems, and I have undertaken its translation 
 because it appears to me eminently to succeed in its 
 purpose. 
 
 K. W. MONSARRAT. 
 
 Liverpool, July, 1906. 
 
AUTHOR'S PREFACE. 
 
 I HAVE been induced to write this book by the fact that 
 practitioners have frequently expressed to me a desire to 
 possess some concise work, which would serve as a guide in 
 determining the necessity for surgical intervention in 
 diseases of the internal organs. 
 
 I have written essentially for the practitioner. I have, 
 therefore, avoided all prolix discussion, and confined myself 
 to the consideration of the questions indicated by the 
 special design of the work. On the advice of colleagues, 
 whom I have consulted, I have included in each chapter 
 some remarks on etiology, pathological anatomy, clinical 
 course, diagnosis, and differential diagnosis, with a view 
 to enabling the practitioner to quickly obtain a general 
 grasp of the condition under consideration. These para- 
 graphs are, however, subordinate to the main purpose of my 
 undertaking, that of enabling medical men, who are not in 
 hospital practice, to arrive at an independent opinion on the 
 advisability of operation in cases of internal lesion. I do 
 not claim, however, to have given separate consideration 
 to all the internal affections which have been submitted to 
 operation from time to time. 
 
 To avoid misconception, it must be stated, that the 
 references to literature at the end of each chapter are given 
 only with the idea of assisting the reader to consult the 
 authorities quoted ; in many instances articles equal in 
 importance to those cited are omitted for want of space. 
 
 The reader must not entertain the idea that this is a mere 
 compilation. Many years' work in hospital and private 
 
X PREFACE. 
 
 practice have given me the opportunity of acquiring a large 
 experience in the questions which are discussed in this book, 
 and on this experience I have largely drawn in writing it. 
 There should be some advantage in the circumstance, that 
 a Physician who is in full sympathy with the standpoint of 
 the Surgeon, here presents to the Practitioner a discussion 
 of the question of surgical intervention. 
 
 Hermann Schlesinger. 
 
 Vienna. 
 
CONTENTS, 
 
 CHAPTER I. 
 
 DISEASES OF THE BRAIN AND ITS MENINGES. 
 
 TUMOURS OF THE BRAIN CEREBRAL ABSCESS SINUS THROMBOSIS 
 
 AND SINUS PHLEBITIS HYDROCEPHALUS EPILEPSY 
 
 CEREBRAL PALSY OF CHILDREN CEREBRAL HEMORRHAGE 
 
 TUBERCULAR MENINGITIS ACUTE LEPTOMENINGITIS - pp. 1-39 
 
 CHAPTER II. 
 DISEASES OF THE SPINAL COLUMN AND CORD. 
 
 TUBERCULAR SPONDYLITIS (POTT's DISEASE) OSTEOMYELITIS 
 
 OF THE VERTEBRA TRAUMATIC AFFECTIONS OF THE SPINAL 
 
 CORD TUMOURS OF THE SPINAL CORD ACUTE POLIOMYELITIS 
 
 pp. 41—60 
 
 CHAPTER III. 
 
 DISEASES OF THE PERIPHERAL NERVES. 
 
 NEURALGIA OF THE FIFTH CRANIAL NERVE (TIC DOULOUREUX) 
 
 OCCIPITAL NEURALGIA BRACHIAL NEURALGIA INTERCOSTAL 
 
 NEURALGIA MERALGIA PARAESTHETICA (ROTH-BERNHARDT)— 
 
 SCIATICA FACIAL SPASM SPASM OF CERVICAL MUSCLES 
 
 (SPASMODIC TORTICOLLIS) PERFORATING ULCER OF THE FOOT pp. 61-77 
 
 CHAPTER IV. 
 NEUROSES. 
 
 EXOPHTHALMIC GOITRE INTERMITTENT HYDRARTHROSIS pp. 79-85 
 
 CHAPTER V. 
 DISEASES OF THE LARYNX. 
 
 STENOSIS OF THE LARYNX LARYNGEAL PARALYSIS OF NERVOUS 
 
 ORIGIN DIPHTHERIA ----- pp. 87-95 
 
xii CONTENTS. 
 
 CHAPTER VI. 
 
 DISEASES OF THE BRONCHI AND THE LUNGS. 
 
 BRONCHIECTASIS GANGRENE OF THE LUNG ABSCESS OF THE 
 
 LUNG PULMONARY TUBERCULOSIS HYDATID CYST OF THE 
 
 LUNG ACTINOMYCOSIS OF THE LUNG - - . pp_ 97-II3 
 
 CHAPTER VII . 
 
 DISEASES OF THE PLEURA. 
 
 PLEURISY AND EMPYEMA PNEUMOTHORAX H YDROTHORAX 
 
 TUMOURS OF THE PLEURA - - . . pp_ 115-129 
 
 CHAPTER VIII. 
 
 DISEASES OF THE MEDIASTINUM. 
 
 SUPPURATIVE MEDIASTINITIS MEDIASTINAL TUMOURS - pp. I 3 I-I 37 
 
 CHAPTER IX. 
 DISEASES OF THE HEART AND BLOOD-VESSELS. 
 
 PERICARDITIS ANEURYSM HYDROPS ANASARCA - - pp. I39-I49 
 
 CHAPTER X. 
 INDICATIONS FOR VENESECTION. 
 
 INTOXICATIONS INSOLATION URAEMIA ECLAMPSIA PNEU- 
 MONIA CIRCULATORY DISTURBANCE CHLOROSIS - pp I 5 I-I 55 
 
 CHAPTER XI. 
 DISEASES OF THE MOUTH AND PHARYNX. 
 
 HYPERTROPHY OF THE TONSILS SEPTIC PHARYNGITIS RETRO- 
 PHARYNGEAL ABSCESS AND RETROPHARYNGEAL CELLULITIS pp. 157-163 
 
 CHAPTER XII. 
 DISEASES OF THE CESOPHAGUS. 
 
 FUSIFORM DILATATION OF THE CESOPHAGUS DIVERTICULUM OF 
 
 THE CESOPHAGUS CESOPHAGEAL STENOSIS : CICATRICIAL AND 
 
 CARCINOMATOUS ..-.-. pp_ 1 65-1 73 
 
CONTENTS. xiii 
 
 CHAPTER XIII. 
 
 DISEASES OF THE STOMACH. 
 
 GASTRIC ULCER CARCINOMA OF THE STOMACH SJMPLE TUMOURS 
 
 AND FOREIGN-BODY TUMOURS OF THE STOMACH — PYLORIC 
 
 STENOSIS, GASTRIC DILATATION, AND HOUR-GLASS STOMACH 
 
 CONGENITAL HYPERTROPHIC STENOSIS OF THE PYLORUS pp. I7S-I97 
 
 CHAPTER XIV. 
 DISEASES OF THE INTESTINES. 
 
 DUODENAL ULCER DUODENAL STENOSIS INTESTINAL TUBERCU- 
 LOSIS ACTINOMYCOSIS OF THE INTESTINE CHRONIC DYSEN- 
 TERY AND ULCERATIVE COLITIS MUCOUS COLITIS AND MEM- 
 BRANOUS ENTERITIS EMBOLUS AND THROMBOSIS OF THE 
 
 MESENTERIC VESSELS HEMORRHOIDS PROCTITIS - pp. I99-223 
 
 CHAPTER XV. 
 
 DISEASES OF THE INTESTINES— coM^^mwe^. 
 
 INTESTINAL STRICTURE INTESTINAL OBSTRUCTION INTUSSUS- ' 
 
 CEPTION INTESTINAL CANCER CANCER OF THE RECTUM 
 
 CONGENITAL DILATATION OF THE COLON SUBCUTANEOUS IN- 
 JURIES OF THE STOMACH AND INTESTINE APPENDICITIS pp. 225—268 
 
 CHAPTER XVI. 
 
 -DISEASES OF THE PERITONEUM. 
 
 ACUTE CIRCUMSCRIBED PERITONITIS DIFFUSE PERITONITIS 
 
 CHRONIC EXUDATIVE PERITONITIS CHRONIC INDURATIVE AND 
 
 ADHESIVE PERITONITIS TUBERCULAR PERITONITIS - pp. 269-29 I 
 
 CHAPTER XVII. 
 
 DISEASES OF THE PERlT01<iElJM—conimued. 
 
 TUMOURS OF THE PERITONEUM, OMENTUM AND MESENTERY 
 
 ASCITES SUBPHRENIC ABSCESS . . - pp_ 293-304 
 
 CHAPTER XVIII. 
 DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 
 
 CHOLELITHIASIS (GALL-STONES) HYDROPS OF THE GALL-BLADDER 
 
 CHOLECYSTITIS: EMPYEMA OF THE GALL-BLADDER 
 
 INTESTINAL OBSTRUCTION BY GALL-STONE — CARCINOMA OF 
 
 JHE GALL-BLADDER ... - - pp. 305-327 
 
xiv CONTENTS. 
 
 CHAPTER XIX. 
 
 DISEASES OF THE LIVER. 
 
 TUMOURS OF THE LIVER HYDATID CYST OF THE LIVER ABSCESS 
 
 OF THE LIVER ATROPHIC CIRRHOSIS OF THE LIVER MOVABLE 
 
 LIVER THE CONSTRICTED LIVER - - - pp. 329-35O 
 
 CHAPTER XX. 
 
 DISEASES OF THE SPLEEN. 
 
 TUMOURS AND CHRONIC HYPERPLASIA OF THE SPLEEN BANTl'S 
 
 DISEASE FLOATING SPLEEN RUPTURE OF THE SPLEEN 
 
 ABSCESS OF THE SPLEEN . . . . pp_ 35I-365 
 
 CHAPTER XXI. 
 DISEASES OF THE PANCREAS. 
 
 INFLAMMATION AND NECROSIS PANCREATIC CALCULUS 
 
 PANCREATIC CYSTS SOLID TUMOURS OF THE PANCREAS - pp. 367-379 
 
 CHAPTER XXII. 
 
 DISEASES OF THE KIDNEY AND RENAL PELVIS. 
 
 BRIGHT'S disease RENAL NEURALGIA (NEPHRALGIA H^MA- 
 
 TURICA, ANGIONEUROTIC HEMATURIA) RENAL CALCULUS 
 
 RENAL CONTUSIONS MOVABLE KIDNEY - - pp. 38 I-4O5 
 
 CHAPTER XXIII . 
 
 DISEASES OF THE KIDNEY AND RENAL V'E'LYIS— continued. 
 
 TUMOURS OF THE KIDNEY CYSTIC KIDNEY HYDATID CYST OF 
 
 THE KIDNEY HYDRONEPHROSIS AND PYONEPHROSIS TUBER- 
 CULOSIS OF THE KIDNEY PYELITIS AND SUPPURATIVE 
 
 NEPHRITIS PERINEPHRITIS . - - - pp. 407-437 
 
 CHAPTER XXIV. 
 
 DISEASES OF THE BLADDER. 
 
 CYSTITIS NOCTURNAL ENURESIS TUBERCULOSIS OF THE BLADDER 
 
 pp. 439-446 
 
 CHAPTER XXV. 
 DISEASES OF THE JOINTS AND BONES. 
 
 THE NERVOUS ARTHROPATHIES ARTHRITIS DEFORMANS OSTEOMALACIA 
 
 pp. 447-456 
 
CONTENTS. XV 
 
 APPENDIX I. 
 
 INDICATIONS FOR THE INDUCTION OF PRExMATURE 
 LABOUR. 
 
 CARDIAC DISEASE DISEASES OF THE RESPIRATORY ORGANS 
 
 DISEASES OF THE BLOOD THE INFECTIOUS FEVERS — DISEASES 
 
 OF THE KIDNEY, ECLAMPSIA DISEASES OF THE STOMACH 
 
 APPENDICITIS DISEASES OF THE LIVER DISEASES OF THE 
 
 NERVOUS SYSTEM - -' - - - pp. 459-472 
 
 APPENDIX II. 
 
 OPERATIONS ON DIABETICS. pp. 473-476 
 
 APPENDIX III. 
 
 THE GENERAL INFLUENCE OF OPERATIONS ON 
 THE BODY. 
 
 POST-OPERATIVE PSYCHIC DISTURBANCES SHOCK, PNEUMO- 
 THORAX THE EFFECTS OF OPENING THE ABDOMEN, THE 
 
 CRANIUM AND THE SPINAL CANAL THE EXTIRPATION OF 
 
 GLANDULAR ORGANS ANESTHETICS THE INFLUENCE OF 
 
 CERTAIN DISEASES ON THE INDICATIONS FOR OPERATION 
 
 IMPORTANT COMPLICATIONS AFTER OPERATION - - pp. 477— 49O 
 
 INDEX -.--.-. pp, 491-498 
 
CHAPTER I. 
 
 Diseases of the Brain and its Meninges. 
 
INDICATIONS FOR OPERATION. 
 
 Chapter I. 
 DISEASES OF THE BRAIN AND ITS MENINGES. 
 
 TUMOURS OF THE BRAIN. 
 
 Etiology. — Of greatest importance in determining the 
 etiology of brain tumours are the presence of primary new 
 growths in other parts of the body, and the discovery of 
 syphihtic lesions in the skin, mucous membranes, or some 
 other locality. The existence of tuberculosis, especially in 
 the lungs, a history of severe trauma to the head preceding 
 the cerebral symptoms, the discovery of the cysticercus or 
 of a hydatid cyst in some organ, are all likew^ise etiologically 
 significant. 
 
 Pathological Anatomy. — Brain tumours may be 
 primary or secondary. Surgical treatment concerns itself 
 of course with the primary growths only. One of the most 
 common types, the glioma or gliosarcoma, occurs primarily 
 only in the brain ; sarcomata may be primary or secondary. 
 Cerebral tuberculosis is almost always associated with 
 tuberculosis elsewhere ; the gumma usually co-exists with 
 syphilitic changes in the meninges. Carcinoma occurs only 
 as a metastasis, and is not infrequently multiple ; the 
 latter is true also of tuberculosis and gumma, whereas the 
 sarcoma and the glioma are usually solitary. Sarcomata 
 usually show a sharp differentiation from the surroundmg 
 brain tissue, and tubercular lesions are also commonly 
 circumscribed, but the gumma is seldom well defined, and 
 the glioma diffusely infiltrates the surrounding brain sub- 
 stance. Not infrequently gummata originating in the 
 meninges make their way into the brain substance in such a 
 manner that they appear to have started in the latter. 
 There is rarely any true extension of meningeal tumours 
 into the brain substance, and still less frequently does this 
 
4 INDICATIONS FOR OPERATION IN 
 
 occur in the case of tumours originating in the cranial bones. 
 These latter are often metastatic in origin, secondary to 
 sarcomata and carcinomata of the thyroid, mamma, adrenal, 
 prostate, or ovary, and sometimes attain to very large pro- 
 portions. The sarcomata are often remarkably vascular. 
 
 With regard to situation, the cerebral hemispheres are most 
 commonly the seat of new growths, next the cerebellum 
 and the pons. Solitary tubercular lesions occur character- 
 istically in the two latter situations, while the glioma is 
 most frequent in the brain. 
 
 Tumours of the posterior cranial fossa are often associated 
 with the development of pronounced internal hydrocephalus. 
 Sometimes the surrounding brain substance is markedly 
 altered in contour by the compression of a new growth, and 
 softening often occurs. Cranial nerves may be compressed 
 and destroyed. The cranial bones are frequently thinned ; 
 in two cases under my own observation, however, the 
 calvarium over the tumour was enormously thickened. 
 
 Clinical Course. — The symptoms of brain tumour fall 
 into two categories, the general and the localizing. Of the 
 first, the most constant and important are intense headache 
 and the presence of double optic neuritis. Symptoms of 
 importance, but less constant than the above, are drowsiness, 
 intellectual dullness (a striking delay in answering questions), 
 general convulsions, vertigo, vomiting, a slow pulse, and 
 transitory loss of consciousness. 
 
 In many cases these general symptoms are the only ones 
 present ; but in others there are, in addition, signs which 
 are characteristic of the situation of the lesion. Such 
 phenomena may be due to a lesion directly provoked by 
 the growth in a certain area, or by the influence of the 
 tumour on its immediate surroundings (the " vicinity " 
 symptoms of Oppenheim and Bruns), or by its effect on 
 more distant regions of the brain. Occasionally the site is 
 revealed by a definitely localized tenderness on skull 
 percussion. 
 
 Characteristic focal symptoms are found when the tumour 
 is situated in the Rolandic region. In such cases typical 
 attacks of motor Jacksonian epilepsy may occur (p. 28), 
 preceded frequently by attacks of sensory cortical epilepsy 
 affecting the same area in which the motor convulsions later 
 appear. In the early stages transitory paralytic symptoms 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 5 
 
 are present ; in the later stages they become persistent. 
 Often at the beginning they are of a monoplegia type, 
 becoming hemiplegia in course of time. The convulsions 
 occur first in the paralytic muscles ; the senses of touch and 
 of position are frequently much interfered with in the 
 paralysed areas. 
 
 The tumours of the third left frontal convolution give rise 
 to a motor aphasia which declares itself early, but becomes 
 complete only by slow degrees. Tumours of the other 
 parts of the frontal lobes present no such characteristic 
 symptoms, but a diagnosis may sometimes be arrived at ; 
 frequently an unsteadiness of gait is present, resembling the 
 ataxia of cerebellar disease (Bruns). The intellectual powers 
 are often markedly dull. Optic neuritis is frequently a late 
 symptom and not uncommonly unilateral. In some cases 
 there is localized percussion tenderness, and, according to 
 Bruns, a tympanitic note may be elicited over the affected 
 area. The diagnosis of frontal tumour is further confirmed 
 when, following on the above symptoms, or of hemi- or 
 monoparesis, there supervene, in later stages, signs of 
 general feebleness of the trunk muscles, or of cortical 
 epilepsy, or deviation of the head to one side with rigidity 
 of the neck and conjugate deviation of the eyes. 
 
 Growths of the left temporal lobe are often associated 
 with sensory aphasia (this appears in the case of tumours 
 of the right temporal lobe when the subject is left-handed) ; 
 sometimes convulsions are in such a case preceded by aural 
 premonitory symptoms. In the late stages hemianopsia, 
 hemiansesthesia, and hemiparesis are sometimes found. 
 
 A tumour of the occipital lobe may, in addition to the 
 general symptoms, give rise to a crossed hemianopsia, with 
 absence of the hemiopic pupil reaction. The diagnosis 
 obtains confirmation if symptoms of ocular irritation and 
 psychic phenomena appear. The presence of hemianopsia, 
 alexia, and optic aphasia in combination point, according 
 to Bruns, to a lesion of the left occipital lobe. A bilateral 
 lesion of the occipital lobes gives rise to general mental 
 dullness. 
 
 Tumours of the superior parietal lobule often occasion 
 defects of sensibility, notably of the sense of position and of 
 the stereognostic sense ; these may be associated with 
 ataxia, which is in this case probably a direct result of the 
 
6 INDICATIONS FOR OPERATION IN 
 
 lesion (Oppenheim). Signs of motor irritation and paralysis 
 are not uncommon. Deep-seated tumours of the inferior 
 parietal lobe may occasion hemianopsia ; alexia and optic 
 aphasia are only associated with such growths when they 
 are left-sided. 
 
 Tumours of the cerebellum give rise directly only to the 
 two symptoms ataxia and vertigo. Symptoms due to 
 compression of the surrounding parts are usually absent 
 when such growths are situated dorsally, but are common 
 in basal tumours. When they occasion unilateral paralysis 
 of the fifth to the twelfth cranial nerves the tumour is 
 usually to be found on the same side as the paralysis ; and 
 the same holds for the associated paralysis of the abducens. 
 Signs of cerebral compression appear early, and convulsions 
 with opisthotonus are frequent (Oppenheim). 
 
 Diagnosis. — The diagnosis of a cerebral tumour can be 
 established in the majority of cases. Severe persistent 
 headache which resists treatment is always suspicious. If 
 with this there co-exist double optic neuritis, dulling of the 
 intellect, and vomiting during the height of the attack, then 
 the presence of tumour is very probable. Certain other 
 general s\^mptoms assist in arriving at a correct opinion — 
 vertigo, slowness of the pulse, alterations in the urinary 
 secretion, and epileptiform attacks, particularly if there is 
 a steady increase in their severity, and if attacks become 
 gradually more frequent.* 
 
 The diagnosis of situation is more readily made when 
 progressive focal signs have been present for a considerable 
 period. If optic neuritis is absent, its appearance must 
 usually be awaited before a positive diagnosis is possible. 
 A fact of practical importance is, that signs of irritation and 
 paralysis referable to lesions of the Rolandic region are 
 usually due to tumour. The onset of general symptoms 
 is to be expected later in the case of growths of this region 
 than elsewhere, and consequently the less importance is to 
 be attached to their absence (Bruns). With regard to the 
 diagnosis of tumour in other situations, reliance must be 
 
 * Sometimes the disease shows itself abruptly in a condition of other- 
 wise good health ; such an onset has several times come under my own 
 observation. In two such cases the tumour made its way outwards and 
 was palpable under the scalp. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 7 
 
 placed on the above described symptoms, always remem- 
 bering that only well developed symptoms should be relied 
 on ; the successive development of phenomena must also 
 be carefully studied, and the local signs on the skull must 
 be compared with those other which appear to indicate the 
 site of the growth. 
 
 Further mention must be made of these cranial indica- 
 tions. The most important are, strictly localized headache 
 corresponding with defined tenderness to percussion, the 
 occurrence of tumour-like protrusion of the skull, and the 
 presence of the cracked-pot sound. This last sign, whose 
 importance has been lately emphasized by several competent 
 observers (Macewen, Bruns, Oppenheim), is more frequently 
 present in children. In adults I have failed to find it in 
 twenty cases ; if it is present, and corresponds with other 
 focal signs, it is of great importance. In several cases 
 circumscribed tenderness to percussion has enabled a 
 diagnosis to be made at an early stage. If the skull is 
 eroded by the tumour, and the latter presents as a palpable 
 fluctuating swelling (as especially occurs in cases of 
 hydatid cyst), a diagnosis of situation can, of course, be 
 made at once. 
 
 This apparently definite local sign, the erosion of the 
 skull, may, however, occasionally give rise to some confusion 
 in diagnosis, for a bone tumour may co-exist with and even 
 correspond in position with a cerebral tumour beneath, or a 
 growth of the dura may exhibit a similar relationship. Two 
 such cases have come under my own observation. The first 
 was that of a woman, aged 52, who came into hospital in a 
 condition of marked stupor, with complaint of only occasional 
 headache, no convulsions, and normal pulse. There was 
 slight exaggeration of the tendon reflexes on the right side, 
 but no motor or obvious sensory disturbances, and the 
 cranial nerves were normal. Immediately before death the 
 left optic disc was blurred, and for a few days before this a 
 rapidly progressive hemiparesis of the right side of the body 
 made its appearance. Six years before, a recurrent fibro- 
 sarcoma of the abdominal wall had been removed, and, in 
 view of this, great importance was attached to the presence 
 of a tumour situated in front of and above the left ear, of 
 bony consistence and the size of half a plum-stone ; this 
 was looked upon as a bony metastasis pressing on the frontal 
 
8 INDICATIONS FOR OPERATION IN 
 
 lobe. The general condition of the patient precluded 
 surgical treatment. At the necropsy a large sarcoma of the 
 frontal lobe was found, and, situated exactly over but quite 
 distinct from this, an exostosis of the skull. 
 
 The second case was a man, aged 26, complaining of severe 
 occipital headache, excessive rigidity of the neck, and 
 frequent vomiting. From time to time he had attacks of 
 stupor, and tonic contractions of the muscles generally, 
 with opisthotonus. The cranial nerves were unaffected, 
 except the left hypoglossal (deviation of the tongue to 
 the left) and the optic. As far as could be ascertained there 
 was left homonomous hemianopsia. At the upper part of 
 the occipital bone on the right side there was a large flattened 
 protrusion very sensitive to pressure. Double optic neuritis 
 rapidly progressed to atrophy. The diagnosis was made of 
 tumour of the bone or dura over the right occipital lobe. 
 Death occurred suddenly. The necropsy demonstrated an 
 endothelioma of the dura mater over the right occipital lobe, 
 with pronounced erosion of the skull, and, in addition, 
 a large glioma of the right occipital lobe with a recent 
 haemorrhage into it. 
 
 The discovery of a vascular bruit will lead to the diagnosis 
 of aneurysm, or of a highly vascular growth (sarcoma) ; the 
 co-existence of tuberculosis, of syphilitic lesions, of a primary 
 malignant growth, or of the echinococcus or cysticercus 
 elsewhere, will indicate the probable nature of the intra- 
 cranial lesion. 
 
 Differential Diagnosis. — So long as a tumour gives rise to 
 general symptoms only, there is considerable probability of 
 its being confused with other morbid conditions. Optic 
 neuritis narrows the limits of possible error, and if this 
 co-exist with persistent headache and stupor, these limits 
 are further circumscribed. Sometimes the differentiation 
 from cerebral abscess (p. 17) is very difficult. In addition 
 to what is said on the subject elsewhere, abscess sometimes, 
 in my experience, gives rise to optic neuritis in its early 
 stages. This is, however, undoubtedly exceptional. 
 
 Fever is not an exclusive sign of abscess ; it may also 
 exist in cases of tumour (in tuberculosis, more rarely in 
 carcinoma), especially in children with tubercular lesions 
 elsewhere. In a case which was for several weeks under my 
 observation, and in which an affection of the frontal lobe 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 9 
 
 was suspected, irregular fever was present for some weeks. 
 At the autopsy a diffuse glioma infiltrating the convolutions 
 of the right frontal lobe was discovered. A most careful 
 examination, carried out by Prof. Weichselbaum, failed to 
 reveal any other lesion to account for the fever. 
 
 More rarely there arises a difficulty in differentiating 
 between tumour and sinus thrombosis (q.v.). 
 
 Oppenheim has rightly remarked that the differential 
 diagnosis between tumour and acquired hydrocephalus can 
 hardly ever be made with certainty, especially as the latter 
 affection very often complicates tumour. He has enunciated 
 the following points in favour of hydrocephalus : the 
 characteristic hydrocephalic shape of the skull, a duration 
 of several years, and the absence of well-marked focal 
 symptoms. 
 
 Of greater practical importance is the probability of 
 confusion with general paralysis, especially when the latter 
 exhibits in its early stages the characters of cortical 
 epilepsy. Optic neuritis will exclude general paralysis, and 
 complete reflex immobility of the pupil is rarely present 
 except in cases of tumour. In the late stages of tumour, and 
 especially of multiple tumours, the symptoms may closely 
 resemble those of general paralysis. I have seen a case of 
 cerebral tumour, operated on with good result, which had 
 been diagnosed as general paralysis by several distinguished 
 physicians. The examination of the fundus oculi revealed 
 the presence of optic neuritis, and this led to a correct 
 diagnosis. 
 
 When a tumour is associated with convulsions at an 
 early stage, a differential diagnosis from ordinary epilepsy 
 has to be made ; the presence of other symptoms will 
 facilitate this, in particular optic neuritis, which is not found 
 in ordinary epilepsy. The phenomena of Jacksonian 
 epilepsy which is not caused by tumour (e.g., that due to 
 softening or scar formation), do not show, as a rule, the 
 tendency to progression which is found in tumour. 
 
 Uraemia may give rise to symptoms resembling those of 
 cerebral growth. Headache, vomiting, slowness of pulse 
 occur in the course of both affections, and renal disease may 
 give rise to optic neuritis, with swelling of the disc. On the 
 other hand, a brain tumour may cause albuminuria. The 
 presence of renal epithelium in the urine will always point 
 
lo INDICATIONS FOR OPERATION IN 
 
 to the probability of uraemia, although the possibility of 
 the simultaneous development of a renal inflammation and 
 a cerebral tumour must be borne in mind, and has occurred 
 in several instances which have been under my observation. 
 Multiple sclerosis is rarely likely to be confused with tumour ; 
 it is distinguished from the latter by the absence of optic 
 neuritis, persistent headache and stupor, by the absence of 
 percussion-tenderness of the skull, and by the presence of 
 definite spinal phenomena. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation may be undertaken : — 
 
 1. For the radical extirpation of the growth. 
 
 2. For the relief of symptoms by some palliative procedure. 
 Indications for extirpation are met with only in a 
 
 restricted number of cases. They may be said to be present 
 when the diagnosis of tumour is definite, when localization 
 is possible, and the tumour is in a situation accessible to the 
 knife. Eradication is possible when the tumour is circum- 
 scribed and of moderate dimensions. With regard to acces- 
 sibility, Bruns has placed the different parts of the brain in 
 the following order : (i) The Rolandic region ; (2) The speech 
 centres ; (3) The frontal lobes ; (4) The occipital lobes ; (5) 
 The temporal lobes. These are also the areas, lesions of which 
 may be diagnosed earliest and most definitely, and when 
 the signs of tumour are clear the prognosis of operation is 
 relatively good. With regard to tumours of the cerebellum, 
 although they are often accessible, the results of operations 
 for their removal have been hitherto so bad that one is 
 forced to agree with Oppenheim and Bruns, that operation 
 is not advisable in most cases. Operation is also inadvisable 
 when the tumour is situated in other situations than those 
 enumerated above, and at the base ; the prognosis quoad 
 vitam is, at present at any rate, most unfavourable. It is 
 usually impossible to be sure beforehand whether a tumour 
 has originated in brain, meninges, or bone ; from the point 
 of view of operation this point is unimportant, if its 
 situation as regards the brain can be definitely ascertained, 
 nor will a supposed subcortical position of the tumour in 
 the regions mentioned alter the indications for operative 
 interference. 
 
 With regard to the diagnosis of the nature of a growth, 
 
DISEASES OF THE BRAIN AND ITS MENINGES, ii 
 
 and the bearing of this diagnosis on operation, the following 
 considerations should be borne in mind. When tuberculosis 
 is discovered in some other organ of the body, and pyrexia 
 is present, the cerebral tumour is probably also tubercular ; 
 as a rule, however, tubercular foci are not single, and some- 
 times co-exist with diffuse changes in the meninges and 
 cord. In spite of the latter facts, however, my own expe- 
 rience agrees with that of Kronlein and other authors, that 
 under certain circumstances brain tubercle ought to be 
 operated on (a) When there are no signs of widely diffused 
 tuberculosis in other organs and the general condition of 
 the patient is good, and when the pyrexia is not high ; 
 {b) When symptoms of meningitis and spinal disease are 
 absent ; (c) When the symptoms point to a single focus. 
 
 If the symptoms of tumour are preceded by those of 
 syphilis, if tertiary lesions have presented themselves 
 elsewhere and the diagnosis of cerebral gumma is practically 
 certain, surgical measures will only be undertaken under 
 certain conditions, on which my own opinion coincides with 
 that of Friedlander ; they are as follows ; (i) When the 
 symptoms are progressive in spite of energetic specific 
 treatment, and threaten life ; (2) When the tumour remains 
 stationary after a course of treatment, and the focus is easily 
 accessible and to all appearance of small dimensions ; (3) 
 When symptoms of Jacksonian epilepsy persist after the 
 earlier tumour symptoms have disappeared. Even when 
 these conditions are present operation is contra-indicated 
 when there are {a) Signs of basal or advanced spinal syphilis ; 
 (b) Pronounced cachexia, and the presence of amyloid and 
 other serious complications in internal organs. 
 
 When the diagnosis of a metastatic growth is made, 
 operation is seldom justified. It is indicated : (i) When 
 the primary tumour has been removed, and there are no 
 clinical signs of other metastases ; (2) When the symptoms 
 give cause for the belief that the brain tumour is single and 
 situated in an easily accessible region ; (3) When the general 
 condition is good. 
 
 The presence of multiple growths, when this is known 
 before operation, or definitely suggested by the symptoms, 
 is an absolute contra-indication to radical operation. A 
 diagnosis of multiple tumour must not, however, be founded 
 on a discovery that the disease is of a type which usually 
 
12 INDICATIONS FOR OPERATION IN 
 
 gives rise to multiple lesions of the nervous system (tubercle, 
 gumma, cysticercus, etc.). 
 
 With regard to the size of a tumour there are rarely exact 
 data, and if other indications for operation are favourable, 
 the supposition that the tumour is of large size should not 
 be allowed to weigh against them. 
 
 The earlier operation is undertaken, the more favourable 
 are the chances of complete extirpation. This consideration 
 must not, however, lead one to recommend operation until 
 a definite diagnosis has been reached ; but, as soon as the 
 general and local diagnosis of a cerebral tumour has been made, 
 when syphilis and tubercle have been excluded, and when the 
 possibility of surgical intervention has been decided, then 
 operation should be undertaken without delay. 
 
 Palliative operation for cerebral tumour is indicated in 
 the absence of focal symptoms, when signs of cerebral com- 
 pression are prominent, and the latter is giving rise to 
 insupportable suffering. It is especially indicated when 
 the patient is suffering agonizing headache, and when an 
 optic neuritis is present which threatens to proceed to 
 atrophy ; in several cases blindness has been thereby 
 averted. Operation is also called for in the presence of 
 frequent general convulsions. 
 
 Such palliative operations comprise lumbar puncture, 
 and opening of the skull, with eventual puncture of the 
 ventricle. We have now a considerable number of observa- 
 tions on lumbar puncture in cerebral tumour, which go to 
 show that the procedure is not without risk. Lichtheim 
 and Fiirbringer have published four cases of death following 
 immediately after lumbar puncture, and others have since 
 been reported. I have had a similar experience, which I 
 related, some years ago. A young man, with signs of 
 tumour in the occipital lobe, developed symptoms of severe 
 intracranial pressure (marked slowing of the pulse, vomiting, 
 agonizing headache, and Cheyne-Stokes respiration). In- 
 ternal medication was useless, and lumbar puncture was 
 performed. After the drawing off of a few cc. the head- 
 ache became insupportable, and stupor came on, followed 
 by convulsions. He died twenty-four hours later. The 
 autopsy revealed a recent haemorrhage into a glioma of the 
 right occipital lobe. 
 
 In other cases (for example in one on whom I performed 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 13 
 
 lumbar puncture four times) a certain amelioration of some 
 of the symptoms takes place. The operation is indicated 
 when in the presence of symptoms of severe intracranial 
 pressure trephining is refused, and when optic neuritis 
 shows signs of passing into atrophy. If there are indica- 
 tions that the tumour is very vascular, lumbar puncture 
 is contra-indicated. It must be performed with great 
 care ; the rapid escape of fluid must be prevented, and 
 the operation be at once abandoned : (a) If the pressure 
 is very low at the beginning, or rapidly becomes so ; (b) 
 If marked embarrassment of circulation and respiration 
 supervenes. 
 
 Opening the skull has frequently been resorted to during 
 the last few years for the relief of intracranial pressure. If 
 the brain bulges into the opening and so prevents the free 
 escape of fluid, and if the signs of compression persist (which 
 may not always be the case), puncture of the ventricle is 
 indicated ; by this means even well-established focal symp- 
 toms due to inoperable neoplasm may be arrested. I am able 
 to cite a very instructive case illustrative of this fact. 
 A young man developed convulsions of the type of cortical 
 epilepsy several months after an injury. Under treatment 
 with bromides the symptoms disappeared for two years. 
 There then supervened status epilepticus, stupor, marked 
 optic neuritis, severe headache, and left hemiplegia. The 
 skull and dura were opened over the Rolandic area, and a 
 large hernia developed here, covered only by the soft parts. 
 Although nothing was done to the prolapse the paralysis 
 improved considerably, the convulsions ceased, and the 
 headache and optic neuritis disappeared. The patient was 
 able to resume his occupation for several months. His 
 symptoms reappeared suddenly, and he died shortly after- 
 wards. Post mortem a huge gliosarcoma was found 
 infiltrating the whole of the right hemisphere. The growth 
 of the tumour had evidently continued, yet after the opera- 
 tion the general and focal symptoms had markedly improved. 
 {v. Neurol. Centralb., 1895, p. 702, and 1898, p. 974.) 
 
 In a case under my care of basal tumour, the result 
 was disappointing. The skull was opened, and the bone 
 replaced; the latter promptly healed. Neither the optic 
 neuritis nor any other symptom was improved by the 
 operation. 
 
14 INDICATIONS FOR OPERATION IN 
 
 Prognosis. — Regarding the prognosis of the operation, 
 the numerous ill-successes of recent years have made one 
 more circumspect. About 6 per cent of cases fulfil all the 
 conditions for direct surgical intervention, but in 3 to 4 
 per cent only is complete ablation and cure achieved. 
 Tumours of the Rolandic region offer the best prognosis, 
 because they can be diagnosed the soonest and with the 
 greatest certainty. The operative treatment of tumours in 
 other situations is attended with less success, and the 
 prognosis of operable tumours of the cerebellum is worst 
 of all. 
 
 Operative interference may be directly responsible for 
 death ; Oppenheim placed the mortality of operation at 
 37'7 P^r cent. Again, much more severe symptoms may 
 follow operation than those which the tumour gave rise to; 
 in particular, more extensive paralysis. In one of my own 
 cases a complete motor aphasia supervened, which disap- 
 peared only after a lapse of several months ; another case 
 developed marked cortical ataxia. As a rule, lesions caused 
 by operation reach their maximum intensity at first, and 
 afterwards gradually improve. A steady increase in the 
 severity of symptoms after complete extirpation, such as 
 would be produced by encephalitis, appears to have very 
 rarely occurred. The possibility that the operation may 
 give rise to pronounced paralysis should not be allowed to 
 influence one against recommending it, for the tumour itself 
 is a definite menace to life. 
 
 The prognosis if no operation is undertaken. — If in the 
 face of the indications which have been given, no operation 
 is done, internal medication offers little chance of success. 
 Sometimes, in non-syphilitic cases, large doses of potassium 
 iodide and mercurial injections have appeared to cause 
 some amelioration of symptoms for a time, but complete 
 cure by medical treatment is a very rare event. Sponta- 
 neous recovery by calcification of the tumour is also extremely 
 unusual. Death is, therefore, to be expected when operation 
 is not undertaken, and when no palliative operation is done 
 the symptoms will show steady progression. 
 
 Risks of operation when the diagnosis is faulty. — Open- 
 ing the skull is not an operation free from risk. Fatal 
 haemorrhage from the diploic vessels has been recorded, and 
 traumatic encephalitis and oedema of the brain may occur. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 15 
 
 Sometimes a persistent hernia develops, or Jacksonian 
 epilepsy from meningeal adhesions. Opening of the skull 
 with chisel or trephine should, therefore, only be undertaken 
 when the diagnosis of tumour is clear. 
 
 LITERATURE. 
 
 Oppenheim. Hirntumoren. Nothnagel's Handbuch d. spez. 
 Pathol. 2nd Ed., Vienna, 1902. 
 
 Bruns. Geschwiilste des Nervensystems. Berlin. 1897. 
 
 Bergmann. Die Chirurgische Behandlung der Hirnkrankheiten. 
 3rd Ed., Berlin, 1899. 
 
 GowERS. Diseases of the Nervous System. 
 
 A. Starr. Tumours of the Brain. Med. News, June, 1886. 
 
 Chipault. Chirurgie Oper. du Systeme Nerveux. Paris, 1895. 
 
 A. PiLCz. Tumor Cerebri und chir. Eingriffe. Centralb. f. d. 
 Grenzgebiete d. Med. u. Chir. 1899. 
 
 F. ScHULTZE. Zur Diagnostik u. Chir. Behandl. d. Hirntumoren. 
 Dent. Zeit. f. Nervenheilk. Bd. ix. 
 
 Henschen. Hirntumoren. Handbuch der spez. Therap., von 
 Penzoldt-Stintzing. 3rd Ed. 
 
 Kronlein. Dauerheilung eine Hirntuberkels. Arch. f. klin. 
 Chirurgie. Bd. Ixiv. 
 
 CEREBRAL ABSCESS. 
 
 Etiology. — Cerebral abscess almost always occurs as a 
 secondary lesion. The most important etiological factors 
 are : (i) Affections of the ear ; (2) Injuries of the skull ; 
 (3) Diseases of the nose ; (4) Metastatic lesions (especially 
 following putrid affections of the lungs and general sepsis) ; 
 (5) Chronic cranial suppurations. The first two of these are 
 by far the most frequent. Of ear affections, those in question 
 are purulent otitis media and mastoid disease. 
 
 Pathological Anatomy. — Cerebral abscess may be acute, 
 subacute, or chronic ; as a rule it is single ; metastatic 
 abscesses alone are wont to be multiple. The acute abscess 
 originating by continuity from some neighbouring focus is 
 usually superficial ; the chronic abscess usually more deeply 
 situated. With regard to localization, those originating 
 from some traumatic lesion usually develop superficially 
 at the site of injury ; otogenic abscesses are found especially 
 in the temporal lobe and cerebellum ; the rhinogenic in the 
 frontal lobes ; and those which follow bone disease usually 
 in the immediate vicinity of the affected bone. These 
 abscesses may reach the size of an apple or larger. The 
 
t6 indications FOR OPERATION IN 
 
 meninges are regularly involved in traumatic abscess, and 
 frequently in the otitic. In the ultra-acute type an acute 
 suppurative cerebrospinal meningitis is often present ; in 
 the subacute form the meningitis is usually local, with 
 adhesions to the brain surface, but sometimes there is a 
 serous meningitis with abundant serous exudate. Otitic 
 abscesses are sometimes complicated by thrombosis of the 
 lateral sinus and extradural abscess. Old standing abscesses 
 may become encapsuled ; they may extend later and burst 
 even after several years' duration. 
 
 Clinical Course. — An abscess may run a latent course 
 throughout. In other instances symptoms of general and of 
 cerebral disturbance are present : headache, vertigo, local 
 tenderness of the skull, stupor, slowness of pulse, convul- 
 sions, and delirium. The temperature may be raised, and 
 frequently there are rigors ; the absence of fever is, how- 
 ever, not rare (Macewen). Optic neuritis i^ more frequent, 
 especially in the subacute cases, than was at one time 
 thought. Of the focal symptoms (which often first appear 
 at a late stage) the following are the most important : 
 
 In temporal abscess, sensory aphasia and double hemi- 
 anopsia of the same side. In many instances (Oppenheim) 
 as a characteristic sign, the so-called " optic aphasia " is 
 present, that is to say, the patient cannot name objects 
 shown to him. In the later stages, when the process 
 advances rapidly, hemiparesis of the opposite side of 
 the body appears, with convulsions of the character of 
 cortical epilepsy. 
 
 In frontal abscesses there are often no localizing signs, 
 even when they are of large size. Sometimes there is 
 ataxia resembling that of cerebellar disease, and certain 
 peculiar psychical disorders. In the late stages a rapidly 
 progressing hemiplegia of the opposite side appears. Optic 
 neuritis often appears only towards the end. 
 
 Abscesses of the motor region give rise to paralysis, often 
 of monoplegic type, and attacks of cortical epilepsy. 
 
 In cerebellar abscesses there are observed sometimes slight 
 rigidity of the muscles of the back of the neck, occipital 
 headache, vertigo, and inco-ordination. 
 
 Occipital abscesses often give rise to bilateral homonomous 
 hemianopsia. The skull is sometimes sensitive to percussion 
 over the affected area. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 17 
 
 Diagnosis. — A correct diagnosis is often possible. It is 
 usually based first on the discovery of a septic focus in 
 some part of the skull, especially the ear and the frontal 
 sinus, or in some other part of the body, notably the 
 bronchi ; secondly, on the presence of fever, rigors followed 
 by sweating, signs of a rapidly progressing affection, in- 
 creasing intracranial pressure (optic neuritis, paralyses, 
 sensory or optic aphasia, hemianopsia), headache, vertigo, 
 convulsions, percussion-tenderness of the skull, bruit de pot 
 fele, and vomiting. 
 
 Localization is often beset with considerable difficulty. 
 " The greatest certainty in the diagnosis of otitic abscesses 
 is reached when symptoms are present which can be assigned 
 to the involvement of some region of the brain, in which such 
 abscesses are known to be commonly found " (Korner). 
 
 In regard to differential diagnosis, it is of especial 
 importance to be able to distinguish otitic brain abscesses 
 from otitic extradural abscesses (pachymeningitis externa 
 purulenta), sinus thrombosis, and purulent cerebrospinal 
 meningitis. The clinical picture may be of the same type 
 in all these affections. 
 
 By lumbar puncture information may be obtained as to 
 the presence of meningitis. If the affection develops from one 
 to two weeks after an injury, and if focal symptoms and signs 
 of meningitis are present together, then there is probably 
 an abscess in the cortex. When there is torticollis, tender- 
 ness and infiltration along the jugular vein, and other signs 
 of thrombosis, then thrombosis of the lateral sinus will be 
 diagnosed ; oedema and tenderness over the mastoid process 
 will confirm this. These two last signs are also evidence 
 in favour of the presence of an extradural abscess. A point 
 of considerable practical importance is the fact that a simple 
 suppurative mastoiditis may be the cause of severe cerebral 
 symptoms, probably by setting up a serous meningitis. 
 
 In distinguishing abscess from tumour, the presence of 
 fever is important ; in tumour there is usually no rise of 
 temperature. In abscess, also focal symptoms appear at a 
 relatively late period ; in fact, they usually mark the 
 beginning of the end. 
 
 In children with tubercular lesions, glands, etc., if fever 
 supervenes, the possibility of a cerebral or meningeal tuber- 
 culosis should be considered. 
 
1 8 INDICATIONS FOR OPERATION IN 
 
 INDICATIONS FOR OPERATION. 
 
 Whenever there are definite dinical signs of intracranial 
 suppuration, operation is called for without delay, whatever 
 the origin of the abscess may be. The only exceptions will 
 be when there are signs of diffuse purulent cerebrospinal 
 meningitis, and when the general condition is extremely bad 
 owing to some other intercurrent affection. An exact 
 topical diagnosis, although of course of great advantage, 
 should not be considered absolutely necessary. The original 
 seat of the septic affection is of great importance as a guide 
 to the probable situation of the abscess and the operation. 
 Otitic abscesses are usually found in the temporal lobe of the 
 cerebellum ; abscesses secondary to nasal disease in the 
 frontal lobes. 
 
 If suppurative ear disease is present, accompanied by 
 cerebral symptoms, which do not, however, with certainty 
 point to abscess in the brain, operation should be 
 undertaken, and this may reveal a septic focus in the 
 mastoid, or an extradural abscess. In such cases the 
 only contra-indications to operation will be the presence 
 of severe acute sepsis, involvement of the ventricles, 
 and the presence of diffuse purulent meningitis as revealed 
 by lumbar puncture. Operation should still be under- 
 taken when there is doubt whether one has to deal with 
 a purulent meningitis or a brain abscess. The earlier the 
 operation the greater the chances of recovery. Even when 
 an exact topographical diagnosis has been made the abscess 
 may not be discovered at the operation, or a second abscess 
 may be overlooked. 
 
 Prognosis. — // operation be undertaken. — Korner's statis- 
 tics, dealing with 212 otitic brain abscesses, show recovery in 
 50 per cent ; in 55 cerebellar cases there were 52 per cent 
 successes. In many cases recovery from paralysis and 
 speech defects have followed operation. 
 
 // operation he not undertaken. — The patient dies in a short 
 time from rupture of the abscess into the ventricles, or 
 diffusion throughout the meninges with consequent purulent 
 meningitis. Only in very rare instances the abscess has 
 discharged externally through the ear, the nose, or the 
 temporal bone, and recovery has followed. Delay in these 
 cases is therefore fraught with grave danger to the life of 
 the patient. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 19 
 
 Consequences of operation when the diagnosis is at fault. — 
 Operation is always serious, and may be fatal, but the 
 risks of operation are in most cases not so great that they 
 should be allowed to weigh against intervention ; the 
 prognosis of abscess is too absolutely unfavourable to allow 
 them to do so. Operation may give rise to traumatic 
 spreading encephalitis, serous meningitis, or hernia of the 
 brain. 
 
 LITERATURE. 
 
 Oppenheim. — Hirnabscess. Nothnagel's Handbuch d. spez. 
 Pathol. 
 
 Macewen. Pyogenic Infective Diseases of the Brain and Spinal 
 Cord. 1893. 
 
 GowKRS. — Diseases of the Nervous System. Vol. ii. 
 
 KoRNER. — Die otitischen Erkrankungen des Hirnes, der Hirnhaute. 
 und der Blutleiter. 3rd Ed., 1902. 
 
 Dreyfuss. — Die Krankheiten des Gehirnes u. seiner Adnexa im 
 Gefolge V. Naseneiterungen. 1896. 
 
 Dreyfuss. — Rhinogene Gehirnaffectionen. Zentralb. f. d. Grenz- 
 gebiete d. ]Med. u. Chir. 1898, p. 193. 
 
 Henschen. — Hirnabscess. Handbuch d. spez Therap. heraus- 
 gegeben. von Pentzoldt-Stintzing. 3rd Ed. 
 
 SINUS THROMBOSIS AND SINUS PHLEBITIS. 
 
 Etiology. — -Sinus thrombosis may arise from several 
 causes. Thrombi may form in the course of some prolonged 
 and exhausting affection of different organs ; from encroach- 
 ment on or compression of the sinus by a new growth ; 
 from the spread to the sinus of some inflammatory process 
 of the face and head ; from otitis media and caries of the 
 temporal bone ; from some general change in the condition 
 of the blood. Thrombosis of the lateral sinus complicating 
 middle-ear and mastoid disease will chiefly engage our 
 attention. 
 
 Pathological Anatomy. — The thrombus may be local, 
 or involve the greater part of the sinus, the latter 
 especially in the case of the longitudinal sinus. The 
 inflammatory thrombi are found in the neighbourhood 
 of the primary focus ; thus, in ear affections the lateral 
 sinus is attacked, in diseases of the orbit the cavernous 
 sinus. The thrombosis is set up either by spread of 
 the inflammatory process to the wall of the sinus, by 
 compression of the latter, or by direct extension through 
 
20 INDICATIONS FOR OPERATION IN 
 
 a venule from the seat of disease (the rare osteo-phlebitis 
 of Korner) ; occasionally it is due to the erosion of the 
 sinus by new growth. Thrombosis of the lateral sinus, 
 by far the most frequent of all forms, often extends into the 
 internal jugular vein. Usually, when secondary to ear 
 disease, septic disorganization of the clot occurs, and by 
 extension of the process to surrounding structures local or 
 diffuse purulent meningitis, an extradural abscess, or a brain 
 abscess may follow ; all four conditions may be present in 
 any given case. When the process spreads along the 
 internal jugular vein, the vein wall is attacked ; abscesses 
 then develop around it and deep-seated suppuration in the 
 neck. By absorption of the septic material and disorgani- 
 zation of the putrid clot, pulmonary abscesses and pyaemia 
 appear in the later stages. 
 
 Clinical Course. — Frequentlj/ thrombosis is discovered 
 only by chance, or is masked by other symptoms. The 
 forms which are of chief clinical importance, that is to say, 
 thrombosis of the lateral and cavernous sinuses, are usually 
 characterized by high fever, intense headache, rigors, a 
 semi-conscious condition, increased pulse rate, optic neuritis 
 (in particular unilateral), frequent vomiting, profuse 
 diarrhoea, and irregular and sudden oscillations of tempera- 
 ture, with profuse sweating. After several days, jaundice 
 frequently appears, with characteristic coloration of the 
 urine ; in this sometimes only urobilin is found. In the 
 late stages swellings of the joints, gangrene of the lung, and 
 other septic complications are common. 
 
 In addition to these symptoms, the following are also 
 often observed : in thrombosis of the lateral sinus, oedema, 
 swelling, and tenderness over the mastoid process, pain on 
 skull percussion, and unilateral or bilateral optic neuritis. 
 The attitude of the head (caput obstipum) is characteristic, 
 and the patient complains of intense pain in the side of his 
 neck. Pressure over the course of the jugular vein is painful, 
 and sometimes the thrombosed vein can be felt as a long 
 cord, the surrounding parts being also swollen. Active 
 rotation of the head is usually impossible, and passive 
 rotation is painful ; nodding is usually possible and painless, 
 according to my observation. In other cases there is rigidity 
 of the neck, tenderness on pressure over the vertebrae, and 
 pain in swallowing. Very rarely paralysis of the palate or 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 21 
 
 vocal cords is found ; it has not been present in any of the 
 numerous cases I have seen. Unequal distension of the 
 jugular vein is very uncommon. 
 
 Thrombosis of the cavernous sinus is usually accompanied 
 by protrusion of the eyeball, oedema of the lids, or chemosis. 
 The cerebral and palpebral veins are distended, and the 
 forehead is cyanotic. Patients often complain, in the early 
 stages, of pain along the frontal branch of the fifth cranial 
 nerve ; diplopia is also present, owing to involvement of the 
 nerves supplying the eye muscles, and sometimes immobility 
 of the eye develops rapidly from paralysis of the oculo- 
 motor, abducens, and trochlear nerves. Optic neuritis is 
 frequent. 
 
 Diagnosis — When there is present one of the head 
 affections which are commonly complicated by sinu3 
 thrombosis, such as chronic middle-ear disease, and the 
 patient exhibits the symptoms described above, the diag- 
 nosis may be made ; it is often impossible, however, to be 
 sure how far the meninges on the one hand, and the brain 
 on the other, are involved. Meningeal symptoms may be 
 simply due to irritation. In my experience much importance 
 is to be attached to oedema over the mastoid process, the 
 typical attitude of the head, tenderness over the jugular 
 vein, and signs of thrombosis in it, when these are associated 
 with phenomena of pyaemia. Sinus thrombosis is always 
 very probable when pyaemic symptoms supervene on an 
 otitis (Lenhart). Brieger has, however, drawn attention to 
 the fact that phlebitis of the diploic veins may be the 
 starting-point of otitic pyaemia without infection of the 
 sinus ; such cases are, however, exceptional. 
 
 Differential diagnosis. — As above stated, it is im- 
 possible in many cases to arrive at a certain diagnosis 
 between sinus thrombosis and brain abscess, extradural 
 abscess, or diffuse meningitis, especially since the former is 
 often complicated by one of these. A rapid and irregular 
 pulse, a high temperature with rapid remissions, profuse 
 sweating and diarrhoea, frequent rigors and pyaemic symp- 
 toms, point to sinus thrombosis. The intellectual faculties 
 often remain unclouded to the last stages. The early appear- 
 ance of a transitory motor aphasia, the presence of pus and 
 the formation of a coagulum in the fluid obtained by 
 lumbar puncture, are in favour of a diagnosis of meningitis. 
 
22 INDICATIONS FOR OPERATION IN 
 
 Hemianopsia and optic aphasia point to cerebral abscess. 
 In abscess the temperature is usually only moderately high, 
 the pulse is slow, and the intellectual faculties dull. 
 
 It should be remembered that tenderness on pressure 
 along the course of the jugular may be due to other 
 inflammatory lesions, such as lymphadenitis and abscesses 
 secondary to cervical caries. A lymphangitis may also give 
 rise to the formation of a tender cord-like swelling in the 
 neighbourhood of the jugular vein, and may complicate 
 mastoid disease without the sinus being involved. 
 
 INDICATIONS FOR OPERATION. 
 
 Sinus phlebitis has often been operated on with success*, 
 frequently when pysemic symptoms have commenced, and 
 thrombosis of the jugular is established. Operative inter- 
 ference is therefore indicated in all cases of uncomplicated 
 sinus thrombosis (see paragraph above) unless severe com- 
 plications are already present in other organs and the 
 patient's vitality is greatly depressed. Although it is 
 impossible to be certain before operation whether the lesion 
 is confined to the sinus, yet this must not be allowed to weigh 
 against operation if the two contra-indications just mentioned 
 are absent. Operation is equally indicated if it is thought 
 probable that the sinus phlebitis is complicated by cerebral 
 abscess, or extradural abscess, or circumscribed meningitis. 
 The earlier the operation, the better the chances of success. 
 Commencing jugular thrombosis is no contra-indication. 
 
 Sinus phlebitis is so often undiagnosed that it is advisable 
 in all cases of extensive operation for acute purulent ear- 
 disease to open the lateral sinus on diagnostic and thera- 
 peutic grounds. 
 
 Contra-indications to operation are severe pyaemia, 
 multiple metastatic foci in distant organs (e.g., the lungs) ;^, 
 gangrene of the lung following septic and gangrenous infarct, 
 endocarditis, nephritis, pyaemic arthritis, jaundice. 
 
 If lumbar puncture reveals the presence of purulent 
 cerebrospinal meningitis, no operation should be undertaken 
 
 * In 305 cases of operation collected by Korner, 180 recovered and 
 125 died. 
 
 § A solitary pulmonary abscess is no absolute bar to operation, but 
 can rarely be diagnosed clinically. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 23 
 
 (recently some authors have urged operation in these 
 desperate cases on the ground of an occasional success). 
 If there is reason to believe that there is phlebitis of the 
 cavernous as well as the lateral sinus, operation is almost 
 always contra-indicated on account of the extent of the 
 lesion. 
 
 Tuberculosis of the mastoid process or the temporal bone, 
 with consecutive sinus thrombosis, does not contra-indicate 
 operation, unless the general condition of the patient is very 
 bad, or advanced tuberculosis is discovered in other organs. 
 No operation should be done in carcinoma of the temporal 
 bone. 
 
 Prognosis. — Of operation. — The figures which have been 
 quoted above show that the prognosis is relatively good ; 
 the more favourable the earlier the operation. Two out 
 of five operated on died. 
 
 When no operation is undertaken, the results of sinus 
 phlebitis are in general very bad. In most cases the disease 
 is rapidly fatal. Exceptionally, however, a case of advanced 
 sinus phlebitis has recovered without operation. 
 
 Risks of operation when the diagnosis is faulty. — The danger 
 attached to opening the sinus is comparatively small. Fatal 
 air aspiration has been recorded once (Kuhn) ; infection 
 through the wound of the sinus is rare. 
 
 The trauma entailed by the operation of opening the 
 skull may set up a traumatic encephalitis, but this is very 
 exceptional. 
 
 LITERATURE. 
 
 O. KoRNER. Die otitischen Erkrankungen des Hirnhaute und 
 der Blutleiter, 3rd Ed., 1902. 
 
 Oppenheim. Hirnabscess. Nothnagel's Handbuch d. spez. Pathol. 
 
 Macewen. Pyogenic Infective Diseases of the Brain and Spinal 
 Cord. 1893. 
 
 Bergmann. Die Chirurgische Behandlung der Hirnkrankheiten, 
 3rd Ed., 1899. 
 
 Zaufal. Sinusphlebitis. Prag. Med. Wochens. 1884, p. 474, 
 und 1896, No. 49. 
 
 Hammerschlag. Monats. f. Ohrenheilk, 1900, p. 127. 
 
 HYDROCEPHALUS. 
 
 Etiology. — The general etiology of hydrocephalus need 
 not be discussed here, for only a few of the forms of the 
 condition are suitable for surgical treatment ; acute hydro- 
 
24 INDICATIONS FOR OPERATION IN 
 
 cephalus, due to serous or tubercular meningitis, or to 
 cerebral tumour, is not, in my opinion, included among 
 these. Operation is called for in the chronic congenital 
 type, but not in the chronic acquired form, such as that 
 following closure of the foramen of Magendie or the foramen 
 of Monro, or that due to tumour, for the reason that a 
 differential diagnosis between the latter and cerebral tumour 
 is hardly possible, and consequently the chances of successful 
 surgical treatment are of the smallest. In such cases the 
 most that can be done is a palliative operation for the relief 
 of intracranial pressure, prolonging a miserable existence for 
 a short period. 
 
 Pathological Anatomy. — Bergmann's definition gives in 
 a few words the essential points. He says : " Chronic 
 hydrocephalus is characterized by a progressive increase of 
 the fluid in the ventricles of the brain, and by a correspond- 
 ing distension of the skull of the child, whose sutures and 
 fontanelles are still unclosed." The amount of fluid in the 
 ventricles is sometimes enormous, the cortex and the rest of 
 the brain being extremely thin and diffusely atrophic, the 
 floor of the third ventricle forming a cystic swelling. The 
 sutures gape and the fontanelles are greatly enlarged, the 
 forehead bulging forwards. The structures at the base of 
 the brain appear compressed. The fluid in the ventricles is 
 similar in composition to the cerebrospinal fluid. The 
 circumference of the head is much greater than normal, 
 and the bones of the skull are not unusually thin and 
 transparent. 
 
 Clinical Course and Diagnosis. — In addition to the 
 signs already mentioned, a few others only require to be 
 noted in regard to the question of diagnosis. The face 
 appears small, the position of the eyeballs is modified by the 
 narrowing of the orbits, and the hair is scanty ; often 
 nystagmus and tremors of the face are to be noted, and 
 optic neuritis or a simple optic atrophy. The intellectual 
 faculties are often feeble, and definite dementia is not 
 uncommon. 
 
 Often the head cannot be held upright ; sometimes motor 
 paresis of the upper and lower extremities is present, often 
 associated with spastic phenomena or tremors. The tendon 
 reflexes are much exaggerated, and in advanced stages 
 general convulsions occur. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 25 
 
 Differential diagnosis. — The differential diagnosis from 
 rachitic changes in the skuh is of special importance, these 
 being only part of general bone changes throughout the 
 skeleton. In rickets the skull is square, and craniotabes is 
 not uncommon. A very pronounced increase in the size of 
 the skull negatives simple rachitis, while favourable results 
 from the administration of phosphorus are evidence in its 
 favour. 
 
 It is also important to distinguish the congenital from the 
 acquired form of hydrocephalus. The most important point 
 is the fact that in the latter the enlargement of the head 
 does not date from the first few months of the child's life. 
 If the evidence on this point is not clear, assistance may be 
 obtained from a history of meningeal symptoms having 
 preceded the enlargement of the head ; if this is the case it 
 will point to the acquired form. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation does not necessarily follow on a diagnosis of 
 congenital hydrocephalus ; the condition may spontaneously 
 come to a standstill. When the increase of the head is rapid 
 and continuous, and the signs of intracranial hypertension 
 become prominent (slowing of the pulse, Cheyne-Stokes 
 respiration, vomiting, and intellectual dullness), and if 
 general convulsions make their appearance, then the question 
 of operation must be considered. Generally speaking, opera- 
 tion is justifiable when the condition endangers life : such 
 an operation may be either lumbar puncture or drainage of 
 the ventricles. 
 
 Another indication for operation arises when optic neuritis 
 or commencing atrophy threatens total blindness ; and, 
 thirdly, when there is intense and persistent headache. 
 
 Operation has been undertaken of late years in the hope 
 of improving the bodily and mental functions which suffer 
 so severely in the course of the disease, and with a view to 
 improving the hydrocephalic dementia, using the latter 
 term in its widest sense. 
 
 Contra-indications. — Operation should not be undertaken 
 if prolonged antisyphilitic treatment or the administration 
 of phosphorus has brought about an arrest in the progress 
 of the condition, or a disappearance of the symptoms of 
 raised intracranial pressure. Operation must be looked 
 
26 INDICATIONS FOR OPERATION IN 
 
 upon as by no means free from risk. It will not be recom- 
 mended when the general condition is very low, when there 
 is marked dementia, when optic atrophy is complete, or 
 when the child is suffering from some other severe compli- 
 cating affection. Even when operation is well borne, the 
 good local results are liable to be outweighed by persistent 
 intellectual defect, idiocy, and imbecility. Chronic stationary 
 hydrocephalus should not be operated on when the skull is 
 completely ossified ; no improvement would follow under 
 such circumstances. 
 
 Prognosis. — After operation. — This will vary according 
 to the mode of intervention. Spinal puncture, if done with 
 the necessary precautions, is not particularly dangerous, but 
 what improvement it causes is only temporary, and it has to 
 be frequently repeated to obtain a permanent result. It 
 can only be successfully done when the aqueduct of Sylvius, 
 the foramen of Magendie, and the other channels are patent. 
 The operations by which fluid is evacuated directly from 
 the dilated ventricles are all attended with risk, and only a 
 few cases have been benefited or cured thereby. In sixty- 
 five cases collected by Henschen there were twenty-four 
 fatalities ; in twelve there was no improvement, sixteen were 
 cured, and thirteen improved. Probably many unfavourable 
 cases are not reported, and there is reason to believe that 
 the mortality is higher than these figures represent. 
 Drainage of the ventricles gives the worst results of all ; of 
 twenty-three cases thus treated, sixteen died. 
 
 The operations which have been hitherto devised for hydro- 
 cephalus {especially ventricular drainage) must therefore he 
 considered of very doubtful utility ; but at the same time it 
 cannot be denied that definite cure may he obtained by these 
 means. 
 
 Consequences of operation. — Operation may be followed by 
 fatal septic infection (meningitis, abscess). Spinal puncture 
 alone may occasion serious and even lethal syncope, owing 
 to a too rapid and abundant escape of fluid ; it is well to 
 repeat, therefore, that it is attended with definite risks. 
 When a palliative operation is undertaken, with the idea of 
 rescuing the patient from complete blindness, the least 
 dangerous, that is to say spinal puncture, should be 
 chosen. 
 
 Prognosis without operation. — The hydrocephalus itself 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 27 
 
 may become stationary, while marked motor and intellectual 
 symptoms persist (an unusual event), and the damage to the 
 sensory nerves, especially the optic nerves, progresses. On 
 the other hand the hydrocephalus may increase and produce 
 symptoms of progressive intracranial tension, with or 
 without intercurrent complications, bringing about a fatal 
 result in the course of time. This may be a few months or 
 several years. 
 
 Spontaneous recovery may take place, but the chances of 
 its occurrence are small in any given case. Sometimes the 
 fluid finds an exit by the nose, throat, or orbit ; then recovery 
 may follow if no secondary infection intervenes. About a 
 dozen cases of spontaneous rupture are recorded in the 
 literature. 
 
 LITERATURE. 
 
 Bergmann. Die Chirurgische Behandlung der Hirnkrankheiten. 
 3rd Ed. Berlin, 1899. 
 
 D'AsTROS. Les Hydrocephalies. Pads, 1898. G. Steinheil. 
 
 Neurath. Lumbalpunktion. Zentralb. f. d. Grenzgebiete d. 
 Med. u. Chir. 1898. 
 
 A. Starr. Cerebral Surgery. 
 
 Henle. Wasserkopf. Mitteilung. aus den Grenzgebieten. 
 Bd. I. 
 
 HEN5CHEN. Handbuch der spez. Therap. von Penzoldt-Stintzing. 
 3rd Ed. 
 
 EPILEPSY. 
 
 Definition, Etiology, and Pathological Anatomy. — 
 By the term epilepsy is understood a condition characterized 
 by frequently recurring attacks of sudden loss of conscious- 
 ness, with general convulsions, at first of tonic, and later of 
 clonic, type. In habitual epilepsy generally speaking, an 
 idiopathic, a symptomatic, and a reflex type are to be 
 distinguished, although this distinction is not always 
 possible. 
 
 To the symptomatic type belong those cases in which 
 gross anatomical cerebral lesions (hydrocephalus, tumour, 
 abscess, extensive softening) or diseases of other organs, 
 such as the kidneys, are associated with epileptic attacks 
 in addition to other symptoms. Reflex epilepsy is that 
 form in which convulsions of epileptic type are set up by 
 some discoverable irritation of the peripheral nervous 
 system ; in such cases, it must be noted, that a state of 
 
28 INDICATIONS FOR OPERATION IN 
 
 pathological excitability of the central nervous system is 
 also present. 
 
 In idiopathic epilepsy no constant and characteristic 
 anatomical changes have yet been found, but among other 
 lesions the following have been most frequently observed : 
 old cicatrices, circumscribed cysts, local sclerosis, haemor- 
 rhages (traumatic), bone splinters, and hyperostoses. There 
 are many cases in which no anatomical anomalies are 
 found. 
 
 The most important etiological factors in epilepsy are 
 the intoxications (alcohol, lead), the infective diseases 
 (syphilis, malaria), heredity, psychic influences, and head 
 injuries. 
 
 Clinical Course. — Epileptic seizures are of several 
 different types : (i) The " petit mal " ; minor attacks 
 without or with only slight convulsive movements, but with 
 loss of consciousness. (2) The major attacks, with pro- 
 dromal symptoms of the nature of an " aura," with loss of 
 consciousness, first tonic and then clonic convulsions of the 
 whole muscular system, initial cry, and biting of the tongue, 
 followed by stupor and drowsiness, and sometimes by 
 psychic disturbances. (3) The partial seizures (cortical 
 epilepsy, Jacksonian epilepsy), in which, after a prodromal 
 " aura," the convulsions either chiefly or exclusively affect 
 one side of the body and then pass off, usually in the order 
 in which they appeared. 
 
 If the convulsions, first tonic, then clonic, are confined to 
 one side, consciousness is usually unaffected ; if they spread 
 to the opposite side it is usually lost. The attacks of the 
 second and third types often appear in series. When the 
 attacks succeed each other with great rapidity, a status 
 epilepticus is established. 
 
 Diagnosis and Differential Diagnosis. — When the 
 attacks are well marked the diagnosis is readily made. They 
 will be distinguished from hysteria by the biting of the 
 tongue, the serious injuries which the patient sometimes 
 suffers in an attack, and by the complete loss of conscious- 
 ness. Incontinence of urine and faeces during an attack, 
 and the occurrence of the latter during sleep, point to true 
 epilepsy. Hysterical phenomena and hysterical convulsions 
 will enable one to distinguish hysteria from an apparent 
 " petit mal." Symptomatic epilepsy may be distinguished 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 29 
 
 from idiopathic epilepsy by the presence of anomalous 
 phenomena not characteristic of the latter, at any rate after 
 one has had the patient under observation for some time. 
 
 INDICATIONS FOR OPERATION. 
 
 These have been very differently stated at different 
 periods. At the present time the following may be given : — 
 
 Reflex epilepsy. — Operation is called for when the diagnosis 
 of a reflex epilepsy is clear ; that is to say when the attacks 
 are dependent on some peripheral lesion (a tumour, a painful 
 ricatrix), as shown by the fact that the aura makes its 
 appearance in the latter, with twitching of the neighbouring 
 muscles, and spreads thence to the rest of the body, and 
 when the attacks can be set up by pressure at the seat of 
 the lesion. Such operation will consist in the removal of 
 the disease focus (tumour, scar, hyperostosis). 
 
 Symptomatic epilepsy. — The indications for operation will 
 here be guided by those relative to the tumour, abscess, or 
 other condition to which the epileptic attacks are due. In 
 this type, as also in Idiopathic epilepsy, the skull should be 
 opened when there is a history of a trauma shortly preceding 
 the onset of the convulsions. Operation is absolutely 
 indicated in recent cases in which there is a palpable lesion, 
 such as a depression of the bones of the skull, or in which 
 there are one-sided convulsions associated with other marked 
 cerebral symptoms. It is also indicated in cases of somewhat 
 longer standing, in which there is definite cortical epilepsy 
 constantly commencing at a definite spot on one side of the 
 body, and when there is an " aura " referred to that part 
 in which the muscular twitchings first occur. In all such 
 cases, however, operation will only be undertaken when 
 a course of treatment with bromides has been tried and 
 found ineffectual. 
 
 Centra-indications to operation. — In reflex epilepsy, the 
 generalization of the convulsions over the whole muscular 
 system in each attack negatives the idea of operation. When 
 this is the case it indicates the existence of such pronounced 
 changes in the central nervous system as to make it probable 
 that even after removal of the original irritative cause the 
 convulsions will continue. 
 
 In idiopathic epilepsy, operation is contra-indicated vv'hen 
 there are no local symptoms enabling one to diagnose the 
 
30 INDICATIONS FOR OPERATION IN 
 
 site of a local brain lesion, when convulsions are not one- 
 sided, when no bone depression or exostosis is manifest in a 
 case presenting the history of a trauma, and so on. 
 
 Simple trephining of the skull at some point or other, 
 which was at one time frequently practised, often produces 
 a transitory improvement, but no permanent good result. 
 For resection of the sympathetic, which has been done in 
 many cases more recently, no favourable curative results can 
 be claimed. 
 
 In cortical epilepsy, when operation reveals no apparent 
 abnormality of the cortex, no resection of the latter should 
 be done, although Horsley recommended it. 
 
 In all cases where there is no history of acute onset 
 (trauma), no operation should be undertaken for the con- 
 vulsions until energetic treatment with bromides has been 
 tried and failed. If there is a definite or even only a 
 probable history of syphilis, an antisyphilitic course of 
 treatment should be prescribed before recommending 
 operation. 
 
 Prognosis. — Risks of operation. — In reflex epilepsy these 
 are usually slight. They are more serious when the skull is 
 opened, for this operation is itself always a severe one. 
 Sensory and motor defects may persist for a long time after 
 the removal of apparently normal portions of the cortex in 
 hemi-epilepsy. I have seen such still existent years after 
 operation. In every case of trephining there is a risk that 
 the resulting scar may itself prove the cause of epileptic 
 seizures. 
 
 Results without operation. — In reflex epilepsy the establish- 
 ment of general epileptic attacks is to be expected ; this is 
 true also for traumatic and non-traumatic cortical epilepsy. 
 
 LITERATURE. 
 
 BiNSWANGER. Die Epilepsie. Xothnagel's Handbuch der 
 spez. Pathol. Wien. 1899. 
 
 Jolly. Handbuch der praktischen ^ledizin (Ebstein-Schwalbe), 
 1900. 
 
 Bergmann. Die Chirurgische Behandlung der Hirnkrankheiten. 
 3rd. Ed., Berlin, 1898. 
 
 PiLCZ. Die Chirurgische Behandlung der Epilepsie. Centralb. f. 
 d. Grenzgebiete d. Med. u. Chir. 1901. 
 
 GowERS. Epilepsy. 
 
 Henschen. Epilepsie. Handbuch der spez. Pathol. von 
 Penzoldt-Stintzino;. 2nd Ed. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 31 
 
 THE CEREBRAL PALSY OF CHILDREN. 
 
 Etiology. — This condition may be either congenital or 
 acquired. The acquired form is caused by injuries at birth, 
 injuries of other kinds, the infectious diseases, embolus, and 
 thrombosis of the cerebral vessels, the latter associated 
 specially with syphilis. 
 
 Pathological Anatomy. — No constant anatomical 
 changes have been found ; usually some process which is 
 no longer active, the chief being foci of softening, cysts, 
 indurations, and porencephaly. Sometimes a fine plication 
 of the grey matter of the cortex has been found, the so- 
 called microgyria. Thickening of the meninges and cysts 
 of the meninges are common. Often the whole hemisphere 
 is shrunken and sclerotic. The motor region is that most 
 commonly and most severely affected. 
 
 Clinical Phenomena. — Hemiplegia is the characteristic 
 phenomenon. The paralysis does not, however, remain 
 complete, but recedes to a certain extent. It affects, as in 
 the adult, the extremities and the face on one side, and 
 there is often also paresis of the hypoglossal on the same 
 side. The paralysis is of the spastic type, and contracture 
 is in many cases a more prominent symptom than the 
 paralysis. The reflexes are exaggerated on the paralysed 
 side, and Babinski's sign is often present. Hemiathetosis 
 and hemichorea are exceptionally frequent. Usually there 
 are no sensory abnormalities. The paralysed extremities 
 often show arrest in growth and muscular development. 
 Epilepsy and idiocy are common, but the idiocy is not 
 complete, and may only consist of slight w^eakness of intellect, 
 or some anomalous characteristics. In many cases the 
 condition is bilateral (cerebral diplegia). 
 
 Diagnosis. — The symptoms will render the diagnosis 
 clear ; the spastic and non-degenerative character of the 
 hemiplegia, the intellectual weakness, the epilepsy, hemi- 
 chorea, hemiathetosis, etc. As a rule it is easy to avoid 
 confounding the condition with birth palsy (the flaccid 
 paralysis of an arm), or poliomyelitis (degenerative paralysis). 
 
 INDICATIONS FOR OPERATION. 
 
 Trephining, with removal of the morbid focus, is indicated 
 if epilepsy, chorea, and athetosis are present, unless some 
 
32 INDICATIONS FOR OPERATION IN 
 
 particular contra-indication is present, such as general 
 feebleness, heart failure, tuberculosis (Henschen). The 
 hemiplegia will not be improved by operation, and therefore 
 in itself is not an indication for intervention. Plastic opera- 
 tions on the muscles and tendons are indicated for the 
 disabilities produced by contracture and paresis. 
 
 Contra-indicaiions. — In addition to those already men- 
 tioned the presence of diplegia is against operation, nor 
 should this be advised when epileptic seizures are only 
 occasional, because, although they are sometimes improved 
 thereby, it is b}^ no means certain that this will follow in 
 any given case. 
 
 Prognosis. — Dangers and results of operation. — Hitherto 
 the results of trephining have not been particularly encourag- 
 ing, for in some of the cases death has followed and been 
 directly assignable to it. It must therefore be looked upon 
 as distinctly dangerous. In another group of cases the im- 
 provement that has followed has been only transient. The 
 attacks of muscular spasm or the epileptic seizures improve 
 or disappear, only to return after the lapse of a longer or 
 shorter period. Usually they appear after a few months, 
 and sometimes worse than ever. Complete recovery is 
 exceptional. Only therefore in cases where the symptoms 
 (epilepsy, choreiform spasm) are extreme and intolerable, 
 will operation be recommended : that is to say, trephining, 
 with removal of the morbid focus. 
 
 The results of tendon transplantation are more encourag- 
 ing. The function of useless limbs can be, in part at any 
 rate, restored, and the risks of operation are minimal. 
 
 Results without operation. — When contracture, athetosis, 
 or chorea develop, the limb will be rendered almost com- 
 pletely useless. The onset of epileptic fits leads up to 
 chronic epilepsy and the danger of the status epilepticus. 
 Generally speaking, however, the life of the patient is not 
 endangered by his affection. 
 
 LITERATURE. 
 
 Freud. Kinderlahmung. Nothnagel's Handbuch d. spez Pathol, 
 u. Therap. Bd. ix. Wien. 
 
 Sachs. Hirnlahmungen der Kinder. Volkmann's Sammlung 
 klin. Vortrasje. Neue Folge, 46 and 47. 
 
 Henschen. Cerebrale Kinderlahmung. Handbuch der spez. 
 Therap. von Penzoldt-Stintzing. Bd. vi 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 33 
 
 CEREBRAL HAEMORRHAGE. 
 
 The cerebral haemorrhage which follows injury will alone 
 be discussed here ; the spontaneous haemorrhages of the 
 brain have so rarely been submitted to operation, that 
 no discussion of indications and contra-indications is 
 possible. 
 
 Etiology. — ^Traumatic cerebral haemorrhage may be 
 occasioned by a comparatively slight as well as by a severe 
 injury. 
 
 Pathological Anatomy. — There may or may not be a 
 severe skull lesion associated with the intracranial haemor- 
 rhage. Extradural haemorrhage is usually due to tearing of 
 the middle meningeal artery ; intradural haemorrhage 
 usually comes from a pial vein. The clot may be very 
 large and exert severe pressure on the brain. Multiple 
 lesions of brain, meninges, and skull are often caused by the 
 one injury. 
 
 Clinical Course. — It may be very difficult to decide 
 whether haemorrhage is intra- or extradural ; in many of 
 my cases of intradural haemorrhage, the fluid drawn off by 
 lumbar puncture has contained blood. As a rule there is an 
 interval, which may be an hour or may be as long as ten days, 
 between the injury and the onset of pressure symptoms ; 
 the patient then becomes increasingly drowsy, his pulse 
 slows, and vomiting and convulsions commence. The 
 convulsions may be of the type of cortical epilepsy, 
 and may be strictly localized, e.g., to the face muscles. 
 Hemiplegia then appears and becomes more and more 
 pronounced, affecting the side of the body (including 
 the face) opposite to that of the injury ; hemihyperaesthesia 
 may be associated with this. In left-sided lesions aphasia 
 may sometimes be made out. As the haemorrhage and 
 the pressure increase, paresis develops on the same side 
 as the lesion, the respiratory rhythm becomes of the 
 Cheyne-Stokes type, the pupils become dilated, and the 
 patient passes into a condition of coma, terminating in 
 death. 
 
 Diagnosis. — The diagnosis is based on the appearance 
 after injury of the symptoms enumerated ; paralysis of the 
 opposite side, cortical epileptic attacks, and the gradual 
 increase of the signs of cerebral compression. 
 
 3 
 
34 INDICATIONS FOR OPERATION IN 
 
 INDICATIONS FOR OPERATION. 
 
 The skull must always be opened when, after injury to the 
 head, signs of progressive cerebral compression are associated 
 with the presence of a definite lesion of the cranial vault. 
 If no such lesion can be found, operation should still be under- 
 taken when the signs of compression steadily advance, and 
 when these signs are such that the site of the haemorrhage can 
 be diagnosed. If, however, the compression symptoms are 
 stationary, and not of a severe type, the advice given by 
 Allen Starr is to wait, for the reason that in many cases the 
 paralyses clear up spontaneously by resorption of the 
 haemorrhage. Under such circumstances, however, the 
 patient must be watched carefully, and if the compression 
 symptoms increase in severity, operation must be undertaken 
 without delay.* 
 
 Contra-indications. — If, after a head injury, signs of 
 compression supervene without any localizing symptoms, 
 and if no bony lesion is discoverable, there are no sufficient 
 indications for operation. In such a case operation would 
 only be done in the hope of finding the source of the 
 haemorrhage, and this hope is exceedingly unlikely to be 
 realized. 
 
 Prognosis. — Results of operation. — In many cases the 
 removal of clots, and the discovery and ligature of 
 the bleeding vessel, have been followed by complete 
 recovery. 
 
 Risks of operation. — These must be considered serious 
 when an exact diagnosis of the situation of the lesion is 
 wanting, ■'^f When the site of the haemorrhage is correctly 
 diagnosed the risk is less. 
 
 Results without operation. — The haemorrhage sometimes 
 ceases spontaneously, and after remaining stationary for a 
 long time, the symptoms in such a case may be expected to 
 gradually disappear. If, however, the symptoms steadily 
 become more severe, the intracranial tension increases. 
 
 * A case was recently recorded by Saenger and Grisson in which 
 cortical epilepsy suddenly appeared four days after a head injury ; 
 this commenced in the face and persisted. Some loss of consciousness 
 supervened later, and operation was then done. After incision of the 
 dura a hsematoma overlying the central convolutions was found and 
 removed. Recovery followed. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 35 
 
 and the paralysis extends, unless operation is undertaken 
 death will follow with the symptom-complex of cerebral 
 paralysis. 
 
 LITERATURE. 
 
 Allen Starr. Brain Surgery. 1893. 
 Jacobson. Guy's Hospital Reports. 1886. 
 DuRET. La Semaine Medicale. April, i8qi. 
 
 WiESMANN. Die modernen Indikationen der Trepanation. 
 Deut. Zeits. f. Chirurgie. Bd. xxi and xxii. 
 
 TUBERCULAR MENINGITIS. 
 
 Etiology. — This affection is almost always of a secondary 
 character, associated especially with tuberculosis of the 
 lungs, glands, bones, and joints. 
 
 Pathological Anatomy. — The chief characteristics are 
 the occurrence of inflammatory changes in the pia mater 
 and arachnoid, the development of tubercles of varying 
 size in these membranes, and the accumulation of an 
 excessive amount of cerebrospinal fluid in the ventricles. 
 The membranes at the base of the brain are chiefly 
 involved. 
 
 Clinical Course. — ^After a prodromal stage of varying 
 length, during which the patient suffers from lassitude, 
 headache, and irritability, and sometimes a transitory 
 aphasia, more pronounced signs of cerebral irritation begin 
 to make their appearance. Such signs are : stiffness of the 
 neck, cutaneous hypergesthesia, inequality of the pupils, 
 photophobia, headache, delirium, convulsions, vomiting, 
 slowing or irregularity of the pulse. Constipation is usual, 
 and retraction of the abdomen, and Trousseau's sign {taches 
 cerebrales) may be present. Flexion of the hip with the leg 
 extended causes considerable pain, and the legs cannot be 
 extended in the sitting posture (Kernig's sign). A slight 
 elevation of temperature is almost always found. After 
 some days or weeks the patient becomes comatose, paralyses 
 of the cranial nerves appear, the pupils do not react, and 
 examination of the fundus oculi shows tubercles in the 
 choroid. The pulse rate increases, and Cheyne-Stokes 
 respiration develops. At the time of death there is often 
 marked hyperpyrexia. The symptoms are, on the whole, 
 very variable in their character and evolution. 
 
 Diagnosis and Differential Diagnosis. — The earlv 
 
^6 INDICATIONS FOR OPERATION IN 
 
 appearance of rigidity of the neck, and of Kernig's symptom, 
 and examination of the fluid obtained by lumbar puncture, 
 will clear up the diagnosis. The cerebrospinal fluid is 
 turbid, and on standing a scum often forms, in which 
 tubercle bacilli may be found. The diagnosis from typhoid 
 fever (Widal's reaction), prevertebral cellulitis, acute 
 infectious diseases with meningeal symptoms, brain tumour 
 and abscess, and cerebral haemorrhage, is often difficult, 
 but is much facilitated by lumbar puncture. 
 
 INDICATIONS FOR OPERATION. 
 
 Of the different operative procedures which have been 
 tried in tubercular meningitis (puncture of the lateral 
 ventricles, and of the fourth ventricle, opening and drainage 
 of the spinal canal by laminectomy, puncture of the spinal 
 canal) spinal puncture alone appears to be justifiable. This 
 is indicated (a) for diagnostic purposes ; (b) to relieve or 
 ameliorate symptoms of severe cerebral compression. The 
 advice which has been given by several authors that puncture 
 should be undertaken with the idea of gaining time for the 
 carrying out of some curative treatment, is of theoretical 
 rather than of practical interest. 
 
 Prognosis. — Results of spinal puncture. — Headache and 
 other pressure symptoms are often markedly improved, and 
 the patient may obtain marked relief for some hours or even 
 days. I have often practised spinal puncture with the view 
 of affording this relief. It is only in very exceptional cases 
 (Freyhan), and then only by repeated puncture, that 
 recovery or considerable prolongation of life has been 
 obtained. Puncture must thus be looked upon only as a 
 means of relieving certain of the symptoms. 
 
 The risks of spinal puncture are very small in uncompli- 
 cated tubercular meningitis, if too rapid escape of fluid 
 is prevented, and if the operation is interrupted on the 
 appearance of symptoms of collapse. It is therefore contra- 
 indicated in a relatively small number of cases. Although 
 lumbar puncture has been performed in a large number of 
 cases by myself and under my supervision, I have never 
 experienced any disagreeable accident. It is only contra- 
 indicated when the patient has already reached the stage of 
 paralysis, and when the general condition will not tolerate 
 any interference, however slight. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 37 
 
 LITERATURE. 
 
 Neurath. Lumbalpunktion. Zentralb. f. d. Grenzgebiete d. 
 Med. u. Chir. 1898. 
 
 Freyhan. Deut. med. Wochens. 1894, No. 36. 
 FiJRBRiNSER. Berl. klin. Wochens. 1895, ^o- ^3- 
 
 ACUTE LEPTOMENINGITIS. 
 
 Etiology. — The disease is probably always due to 
 bacterial infection. The organisms reach the meninges 
 either from some distant focus by metastasis, or directly 
 from some inflammatory lesion, more or less directly in 
 contact with the meninges, either within (brain abscess) or 
 without. Such lesions may be in the scalp, the ear, the 
 frontal sinus, the nasal, oral, and orbital cavities, etc. 
 
 Pathological Anatomy. — The infection makes its way 
 through lymph and blood channels, and spreads rapidly 
 throughout the cerebral and spinal meninges. There is also 
 a localized type. The exudation may be either serous, 
 haemorrhagic, or purulent. 
 
 Clinical Course. — The disease usually begins acutely, 
 with fever, rigors, and intense headache, and vomiting. 
 Consciousness is also often affected, and various signs of 
 irritation appear, cutaneous hypersesthesia, headache, photo- 
 phobia, nystagmus, muscular spasm, and sometimes con- 
 vulsions. Rigidity of the neck and Kernig's sign are 
 specially important, the latter being the impossibility of 
 extending the legs with the patient in the sitting posture. 
 The pulse is slowed, and the pupils are unequal or contracted. 
 Later, paralyses occur, and the pulse-rate increases, and 
 there appear strabismus, dilatation of the pupils, paresis of 
 a single or of all extremities, Cheyne-Stokes respiration, 
 deep stupor, and retention or incontinence of urine. In 
 epidemic - cerebrospinal meningitis there is, as a rule, a 
 diffuse herpetic eruption, and paresis of the ocular muscles 
 is often an early symptom. 
 
 The serous meningitis of Quincke may run an acute or 
 chronic course : fever is intermittent and slight, and all 
 the symptoms are of a rather subdued type. Purulent 
 non-epidemic meningitis, on the other hand, usually 
 exhibits severe symptoms from the beginning, and relatively 
 often some local symptoms. Non-suppurative meningo- 
 encephalitis often follows some acute infectious disease, and 
 
38 INDICATIONS FOR OPERATION IN 
 
 marked irritative or paralytic symptoms are frequently 
 observed from the commencement. 
 
 Differential Diagnosis. — The condition is to be 
 differentiated in particular from tubercular meningitis and 
 enteric fever. In the latter there is no slowing of the pulse 
 and no leucocytosis, while Widal's reaction is positive. In 
 cerebral tumour the course is apyrexic ; when the symptoms 
 are chronic in type and local, and when definite optic neuritis 
 is present, tumour is indicated. Septic processes in the 
 vicinity of the meninges are often with difficulty differ- 
 entiated from meningitis, and are indeed often associated 
 with the latter. If rapid improvement takes place after the 
 evacuation of pus, definite meningitis is probably absent. 
 Tubercular meningitis is distinguished by the discovery of 
 the bacilli in the cerebrospinal fluid. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation may be undertaken as a prophylactic measure, 
 or when meningitis is fully established. All accessible 
 septic foci bordering on the meninges should be evacuated 
 as early as possible, whether meningitis threatens or not. 
 When intracranial pressure threatens life, or if intense and 
 persistent pain is complained of in the head and neck, 
 lumbar puncture should be done, and may be repeated if 
 these symptoms reappear. 
 
 With regard to direct operative interference in meningitis 
 by trephining, puncture of the ventricles or of the meninges, 
 clinical experience has not yet been sufficiently great to 
 permit of the formulation of indications. 
 
 Contra-indications. — Lumbar puncture is only contra- 
 indicated when the patient is moribund. 
 
 Prognosis. — Results of operation. — Localized meningitis 
 often disappears when the neighbouring septic focus is success- 
 fully treated. Lumbar puncture often brings about a marked 
 relief to the symptoms of cerebral compression ; sometimes 
 this relief is only of short duration, but the puncture may 
 be repeated. Occasionally lumbar puncture has a curative 
 influence.* 
 
 * Recently, in a case of hsemorrhagic meningo-encephalitis, under 
 my care, lumbar puncture was repeated three times. Marked improve- 
 ment resulted, although the patient was extremely ill, and he ultimately 
 recovered. 
 
DISEASES OF THE BRAIN AND ITS MENINGES. 39 
 
 Risks of operation. — If too much fluid is not removed, and 
 it is not allowed to run too fast, the dangers of lumbar 
 puncture are minimal, even if the foramen of Magendie is 
 obstructed. 
 
 // no operation is undertaken, death from cerebral com- 
 pression is to be expected. 
 
 LITERATURE. 
 
 Henschen. Hirnkrankheiten. Handbuch der spez. Therap. 
 von Penzoldt-Stintzing. Jena. 2nd Ed. 
 
 Quincke. Meningitis Serosa. Volkmann's Hefte, Neue Folge, 
 No. 67. 
 
 Neurath. Lumbalpunktion. Zentralb. f. d. Grenzgebiete d. 
 Med. u. Chir. i8q8. 
 
CHAPTER 11. 
 Diseases of the Spinal Column and Cord. 
 
43 
 
 Chapter II. 
 
 DISEASES OF THE SPINAL COLUMN AND CORD. 
 
 TUBERCULAR SPONDYLITIS (Pott's Disease). 
 
 Etiology. — The various etiological factors which influence 
 the development of tubercular disease are concerned in the 
 etiology of tuberculosis of the spinal column. Injury is an 
 etiological factor of some importance. 
 
 Pathological Anatomy. — The disease is somewhat 
 frequently discovered at post-mortems. Out of 35,000 
 autopsies at the Pathological Institute in Vienna, it was 
 found in 420 instances. The vertebral bodies are much 
 more frequently affected than the vertebral arches, and the 
 process gives rise to destructive lesions by caseation and 
 caries. When a vertebra is destroyed and those on each 
 side are also involved, a kyphosis is developed, with an 
 angular projection corresponding to the carious segment. 
 The thorax and pelvis both undergo considerable secondary 
 changes in form. The ventral portion of the vertebral body 
 being usually chiefly affected, pus, when formed, usually 
 passes forwards between the centrum and the anterior 
 common ligament. Abscesses from high cervical disease 
 usually present behind or to one side of the pharynx 
 or oesophagus, or make their way into the posterior 
 mediastinum. In dorsal disease the abscess may point 
 behind directly over the lesion, or come forwards into 
 the pleura or lung, or, more commonly, enter the 
 sheath of the psoas muscle. Abscesses associated with 
 lumbar disease pass into the loin, the iliac fossa, or 
 the pelvis. In many cases the course of the abscess is 
 aberrant, and perforation may occur into the oesophagus, 
 trachea, intestine, and bladder. Sometimes there is a 
 bilateral abscess cavity, usually communicating the one side 
 with the other. The spinal cord is often compressed by 
 collections of pus, or by tubercular granulation tissue, 
 arising from the bone disease or from the spinal dura mater. 
 
44 INDICATIONS FOR OPERATION IN 
 
 According to Trendelenburg, it is only in rare instances that 
 compression is due to the bone impinging on the cord. On 
 an average, compression of the cord occurs once in nine 
 cases. 
 
 Clinical Course. — The disease often remains long latent. 
 The first symptoms may be attributable to [a) The bone 
 disease itself ; {h) The involvement of the cord and nerve 
 roots ; (c) The development of an abscess ; or {d) The effect 
 of the disease on the general health. Pain is one of the most 
 important and early symptoms. It is sometimes only com- 
 plained of in one position, standing or lying down, and is 
 often very severe and of a throbbing character. Sometimes 
 it is spontaneous, but more frequently it is only complained 
 of when pressure is brought to bear on the affected vertebrae 
 •by pressing on the head or shoulders (this manoeuvre must 
 be cautiously carried out), and is referred to the situation of 
 the disease. Hot local applications and the galvanic current 
 also bring out this symptom of local tenderness. Rigidity 
 of the spine is a sign of importance, due to muscular con- 
 traction, or, in some instances, to anatomical bone changes, 
 and best seen when the patient stoops and rises. This 
 rigidity is often transitory, and may be mistaken for 
 " rheumatism ; " a transitory torticollis in a young subject 
 should always make one suspect spondylitis. When situated 
 in the upper cervical region the patient often supports his 
 head with his hands. Any sudden movement is very 
 painful. 
 
 Destruction of one or more vertebral bodies results in 
 angular curvature ; if the caries affects one side more than 
 another, a lateral may be added to the antero-posterior 
 deformity. Occasionally there is more than one such 
 curvature. Swelling of the surrounding soft parts may 
 make the deformity still more pronounced, and sometimes, 
 in children, simulates a vertebral tumour, especially in the 
 lumbar region. 
 
 General symptoms accompany the development of the 
 bone disease : fever, profuse sweating, loss of flesh, etc. 
 
 Retropharyngeal abscess may interfere with respiration 
 and deglutition. Psoas abscesses destroy the muscle and 
 cause flexion of the corresponding thigh ; later they appear 
 in the iliac fossa, or the groin, more rarely in the back. 
 
 The nervous phenomena are : neuralgia, and hyper- 
 
DISEASES OF THE SPINAL COLUMN AND CORD. 45 
 
 aesthesia, due to pressure on the nerve roots, or a plexus ; 
 and, in a later stage, paresis or paralysis below the lesion 
 due to compression of the cord. Paraplegia of the lowei 
 limbs is usually associated with rigidity and with exaggera- 
 tion of the tendon reflexes ; the skin reflexes are retained 
 or exaggerated. Girdle pain is often complained of ; the 
 functions of bladder and rectum are often affected. When 
 cord conduction is completely abolished there is anaesthesia 
 of the parts below as far up as the affected spinal segment ; 
 above the aucesthetic area there is often a hyperaesthetic 
 zone. When the disease is situated in the lowest dorsal 
 region the paralysis is flaccid, not spastic. When the lower 
 cervical vertebrae are affected there will be atrophic paralysis 
 of the arms, with spastic paresis of the legs. Paralysis in 
 suboccipital disease will include bulbar symptoms. 
 
 Diagnosis and Differential Diagnosis. — In well- 
 marked cases the diagnosis presents no difficulties, but in 
 others these are considerable. A radiograph affords 
 valuable assistance. Relatively often the disease is mistaken 
 for vertebral tumour in its early stages. In the latter con- 
 dition the pain is usually much more severe and more 
 continuous ; the deformity caused by tumour is not the 
 acute angular curvature of spondylitis. 
 
 The traumatic spondylitis of Kiimmel develops after a 
 period varying from a month to a year after an injury to the 
 spinal column ; an angular deformity develops, with symp- 
 toms of compression of the cord and pain ; but after some 
 time recovery follows, or at least the condition becomes 
 stationary. 
 
 INDICATIONS FOR OPERATION. 
 
 It must first be stated that there is no uniformity of 
 opinion on the indications for surgical interference in this 
 disease, but the majority, both of surgeons and physicians, 
 recommend conservative methods, and only advise opera- 
 tion for the relief of paralysis, abscess, and other com- 
 plications. 
 
 For the relief of paralysis there are only two procedures 
 which need be discussed : laminectomy, and the forcible 
 correction of angular curvatures. 
 
 Laminectomy is performed for the direct treatment of 
 vertebral caries, particularly when paralysis is present. 
 
46 INDICATIONS FOR OPERATION IN 
 
 Experience has shown that the actual bone disease cannot 
 as a rule be removed ; only the masses of tubercular 
 granulation tissue can be dealt with, and intradural abscesses 
 opened. Oppenheim has expressed his views on the subject 
 as follows : " Laminectomy is called for in compression 
 paralysis (a) In the exceptional cases of caries of the 
 vertebral arch when conservative treatment has failed ; 
 (b) When, in opening an abscess, direct access is found to be 
 obtainable to the affected vertebral body." Schede, 
 Tillmanns, and Trendelenburg have also formulated indica- 
 tions for this operation. Schede considers laminectomy 
 only a last resource, " when the condition of the patient is 
 desperate " (Vulpius). Tillmanns advises it when palliative 
 treatment has failed, in cases where high fever indicates the 
 presence of pus, or where paralysis persists. Trendelenburg, 
 in addition to these, recommends operation in old-standing 
 cases in which an incomplete paralysis persists. 
 
 Calot's method, the forcible reduction of angular curvature, 
 is hardly ever now employed in the form in which it was 
 introduced ; gradual reduction is practised by some surgeons, 
 and appears particularly advisable in cases in which 
 paralysis of a severe type is present. 
 
 When an abscess is retropharyngeal in position, and 
 obstructs respiration, it should be opened ; for abscesses 
 in other situations, puncture, followed by iodoform and 
 glycerin injection, is the best method (Henle, Vulpius). 
 
 Contra-indications. — In acute tubercular processes all 
 operations are contra-indicated, except the treatment of 
 abscess. No operation for curvature or paralysis should be 
 undertaken unless palliative treatment has been given a 
 long trial and been found ineffective, and no operation of 
 any kind should be done when there is marked tuberculosis 
 of other organs, advanced renal disease, an unsatisfactory 
 general condition, or other like complication. 
 
 Prognosis. — The results and risks of operation. — The 
 operative treatment of cases of spondylitis has given 
 generally disappointing results, and the limits of indication 
 have been correspondingly narrowed. Chipault's statistics 
 of 103 cases of laminectomy showed only fifteen recoveries, 
 and forty-three deaths soon after the operation. Cases of 
 severe paralysis may improve or recover entirely after 
 gradual correction of the deformity, or laminectomy, if the 
 
DISEASES OF THE SPINAL COLUMN AND CORD. 47 
 
 bone disease is not of a very active type. Cold abscesses 
 often subside or disappear after iodoform injection, f c 
 
 Without operation. — Complete rest, immobilization, ex- 
 tension, and the plaster jacket often bring about recovery. 
 Many times I have seen paralysis of all four extremities 
 recover under treatment with the plaster jacket. Oppen- 
 heim has recorded recovery to the extent of being able to 
 walk, in a case of paraplegia of seven years' standing. 
 About half the cases may be expected to recover with the 
 use of orthopaedic apparatus. 
 
 LITERATURE. 
 
 VuLPius. Die moderne Behandlung der Spondylitis. Zentralb. 
 f. d. Grenzgebiete d. Med. u. Chir. 1899. 
 
 Henle. Spondylitis. Handb. d. prakt. Chir., von Bergmann, 
 Bruns, md Mikulicz. Bd. II., 1900. 
 
 Oppenheim. Lehrbuch d. Nervenkrankheiten. 3rd Ed., Berlin, 
 1902. 
 
 LoRENZ. Spondylitis. Realencyklop. d. Heilkunde. 3rd Ed. 
 
 Krause. Tuberkulose der Knochen u. Gelenke. Deutsche 
 Chirurgie, 28a. 
 
 OSTEOMYELITIS OF THE YERTEBRiE. 
 
 Etiology. — Infection with staphylococcus aureus and 
 albus, as in osteomyelitis of other bones. Trauma is a 
 causative agent in a relatively large proportion of cases. 
 
 Pathological Anatomy. — The lumbar vertebrae, and 
 next, the dorsal vertebras, are the most frequently affected. 
 Sometimes one, sometimes several vertebrse are attacked, 
 and either the centrum, or the arch, or spinous process may 
 be involved. The sequestrum may be of such a size that 
 an angular curvature is formed. Pus may compress the 
 cord, or point under the skin of the back, or behind the 
 pharynx. Sometimes a psoas abscess is formed. 
 
 Clinical Course. This rare affection usually begins 
 acutely with symptoms of general constitutional disturbance, 
 high fever, and frequently rigors. Sometimes, but rarely, 
 the onset is more gradual. Tenderness of the affected 
 vertebrae, with rigidity, appears early. At the end of the 
 first week there is marked inflammatory swelling of the 
 tissues of the back, at the site of the disease, going on to 
 abscess formation. If the vertebral bodies are affected, a 
 retropharyngeal abscess forms if the disease is cervical ; 
 
48 INDICATIONS FOR OPERATION IN 
 
 but if it is situated lower, an abscess forms which may burst 
 into the pleura, and is hardly recognizable clinically. 
 
 Diagnosis.— The diagnosis may sometimes be made when 
 severe constitutional symptoms are present, with localized 
 tenderness over the spine, inflammatory oedema, and abscess. 
 The disease is more easily recognized when it affects the 
 laminae and spines, than when the centra are involved. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation should be undertaken immediately the diagnosis 
 has been made. Pus is evacuated, and, when possible, the 
 diseased bone is removed. 
 
 Risks of operation. — These are greatest when operation 
 has been delayed ; the condition of the patient will be then 
 more unsatisfactory and the operation more extensive. 
 
 Prognosis. — // }io operation is performed death will 
 probably take place, the total mortality of all cases, 
 including those successfully operated on, being over 60 
 per cent. At the best, a prolonged illness, with probably 
 amyloid disease, is to be expected. 
 
 Results of operation. — In most cases the disease has been 
 cut short by operation, with recovery ; sacral osteomyelitis 
 nas, however, up to the present, given bad results. 
 
 LITERATURE. 
 
 Hahn. Die akute infektiose Osteomyelitis der Wirbel. Beitr 
 z. klin. Chir., Bd. xxv. p., 176. 
 
 TRAUMATIC AFFECTIONS OF THE SPINAL CORD. 
 
 Etiology. — Traumatic affections of the spinal cord 
 result from direct or indirect violence to the spinal column ; 
 actual lesions of the latter may or may not be present in 
 association. 
 
 Pathological Anatomy. — Trauma may give rise to 
 severe and extensive destruction of the spinal cord, especially 
 of its central parts, by necrosis and haemorrhage, without 
 any discoverable lesion of the spinal column, such as fracture 
 or dislocation, or of the meninges. On the other hand the 
 cord may be markedly compressed by a detached bone 
 splinter or a dislocated vertebra without any notable 
 change in its structure, even when the lesion has existed for 
 several months. Speaking generally, however, injuries of 
 
DISEASES OF THE SPINAL COLUMN AND CORD. 49 
 
 the spinal column are usually complicated by lesions of the 
 cord. In 100 cases collected by Wagner and Stolper, the 
 cord was involved in seventy-one, unaffected in twenty-nine. 
 It is often completely pulped at the point of greatest 
 compression. Epidural haemorrhages are common and often 
 very extensive, but do not as a rule cause compression 
 of the cord. The nerve roots are very rarely destroyed, 
 compressed, or damaged by bone splinters. They are 
 usually compressed along with the cord when the latter 
 is pulped, either at their attachment or in their course 
 through the intervertebral foramina. Occasionally, but 
 rarely, the cord is compressed by callus thrown out 
 after fracture or by connective tissue formed at the site of 
 meningeal lesions. 
 
 Clinical Signs. — These may be divided into two groups ; 
 the first comprising those which are due to anatomical 
 changes in the spinal column, the second those which belong 
 to the nervous system. Luxation may be complete or 
 incomplete, unilateral or of both intervertebral joints. 
 As a rule defo;mity can be made out by palpation or by 
 X-ray examination ; it may show itself as a displacement 
 forwards of a spinous process, and in the neck a prominence 
 may be felt on palpation of the pharyngeal wall. In 
 unilateral dislocations the spine is rotated with the con- 
 vexity on the side of the displacement. Dislocations are 
 most common in the cervical and rarest in the lumbar 
 regions. 
 
 Fracture gives rise to very similar deformities. Occasion- 
 ally detached bony fragments can be palpated. Radio- 
 graphy is of great value. In one of my own cases a radio- 
 graph showed a bony lesion unrevealed by any other sign, 
 the case being apparently a pure cord lesion. Fracture 
 is most common in the lower dorsal and upper lumbar 
 regions. The combination of total luxation with fracture 
 is comparatively common, especially in the lower dorsal 
 segment. 
 
 In some cases of fracture-dislocation the cord escapes. 
 When it is involved, the symptoms may indicate a complete 
 or an incomplete interruption of conduction. Complete 
 interruption, whether due to pulping, haemorrhage, 
 necrosis, laceration, or compression, is characterized by 
 the following signs : — 
 
 4 
 
50 INDICATIONS FOR OPERATION IN 
 
 1. Loss of cutaneous sensibility in the areas whose 
 sensory nerves reach the cord below or at the level of the 
 cord lesion. The area of anaesthesia does not, however, 
 extend as far upwards as the vertebra concerned ; its upper 
 level is usually below this, even when one takes into account 
 the fact that the spinous process which projects backwards 
 does not usually belong to the vertebra which is causing 
 the compression. This difference in level between the bone 
 lesion and the area of anaesthesia is due to the oblique 
 course which the spinal nerves pursue in the spinal canal, 
 and to the fact that they usually escape injury at the site 
 of the fracture-dislocation. The nearer the latter is to the 
 point where the cord ends, the more marked is the difference 
 between the levels of the lesion and the anaesthesia. 
 
 2. Flaccid paralysis of the muscles whose motor nerves 
 leave the cord below or on a level with the lesion. Only 
 the muscles innervated from the spinal segment or segments 
 destroyed undergo atrophy. 
 
 3. The motor and sensory paralysis is congruent and 
 symmetrical. 
 
 4. The patellar reflexes are at once lost and remain 
 absent. 
 
 5. Interference with the functions of the bladder and 
 rectum is the rule ; renal affections are common. 
 
 6. Vasomotor paralysis is present and coterminous with 
 the motor and sensory paralysis. Wagner and Stolper 
 emphasize three signs as being diagnostic of a total trans- 
 verse lesion of the cord. (a) The congruence and 
 symmetry of motor and sensory paralysis, (b) The absence 
 of any signs of irritability in the paralyzed area, (c) The 
 loss of the patellar reflexes. 
 
 The same authors look upon the following as indicative 
 of a partial cord lesion : — 
 
 1. When the motor paralysis and the sensory paralysis 
 do not coincide in extent. 
 
 2. When the paralysis is not symmetrical. 
 
 3. When there are signs of irritation, either motor or 
 sensory, in the paralyzed area. 
 
 4. Retention of the patellar reflexes ; these are rarely 
 abolished in incomplete lesions, are usually exaggerated, 
 often differ on the two sides, and never remain permanently 
 absent. 
 
DISEASES OF THE SPINAL COLUMN AND CORD. 51 
 
 5. When the paralysis lessens in degree, or sets in late, 
 or is incomplete in both motor and sensory spheres. 
 
 6. When function is either completely or partly restored 
 in the first or second week. 
 
 Compression of posterior roots is shown by the presence 
 of radiating pains, and by hypersesthetic or anaesthetic 
 spots in the corresponding skin areas. Phenomena of 
 motor irritation (twitching, spasm) or of atrophic paresis 
 in the muscles point to compression of anterior roots 
 through which the muscles concerned derive their nerve 
 supply. When the vertebral lesion is below the second 
 lumbar level the cauda equina alone will be involved. 
 Lesions of the latter can hardly be differentiated from 
 lesions of the conus terminalis. In cauda lesions, how- 
 ever, phenomena of sensory irritation are relatively 
 common, and the paralyses are often unsymmetrical and 
 incomplete, while in conus lesions there is symmetry, and 
 complete paralysis is more frequent. 
 
 Differential Diagnosis. — There may be some difficulty in 
 differentiating these lesions from spinal concussion without 
 vertebral injury ; indeed, according to Kocher, there is 
 always some traumatic necrosis or haematomyelia in 
 concussion. Rapid retrogression of symptoms will show 
 that there is no necessity for operation. Traumatic 
 spondylitis (Kiimmel), which appears some time subsequently 
 to trauma, with pain, rigidity, and signs of compression of 
 the cord, is always associated with the development of an 
 angular curvature, and spontaneous recovery occurs when 
 the patient is kept at rest. 
 
 Latent and stationary Pott's disease may be aggravated 
 by trauma with the development of symptoms pointing to 
 compression of the cord, and the same is true of cases of 
 vertebral neoplasm. A benign tumour in the spinal canal 
 can hardly be distinguished from exuberant vertebral 
 callus. A malignant tumour progresses rapidly and gives 
 rise to persistent agonizing pain, while the pain associated 
 with vertebral injuries gradually lessens in intensity. 
 There can rarely be any confusion with vertebral tubercu- 
 losis. Crushing of the intervertebral disc is to be recognized, 
 according to Kocher, by local pain on pressure on the head 
 or shoulders, and tenderness, swelling, and prominence 
 over the spines immediately above. 
 
52 INDICATIONS FOR OPERATION IN 
 
 INDICATIONS FOR OPERATION. 
 
 At present there is no agreement as to the indications 
 for surgical intervention in cases of fractured spine. It is 
 agreed, however, that laminectomy is advisable in cases of 
 some standing, when the symptoms are those of incomplete 
 interruption of cord conduction. Quite recent cases should 
 not be operated on, for the early symptoms may clear up 
 spontaneously to a very great extent*. 
 
 Too long delay may, however, result in irreparable 
 damage to the cord. Most writers advise operation when 
 symptoms persist, not earlier than the fifth week, and not 
 later than the third month after the accident. Early 
 operation is, on the other hand, to be recommended when 
 there is a comminuted fracture of the vertebral arches, 
 with depression and probable damage to the cord ; also in 
 irreducible fracture-dislocations in the region of the cauda 
 equina, and in cord lesions produced by firearms and sharp 
 instruments. 
 
 In fractures which do not belong to one or other of these 
 types, few surgeons at the present time advise early 
 operation, though at one time it had many advocates 
 (Wagner, Chipault, Lejars, Biddle, Hammond, and others). 
 
 In cases of persistent paralysis, when there is a deformity 
 pointing to fracture of the vertebral arch, laminectomy is 
 indicated. It is also recommended by many authors, 
 even when there is no obvious deformity, in cases in which 
 the paralysis is not old-established, when compression seems 
 probable, and cord conduction is not completely interrupted. 
 
 If paralysis come on some weeks or months after the 
 fracture, and appear to be due to cord compression, an 
 exploratory laminectomy should be done with the idea of 
 dealing with exuberant callus, or adhesions between the 
 meninges and the more or less displaced vertebra. 
 
 In luxations, reposition should be done as far as possible. 
 Laminectomy should, according to Chipault, be done only 
 in old-standing luxation with slight symptoms. Kirmisson, 
 
 * In one of my cases a fall from a great height was followed by motor 
 and sensory paralysis of the lower limbs. Examination pointed to 
 a probable fracture of the first lumbar vertebra. The paralysis gradually 
 disappeared spontaneously and had gone completely at the end of 
 about a year. 
 
DISEASES OF THE SPINAL COLUMN AND CORD. 53 
 
 however, advises it when the attempts at reposition have 
 proved unsuccessful, but the symptoms must be of a 
 certain degree of severity to justify the operation. 
 
 Contra-indications. — When the symptoms point to 
 complete local destruction of the cord, no operation should 
 be done. Persistent complete loss of cord conduction is, 
 therefore, a contra-indication. From what has been said 
 already it will be gathered that I consider no operation 
 is called for in recent cases, nor in cases of some years' 
 standing in which the paralysis is stationary. 
 
 Prognosis. — // operation he undertaken. — Hahn has col- 
 lected sixty-four cases of laminectomy for vertebral fracture, 
 recorded between the years 1893 and 1897. In 30 per cent 
 recovery or improvement resulted ; in 19 per cent the 
 improvement was insignificant ; in 12 per cent there was 
 no change ; and in 39 per cent death occurred. The results 
 were most unfavourable (66 per cent fatalities) in cervical 
 and high dorsal fractures, and most successful in lumbar 
 fractures. There is no doubt that in a not inconsiderable 
 number of cases operation has been harmful ; it should, 
 therefore, only be recommended when the indications are 
 clear. On the other hand, one must not lose sight of the 
 fact that in a certain number of cases complete success 
 has been attained, cases which, left to themselves, would 
 have remained paraplegic all their lives, and died at an 
 earlier age. 
 
 When no operation is undertaken in suitable cases, the 
 patient is condemned to a condition of permanent marasmus, 
 and to the risks of life which arise from cystopyelitis, 
 pressure-sores, and other complications. Operation also 
 may be delayed too long to stay the progress of degeneration 
 processes in the spinal cord. 
 
 LITERATURE. 
 
 F. Hahn. Die traumatischen Erkrankungen der Wirbelsaule. 
 Sammelref. Zentralb. f. d. Grenzgebiete d. Med. u. Chir. 1898. 
 
 KocHER Die Verletzungen der Wirbelsaule. Mittelungen aus 
 d. Grenzgebiete d. Med. u. Chir. Bd. i. 
 
 Wagner und Stolper. Die Verletzungen der Wirbelsaule. 
 Deut. Chirurgie. Stuttgart. 1898. 
 
 Thorburn. a Contribution to the Surgery of the Spinal Cord. 
 London. 1889. 
 
 Goldscheider. Ueber Chirurgie bei Riickenmarkskrankheiten. 
 Deut. med. Wochens. 1894, Hf. 29. 
 
54 INDICATIONS FOR OPERATION IN 
 
 Henle. Wirbelkrankheiten. Handbuch d. prakt. Chirurgie. 
 von Bruns, Mikulicz, u. Bergmann. Stuttgart : Enke. --^ 
 
 Chipault. Chirurgie Oper. du Systeme Nerveux. Paris. 1895. 
 
 KuMMEL. Ueber die traumatischen Erkrankungen der Wirbel- 
 saule. Deut. med. Wochens. Bd. xxi. 
 
 TUMOURS OF THE SPINAL CORD. 
 
 Pathological Anatomy. — The term " tumours of the 
 spinal cord " is intended to include both tumours originating 
 in the cord, and those which originate outside the cord and 
 compress it. Only the latter are suitable for operation ; 
 they may be either intradural or extradural. Of the 
 intra vertebral growths the intradural are about as frequent as 
 the extradural ; tumours of the vertebrae encroaching on 
 the cord are twice as common as all other meningeal and 
 medullary tumours together. Most common are the 
 extramedullary tumours of the dorsal region. Metastatic 
 growths, both carcinomata and sarcomata, are almost 
 always extramedullary. Meningeal growths are usually 
 primary, and more often malignant than benign ; tumours 
 of the vertebrae are almost always malignant. The 
 meningeal tumours very rarely infiltrate the cord ; usually 
 they simply compress the latter from outside. The most 
 common extramedullary tumours (sarcoma, psammoma, 
 endothelioma, hydatid, fibroma, etc.) are well defined. 
 Some types (sarcoma, neurofibroma, gumma, hydatid), 
 may be multiple or diffuse ; diffuse sarcomatosis is usually 
 associated with growth in the cerebellum. Multiple tumours 
 are much less common than single growths. Trauma 
 appears to favour the development of spinal tumours. 
 
 Clinical Course. — In many cases the clinical phenomena 
 make their appearance in a definite order. The first signs 
 are those of irritation of the nerve roots ; then follow those 
 of compression of the cord, at first on the same side as the 
 root irritation phenomena, and later bilateral. Lastly (but 
 sometimes early) localized pains appear, and sometimes 
 vertebral deformity. 
 
 Irritation of the nerve roots is shown chiefly by intense 
 neuralgic pains, usually unilateral, sometimes bilateral ; 
 the pains being associated with hyperaesthesia. If the 
 tumour is situated on an anterior root in the cervical or 
 
DISEASES OF THE SPINAL COLUMN AND CORD. 55 
 
 lumbar enlargements, there are motor disturbances, soon 
 followed by muscular atrophy. 
 
 As the condition progresses hypersesthesia may be replaced 
 by anaesthesia, or the most prominent change may be an 
 extension of the area of hyperaesthesia or anaesthesia. 
 The vertebral column may show rigidity. Usually the root 
 symptoms are rapidly followed by those of cord compression. 
 These take the form of spastic paresis of the extremities, 
 often at first on one side, and later on both. Tumours 
 low down will affect only the lower limb, cervical tumours 
 will affect both upper and lower. At this stage the symptoms 
 resemble transitorily those of Brown-Sequard's paralysis. 
 When complete paraplegia develops, the bladder and rectum 
 functions are disturbed, or this may occur at an earlier 
 stage. The intense neuralgic pains persist along with the 
 signs of cord compression. 
 
 The symptoms vary very much according to the site of 
 the tumour, and no detailed description can be given here. 
 The exact position of tumours near the caudal end of the 
 cord may be very difficult to diagnose. When the symptoms 
 point to the involvement of nerve roots or cord segments 
 at different levels, the case is probably one of multiple 
 tumour. In one of my cases a tumour was diagnosed 
 about the centre of the dorsal spine, and operation was 
 advised ; later, symptoms referable to the lumbar spine 
 appeared, multiple tumour was diagnosed, and no further 
 operation was recommended. The autopsy showed 
 multiple neurofibromata. 
 
 Diagnosis. — One must seek to establish not only the 
 presence, but also the exact position of a tumour. The 
 position, or rather its upper limit, can usually be accurately 
 determined by observing the phenomena of irritation and 
 paralysis caused by lesion to the nerve roots and cord. 
 Neurological works should be consulted for further 
 information on localization. 
 
 Differential diagnosis. — Tumour may most easily be con- 
 fused with vertebral caries ; in the latter the curvature is 
 angular and acute, not arched ; the presence of abscess and 
 of tuberculosis in other organs, the tendency to spontaneous 
 recovery, and the absence of persistent nerve root symptoms 
 point to caries. The presence of a primary growth elsevv^here, 
 of S])ontaneous fractures of long bones, pain without 
 
56 INDICATIONS FOR OPERATION IN 
 
 tenderness over the spine, and the appearance of herpes 
 zoster, are in favour of tumour. 
 
 Syphihs must be considered, and will be indicated by 
 the presence of other lesions elsewhere, and by improvement 
 under antisyphilitic treatment. 
 
 With regard to whether a growth is within the canal, 
 or growing from the bone, it should be noted that metas- 
 tatic growths almost always arise in the bone ; and hydatids 
 are, with few exceptions, within the canal. Osseous 
 growths usually cause greater local destruction than 
 tumours of the canal ; deviation of the spinous processes 
 points to a bone tumour. An exact diagnosis between 
 vertebral and intravertebral, and between extra- and intra- 
 medullary tumours cannot be made with certainty. 
 
 INDICATIONS FOR OPERATION. 
 
 When the symptoms point to the presence of a single, 
 primary, intravertebral, and extramedullary tumour, and 
 enable one to make an exact diagnosis of the level at which 
 it is situated, then an operation for its removal should be 
 undertaken. Operation should only be recommended for 
 a metastatic growth when the primar}^ tumour has been 
 removed, and when there is reason to believe that no other 
 metastases exist. 
 
 Contra-indications. — The operation must be looked upon 
 as a serious one, and should, therefore, not be undertaken 
 unless the general condition is good. When there is reason 
 to believe that the tumour is intramedullary, no operation 
 should be done, in particular when there is bilateral partial 
 anaesthesia of long standing with extensive and rapidly 
 progressive muscular atrophy, paresis of both legs, and 
 marked involvement of the upper limbs. Operation is, 
 likewise, contra-indicated for metastatic vertebral tumours 
 and multiple tumours, and should never be undertaken in 
 any case until antisyphilitic treatment has been tried. 
 
 The dangers of the operation are still great ; about a half 
 of the cases have died, either immediately or some days 
 after intervention. 
 
 Prognosis. — Of operation. — When a growth is successfully 
 removed recovery may follow, providing no irreparable 
 damage has been done to the cord. Up to the present, 
 however, the number of successful cases is small. 
 
DISEASES OF THE SPINAL COLUMN AND CORD. 57 
 
 The results of an error in diagnosis may be disastrous ; 
 for the opening of the vertebral canal is always dangerous, 
 owing to the risks of haemorrhage and infection. 
 
 Prognosis without operation. — Tumour of the spine is 
 necessarily fatal when left alone, but death may be long 
 postponed. My own statistics show, in sixty-three cases of 
 intradural growths, an average duration of life of 25"6 
 months from the appearance of the first symptoms up to 
 death ; in forty-six extradural cases the average was 13" 6 
 months. In these statistics I have not included the very 
 prolonged cases, sometimes surviving ten years. If these 
 were included the figure for extradural cases would rise to 
 17-2 months. In one of my cases death did not occur until 
 four years after the time when operation was recommended ; 
 the autopsy showed that it would have been useless. 
 
 LITERATURE. 
 
 Bruns. Die Geschwiilste des Nervensystems. Berlin. 1897. 
 
 H. ScHLESiNGER. Beitr. z. Klinik der Riickenmarks und Wirbel- 
 tumoren. Jena: G. Fischer. 1898. 
 
 Oppenheim. Lehrbuch d. Nervenkrankheiten. 3rd Ed. Berlin. 
 1902. 
 
 F. Krause. Zur Segmentdiagnose der Riickenmarksge- 
 schwiilste. Berl. klin. Wochens. Nos. 20-22. 1901. 
 
 L. Bruns. Die Segmentdiagnose der Riickenmarkserkrank- 
 ungen. Zentralb. f. d. Grenzgebiete d. Med. u. Chir. Bd. iv. 
 
 Henschen und Lenander. Riickenmarkstumor. Mitteil. a. d. 
 Grenzgebiete d. Med. u. Chir. Bd. x. 
 
 PuLMANN and Warren. The Surgical Treatment of Tumours 
 within the Spinal Canal. Amer. Jour, of Med. Sci. October, 1899. 
 
 ACUTE POLIOMYELITIS. 
 
 Etiology. — Poliomyelitis is probably the result of an 
 infection. Trauma, perhaps, plays a part in its etiology, 
 but there is at present no real proof of this. 
 
 Pathological Anatomy. — ^Poliomyelitis is an acute 
 inflammatory condition of the anterior horns of the grey 
 m^itter of the cord. The meninges and the grey matter of 
 the medulla oblongata may participate in the process. 
 
 Clinical Course. — The disease begins acutely ; the 
 initial symptoms being those of a general febrile disorder. 
 After some hours, or days, paralysis appears, and at once 
 attains to the maximum of its extent. In the great majority 
 
58 INDICATIONS FOR OPERATION IN 
 
 of cases this paralysis affects one or both of the lower limbs ; 
 more rarely the arms or the four extremities. In the course 
 of a week, or a month, the extent of the paralysis often 
 diminishes ; according to Remak this improvement may 
 take place even after the lapse of a year. Increase of the 
 paralysis by successive aggravations is very rare. The 
 paralysis is flaccid and degenerative, and after the early 
 improvement has passed, it persists in several muscles, or 
 muscle groups. Certain muscles, the sartorius for example, 
 are very rarely paralyzed, while others are involved in a 
 large number of cases. In the upper limb the deltoid 
 and other shoulder muscles are exceptionally often affected. 
 If faradic excitability is not lost in a paralyzed muscle, 
 functional power will return to it. Vasomotor paralysis in 
 the paralyzed limbs is shown by the bluish-red colour of 
 the skin. The sensory functions, and those of the bladder 
 and rectum, are undisturbed. As time goes on it is noticed 
 that the paralyzed limb is shorter than its fellow, and the 
 bones themselves are atrophied. In a few instances 
 lengthening has been recorded. Deformities are produced 
 by contracture of the antagonistic muscle groups. For 
 example, if the tibialis anticus is paralyzed, and the peroneal 
 muscles unaffected, pes valgus develops. In an analogous 
 way pes varus, planus, or calcaneus may be produced. 
 Pes equino-varus occurs when the extensor muscles are 
 generally affected, with the exception of the tibialis anticus ; 
 pes planus when the peronei and the flexors of the sole are 
 paralyzed; and pes equinus in paralysis of the calf muscles. 
 Contracture of the flexors of the knee is comparatively 
 frequent. Well-marked contractures of the upper limb 
 muscles are, on the other hand, very uncommon. When 
 the muscles which control a joint are paralyzed the joint 
 becomes flail ; this is especially common in the shoulder 
 and hip, and may be followed by spontaneous luxation. 
 
 Differential diagnosis. — When the affection has been 
 present for some weeks a mistake in diagnosis can hardly 
 occur. Multiple neuritis progressively increases in severity 
 from its commencement for several weeks ; acute polio- 
 myelitis reaches its maximum in the first few days. In 
 multiple neuritis the fever lasts longer ; there is pain and 
 tenderness on pressure in the nerves and muscles, and 
 there are disturbances of sensation, which are almost 
 
DISEASES OF THE SPINAL COLUMN AND CORD. 59 
 
 entirely absent in poliomyelitis. The appearance of oedema 
 and the participation of the cranial nerves point to multiple 
 neuritis (Oppenheim). 
 
 Injuries to the spinal cord may cause symptoms resembling 
 those of poliomyelitis, but the history will make the 
 diagnosis clear. Syringomyelia develops slowly and pro- 
 gressively, and evokes certain sensory disturbances. 
 Obstetric paralysis involves the upper limbs only in the 
 areas supplied by the fifth and sixth cervical nerves. 
 
 INDICATIONS FOR OPERATION. 
 
 Only the effects of the disease can be dealt with by 
 surgical measures. These measures may be divided into 
 three groups, (i) Those undertaken to relieve the 
 paralyses of some parts of the limbs ; (2) Those by which 
 contractures are overcome to render possible the wearing 
 of some orthopaedic apparatus ; (3) The fixation of useless 
 articulations. For the relief of paralyses the grafting of 
 tendons of intact muscles on to those of paralyzed muscles 
 is employed. This method is suitable for cases of partial 
 paralysis of more than a year's standing when healthy 
 vigorous muscles are available adjoining the paralyzed 
 muscles. 
 
 When deformity has been produced by contractures, 
 tenotomy is to be employed to mobilize the affected joints, 
 in particular with a view to the further employment of 
 orthopaedic apparatus. 
 
 The fixation of a joint (arthrodesis) is indicated (i) In 
 total paralysis of all the muscles controlling the joint. 
 (2) Where without total paralysis the joint is nevertheless 
 flail. (3) In complete functional uselessness of a joint 
 owing to secondary contractures. By arthrodesis the 
 necessity for the wearing of special orthopaedic apparatus 
 is avoided, and it is, therefore, of value when the cost of 
 such apparatus cannot be borne, or the time necessary for 
 carrying out orthopaedic treatment is not available. 
 
 In writing of the value of arthrodesis for poliomyelitic 
 paralysis at the shoulder, Vulpius recommends that it should 
 be practised only when there is no prospect of further 
 spontaneous improvement, that is to say, when the paralysis 
 has been present for over a year, and only when the hand 
 is unaffected ; its usefulness is somewhat prejudiced by 
 
6o INDICATIONS FOR OPERATION. 
 
 paralysis of the upper arm muscles, yet it may be properly 
 recommended under such circumstances. 
 
 Results of operation. — Tendon transplantation often 
 restores the function of a limb to a notable degree ; the 
 results reported by Vulpius illustrate this in a remarkable 
 manner. The fixation of joints often greatly increases the 
 usefulness of a limb, and facilitates the application of 
 further orthopaedic treatment. 
 
 The risks of operation are inconsiderable. 
 
 LITERATURE. 
 
 HoFFA. Orthopadische Chirurgie. 3rd Ed. 
 Oppenheim. Lehrbuch d. Xervenkrankhheiten. 31-d. Ed. 
 Vulpius. Zur Sehneniiberpflanzung. Deut. Zeitscli. f. Nerven- 
 heilkunde. Bd. xxii. 
 
 Vulpius. Die Sehneniiberpflanzung. Leipzig, 1902: Veil & Co. 
 
CHAPTER III. 
 
 Diseases of the Peripheral Nerves. 
 
63 
 
 Chapter III. 
 DISEASES OF THE PERIPHERAL NERVES. 
 
 NEURALGIA OF THE FIFTH CRANIAL NERYE 
 
 {Tic Doloureux). 
 
 Etiology. — Trigeminal neuralgia may be due to a 
 variety of causes. It may be associated with one of the 
 infective diseases, such as malaria and influenza, or follow 
 chill or trauma. It may be set up by disease in some 
 neighbouring structure, bone, meninges, vessels, or be due 
 to caries of the teeth, anaemia, affections of the digestive 
 tract, or disorders of the female genital organs. 
 
 Clinical Course. — The affection is characterized by 
 attacks of intense pain, often apparently brought on by some 
 slight extraneous cause, or occurring spontaneously. 
 
 The attack is often accompanied by watering of the 
 eyes, by profuse discharge from the nose, or by excessive 
 salivation, according as the neuralgia particularly affects 
 the first, second, or third branches of the nerve. The 
 skin of the face and the conjunctiva are usually injected, 
 and a herpetic eruption sometimes appears on the nose 
 or the face. Pressure on the points of exit of the branches 
 is often very painful. Occasionally, but very rarely, 
 there is partial anaesthesia of the area supplied by the 
 nerve. The pain radiates from the branch first affected 
 to others, and sometimes to the occipital and cervical 
 nerves. 
 
 Diagnosis and Differential Diagnosis. — The diagnosis 
 is based on the clinical symptoms already noted. The 
 condition must be differentiated from frontal and maxillary 
 sinusitis, which usually follow influenza, are characterized 
 by purulent secretion from the nose, and may be demon- 
 strated by transillumination. It may be distinguished 
 from frontal periostitis, particularly the syphilitic form, 
 
64 INDICATIONS FOR OPERATION IN 
 
 by the local signs revealed by palpation, and by the results 
 of antisyphilitic treatment. Dental neuralgia will be 
 indicated by the presence of carious teeth tender to pressure. 
 Glaucoma is differentiated from neuralgia of the ciliary 
 branches by the increase of ocular tension, restriction of 
 the visual field, and by the appearances seen with the 
 ophthalmoscope. In migraine there is intense pain, but, 
 in addition, photophobia, auditory hypercesthesia, a 
 tendency to vomiting, and relatively severe general disturb- 
 ance. Cephalalgia is usually bilateral, and is different in 
 localization from trigeminal neuralgia. In rheumatism 
 of the scalp the latter is diffusely tender to pressure. When 
 trigeminal neuralgia is due to some central cause there 
 will be present other symptoms referable to involvement 
 of other cranial nerves. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation is only called for when the diagnosis of severe 
 peripheral trigeminal neuralgia is clearly established, and 
 when the various internal and external remedies which 
 are recommended for the condition have proved ineffectual. 
 It is to be looked upon as a last resource when the pain is 
 unbearable and other means have failed. If the neuralgia 
 is confined to one branch, one of the procedures of lesser 
 severity should be employed. If these fail, and only after 
 they have been tried, should removal of the Gasserian 
 ganglion, or section of the nerve behind the ganglion, be 
 undertaken. 
 
 Contra-indications. — In bilateral neuralgia operation will 
 probably be unsuccessful (Friedrich), and is not to be 
 recommended. If after careful resection of a portion of 
 a nerve, symptoms return in the corresponding area of 
 innervation, either immediately or after a short period, 
 then a further operation will probably be attended with 
 little success. When it appears probable that the neuralgia 
 is due to some central lesion no operation on the nerve is 
 justifiable. 
 
 Prognosis. — Of operation. — Of Thiersch's cases, kept 
 under observation for six years, more than a third remained 
 entirely free from recurrence, while in about a third there 
 was a definite return of symptoms. These were all cases 
 of severe trigeminal neuralgia of several years' standing, 
 
DISEASES OF THE PERIPHERAL NERVES. 65 
 
 and were treated by nerve resection. Extirpation of the 
 Gasserian ganglion appears to afford permanent relief ; 
 there was no return of symptoms in any of Krause's cases. 
 
 Risks of operation. — Krause's operation is attended 
 with delinite risk. In about 15 per cent (17 out of 113 
 cases) death has followed the operation. It is remarkable 
 that neuroparalytic keratitis, or other serious complication, 
 has rarely occurred. 
 
 Nerve resection is, of course, a much less serious opera- 
 tion, and, unless complications occur, is unattended by 
 risk to life. 
 
 LITERATURE. 
 
 Krause. Die Neuralgic des Trigeminus. Leipzig, 1896. Also 
 Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. ii. 
 
 Friedrich. Zur chirurg. Behandlung der Gesichtsneuralgie 
 Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. iii. 
 
 Bernhardt. Krankheiten der peripheren Nerven. Nothnagel's 
 Handbuch der spez. Pathol. Bd. xi. Wien. 
 
 Thiersch. Verhandlung d. deutschen Gesellsch. f. Chirurg. 1889. 
 
 OCCIPITAL NEURALGIA. 
 
 Clinical Signs. — Occipital neuralgia is a term used to 
 indicate neuralgia of the sensory branches of the cervical 
 plexus. Usually the pain extends from the neck to the 
 vertex in the distribution of the great occipital. More 
 rarely it is situated laterally in the distribution of the 
 small occipital and great auricular. The pain is paroxysmal, 
 and more frequently complained of in the evening than 
 the morning. During the attack the head is kept rigid 
 and the occiput supported with the hand, the skin over 
 the occiput being often tender to pressure. Three tender 
 points may be demonstrated : the occipital point between 
 the mastoid process and the atlas, the parietal point in the 
 neighbourhood of the parietal eminence, and the cervical 
 point between the anterior border of the trapezius and 
 the posterior border of the sternomastoid. 
 
 Etiology. — Most frequently this affection follows 
 exposure to cold or trauma, or in the course of some infectious 
 disease, or some intoxication. Hysteria and neurasthenia 
 may also influence its onset. Frequently it arises in 
 connection with disease of the vertebrae or the meninges 
 
 S 
 
66 INDICA TIONS FOR OPERA TION IN 
 
 (tuberculosis, carcinoma, syphilis, arthritis deformans). 
 Sometimes it is due to tumour of the brain or other 
 central lesion. 
 
 Diagnosis and Differential Diagnosis. — In diagnosis 
 special attention should be paid to the tender points and 
 to the absence of other phenomena. The posterior 
 pharyngeal wall will be examined for signs of vertebral 
 disease. In rheumatism of the neck muscles the affected 
 muscles are tender to pressure. Hysterical pain in the neck 
 is influenced by suggestion, and usually extends to the 
 back ; the tender spots do not correspond to the points of 
 emergence of the great occipital. In cervical Pott's disease 
 there are spinal symptoms, persistent rigidity of the vertebral 
 column, and swelling of the overlying soft parts. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation may be advised when all medical remedies have 
 proved ineffectual. This will consist of division of the 
 nerve near its proximal end, and exeresis of the peripheral 
 branches by the method of Thiersch. If intense pain 
 persists in spite of this, the more serious operation of division 
 of the posterior roots of the upper cervical nerves in the 
 spinal canal is indicated (Chipault), but this should at 
 present be reserved for what may be called the desperate 
 cases. 
 
 Prognosis. — Risks of operation. — The risk of cutting or 
 injuring the phrenic nerve is small if Krause's procedure be 
 followed. The division of the posterior roots is a distinctly 
 dangerous operation. 
 
 Contra-indications to operation. — If some disease of the 
 vertebrae is present, if there is some central lesion, or if 
 the neuralgia is due to functional causes, no operation 
 should be done on the nerves or roots. 
 
 LITERATURE. 
 
 Bernhardt. Krankheiten der peripheren Nerven, ii. Noth- 
 nagel's Handbuch d. spc. Pathol. Bd. xi. Wien. 
 
 Chipault et Demoulin. La Resection Intradurale des Racines 
 Medullaires. Nouv. Iconograph. de la Salpetriere. No. 95, 1895. 
 
 Krause. Die operative Behandlung der schweren Occipital- 
 neuralgic. Beitr. z. klin. Chir. Bd. xxiv. 
 
DISEASES OF THE PERIPHERAL NERVES. 67 
 
 BRACHIAL NEURALGIA. 
 
 Etiology. — According to Oppenheim some neuropathic 
 predisposition is usually present in cases of brachial 
 neuralgia. The infective disorders, anaemic and cachectic 
 states, diabetes, and gout also predispose to the affection. 
 
 Many cases are due to trauma, such as wounds or fractures 
 of the upper arm and clavicle ; others are due to affections 
 of the subclavian artery or aorta, or to the presence of a 
 cervical rib. 
 
 Pathological Anatomy. — Brachial neuralgia may be 
 caused by gross anatomical lesions in the neighbourhood 
 of the nerves, but under such circumstances neuritis, more 
 commonly than neuralgia, results. Such gross lesions may 
 be the result of the pressure of a cervical rib (especially if 
 affected with periostitis), the pressure of callus or scar 
 tissue, of a bone splinter, or a foreign body. In torticollis 
 the contractured neck muscles may exert direct pressure 
 on the nerves of the brachial plexus. 
 
 Clinical Signs. — Generally, in brachial neuralgia, the 
 distribution of the pain is not sharply defined, but it may 
 chiefly affect the distribution of a single nerve. The pain 
 is sometimes continuous, more frequently paroxysmal, and 
 easily set up by movements of the arm. Painful spots are 
 found at the point where the radial nerve passes to the 
 dorsum, over the ulnar nerve by the side of the olecranon, 
 over the median in the fold of the elbow, over the joints of 
 the hand, and over the plexus itself, to the side of the 
 lowest cervical vertebrae. Trophic disturbances develop only 
 when neuritis is present. 
 
 Diagnosis and Differential Diagnosis. — In many 
 affections of the central nervous system pain may be present 
 in the distribution of the brachial plexus, for example in 
 tabes, syringomyelia, tumour of the cord, pachymeningitis, 
 and spondylitis ; but these are differentiated by the presence 
 of other characteristic symptoms, and the same is true of 
 diseases of the large vessels. The diagnosis is only arrived 
 at after excluding diseases of the bones, joints, and muscles. 
 
 INDICATIONS FOR OPERATION. 
 
 The indications may be divided into two classes. If the 
 signs point to compression of nerves by callus or other means, 
 
68 INDICATIONS FOR OPERATION IN 
 
 or to complete or partial severance of nerves, these lesions 
 should be dealt with by operation as soon as possible. 
 Cervical ribs should be removed, if no other cause for the 
 neuralgia is to be found ; in two such cases under my care, 
 removal of the rib was followed by complete disappearance 
 of the pain. If torticollis is complicated by constant 
 bronchial neuralgia, the sternomastoid should be divided. 
 
 When no gross anatomical lesion can be discovered to 
 account for the neuralgia, operation, that is to say, stretching 
 of the nerve, either after open operation or by the bloodless 
 method of Naegeli, should only be practised when all other 
 methods of treatment have failed. 
 
 Contra-indications. — No proposal to operate will be 
 entertained if the neuralgia is caused by some inaccessible 
 anatomical lesion. 
 
 All symptomatic neuralgias, such as those secondary 
 to diseases of the spinal cord and vertebrae (except tumours 
 of the nerve roots and meninges), or to affections of the 
 large vessels, are also unsuitable for operation. 
 
 When no operation is undertaken the lesion which is 
 setting up the neuralgia will, in many cases, give rise to 
 destructive anatomical changes in the nerve, and the 
 resulting damage may be irreparable. 
 
 LITERATURE. 
 
 Befnhardt. Krankheiten der peripheren Nerven, Th. ii. 
 Nothnagel's Handbuch d. spez. Pathol. Bd. xi. Wien. 
 
 Bernhardt. Ueber Halsrippen. Berl. klin. Wochens, 1895. 
 No. 4. 
 
 Oppenheim. Lehrbuch d. Nervenkrankheiten. 3rd Ed. 1902. 
 
 H. Weiss. Die Halsrippen und ihre klin. Erscheinungen. Zentralb. 
 f. d. Grenzgebiete d. Med. u. Chir. 1900. 
 
 Kader. Neuralgic des Plexus Cervicalis und Brachialis. jMitteil. 
 a. d. Grenzgebiete d. Med. u. Chir. Bd. ii. 
 
 Naegeli. Therapie v. Neuralgien durch Handgriffe. 2nd Ed. 
 Jena. 1899. G. Fischer. 
 
 INTERCOSTAL NEURALGIA. 
 
 Etiology. — Intercostal neuralgia is especially common 
 in anaemic individuals, in pulmonary tuberculosis, and after 
 influenza. Among other etiological factors must be men- 
 tioned hysteria, debility after fevers and during lactation, 
 and some affections of the circulatory system. 
 
DISEASES OF THE PERIPHERAL NERVES. 69 
 
 Clinical Signs. — The pain is usually in the distribution 
 of the anterior branches of several of the intercostal nerves ; 
 it is sometimes very intense and increased by movements, 
 such as coughing and sneezing. There are usually three 
 tender spots ; one close to the vertebra — the vertebral point ; 
 one in the axillary line — the lateral point ; and one near the 
 middle line in front. The skin of the affected area is usually 
 hypertesthetic. The affection is more common on the left 
 than on the right side of the body. 
 
 Diagnosis and Differential Diagnosis. — Intercostal 
 neuralgia is very often a symptom of disease elsewhere. It 
 may be produced by disease (tuberculosis or tumour) of the 
 vertebrcE, of the meninges (meningitis, tumour), or of a 
 spinous process. It is frequently a symptom of the neuritis 
 of herpes zoster ; it may also be associated with injuries 
 to the ribs, or with aortic aneurysm. Such conditions will 
 be recognized by other characteristic signs. The presence 
 of anaesthesia is against a simple neuralgia, as is also the 
 presence of vertebral deformities, severe cord symptoms, 
 or of abnormalities of the ribs. The diagnosis will be 
 based on the clinical signs already related. 
 
 INDICATIONS FOR OPERATION. 
 
 Most intercostal neuralgias improve spontaneously, or 
 after internal medication, so that only the subacute and 
 chronic forms are suitable for operation if, after other 
 methods of treatment have been tried, the pain still persists 
 in an intense form, and is not merely symptomatic of 
 disease elsewhere. Operation will take the form either 
 of stretching, resection of the nerve, or division of the 
 posterior root within the dura mater. 
 
 Contra-indications. — Operation will not be undertaken 
 when lesions, such as aneurysm, spinal disease, etc., are 
 present. According to our present knowledge of herpes 
 zoster, operation is not justifiable for the associated 
 neuralgia. 
 
 Prognosis. — Risks of operation. — The resection of 
 one or more nerves is not attended by any risk, but the 
 results have been favourable only in a certain number of 
 cases. Nerve stretching may also fail to relieve. Division 
 of the posterior roots is an operation dangerous to life, and 
 recovery from the neuralgia, cannot be guaranteed. 
 
70 INDICATIONS FOR OPERATION IN 
 
 LITERATURE. - 
 
 Oppenheim. Lehrbuch d. Nervenkrankheiten. 3rd Ed. p. 523. 
 
 Bern.^ardt. Krankheiten der peripheren Nerven. Nothnagel'S 
 Handbuch d. spez. Pathol. Bd. ix., 2 Halfte, p. 318. 
 
 ScHEDE. Handbuch d. spez. Therap. von Penzold-Stintzingj 
 2nd Ed. 
 
 MERALGIA PARAESTHETICA (Roth-Bernhardt). 
 
 [Neuralgia of the Nervus Cutaneus Femoris Externus.) 
 
 Etiology. — This affection often develops after exposure 
 to cold, injury, acquired syphilis, infectious diseases, gout, 
 and pregnancy. It occurs with especial frequency in 
 alcoholics, more rarely in affections of the central nervous 
 system. 
 
 Pathological Anatomy. — Often some anatomical 
 peculiarity can be demonstrated causing pressure on the 
 nerve, and in particular pressure by the iliofemoral band, 
 with which the nerve is in close association for a considerable 
 part of its course. In one case pressure by the sharp edge 
 of the iliopectineal ligament was found to be the cause 
 of the pain. Examination of resected portions of the 
 nerve has demonstrated various anatomical changes 
 (neuritis, etc.). 
 
 Clinical Signs. — The characteristic of this condition is 
 the presence of defined areas of sensory disturbance, 
 subjective and objective, over the outer side of the thigh 
 below the trochanter, all the sensory functions being equally 
 affected. Occasionally the front of the thigh is affected. 
 The pains are usually worse when the patient is standing, 
 and relieved when he lies down ; they are often bilateral. 
 The symptoms may persist for many years. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation is only indicated when other treatment, local 
 and general, has failed, and when the affection is present 
 in an acute form. Such operation will consist of stretching 
 or resection of the nerve, or freeing of the ligament which 
 is compressing the nerve. Operation should be recom- 
 mended early, if the patient is prevented from following 
 his usual occupation. When some central lesion is 
 
DISEASES OF THE PERIPHERAL NERVES. 71 
 
 associated with the symptoms of meralgia, no operation 
 should be done on the nerve. 
 
 Results. — When the nerve is resected there will remain 
 anaesthesia over the area of its distribution. As a rule, 
 operation relieves the symptoms entirely ; if there be any 
 return it is usually of a mild type. 
 
 LITERATURE. 
 
 Bernhardt. Krankheiten der peripheren Nerven. Nothnaj2;ers 
 Handbuch d. spez. Pathol. Wien. 1895. 
 
 Roth. Meralgia Paraesthetica. Berlin: Karger. 1895. 
 
 Brisard. Meralgia Paraesthetica. These de Paris. 1900. 
 
 H. ScHLESiNGER. Die Meralgia Paraesthetica. Zentralb. f. d. 
 Grenzgebiete d. Med. u. Chir. 1900. 
 
 Neisser und Pollack. Beitr. z. Kenntniss der Roth-Bernhardt's 
 Meralgia. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. x. H. 3 
 and 4. 
 
 SCIATICA. 
 
 Etiology. — Exposure to cold, or injury, is frequently 
 concerned in the etiology of sciatica ; also gout, diabetes 
 mellitus, and certain intoxications — alcohol, lead. It may 
 also be set up by venous engorgement in the pelvis, com- 
 pression by tumours, by the gravid uterus, or by fsecal 
 masses, and by certain infective disorders — gonorrhoea, 
 syphilis, enteric fever, influenza, etc. 
 
 Anatomical Changes. — The nerve is in many cases 
 fixed to surrounding parts by adhesions, in others com- 
 pressed by changes in neighbouring organs. Pure sciatic 
 neuralgia is not accompanied by inflammatory changes in 
 the nerve. 
 
 Clinical Signs. — By sciatica is meant a neuralgia of 
 the great sciatic nerve and its branches. Pain is usually 
 complained of along the whole length of the nerve from 
 the buttock to the toes, is increased by pressure, and by 
 movement, and comes and goes in attacks of considerable 
 violence. There is frequently some scoliosis, with the 
 concavity of the curve on the affected side. There are, 
 as a rule, tender spots along the nerve, for example between 
 the trochanter and the tuber ischii. Acute pain is caused 
 if the thigh is flexed with the knee extended. There is 
 no motor paralysis, and, as a rule, no objective sensory 
 
72 INDICATIONS FOR OPERATION IN 
 
 disturbance. Occasionally cold spots may be demonstrated 
 on the skin of the leg. 
 
 Diagnosis and Differential Diagnosis. — The clinical 
 signs just mentioned will make the diagnosis clear. 
 Marked sensory disturbances co-existing with degenerative 
 atrophy point to neuritis. Many affections give rise to 
 pain in the area of the great sciatic, and simulate true 
 sciatica. In lumbago, the tender spots along the nerve 
 are absent ; in affections of the cord, and in tubercular 
 and carcinomatous spondylitis, there are various spinal 
 symptoms which are absent in true sciatica : weakness 
 of the legs, changes in the tendon reflexes, disturbances 
 of the bladder and rectum. Certain vascular affections, 
 arteriosclerosis and endarteritis obliterans, may cause pain 
 in the legs, but are usually associated with alterations in 
 the pulse of the arteries of the foot. Rectal and vaginal 
 examination will enable one to exclude the possibility of 
 pelvic new growths involving the sciatic nerve. In disease 
 of the hip joint all movement at the joint is painful, whether 
 the knee is extended or not. 
 
 INDICATIONS FOR OPERATION. 
 
 When internal treatment has failed and the pain is 
 severe, stretching the nerve should be undertaken, first by 
 the bloodless method ; and then, if this be unsuccessful, 
 by open operation. If sciatica follows a definite trauma, 
 then operation should be advised earlier (stretching of the 
 nerve after exposure by incision), but not infrequently the 
 symptoms are unrelieved thereby. In one case under my 
 own observation there was no improvement until two 
 years after stretching. 
 
 Contra-indications. — Sciatic pains caused by inoperable 
 tumours of the pelvis or spinal column, or secondary to 
 some spinal disease, are not suitable for operation. No 
 operation should be done when the symptoms are due to 
 some disorder of nutrition. 
 
 Risks of the operation. — Bloodless stretching appears 
 to be free from risk. After the open operation, motor and 
 sensory paralysis, both temporary and persisting, have 
 been observed in a few cases. I have seen a case of 
 paralysis persisting five years after operation. 
 
DISEASES OF THE PERIPHERAL NERVES. 73 
 
 LITERATURE. 
 
 Bernhardt. Krankheiten der peripheren Nerven. Nothnagel's 
 Handbuch d. spez. Pathol. Bd. xi. Wien. 
 
 ScHEDE. Chirurgie der peripheren Nerven. Handbuch d. spez. 
 Therap. von Penzold-Stintzing. 2nd Ed. Bd. v. 
 
 FACIAL SPASM. 
 
 Etiology. — Among the causes of facial spasm are : 
 affections in the distribution of the fifth nerve (teeth, 
 cornea, conjunctiva, etc.), direct irritation of the seventh 
 nerve by tumour, aneurysm, or other mechanical cause, 
 psychical disturbances in hysterical and neurasthenic 
 individuals. 
 
 Clinical Signs. — The spasm is more frequently clonic 
 than tonic ; it is sometimes confined to one or two muscles, 
 but usually affects the whole of one side of the face. 
 Generally it occurs in paroxysms, and is provoked by 
 mastication, speaking, emotional disturbance, or exposure 
 to cold. In some cases, particularly in blepharospasm, 
 there are tender spots to be found at the points of emergence 
 of the trigeminal, especially the supra-orbital branch, 
 and pressure on these points may temporarily check the 
 muscular spasm. The affection is usually chronic, and 
 persists for many years. 
 
 INDICATIONS FOR OPERATION. 
 
 Even in inveterate cases, which have resisted other 
 methods of treatment, operation should only be undertaken 
 after it has been explained to the patient that success is 
 exceptional, and when he still persists in his desire that an 
 attempt should be made to relieve him by these means. 
 There cannot, therefore, be said to be any absolute indica- 
 tion for the operation. When the spasm is arrested by 
 compression of the supra-orbital nerve, resection of the 
 latter (not simple division) should be done, and has given 
 relief in many cases. When the spasm is not checked by 
 pressure on any such point, and when the patient persists 
 in his demand for, at any rate, a temporary relief, even at 
 the risk of paralysis, the nerve may be stretched after 
 exposure by incision. When function returns to the 
 facial muscles, the spasm may also return. If this operation 
 
74 INDICATIONS FOR OPERATION IN 
 
 is unsuccessful the application of the actual cautery to 
 the neck may be tried, but the indications for this are no 
 more definite than those for other operative measures in 
 this affection. 
 
 LITERATURE. 
 
 Bernhardt. Krankheiten der peripheren Nerven. Part 2. Noth- 
 nagel's Handbuch d. spez. Pathol. Wien. 1898. 
 
 GowERS. Diseases of the Nervous System. Vol. ii. 
 
 Oppenheim. Lehrbuch d. Nervenkrankheiten. 3rd Ed. 
 
 Brissaud. Lecons sur les Maladies Nerveuses. Tome i., p. 502 
 Paris. 1895. 
 
 ScHOTT. Ueber Facialisdehnung. beim Facialiskrampf. Deut. 
 med. Wochens. No. 44, 1891. 
 
 SPASM OF CERVICAL MUSCLES (Spasmodic Torticollis). 
 
 Etiology. — This affection is most frequently found in 
 individuals of neuropathic tendencies. It may be set up 
 by traumata, intoxications, and organic lesions of the brain 
 and spine. 
 
 Clinical Signs. — The spasm may be clonic or tonic, 
 unilateral or bilateral. Sometimes only one muscle is 
 affected, sometimes a whole muscle group, and sometimes 
 the whole of the muscles of the neck. The sternomastoid 
 and trapezius muscles are involved with special frequency ; 
 sometimes the affected muscles show hypertrophy. The 
 intensity of the attacks is increased by emotional dis- 
 turbances ; for example, if the patient sees that he is being 
 watched the spasm will be exaggerated ; during rest and 
 sleep the attacks tend to pass off. 
 
 Differential diagnosis. — In chorea, the convulsive move- 
 ments are distributed more or less generally over the 
 body, and are less intense ; the same is true of myoclonus. 
 When the spasm is tonic, rheumatic torticollis has to be 
 excluded ; in the latter there is much pain in the neck, 
 and the muscles themselves are tender to pressure. 
 Organic lesions of the cervical spine (tumour, spondy- 
 litis), may give rise to tonic spasm of the neck muscles ; 
 but the other symptoms by which they are characterized 
 enable a correct diagnosis to be made. In congenital 
 torticollis there are changes in the cervical spine and 
 shortening of the muscles. 
 
DISEASES OF THE PERIPHERAL NERVES. 75 
 INDICATIONS FOR OPERATION. 
 
 Operation will only be undertaken when other methods 
 of treatment have failed : when the patient prefers the 
 chance of paralysis of the neck muscles to the condition of 
 spasm from which he is suffering, and of the appearance 
 of spasm in other muscles after the operation. Section, 
 stretching, and even resection of the spinal accessory nerve 
 has sometimes proved inefficient. Tenotomy of one or 
 two of the tendons of the neck muscles is usually 
 unsuccessful, but, as far as present experience goes, more 
 success has attended the operation of Kocher and Quervain, 
 in which the tendons of almost all the muscles of the neck 
 are cut. This operation shows the greatest average number 
 of successes, and next to it comes resection of the spinal 
 accessory. 
 
 Contra-indications. — Operation will probably be inad- 
 visable in cases in which some cerebral or spinal process 
 appears to be the cause of the spasm, or in which some 
 general neurosis is present. 
 
 Prognosis. — Risks of the operation. — Other neighbouring 
 and previously unaffected muscles may develop the spasm 
 soon after the operation, and the latter prove, therefore, 
 useless. The paratysis which follows division of the nerve 
 is often slight, and does not incapacitate the patient to 
 any considerable extent. 
 
 Without operation no serious consequences are to be 
 anticipated ; in many cases treatment without operation 
 is successful even when the condition has been present for 
 a long time. 
 
 LITERATURE. 
 
 Bernhardt. Krankheiten der peripheren Nerven. Part 2. 
 Nothnagel's Handbuch d. spez. Pathol Bd. xi. Wien. 
 
 Richardson and Walton. The Operative Treatment of Spas- 
 modic Torticollis. Amer. Jour. Med. Sci. Jan., 1895. 
 
 Brissaud Torticollis Mental. Lecons sur les Maladies Nerveuses. 
 Tome i., p. 504. Paris. 1895. 
 
 Smith. Brit. Med. Jour. April, 4, 1891. 
 
 PERFORATING ULCER OF THE FOOT. 
 
 Etiology. — This condition is usually due to some 
 pathological change in the peripheral, or central nervous 
 system. Among the most frequent of these are tabes, 
 
76 INDICATIONS FOR OPERATION IN 
 
 syringomyelia, general paralysis, spina bifida, traumatic 
 affections of the cord, leprosy, peripheral neuritis diabetic 
 and alcoholic. 
 
 Clinical Course. — Perforating ulcer of the foot runs 
 a painless and chronic course ; it makes its way steadily 
 into the deeper structures, and usually resists all local 
 treatment ; it tends to recur (Borchard-Nasse). In the 
 neighbourhood of the ulcer, or over the whole foot, there is 
 usually some anaesthesia, and certain trophic disturbances 
 of the bones, joints, muscles, and nails. The most frequent 
 situations for the ulcer are under the metatarsophalangeal 
 joint of the great toe or of the little toe, or under the heel. 
 The first local change is usually the formation of a corn, 
 and suppuration takes place beneath this ; an ulcer is thus 
 formed, surrounded by an edge of thickened skin ; the 
 ulcer penetrates the soft parts, and reaching the bones 
 gives rise to necrosis. A diffuse cellulitis may originate 
 in the ulcer and spread to the tissues of the foot. 
 
 The Diagnosis is readily made from the characteristic 
 appearance and situation of the ulcer. Its painlessness 
 and other characters differentiate it from other forms of 
 ulceration. 
 
 INDICATIONS FOR OPERATION. 
 
 The ulcer may be attacked directly, or the internal 
 plantar nerve may be stretched, with a view to bringing 
 about healing. These two procedures are often combined. 
 Operation should be done when the ulcer does not improve 
 in spite of immobilization of the foot, when, in spite of all 
 care, infection and complications threaten, and when the 
 condition returns again and again after treatment. In 
 the working classes especially, operation will be called for, 
 on account of the impossibility of keeping the foot at rest 
 for a long period. 
 
 Prognosis. — Results of operation. — Chipault and his 
 colleagues have recorded many cases of healing after 
 nerve extension (Chalais collected 15 cases, 14 of which 
 were successful) ; I have also seen favourable results 
 follow the operation. In one of my patients who had had 
 a perforating ulcer for several years, recovery took place 
 after operation, and there was no recurrence two and a half 
 years after, although he walked a great deal. 
 
DISEASES OF THE PERIPHERAL NERVES. 77 
 
 The risks of the operation are small. The stretching of 
 the nerve gives rise to only transitory paralytic phenomena. 
 In one case pain was complained of in the area of the 
 posterior tibial nerve, and in another ansesthesia of the 
 foot was present for some months. One case of rupture of 
 the nerve has been recorded. 
 
 If no operation he done the ulcer is liable to be complicated 
 by extensive cellulitis, and septicaemia and pyaemia are not 
 uncommon. In a case which I have recently seen, a local 
 cellulitis supervened, and was complicated by arthritis 
 of five of the large joints. 
 
 LITERATURE. 
 
 Borchard-Nasse. Handbuch der prakt. Chir. von Bruns, 
 Bergmann, u. Mikulicz. Bd. iv., T. 2, p. 647. 
 
 WiNiWATER. Deutsche Chirurgie. 
 
 H. ScHLESiNSER. Die Syringomyelie. 2nd Ed. Wien. 1902. 
 
 Bergmakn. Die Lepra. Deutsche Chirurgie. 
 
 Recklinghausen. Spina Bifida. Virch. Arch., cv. 
 
 Chipault u. seine Schiiler. Travaux de Neurologic Chirurgicale. 
 4th and 5th Ser. Paris. 1899, 1902. 
 
 Chalais. Traitement du Mai Perforant. These de Paris. 1897. 
 
CHAPTER IV. 
 Neuroses. 
 
Chapter IV. 
 
 NEUROSES. 
 
 EXOPHTHALMIC GOITRE. 
 
 Etiology. — This affection often develops in " nervous " 
 individuals. Its appearance is often preceded by some 
 violent emotional disturbance or fright. Direct heredity 
 is rarely traceable ; exhausting diseases somewhat 
 frequently appear to be the causative factor ; sometimes 
 it follows chronic intoxications. 
 
 Clinical Course. — When fully developed the disease 
 exhibits the following cardinal signs : exophthalmos, 
 a vascular goitre, and tachycardia. In addition to 
 exophthalmos, other eye symptoms occur : Graefe's 
 symptom, diminution of the movements of the lids 
 (Stellwag's symptom), and weakness of the muscles of 
 convergence (Moebius' symptom). The goitre is often 
 very soft and compressible ; it pulsates, and a bruit 
 and thrill are usually present. Pulsation is usually 
 prominent throughout the arterial system, and bruits can 
 •often be heard in these vessels. Frequently the patient 
 exhibits tremors of the fingers, states of depression and 
 exaltation, loss of appetite, attacks of profuse diarrhoea, 
 and excessive perspiration. The galvanic conductibility 
 of the skin is usually diminished. The patient often loses 
 flesh early ; less commonly marked pigmentation of the 
 skin is found, and oedema, either transitory or persistent, 
 in the latter case of cardiac origin. 
 
 Exophthalmic goitre is said to be secondary when its 
 characteristic symptoms develop some considerable time 
 after the appearance of the actual goitre ; primary when 
 the latter appears at the same time as the other symptoms. 
 Sometimes the development of the symptoms takes place 
 in an acute form ; occasionally one or other of the cardinal 
 symptoms is absent. 
 
 6 
 
82 INDICATIONS FOR OPERATION IN 
 
 Differential diagnosis. — Goitre, complicated by pressure 
 on the sympathetic, is with difficulty distinguished from 
 true Graves' disease. In such cases, however, the goitre 
 does not show the vascular phenomena characteristic of 
 Graves' disease, the sympathetic symptoms are one-sided, 
 and signs of pressure on trachea and oesophagus are present. 
 In some highly nervous individuals with goitre or exoph- 
 thalmos it is sometimes difficult to be sure whether one 
 has to deal with one of those forms of true exophthalmic 
 goitre, to which reference has already been made, in which 
 one or other of the cardinal symptoms is absent. 
 
 INDICATIONS FOR OPERATION. 
 
 There is much disagreement among different writers 
 as to the advisability of operation. While some, for 
 example Lemke and Kocher, recommend operation in all 
 cases, others (Buschan) do not advise it under any conditions. 
 The majority hold that under certain circumstances it is 
 to be recommended. The presence of a voluminous goitre 
 giving rise to symptoms which threaten to be fatal, such 
 as tracheal compression, is an absolute indication for 
 operation ; in such a case I have had to perform immediate 
 tracheotomy. Operation is also absolutely indicated in 
 acute Graves' disease, where the symptoms are making 
 rapid progress. 
 
 Most authorities agree (a) That no operation should be 
 done in ordinary cases, unless internal medication has been 
 tried and failed, since spontaneous recovery takes place 
 not infrequently ; (b) That operation should be undertaken 
 in severe cases, provided that the patient's general 
 condition is good, and that signs of commencing cachexia 
 indicate early operation (Sorgo). 
 
 Certain external conditions may also render operation 
 advisable : when the patient cannot take proper care of 
 himself, when he is unable to continue his work, and when 
 he himself has a fixed desire for the operation. A hard, 
 goitrous tumour superiicially situated is a recommendation 
 to operation. According to Sorgo, a case must be considered 
 severe, and therefore suitable for operation (a) When some 
 particular symptom is present in a very pronounced form : 
 for example, excessive exophthalmos indicates the advisa- 
 bility o; resection of the sympathetic ; a very voluminous 
 
NEUROSES. 83 
 
 goitre may render operation necessary for the relief of 
 signs of compression ; (b) When the disease progresses 
 with marked rapidity ; (c) When some comphcation 
 threatens hfe, for example, cachexia, degeneration of 
 cardiac muscle, disorders of the nervous system, etc. 
 
 According to Kocher, the rational operative procedure 
 for exophthalmic goitre consists in a partial excision with 
 ligature of the afferent arteries, often necessarily completed 
 in several stages. Exothyreopexy and resection of the 
 sympathetic do not give such good results. 
 
 Contra-indications. — These have already been discussed. 
 Advanced cachexia is against operation. Considering ihe 
 considerable risks attached to operation, internal medication 
 should first be tried in all cases, although Kocher holds a 
 contrary opinion. 
 
 Prognosis. — The risks of operation. — Often, either during 
 or after operation, very unpleasant and dangerous symptoms 
 supervene, which are attributable on the one hand to a 
 lessened resistance of the organism, and on the other to 
 the increased excitability of the nervous centres. On 
 several occasions sudden death has occurred, and in other 
 cases collapse and symptoms of severe general disturbance, 
 tachycardia, and fever. A general anaesthetic is much 
 more dangerous in a case of Graves' disease than in a 
 case of simple goitre ; for this reason Kocher advises that 
 all cases should be operated on without a general anaesthetic. 
 Previous treatment with iodine, or thyroid extract, makes 
 the prognosis of operation worse, and the same is true of 
 free haemorrhage at the operation. 
 
 Results of operation. — By operation, or rather by several 
 consecutive operations, the symptoms are often so improved 
 that one is justified in speaking of actual cure. In a 
 quarter of the published cases of the individual symptoms, 
 the tachycardia and the exophthalmos were improved. 
 Of the whole number in Sorgo's statistics, half (51 "2 per 
 cent) were improved, a fourth (27-9 per cent) cured, 6*4 
 per cent were not benefited or became worse, and I3"9 
 per cent died either during or directly after the operation. 
 The results are not worse in primary than in secondary 
 cases. 
 
 // no operation be done, the prognosis is guided by the 
 following considerations : the disease is essentially chronic, 
 
84 INDICATIONS FOR OPERATION IN 
 
 and causes death in only a small proportion of cases by 
 cachexia or some other complication ; even in its severe 
 types spontaneous recovery may occur ; in many cases 
 the patient is quite unable to apply herself to any occupation 
 or to enjoy life in any way. The acute cases, happily rare, 
 run a relatively malignant course, and cause death in a 
 higher percentage of cases. 
 
 LITERATURE. 
 
 J. Sorgo. Die operative Behandlung d. Basedow's Krankheit, 
 Zentralb. f. d. Grenzgcbiete d. Med. u. Chir 1898. 
 
 A. KocHER Ueber Morbus Basedowii. Mitteil. a. d. Grenz- 
 gebiete d. Med. u. Chir. Bd ix., Hf. i and 2. 
 
 BuscHAN. Die Basedow'sche Krankheit. Wien. 1894. 
 
 MoEBius. Die Basedow'sche Krankheit. 
 
 Nothxagel's Handbuch d. spez. Pathol, u. Therap. Wien. 
 
 MoEBius. Ueber die Operation beim ^Morbus Basedowii . Miinch. 
 med. Wochens. Xo. i, 1899. 
 
 INTERMITTENT HYDRARTHROSIS. 
 
 Definition. — Intermittent hydrarthrosis is a designation 
 used for cases in which distension of joints with fluid occurs 
 at regular or irregular intervals without leaving any 
 permanent anatomical changes. 
 
 Etiology. — This affection usually occurs in " nervous " 
 individuals following some slight trauma, or some infection 
 or intoxication. It usually occurs between the ages of 
 ten and forty. 
 
 Clinical Course. — After some prodromal symptoms one 
 or more joints become swollen without any accompanying 
 fever. The effusion persists for several days and then 
 disappears spontaneously, and this process repeats itself at 
 intervals. As a rule the knee is affected, either alone, or 
 with other joints ; in sixty-four cases which I collected, 
 only twice was the knee unaffected. The pain is sometimes 
 intense and radiates to the regional nerves . There is no heart 
 lesion. Often there are various nervous phenomena, and 
 sometimes there are circumscribed oedematous swellings of 
 the skin in other situations. The attacks sometimes show 
 a definite relation to the physiological genital functions in 
 their onset and their disappearance. The affection may 
 persist for several years. 
 
NEUROSES. 85 
 
 INDICATIONS FOR OPERATION. 
 
 Operation will be done only as a last resource, when all 
 internal medical treatment has failed. Relatively good 
 results have been obtained by puncture of the joint and 
 injection of some irritating fluid. 
 
 Contra-indications.- — No operation will be recommended 
 when the affection has been present for only a short time ; 
 when it does not always attack one joint, but first one and 
 then another ; and when medical treatment has not been 
 given a proper trial (arsenic, electric current, etc.). 
 
 Prognosis.— i?esM//s of operation.- — Operative treatment 
 is unsuccessful in a relatively large proportion of cases ; 
 the process itself may not be improved, or may reappear 
 in another joint. In one of my cases, puncture of the 
 knee, repeated twice, had no influence either on the 
 recurrence of the effusion, or on the severity of the attacks. 
 
 Without operation the attacks may recur for many years ; 
 sometimes they disappear suddenly ; n other cases there 
 may be long periods (notably during pregnancy) during 
 which they remain absent ; in others the effusion suddenly 
 passes to other joints. 
 
 LITERATURE. 
 
 H. ScHLESiNGER. Die intermit-f. Gelenksschwellungen. Xoth- 
 nagel's Handbuch d. spez. Pathol, u. Therap. Bd. vii., Part 2. 
 Wien. 1903. 
 
CHAPTER V. 
 Diseases of the Larynx. 
 
89 
 
 Chapter V. 
 
 DISEASES OF THE LARYNX. 
 
 STENOSIS OF THE LARYNX. 
 
 Etiology. — A variety of causes may give rise to- 
 laryngeal stenosis. In addition to diphtheria and certain 
 nervous affections, there must be mentioned cedema 
 of the larynx, syphilis, rhinoscleroma, tuberculosis, new 
 growths and scars, and perichondritis laryngea. 
 
 Clinical Signs. — Laryngeal stenosis may be acute,, 
 subacute, or chronic. According to the rapidity with which 
 the stenosis supervenes, one or other symptom may pre- 
 dominate. When it rapidly becomes extreme, signs of 
 suffocation appear, the auxiliary muscles of respiration are 
 called upon, the larynx descends deeply at inspiration, and 
 inspiratory and often expiratory stridor are noticed. 
 The laryngoscope often demonstrates the cause of the 
 stenosis. If the onset is gradual, dyspnoea may be slight 
 and only noticeable on exertion, but when the channel is 
 narrowed, difficulty in respiration may come on at any time 
 from the impaction of pledgets of mucus or crusts. 
 
 Differential diagnosis. — The site of obstruction can be 
 demonstrated with the laryngoscope ; when stenosis is 
 laryngeal the voice is often affected. 
 
 INDICATIONS FOR OPERATION (extra-laryngeal). 
 
 It is necessary to open the larynx or trachea, (i) When 
 dyspnoea is intense, whether the stenosis is of acute or 
 chronic onset ; (2) In cicatricial stenosis, where tracheotomy 
 is employed for systematic dilatation with metal or rubber 
 instruments ; (3) In tumours of the larynx for the purpose 
 of extirpation. 
 
 Contra-indications. — There are no contra-indications under 
 the first heading given above. Systematic dilatation is 
 a tedious proceeding, and may be contra-indicated by an 
 
90 INDICATIONS FOR OPERATION IN 
 
 indifferent general state of health. Sloughing and necrosis 
 of laryngeal growths contra-indicate tracheotomy unless 
 suffocation threatens. 
 
 Prognosis. — Results of operation. — Tracheotomy often 
 saves life. The dilatation of stenosis through a tracheal 
 wound is often successful in restoring the laryngeal passage. 
 The possibility of removing a laryngeal or tracheal growth by 
 operation within the channel will depend upon its extent 
 and infiltration. When these are marked, a more radical 
 proceeding will be necessary. 
 
 Risks of operation. — The risks of tracheotomy as such 
 are very small in competent hands. However, when some 
 septic process is present in the larynx, tracheotomy is not 
 uncommonly followed by pneumonia or gangrene in the 
 lungs. 
 
 LITERATURE. 
 
 V. ScHROTTER. Kehlkopfkrankheitcn. Wien, 1892. 
 
 Stork. Krankheiten des Kehlkopfes. Nothnagel's Handbuch 
 d. spez. Pathol. Bd. xiii. 
 
 Strubing. Krankheiten des Kehlkopfes. Handbuch d. prakt. 
 Med. von Ebstein-Schwalbe. Stuttgart, 1899. 
 
 Heymanx. Handbuch der Kehlkopfkrankheitcn. 
 
 LARYNGEAL PARALYSIS OF NERVOUS ORIGIN. 
 
 Etiology. — Bilateral paralysis of the abductor muscles 
 may be due to a central or a peripheral cause. Most often 
 it follows tabes dorsalis. In all other central lesions 
 involving the bulb (syringobulbar paralysis, progressive 
 muscular atrophy), laryngeal paralysis is exceptional, and 
 it is also rare in lead neuritis and other peripheral paralyses. 
 
 Clinical Course. — The bilateral laryngeal paralyses 
 are the only laryngeal nervous paralyses of surgical interest. 
 Of this group, bilateral recurrent laryngeal paralysis, a rare 
 lesion, has not hitherto been submitted to any surgical 
 treatment, for it gives rise to little interference with 
 respiration or deglutition. In two of my cases the glottis 
 was fixed in the mid position. There was slight stridor on 
 deep respiration, and occasional difficulty in swallowing. 
 Bilateral paralysis of the crico-arytenoids is, on the other 
 hand, of surgical importance. The glottis is reduced to a 
 small slit, and on inspiration the vocal cords come together ; 
 
DISEASES OF THE LARYNX. , 91 
 
 this gives rise to dyspnoea, always inspiratory in character. 
 Inspiration is stridulous ; the voice, however, is unchanged, 
 and may be quite clear and distinct. In many cases the 
 degree of dyspnoea is small, and causes little distress. 
 
 Diagnosis. — The affection is easily diagnosed when the 
 contrast between the signs of inspiratory obstruction and 
 the absence of any interference with the voice is noticed ; 
 laryngoscopy will at once reveal the nature of the lesion. 
 
 INDICATIONS FOR OPERATION. 
 
 According to present knowledge, tracheotomy is the only 
 surgical procedure indicated. It may be called for as a 
 last resource when repeated attacks of dyspnoea threaten 
 asphyxia, or when the narrowing of the glottis is extreme 
 from swelling of the cords. Secondly, it may be indicated 
 as a prophylactic measure .when the patient, subject to 
 these dyspnoeic attacks, is so circumstanced that he is 
 unable to obtain immediate surgical assistance if he should 
 need it. 
 
 Contra-indications. — When dyspnoea is slight, and when 
 assistance can be counted on in an emergency, operation 
 is not called for. 
 
 Prognosis. — Of operation. — Tracheotomy only relieves 
 the dyspnoea ; it has no effect on the lesion ; as a rule the 
 cannula has to be worn permanently. 
 
 When no operation is undertaken, marked narrowing of the 
 glottis is astonishingly well borne if the paralysis supervenes 
 gradually and if secondary contractures develop slowly. 
 One of my patients was entirely without any subjective 
 sensation of dyspnoea when sitting, and even when walking 
 slowly, although he had to be excluded from the general ward 
 on account of his loud inspiratory stridor, which could be 
 heard on a quiet night in a court-yard at a considerable 
 distance from his room. In my experience tracheotomy is 
 rarely necessary in this affection if the patient remains 
 under medical supervision and avoids over-exertion. 
 
 LITERATURE. 
 
 Sp:mon. Nervenkrankheiten des Kehlkopfes. Handbuch d. 
 Laryng. von Heymann. Bd. i. 
 
 GoTTSTEiN. Krankheiten des Kehlkopfes. 4th Ed 189,5. 
 ScHECH. Die Krankheiten des Kehlkopfes. Wicn, 1897. 
 
92 INDICATIONS FOR OPERATION IN 
 
 DIPHTHERIA. 
 
 Etiology. — Infection with the diphtheria bacillus takes 
 place usually through the tonsils, more rarely through 
 the nose, pharynx, and larynx. Almost always there is a 
 mixed infection with streptococci. 
 
 Pathological Anatomy. — Locally the affected area 
 shows inflammatory changes going on to necrosis and the 
 formation of adherent membrane. The local necrosis 
 often causes considerable destruction by deep penetration. 
 There may be more or less free membrane in the pharynx 
 and larynx. The neighbouring lymph glands are usually 
 enlarged. In about 20 per cent of cases there is myocarditis 
 and consequent degeneration of the heart muscle. Bac- 
 teriology has shown that there is no true distinction between 
 diphtheria and the so-called croup. 
 
 Clinical Course. — In the milder cases there is moderate 
 pyrexia, the tonsils, uvula, and soft palate are dusky red, 
 and show membrane at first in discrete spots, and later 
 confluent ; this membrane may extend over the pharyngeal 
 wall, to the nose and to the larynx. When the nose is 
 involved there is a blood-stained discharge, nasal respiration 
 is obstructed, the whole nose is swollen, and whitish or 
 greyish particles of membrane may be seen in the nostrils. 
 The larynx is especially often involved in " malignant " 
 diphtheria. 
 
 The malignant or septic form develops rapidly, with 
 severe general symptoms. The lymphatic glands are early 
 swollen and tender. Within the first three days the patches 
 of membrane are replaced by septic gangrenous ulcers, 
 bleeding easily and foul smelling. The temperature is 
 usually high, but occasionally subnormal. The pulse 
 rapidly weakens, and the profound intoxication induces 
 delirium, stupor, and paralyses, with increasing cyanosis 
 and marked renal changes. Death occurs in very many of 
 these cases. 
 
 When the larynx is involved the voice is changed and 
 cough is troublesome ; inspiratory stridor (croup) is usually 
 noticed about the second or third day, and membrane is 
 seen on the cords with the laryngoscope. In true diphtheria, 
 however, the pharynx, larynx, and trachea may show only 
 catarrhal swelling. With increase in the obstruction of the 
 
DISEASES OF THE LARYNX. 93 
 
 glottis, dyspnoea becomes more intense ; occasionally the 
 patient may have temporary relief after coughing up 
 membrane. When untreated, a patient with laryngeal 
 diphtheria usually dies in from four to seven days with 
 symptoms of asphyxia. Sometimes the process extends 
 into the bronchi, but no peculiar symptoms other than 
 those of laryngeal diphtheria arise from this extension. 
 When recovery occurs in the severe type of the disease, 
 convalescence often takes many weeks. 
 
 Diagnosis and Differential Diagnosis. — Bacterio- 
 logical examination, and the fact that the posterior pharyngeal 
 wall is often as much involved as the tonsils, serve to 
 distinguish diphtheria from follicular tonsillitis. With 
 regard to pseudo-croup^ the attacks in this affection occur 
 at night, respiration is unaffected during the day, the attacks 
 are short, and there is no membrane in the larynx. The 
 aspiration of foreign bodies has often given rise to a mistaken 
 diagnosis of diphtheria. 
 
 INDICATIONS FOR OPERATION. 
 
 Indications for operation have been formulated by many 
 authors ; some favour the early and others the late operation. 
 Baginsky advises operation when inspiration is prolonged, 
 expiration noisy, and the chest is indrawn, also when attacks 
 of dyspnoea occur, even in a moderate degree, with sensa- 
 tions of apprehension. One should never await the onset 
 of signs of asphyxia, cyanosis, or pallor, coldness of 
 the extremities, and diminution of cutaneous sensibility 
 (Baginsky). Most writers advocate early operation. This 
 surgical intervention may take the form of intubation or 
 tracheotomy. It should be a rule to practise intubation 
 primarily, when the respiratory difficulty appears. It may 
 be adopted as a secondary measure when, after tracheotomy, 
 it is found difficult to remove the cannula. If intubation 
 cannot be done for any reason, then tracheotomy must be 
 the primary procedure. If intubation does not relieve the 
 breathing, tracheotomy should follow, and this may be also 
 necessitated by repeated coughing out of the intubation 
 tube, by the presence of pneumonia, by difficulties in 
 feeding, by blockage of the tube and threatening suffocation, 
 and by the breaking of the thread attached to the tube 
 and the impossibility of expressing it. Generally, it may 
 
94 INDICATIONS FOR OPERATION IN 
 
 be said that primary tracheotomy should be done when the 
 following signs are present : asphyxia and pronounced 
 heart failure, marked infiltration and oedema of the soft 
 parts about the entrance to pharynx and larynx, retro- 
 pharyngeal abscess. It is also indicated when the patient 
 is not in hospital, and surgical aid is not immediately 
 available. The recommendation of primary tracheotomy 
 in cases where the diphtheritic process has extended far 
 into the trachea is largely theoretical ; this can rarely be 
 recognized until the trachea has been actually opened. 
 
 Intubation versus Tracheotomy. — Intubation is a relatively 
 insignificant procedure, and can usually be easily and rapidly 
 performed. No anaesthetic or assistants are necessary ; 
 there is no risk of haemorrhage, which may be troublesome 
 during and after tracheotomy ; and there is no wound to 
 be infected (Ganghofner). Treatment is less prolonged 
 after intubation than after tracheotomy, and it is easier 
 to gain the consent of the relatives to the former than 
 to the latter. 
 
 Contra-indications. — The contra-indications have been 
 already mentioned. When there is much secretion of 
 tenacious mucus, tracheotomy rather than intubation is 
 indicated. 
 
 Prognosis. — Risks of intervention.— Intuhaition is an 
 operation that requires a practised hand, and much damage 
 may be done to the larynx by unskilful introduction of 
 the tube. If the tube be left in long it may cause ulcera- 
 tion and subsequent cicatricial contraction ; feeding is 
 somewhat interfered with, and removal of the tube may 
 occasion severe respiratory embarrassment. The latter 
 may also be set up when the tube is introduced by the 
 pushing down of membrane into the trachea, and sometimes 
 the tube is coughed out and the patient threatened with 
 suffocation. 
 
 In low tracheotomy, haemorrhage may be troublesome 
 both during and after operation. Occasionally erysipelas, 
 cellulitis, or diphtheritic inflammation occurs in the 
 tracheotomy wound. When some paralysis of deglutition 
 appears at the same time, pneumonia is to be feared. 
 
 Results of intervention. — Intubation and tracheotomy 
 often save life, especially in cases where antidiphtheritic 
 serum is administered, giving time for the serum to produce 
 
DISEASES OF THE LARYNX. 95 
 
 its curative effect. Secondary intubation is often very suc- 
 cessful in overcoming the difficulties attendant on removal 
 of the tracheotomy tube. Secondary tracheotomy, 
 practised when intubation fails to give relief, is not often 
 successful, because in such cases the diphtheritic process 
 is generally descending. The prognosis of tracheotomy 
 depends very much on the character of the attack. It is 
 bad when the operation is done on a patient in asphyxia 
 or below the age of two years. The progress of the disease 
 when no operation is done has been referred to in the 
 description of the clinical course. 
 
 LITERATURE. 
 
 Ganghofner. Behandlung der Diphtheric. Handbuch d. spez. 
 Therap. von Penzoldt-Stintzing. Bd. i. 
 
 Baginsky. Diphtheric. Nothnagel's Handbuch der spez. PathoL 
 Bd. ii., Teil i. Wien, 1898. 
 
 HoFMEiSTER. Diphtheria des Larynx. Handbuch d. prakt. 
 Chir. von Bergmann, Bruns, u. Mikulicz. Bd. ii. Stuttgart, 
 1900. 
 
 Hoppe-Seyler. Croupos-diphtheritische Erkrankungen des 
 Larynx u. der Trachea. Heymann's Handbuch d. Laryng. u. Rhinol. 
 Bd. i. Wien, 1898. 
 
CHAPTER VI. 
 
 Diseases of the Bronchi and the Lungs. 
 
99 
 
 Chapter VI. 
 DISEASES OF THE BRONCHI AXD THE LUXGS. 
 
 BRONCHIECTASIS. 
 
 Etiology. — The most important etiological factors are 
 chronic bronchial catarrh and chronic interstitial pneumonia, 
 with or without pleurisy. Bronchiectasis may also occur 
 from the blocking of the lumen of a bronchus by scar or 
 foreign body, or from pulmonary emphysema. It occurs 
 rarely as a congenital condition in atelectatic lungs. 
 
 Pathological Anatomy. — A distinction is made between 
 the common (vicarious) diffuse cylindrical and spindle- 
 shaped form and the rarer sacciform (inflammatory) type. 
 The parenchyma between the bronchiectatic cavities, 
 notably in the sacciform type, is more or less shrunken and 
 destroyed. The changes may involve a single bronchus 
 or a w^hole group connected with one or several pulmonary 
 lobules ; the size of the resulting cavity varies from that of 
 a bean to that of the closed fist. The cavity may lie close 
 to the thoracic waU or near the hilus. Ulcerative processes 
 occur in the walls of the bronchi, giving rise to haemorrhage, 
 and becoming gangrenous ; sometimes they heal and form 
 cicatrices. When the cavity is superficial and the lung 
 much shrunken, pleural adhesions develop. 
 
 Clinical Signs. — Frequently there are no characteristic 
 symptoms, only those of a chronic catarrh, and such cases 
 are of no surgical importance. In other cases the signs of 
 cavity (cf. "Gangrene of the Lung") are well developed and 
 the expectoration is copious. This expectoration may occur 
 in great quantity at some particular time of the day (morning), 
 or when the patient adopts some particular attitude. One 
 of my patients expectorated more than a litre of sputum 
 daily for a year. The sputum is purulent, and, when putrid 
 bronchitis is present, it is very foul smelling ; it forms 
 
loo I^WICATIONS FOR OPERATION IN 
 
 three layers on standing ; in uncomplicated bronchiectasis, 
 fragments of lung and elastic tissue are not found. The 
 expectoration often also contains blood. Fever and loss of 
 flesh occur in some cases, not as a rule until the condition 
 has been present for a considerable time. "Drumstick" 
 lingers and clubbed toes are often to be noted. In long- 
 standing cases complications are relatively common, such 
 as cerebral abscess and arthritis. Amyloid disease is unusual ; 
 in some cases there is an associated empyema. 
 
 Diagnosis. — The diagnosis is based on the chronic nature 
 of the affection, on the copious and characteristic sputum, 
 on the signs of cavity more or less evident according as 
 the cavity is full or empty of secretion. Retraction of the 
 thorax, and a certain amount of displacement of the 
 neighbouring organs (heart) towards the affected side, 
 point to the presence of a chronic interstitial pulmonary 
 process and adhesions between the pleura and the thoracic 
 wall, and support the diagnosis of bronchiectasis. The 
 physical signs of cavity will indicate the situation of the 
 lesion, and a radiographic picture may furnish corroborative 
 evidence. 
 
 Differential diagnosis. — It is often difficult to distinguish 
 this affection from tuberculosis. Absence of tubercle 
 bacilli and of elastic fibres from the sputum, the character 
 of the expectoration, the chronic course, and relatively 
 good general condition, will aid in the diagnosis, and the 
 fact that the apices are usually only slightly, or not at all, 
 affected. Sometimes the question of an empyema emptying 
 itself into the bronchi may arise ; in such cases the 
 history is of special importance, pointing to a preceding 
 pleuritis. If there is a history extending over a year or more, 
 the condition is almost certainly a bronchiectasis. With 
 regard to pulmonary abscess, the history will also be of 
 great assistance ; pneumonia or trauma shortly preceding 
 will point to abscess ; in abscess also, fragments of lung 
 tissue are found in the sputum, and are absent in uncom- 
 plicated bronchiectasis. 
 
 INDICATIONS FOR OPERATION. 
 
 There is at present some difference of opinion as to the 
 indications for the opening of bronchiectatic cavities. 
 There cannot be said to be any absolute indications, but a 
 
DISEASES OF THE BRONCHI AND THE LUNGS. loi 
 
 relative one is present when the patient, in the course of his 
 complaint (notably when it is complicated by putrid 
 bronchitis), has to give up work, loses flesh rapidly, becomes 
 melancholic, and cannot mix with his fellows. In such 
 cases operation is, however, only to be recommended when 
 the signs point to a single, unilateral, and superficial cavity, 
 and when the discharge does not escape readily. The large 
 sacciform cavities of the lower lobe are particularly suitable 
 for operation. If the cavities are numerous, and putrid 
 bronchitis is present, with much expectoration, and if the 
 process is limited to one part of the lung, then rib resection 
 over an area corresponding to the disease will favour the 
 falling in of the lung and cicatrization of the foci. 
 
 Contra-indications. — No operation should be advised 
 when both lungs are affected, when the condition, although 
 confined to one lung, is very extensive, when the cavity is 
 deep-seated, when the general condition is good and there 
 is no putrid bronchitis, and when waxy disease is well estab- 
 lished. Operation may be useless from the development 
 of further cavities, and the thoracic fistula that is established 
 may not be any improvement on his former condition. 
 In one of my cases the cavity was exactly localized and 
 was opened ; after several months other cavities had 
 formed to such an extent that his troubles were equal to 
 those before operation, with the addition of a thoracic 
 iistula. 
 
 Prognosis. — Risks of operation. — The operation and its 
 consequences must be considered serious ; Tufher's statistics 
 show a mortality of about 25 per cent. In view of these 
 risks it should be remembered that bronchiectasis is 
 compatible with long life. Rib resection (Quincke) is not 
 a procedure attended with any particular risk. 
 
 Prognosis of operation. — Complete healing of a cavity 
 by operation has been only exceptionally obtained. As a 
 rule the cavity gradually shrinks, but a fistula persists. 
 Rib resection may be followed by a good result when the 
 disease is limited to a small area. In addition to the 
 statistics of Tuffier already quoted, Garre has reported 
 fifty-seven cases of operation by opening the cavity ; of 
 these twenty-one died, either immediately after or within 
 the first week. 
 
 Without operation the cavity increases in size, but this 
 
I02 INDICATIONS FOR OPERATION IN 
 
 brings no risk to life, and waxy disease or other complications 
 may not occur for many years. 
 
 LITERATURE. 
 
 Quincke. Ueber Pneumotomie. Mitteil. a. d. Grenzgebiete d. 
 Med. u. Chir. Bd. i. 
 
 TuFFiER. Chirurgie du Poumon. Paris, 1897. 
 
 Terrier et Reymoxd. Chirurgie de la Plevre et du Poumon. 
 Paris, 1899. 
 
 Hoffmann. Erkrankungen der Bronchien. Nothnagel's Hand- 
 buch d. spez. Pathol. Wien. 
 
 GANGRENE OF THE LUNG. 
 
 Etiology. — Gangrene of the lung most frequently occurs 
 as a direct consequence of pneumonia. Tuffier records 
 seventy-four cases operated on, fifty-five of which followed 
 pneumonia. Predisposing causes are chronic alcoholism, 
 exhausting diseases, diabetes mellitus, putrid bronchitis. 
 Pneumonia caused by the aspiration of foreign bodies is 
 often followed by gangrene, and the same is true of the 
 pneumonias set up by the embolic carrying of septic material 
 to the lungs b}' way of the jugular or uterine veins. Con- 
 secutive gangrene often occurs when ulcerative and septic 
 processes spread to the lung from some adjacent site, such 
 as the oesophagus, spine, larynx, trachea, and mediastinum. 
 
 Pathological Anatomy. — Gangrene is sometimes circum- 
 scribed and sometimes diffuse. The former may occur as a 
 solitary focus or as multiple foci. In the latter case both lungs 
 may be affected, but usually the gangrene is confined to one. 
 Following the necrosis of lung tissue, cavities form, varying 
 in size from that of a nut to that of the fist ; they are bor- 
 dered by sloughing lung tissue, often communicate freely 
 with a bronchus, and not infrequently extend to the pleural 
 surface. The large vessels in the neighbourhood are often 
 thrombosed; the overlying pleura is usually inflamed; and 
 either adhesions form or pus collects in the pleural cavity. 
 When diffuse the gangrenous process may involve a whole 
 lobe ; it is not limited by any suppurating zone. 
 
 Clinical Course. — In cases of pneumonia, gangrene is 
 to be suspected when the expectoration becomes more 
 copious and putrid, with rise of temperature and increase 
 of the cough. In some cases there is no increased fever. 
 
DISEASES OF THE BRONCHI AND THE LUNGS. 103 
 
 The expectoration forms three layers on standing, the 
 lowest of which contains yellowish-grey Dittrich's plugs, 
 and often black pigmented fragments of lung tissue. 
 Elastic fibres are relatively rarely present in any numbers, 
 and haemorrhages are not common. In the lung the focus 
 can often be located, even when it does not lie superficially, 
 by the presence of coarse metallic rales with or without 
 amphoric breath sounds. Other signs of cavity are often 
 present : tympanitic percussion, changing to dullness when 
 the cavity is filled with secretion, alternating percussion 
 note when the mouth is opened and closed, hruit de pot fete. 
 In addition to the symptoms already mentioned, rigors and 
 sweating are not uncommon. In cases of long standing, 
 metastatic abscesses may appear, in the brain and elsewhere. 
 Sometimes the disease resembles enteric fever in its onset, 
 with sustained fever, stupor, and sordes of the mouth and 
 lips. 
 
 Diagnosis. — This is usually easy. The fcetor, associated 
 with the presence of gangrenous lung fragments in the 
 sputum is quite characteristic. It is more difiicult to 
 localize the gangrenous area and to decide whether there 
 is a solitary focus or several. The signs of cavity are 
 those on which the local diagnosis must be based, and a 
 radiographic examination may assist. 
 
 Differential diagnosis. — The condition has to be differ- 
 entiated from putrid bronchitis with or without bronchiec- 
 tasis, but in the latter fragments of lung tissue are not 
 found in the sputum. In an empyema or a subphrenic 
 abscess which ruptures into a bronchus, there are special 
 percussion and auscultation phenomena, and the viscera 
 are displaced. 
 
 INDICATIONS FOR OPERATION. 
 
 Free opening of the cavity is the only justifiable operation ; 
 the exploring needle should not be used on account of the 
 risk of infecting the pleural cavity. When a circumscribed 
 area of gangrene is definitely diagnosed the indication for 
 operation is absolute. The presence of pleural adhesions is 
 favourable for operation, but their absence is no contra- 
 indication. When all the diagnostic signs already described 
 are present the fact that the focus lies deeply is no bar to 
 rjperation. When the typical signs of cavity are absent, 
 
I04 INDICATIONS FOR OPERATION IN 
 
 operation should still be undertaken when the following 
 signs are present (Riegner, A. Frankel) : (a) A circum- 
 scribed patch of dullness, notably in the lower lobe, with 
 normal lung tissue all around it; (b) Fragments of lung 
 tissue in the sputum in abundance, coughed up within a 
 short period ; (c) A shadow in the skiagram corresponding 
 exactly with the patch of dullness revealed by physical 
 examination. 
 
 If there is high sustained fever associated with rigors, 
 operation should be done even when the focus is not super- 
 ficial. Operation is urgently called for when the condition 
 is complicated by empyema, and also when the gangrenous 
 area is apical, as a focus in this situation is particularly 
 dangerous. 
 
 Contra-indi cations. — Even when the diagnosis is certain, 
 no operation should be done when the gangrene is diffuse, 
 when the foci are multiple, when the condition is bilateral, or 
 when there already exists some cerebral or meningeal 
 lesion. When the focus is very small the case is not as a 
 rule suitable for operation, because the diagnosis cannot 
 usually be definitely settled, and definite localization must 
 always be looked upon as an essential preliminary. In 
 diabetics, when the urine contains a large quantity of sugar 
 and acetone, operation is inadvisable. 
 
 Prognosis. — Of operation. — The earlier the condition is 
 operated on, the better the prognosis. Exploratory puncture 
 and the evacuation of the cavity with a trocar are very 
 dangerous procedures. Tuffier estimates the mortality 
 after pneumotomy as 40 per cent ; Garre gives the mortality 
 of 122 cases as 34 per cent ; the prognosis varies with the 
 etiology of the condition. In post-pneumonic gangrene 
 the mortality is high ; in cases where the condition follows 
 pulmonary embolism it is still higher. Recovery after 
 operation occurred in 60 per cent of Tuffier's collected 
 cases ; it is usually complete and permanent. Usually 
 there is no risk of pneumothorax, because in most cases 
 there are pleural adhesions. 
 
 Prognosis without operation. — In about 60 per cent of 
 cases death occurs from exhaustion, or from some complica- 
 tion such as brain or liver abscess or pneumothorax. In 
 many subacute cases the depression of vitality is very 
 pronounced, and waxy disease may develop. In all cases of 
 
DISEASES OF THE BRONCHI AND THE LUNGS. 105 
 
 circumscribed gangrene there is a risk of the process 
 extending to other parts of the lung by aspiration, or of a 
 general infection. 
 
 LITERATURE. 
 
 AuFRECHT. Die Lungenentziindungen. Nothnagel's Handbuch 
 d. spez. Pathol. Wien. 
 
 KuMMEL. Chirurgisclie Krankheiten d. Lunge. Handbuch d. 
 prakt. Chir. Herausgegeben von Bruns, Bergmann, u. ^klikuHcz. 
 Bd. ii. 1900. 
 
 Reymond. Chirurgie de la Plevre et du Poumon. Paris. 1899. 
 
 TuFFiER. Chirurgie du Poumon. Paris. 1897. 
 
 J. ScHULz. Ueber den Lungenabscess, etc. Zentralb. f. d. 
 Grenzgebiete d. Med. u. Chir. 1901. 
 
 RiEGNER. Ulcerose Lungenprozesse. Deutsche med. Wochens. 
 No. 29. 1902. 
 
 Quincke, Lenhartz, Garre. Mitteil. a. d. Grenzgebiete d. Med. 
 u. Chir. Bd. ix., H. 3. 
 
 ABSCESS OF THE LUNG. 
 
 Etiology. — Pneumonia is the most common antecedent 
 of pulmonary abscess, and its occurrence is favoured by 
 previously existing emphysema or induration processes. 
 Abscess also occurs from embolism, especially in pyaemia and 
 puerperal sepsis ; also from wounds and the introduction of 
 foreign bodies into the bronchi. 
 
 Pathological Anatomy. — With the exception of the 
 post-pneumonic cases, abscess arises in. lungs previously 
 healthy. The pneumonic abscesses are usually situated in 
 the lower lobe, those due to foreign bodies develop wherever 
 the foreign body lodges, and this usually occurs in the right 
 primary bronchus or in a secondary bronchus in the right 
 lower lobe. Abscesses may be single or multiple, and in 
 size vary from that of a nut to that of the fist. The 
 antecedent pneumonia is often due to the Fraenkel- 
 Weichselbaum diplococcus or the influenza bacillus, but 
 in many cases to organisms other than these. In recent 
 abscesses the walls fall in when the contents are evacuated ; 
 the pus may be inodorous, but in cases where there is 
 associated gangrene it is foul smelling. In abscesses of 
 long standing the walls are infiltrated and dense. Lung 
 abscesses may be near the surface or deeply situated ; in 
 tlie former then^ is usually })leurisy with adhesions or 
 
io6 INDICATIONS FOR OPERATION IN 
 
 purulent effusion, but in many cases there is no pleurisy 
 at all. 
 
 Clinical Course. — There are local and general symptoms. 
 Of the latter a sustained pyrexia is the most important. 
 In cases following pneumonia the temperature may remain 
 up, or pyrexia may set in again after the crisis. At the 
 same time, or shortly after, the patient expectorates in 
 considerable quantities a purulent creamy secretion, often 
 possessing a somewhat sweetish smell. In this pus there 
 are often fragments of lung tissue and elastic fibres in 
 considerable amount, hcematoidin crystals and fat crystals. 
 Physical signs of cavity are often not to be found when 
 an abscess is deep-seated, or may develop while the patient 
 is under observation. A change in percussion note at one 
 spot, from dull to tympanitic, after the patient has got rid 
 of a quantity of expectoration, associated with bronchial 
 breathing and the other various signs of cavity, may be 
 looked upon as diagnostic. In many cases, however, 
 especially when the abscess is in the lower lobe, the signs 
 of cavity are wanting, owing to collapse of the walls when 
 the collection of pus is discharged. When, after pneumonia, 
 a circumscribed patch of dullness persists, surrounded by 
 normal lung tissue, if the expectoration is abundant and 
 purulent, if fever persists and if a skiagram shows a shadow 
 corresponding to the dull area, a diagnosis of abscess may 
 be confidently made. 
 
 Diagnosis. — Radiography is a valuable aid in localizing 
 an abscess ; when clinical signs suggest multiple abscesses 
 it may also be of much assistance. When an abscess is 
 due to the presence of a foreign body, this may be seen in a 
 skiagram while the process is in an early stage. In a 
 recent abscess, if the sputum becomes foetid, this points to 
 its extension by gangrene of the wall. The following 
 signs point to the presence of pleural adhesions around an 
 abscess : relative immobility of the ribs over a limited 
 area, with inspiratory retraction of the intercostal spaces 
 over the same area; lessened inspiratory movement of the 
 lower border of the lung; no alteration in heart dullness 
 on deep inspiration and maximal expiration. When there 
 has been antecedent pleuritis, adhesions are probably 
 present. 
 
 The differential diagnosis does not, as a rule, present 
 
DISEASES OF THE BRONCHI AND THE LUNGS. 107 
 
 any particular difficulty. Against bronchorrhoea are the 
 signs of cavity, and the presence of elastic fibres and 
 lung fragments in the sputum ; the latter also exclude 
 bronchiectasis. Tuberculosis is excluded by examinations 
 of the sputum for tubercle bacilli. When an empyema 
 opens into a bronchus the discharge of pus is often followed 
 by the signs of partial pyopneumothorax, metallic ausculta- 
 tion, percussion phenomena, andhippocratic succussion. 
 
 INDICATIONS FOR OPERATION. 
 
 When there are definite signs of an acute solitary abscess, 
 or of several abscesses situated close together in one lobe, 
 operation should be undertaken without delay, unless 
 there are signs of spontaneous healing. The condition 
 should not be allowed to become chronic (Quincke). If 
 spontaneous recovery occurs the process takes from three 
 to ten weeks, and will be indicated by decrease in the 
 discharge of purulent sputum and decline of the fever. 
 In one of my own cases it was decided to forego operation on 
 account of the diminution in the amount of sputum, and 
 spontaneous recovery took place in the course of a few 
 weeks. An exact localization is an essential preliminary 
 to operation, and it must also be definitely ascertained that 
 there is only one abscess, and that it is not of very small 
 size. When the general symptoms are of a severe type, 
 with high fever and abundant expectoration of pus and 
 lung debris, and when physical examination shows a definite 
 local area of infiltration in the lower lobe, pneumotomy is 
 justifiable, even in the absence of signs of cavity, when 
 the patch of dullness is surrounded by normal lung tissue. 
 Foci in the lower lobe behind are the most favourably 
 situated for operation ; signs of pleural adhesions will 
 make one recommend operation the more readily. Chronic 
 abscesses, with copious and particularly with putrid secretion, 
 should be operated on by resection of several ribs, free 
 opening of the cavity and, if necessary, partial excision 
 of the abscess wall. 
 
 In abscesses due to the presence of foreign bodies, 
 pneumotomy is only indicated when the foreign body 
 cannot be extracted by the respiratory channels, when 
 the discharge of pus is copious, and the signs of general 
 flisturbance are serious Puncture, without opening the 
 
io8 INDICATIONS FOR OPERATION IN 
 
 thoracic cavity, is a most dangerous proceeding, and should 
 never be done. 
 
 Contra-indications. — No operation should be done when 
 there is reason to believe that there are multiple abscesses 
 present, and this is particularly to be expected in pysemia, 
 puerperal sepsis, and influenza-pneumonia. Operation is 
 also contra-indicated when there are no local signs of cavity 
 with moderate fever, and no alarming symptoms of general 
 disturbance ; often in such cases eventual recovery takes 
 place by discharge of the pus through the bronchi. With 
 few exceptions, which have already been alluded to, abscesses 
 due to foreign bodies are not suitable for thoracotomy. 
 
 Prognosis. — Of operation. — In acute cases statistics show 
 recovery after operation in 73 per cent ; death in 27 per 
 cent. In chronic cases the recoveries were 51 per cent ; 
 23'5 per cent improved, and there were 25'5 per cent of 
 deaths. In more than two-thirds of the acute cases, 
 therefore, operation cured ; in cases complicated by 
 gangrene the prognosis is much worse. The prognosis is 
 less favourable in chronic cases, particularly when the 
 discharge is foetid ; thoracic fistulae often persist. The 
 advantages of pleural adhesions, from the point of view 
 of operation, have been already mentioned. 
 
 // no operation he done the abscess may extend, empyema 
 or pyopneumothorax may develop, or general septic 
 infection mav supervene and cause death. An acute 
 abscess often becomes chronic, and the strength may be 
 exhausted by constant and long-continued discharge. 
 On the other hand, many pulmonary abscesses disappear 
 spontaneously by evacuation through the respiratory 
 channels. (See " Indications.") 
 
 LITERATURE. 
 
 ScHULz. Ueber den Lungenabscess und seine chirurg. Behand- 
 lung. Zentralb. f. d. Grenzgebiete d. Med. u. Chir., No. i und ff. 
 1901. 
 
 Quincke. Ueber Pneumotomie. Mitteil. a. d. Grenzgebiete d. 
 Med. u. Chir. Bd. i, H. 2. 
 
 TuFFiER. Chirurgie du Poumon. Paris, 1897. 
 
 AuFRECHT. Lungenentzundungen. Nothnagel's Handbuch d. 
 spez. Pathol. 
 
 Quincke. Chirurg. Behandlung der Lungenkrankh. Mitteil. a. d. 
 Grenzgebiete d. Med. u. Chir. Bd. ix., H. 3. 
 
 Garre. Lenhartz. Ibid. 
 
DISEASES OF THE BRONCHI AND THE LUNGS. 109 
 
 PULMONARY TUBERCULOSIS. 
 
 There is no need to describe here the etiology and 
 chnical course of this affection. The indications for 
 surgical interference have not yet been settled with sufficient 
 precision to allow one to formulate any exact rules. Many 
 cases have been submitted to operation, but these have 
 been of such diverse types, and the methods of operation 
 have varied to such an extent, that the records do not 
 furnish material for forming any precise opinions on the 
 question. 
 
 The subject has been recently discussed by Quincke, 
 who has devoted so much attention to lung surgery, and 
 by Garre. According to these authors the indications 
 for operation are as follows : only when the patient's 
 general health is still good, and when he presents a single 
 ^circumscribed focus of disease, is operation to be thought of. 
 In such a case, when there are signs of retention and decom- 
 position of secretion, and symptoms of septic absorption, 
 the cavity should be freely opened and drained. In the 
 rare cases of isolated cavity and tubercular focus in the 
 lower lobe, the infiltrated lung tissue should be resected, 
 followed by thoracoplasty. In stationary isolated cavities 
 of the apex, the thoracic wall should be mobilized by 
 resection of the first three ribs, without opening the pleura 
 (Garre). 
 
 Quincke has further expressed his views as follows : 
 When one can say with some degree of certainty that, 
 apart from the question of cavity, the tubercular process 
 in an advanced stage is confined to one upper lobe, present 
 experience indicates that mobilization of the corresponding 
 thoracic wall by thoracoplasty is a justifiable proceeding, 
 and that when combined with other treatment encapsulation 
 and healing of the focus may be brought about thereby. 
 
 The chief difficulty lies in the fact that cases of definitely 
 circumscribed pulmonary tubercle are only rarely met with, 
 and such alone are suitable for operation ; in most cases it 
 is difficult to be certain that the disease is really strictly 
 limited. In opening cavities there is a danger of setting 
 up a gangrenous process ; there is also the risk that a 
 permanent thoracic fistula may result, or that healthy lung 
 tissue may be; infected by the contents of the cavity. 
 
no INDICATIONS FOR OPERATION IN 
 
 LITERATURE. 
 
 Quincke. Ueber die chirurg. Behandlung der Lungenkrankh. 
 ]\Iitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. ix., H. 3. 
 
 Garre. Ibid. 
 
 C. Cornet. Die Tuberkulose. Nothnagel's Handbuch d. spez. 
 Pathol. Wien, 1900. Bd. xix., 2 Halfte, 2 Abteil. 
 
 Berliner. Die operative Behandlung der Lungentuberkulose. 
 Zentralb. f. d. Grenzgebiete d. Med. u. Chir. 1901. 
 
 HYDATID CYST OF THE LUNG. 
 
 Pathological Anatomy. ^As a rule there is a single 
 cyst in one of the lower lobes, most frequently the right, 
 and the cyst is almost always unilocular. It may reach 
 the dimensions of an infant's head, and not infrequently 
 ruptures into a bronchus or into the pleural cavity. Some- 
 times suppuration occurs in the cyst, and even calcification. 
 When suppuration supervenes there are usually inflam- 
 matory changes in the surrounding parts, infiltration, 
 empyema, and occasionally gangrene. 
 
 Clinical Signs. — Occasionally there are no symptoms. 
 Very often there is very troublesome cough, sometimes 
 associated with haemoptysis and attacks of dyspnoea. 
 When there is dullness to percussion it often presents a 
 characteristic vaulted outline ; as a rule rales are absent. 
 Over the dull area breath sounds are usually absent, or 
 there may be indistinct bronchial breathing. The neigh- 
 bouring organs are often dislocated. If suppuration occurs 
 and the pus is discharged into a bronchus, signs of cavity 
 may appear. Suppuration is of course associated with fever. 
 Particles of membrane and vesicles are comparatively 
 frequently coughed up. 
 
 Diagnosis. — The diagnosis is not usually made until 
 membranous particles or vesicles are coughed up, or fluid 
 containing scolices is found by exploratory puncture. If 
 fluid obtained by puncture is limpid, free from albumin but 
 rich in sodium chloride, there can hardly be any doubt that 
 the condition is one of hydatid cyst. If pus is drawn off, 
 the discovery of booklets in it will show the nature of the 
 case. Signs of hydatid elsewhere will aid early diagnosis, 
 when there is a patch of lung dullness with absence of breath 
 sounds and displacement of neighbouring organs. 
 
DISEASES OF THE BRONCHI AND THE LUNGS, in 
 
 Differential diagnosis. — The signs just mentioned will be 
 sufficient to distinguish hydatid cyst from pleurisy with 
 effusion, interlobar pleurisy, chronic pneumonia, and similar 
 affections. 
 
 INDICATIONS FOR OPERATION. 
 
 If the diagnosis is certain and the position of the cyst 
 ascertained, it should be opened through the pleura and 
 lung unless it is very deeply situated. The absence of 
 pleural adhesions fixing the lung is no absolute bar to 
 operation. If suppuration has set in, operation should be 
 done with the least possible delay. 
 
 Contra-indications. — When a skiagram shows the cyst to 
 be close to the hilum, operation is inadvisable. With this 
 exception there are no contra-indications, provided that 
 the general condition of the patient has not been allowed 
 to become very bad. 
 
 Prognosis. — Results and risks of operation. — In many 
 cases a complete cure has been obtained, in others a 
 thoracic fistula persists. The risks of operation are at 
 present considerable. In one of my cases where the cyst 
 had suppurated and where it was only possible to make a 
 simple incision, death followed in a month from waxy 
 disease due to the chronic discharge. 
 
 // no operation he done the prospect is that the cyst will 
 grow, eventually become infected and cause death from 
 exhaustion. Without operation about 60 per cent of the 
 cases die. 
 
 LITERATURE. 
 
 Mosler-Peiper. Die tierischen Parasiten. Nothnagel's Handbuch 
 d. spez. Pathol. Wien, 1894. 
 
 Neisser. Die Echinococcenkrankheit. Berlin, 1877. 
 
 Lenhartz. Handbuch der prakt. Medizin. Ebstein-Schwalbe 
 Bd. i. Stuttgart. 
 
 ACTINOMYCOSIS OF THE LUNG. 
 
 Etiology. — -Pulmonary actinomycosis usually results 
 from the aspiration of infected barley grains into the bronchi. 
 More rarely it is secondary to actinomycosis of the mouth. 
 
 Pathological Anatomy. — At the site of the disease 
 the lung is usually collapsed, thickened, and infiltrated 
 witli dense connective tissue, and often interspersed with 
 
112 INDICATIONS FOR OPERATION IN 
 
 small pus-containing cavities. As the disease progresses 
 the pleura is greatly thickened and adherent, and the skin 
 becomes of a board-like hardness from infiltration. The 
 skin, pleura, and lung are often riddled with fistulous 
 tracts. When the disease is extensive there is much 
 sclerosis and shrinking of the lung. 
 
 Clinical Course. — In typical cases three stages may be 
 distinguished (Israel). First there is bronchial catarrh, 
 followed by signs of interstitial infiltration of a lower 
 lobe and the formation of cavities and general s^^mptoms 
 resembling those of tuberculosis, fever, loss of flesh, pallor, 
 and sweating. In the second stage there are pleural signs, 
 adhesions, etc., and retraction of the thoracic wall is often 
 to be noted. In the third stage the skin becomes involved 
 and suppurates, with the formation of multiple sinuses. 
 In the pus the characteristic golden yellow granules 
 are to be seen, and in the sputum often elastic fibres in 
 addition. 
 
 Diagnosis and Differential Diagnosis. — The condition 
 may easily be confounded with tuberculosis ; the absence 
 of tubercle bacilli and the presence of the actinomycotic 
 grains are the only signs by which the distinction can be 
 made. 
 
 INDICATIONS FOR OPERATION. 
 
 Actinomycosis of the thoracic wall over an infiltrated 
 lung warrants operation ; sinuses often lead directly from 
 the skin into the lung disease. Some surgeons hold the 
 view that operation should not be done unless septic 
 infection of the skin supervenes. 
 
 Contra-indications. — When the general condition is bad 
 and the lung disease very extensive, no operation will be 
 recommended. 
 
 Prognosis. — Of operation. — Complete success is rarely 
 obtained ; usually the lung disease has advanced too far by 
 the time its nature is revealed by involvement of the skin. 
 Occasionally the whole area of disease has been successfully 
 removed, but usually its extent is so great that this is 
 impossible, and only partial excision can be done. 
 
 Without operation recovery may be anticipated under 
 expectant treatment in a fair number of cases, but in the 
 great majority the disease proves fatal. 
 
DISEASES OF THE BRONCHI AND THE LUNGS. 113 
 
 LITERATURE. 
 
 Illich. Klinik der Aktinomykose. Wien, 1892. 
 
 ScHLANGE. Prognose der Aktinomykose. Arch. f. klin. Chir. 
 1892. 
 
 Israel. Klin. Beitr. zur Kenntnis der Aktinomykose des 
 Menschen. Berlin, 1885. 
 
 KoRANYi. Aktinomykose. Nothnagel's Handbuch d. spez. Pathol, 
 u. Therap. Bd. v., i Halfte. Wien, 1897. 
 
 NossAL. Die Lungenaktinomykose. Zentralb. f. d. Grenzgebiete 
 d. Med. u. Chir. 1902. 
 
 Karewsky. Beitr. z. Lehre von der Aktinomykose der Lunge. 
 Berl. klin. Wochens. 1898, 15^17. 
 
CHAPTER VII. 
 Diseases of the Pleura. 
 
117 
 
 Chapter VII. 
 DISEASES OF THE PLEURA. 
 
 PLEURISY AND EMPYEMA. 
 
 Etiology. — In a certain number of cases pleurisy is a 
 primary affection, and in the majority of these the disease 
 is of tubercular nature. In a second group of cases pleurisy 
 is secondary to disease of adjacent organs, and to this class 
 belong the para- and metapneumonic pleurisies, pleurisy 
 following abscess, gangrene, infarct, and tumours of the 
 lung, bronchiectasis, and mediastinal affections, and those 
 secondary to disease in the abdomen, subphrenic abscess, 
 peritonitis, malignant growths of the intestine and stomach, 
 affections of the liver. In a third group the disease is of a 
 metastatic type occurring in the course of, or following, 
 some general infective process, puerperal sepsis, the acute 
 exanthemata, erysipelas, diphtheria, acute rheumatism. 
 Lastly, it may occur in association with some general 
 dyscrasia, gout, scorbutus, morbus maculosus, renal disease. 
 In serous pleurisy the common pyogenic organisms are 
 usually found, tubercle bacilli only occasionally. In meta- 
 pneumonic cases the Diplococcus Fraenkel-W eichselhauni 
 is the usual organism. In empyemata the pyogenic 
 organisms, and particularly streptococci, are found. 
 
 Pathological Anatomy. — In both the dry and the 
 exudative form the pleura becomes covered with membrane 
 when the affection has been present for a long time. The 
 effusion may be serous, purulent, hsemorrhagic, putrid, or 
 chylous ; unless there are limiting adhesions it occupies the 
 lowest part of the pleural space. As the exudate is absorbed, 
 adhesions may shut off separate fluid-containing spaces. 
 When the inflammatory changes are intense, dense adhesions 
 may form between lung and chest wall, and cause retraction 
 of tlic latter. 
 
ii8 INDICATIONS FOR OPERATION IN 
 
 Clinical Course. — The early symptoms of pleurisy are 
 often very slight, and even large effusions may form un- 
 recognized ; this is especially true of the tubercular type. 
 Usually there is pain in the side, immobility of the affected 
 half of the chest, and cough ; but when effusion is encysted 
 there is often no cough. Fever may be absent ; when it 
 develops it indicates an extension of the inflammatory 
 process ; when the latter becomes stationary the fever 
 usually intermits, and when the exudation is becoming 
 absorbed the temperature returns to the normal. If the 
 onset is attended by rigor, it suggests a complicating pneu- 
 monia, or that the disease is embolic or septic in character. 
 When the effusion is large the tension of the pulse falls, and 
 diuresis diminishes. Friction is heard at the beginning, and 
 towards the end when there is effusion ; and from the time 
 of the appearance of the latter, percussion dullness can be 
 made out, and the affected side of the thorax bulges and 
 becomes more or less immobile. The outline of the limits 
 of the effusion will vary somewhat according to the attitude 
 adopted by the patient. 
 
 When the amount of exudation is large the neighbouring 
 organs are displaced. When it is on the left side there is 
 dullness in Traube's semilunar space. One of the most 
 important signs is the unilateral enlargement of the thorax, 
 though it must be remembered that normally the left side 
 is ^ to 1^ cm. smaller than the right. Sometimes there are 
 attacks of syncope and collapse, but sudden death is rare. 
 
 When, in a patient who has had pleurisy, an area of 
 dullness is present with an irregular outline, and when in 
 this area the other physical signs of fluid are also found, a 
 diagnosis of encysted exudation is indicated. When the 
 lung is adherent to the chest wall, breath sounds will be 
 audible at the point of adhesion. It can only be certain 
 that there is more than one separate collection when the 
 exploring needle obtains fluid of different character at 
 different points, or when, after complete evacuation with 
 the aspirator, more fluid is obtained from some other spot. 
 The exploring needle should be used in all cases of pleurisy 
 with effusion, for the purpose of discovering the exact 
 character of the fluid. An empyema spontaneously dis- 
 charges through the chest wall only when it is associated 
 with some acute septic or gangrenous process ; occasionally 
 
DISEASES OF THE PLEURA. 119 
 
 empyemata are pulsatile. When an empyema discharges 
 through the lung the patient coughs up very large quantities 
 of pus, and signs of pyopneumothorax appear. Meta- 
 pneumonic empyemata often heal spontaneously by this 
 evacuation through the respiratory channels. 
 
 Differential Diagnosis. — In pneumonia the fever is 
 higher and more sustained , the chest wall on the affected side 
 is not bulged, the intercostal spaces move with respiration, 
 and the other known physical signs of pneumonia are present. 
 Sometimes there is difficulty in distinguishing between 
 bronchiectasis and empyema ; when repeated examination 
 gives variable results in the physical signs, bronchiectasis 
 is the more probable. New growths involving the pleura are 
 associated with very severe general symptoms : the supra- 
 clavicular glands are usually enlarged, the area of dullness 
 is irregular, the exudate is often haemorrhagic, and when 
 the exploring needle is used there is a sensation of passing 
 it through a hard mass. In subphrenic abscess the 
 diaphragm is pushed upwards in a dome-shaped manner 
 usually on both sides, and there are also signs pointing 
 to abdominal disease and peritonitis. Hydro thorax is 
 apyrexic, often bilateral, and there is no friction, while 
 there will be present other signs of circulatory disturbance. 
 
 INDICATIONS FOR OPERATION. 
 
 The different operative procedures must be discussed 
 separately. 
 
 I. Paracentesis Thoracis is absolutely indicated in 
 serous effusions under the following circumstances : — 
 
 {a). When the effusion is endangering life ; dangerous 
 symptoms are — continuous or intermittent severe orthopnoea, 
 attacks of syncope, a small pulse, cyanosis of the skin and 
 mucous membranes, marked engorgements of the veins of 
 the neck, extreme displacement of the neighbouring organs, 
 particularly the heart ; these symptoms occur when the 
 effusion is very large in amount, and provide an indication 
 for thoracocentesis without delay. 
 
 [h). When other methods are attended with unsatisfactory 
 results. If an effusion persists for several weeks, and is not 
 fiiminislied by expectant treatment with drugs, etc., it should 
 be drawn off. It will depend upon the amount of the 
 effusion how early aspiration will be indicated. As a rule 
 
I20 INDICATIONS FOR OPERATION IN 
 
 it will not be called for before the third week, and it should 
 not be done whilst fever due to the pleurisy persists, unless 
 there is some exceptional reason for resorting to it early ; 
 however, even if fever continues, aspiration should not be 
 put off if the effusion is progressive, or remains stationary ; 
 sometimes it has to be repeated. The best results are 
 obtained when fever is absent, or at least declining, and 
 when the effusion is stationary, and the urinary secretion 
 small. This is true for tubercular pleuritic cases, as well 
 as for others. 
 
 (c). When the distress of the patient is intolerable ; this is 
 especiall}^ the case in patients who have an associated lung 
 disease, tuberculosis, neoplasm, etc. 
 
 In hsemorrhagic effusions the indications under the 
 headings n. and c. are alone pertinent. In a case of endo- 
 thelioma pleurte under my care I practised thoracocentesis 
 almost weekly for several months, the effusion constantly 
 threatening death. 
 
 Chylous effusion should, as far as possible, only be drawn 
 off when the fluid has ceased to increase in amount, and 
 has been stationary for several weeks. 
 
 Contra-indications to Paracentesis.— K sustained tempera- 
 ture is a contra-indication during the first three weeks unless 
 there is danger to life, and this operation is also inadvisable 
 when the effusion is hgemorrhagic or chylous, unless it is 
 very large in amount and producing serious symptoms. 
 If the fluid be removed under these circumstances it will 
 rapidly reaccumulate, and the operation will have to be 
 repeated. In cases of serous effusion following pneumo- 
 thorax, in which the air has been reabsorbed, and also in 
 cases of effusion after hgemorrhagic infarct of the lung, 
 it is wise not to remove the whole of the fluid, and not to 
 aspirate with high suction pressure, because the visceral 
 pleura is exceptionally friable in these conditions (Gerhardt). 
 
 Risks and accidents of Thoracocentesis. — With patients 
 who are seriously ill sudden death may follow aspiration, 
 especially when large quantities of fluid (over 1500 cc.) 
 are removed at one time. Such deaths occur from 
 thrombosis of the pulmonary veins and embolus ; some 
 are due to cerebral anaemia. In exceptional cases death 
 occurs from haemorrhage into the pleural cavity, or injury 
 to the lung. Pneumothorax is a comparatively frequent 
 
DISEASES OF THE PLEURA. 121 
 
 occurrence after aspiration, and is very often overlooked ; 
 as a rule, in my experience, it disappears in the course of 
 three or four days without causing any alarming symptoms. 
 
 Sometimes after paracentesis there is expectoration of 
 clear fluid, rich in albumin, in large quantities ; this usually 
 ceases after a few hours. The formation of a fistula through 
 the puncture is very unusual ; when aseptic precautions 
 are taken the conversion of serous into purulent effusion 
 need not be feared. 
 
 Results of Paracentesis. — The dyspnoea diminishes, the 
 displaced organs regain their normal situations unless 
 adhesions have formed, the pulse becomes fuller and slower, 
 diuresis increases, and the bulging of the thorax dis- 
 appears. In many cases the effusion is finally cured by the 
 operation. 
 
 Paracentesis in Empyema. — This should only be employed 
 when it can be combined with continuous aspiration- 
 drainage after the method of Biilau ; but this method is 
 rarely employed now. Exceptionally, it is indicated as a 
 preliminary to thoracotomy when the symptoms call for 
 urgent relief. 
 
 2. Thoracotomy. — This operation is indicated : 
 
 {a). When the effusion is purulent, provided that the 
 patient's general condition is sufficiently good. It should 
 be done as soon as the purulent nature of the fluid is recog- 
 nized, except, perhaps, in the metapneumonic empyemata 
 of children ; according to Gerhardt it is not uncommon in 
 the latter cases for spontaneous recovery to take place by 
 rupture of the fluid into the respiratory passages ; in no 
 case, however, should one delay more than three weeks. 
 
 In a case quite recently under my charge there was a 
 patch of pneumonia centrally localized in the right upper 
 lobe. The temperature remained high, and there gradually 
 developed a narrow band of dullness approximately parallel 
 with the lower border of the lung ; below this dull area 
 breath sounds were normal. A leucocytosis was present. 
 A diagnosis of interlobar empyema was made, and the 
 exploring needle drew off pus. Operation (Lotheissen) 
 was immediately undertaken, and a large empyema was 
 found, situated partly between the upper and middle lobes 
 and partly in front of the middle lobe, connected with an 
 abscess in the lung. 
 
122 INDICATIONS FOR OPERATION IN 
 
 (b). When the effusion is putrid. 
 
 (c). In cases of long-standing pyopneumothorax. 
 
 Contra-indications to Thoracotomy. — The operation should 
 not be entertained when acute phthisis coexists, it will 
 only hasten the end. A very low vitality and signs of 
 heart failure are against operation, although cases almost 
 moribund are sometimes rescued. Serious complications 
 in other organs also contra-indicate it. With regard to the 
 relatively rare double empyema opinions are divided. 
 Unverricht considers that in these cases the fluid is always 
 encysted, and can, therefore, be dealt with by double 
 thoracotomy. Chronic pulmonary tubercle is no bar to 
 operation unless it is very extensive. 
 
 Risks. — The dangers, during and after thoracotomy, with 
 rib resection, are in the first instance dependent on the 
 disease itself for which the operation is done. When the 
 case is complicated by severe pulmonary disease, such as 
 tuberculosis or gangrene, the risks are relatively great. 
 Thoracotomy without rib resection is attended by many 
 dangers, and has been, for that reason, almost entirely 
 abandoned. 
 
 Prognosis. — Results of operation. — In many cases, 
 especially in young patients, complete recovery follows. 
 The prognosis is very good in young subjects whose general 
 condition is well maintained ; the great majority recover 
 (at least four-fifths) after a comparatively short conval- 
 escence, if the operation is done in good time. 
 
 Prognosis without operation. — In cases of serous pleurisy 
 the effusion may organize ; in some cases bronchiectasis 
 results, and the thorax may be retracted on the affected 
 side. Purulent effusion is very rarely spontaneously 
 absorbed ; with the exception of the metapneumonic 
 collections, empyemata rarely discharge into the lung or 
 to the exterior, and should this take place high continued 
 fever usually results, and enfeebles the patient ; sometimes 
 metastatic abscesses are formed. 
 
 When the exudate is putrid it often causes death, with 
 symptoms of septicaemia. If a purulent exudation makes 
 its way to the exterior, fistulae form, and discharge persists 
 for a long time ; under such conditions waxy disease 
 of the internal organs commonly supervenes. 
 
DISEASES OF THE PLEURA. 123 
 
 LITERATURE. 
 
 Gerhardt. Die Pleuraerkrankungen. F. Enke. 1892. 
 
 Unv^erricht. Die Krankheiten der Pleura. Handbuch der prakt. 
 Med. von Ebstein-Schwalbe. 1899. Bd. i. 
 
 RosENBACH. Die Pleuraerkrankungen. Nothnagel's Handbuch d. 
 spez. Pathol. Wien. 
 
 Bahrgebuhr. Chylose Ergiisse in serosen Hohlen. Deut. 
 Arch. f. klin. Med. Bd. civ. 
 
 Kummel. Handbuch der prakt. Chir. von Bergmann. Bruns, u. 
 Mikulicz. Stuttgart, 1900. 
 
 Schede. Chirurgie der Pleura. Handbuch der spez. Therap. 
 von Penzoldt-Stintzing. Bd. iii. 
 
 PNEUMOTHORAX. 
 
 Etiology. — Pneumothorax may result from a wound 
 penetrating the chest wall ; it also follows diseases of the 
 lungs in which the pleura is damaged, the most important 
 being tuberculosis, gangrene, and abscess, and, among 
 the less common, bronchiectasis, pulmonary infarct, 
 emphysema, and hydatid. Occasionally it occurs from 
 disease in the alimentary tract encroaching on the pleura, 
 and may also be caused by the rupture of an empyema into 
 the lung. 
 
 Pathological Anatomy. — In recent cases the physical 
 signs are often very confusing ; in old-standing cases the 
 lung is retracted, the neighbouring organs are displaced, 
 and the pleura is thickened and friable. Pneumothorax 
 is often total, but sometimes only partial, when adhesions 
 prevent its extension. Usually there is a patent com- 
 munication with the lung, and the condition is spoken of 
 as open pneumothorax ; more rarely there is no pulmonary 
 fistula, and the term closed pneumothorax is used. In cases 
 of long standing there is always some fluid in the pleural 
 cavity, either simple or septic and foetid pus. 
 
 Clinical Course. — The condition usually has an acute 
 onset, with pain and intense dyspnoea. On the affected 
 side, the chest bulges, and the intercostal spaces project, 
 while the heart, liver, diaphragm, and sometimes the spleen, 
 are displaced. The percussion note is hyper-resonant, 
 and a metallic note (bell sound) is obtained with the ples- 
 simeter. The auscultatory sounds also have a somewhat 
 metallic rjuality, both the respiratory bruit, and also those 
 
124 INDICATIONS FOR OPERATION IN 
 
 heard when the patient coughs or speaks, but only excep- 
 tionally is this noticeable in the case of the heart sounds. 
 The " tinkle " of falling drops is often heard, and sometimes 
 there are sounds resembling those produced in a " hookah." 
 An important phenomenon is the so-called hippocratic 
 succussion, iirst appearing after the pneumothorax has 
 been present for some days. Sometimes, and in particular 
 in traumatic cases, no breath sounds at all are audible on 
 the affected side. The fluid present is free in the pleural 
 cavity, and its limits, as revealed by percussion dullness, 
 vary according to the patient's attitude ; it occupies what- 
 ever for the time being is the most dependent part, and its 
 upper limit is horizontal. When there is a persistent open 
 communication with the lung there is no displacement or 
 retraction of the heart and other structures ; the tympanitic 
 physical signs are usually present in such cases and not 
 infrequently a bruit de pot fele is also heard. A pneumo- 
 thorax in a pleural cavity more or less obliterated by 
 adhesions, is partial ; often under these circumstances 
 there is much deformity from retraction,' but sometimes 
 this is wanting. Usuall}- succussion can be elicited when 
 the condition is of long standing. Radiography shows a 
 clear zone corresponding to the pneumothoracic space or 
 spaces. 
 
 Diagnosis and Differential Diagnosis. — If the phy- 
 sical signs are well developed there can be no difficulty 
 about the diagnosis. A partial pneumothorax may be 
 mistaken for a cavity in the lung, but in the latter condition 
 the characteristic tympanitic signs are very rarely present, 
 and succussion is hardly ever found. The sudden develop- 
 ment of the symptoms, their localization at the base, and the 
 displacement of neighbouring organs, make the diagnosis 
 of pneumothorax certain, for lung cavities of large size are 
 hardly ever present except in the upper lobe, are gradual 
 in development, and are not associated with visceral 
 displacements. 
 
 Subphrenic pyopneumothorax is often difficult to 
 distinguish from pneumothorax, but a history of primary 
 abdominal signs pointing to some suppurative lesion in 
 the abdomen will probably be obtainable in the case of the 
 former. Rarely, there may be some difficulty in deciding 
 whether clinical signs resembling pneumothorax are not 
 
DISEASES OF THE PLEURA. 125 
 
 due to extreme gastric dilatation, or a diaphragmatic 
 hernia. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation is undertaken in some cases for the rehef of 
 extreme dyspnoea, in others for the cure of the condition 
 itself. If dangerous dyspnoea is present, thoracocentesis 
 is indicated ; it is more beneficial to extract fluid than air 
 from the pleural cavity. This vital indication holds for 
 both the curable and incurable cases. No general rules 
 for thoracotomy can be laid down ; the decision will depend 
 on the cause of the pneumothorax, the general condition 
 of the patient, and other matters. The following rule of 
 Gerhardt's will, however, cover many cases: " Pyopneumo- 
 thorax which persists for several days, and is not essentially 
 incurable, should be treated by thoracotomy." The 
 operation is particularly indicated when the condition is 
 secondary to some acute lung disease, such as gangrene 
 and abscess ; if it is secondary to tuberculosis of the lung, 
 more or less circumscribed, the operation is also called for 
 when the patient's strength is well sustained, when fever 
 is absent, and there are no signs that the tubercle is of the 
 rapidly progressive type. 
 
 Spontaneous rupture of an empyema with resulting 
 pneumothorax almost always necessitates operation, but 
 I have seen one such case recover spontaneously after the 
 lapse of a considerable period. 
 
 Contra-indications. — If the fundamental cause of the 
 disease is incurable and extensive, as in such conditions as 
 advanced phthisis, or ulceration and perforation of an 
 oesophageal cancer, thoracotomy is inadvisable ; it is also 
 inadvisable in pneumothorax secondary to infarct, because 
 in this condition there are usually present serious circulatory 
 lesions. If it is suspected that the pneumothorax is of a 
 valvular character, aspiration is contra-indicated. Traumatic 
 pneumothorax, following fracture of the ribs, tends to 
 right itself spontaneously, and- no operation should be 
 done in the early stages. 
 
 Risks of operation. — Simple paracentesis may be followed 
 by extensive cutaneous emphysema if the puncture is above 
 the level of the fluid. Thoracotomy, with washing out, is 
 attended with the same risks as in simple empyema ; 
 
126 INDICATIONS FOR OPERATION IN 
 
 convulsions, paresis, and other serious symptoms, may 
 occur from embolus. In weak subjects the risks of general 
 anaesthesia are to be considered. Miliary tuberculosis may 
 follow operation on tubercular cases, and this has occurred 
 in my own experience. 
 
 Prognosis. — Without operation. — Pyopneumothorax 
 following acute pulmonary disease is attended by risk to 
 life from exhaustion and the other conditions produced by 
 chronic suppuration. The prognosis in tubercular cases is 
 very unfavourable, according to West. When pneumothorax 
 supervenes on pulmonary tubercle death occurs in 90 per 
 cent of the cases within a month. 
 
 Prognosis of operation. — Thoracotomy is often curative 
 when the causal condition of the pneumothorax is some 
 acute destructive pulmonary lesion. In other conditions, 
 where the lung lesion is of more serious and obstinate type, 
 death often occurs in spite of operation from chronic 
 suppuration or some complication. In Schede's words, 
 " the prognosis of the operation for empyema depends 
 directly upon the prognosis of the affection to which the 
 empyema is due.'" 
 
 LITERx\TURE. 
 
 Gerhardt. Die Pleuraerkrankungen. Stuttgart: F. Enke, 1892. 
 
 Unverricht. Pneumothorax. Handbuch der prakt. Med. von 
 Ebstein-Schwalbe, 1900. Bd. i. 
 
 SxiNTZiNG und ScHEDE. Pneumothorax. Handbuch d. Therap. 
 innerer Krankheiten (Penzoldt-Stintzing), iii. 
 
 Baumler. Die Behandlung der Pleura-Empyema bei Lungen- 
 tuberkulosen. Deut. med. Wochens. 1894. Nos. ^y and 38. 
 
 HYDROTHORAX. 
 
 Etiology. — Hydrothorax is caused by the conditions 
 which produce general anasarca ; it occurs as part of the 
 general oedema associated with cardiac and pulmonary 
 disease, or it may be due to the local effect of mediastinal 
 growths, or to a condition of hydraemia. 
 
 Pathological Anatomy. — Either one or both pleural 
 cavities contain a slightly albuminous fluid, but there are 
 no signs of pleural inflammation. The lung is compressed 
 and the diaphragm pushed down as in pleuritic effusion. 
 
DISEASES OF THE PLEURA. 127 
 
 Clinical Course. — The physical signs of fluid are 
 present, but there are no signs of an inflammatory process, 
 nor, usually, are neighbouring organs displaced. The area 
 of dullness is largely dependent on the attitude of the 
 patient ; the fluid of transudation is apparently more 
 mobile than the fluid of exudation, and its specific gravity 
 is below 1014. Relatively frequently in organic heart 
 failure and heart disease there is an effusion on the right 
 side only, which progresses slowly and is very rebellious to 
 internal medical treatment. 
 
 INDICATIONS FOR OPERATION. 
 
 Thoracocentesis may be indicated : (i) By the occurrence 
 of general dropsy, and of marked embarrassment in the 
 movements of the diaphragm and heart, which occurs 
 particularly when there is much ascites. The operation 
 may be performed on one or both sides. (2) By the 
 persistence of hydro thorax, when the general dropsy else- 
 where has disappeared. If the effusion is allowed to remain 
 in such cases the heart is considerably embarrassed, and 
 fresh disturbances of compensation may develop. 
 
 If these indications recur the aspiration will be repeated. 
 
 Contra-indications. — It is inadvisable to rely on repeated 
 paracentesis without the administration of digitalis and 
 other cardiac remedies. 
 
 Prognosis. — // paracentesis is withheld in the first class 
 of cases the sufferings of the patient are greater, and 
 death occurs earlier; in the second class, fresh compensation- 
 defects will arise. 
 
 Risks of operation. — Acute pulmonary oedema, sudden 
 serious cardiac insufficiency, and even cardiac paralysis, 
 are accidents which may follow immediately upon aspiration. 
 
 Results of operation. — The removal of a hydrothorax is 
 often followed by much improvement in the function of the 
 circulatory system, and remedies previously ineffective 
 may then produce good results. 
 
 LITERATURE. 
 
 Gekhardt. Pleurakrankheiten. Deut. Chir. Stuttgart, 1892. 
 KiJMMEL. Die Krankheiten der Pleura. Handbuch der prakt 
 Med. Ebstein-Schwalbe. Bd. i. 
 
128 INDICATIONS FOR OPERATION IN 
 
 TUMOURS OF THE PLEURA. 
 
 Pathological Anatomy. — Tumours of the pleura may 
 be primary or secondary. The primary tumours are 
 endothehomata ; they form dense and extensive masses, 
 spreading for the most part on the surface. Secondary 
 tumours usually co-exist with growths in the lungs. Usually 
 there is effusion in the pleural cavity, and this is often 
 haemorrhagic. 
 
 Clinical Course. — The disease is often masked by 
 extensive effusion. This often develops rapidly without 
 fever, and produces much displacement of organs, and if 
 removed by puncture rapidly collects again. Although 
 often haemorrhagic it may not be so in its early stages, as 
 in a case under my care, in which blood was found present 
 only after the fluid had been drawn off three times. Par- 
 ticles of growth may be found in the fluid, and their discovery 
 has often led to a correct diagnosis. Diagnosis may also 
 be assisted by enlargement of supraclavicular glands, 
 rapid wasting, and the persistence of dullness after puncture 
 in atypical situations. Expectoration of bright red sputum, 
 pointing to growth in the lung, and the rapid development 
 of implantation growth along the puncture track will reveal 
 the true nature of the condition. I have seen such implanta- 
 tion metastases in two cases ; in one, a nodule the size of a 
 hazel nut developed within the short space of forty-eight 
 hours after the aspiration. 
 
 INDICATIONS FOR OPERATION. 
 
 A radical operation is never possible in the case of primary 
 tumours ; but thoracocentesis may be done to prolong life. 
 The interval between one aspiration and another should be 
 kept as long as possible, for the fluid often rapidly reaccumu- 
 lates ; and the drawing off of the highly albuminous fluid 
 at short intervals may hasten rather than delay the fatal 
 termination. 
 
 Secondary involvement of the pleura by growths of the 
 thoracic wall is no contra-indication to operative treatment ; 
 if there is very distressing pain, or symptoms develop 
 which directly threaten life, operation is indicated, even if 
 metastases are already present (Amburger). 
 
 Prognosis. — Dangers of operation. — The risks are greater 
 
DISEASES OF THE PLEURA. 129 
 
 than in dealing with ordinary pleuritic effusions ; it is more 
 frequently followed by haemorrhage into the pleura, and 
 collapse. If the pleural growth is secondary, and there are 
 general metastases, it is, on the whole, wise to do nothing. 
 
 LITERATURE. 
 
 Unverricht. Krebsige Pleuraergiisse. Zeits. f. klin. Med. 
 Bd. iv. 
 
 V. Weismayer. Tumoren der Pleura. Wien, 1897. 
 
 Zagari. Tumori Maligni Primari della Pleura. Naples, 1896. 
 
 RosENBACH. Krankheiten des Brustfells. Nothnagel's Handbuch 
 der spez. Pathol, u. Therap. Bd. xiv., i Halfte. 
 
 Amburger. Brustwandgeschwiilste. Beitr. z. klin. Chir_ 
 Bd. XXX. 
 
CHAPTER VIII. 
 
 Diseases of the Mediastinum. 
 
133 
 
 Chapter VIII. 
 DISEASES OF THE MEDIASTINUM. 
 
 SUPPURATIVE MEDIASTINITIS. 
 
 Etiology. — Hoffmann distinguishes three etiological 
 types : firstly, mediastinitis caused by the spread of inflam- 
 matory processes from neighbouring organs ; secondly, 
 metastatic abscesses ; thirdly, traumatic mediastinitis. 
 Tuberculosis is the most common cause of purulent collec- 
 tions here, less frequently the presence of foreign bodies in 
 the oesophagus or new growths of this channel. In a 
 relatively large number of cases mediastinal suppuration 
 has its origin in the neck or in the buccal cavity or the 
 vertebral column, and makes its way downwards ; occasion- 
 ally it results from the extension of a pulmonary lesion or of 
 a subphrenic abscess. As a metastatic process it is met 
 with in erysipelas and typhoid fever. I have met with two 
 cases in syphilitic subjects. 
 
 Pathological Anatomy. — Suppuration appears to occur 
 more frequently in the anterior than the posterior medias- 
 tinum. Very large collections may form and may make 
 their way into neighbouring organs, or come to the surface. 
 As a rule the lesions are complex and affect parts other than 
 the mediastinum. The pus is often of a highly septic or 
 putrid type. 
 
 Symptoms and Diagnosis. — Mediastinal suppuration 
 must be looked upon as an uncommon lesion ; it is almost 
 always attended by fever, but in tubercular cases this may 
 be of very slight degree. Pain, and particularly throbbing 
 pain, is usual, but not always present; in two cases of my 
 own it was entirely absent. There may be tenderness on 
 pressure over the sternum, and the skin here may be red 
 and fjedematous. Sometimes a skiagram shows a shadow 
 corresponding to the j)urulent collection. I have several 
 
134 INDICATIONS FOR OPERATION IN 
 
 times noted dullness in the first and second intercostal 
 spaces. Various symptoms may arise from compression 
 and narrowing of the mediastinal space, the neighbouring 
 organs and channels are all more or less affected, but in 
 varying degrees. In two of my cases the laryngoscope 
 showed compression of the trachea, and the cause of this 
 was cleared up when a large collection of pus ruptured into 
 the trachea, the mediastinal symptoms then subsiding. 
 Other symptoms that may be met with are paralysis of 
 the recurrent laryngeals, oesophageal symptoms, cardiac 
 embarrassment, engorgement of the cervical veins. In 
 a considerable proportion of cases, both tubercular and 
 non-tubercular, the pus finds its way to the surface through 
 an intercostal space. In many cases the gravity of the 
 primary lesion is such that death results ; occasionally 
 recovery follows discharge of the pus, or a chronic lesion 
 may eventuate. 
 
 INDICATIONS FOR OPERATION. 
 
 As soon as a diagnosis of suppurative mediastinitis has 
 been made, the focus should be opened, provided it is acces- 
 sible, and the patient's general condition admits of operation. 
 The diagnosis is most clear when there is a lesion of the bones 
 adjacent to the mediastinum (sternum, vertebrae), or 
 when the presence of a foreign body in the oesophagus is 
 associated with fever and signs of compression of the medias- 
 tinal organs, but such indications are present in only a 
 small proportion of cases. In most, the indication leading 
 to operation will be the appearance of a circumscribed 
 oedema on some part of the thoracic wall, or the discovery 
 of an abscess which has extended downwards, pointing to 
 some septic lesion at a higher level ; or the discovery of 
 carious bone or of a foreign body in the gullet may lead to 
 a true understanding of the case. Operation consists in 
 opening the mediastinum, either by trephining the sternum 
 or by resection of ribs. 
 
 Contra-indications. — No operation should be done if the 
 exact situation of the pus is not known, if the mediastinal 
 abscess is only one of many metastatic abscesses, or if the 
 suppuration is due to some necessarily fatal lesion. 
 
 Prognosis.— i^esw/i(s of operation. — The results of operation 
 are uncertain. In one case recently under my care the 
 
DISEASES OF THE MEDIASTINUM. 135 
 
 immediate result was good, but the suppurative process 
 steadily extended. 
 
 LITERATURE. 
 
 Hoffmann. Erkrankungen des Mediastinums. Nothnagel's 
 Handbuch d. Spez. Pathol, u. Therap. 1897. 
 
 Hare. The Pathology, Clinical History, and Diagnosis of 
 Affections of the Mediastinum. Philad., 1889. 
 
 Enderlen. Ein Beitr. z. Chir. des hinteren Mediastinums. 
 Deut. Zeit. f. Chir. Bd. cxi. 
 
 HuisMANS. Mediastinale Erkrank. Wiener klin. Rundschau, 
 1901, No. 37. 
 
 MEDIASTINAL TUMOURS. 
 
 Pathological Anatomy. — Tumours of the mediastinum 
 are either primary or secondary, the former alone being 
 suitable for operative treatment. Primary growths may be 
 simple or malignant. The lymphosarcomata are often 
 very extensive and may occupy the whole mediastinal 
 space and envelop the trachea and vessels. The sarcomata 
 earty infiltrate the trachea or the bronchi. Carcinomata 
 are usually secondary. The simple growths are less common 
 than the malignant ; they occur in the following order of 
 frequency : endothoracic goitre, dermoid cyst, fibroma, 
 lipoma, hydatid cyst. An endothoracic goitrous tumour 
 may be retrosternal, and may compress the innominate vein 
 and the trachea, or it may lie behind the clavicle and extend 
 laterally into the thorax and compress the lung ; often it is 
 connected with the thyroid gland by a pedicle of varying 
 size. Occasionally two such growths have been met with, 
 both connected with the thyroid gland. Dermoid cysts 
 are always situated in the upper half of the anterior medias- 
 tinum, and almost always extend to one side of the thorax 
 only. They may reach large dimensions, usually project 
 into the neck or into an intercostal space, and may rupture 
 into a bronchus or into the pericardium or a large vessel ; 
 they often form adhesions to surrounding structures. 
 
 Clinical Course. — The symptoms caused by mediastinal 
 tumours are very variable. In addition to the general 
 symptoms only produced by malignant growths, there is a 
 whole series of important local signs. Dilatation of the 
 veins of the anterior thoracic wall is especially common, 
 and is sometimes associated with oedema. The tumour is 
 
136 INDICATIONS FOR OPERATION IN 
 
 sometimes palpable from the neck ; in intrathoracic goitre 
 it is almost always possible to feel a prolongation from 
 the thyroid passing downwards behind the sternum or the 
 clavicle. Dullness is usually found in the first intercostal 
 space, and signs of pressure on the trachea and bronchi 
 and the other mediastinal structures, oesophagus, nerve 
 trunks, etc. Glandular swellings in the neck are usually 
 only present when the growth is malignant. Pleural 
 effusion is often an associated sign ; even without this the 
 thoracic wall is often bulged, particularly by dermoid 
 growths. When a dermoid cyst ruptures into a bronchus, 
 hair is coughed up by the patient, if it ruptures externally 
 it discharges an oily, viscous fluid ; such a fistula often heals 
 and then breaks down again. 
 
 Diagnosis. — It is of the greatest importance that an 
 early diagnosis of simple mediastinal growths should be 
 made. They are distinguished by their slow development 
 and by the absence of any sudden onset of compression 
 symptoms. The presence of a goitre in the neck will at 
 once indicate the nature of a growth in the upper anterior 
 mediastinum. Dermoid cysts may sometimes be diagnosed 
 by exploratory puncture, as in a case recently seen in a clinic 
 in Vienna (Tiirk) ; in other cases, the discharge from a 
 recently established fistula, or the coughing up of hair 
 associated with signs of mediastinal tumour in a young 
 individual, has established the diagnosis. In one case a 
 skiagram revealed the true nature of such a tumour. 
 
 The greatest difficulty lies in differentiating between 
 tumours and aneurysm, encapsuled pleural effusion, or 
 empyema. Dermoid cysts may be actually associated 
 with the latter. Sometimes a bronchiectasis which ruptures 
 into a bronchus may cause difficulty in diagnosis. 
 
 INDICATIONS FOR OPERATION. 
 
 If a simple tumour of the anterior mediastinum is 
 definitely diagnosed, operation for its removal should be 
 undertaken, unless the patient is very weak or the tumour 
 is of very large dimensions. Very large growths have, 
 however, been successfully removed ; for example, a dermoid 
 cyst of great size was successfully dealt with by v. Eiselberg 
 and Tiirk. 
 
 Contra-indications. — In cases of intrathoracic goitre or 
 
DISEASES OF THE MEDIASTINUM. 137 
 
 other growths, when the symptoms are not urgent, operation 
 should not be undertaken until internal treatment with 
 thyroid extract has been tried. In one case of a most severe 
 type I have observed almost complete disappearance of all 
 symptoms under this treatment. Antisyphilitic treatment 
 should also be tried when there are such signs as glandular 
 swellings. When cachexia, glandular enlargement, and 
 the presence of other growths point to the malignant 
 character of a mediastinal growth, operation would be 
 useless. 
 
 Prognosis. — Risks and results of operation. — The risks of 
 a radical operation must necessarily be great ; but many 
 successful operations on simple growths have been recorded. 
 In many cases of dermoid cyst where extensive secondary 
 adhesions have formed, only incision and drainage is to be 
 recommended. This procedure is much less dangerous 
 than a radical operation, but less likely to be successful in 
 curing the condition. 
 
 // no operation he done, a tumour, although of simple 
 character, will cause death by its mechanical effects. All 
 cases of dermoid cyst left alone have died either directly 
 from the growth, or from some complication (Ekehorn). 
 There are cases, however, in which the presence of the 
 tumour is compatible with a comparatively long life. I am 
 acquainted with a patient who has had tracheal stenosis 
 from a mediastinal growth for seven years, yet he is still in 
 good condition, and the large growth produces relativeh' 
 few local symptoms. 
 
 LITERATURE. 
 
 Hoffmann. Krankheiten. des Mediastinums. Xothnagel's 
 Handbuch d. spez. Pathol, u. Therap. Bd. xiii. 
 
 WuHRMANN. Endothorakale Strumen. Deut. Zeit. f. Chir. 
 Bd. xciii. 
 
 E. Pflanz. Dermoidcvsten des Mediast. Ant. Zeit. f. Heilk. 
 Bd. xvii. 
 
 Ekehorn. Die Dermoidcvsten des Mediast. Ant. Arch. f. 
 klin. Chir. Bd. cvi. 
 
 GussENBAUER. Lipom des Mediastinums. Arch. f. kUn. Chir. 
 Bd. xciii. 
 
CHAPTER IX. 
 
 Diseases of the Heart and Blood-Vessels. 
 
141 
 
 Chapter IX. 
 DISEASES OF THE HEART AND BLOOD-VESSELS. 
 
 PERICARDITIS. 
 
 Etiology. — Pericarditis is most frequently caused by 
 acute rheumatism, tuberculosis, and pleuropneumonia ; 
 next in order of frequency come septicsemia, scarlatina, 
 acute periostitis, and the dyscrasic affections, particularly 
 scurvy, hsemophilia, carcinoma, and Bright's disease. It 
 also appears that a primary infection of the pericardium by 
 way of the blood stream may occur, a form to which the 
 term idiopathic pericarditis is applied. The pericardium 
 also may be involved in contiguous septic processes, bronchi- 
 ectasis, pulmonary gangrene, subphrenic abscess, oesophageal 
 cancer, empyema, mediastinitis, etc. 
 
 Pathological Anatomy. — The inflammatory process 
 may be adhesive or exudative. Exudation may be serous, 
 hsemorrhagic, purulent, or septic. The fluid collects earliest 
 and in greatest amount about the great vessels and in the 
 angle between heart and liver ; when the pericardium 
 becomes distended, fluid collects behind the heart. The 
 amount may reach 1500 cc. or even 2000 cc. The heart 
 muscle is usually involved in the inflammatory process ; 
 when healing takes place the pericardial space is often more 
 or less obliterated. 
 
 Clinical Course. — The affection is characterized by the 
 appearance of friction sounds which are not completely 
 isochronous with the heart phases, are entirely independent 
 of respiration, and are increased in intensity when the 
 stethoscope is pressed on the chest wall. The exudation 
 first fills the cardio-hepatic angle and elevates the base ; 
 later the dullness extends to the left beyond the apex point, 
 and assumes a roughly triangular shape with a broad base ; 
 it extends as the condition progresses. To the left, behind 
 and below, the percussion note is usually tympanitic in the 
 
142 INDICATIONS FOR OPERATION IN 
 
 early stages and the breath sounds are indistinct. Very often 
 a pleuritic inflammation is associated with the pericarditis. 
 The veins of the neck are usually distended ; fever is usual, 
 but not constant ; when the exudate is large the pulse is 
 small and irregular. 
 
 Pericardial effusion takes weeks to absorb, and when 
 large in amount often causes death. The prognosis of puru- 
 lent effusion is bad even when it is small in quantity ; the 
 "rheumatic" cases are the most favourable. 
 
 Differential diagnosis. — Pericarditis externa is differen- 
 tiated by the fact that the friction is influenced by the breath 
 sounds. It is often difficult to distinguish pericardial bruits 
 from endocardial when the right ventricle is dilated. The 
 character of the '' rub," its definite localization at a certain 
 spot, the fact that it does not absolutely correspond with 
 the cardiac phases, and the increased distinctness when 
 the stethoscope is pressed on the thoracic wall, will clear 
 up the diagnosis. In doubtful cases, according to Romberg, 
 the most reliable signs are the gradual increase in the area 
 of dullness and the remarkable correspondence of relative 
 and absolute dullness. 
 
 INDICATIONS FOR OPERATION. 
 
 When the heart begins to fail from the pressure of a large 
 pericardial effusion, puncture of the pericardial sac is 
 absolutely indicated. Puncture is also indicated when a 
 large effusion persists in spite of prolonged medical treatment, 
 and is gradually enfeebling the patient. When pus is 
 present in the pericardium, the latter must always be freely 
 opened unless the general condition is desperately bad. An 
 exploratory puncture will demonstrate the character of the 
 fluid. An effusion is probably purulent when there is pus 
 in the pleura and inflammatory oedema of the chest wall. 
 
 Contra-indications. — Operation is only contra-indicated by 
 the presence of advanced disease elsewhere, such as pro- 
 nounced valvular lesions, new growths, phthisis, Bright's 
 disease. 
 
 Risks of operation. — The risks are considerable, because 
 the heart muscle is usually affected. The right mammary 
 artery and even the right ventricle have been wounded. 
 Obliteration of the pericardial sac often follows operation, 
 and is a serious lesion. 
 
DISEASES OF THE HEART AND BLOOD-VESSELS. 143 
 
 Prognosis. — In many desperate cases recovery has been 
 brought about by operation ; v. Schrotter records 47 
 recoveries and 53 deaths in 100 cases, — but it should be 
 remarked that only the most serious cases have hitherto 
 been submitted to operative treatment. 
 
 LITERATURE. 
 
 V. Schrotter. Erkrankungen des Herzbeutels. Nothnagel's 
 Handbuch. Wien, 1894. Bd. xv., Teil 2. 
 
 Romberg. Krankheiten des Herzbeutels. Spez. Pathol, u. Therap. 
 von Ebstein-Schwalbe. Stuttgart, 1899. Bd. i. 
 
 V. Elsberg. Incision des Herzbeutels. Wien. klin. Wochens. 
 1895, No. 2. 
 
 ANEURYSM. 
 
 Etiology. — Arteriosclerosis is the most important cause 
 of aneurysm ; hence its relative rarity in young subjects. 
 All the conditions which produce atheroma : — alcoholism, 
 laborious occupations, etc., favour the development of 
 aneurysm. Other factors are syphilis and trauma — and 
 the latter may be either single and severe, or slight and 
 repeated. Embolism of the smaller arteries may produce 
 " embolic " aneurysm, and " erosion " aneurysms occur 
 from erosion of vessels from the outside. 
 
 Pathological Anatomy. — The term aneurysm is applied 
 only to circumscribed arterial dilatation ; diffuse dilatation 
 such as that met with in aortic incompetence and atheroma 
 are not so designated. In true aneurysm all the walls of 
 the vessel participate in the formation of the sac, in false 
 aneurysm the sac is formed by some part of the vessel wall 
 along with surrounding structures. Aortic dilatations 
 may be fusiform or saccular. In fusiform aneurysms 
 coagulation and thrombus formation is rare ; in the saccular 
 aneurysms it is common, but organization of thrombus is 
 very rare. The sac may communicate with the artery by a 
 large or a small aperture, it is often extremely adherent to 
 its surroundings, and erodes any bony structures with which 
 it is in contact. 
 
 Aneurysms of the aorta constitute about a half of all 
 aneurysms in man ; they may involve secondarily any 
 structure in the mediastinum, either by simple compression 
 or by the formation of adhesions in addition; ribs, clavicle, 
 
144 INDICATIONS FOR OPERATION IN 
 
 or vertebrae may be eroded. In large aneurysms in place of 
 a single sac there may be secondary or tertiary protrusions 
 communicating with the primary sac by apertures of 
 greater or less size. When an aortic aneurysm penetrates 
 the thoracic wall this almost always takes place through 
 the formation of a secondary protrusion from a saccular 
 aneurysm — a fact of much importance from the point of 
 view of surgical treatment. In the neighbourhood of an 
 aneurysm there is almost always great overgrowth of fibrous 
 tissue embracing the wall ; this assists in preventing 
 perforation in the early stages, but is not equal to preventing 
 it later. 
 
 Rupture may take place externally or into a hollow 
 organ or a serous cavity. Rupture into an adjacent 
 vein produces the so-called varicose aneurysm ; a dissecting 
 aneurysm is one formed in the vessel wall itself by rupture 
 of the inner coat. The vessels originating near the aneurysm 
 undergo changes : traction may make their orifices slit-like, 
 thrombosis and endarteritis may in part obstruct them, or 
 they may be directly compressed. Genuine spontaneous 
 healing of aneurysm is very uncommon. 
 
 Clinical Course. — The clinical signs and symptoms of 
 aneurysm are various. 
 
 Aneurysm of the ascending aorta and arch, as all other 
 vascular tumours, produce subjective and objective 
 phenomena. Pain, often of the character of angina pectoris, 
 is the chief subjective sign, and objectively there are found 
 displacement and compression of neighbouring organs and 
 the development of a pulsating tumour. 
 
 An aneurysm confined to the thorax is often discovered 
 by chance, either from a radiograph or on percussing the 
 chest, or in the course of a laryngoscopic examination. 
 Marked accentuation of the first or second sounds over the 
 course of the aorta, or bruits superadded to these in the same 
 region, will raise the suspicion of aneurysm. Dullness in 
 the first and second intercostal spaces close to the sternum, 
 pronounced pulsation in the suprasternal region, pulsatile 
 elevation of the upper part of the sternum, and pulsation 
 to the right of the manubrium, are definite signs of aneurysm. 
 Associated with or independent of these signs there may be 
 distinct difference in distension of the carotids or subclavians, 
 much more rarely, a delay in the right radial as compared 
 
DISEASES OF THE HEART AND BLOOD-VESSELS. 145 
 
 with the left, or vice versa. Paralysis of the left recurrent 
 laryngeal nerve and corresponding vocal cord is frequent, 
 also localized pulsatile elevation of the tracheal wall, left 
 bronchial stenosis, a laryngeal tug, and more or less marked 
 oesophageal obstruction. When the vertebrae are eroded 
 there is local tenderness on pressure, and rigidity, with 
 unilateral or bilateral intercostal neuralgia. 
 
 If the sternum or the ribs are eroded, the aneurysm may 
 present as a pulsatile and expansile hemispherical tumour. 
 When a saccular aneurysm of the arch causes bronchial 
 stenosis there is stridor and interference with the respiratory 
 cycle on the left side ; an aneurysm situated here also often 
 causes left sympathetic paralysis, but venous compression 
 is rare even in the case of large tumours. 
 
 Aneurysms of the descending thoracic aorta are compara- 
 tively rare ; they may present all the above-named 
 symptoms, but more often are only revealed by the presence 
 of a circumscribed dullness. Sometimes aneurysms are very 
 elongated in outline. I have seen a case in which an 
 aneurysm of the arch extended into the neck from the origin 
 of the carotid to the upper third of the trachea ; death took 
 place from rupture into the trachea. 
 
 Aneurysm of the abdominal aorta is very uncommon ; it 
 is revealed by palpation and auscultation. 
 
 Diagnosis and Differential Diagnosis. — Aneurysms 
 suitable for operation cannot be confounded with many 
 other affections. Simple atheroma of the aorta does not 
 erode and push forward the sternum. Very vascular new 
 growths sometimes give rise to considerable difficulties. 
 Venous distension over the thoracic wall points to new 
 growth, as do also glandular enlargements, the presence of 
 tumours elsewhere, marked cachexia, and soft systolic and 
 diastolic bruits over the swelling. The absence of expansile 
 pulsation is against aneurysm ; abscesses as well as new 
 growths may have pulsation communicated from the aorta, 
 and are differentiated from aneurysm by the same sign. 
 A pointing pulsatile empyema is to be distinguished by 
 the history, the position of the heart, and by exploratory 
 puncture. 
 
 INDICATIONS FOR OPERATION. 
 
 Different operative measures have been employed, and 
 indications vary according to their severity. Complete or 
 
 10 
 
146 INDICATIONS FOR OPERATION IN 
 
 practically complete recovery occurs in rare cases by organi- 
 zation of clot. Such an event occurs almost exclusively iv 
 saccular aneurysms communicating with the vessel by a small 
 aperture ; in fusiform aneurysms it is exceedingly unusual. 
 If an aneurysmal sac has developed secondary extensions, 
 as is almost always the case in those penetrating towards 
 the surface of the chest, the prognosis is unfavourable, 
 but even in these some improvement may be brought 
 about. When the sufferings of the patient are great, 
 the possibility of improving or relieving him of some 
 of his symptoms by surgical intervention is well worth 
 consideration. 
 
 Operation is therefore in a measure indicated when the 
 physical signs point to the presence of a saccular aortic 
 aneurysm with a narrow neck ; a skiagram may be of great 
 assistance. There are, however, other points to be con- 
 sidered : the aneurysm should not be deep seated, but should 
 underlie the thoracic wall or extend beyond the limits of 
 the chest above* ; the condition of the heart must be good 
 without dilatation, and such serious complications as 
 extensive atheroma must be absent. Medical treatment 
 should always be first tried, and operation will only be con- 
 sidered when this has failed. The operation of Brasdor, 
 ligature of the common carotid, or subclavian, or both, does 
 not require that an aneurysm should be saccular and possess 
 a narrow neck, but may be employed in the absence of these 
 conditions. Acupuncture, galvanopuncture, and the intro- 
 duction of foreign material into the sac have the same 
 general indications : the aneurysm should present near the 
 surface, the general state of health must be satisfactory, 
 other vascular changes must not be of an advanced type, 
 and the aneurysm should be connected with the main vessel 
 by a more or less narrow neck. The subjective condition 
 of the patient should have considerable weight attached to 
 it; if his sufferings are extreme, operation may be justifiable 
 even though its chances of success seem small. Sub- 
 cutaneous injections of gelatin may be employed whatever 
 the site and size of an aneurysm, but according to Sorgo it 
 
 * Many writers do not consider this condition necessary, and would 
 recommend operation whether the aneurysm protrudes from the thorax 
 or not. 
 
DISEASES OF THE HEART AND BLOOD. VESSELS. 147 
 
 is only in the saccular form that there is a prospect of 
 success. 
 
 Contra-indications. — These have been already generally 
 indicated. When the sac wall is very thin Brasdor's 
 operation is contra-indicated for fear of rupture. When 
 there are valvular lesions, or when the aneurysm is of great 
 size, no operation will be done. When the trachea is com- 
 pressed, tracheotomy is not advisable, because the pressure 
 of the tube is very likely to lead to rupture of the aneurysm 
 into the trachea. I have seen this happen twice a few days 
 after tracheotomy. In patients with renal disease gelatin 
 injections are contra-indicated. 
 
 Risks of operation in internal aneurysm. In acupuncture, 
 galvanopuncture, and the introduction of foreign matter 
 into the sac, experience has shown that the danger of profuse 
 haemorrhage from the wound is not great ; but when these 
 measures are employed, and the communication with the 
 aorta is large, emboli may be carried into the arterial 
 system. The dangers of Brasdor's operation are those 
 associated with carotid ligature and subclavian ligature ; 
 that is to say, cerebral anaemia and softening on the one 
 hand and gangrene of the arm on the other. Extensive 
 thrombosis of peripheral vessels may follow gelatin injec- 
 tions, and tetanus is a risk if the most careful precautions 
 are not taken. 
 
 Prognosis. — The prospect of cure is small whatever 
 operative measures are employed, but long-lasting improve- 
 ment may be produced. In a case reported by Stewart 
 which was treated by galvanopuncture, improvement lasted 
 three years ; in a case of Baumler's it lasted two years after 
 acupuncture following Brasdor's operation. Cure has been 
 brought about in a relatively large number of cases by 
 Brasdor's operation, and the prognosis is particularly good 
 in innominate aneurysms. In many cases, however, opera- 
 tion has no influence on the progress of the condition. 
 
 When no operation is undertaken, recovery occurs very 
 rarely spontaneously or under medical treatment, but by 
 the latter means and dietetic regulation progress may be 
 checked and the condition improved. Death occurs in 
 the large majority of cases from rupture of the sac or 
 other complicatior. 
 
148 INDICATIONS FOR OPERATION IN 
 
 LITERATURE. 
 
 V. ScROTTER. Die Erkrankungen der Gefasse. Nothnagel's 
 Handbuch d. spez. Pathol, u. Therap. Wien, 1899. Bd. xv., Teil iii. 
 
 Ch. Baumler. Die Behandlung d. Aneurysmen. Handbuch d. 
 Therap. von Penzoldt-Stintzing. Bd. iii. 2nd Ed. 
 
 Romberg. Die Krankheiten der Gefasse. Handbuch der prakt. 
 Med. von Ebstein-Schwalbe. Stuttgart, 1898. Bd. i. 
 
 Quincke. Aneurysmen. Ziemssen's Handbuch. Bd. v. 
 
 Stewart. On the Treatment of Aneurysm. Brit. Med. Jour., 
 Aug. 14th, 1897. 
 
 Mace WEN. Aneurysm. Lancet, 1890. Vol. ii., 1086. 
 
 Sorgo. Die Behandlung d. Aneurysmen mit Gelatine. Therap. 
 d. Gegenwart, 1900. 
 
 HYDROPS ANASARCA. 
 
 Indications for Operative Treatment. — The anasarca 
 due to cardiac and renal disease is alone in question ; for the 
 oedema of cachexia no operation is justified. There is some 
 difference of opinion as to the best time for operative treat- 
 ment ; some employ it only when all other therapeutic 
 procedures have failed, others advise it early. It is well to 
 follow the indications formulated by Romberg : when 
 diuretic stimulation fails and diaphoresis is impracticable or 
 ineffective, and the condition of the patient calls for urgent 
 relief from the oedema, puncture of the skin should be 
 employed. This is a vital indication, and apart from this 
 the operation is advisable when the anasarca is great and 
 distressing to the patient, and is unrelieved by drugs, 
 particularly if the general condition is good. Incision may 
 take the place of puncture if the state of the skin is not 
 favourable for the latter. 
 
 Contra-indications. — Erysipelas, phlebitis, and other 
 extensive inflammatory processes of the lower limbs contra- 
 indicate operative treatment, and it is the same in my 
 experience when the legs are in a condition of elephantiasis, 
 with much thickening of the skin and overgrowth of 
 connective tissue beneath — in such condition only very 
 small quantities of fluid can be drawn off. If the patient is 
 stupid, unreasonable, and unruly, the risks are considerable. 
 
 Prognosis. — Risks of operation. — If the patient is difficult 
 to manage, and if drainage is kept up for a long time, there 
 are risks of infection. If large incisions are made and the 
 fluid escapes very rapidly, the drainage may be, and often 
 
DISEASES OF THE HEART AND BLOOD-VESSELS. 149 
 
 has been, followed by collapse and sudden death. I have 
 seen sudden death occur several times on the second, third, 
 or fourth day after the rapid drawing off of the fluid, and 
 after a period of comparative well-being, and I consider that 
 at the most four litres pro die should be removed by punc- 
 ture or scarification. It is also necessary to bear in 
 mind that scarification and puncture, often repeated, result 
 in so considerable a loss of albumin that amyloid changes 
 in the viscera may be induced thereby. 
 
 Results. — Operative treatment often saves life ; the 
 heart is considerably relieved, and the circulatory disturbance 
 may then right itself. The subjective condition of the patient 
 often improves greatly in the course of a few hours ; the pains 
 in the bones and the dyspnoea disappear. Usually puncture 
 promotes diuresis, and diuretics and cardiac stimulants are 
 more effective after than before it. In a case of mine of 
 mitral insufficiency and stenosis, with extreme and universal 
 anasarca, after puncture of the ascites and drainage of the 
 skin of the legs for some days, the oedema entirely disappeared, 
 and remained absent absolutely for three years. 
 
 LITERATURE. 
 
 GuMPRECHT. Die Chir. Behandlung der Hautwassersucht einst 
 und jetzt. Zentralb. f. d. Grenzgebiete d. Med. u. Chir. 1899. 
 Nos. 1-3. 
 
 FuRBRiNGER. Bchandlung des Hydrops. Deut. med. Wochens. 
 1899. No. I. 
 
 RoTMANN. Die Chir. Behandlung der Hautwassersucht. Deut. 
 med. Wochens. i8q6. No. 48. 
 
 Romberg. Behandlung d. Herzkrank. Handbuch der prakt. 
 Med. von Ebstein-Schwalbe. Bd. i., p. 912. 
 
 Krcnig. Operative Behandlung der Hautwassersucht. Ver- 
 handlung des Kongresses f. innere Med., 1897, p. 555. 
 
CHAPTER X. 
 
 The Indications for Venesection. 
 
153 
 
 Chapter X. 
 THE INDICATIONS FOR VENESECTION. 
 
 Venesection, once so common and then abandoned, is 
 again employed to-day under certain circumstances. The 
 two fundamental indications - are the removal of toxic 
 products and the relief of the circulation ; it is no longer 
 done on ' ' antiphlogistic " principles. The most generally 
 accepted indications are as follows : — 
 
 INTOXICATIONS. 
 
 In the intoxications venesection is an important thera- 
 peutic agent, in particular in the cases of poisons which 
 concentrate themselves in the blood and directly affect it. 
 As much as 300-400 cc. may be drawn off from patients 
 suffering from the effects of the inhalation of poisonous gases : 
 sulphuretted hydrogen, coal gas, carbonic oxide, hydro- 
 cyanic acid, and anaesthetic nitrous oxide. The risks of the 
 blood-letting are minimal compared with those to which such 
 patients are exposed, particularly if followed immediately 
 by transfusion of saline ; the risks are greatest in anaemic 
 and least in full-blooded individuals. 
 
 INSOLATION. 
 
 In insolation bleeding is indicated when internal rnedica- 
 tion fails and convulsions make their appearance. Of 
 twenty cases thus treated Gerand lost none. 
 
 UREMIA. 
 
 In uraemia bleeding should always be tried ; when 
 attacks come on suddenly and other methods fail, life has 
 often been saved by this means. The risk is comparatively 
 insignificant. In the clironic forms of uraemia, in which the 
 
154 THE INDICATIONS FOR 
 
 patient may remain for weeks in a somnolent condition, 
 interrupted by attacks of dyspnoea and vomiting, bleeding 
 may be of great use on the onset of convulsions or coma. 
 According to Strubell the abstraction of blood and trans- 
 fusion of saline has sometimes saved life under these 
 circumstances. This form of chronic uraemia is usually 
 associated with idiopathic or secondary interstitial nephritis. 
 Bleeding is also of great value in uraemia due to acute and 
 subacute nephritis ; according to Leube it lessens the gravity, 
 the risks, and the length of the attacks. 
 
 ECLAMPSIA. 
 
 According to Zweifel copious bleeding up to 500 cc. 
 is advisable in this affection. It is valuable as a 
 preliminary to the production of artificial labour, and the 
 combination of these two procedures has given results 
 superior to all other methods of treatment, deep cervical 
 incisions and the like. It is absolutely indicated when 
 eclampsia comes on during labour, or persists after natural 
 or artificial delivery. 
 
 PNEUMONIA. 
 
 Bleeding is only indicated in pneumonia in the presence 
 of established or commencing pulmonary oedema associated 
 with commencing heart failure. Feebleness of the second 
 pulmonary sound indicates the onset of heart failure ; 
 bleeding often gives such relief that the patient's 
 strength is thereby enabled to hold out until the crisis. 
 Under these circumstances the indication is absolute unless 
 some other dangerous lesion is present elsewhere or the 
 enfeeblement of the patient is already extreme. I have 
 often seen venesection save life in pneumonia, especially 
 in patients with some heart lesion. 
 
 CIRCULATORY DISTURBANCE. 
 
 In circulatory disturbance due to valvular or myocardial 
 lesions the indications for venesection are not definitely 
 determined. According to H. Pavy it is indicated in 
 commencing heart failure, dilatation of the right ventricle 
 with progressive dyspnoea, commencing oedema of the bases, 
 
VENESECTION. 155 
 
 and diminished pulmonary second sound. It is indicated 
 early, according to Strubell, in bronchitis of a severe type, 
 and pneumonia in alcoholic subjects. In chronic heart 
 disease its effect is transient, and in several patients thus 
 affected bleeding has been followed by thrombosis, for 
 example in the basilar artery. 
 
 CHLOROSIS. 
 
 Venesection has been employed in chlorosis, but is not 
 to be recommended. 
 
 LITERATURE. 
 
 Strubell. Der Aderlass. Zentralb. f. d. Grenzgebiete d. Med. 
 u. Cliir., 1902. 
 
 Jaksch. Ueber die Therap. Wert der Blutentziehungen. Prager 
 med. Wochens. 1894, 32-35. 
 
 NcNNE. Aderlass bei Chlorose. Aertzl. Verein zu Hamburg, 25 
 Juni, 1895. Deut. med. Wochens. 1896. 
 
 Leube. Nierenkrankheiten. Handbuch d. Therap von Penzoldt- 
 Stintzing. Bd. vi. 
 
 ZwEiFEL. Zur Behandlung der Eklampsie. Zentralb. f. Gynak., 
 1895, No. 46. 
 
 AuFRECHT. Lungenentziindungen. Nothnagel's Handbuch d. spez. 
 Pathol. Bd. xiv. 
 
 B.4.UMLER. Kreislaufsstorungen. Handbuch d. spez. Therap. 
 von Penzoldt-Stintzing, Bd. hi. 2nd Ed. 
 
 Pavy. The Indications for Bleeding. Birmingham Med. Review. 
 Dec, 1900. 
 
CHAPTER XL 
 Diseases of the Mouth and Pharynx. 
 
159 
 
 Chapter XI. 
 DISEASES OF THE MOUTH AND PHARYNX. 
 
 HYPERTROPHY OF THE TONSILS. 
 
 Etiology. — There often appears to be some hereditary- 
 tendency to this condition. It may follow repeated attacks 
 of tonsillitis, and is also associated with the so-called 
 scrofulous condition. 
 
 Pathological Anatomy. — Tonsillar hypertrophy is 
 usually bilateral, and often so considerable as to markedly 
 obstruct the pharyngeal channel. The tonsils are sometimes 
 soft, sometimes hard, and often fissured. The crypts often 
 contain calculi, plugs of mucus, or pus, the latter often only 
 revealed on squeezing the tonsil, and associated with 
 thrombosis of the neighbouring veins. I have seen several 
 cases of fatal septiceemia due to such purulent collections 
 only revealed by a specially careful examination at autopsy. 
 
 Clinical Signs. — Tonsillar hypertrophy favours recurrent 
 attacks of inflammatory mischief, attacks which it is now 
 well recognized are far from being harmless. When hyper- 
 trophy is marked, respiration is prejudiced, especially 
 during sleep, and there are difficulties of phonation and 
 deglutition. Pharyngeal catarrh often co-exists, and the 
 Eustachian tubes and middle ear are then frequently 
 affected. The pharyngeal adenoid tissue is also very often 
 hypertrophied. 
 
 INDICATIONS FOR TONSILLOTOMY. 
 
 Hypertrophied tonsils should be removed if they are 
 giving rise to the least trouble. The operation is therefore 
 indicated when the tonsils are subject to repeated attacks 
 of inflammation, when there are disturbances of phonation 
 or deglutition, when there are any signs of middle-ear 
 trouble or deafness, or when sleep is disturbed and restless. 
 
i6o ■ INDICATIONS FOR OPERATION IN 
 
 Contra-indications. — Haemophilia and leukcemia are the 
 only contra-indications. 
 
 Prognosis. — Risks of operation. — These are minimal. 
 Occasionally troublesome haemorrhage has occurred from the 
 tonsillar branch of the pterygopalatine (O. Zuckerkandl). 
 In one case of unrecognized lijemophilia under my care the 
 operation caused dangerous haemorrhage. 
 
 If no operation is done the tendency to tonsillitis will 
 remain, with the risks of middle-ear disease, pharyngitis, 
 extensive suppuration, and septicaemia. 
 
 LITERATURE. 
 
 Frankel. Article " Tonsillen " in Eulenberg's Realency- 
 klopadie. 
 
 LiCHTWiTZ. Archiv. fiir Laryngologie. Bd. ii. 
 
 Stork. Erkrankungen der Nase und des Rachens. Nothnagel's 
 Handbuch d. spez. Pathol. 
 
 Fleiner. Krankheiten der Verdauungsorgane. Teil i. Stutt- 
 gart, 1896. 
 
 SEPTIC PHARYNGITIS. 
 
 Etiology. — This affection is frequently due to the strepto- 
 coccus, and may be secondary to infections elsewhere in the 
 mouth, for example in the tonsils and the teeth. It is 
 common in diphtheria and scarlatina. 
 
 Pathological Anatomy. — The inflammatory process 
 affects the connective tissue between the tonsils and the soft 
 palate, or the substance of the tonsils themselves. As a 
 rule the process goes on to suppuration ; sometimes it 
 extends widely in the connective tissue of the neighbourhood, 
 and may occasion an intense phlegmonous inflammation of 
 the floor of the mouth and the pharynx, with marked 
 collateral oedema ; this sometimes involves the entrance to 
 the larynx, and in fatal cases this is' the cause of death. 
 
 Clinical Course. — There is usually high fever, and much 
 pain is complained of, particularly on swallowing and 
 opening the mouth. Examination shows marked swelling 
 and dusky red coloration of the soft palate (usually more 
 intense on one side), of the anterior pillars, and often of the 
 tonsils themselves ; the surrounding parts are oedematous, 
 particularly the uvula and faucial pillars, more rarely the 
 laryngeal entrance. After some days suppuration occurs ; 
 this is first deeply situated, and later comes to the surface. 
 
DISEASES OF THE MOUTH AND PHARYNX. i6x 
 
 Usually after about a week the pus escapes ; in a relatively- 
 small number of cases, however, the process goes on to an 
 extensive phlegmonous inflammation of the floor of the 
 mouth, the so-called Angina Ludovici, and this may produce 
 a fatal acute oedema of the glottis. 
 
 INDICATIONS FOR OPERATION. 
 
 As soon as pus is suspected incisions should be made, 
 whether the collection appears to be superficial or deep. 
 Incision is therefore called for when the signs and symptoms 
 above described have been present for several days ; if 
 the pain is very intense, early deep incision is advisable ; 
 in other cases it is well to wait until an abscess has 
 definitely developed (Stork recommends that one should 
 always wait until fluctuation is discovered) ; certainly, 
 at whatever stage fluctuation is found an incision will at 
 once be made. 
 
 It may be said that no contra-indications exist. 
 
 Prognosis.— Resulis of incision. — The patient is at once 
 relieved, and the inflammation subsides. If pus is not 
 found at the time of incision, it may be expected that it 
 will come to the surface and escape through the incision in 
 the course of a few hours or days. There is no risk when 
 the incision is made at the right spot, that is to say in the 
 centre of the space between the uvula and the crown of the 
 upper wisdom tooth. 
 
 // no incision is made, the symptoms may persist for a 
 considerable time, and sometimes as a consequence there 
 occur oedema of the glottis, Ludwig's angina, or extensive 
 abscess burrowing. Such an abscess may even extend into 
 the mediastinum. 
 
 LITERATURE. 
 
 Stork. Krankheiten der Nase, des Rachens. Nothnagel's Hand- 
 buch d. spez. Pathol. Wien, 1895. 
 
 Strubixg. Krankheiten des Rachens. Handbuch d. prakt. Med. 
 von Ebstein-Schwalbe. Bd. i. 1899. 
 
 RETROPHARYNGEAL ABSCESS 
 AND RETROPHARYNGEAL CELLULITIS. 
 
 Etiology. — In young children the most frequent cause 
 of retropharyngeal abscess is suppuration of the two 
 
i62 INDICATIONS FOR OPERATION IN 
 
 prevertebral lymphatic glands, which are constantly present 
 in front of the second and third cervical vertebrae ; it is 
 secondar}' in these cases to inflammatory affections of the 
 pharynx. The other common cause is a tuberculosis of 
 the vertebral bodies. I have seen two cases in which the 
 primary affection was a syphilitic lesion of the cervical 
 spine, but this is very rare. Sometimes these inflammatory 
 processes are due to some general infection, or may follow 
 trauma, in particular cauterization, of the posterior wall 
 of the pharynx. Occasionally a retropharyngeal abscess 
 is secondary to a chronic otitis media. 
 
 Clinical Signs. — Retropharyngeal abscess produces a 
 series of characteristic symptoms. The posterior pharyngeal 
 wall is swollen, and fluctuation can be made out; swallowing 
 and expectoration are painful and difficult ; when the 
 condition is well established no solid food can be swallowed, 
 and fluids also cause difficulty, and tend to return through 
 the nose or the mouth. Speech is guttural, as though the 
 patient had his mouth full of food, and breathing is difficult 
 and snoring, particularly with the head inclined forwards. 
 Asphyxial attacks sometimes come on when the patient is 
 lying down. In acute abscesses there is often high fever ; 
 in the chronic form it may be absent. Acute cellulitis 
 may cause pronounced prostration and symptoms of septic 
 intoxication. There are often enlarged and tender glands 
 below the jaw, and oedema about the laryngeal inlet. 
 
 Differential Diagnosis. — The presence of fluctuation 
 differentiates abscess from tumour, simple lymphadenitis, 
 and adenoids. 
 
 INDICATIONS FOR OPERATION. 
 
 As soon as abscess is definitely diagnosed it should be 
 incised. It should be opened in the neck when it is of 
 very large size, when it is due to tubercular vertebral 
 disease or to the presence of a foreign body, and when there 
 is severe pharyngeal cellulitis. The common retropharyngeal 
 abscess should be opened from the mouth when the diagnosis 
 is clear. If no fluctuating spot can be found, if the respira- 
 tion is very embarrassed, or if there is commencing oedema 
 glottidis, tracheotomy is indicated. When suppuration is 
 definitely made out there are no contra-indications to 
 operation. 
 
DISEASES OF THE MOUTH AND PHARYNX. 163 
 
 Prognosis. — Risks of operation. — If a large quantity of 
 pus enter the larynx, asphyxia may occur or pneumonia 
 may follow. 
 
 // no operation is done, death may occur from asphyxia, 
 the abscess may make its way into the mediastinum, or 
 septicaemia may supervene. In Bokai's statistics 11 out of 
 144 cases of retropharyngeal abscess died. 
 
 LITERATURE. 
 
 Fleiner. Erkrankungen der Verdauungsorgane, Teil i. Stutt- 
 gart : E. Enke. 
 
 ScHECH. Krankheiten der Mundhohle und des Rachens. 4th Ed. 
 
 Alexy. Retropharyngealabscesse. Jahrb. f. Kinderheilk., 
 1892, Neue Folge, Bd. xvii. 
 
 Neumann. Akute Entziindung der Retropharyngeal Lymph- 
 driisen. Arch. f. Kinderheilk, Bd. xv. 
 
CHAPTER XII. 
 
 Diseases of the CEsophagus. 
 
16; 
 
 Chapter XII. 
 DISEASES OF THE (ESOPHAGUS. 
 
 FUSIFORM DILATATION OF THE (ESOPHAGUS. 
 
 Etiology. — In one class of case spasm of the cardiac 
 orifice is the primary cause ; in a second class atony and 
 dilatation of the oesophagus is the primary lesion, followed 
 by spasm of the cardia. In both classes the time of onset 
 is usually between the 20th and 40th years. It is usually 
 an acquired condition, and equally common in men and 
 women. 
 
 Pathological Anatomy. — The dilatation begins usually 
 just below the level of the larynx, increases throughout the 
 middle and lower thirds, sometimes to enormous dimensions 
 (in Rokitansky's case to the size of a man's forearm), and 
 then reaches normal dimensions again at about the lower 
 1-2 cm. The size of the dilatation may be such that the 
 oesophagus will hold as much as 150G cc. The cardiac 
 orifice is usually free from cicatricial stenosis, but there is 
 often local hypertrophy of the wall here. 
 
 Symptoms. — The symptoms are chiefly those of 
 oesophageal stenosis. If food and fluids cannot be got into 
 the stomach they are regurgitated without any actual 
 vomiting. Rumination is common. Examination with the 
 stomach tube gives most important information ; when the 
 tube is in the oesophagus it brings up quantities of altered 
 food material free from hydrochloric acid or pepsin ; when 
 pushed further on into the stomach, which often necessitates 
 the overcoming of some resistance, food material is siphoned 
 up containing both these substances, provided the condition 
 of the stomach is healthy. Such an observation demon- 
 strates the presence of a cavity above the cardia. The same 
 may be demonstrated by passing one tube into the stomach 
 and a second into the oesophagus, and introducing some 
 
i68 INDICATIONS FOR OPERATION IN 
 
 colouring matter through the latter ; the coloured fluid 
 comes through the oesophageal but not through the stomach 
 tube. 
 
 Diagnosis and Differential Diagnosis. — The symp- 
 toms just mentioned may also be caused by an oesophageal 
 diverticulum situated at a low level. Leube's sound will 
 often settle the question. If this passes into the stomach 
 without difficulty the case is probably one of concentric 
 dilatation. The second deglutition sound which is heard 
 over the cardiac orifice is altered in cases of fusiform 
 dilatation ; that is to say, it may be postponed several 
 minutes after the act of swallowing. Sometimes a radio- 
 graph gives useful information. 
 
 INDICATIONS FOR OPERATION. 
 
 Hitherto gastrostomy is the only operative procedure 
 which has been done in these cases, and then only as a 
 last resource when the patient threatens to die of starvation, 
 that is to say, is in an advanced stage of the condition. 
 Rumpel has proposed direct operative treatment, but the 
 suggestion has not been followed. 
 
 Prognosis. — Gradual increase is the rule in this condition, 
 and death may follow from starvation. In many cases life 
 tnay be prolonged without operation for ten years or more, 
 so that vitally the prognosis is not entirely unfavourable. 
 
 LITERATURE. 
 
 Neumann. Die einfache gleichmassige Erweiterung der 
 Speiserohre. Zentralb. f. d. Grenzgebiete d. Med. u. Chir. 1900. 
 
 Krauss. Krankheiten der Speiserohre. Nothnagel's Handbuch 
 d. spez. Pathol. 1901. 
 
 DIVERTICULUM OF THE (ESOPHAGUS. 
 
 Etiology. — There are two types of this condition : the 
 pressure diverticulum and the traction diverticulum. The 
 former is probably due primarily to some congenital 
 anomaly of the nature of a defect in the lower part of the 
 pharyngeal wall, which yields when some traumatic influence 
 IS brought to bear on it. The traction diverticula are 
 produced by adhesions following some inflammatory affection 
 in the parts surrounding the oesophagus, as, for example, 
 lymphadenitis, pleurisy, pericarditis, vertebral disease, etc. 
 
DISEASES OF THE (ESOPHAGUS. 169 
 
 Pathological Anatomy. — The traction diverticula are 
 often situated at the level of the tracheal bifurcation ; they 
 are small, and clinically of little importance. Pressure 
 diverticula may be situated high up or in the lower part. 
 The pharyngo-oesophageal form has its origin in some weak 
 spot in the muscular coat of the pharynx, usually about the 
 level of the cricoid cartilage, and sometimes communicates 
 with the pharynx by quite a small opening. It is sacciform 
 in shape, and when full may greatly compress the oesophagus, 
 by the side of which it lies. It may reach the size of a man's 
 fist ; in one of my cases the capacity was a quarter of a litre. 
 The deep diverticula may be equally large and originate in 
 the anterior wall near the tracheal bifurcation. These 
 diverticula may produce an inflammatory reaction around 
 them, and become firmly adherent to other structures; the 
 trachea as well as the oesophagus may be compressed. The 
 pressure diverticula have a lining of mucous membrane. 
 
 Symptoms. — The traction diverticula do not produce any 
 symptoms by which they can be recognized during life. 
 The pressure or "Zenker's" diverticula give rise at the 
 beginning to slight difficulty in swallowing, irritation in the 
 throat, and expectoration. Vomiting after a meal is common. 
 In the later stages, when the condition has been present 
 for some years, the difficulties in swallowing increase, the 
 sac lills at the beginning of a meal, and the food material 
 remains there and decomposes. By traction and direct 
 pressure the oesophagus becomes much narrowed. After 
 a varying period the contents are vomited ; they contain 
 no free hydrochloric acid, but sometimes inverted starch ; 
 they are undigested and mixed with a large amount of 
 mucus. In about a third of the cases a soft, fluctuating 
 swelling is to be found in one or both supraclavicular 
 regions, and over this bruits can be made out. There is 
 often excessive foetor of the breath. A sign of much 
 importance is the gradual displacement downwards of the 
 site of compression, taking place slowly during the course of 
 some years. Examination with the sound and skiagraphy 
 may both be of much assistance in forming a diagnosis. 
 The affection is one of old age and eminently chronic ; it 
 may cause extreme emaciation. 
 
 In a case recently under my own observation a difficulty 
 in swallowing gradually developed. The sound was arrested 
 
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 at a point 28 cm. from the teeth ; there was frequent 
 vomiting of decomposed food material, and lavage showed 
 that the sac was capable of containing about a quarter of a 
 litre. Lotheissen was able to see the entrance to the sac 
 and guide the oesophageal sound past it. With the X-rays 
 the sac was well seen when filled with bismuth, and a U-shaped 
 lead sound introduced into it was also demonstrated. It 
 had reached the thoracic cavity and moved with respiration ; 
 the mucous membrane was ulcerated in patches, and there 
 was an enormous production of mucus. Vomiting was 
 painless and occurred on coughing. The patient could only 
 be fed by enemata, and a gastrostomy was done at a time 
 when there were signs of commencing pneumonia. Death 
 took place some days later, and the large diverticulum was 
 demonstrated post mortem behind the oesophagus, with 
 commencing carcinoma at its entrance. 
 
 The deep-seated diverticula often give rise to stenosis 
 phenomena and pain only when the sac is filled during the 
 meal ; but the symptoms may be in general very similar 
 to those of the diverticula above, and the physical signs are 
 the same. For radiographic demonstration the patient is 
 fed with bismuth and mashed potato. 
 
 The diagnosis will be based on the history, the presence 
 of the tumour in the neck, the examination with the sound, 
 and the age of the patient. The chronic course of the 
 affection will distinguish it from carcinoma, and the history 
 from cicatricial stenosis. 
 
 INDICATIONS FOR OPERATION. 
 
 If there is impermeable stenosis, gastrostomy may be 
 indicated, and from the point of view of the life of the 
 patient it may be said to be as successful as radical extir- 
 pation. It is particularly indicated in debilitated individuals 
 who first come under observation at a late stage, also in 
 patients who are not favourable subjects for a general 
 anaesthetic, and thirdly, when stenosis is so marked that 
 radical operation promises little success. It may also be 
 undertaken with a view to retrograde dilatation with 
 sounds. 
 
 Extirpation of the diverticulum may be undertaken when 
 it is situated high up, whatever its size, and when it is 
 interfering with feeding and causing stenosis. It should 
 
DISEASES OF THE (ESOPHAGUS. 171 
 
 be done at as early a stage as possible. It is not free from 
 risk, and will therefore not be advisable in advanced debility. 
 Gastrostomy is practically free from risk ; total extirpation 
 is comparatively dangerous. 
 
 // no operation is undertaken, the condition is chronically 
 progressive, and will cause a very distressing death from 
 inanition. 
 
 LITERATURE. 
 
 Krauss. Die Erkrankungen der Speiserohre. Nothnagel's 
 Handbuch d. spez. Pathol. Bd. xvi. 
 
 H. Starck. Die Divertikel der Speiserohre. Leipzig, 1900. 
 
 W. Rosenthal. Die Pulsionsdivertikel des Schlundes. Leipzig, 
 1902. 
 
 (ESOPHAGEAL STENOSIS: CICATRICIAL AND 
 CARCINOMATOUS. 
 
 Etiology. — Cicatricial stenosis is usually due to scald or 
 the burn of some corrosive, more rarely to wound or other 
 trauma. Occasionally it is due to the pressure and adhesion 
 of lymphatic glands or to the contraction of an ulcer caused 
 by a perforating diverticulum. 
 
 Pathological Anatomy. — The stenoses caused by 
 corrosion tend to occur at the natural isthmuses of the 
 oesophagus, that is to say, at the level of the cricoid cartilage, 
 and at the cardia or immediately above it. Such strictures 
 are usually annular; if their extent is more than from 5 to 
 10 cm. they are spoken of as cylindrical ; sometimes the tube 
 dilates above, and this dilatation may show ulceration, and 
 may even go on to perforation. 
 
 Carcinoma is almost always primary ; very rarely a 
 growth of the cardiac end of the stomach spreads to the 
 oesophagus ; the common site is the level of the tracheal 
 bifurcation. Sometimes the growth is scirrhous and 
 produces pronounced stenosis, sometimes it is exuberant 
 and cauliflower-like. Perforation into the lung, pericardium, 
 and other organs is common, and the mediastinum and 
 vertebral column are encroached upon. 
 
 Symptoms. — Cicatricial stenosis causes difficulties of 
 deglutition, which become more marked as the stenosis 
 increases, and lead to defective nutrition. The same signs 
 are present in carcinoma, but the patient shows cachexia 
 
172 INDICATIONS FOR OPERATION IN 
 
 at an earlier stage. Regurgitation of food is usual, and 
 often there is an excessive mucous secretion. Examination 
 with the sound usually demonstrates a stricture, but not 
 always ; pain is sometimes present independent of the taking 
 of food. (Esophagoscopy may directly demonstrate a new 
 growth. The normal deglutition bruit is sometimes absent. 
 In late stages signs of the involvement of other organs may 
 appear, and the supraclavicular glands may be enlarged. 
 The actual stenosis may vary if parts of the growth slough 
 from time to time. 
 
 Differential Diagnosis. — The true character of a 
 cicatricial stricture is usually revealed by the history, and 
 oesophageal cancer produces such characteristic symptoms 
 that the diagnosis is seldom in doubt. The affections which 
 may give rise to difficulty are aortic aneurysm, fusiform 
 dilatation of the oesophagus, and diverticulum. In aneurysm 
 other and characteristic symptoms are almost always present, 
 and radiography will aid in diagnosis. Any abrupt change 
 in the stenosis symptoms is against cancer. If there is a 
 disproportion between the difficulty in swallowing and the 
 difficulty in passing a bougie, it will point to spasm. A slow 
 development and the regurgitation of large quantities of 
 decomposed food point to diverticulum. 
 
 INDICATIONS FOR OPERATION. 
 
 If a cicatricial stricture is situated in the upper part 
 of the oesophagus, if it is annular and shallow and so 
 rigid that it cannot be dilated, then the advisability of 
 total extirpation should be considered. This operation 
 may also be indicated when in such a high stricture there 
 are pouches or kinking above, which oppose great difficulties 
 to non-operative measures (H. Starck). According to 
 Hacker, gastrostomy is advisable in all cases of impassable 
 stricture, particularly of the lower oesophagus. The 
 time of choice for operation is when it has been definitely 
 ascertained that the body weight and the urine secretion 
 are progressively diminishing. In cicatricial stenosis 
 gastrostomy affords the opportunity of retrograde dilatation, 
 and one is only rarely content with the simple provision of 
 a food fistula. 
 
 In carcinoma of that part of the oesophagus which lies in 
 the neck, early removal of the growth by oesophageal 
 
DISEASES OF THE (ESOPHAGUS. 173 
 
 resection is indicated. If the carcinoma is below, gastros- 
 tomy should be done. There is no general agreement as to 
 the best time for this operation ; Hacker advises it as soon 
 as the diflculty in taking food causes loss of weight. If the 
 carcinoma is high, and if resection is impossible and feeding 
 by the mouth cannot be continued, oesophagotomy is 
 advised by Starck, and the formation of a fistula for feeding 
 purposes. 
 
 Prognosis. — Results of operation. — In cicatricial stricture 
 total extirpation is a somewhat serious procedure, but 
 success has been obtained in four-fifths of the cases. The 
 formation of a stomach fistula for the purpose of dilatation 
 from below is very rarely indicated, according to Starck, 
 but in the fifty-two cases reported by Hacker in which 
 other methods had failed, success was obtained by this 
 retrograde dilatation. 
 
 Resection for carcinoma is reported by Starck in eighteen 
 cases ; five cases died soon after operation ; in the others 
 the immediate result was good, but none survived more than 
 two years. 
 
 QEsophagostomy often gives very good results ; the patient 
 puts on weight and lives for a relatively long period. The 
 results of gastrostomy are better the earlier it is done ; 
 frequently it is noticed that food passes the stricture more 
 easily after the operation, and the weight almost always 
 increases for some weeks. The average period of life in 66 
 cases in the Breslau clinic was five months. 
 
 Risks of operation. — Resection of the oesophagus is a 
 serious operation ; gastrostomy relatively free from risk. 
 If the stenosis is low down below the aortic arch, and if there 
 are adhesions around, resection is contra-indicated, and 
 oesophagotomy is unsuitable. 
 
 // no operation is done, it may be impossible to employ 
 methods of dilatation, in which case the patient dies from 
 starvation. 
 
 LITERATURE. 
 
 H. Starck. Die Behandlung der CEsophagusstenosen. Zentralb. 
 f. d. Grenzgebiete d. Med. u. Chir., 1902. 
 
 Kraus. Krankheiten des QEsophagus. Nothnagel's Handbuch 
 d. spez. Pathol. Bd. xvi. Wien, 1902. 
 
 Hacker. Magenoperationen bei Carcinom. Wien. klin. Wochens. 
 1895, p. 447. 
 
CHAPTER XIII. 
 
 Diseases of the Stomach. 
 
177 
 
 Chapter XIII. 
 DISEASES OF THE STOMACH. 
 
 GASTRIC ULCER. 
 
 Etiology.— The pathogenesis of gastric ulcer is uncertain. 
 Traumatic lesions of the mucous membrane do not lead 
 to ulcer. Some authors have stated that from 5 to 13 per 
 cent of all individuals are affected with gastric ulcer, but 
 the truth of this is very questionable. The affection is 
 more common in women than in men. 
 
 Pathological Anatomy. — In four-fifths of the cases 
 the ulcer is situated on the posterior wall near the pylorus. 
 The front wall is affected in 5 per cent only, but it is here 
 that the perforating ulcer is most common. According to 
 Brunner, of a series of cases of perforating ulcer 278 were 
 on the anterior, 48 on the posterior wall. The annular 
 ulcer is uncommon. The ulcer usually has a sharply- 
 marked edge and may be crateriform ; sometimes the edge 
 is much thickened. If it extends deeply, it tends to form 
 adhesions, which sometimes make up a tumour-like mass. 
 If adhesions form, rupture into the general peritoneal 
 cavity is prevented ; adhesions between the ulcer and the 
 front wall of the abdomen are the least common. Peri- 
 gastric abscesses may result from the penetration of an 
 ulcer, in particular left subphrenic abscess. A healing 
 ulcer may cause pyloric obstruction by contraction of the 
 cicatrix, or if it is about the centre of the stomach, an 
 hour-glass deformity may be produced in this way. In 
 about 5 per cent of cases of chronic ulcer, carcinoma 
 supervenes. 
 
 Clinical Course. — The cardinal symptoms of gastric 
 ulcer are : Hsematemesis, pain shortly after taking food, 
 tenderness on pressure in the stomach area. One or other 
 or all of these symptoms are often absent, and there may 
 
 12 
 
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 be only a complaint of an indefinite uneasiness in the 
 epigastrium. There are often points tender to pressure 
 alongside the lower dorsal vertebrae, tarry stools, loss of 
 appetite, severe anaemia, and a general disturbance of 
 health. Persistent vomiting without hsematemesis is also 
 common. If the ulcer is at the pylorus, signs of obstruction 
 develop, such as abnormal peristalsis and contraction of 
 the stomach wall, retention of stomach contents, with 
 fermentative changes and the multiplication of sarcinge. 
 The amount of hydrochloric acid in the stomach is usually 
 above the normal, and the digestive capacity is unaltered. 
 
 If the margin of the ulcer is much indurated it may 
 sometimes be felt as a palpable lump in the epigastrium. 
 If perigastritis supervenes, a large swelling is often to be 
 felt, particularly if adhesions are formed with the anterior 
 abdominal wall ; if there is a collection of pus between 
 the adhesions, there will be some pyrexia. 
 
 Gastric ulcer frequently runs a very chronic course, the 
 symptoms often subsiding only to recur after a time, and 
 the persistent pain and repeated haemorrhages may reduce 
 the patient to a very low state of health. According to 
 Leube, perforation occurs in about i per cent of cases, but 
 other authors (Broadbent, Brinton, Debove et Remond) 
 give a much higher figure, even up to 20 per cent. It 
 seems that perforation, which is quite a rarity in Vienna, 
 is much more common in England and America, possibly 
 owing to different habits of life. 
 
 In one of my cases small haemorrhages had frequently 
 occurred ; there was persistent pain and tenderness in the 
 epigastrium, and increasing anaemia. She was subjected 
 to a long course of medical treatment, and for a week the 
 stomach was given complete rest, but the symptoms 
 persisted. Operation showed slow perforation of an ulcer, 
 with adhesions'; gastro-enterostomy cured her completely. 
 
 Diagnosis. — The diagnosis is easy in the presence of 
 the cardinal symptoms ; if these are absent ulcer can for 
 the most part only be suspected. The most important 
 symptom of all is haematemesis. However carefully the 
 patient is examined, it is usually impossible, according to 
 many authors, to diagnose the position of an ulcer. Acute 
 perforation into the general peritoneal cavity is shown by 
 the following symptoms. There is sudden pain in the 
 
DISEASES OF THE STOMACH. 179 
 
 stomach region of intense severity, the abdomen is retracted, 
 the abdominal muscles are board-like, and there are usually 
 repeated attempts to vomit. The patient is collapsed, the 
 pulse small and rapid, the temperature somewhat below the 
 normal, and the respirations rapid and shallow. At the end 
 of several hours, disappearance of the liver dullness is some- 
 times to be made out, and when the contraction of the 
 abdominal muscles relaxes, the signs of free fluid in the 
 peritoneal cavity can be elicited ; the pulse becomes fuller 
 after the first collapse passes off, but remains rapid, and at 
 the same time the temperature usually commences to rise. 
 
 The diagnosis will be assisted by enquiring for a previous 
 history of epigastric pain. 
 
 A patient who was undergoing a strict course of treat- 
 ment for ulcer was suddenly seized with agonizing abdominal 
 pain, although at the time she was resting quietly in bed. 
 Some hours later, when I saw her, she was collapsed, the 
 abdominal wall was rigid and tender to pressure, the liver 
 dullness absent, and the pulse very rapid. Operation was 
 done three hours after the onset of symptoms, and a small 
 perforation was found near the pylorus. The perforation 
 was closed and gastro-enterostomy was performed. The 
 patient unhappily died four days later from peritonitis. 
 
 Differential Diagnosis. — It is often difficult to diagnose 
 ulcer from carcinoma. The presence of a large amount of 
 lactic acid and of long bacilli, the absence of hydrochloric 
 acid and sarcinse, the early onset of stagnation phenomena, 
 diminished digestive capacity of the gastric juice, and 
 painless glandular enlargements, point to cancer. In 
 hcemorrhage from the stomach due to hepatic cirrhosis, the 
 spleen is enlarged and the liver altered. 
 
 In cholelithiasis gastric haemorrhage is uncommon, but 
 if a calculus becomes impacted in the common duct it may 
 give rise to a palpable tumour and symptoms of pyloric 
 stenosis. A test meal will show that the gastric secretion 
 is normal in spite of the stasis, or there may be some excess 
 of hydrochloric acid ; a history of attacks of colic followed 
 by jaundice will also clear up the diagnosis. 
 
 In Reichmann's disease, that is to say acid hypersecretion, 
 the pain is usually relieved by the taking of food, and there 
 is no trace of blood either in the stomach contents or the 
 stools. 
 
i8o INDICATIONS FOR OPERATION IN 
 
 Hysterical and neurasthenic conditions are differentiated 
 by the irregularity and changeableness of symptoms and 
 the absence of hemorrhage. Epigastric hernia often 
 causes severe gastric symptoms, which may simulate those 
 of ulcer ; the discovery of an irreducible tender hernia in 
 the middle line will clear up the cause of the pains ; operation 
 on such a hernia relieved all symptoms in a case which 
 came under my observation, and which had long been 
 looked upon as one of gastric ulcer. Simple erosions of 
 the gastric lining may cause haemorrhage and other 
 symptoms in such a way as to be indistinguishable from 
 ulcer. 
 
 INDICATIONS FOR OPERATION. 
 
 Leube, one of the most experienced and expert of 
 clinicians, has formulated the following indications for 
 surgical intervention : — 
 
 I. — In haemorrhage from the stomach, operation is 
 (a) Absolutely indicated when the haemorrhages are small 
 and recurrent in spite of treatment, particularly where 
 gastrectasis coexists ; (b) Not indicated for a single pro- 
 fuse haemorrhage ; (c) Relatively indicated in repeated 
 abundant haematemesis. 
 
 2. — In the case of severe pains and persistent attacks 
 of vomiting, causing inanition, which do not yield to medical 
 treatment, gastro-enterostomy is relatively indicated. 
 
 3. — In perigastritis, gastric adhesions, subphrenic and 
 other peritonitic abscesses, operation is (a) Absolutely 
 indicated in abscess arising from ulcer, and in palpable 
 more or less tumour-like inflammatory masses in the 
 stomach region ; (b) Not indicated, or only exceptionally, 
 after failure of medical treatment when adhesions are only 
 suspected and not palpable. 
 
 4. — In ulcer perforating into the peritoneal cavity 
 operation is absolutely indicated as soon as possible after 
 the first shock has passed, but not indicated in what 
 has been vaguely called threatened perforation. 
 
 Mikulicz has formulated somewhat similar indications. 
 Surgical treatment of uncomplicated gastric ulcer is indi- 
 cated (a) When phenomena arise which directly or indirectly 
 endanger life, e.g., repeated haemorrhages, increasing 
 emaciation, commencing perigastritis, and suspected 
 
DISEASES OF THE STOMACH. i8i 
 
 carcinoma ; (&) When medical treatment methodically 
 carried out gives either no relief or only for a short period, 
 and the pain, vomiting, and dyspepsia render the patient 
 unfit for work or cause a condition of perpetual suffering. 
 
 My own opinion is in agreement with these views, and I 
 would say by way of summary that the treatment of ulcer 
 in its early stages belongs almost exclusively to the physician, 
 and that it is the complications and the chronic forms of 
 the disease which call for surgical treatment. It should 
 be added that the development of a frequent and very 
 important complication of pyloric ulcer — cicatricial stenosis 
 and dilatation — is an absolute indication for surgical 
 intervention, whether signs of ulcer are present or not. 
 Most of the operations performed have been undertaken 
 in consequence of this complication and for perforation. 
 Gastro-enterostomy, pyloroplasty, and gastric resection 
 are the most commonly performed operations ; hour-glass 
 stomach has been dealt with either by gastroplasty, gastro- 
 gastrostomy, or gastro-enterostomy. 
 
 Contra-indications. — These have been already considered 
 in part. It is not necessary to operate for a single large 
 haemorrhage, nor for chronic ulcer with hyperacidity and 
 pyloric spasm until medical treatment has proved ineffectual. 
 
 Prognosis. — Risks and results of operatiojt. The direct 
 operative risks are general collapse and shock, peritonitis, 
 or pneumonia. In perforated ulcer, operation during the 
 first shock may increase the latter to such an extent as to 
 cause death, and it is therefore advisable as a rule to wait 
 until this period has passed. Delay must never, however, 
 be prolonged beyond an hour or two ; the chances of recovery 
 are four times greater during the first twelve hours than 
 later. Of 377 cases of perforated gastric ulcer collected 
 by Brunner, 201 (52 per cent) recovered after operation, 
 but his estimate that of all cases operated on at least two- 
 thirds die, and at the highest one-third recover, is un- 
 doubtedly correct. The mortality of those operated on 
 during the first twelve hours is about 25 per cent. 
 
 It is a striking fact that both after a general anaes- 
 thetic and after local anaesthesia, cases of laparotomy not 
 infrequently develop pneumonia, sometimes of a fatal 
 type. 
 
 Operative peritonitis is rarer, and tends to become more 
 
i82 INDICATIONS FOR OPERATION IN 
 
 and more infrequent. Of all cases of operation on the 
 stomach in the Wurzburg clinic, 2 per cent died from this 
 complication, so that it is not altogether negligible. 
 
 The operative risk varies with the nature of the operation 
 and the surgeon. Mayo Robson records 165 recoveries in 
 177 cases, and of eight cases of perforating ulcer of the 
 stomach on which he operated, two died. The cases of 
 resection gave the highest mortality (27 "8 per cent). 
 According to Mikulicz the mortality of gastro-enterostomy 
 is 16 per cent, that of pyloroplasty 13 per cent. 
 
 The latter operations are therefore generally preferable 
 to resection, but each method has its particular indications ; 
 for example, if an ulcer is situated on the anterior wall 
 resection may be technically easy, and therefore advisable. 
 A complication which occurs after gastro-enterostomy is 
 regurgitant vomiting, but this is to be avoided by proper 
 operative technique and the prevention of any spur or 
 kink preventing the onward passage of the jejunal contents. 
 
 In cases of pyloric obstruction, when operation is 
 successful, the motor and secretory functions of the stomach 
 return to the normal in the course of a few months, the 
 haemorrhages which had resisted medical treatment cease, 
 and the patient loses his sense of discomfort and pain. A 
 recurrence of obstructive signs after operation sometimes 
 takes place, but is rare, as is also a reappearance of signs 
 of ulcer ; Neumann has, however, collected eight cases 
 of peptic ulcer after gastro-enterostomy, four of which 
 succumbed to perforation. The end results of operation 
 are also good ; Mikulicz records 48 permanent recoveries 
 in 54 cases of ulcer and pyloric stenosis ; the best results 
 were obtained by gastro-enterostomy. 
 
 Without operation. — The great majority of cases of gastric 
 ulcer recover under careful medical treatment. Leube 
 records, among 424 of his patients, rapid and permanent 
 recovery in 74 per cent after four to five weeks' treatment, 
 improvement in 22 per cent, no improvement in 16 per 
 cent. The percentage mortality was 2*4 per cent. This 
 low mortality corresponds with my own experience. The 
 figures given by some French (Doyen) and English (Barling) 
 surgeons, viz., 10 per cent to 50 per cent, are in my opinion 
 much too high. A repetition of the course of treatment 
 completes recovery in a large proportion of those cases 
 
DISEASES OF THE STOMACH. 183 
 
 which are at first only improved. If gastric ulcer is 
 untreated, the mortality on the other hand reaches about 10 
 per cent ; of these 6 to 7 per cent succumb to perforation, 
 3 to 5 per cent to a profuse haemorrhage. 
 
 According to Gerhardt, cicatricial stenosis of the pylorus 
 occurs in about 10 per cent, and this if untreated by operation 
 will probably prove fatal. 
 
 When ulcer persists for a long period, it not infrequently 
 is the starting point of carcinoma. 
 
 If not operated on, about 95 per cent of cases of perfora- 
 tion die, 50 per cent during the first twenty-four hours after 
 the accident ; the few cases which recover are those in 
 which the stomach was empty at the time of perforation. 
 
 LITERATURE. 
 
 F. Gross et G. Gross. Perforation de I'Estomac par Ulcere. 
 Rev. de Chirurg. Paris, 1904. 
 
 RoBsoN. Lecture on the Complications of Gastric Ulcer. Brit. 
 Med. Jour., Vol. I, 1901, p. 257. 
 
 KoRTE. Ueber die chirurgische Behandlung des Magengesch- 
 wiirs und seiner Folgezustande. Arch. f. klin. Chir. Bd. Ixiii. 
 
 Brunner. Das akut in die freie Bauchbohle perforierende 
 Magengeschwiir. Deut. zeit. f. Chir. Bd. Ixix, p. 106. 
 
 Finney. Perforated Ulcer of the Stomach. Annals of Surgery, 
 1900, Vol. 33. 
 
 Terrier et Hartmann. Chirurgie de I'Estomac, 1899. 
 
 V. Mikulicz. Die chirurgische Behandlung des chronischen 
 Magengeschwiirs. Mitteil. a. d. Grenzgebieten d. Med. u. Chir. 
 Bd. ii. 
 
 Leube. Erfolge der internen Behandlung des peptischen 
 Magengeschwiirs. Ibidem. 
 
 Rencki. Ueber die funktionellen Ergebnisse nach Operationen 
 am Magen bei Ulcus und gutartiger Pylorusstenose. Ibid. Bd. 
 viii. Hft. 3. 
 
 Lincner lind Kuttner. Die Chirurgie des Magens und ihre 
 Indikationen. Berlin, 1898. 
 
 T^.neffi. Resezione dello Stomacho per Ulcera Gastrica. 
 Supplem. al Policlinico, No. 12, 1902. 
 
 CARCINOMA OF THE STOMACH. 
 
 Pathological Anatomy. — The commonest site of 
 carcinoma of the stomach is in the neighbourhood of the 
 pylorus (30 per cent), then on the greater and lesser 
 curvatures (together 30 per cent). In more than 70 per 
 cent the growth is of the scirrhous type ; the medullary and 
 
i84 INDICATIONS FOR OPERATION IN 
 
 colloid types grow rapidly and ulcerate early. Cancer 
 often develops on the site of an old ulcer ; it is almost 
 always a primary growth ; the softer growths are the 
 earliest to form metastases. Cancer at the cardiac orifice 
 shows no tendency to invade the oesophagus, and pyloric 
 cancer does not extend to the duodenum. 
 
 Clinical Course. — The disease usually begins insidi- 
 ously. In some cases there are only general symptoms : 
 weakness, rapid wasting, anaemia, loss of appetite, and 
 distaste for food. The most important of the stomach 
 symptoms are regurgitation and vomiting of stomach 
 contents, often acid in taste, vomiting of mucus and coffee- 
 ground masses, pain in the epigastrium, particularly after 
 eating, and tenderness in the epigastrium. The most 
 important sign is the presence of an epigastric tumour. 
 This may move with respiration, but can then be fixed in 
 the situation where it lies on expiration. In pyloric cancer, 
 symptoms of gastric dilatation are often present, the 
 stomach contents are retained long after a meal, there is 
 vomiting of large quantities, and often excessive peristalsis. 
 
 Examination of the stomach contents shows absence or 
 diminution of hydrochloric acid, defective capacity of 
 peptic digestion, and later the presence of lactic acid and 
 other stagnation products, even when there is no pyloric 
 stenosis. Numbers of long bacilli and blood pigment 
 material are also often present. The normal leucocytosis 
 of digestion is absent. 
 
 Metastases may be clinically recognizable before the 
 primary tumour, particularly glandular metastases above 
 the left clavicle. The development of ascites is almost 
 always a sign of the presence of metastases in the perito- 
 neum or the glands of the portal fissure. 
 
 In the later stages fever and cachexia make their 
 appearance. 
 
 Diagnosis. — A palpable tumour is the most valuable 
 sign, but the presence of the above-mentioned secretion- 
 anomalies, along with retention of stomach contents and 
 numbers of long bacilli, is sufficient for a fairly confident 
 diagnosis, and it becomes more certain if repeated examina- 
 tion shows that these signs are constant and persistent. 
 
 In cancer of the cardiac orifice, the symptoms may be 
 those of oesophageal obstruction, obstruction to the passage 
 
DISEASES OF THE STOMACH. 185 
 
 of solid food, delay or absence of the second bruit of 
 deglutition, and the sound may demonstrate stenosis. 
 Pain is then most common at the xiphisternum. The 
 tumour may be visible with the oesophagoscope, but it 
 remains impalpable until the latest stages. 
 
 The carcinomatous ulcer usually presents the character- 
 istic ulcer history. When repeated examinations at short 
 intervals demonstrate a change in the gastric chemistry, 
 hyperchlorhydria first disappearing and then giving place 
 to hypochlorhydria, increase in lactic acid, decreased 
 capacity for peptic digestion, multiplication of long bacilli 
 and stagnation phenomena, then the diagnosis will be 
 carcinoma developed from a chronic gastric ulcer. 
 
 In a patient fifty years of age the history pointed to gastric 
 ulcer of some years' standing. For six months pain had 
 developed anew after food, vomiting had been frequent, 
 and there was loss of flesh, melsena, and great tenderness on 
 pressure over the stomach. Tenderness was also marked 
 on pressure in the neighbourhood of the lower dorsal 
 vertebrae. Examination of the stomach contents showed 
 at first a high degree of hyperchlorhydria, which later 
 gradually gave place to a normal amount of hydrochloric 
 acid, associated with the appearance of lactic acid and 
 signs of retention of stomach contents. Laparotomy 
 showed a carcinoma on the posterior stomach wall developed 
 on the site of an old ulcer. Gastro-enterostomy was 
 performed, but death occurred some days later. 
 
 In pyloric cancer the signs of pyloric stenosis are clinically 
 the most prominent. Lactic and butyric acid are especially 
 abundant ; the tumour is palpable comparatively early. 
 In regard to differential diagnosis, there are many con- 
 ditions which have to be considered. Chronic ulcer is 
 associated with increased amount of hydrochloric acid, 
 and lactic acid is not present. Kinking by adhesions to 
 the gall-bladder, etc., is not associated with any particu- 
 lar change in the chemistry of the secretion. Atonic 
 inefficiency is not associated with tumour or with abnormal 
 peristalsis. 
 
 In atrophy of the gastric mucous membrane there is no 
 palpable tumour, examination of the blood shows the 
 changes of progressive pernicious auccmia, and there is no 
 bIor)d in the gastric contents. 
 
i86 INDICATIONS FOR OPERATION IN 
 
 The alterations in the gastric secretion are also of valiie 
 in excluding tumours of the gall-bladder, omentum, 
 intestine, and pancreas. Renal tumours bulge into the 
 loin and lie behind the colon. 
 
 Chronic gastric catarrh does not provoke any grave 
 alteration in health ; the amount of hydrochloric acid 
 varies, and improvement and changes for the worse alternate. 
 The secretion of mucus is generally excessive ; if this 
 decreases one will usually note improvement in the secretory 
 functions. 
 
 INDICATIONS FOR OPERATION. 
 
 All authors agree that when carcinoma is diagnosed at 
 an early stage operation is absolutely indicated. Un- 
 fortunately at this stage diagnosis is attended with great 
 difficulties, and usually no positive opinion is arrived at 
 until a palpable tumour appears. When this stage is 
 reached the disease has usually made considerable progress. 
 
 For this reason there are certain signs and conditions 
 which constitute absolute indications for operation, 
 although the diagnosis of cancer may be uncertain. 
 Operation is called for (i) When the signs point definitely 
 to progressive stenosis of the pylorus, and the other signs 
 point to cancer, although there is no palpable tumour ; 
 
 (2) When a palpable tumour is present which is apparently 
 without adhesions to the surrounding parts and has not 
 produced recognizable metastases in other organs ; 
 
 (3) When there is marked interference with the motor 
 function, even when the tumour is not at the pylorus and 
 adhesions cannot be excluded, if vomiting and motor 
 insufficiency are producing inanition. 
 
 Opinions differ as to the advisability of exploratory 
 laparotomies. According to what has just been said it is 
 clear that many operations are bound to be exploratory 
 in the first instance, to be followed by a radical procedure 
 under favourable circumstances. Kuttner is of opinion 
 that exploratory laparotomy ought to be considered if 
 the symptoms as a whole suggest cancer, and there is 
 reason to think that it may be possible to remove the 
 growth, particularly if there are definite signs of stenosis. 
 Ringel agrees with Kummel that if there is a definite 
 suspicion of cancer the abdomen should be opened. 
 
DISEASES OF THE STOMACH. 187 
 
 My own view is that exploratory laparotomy should be 
 undertaken in all cases where the clinical phenomena 
 suggest the development of cancer on the site of a chronic 
 ulcer, even when no tumour is to be felt and symptoms of 
 pyloric stenosis are absent. 
 
 The operations that may be performed are : — 
 
 1. Resection, the radical operation by which alone 
 complete recovery is obtainable. 
 
 2. Gastro-enterostomy, to be employed when the tumour 
 cannot be extirpated, when there is marked gastric 
 inefficiency, and there is some hope of prolonging life for 
 a considerable period. 
 
 3. Gastrostomy, in cancer of the cardia, to feed the 
 patient and avoid the irritant effect of food passing over 
 the seat of disease. Whether resection or gastro- 
 enterostomy is advisable in any given case it is not as a 
 rule possible to say until the stomach has been opened 
 and the extent of the disease explored. 
 
 Contra-indications. — With the following opinion of 
 Mikulicz I entirely agree. He says : " When the result of 
 palpation is negative, and there are no motor disturbances, 
 operation is inadvisable, at least for the time being, even 
 if all other signs point to cancer. Only a radical operation 
 will be considered under such circumstances, and experience 
 has shown that a stomach cancer which has already caused 
 definite clinical symptoms, and yet is not palpable, is 
 almost always so situated as to be inaccessible for radical 
 removal." 
 
 ■Emphysema, chronic bronchitis and tuberculosis of the 
 lungs, if of a pronounced type, contra-indicate operation, 
 and the same is to be said of advanced atheroma, uncom- 
 pensated heart disease, and any other serious organic lesion. 
 
 The presence of metastases, particularly in the liver, and 
 of carcinomatous peritonitis, contra-indicate intervention. 
 
 Prognosis. — Results of operation. It is difficult to 
 formulate any definite prognosis of operation ; the results 
 vary much in the different tables given ; some surgeons 
 operate on cases which others would refuse, and the same 
 surgeon obtains different results at different stages of 
 his experience and with different methods. The immediate 
 operation results show recovery in at the most 75 per 
 cent, and on an average about a half or less get over the 
 
i88 INDICATIONS FOR OPERATION IN 
 
 operation. The mortality among 56 cases in Mikulicz' 
 hands was 46-5 per cent, in the next 44 cases 25 per cent. 
 
 Nine out of twenty-four in Czerny's clinic died from the 
 operation (38 per cent), 17 out of 25 in Rydygier's clinic 
 (68 per cent). Kronlein reports an operative mortality 
 of 28 per cent in 50 resections, Kappeler 26 per cent in 
 30 cases, Ringel 59-4 per cent in 63 cases, Roux 33 per cent 
 in 39 cases. The Mayos report 5 deaths in 20 cases in a 
 first series, i death out of 15 in a second series. 
 
 The operative mortality is therefore high, though it 
 varies considerably ; approximately a quarter die. The 
 causes of death are shock, pneumonia, pulmonary embolism, 
 cardiac failure, peritonitis. The risks of gastro-enterostomy 
 in cancer are also high. Of 82 cases reported by Ringel, 
 62 per cent died from shock, pneumonia, peritonitis, 
 pulmonary embolism, or cachexia. Of 96 patients in Roux's 
 clinic, 28 per cent succumbed, 7 from general weakness, 
 5 from pulmonary complications, 4 from cardiac failure, 
 4 from faulty technique, 3 from peritonitis, etc. 
 
 The end results of resection are comparatively good, 
 considering that the disease is inevitably fatal without 
 operation, but recurrence is the rule. The results in 58 
 of Mikulicz' cases who survived the operation are as follows : 
 17 alive more than a year, 10 more than 2 years, and 4 
 more than 3^ years after the operation. The average 
 duration of life of the cases who died from recurrence was 
 more than 16 months. 
 
 Wolfler has recorded several cases alive some years after 
 operation ; 14 survived 4 years, 4 more than 5 years, and 
 2 longer than this. 
 
 The average duration of life in the cases reported by 
 Kolbe from Roux's clinic was at the time of publication 
 three years and eight months, the oldest being nine years 
 and four months. The length of life in 12 cases which 
 had died was on an average two years and two months. 
 
 Gastro-enterostomy also increases the average duration of 
 life, but not to so marked an extent as gastrectomy. Of 
 67 patients operated on in Mikulicz's clinic who survived the 
 operation, 2 only lived more than 2 years, 10 more than 
 I year, 11 more than six months, and the remaining 44 
 less than six months. The average duration of life after 
 operation was 6"4 months. Ringel's figures give the 
 
DISEASES OF THE STOMACH. 189 
 
 average post-operative survival as six and a half months. 
 In a few cases patients have lived three years or more 
 (Stendel-Czerny, Alsberg, Strauss) ; a patient under my 
 own observation survived more than two years and a half. 
 
 These various statistics show that operative interference 
 of whatever kind is attended with a high degree of 
 immediate risk in gastric cancer, but that nevertheless it 
 is often proper to recommend it in the hope of permanent 
 cure in some cases, in others for the relief of distressing 
 symptoms and for the prolongation of life. 
 
 The general condition is often remarkably good after 
 resection ; the patient puts on weight and regains appetite. 
 Slight epigastric uneasiness often persists, and there may 
 be distaste for flesh foods. In some cases the anaemia 
 persists for a long time. The stomach often regains its 
 normal motility, according to Mikulicz, and sometimes 
 this even surpasses the normal. The gastric secretion 
 does not as a rule return to the natural state, but sometimes 
 free hydrochloric acid reappears ; the production of lactic 
 acid on the other hand tends to persist for a long time. 
 
 The effect of gastro-enterostomy is much less striking. 
 I have indeed seen cases who improved for a time and put 
 on weight, but after a short period they commenced to go 
 down hill and rapidly succumbed. In the majority of 
 cases the general condition is little changed, and the 
 marasmus remains. Some symptoms, however, vomiting 
 and foetid eructations, are often greatly relieved, and in 
 cases of pyloric obstruction the pains due to spasmodic 
 contractions of the stomach are eliminated. 
 
 Without operation. — When there is no pyloric obstruction, 
 the general symptoms, weakness, anaemia, etc., are the 
 most prominent. Patients usually succumb with symptoms 
 of heart failure ; in other cases they die from septicaemia. 
 If there is pyloric obstruction, the disease runs a rapid 
 course, and the repeated vomiting of the stagnant stomach 
 contents quickly exhausts the strength. My experience, 
 however, agrees with that of others who have recorded 
 improvement, and even increase of weight in some cases 
 in which the stomach has been regularly washed out. In 
 ulcerating carcinoma, haemorrhages and fever complicate 
 the history, and once metastases form the progress of the 
 disease is very rapid. 
 
I90 INDICATIONS FOR OPERATION IN 
 
 According to Kronlein, cancer of the stomach without 
 surgical treatment terminates fatally in about a year ; 
 Riegel places the average period between one and two 
 years. When the carcinoma causes pyloric stenosis, the 
 course of the disease is often very short. I have seen death 
 supervene in a few weeks after the onset of the first clinical 
 svmptoms. 
 
 LITERATURE. 
 
 RiNSEL. Die Resultate der operativen Behandlung des 
 Magencarcinoms. Beitr. z. klin. Chir. Bd. xxxviii. 
 
 Mikulicz and Kausch. " INIagencarcinom " in Handbuch d. 
 prakt. Chir. Bergmann, ^Mikulicz, u. Bruns. Bd. iii. 2nd ed., 
 1903. 
 
 Kronlein. Die bisherigen Erfahrungen bei der Radikalen 
 Operationen des [Magencarcinoms. Arch f. khn. Chir., Bd. Ivii. 
 
 Riegel. Die Krankheiten des INIagens. 2nd Ed. Nothnagel's 
 Handbuch d. spez. Pathol, u. Therap. 
 
 Terrier at Hartm.ann. Chirurg. de TEstomac. Paris, 1899. 
 
 MoRiscN. After Progress of Five Cases of Partial Gastrectomy 
 for Cancer. Lancet, Jan. 11, 1902. 
 
 Syme. Gastrectomy for Carcinoma of the Pylorus. Lancet, 
 Sept. 13, 1902. 
 
 CuMSTON. The Indications for Operation in Malignant Neoplasms 
 of the Stomach. Boston Med. and Surg. Jour., Sept. 5, 1901. 
 
 ScHiFF. Die Diagnose des Magencarcinoms. Centralb. f. d. 
 Grenzgebiete d. Med. u. Chir., 1898. 
 
 Mathieu. Maladies de I'Estomac. Pari?. , 1901. 
 
 SouPAULT et Hartmann. Resultats Eloignes de la Gastro- 
 enterostomy. Rev. de Chir., 1899. 
 
 Gluzinski. Friihdiagnose des Magencarcinoms und Aussichten 
 der ladikal Operation. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. 
 Bd. V. 
 
 Lindner und Kuttner. Die Chirurgie des Magens und ihre 
 Indikationen. Berlin. 1898. 
 
 GozEL. Le Traitement du Cancer de I'Estomac par la Gastro- 
 entero-anastomose. Rev. de Chir., Feb., if;o4. 
 
 KoLBE. Le Cancer de I'Estomac et son Traitment Chirurgical. 
 Lausanne: Borgeand. 1901. 
 
 Ferrari. Contributo alio Studio della Pathologia di Ventriculo. 
 Clinica Chirurgica, 10, 1902. 
 
 Ceccherelli. Sulla Chirurgia Gastrica. Alti del x Congresso 
 Medico dell' Alta Italia. Mantova. 1902. 
 
 SIMPLE TUMOURS AND FOREIGN-BODY TUMOURS OF 
 THE STOMACH. 
 
 Etiology. — The foreign-body tumours of the stomach 
 occur from the habitual eating of hair or vegetable fibre, 
 
DISEASES OF THE STOMACH. 191 
 
 or gelatin-containing fluid. They are found most 
 commonly in women, and relatively frequently in young 
 girls. The simple, true growths of the stomach (myoma) 
 may occur at any age. 
 
 Pathological Anatomy. — The foreign-body masses 
 are often freely movable in the stomach ; when of large 
 size they may have the shape of a complete cast of the 
 stomach, as in a case recorded by myself. Ulceration and 
 perforation, with consequent peritonitis, are typical results. 
 
 The simple new growths are uncommon ; usually they 
 are myomata, and may attain a large size, protruding more 
 frequently into the peritoneal cavity than into the stomach. 
 In two cases I have seen transformation into sarcoma. 
 
 Clinical Course. — Foreign-body masses can often be 
 recognized by palpation. At first they are freely movable, 
 and at this stage the stomach symptoms are slight, but 
 later vomiting becomes uncontrollable, with pain in the 
 epigastrium and signs of peritoneal irritation. After several 
 years they may cause perforation and peritonitis. 
 
 The true simple growths are also compatible with long life. 
 The secretory functions of the stomach are little interfered 
 with, and whether or not its motor functions are embarrassed 
 depends on the site and attachments of the tumour. 
 
 Diagnosis. — A positive diagnosis is only exceptionally 
 arrived at in the case of the foreign-body masses. A 
 history of long ingestion of hair or vegetable fibre in a 
 young individual, free mobility of the swelling, which is 
 shown by inflation to belong to the stomach, and in 
 particular the discovery of hair in the fcEces, will point to 
 the true nature of the case. Incorrect diagnoses of stomach 
 cancer, movable kidney, splenic tumour, and renal tumour 
 have been made. 
 
 A tumour of the stomach which has been known to have 
 been slowly growing for some years, is probably of a simple 
 nature ; the general condition will be good, and the functions 
 of the stomach normal. A correct diagnosis is rarely made, 
 the condition being usually taken for carcinoma. 
 
 INDICATIONS FOR OPERATION. 
 
 If a tumour is found in the stomach region, and there is 
 even a suspicion of its being a hair ball or similar mass, 
 an operation slioiild be advised, and signs of peritoneal 
 
192 INDICATIONS FOR OPERATION IN 
 
 irritation point to its being urgently necessary. Perforation 
 is of course an absolute indication for intervention. The 
 foreign body will be removed by gastrotomy, the stomach 
 being then closed. Benign new growths also call for 
 extirpation and partial resection of the stomach ; the 
 fact that these growths sometimes become malignant 
 makes their removal necessary, even though they may be 
 causing little inconvenience. The only contra-indication 
 to operation is the presence of some condition which renders 
 abdominal section a risky proceeding. 
 
 Prognosis. — Results of operation. All the cases of 
 operation for hair ball which were collected by Schopf, 
 nine in number, were successful. Since the appearance 
 of his paper further successes have been recorded. Opera- 
 tion for myoma is a more serious undertaking, as it involves 
 partial gastrectomy. 
 
 Withotit operation. — Hair balls and other similar masses 
 relatively often cause pressure necrosis of the stomach wall 
 and fatal peritonitis. A myoma may undergo sarcomatous 
 transformation. If pedunculated it may become strangu- 
 lated by torsion of the pedicle, and in this way cause 
 danger to life. 
 
 LITERATURE. 
 
 Steiner. Myome des Magen-Darmkanals. Beitr. z. klin. 
 Chir., Bd. xxii. 
 
 F. Schopf. Ein Trichobezoar im Magen. Wien. klin. Wochen., 
 p. 1 145, 1899. 
 
 W. AF ScHULTEN. Uebct Haargeschwiilste un Magen. Mitteil. 
 a. d. Grenzgebiete d. Med. u. Chir. Bd. ii. 
 
 Gemmel. Foreign Bodies in Ihe Stomach. Lancet, Vol. ii. 1899. 
 
 BoRRMANX. Ueber Netz- und Pseudo-Netztumoren nebst 
 Bemerkungen iiber Myome des Magens. Mitteil. a. d. Grenzgebiete 
 d. Med. u. Chir. Bd. vi. 
 
 Cernerri. Sui leiomiomi dello Stomaco. II Morgagni, No. 3, 1903. 
 
 Caminiti. Myome du Pylore, Gazette Hebdomadaire, No. 
 89, 1901. 
 
 KoEPPELiN. Corps Etranger de I'Estomac. Lyon Medical, 
 No. 30, 1 90 1, p. 121. 
 
 PYLORIC STENOSIS, GASTRIC DILATATION, AND 
 HOUR-GLASS STOMACH. 
 
 Pathological Anatomy. — Stenosis of the pylorus may 
 arise from a variety of causes. In some cases it follows 
 
DISEASES OF THE STOMACH. 193 
 
 carcinoma or the cicatrization of an ulcer ; in others 
 adhesions cause kinking, or the outlet is compressed from 
 without or blocked by a gall-stone. Clinically the stenoses 
 in the neighbourhood, as far as the papilla of Vater, may 
 be classed with the stenoses of the actual pylorus. In a 
 group of cases the obstruction is due to pyloric spasm. 
 When pyloric stenosis has been present for some time, 
 the stomach becomes secondarily dilated and the muscular 
 wall hypertrophied. 
 
 Hour-glass stomach is usually caused by the cicatrization 
 of an ulcer of the body of the stomach, more rarely by 
 carcinoma or adhesions. 
 
 Clinical Course. — Certain symptoms are common to 
 stenosis, however caused ; others vary according to the 
 original lesion. In all cases there is a sensation of fullness 
 in the stomach region, and usually loss of appetite and 
 eructations. Vomiting is hardly ever absent, and the 
 motor functions of the stomach are altered. 
 
 In the slighter forms (motor inefficiency of the first 
 degree) there is long delay in emptying the stomach, but 
 by the early morning the organ has passed on its contents 
 and is empty. 
 
 In motor inefficiency of the second degree there is always 
 food material in the stomach ; splashing can be elicited over 
 a wide area, and many hours after a meal. When the 
 stomach is inflated, it is seen that it extends abnormally 
 low. If the patient is given salol, the elimination of 
 salicylic acid and phenic acid in the urine persists for an 
 abnormally long time. 
 
 Very often, particularly when the condition is advanced, 
 a very pronounced peristalsis can be seen and felt passing 
 from left to right ; these tetanic contractions are painful, 
 and as the wave passes the wall becomes consecutively 
 contracted and relaxed. 
 
 The state of the gastric secretion depends on the nature 
 of the causal condition. When there is hyperacidity the 
 total amount withdrawn with the stomach tube is often con- 
 siderably greater than that which the patient had swallowed. 
 Almost always sarcinse are present when hydrochloric acid 
 is present, and lactic acid when hydrochloric acid is absent. 
 A diminution of hydrochloric acid runs parallel with a 
 diminution of sarcin^e ; when the amount of lactic acid 
 
 13 
 
194 INDICATIOXS FOR OPERATION IN 
 
 is large the long bacilli are numerous and the sarcinse few. 
 The amount of urine secreted is usually small, and decreases 
 as the stenosis becomes more pronounced ; the patient 
 complains much of thirst, and is constipated. Generalized 
 tetany, involving the muscles of the trunk, diaphragm, and 
 larynx, may be the cause of death. 
 
 Diagnosis. — The presence of motor inefliciency and 
 stagnation of gastric contents will lead to a diagnosis of 
 pyloric obstruction. When remains of food are found in 
 the stomach many hours after a meal, and there is abnormal 
 peristalsis, the diagnosis is quite clear, but the cause can 
 only be determined by careful examination into the 
 chemistry of the stomach, the history, and the other 
 symptoms. 
 
 Hour-glass stomach can sometimes be diagnosed by 
 inflation. In some cases, on pressure at the cardiac end, 
 the contents can be made to pass with a rush through the 
 stricture. The presence of marked and painful peristalsis 
 is against simple atonic dilatation, this symptom being 
 usually absent in the latter. 
 
 Spasmodic stenosis of the pylorus does not seem to often 
 cause marked motor inefficiency ; if the latter is present, 
 it is not possible to differentiate between spasmodic and 
 anatomical stenosis. 
 
 INDICATIONS FOR OPERATION. 
 
 If there are definite signs of stenosis, but the motor 
 inefficiency is of the first degree only, operative interference 
 is in general only indicated when new growth is suspected. 
 If, however, in the presence of motor inefficiency of the 
 first degree, the patient suffers much and is unrelieved by 
 medical treatment, or if in consequence of his occupation 
 or other cause he cannot submit to a long course of medical 
 and dietetic treatment, operation is justified. This is 
 particularly the case when the patient understands the 
 risks and is still anxious for operation. 
 
 Motor inefficiency of the second degree is an absolute 
 indication for operative treatment ; this is also the case 
 when the symptoms steadily advance in spite of medical 
 treatment, the urine becoming small in quantity and the 
 patient losing weight and strength. 
 
 The primary object of operation will be to deal with the 
 
DISEASES OF THE STOMACH. 195 
 
 actual cause of the stenosis, that is to say, in cancer by 
 resection, in the case of adhesions by their detachment. 
 In cicatricial stenosis, however, and in inoperable cancer, 
 gastro-enterostomy is the method of choice for the relief of 
 obstruction. Hour-glass stomach may be dealt with either 
 by gastrogastrostomy, gastro-enterostomy, or gastroplasty, 
 or a combination of more than one method. 
 
 Contra-indications. — All the conditions which militate 
 against the success of a serious operation — advanced age, 
 marked atheroma, heart lesions, diabetes, etc. — are contra- 
 indications. 
 
 If the clinical phenomena point to a motor inefficiency 
 of a slight degree, operation should not be advised until 
 medical treatment has been given a trial. In the presence 
 of tetany or symptoms of auto-intoxication, such as 
 acetonuria, albuminuria. Trousseau's sign, etc., operation 
 is not advisable. 
 
 Gastric neuroses are in general not suitable for operative 
 treatment. 
 
 Prognosis. — Results of operation. The results of opera- 
 tion vary with the nature of the causative lesion. In 
 many cases recovery is complete, the pains and stagna- 
 tion phenomena entirely disappear, and the motor and 
 chemical functions return to the normal. In carcinoma, 
 however, even after resection the gastric secretion does 
 not entirely regain its normal composition. In a few cases 
 a certain degree of dyspepsia and motor inefficiency persist. 
 In many cases of hour-glass stomach the result of operation 
 has been very good ; Moynihan has reported six recoveries, 
 Frada three. The operative mortality of the condition is 
 8"9 per cent. 
 
 Risks of operation. — The risks of operation, apart from 
 those common to abdominal section, depend upon the 
 extent of the necessary procedure. Gastric resection, 
 whether for simple or malignant stenosis, is attended by 
 the highest mortality, while that associated with gastro- 
 enterostomy and pyloroplasty is much smaller (See articles 
 on (iastric Ulcer and Carcinoma of the Stomach). 
 
 Pneumonia occurs in a certain proportion of cases, and 
 is often of a severe type. After gastro-enterostomy, peptic 
 ulcer of the jejunum has been recorded, and in a few cases 
 has led to fatal perforation. 
 
196 IXDICATIONS FOR OPERATION IN 
 
 Without operation. — Gastric inefficiency of the first 
 degree is often successfully treated by medicinal and 
 dietetic means. In marked inefficiency, on the other hand, 
 the patient steadily loses ground and eventually succumbs. 
 In a fair number of cases generalized tetany is the cause of 
 death ; in three under my own observation the convulsions 
 involved the extremities and back, and finally the diaphragm 
 and the laryngeal muscles. In hour-glass stomach the 
 prognosis is similar : the patient suffers from inanition and 
 exhausting pain, and the affection may end in perforation 
 or fatal exhaustion. 
 
 LITERATURE. 
 
 Mikulicz und Kausch. Pylorusstenose. Handbuch der prakt. 
 Chir Bd. iii. v. [Mikulicz, Bergmann u. Bruns. 1903. 
 
 EwALD. Diagnostik des Sanduhrmagens. Deutsche Arch. f. 
 klin. Med. Bd.'lxxiii. 
 
 Lindner und Kuttner. Die Chirurgie des Magens. Berlin, 
 1898. 
 
 H. Weiss. Der Sanduhrmagens. Centralb. f. d. Grenzgebiete 
 d. Med. u. Chir. 1898. 
 
 H. Petersen. L^eber die chirurgische Behandlung gutartiger 
 Magenerkrankungen. Deutsche med. Wochen, , 1899, Nos. 24 and 25. 
 
 Hartmann et SouPAULT Les Resultats Eloignes de la Gastro- 
 enterostomie. Rev. de Chir., 1899, pp. 137. 
 
 Mathieu. Maladies de rEstomac. Paris, 1901. 
 
 Fleiner. Krankheiten des Verdauungstraktes. Stuttgart. 1896. 
 
 Kausch. Ueber funktionelle Ergebnisse nach Operationen am 
 Magen. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. iv. 
 
 Kronlein. LTeber Ulcus und Stenose des Magens nach Trauma. 
 Ibidem. 
 
 Maragliano. Erfahrungen a. d. Gebiete der Magen-Darm- 
 chirurgie. Beitr. z. klin. Chir., Bd. xli. 
 
 Monprofit. De la Gastro-Enterostomie pour Estomac Bilocu- 
 laire. Arch. Prov. de Chir., Feb., 1904. 
 
 Moynihan. Hour-glass Stomach. Brit Med. Jour., Feb. 
 20, 1904. 
 
 Frada. La Gastro-enterostomia nello Stomaco a Clessidra. 
 Riforma Medica. 1901. 
 
 CONGENITAL HYPERTROPHIC STENOSIS OF THE 
 PYLORUS. 
 
 This condition is usually found in children of healthy 
 parents, but more than one infant in the same family may 
 be affected. 
 
DISEASES OF THE STOMACH. 197 
 
 Pathological Anatomy. — Usually the pyloric stenosis 
 is of a most marked degree ; the wall is much thickened, 
 due to the hypertrophy of the muscular coat. The stomach 
 is usually dilated. 
 
 Clinical Course. — The most important signs are 
 uncontrollable vomiting, setting in soon after birth, and 
 the presence of a lump in the epigastrium. Cachexia 
 usually supervenes in a short time. There is often both 
 motor and chemical inefficiency of the stomach and 
 obstinate constipation. If constant vomiting comes on 
 soon after birth, and the vomited matter never contains 
 bile pigment, while at the same time there is a lump in the 
 epigastrium and exaggerated peristalsis, the diagnosis is 
 clear. 
 
 INDICATIONS FOR OPERATION. 
 
 If the characteristic symptoms are present, and do not 
 yield to internal treatment, and if the child is losing weight, 
 operation is called for. It is urgent when the child, although 
 hungry, can no longer take the breast. The usual and only 
 satisfactory procedure is gastro-enterostomy. Operation 
 should not as a rule be advised until a trial has been given 
 to medical treatment. 
 
 Prognosis. — Trautenroth has collected 12 cases sub- 
 mitted to operation ; among these there were 5 fatalities ; 
 the remaining 7 made a complete recovery. Without 
 operation the majority of cases succumb to inanition ; in 
 some cases the symptoms are relieved by medical treatment. 
 
 LITERATURE. 
 
 Neurath. Die angeborene Pylorusstenose der Sauglinge. 
 Centralb. f. d. Gren^gebiete d. Med. u. Chir. 1899. 
 
 Trautenroth. Ueber die Pylorusstenose der Sauglinge. Mitteil. 
 a. d. Grenzgebiete d. Med. u. Chir. Bd. ix. 
 
 ScHOTTEN. Die angeborene Pylorusstenose der Sauglinge. 
 Volkmann's Hefte. New Series, No. 368, 1904. 
 
 MacCaw and Campbell. Congenital Hypertrophic Stenosis 
 of the Pylorus. Brit. Med. Jour., June 25, 1904. 
 
 Weill et Pehu. Les Stenoses Pyloriques chez le Nouveau-ne 
 et le Nourisson. Gaz. des Hopit., Nos. 1 1 2 and 115, 1901. 
 
CHAPTER XIV. 
 
 Diseases of the Intestines. 
 
Chapter XIV. 
 DISEASES OF THE INTESTINES. 
 
 DUODENAL ULCER. 
 
 The round ulcer of the duodenum is a distinct clinical 
 type, and it is therefore proper that it should be given a 
 special article. It is more common in men than in women, 
 and occurs most frequently in individuals of middle age and 
 in young children. Alcoholism, chronic tobacco poisoning, 
 burns, and frost-bites appear to have etiological relationship 
 with the condition. It has been found in a considerable 
 number of instances in patients affected with nephritis and 
 cardiac disease. There is a difference of opinion as to 
 whether it ever results from trauma. 
 
 Pathological Anatomy. — The ulcer is usually solitary, 
 varying in size from a lentil to a florin. It is usually found 
 in the upper horizontal portion of the duodenum. Perfora- 
 tion occurs in a large proportion of cases, probably more 
 than a third, either into the general peritoneal cavity or 
 some neighbouring organ. Subphrenic abscess is relatively 
 common. When the ulcer heals, the resulting cicatricial 
 contraction may cause stenosis ; profuse haemorrhage 
 sometimes occurs from erosion of large vessels. 
 
 Clinical Course. — In many cases there are either no 
 symptoms, or only some slight complaint of discomfort. In 
 other cases there is pain coming on usually a long time 
 after a meal, and often relieved by again taking food or by 
 alkalies. There is tenderness as well as pain in the neigh- 
 bourhood of the pylorus. Vomiting and retention of 
 stomach contents are common, and in a third of the cases 
 there is haemorrhage, evidenced by melsena or hccmatemesis. 
 
 Chronic perforation of the ulcer usually causes intense 
 localized pain and peritoneal symptoms, i.e., meteorism, 
 diffuse tenderness, fever, and sometimes free exudation. 
 
202 INDICATIONS FOR OPERATION IN 
 
 If signs of subphrenic abscess develop, the gastric symptoms 
 are overshadowed. In other cases pus maizes its way down- 
 wards, and appendicitis is simulated. 
 
 Acute perforation is associated with symptoms similar to 
 those of perforation of a gastric ulcer. 
 
 Diagnosis. — When there is a history of long-continued 
 pain in the right hypochondrium, which reaches its 
 maximum some hours after taking food, is not particularly 
 altered by vomiting, and is increased by pressure in the 
 pyloric region, duodenal ulcer will be suspected, and the 
 diagnosis will be sustained if blood is present in the stools. 
 It will be remembered that the condition runs a chronic 
 course, and is particularly associated with extensive burns. 
 It is only rarely that a definite diagnosis is made. 
 
 With regard to the differentiation from gastric ulcer, it 
 should be remembered that duodenal ulcer is particularly 
 common in the male, and that it is not often accompanied 
 by haematemesis. Cholelithiasis is very rarely associated 
 with mel?ena, and the history of the case, the examination 
 of the gall-bladder by palpation, and, possibly, the passage 
 of calculi, will render the diagnosis clear. 
 
 From appendicitis duodenal ulcer is distinguished by the 
 seat of the pain, the maximum point of tenderness, and the 
 periodicity of the pain ; a tender swelling in the right iliac 
 region will of course point to the appendix. 
 
 INDICATIONS FOR OPERATION. 
 
 Duodenal ulcer has rarely been directly treated by 
 operation on account of the difficulties of diagnosis. The 
 indications for operation are virtually the same as in gastric 
 ulcer (q.v.). It is usually confounded with the latter, and 
 the actual seat of the ulcer has often been demonstrated 
 only at operation or autopsy. 
 
 Perforation occurs in a large proportion of cases, and 
 furnishes an absolute indication for operation. The same 
 is true of the other common complication, subphrenic 
 abscess. As the subphrenic abscess following duodenal 
 ulcer does not differ in features from that arising 
 from other causes, the reader is referred to the special' 
 article on the subject. It may simply be said here 
 that the definite presence of a subphrenic empyema calls 
 for operation, wliatever the cause. Chronic perforation 
 
DISEASES OF THE INTESTINES. 203 
 
 may give rise to abscess in other situations, and these 
 also necessitate operation. 
 
 Repeated hcemorrhages, revealed by melaena or ha^mate- 
 mesis, constitute an indication for operation if medical 
 treatment fails and the patient becomes an?emic and declines 
 in general health. Gastro-enterostomy is the operation of 
 choice. 
 
 Contra-indications. — Operation will not be advised until 
 medical treatment has been properly tried. A single 
 haemorrhage, even if large in amount, does not necessitate 
 operation. Generally speaking, the contra-indications are 
 the same as in gastric ulcer. 
 
 Prognosis. — Results of operation. — In cases of acute 
 perforation the prognosis is very serious, even if operation 
 is done soon after the accident. Laspeyres has collected 
 17 cases ; in 2 the perforation could not be closed, and had 
 to be tamponed ; both were fatal. Of the remainder a 
 third recovered. In two unpublished cases of my own, 
 death occurred in spite of operation. In Pagenstecher's 28 
 collected cases the mortality was 86 per cent. The figures 
 of Weisl and Foote show how important is early operation ; 
 those operated on within eleven hours gave a mortality of 
 39 per cent, those operated on between the twelfth and 
 twenty-fourth hour gave a mortality of 76 per cent, and of 
 those dealt with later, 87 per cent died. 
 
 In a considerable number of cases complete recovery has 
 followed gastro-enterostomy. 
 
 These figures show that duodenal ulcer is a grave disorder, 
 and often causes complications which have to be dealt with 
 by operation to save life. The mortality of these complica- 
 tions is still to-day very high. 
 
 Without operation. — Death occurs in many cases from 
 perforation or profuse haemorrhage. In some cases the 
 affection runs a very chronic course ; remissions alternate 
 witli exacerbations over a period of many years. In a 
 not inconsiderable number of cases healing results in a 
 cicatrization which causes stenosis. 
 
 LITERATURE. 
 
 E.JiSi'iCYKrcs. Das runde Duodenalgeschwiir. Ccntralb. f. d. 
 <ircnzgebictc d. Med. u. Chir., igo2. 
 
 XoTHNAG7-:(,. Krankheiten dcs Darmes und des Peritoncurns. 
 2nd Ed., 1003. 
 
204 INDICATIONS FOR OPERATION IN 
 
 BuRWiNKEL. Peptisches Duodenalgeschwiir. Deut. med. Wochen. 
 No. 52, 1898. 
 
 Pagenstecher. Die chirurgische Behandlung des Duodenal- 
 geschwiires. Deutsche. Zeit. f. Chir., Bd. lii. 
 
 Darras. De la Perforation dans I'Ulcere Simple du Duodenum. 
 These de Paris, 1897. 
 
 Schwarz. Peritonites Septiques Diffuses Produits par 1' Ulcer 
 Perforant du Duodenum. Bullet, et Mem. de la Soc. d; Chir. 
 Paris, 1898. 
 
 Savariand. Les Gastrorrhagies dans I'Ulcere du Duodenum et 
 leur Traitement Chirurgical. Gaz. des Hopit., Jan., 1899. 
 
 Perry and Shaw. On Diseases of the Duodenum. Guy's 
 Hospital Reports, p. 171, 1894. 
 
 Ladeveze. Traitement de I'Ulcere du Duodenum. These de 
 Paris, 1 900. 
 
 Lennander. Die Behandlung des perforirenden Magen- und 
 Duodenalgeschwiires. INlitteil a. d. Grenzgebiete d. Med. u. Chir. 
 Bd. iv. 
 
 DUODENAL STENOSIS. 
 
 Etiology and Pathological Anatomy. — The cause of 
 duodenal stenosis may be outside the bowel, as in the case 
 of adhesions, tumours of the pancreas, and glandular 
 tumours, or within the lumen itself, as in cicatricial con- 
 traction after ulcer, gall-stones, and tumours of the gut. 
 The point of stenosis may be in any of the three parts 
 of the duodenum. 
 
 Clinical Course. — Obstruction may set in acutely, 
 and begin, as in other forms of acute obstruction, with 
 marked collapse, vomiting, etc. Meteorism and fcecal 
 vomiting, however, are absent, and fgeces and flatus may be 
 passed. The stomach is often much distended. 
 
 Suprapapillary stenosis is clinically similar to pyloric 
 stenosis, and cannot be distinguished from it. When the 
 obstruction is in the neighbourhood of the papilla, the signs 
 of common duct obstruction are present (jaundice, bile in 
 the urine, and colourless stools), and the stools are fatty, 
 from obstruction of the duct of Wirsung. When the 
 stenosis is below the papilla there is often copious vomiting 
 of bilious matter, and on washing out the stomach the fluid 
 at the end of the washing is bile-stained. This last sign was 
 most marked in one of my cases. The gastric secretion 
 often shows no diminished digestive capacity, but free 
 hydrochloric acid is often absent. This phenomenon 
 
DISEASES OF THE INTESTINES. 205 
 
 is sometimes only transitory, and the variability of the 
 symptoms is quite a characteristic feature of infrapapillary 
 stenosis. When the stomach is empty of food, alkaline 
 duodenal secretion can sometimes be obtained from it, 
 showing action on proteid, starch, and fat. 
 
 Diagnosis. — The symptoms just enumerated will be 
 sui^cient for a diagnosis. The vomited matter is abundant 
 and the epigastrium distended. General meteorism is 
 against duodenal stenosis. Differentiation from pyloric 
 stenosis is often not easy ; the chemical changes, however, in 
 many cases demonstrate the situation of the stenosis. 
 Chronic obstruction of the common duct by calculus is 
 distinguished from duodenal obstruction by the absence of 
 duodenal secretion from the stomach and by the histor}^ of 
 the case. 
 
 INDICATIONS FOR OPERATION. 
 
 Operative treatment is necessary whenever serious 
 symptoms make their appearance, and do not yield to 
 internal treatment. Under this heading come persistent 
 vomiting, increasing inanition, diminution of urine secretion. 
 The presence of these justifies intervention. 
 
 The operation will either be gastro-enterostomy, removal 
 of a biliary calculus, or the separation of adhesions. The 
 removal of a neoplasm will depend upon the presence or 
 absence of metastases. 
 
 Sometimes duodenal perforation is a consequence of 
 stenosis, and operation will of course be done here as in a 
 perforating ulcer, in both the acute and the chronic types. 
 
 Contra-indication. — Operation will not be advised until 
 lavage and medical treatment have been tried and failed to 
 relieve. 
 
 Prognosis. — Operation has been relatively seldom done 
 for duodenal stenosis. The risks are the same as in the 
 operation for duodenal ulcer. In many of the cases the 
 condition has been entirely cured. If no operation is 
 undertaken the symptoms can sometimes be relieved in 
 jjart by medical treatment ; if this is not the case, death 
 will follow sooner or later from inanition and cachexia. 
 
 LITERATURE. 
 
 Albu. Die Diagnose und Therapie der Duodenalstenose. 
 Ccntralb, f. d. Grenzgebiete d. Med. u. Chir., 1899. 
 
2o6 INDICATIONS FOR OPERATION IN 
 
 XoTHNAGEL. Erkrankungen des Darmes und des Peritoneuras. 
 2nd Ed. 1903. 
 
 Adrien Pic. Cancer du Duodenum. Rev. de Med.. 1894 and 
 1895. 
 
 Laspevres. Das Runde Duodenalgeschwiir. Centralb. f. d. 
 Grenzgebiete d. ;\Ied. u. Chir., 1902. 
 
 Jaboulay. Ulcere du Duodenum. Duodenoplastie. Lyon. 
 Med., No. 27, 1899. 
 
 Perry and Shaw. Diseases of the Duodenum. Guy's Hospital 
 Reports. 1894. 
 
 CoDiviLLA. Contributo alia Chirurgia Gastrica. Bologna. 1898. 
 
 Wilms. Die Stenose des unteren Duodenum. Beitr. z. 
 klin. Chir. Bd. xviii. 
 
 INTESTINAL TUBERCULOSIS. 
 
 Etiology. — In the great majority of cases intestinal 
 tuberculosis is a secondary affection, and is therefore 
 dependent on all conditions which tend to establish tuber- 
 culosis in the lungs and other organs. It may develop at 
 any age ; the tumour-like tuberculous masses are most 
 frequently found in the middle-aged. 
 
 Pathological Anatomy. — There are three types dis- 
 tinguished : — (i) The disseminated type, without tendency 
 to healing ; (2) The solitary or multiple type, with tendency 
 to healing ; (3) The tumour-like tuberculosis of the ileo- 
 Cctcal region. In the second type, solitary or multiple ulcers 
 are formed, and the solitary ulcer is usually in the ileoccecal 
 region. If the ulceration extends transversely to the axis 
 of the bowel, stenosis tends to follow its cicatrization. Such 
 strictures are not uncommonly multiple ; as many as fifteen 
 have been met with ; sometimes they are ^annular, some- 
 times tubular. They are most frequent in the ileum. 
 
 The tumour-like mass of the ileocaecal region remains 
 long localized, and stenosis may result from great thickening 
 of the bowel wall. 
 
 According to Conrath, the lesions of intestinal tuberculosis 
 may commence in the subserous layer or as ulcers of the 
 mucous membrane. In some cases they are more numerous 
 in the ileum, in others in the csecum, and in old-standing 
 cases they may be widely distributed. 
 
 The peritoneum may remain free from involvement, even 
 in cases where the other lesions have long been present. 
 
 Clinical Course. — With stenosing tuberculosis of the 
 
DISEASES OF THE INTESTINES. 207 
 
 bowel, patients are usually in indifferent general health, and 
 usually have clinically recognizable tubercular lesions in 
 other organs. The disease as a rule begins insidiously, and 
 the first sign is irregularity of the bowels, and constipation, 
 alternating sometimes with diarrhoea. There is usually a 
 complaint of dull intermittent pains in the abdomen, the 
 attacks becoming more and more frequent. During an 
 attack there is exaggerated peristalsis, and distended and 
 firmly-contracted coils are to be felt ; the pains are severe, 
 and pass off with borborygmi. The peristaltic movements 
 concern the small intestine. Vomiting is common, and 
 during the attack neither faeces nor flatus are passed. 
 Occasionally there is slight fever. 
 
 The symptoms of the tumour-like ileocecal tuberculosis 
 are also those of intestinal stenosis, but the typical attacks 
 of stenosis may be preceded for months and even years by 
 indefinite pains in the abdomen without any constant 
 localization. 
 
 Attacks of severe diarrhoea or of large hgemorrhages are 
 unusual. After the symptoms have been present for some 
 time, a hard, nodular, slightly tender and mobile mass 
 becomes recognizable in the ileocsecal region, which grad- 
 ually becomes immobile. In some cases cold abscesses are 
 formed, and perforation of the tuberculous bowel may take 
 place into other hollow organs or the exterior. 
 
 In both of these types of intestinal tuberculosis the 
 peritoneum is, as a rule, not affected. 
 
 Diagnosis. — If intestinal stenosis makes its appearance 
 in a young individual, with tuberculosis in some other organ, 
 it is probably tuberculous in nature. The discovery of 
 small and repeated haemorrhages in the stools revealed by 
 the guaiac or aloin tests, or of tubercle bacilli, will make the 
 diagnosis certain. If it is possible to diagnose multiple in- 
 testinal stenosis in a young patient without syphilitic lesions 
 or history, the probability is that it is due to tuberculosis. 
 
 In several cases I have found it possible to diagnose 
 multiple tubercular stricture without palpable tubercular 
 masses. In all I have met with five such cases, and I look 
 upon the following points as characteristic : the repeated 
 observation of simultaneous spasmodic contraction in 
 different segments of bowel at a distance from one another, 
 the intervening segments remaining fiaccid, particularly if 
 
2o8 INDICATIONS FOR OPERATION IN 
 
 these are of different diameter and there is no general 
 meteorism ; the practically identical position of these 
 contracted segments during the different attacks ; the 
 simultaneous disappearance of the contractions, along with 
 marked intestinal gurgling. 
 
 One of my patients was a man of twenty-three, who 
 complained of cough and presented an early consolidation 
 of the right apex. For three years he had had attacks of 
 abdominal pain off and on, the attacks passing off with 
 gurgling, and increasing in frequency. Contractions, some- 
 times simultaneous, of three different thickened intestinal 
 coils, could be recognized, and the diagnosis of multiple 
 tubercular stricture of the bowel was made. The operation 
 revealed three tubercular strictures, the lowest in the ileo- 
 caecal region. Entero-anastomosis was performed. The 
 patient died from peritonitis on the lifth day ; the autopsy 
 showed the presence of a fourth stricture. 
 
 In another case multiple tubercular stenoses were diagnosed 
 from the presence of similar symptoms ; there was no 
 syphilis and no pulmonary tuberculosis. Operation revealed 
 the presence of twelve tubercular strictures. Entero- 
 anastomosis was performed, and two metres of small intestine 
 were excluded. The symptoms of stenosis disappeared, and 
 except for insignificant pains the boy is well a year and a 
 half after operation. 
 
 Ileocaecal tuberculosis in the form of a tumour-like mass 
 can be recognized when intestinal stenosis is associated with 
 a mass in the right iliac region in a tuberculous individual, 
 the symptoms being chronic and associated with a sub- 
 febrile temperature. 
 
 A case under my care was that of a woman aged 50, with 
 earh^ apical lesions. Associated with diarrhoea and severe 
 pain, a hard nodular mass developed in the ileocaecal region. 
 The general health suffered greatly, and she became anaemic. 
 The pulmonary condition, which was confirmed by bacterio- 
 logical examination, led one to diagnose intestinal tuber- 
 culosis. The operation showed marked thickening of the 
 wall of the lower part of the ileum and of the caecum, and 
 tubercular ulcers of the mucous membrane in the same 
 portions of gut. The lumen of the bowel was reduced to 
 the diameter of a quill. Resection was performed, and the 
 intestinal symptoms disappeared. 
 
DISEASES OF THE INTESTINES. 209 
 
 Differential diagnosis is often difficult and sometimes 
 impossible. From new growth the affection is distinguished 
 by its more chronic course, by the association with tuber- 
 cular lesions elsewhere, and by preceding diarrhoea. These 
 points led me to diagnose tuberculosis in a patient in spite 
 of his advanced age, whom I saw some years ago, and the 
 operation proved that the opinion was correct. Long 
 observation is sometimes necessary before cholelithiasis or 
 nephrolithiasis can be excluded. 
 
 One of my cases was that of a hospital sister, apparently 
 in good health. For some years she had suffered from 
 severe pains, which were first ascribed to cholelithiasis and 
 later to renal calculus. I saw her during an attack, found 
 a lump in the ileocsecal region, and diagnosed chronic 
 appendicitis ; the possibility of tuberculosis was also con- 
 sidered in view of her occupation. A tumour-like mass was 
 found at the operation, involving the caecum and causing 
 stenosis. Entero-anastomosis was performed, and per- 
 manent relief of symptoms followed. 
 
 Before operation diagnosis may be impossible from chronic 
 non-tubercular appendicitis, chronic intussusception, and 
 other conditions. 
 
 INDICATIONS FOR OPERATION. 
 
 Many of these cases are operated on for some other 
 supposed condition, the diagnosis being made only when 
 the abdomen is opened. There are two signs which indicate 
 the necessity for intervention : symptoms of intestinal 
 stenosis, and the presence of a mass in the ileocsecal region. 
 
 If the symptoms of intestinal stricture are definite, and 
 if in addition to the sign of contracture the bowel wall can 
 be felt to be markedly hypertrophied, the stenosis is 
 evidently extreme, and surgical intervention is absolutely 
 necessary. 
 
 The presence of a mass in the ileocaecal region, associated 
 with pain, fever, or stenosis symptoms, is also an indication 
 for operation. 
 
 If the signs are sufficient for a diagnosis of multiple 
 stricture, this in itself is an indication for operation. 
 
 The operative procedures employed are : exclusion of a 
 portion of the gut by entero-anastomosis, or resection of 
 tlio affected segment, a much more serious undertaking. 
 
 14 
 
2IO INDICATIONS FOR OPERATION IN 
 
 Contra-indications. — A state of pronounced cachexia, 
 advanced pulmonary tuberculosis, amyloid disease, and 
 any serious complications in other organs, contra-indicate 
 operation. If tubercular peritonitis is present, no com- 
 plicated operative procedure is advisable. 
 
 Prognosis. — Results of operation. — Eighty-one cases of 
 tubercular ileocsecal " tumour " have been analysed by 
 Conrath. In 48 cases resection with anastomosis was 
 practised, and of these 9 either died after the operation or 
 remained unhealed, while in 5 others it was necessary to 
 establish an artificial anus. With regard to the end results, 
 30 cases who recovered after operation had the following 
 subsequent histories : 11 died from a month to four years 
 later, 4 from local return or tubercular peritonitis, the 
 remainder from phthisis pulmonalis ; of the 19 survivors, 
 2 had had recurrence, and 16 remained well several years 
 after operation. 
 
 Entero-anastomosis was performed in 10 of Conrath's 
 cases, with 9 recoveries, and in 8 of these the relief was 
 permanent ; in 8 cases the affected segment was excluded, 
 some with and others without subsequent removal of the 
 excluded portion ; two of these cases died from the operation. 
 
 There are many unpublished cases. Lotheissen, for 
 example, has performed entero-anastomosis in five of my 
 cases during the last two years. 
 
 After operation the intestinal troubles have in many cases 
 disappeared, and the general health has become excellent. 
 In other cases, in some of my own for example, attacks of 
 pain and distension have persisted during the first month 
 after operation, relieved by aperients. Probably these were 
 due to spasmodic contractions of the bowel. Several of 
 these cases have later entirely lost their symptoms. 
 Occasionally, in spite of operation, the tubercular pro- 
 cess progresses and gives rise to abscess or tubercular 
 peritonitis. 
 
 Without operation. — The stenosis is progressive in 
 character, and the pains and other symptoms increase in 
 severity. Acute obstruction or perforation of the bowel 
 may prove rapidly fatal. If a perforation occurs gradually, 
 intestinal fistulas or artificial anus may result. In some 
 cases a slowly progressive suppurative peritonitis develops ; 
 this I have myself seen in several cases. 
 
DISEASES OF THE INTESTINES. 211 
 
 LITERATURE. 
 
 CoNRATH Die lokale chronische Caecumtuberkulose. Beitr. z. 
 klin. Chir., Bd. xxi. 
 
 Reach. Die multiplen Darmstenose. Centralb. f. d. Grenzgebiete 
 d. Med. u. Chir. 1900. 
 
 HoFMEiSTER. Uebcr multiple Darmstenosen tuberculosen 
 Ursprungs. Beitr. z. klin. Chir., Bd. xvii. 
 
 H. ScHLESiNGER. Zur Diagnose multipler Darmstenosen. 
 Centralb. f. innere Med. 1903. 
 
 NoTHNAGEL. Krankheitcn des Darmes und des Peritoneums. 
 2nd Ed. 1903. 
 
 Alglave. Traitement Chirurg. de la Tuberculose du Segment 
 Ileocaecal de ITntestin. These de Paris-. 1904. 
 
 Belgrand. Tuberculose Chirurgicale de la Region IleocaecaL 
 These de Paris. 1904. 
 
 Delore et Patel. Rev. de Chir. pp. 305, 669, and 797. 1901. 
 
 Berard et Leriche. Les Stenoses Tuberculeuses Multiples de 
 ITntestin Grele cliez ITnfant. Rev. de Chir. 1904, Ncs. 8 and 9. 
 
 ACTINOMYCOSIS OF THE INTESTINE. 
 
 Infection usually comes from eating wheat grains, and 
 most commonly occurs in men of middle age. 
 
 Pathological Anatomy. — The rectum and the cascum 
 are the parts most often affected. Of iii cases collected 
 by Grill, in 62 the caecum and appendix were the certain or 
 probable original seat. The disease is a chronic inflam- 
 matory process, leading at one and the same time to tissue 
 proliferation and tissue necrosis, extending deep to the 
 surface and invading neighbouring structures after the 
 formation of adhesions. In some cases extension is chiefly 
 towards the peritoneal cavity, in others towards the 
 abdominal wall. The disease often causes the formation of 
 intestinal fistulse ; the infiltration which occurs is often 
 very wide in extent. 
 
 Clinical Course. — The development of the disease is of 
 a chronic type. The following stages may be distinguished : 
 (i) The early stage, with indefinite phenomena and often 
 intestinal catarrh. (2) The stage of tumour. After some 
 months a mass, which often reaches considerable proportions, 
 forms, usually in the ileoccccal region ; later it becomes 
 incorporated with the abdominal wall, is ill-defined, intensely 
 hard, and usually very slightly tender to pressure. (3) The 
 stage of fistula;. The infiltration usually reaches the 
 
212 INDICATIONS FOR OPERATION IN 
 
 surface at several points, and forms several fistulfe, with a 
 complicated system of holes and passages. The character- 
 istic yellow-gold granules are found in the pus. The fistulse 
 may connect with the bowel, and the discharge is then fsecu- 
 lent. Symptoms of intestinal stenosis are absent. There 
 is usually some fever, and the general condition suffers to a 
 marked degree. Perforation into the general peritoneal 
 cavity is very unusual ; the formation of fistulce into 
 neighbouring organs is common. 
 
 Diagnosis. — The disease is sometimes recognized in the 
 second stage, when there is an infiltration of intense hardness 
 with a history of chronic development ; more often the 
 diagnosis is not made until fistulfe form, the granules are 
 recognized in the pus, or the organism is demonstrated in 
 portions of tissue removed. In the stage of freely movable 
 mass in the ileocgecal region, a delinite diagnosis from 
 appendicitis, carcinoma, and other conditions is practically 
 impossible. When invasion of the abdominal wall has 
 taken place, the condition is distinguished from ordinary 
 cellulitis by the acute course of the latter and the marked 
 constitutional disturbance, and from true tumours of the 
 parietes by the more defined limits of the latter, by the 
 absence of fever and of extensive infiltration of the skin. 
 
 When fistulse have formed, diagnosis has to be made from 
 tuberculosis, chiefly by the result of examination of the 
 discharge, and from syphilis. 
 
 INDICATIONS FOR OPERATION. 
 
 If a tumour is present in the ileocaecal region, if fever and 
 pain are present, laparotomy, with resection of the mass, or 
 entero-anastomosis, is indicated. If the abdominal wall is 
 infiltrated, it is necessary, if iodide of potassium gives no 
 result, to slit up the whole area of fistulous tracts, and if 
 this proves unsatisfactory to remove the whole area with 
 the knife and spoon. 
 
 Contra-indications. — If the diagnosis of actinomycosis is 
 tolerably certain and the delimitation of the mass indefinite, 
 it is not of much use attempting radical extirpation, as the 
 disease is practically certain to extend in spite of it. 
 
 Prognosis. — Results of operation. — The results of operative 
 treatment are comparatively good, considering that it is 
 seldom possible to remove the whole area of disease. Of 
 
DISEASES OF THE INTESTINES. 213 
 
 Grill's III cases operated on, 45 died, 22 were cured, and 
 10 improved. 
 
 Without operation. — Without eneirgetic treatment intestinal 
 actinomycosis is a very aggressive process, and never tends 
 to spontaneous cure. Iodide of potassium given internally 
 seems to have some favourable influence on the disease, but 
 recovery without operation is excessively rare. 
 
 LITERATURE. 
 
 H. Herz. Ueber Aktinomycose des Verdauungsapparates. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir., 1900. 
 
 O. Frey. Klinische Beitr. z. Aktinomykose. Beitr. z. klin. 
 Chir., Bd. xix. 
 
 NoTHNAGEL. Krankheiten des Darmes und des Peritoneums, 
 2nd Ed., 1903. 
 
 Mikulicz und Kausch. Krankheiten des Darmes. Handbuch d. 
 prakt. Chir. Bergmann, Mikulicz, u. Bruns. Bd. iii. 2nd Ed. 
 1903. 
 
 Grill. Aktinomykose des Magens und Darmes. Beitr. z. kUn. 
 Chir., Bd. xiii. 
 
 PoNCET. De rActinomycose Ano-Rectale. Gaz. Hebdom. de 
 Med. et de Chir., Sept., 1898. 
 
 Fairweather. Actinomycosis Commencing in the Vermiform 
 Appendix. Brit. Med. Jour., June 27, 1897. 
 
 Fantino e Grill. Contribute alio Studio dell' Actinomicosi 
 Umana. Riforma Medica. Nos. 90-92 and 1 01-103, 1898. 
 
 CHRONIC DYSENTERY AND ULCERATIVE COLITIS. 
 
 Etiology and Pathological Anatomy. —Chronic dysen- 
 tery follows the acute disease, both the amoebic form and 
 the so-called catarrhal form. The ulcers are usually in the 
 descending colon, are often of considerable depth and extent, 
 and have thickened edges. When extensive, the ulceration 
 gives a dense, thickened feeling to the whole bowel. Secon- 
 dary peritonitis is uncommon. 
 
 Under the title of ulcerative colitis a series of affections 
 is described, with different pathological lesions ; catarrhal, 
 dysenteric, tubercular, and syphilitic processes have been 
 thus grouped together. The ulcerative condition may 
 involve more or less the whole colon, causing dense infiltra- 
 tion throughout its whole length. 
 
 Clinical Course. — Kartulis describes the following 
 clinical types of chronic dysentery : — (i) That in which the 
 
214 INDICATIONS FOR OPERATION IN 
 
 symptoms follow an acute attack and persist in a milder 
 form for many months. (2) In the course of convalescence 
 from acute dysentery a relapse takes place, and improve- 
 ment alternates with relapse for a long time. (3) At the 
 beginning the symptoms are only those of catarrhal diarrhoea, 
 dysenteric symptoms coming on later. 
 
 Tenesmus is not pronounced in chronic dysentery ; the 
 stools are liquid, of greenish or black-brown colour. Blood, 
 mucus, and pus are often present in considerable quantity. 
 Pain and tenderness are present along the colon, whose wall 
 is usually much thickened. Meteorism is often marked. 
 In the severer cases the number of stools is very great and 
 the amount of blood considerable. Fever and vomiting 
 are also common. 
 
 In ulcerative colitis the same clinical phenomena are 
 presented, but there is no history of a preceding attack of 
 acute dysentery. 
 
 Diagnosis. — In the presence of the symptoms just 
 described, after an acute dysenteric attack the diagnosis 
 is clear. The passage of large quantities of mucus, blood, 
 and pus, tenderness and resistance along the colon, diarrhoea, 
 and sometimes tenesmus, point to the presence of ulcerative 
 colitis. From haemorrhoids both conditions are distinguished 
 by the diarrhoea and the purulent discharge. From new 
 growth the diagnosis is often difficult, but the great extent 
 of the iniiltration and thickening of the bowel will be 
 evidence against this. 
 
 INDICATIONS FOR OPERATION. 
 
 If the methods of treatment which are advocated for 
 obstinate and advanced ulcerative lesions of the bowel are 
 ineffectual, if the patient is steadily losing strength and 
 there is much suffering, surgical intervention is called for 
 with a view to giving rest to the affected portion 
 of bowel. 
 
 The methods which have so far been employed are the 
 temporary establishment of an artiftcial anus at the caecum 
 or near it, or the performance of an entero-anastomosis 
 excluding the affected bowel. Occasionally portions of intes- 
 tine have been resected. The artificial anus has been closed 
 after a period varying from six weeks to two and a half 
 years ; in some cases, however, it has not been possible to 
 
DISEASES OF THE INTESTINES. 215 
 
 close it even after several years. Operation should not be 
 resorted to until other methods have been tried. 
 
 Prognosis. — Results of operation. — Colostomy is an opera- 
 tion not entirely free from risk, and resection is much more 
 dangerous. 
 
 A considerable number of cases have been operated on^ 
 Hermann's recent statistics include 50 — most of them with 
 good results. Twenty-four of these cases were cured and 
 eleven relieved. The artilicial anus cannot be closed for 
 several months at the earliest, the time varying considerably, 
 as has already been remarked. Ewald, Korte, and others 
 have reported unsuccessful cases, and probably several 
 others have not been recorded in which no improvement or 
 only the relief of a single symptom, such as pain, was 
 obtained. Six fatal cases are on record. 
 
 Without operation. — The prognosis of chronic ulcerative 
 lesions of the colon is extremely grave in the average case. 
 Ancemia, persistent suffering, and wasting usually end in 
 death after a long, trying illness. The apparently cured 
 often relapse. 
 
 LITERATURE. 
 
 Boas. Colitis Ulcerosa. Deut. med. Wochens., 1903, No. 11 ; 
 and Vereinsbeilage, p. 50. 
 
 Ewald. Klinik der Verdauungskrankheiten, Teil iii. Berlin, 
 1902. 
 
 Giordano. Rivista Venet. di Scienze Mediche, 901. 
 
 Hermann. Chronische Entzundungsprozessen des Dickdarms. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir., 1904. 
 
 Kartulis. Dysenterie. Nothnagel's Handbuch d. spez. Pathol., 
 1898. 
 
 Labey-Quenu. De ITntervention Chirurgicale dans les Formes 
 Graves des Colites Rebelles. Paris, 1902. 
 
 Murray. Annals of Surgery, 1901. 
 
 Xothnagel. Krankheiten des Darmes und des Peritoneums, 
 2nd Ed., 1903. 
 
 Orsini. Rivista Venet. di Scienze Mediche, 1896. 
 
 Summers. Jour. Amer. Med. Assoc, July, 1903. 
 
 MUCOUS COLITIS AND MEMBRANOUS ENTERITIS. 
 
 Etiology aND Pathological Anatomy. — The disease 
 is far more common in women than men, and occurs 
 especially in " nervous " individuals. Diseases of the 
 female genital organs and chronic constipation are important 
 
2i6 INDICATIONS FOR OPERATION IN 
 
 etiological factors. Membranous enteritis not infrequently 
 follows irrigation of the bowel with irritating fluids, solutions 
 of alum, tannin, nitrate of silver, etc. Hitherto little has 
 been recorded on the pathological anatomy of the disease ; 
 usually there are no recognizable signs of intestinal 
 inflammation. 
 
 Clinical Course. — The different types have one symptom 
 in common, the passage of mucomembranous masses ; 
 these often take the form of tubular masses of coagulum of 
 a greyish white colour ; in other cases these are merely 
 shreds and ribands. The passage of these masses occurs 
 usually at intervals, and is accompanied by much pain ; the 
 intervals between attacks vary, sometimes extending to a 
 month. Constipation is usual in these cases, even in the 
 intervals when no mucus is passed. In other cases the 
 passage of membrane is continuous but painless, the patients 
 suffering alternately from constipation and diarrhoea. 
 
 Diagnosis. — The passage of the membranous material 
 is sufficient to show the nature of the disease. From simple 
 catarrh with mucous discharge it is differentiated by this 
 passage of membrane and in some cases by the recurrence 
 of attacks. 
 
 INDICATIONS FOR OPERATION. 
 
 In several cases an artificial anus has been established and 
 the colon irrigated. In other cases intestinal adhesions 
 have been separated, or a uterus, fixed in a position of retro- 
 version, has been rectified. 
 
 The affection itself is not so troublesome or dangerous as 
 to justify as a rule any operation of a serious nature. The 
 number of cases so far operated on is not sufficiently large 
 for the formulation of any definite indications. 
 
 Certainly operation should only be advised as a last 
 resource when medical treatment has entirely failed, when 
 the sufferings are intolerable, and when the patient desires 
 it although informed of the inconveniences of an artificial 
 anus. 
 
 Prognosis. — Results of operation. — In several cases, the 
 first of which was reported by Franke in 1891, complete 
 cure has been obtained by operation, but sometimes after 
 a long period of relief the attacks have recurred. Gant 
 considers that colostomy hastens cure by (a) facilitating 
 
DISEASES OF THE INTESTINES. 217 
 
 the emptying of the bowel and avoiding constipation ; 
 (b) Making it possible to keep the intestine thoroughly 
 clean with irrigation, and to apply suitable lotions. 
 
 Without operation. — In many cases recovery occurs with- 
 out treatment, or after internal or local treatment. The 
 affection is not associated with any serious complications. 
 
 LITERATURE. 
 
 Delbet. Traite de Chirurgie, Vol. viii., 1899. 
 
 Douglas. Membranous Colitis. Jour. Amer. Aled. Assoc.,. 
 Aug. 31, Vol. xxvii. 
 
 EiNHORN. Membranose Enteritis. Arch. f. Verdauungskrank- 
 heiten, Bd. iv. 
 
 Froussard. Contribution a I'Etude de I'Entero-Colite Muco- 
 membraneuse. These de Paris, 1900. 
 
 Gant. Diseases of the Rectum and Anus. 
 
 Hale White and Golding Bird. Brit. Med. Jour., 1902, 
 Vol. i., p. 1337. 
 
 Nothnagel. Krankheiten des Darmes und des Peritoneums. 
 2nd Ed., 1903. 
 
 EMBOLUS AND THROMBOSIS OF THE MESENTERIC 
 
 VESSELS. 
 
 Etiology. — Embolus of the mesenteric arteries is as a 
 rule associated with endocarditis or thrombus formation in 
 the heart. Thrombosis of the arteries occurs in connection 
 with atheromatous changes. Thrombosis of the mesenteric 
 veins may be the result of any of the conditions which cause 
 thrombosis in the portal system. The affection occurs as a 
 rule in middle and advanced age. 
 
 Pathological Anatomy. — Embolus occurs more fre- 
 quently in the superior mesenteric artery than in the 
 inferior, the proportions in 86 cases being yy : 9 (Neutra). 
 The block may be partial or complete. The portion of 
 bowel and mesentery supplied by the obliterated vessel is 
 engorged and infiltrated with blood, and there is blood also 
 in the bowel. If the condition persists, more or less 
 extensive necrosis of the intestinal wall results. The 
 anatomical changes are the same in thrombosis of the veins 
 as in embolus of the arteries. Sometimes obliterating 
 endarteritis is the cause of embolic or thrombotic ulcers 
 of the intestine. 
 
 Clinical Course. — In many cases tlic affection begins 
 
2i8 INDICATIONS FOR OPERATION IN 
 
 suddenly, with colic-like pains, which may be either diffuse 
 or localized ; vomiting and diarrhoea follow, and the stools 
 later contain blood. The amount of blood passed is often 
 very large, and the general signs of severe haemorrhage are 
 then present. After an interval of one to two days the 
 abdomen becomes tender, the pain increases, and fluid is 
 found in the peritoneal cavity, all the signs of peritonitis 
 developing. In other cases the signs of acute bowel 
 obstruction predominate : neither faeces nor flatus are 
 passed ; vomiting is repeated, at first of stomach contents, 
 then blood, and then faeces. The clinical phenomena of 
 arterial and of venous obstruction are identical. 
 
 Diagnosis. — The occurrence of haemorrhage from the 
 bowel which has no other obvious cause, in a patient who 
 has some condition which leads to embolism, such as 
 endarteritis, has in many cases led to correct diagnosis. 
 This will be particularly confident if there are signs of 
 embolism in other organs, and if intense abdominal pain 
 accompanies or precedes the haemorrhage. The tempera- 
 ture is low. In one of my cases the abdominal symptoms 
 were preceded by embolism of the artery of the sylvian 
 fossa and of one radial artery ; in another case there 
 were signs of splenic and renal embolism. If symptoms 
 of peritonitis develop, the diagnosis is still further 
 supported. 
 
 In atypical cases there may be great difficulties. If 
 there is no haemorrhage it may be impossible to exclude 
 acute intestinal obstruction from internal hernia, volvulus, 
 and other causes. In intussusception the onset is usually 
 not so extremely acute ; and a tumour is usually palpable. 
 Gall-stone obstruction is associated with a history of long- 
 continued antecedent colic. 
 
 In the early stages of hepatic cirrhosis there is often 
 haemorrhage from the bowel, but there is no pain. 
 
 INDICATIONS FOR OPERATION. 
 
 Some authors advise operation as early as possible, and 
 either resection or the formation of an artificial anus. 
 Most of the cases operated on (under mistaken diagnosis) 
 have, however, terminated fatally soon after, so that actual 
 experience points to the inadvisability of recommending 
 operation if the diagnosis is definite. There is a chance, 
 
DISEASES OF THE INTESTINES. 219 
 
 even though only a small one, that the process may recover 
 spontaneously. Also the affection usually occurs in 
 individuals who are wholly unequal to the strain of a 
 serious operation. In only a very small number of cases 
 has operation been followed by good results. 
 
 Prognosis. — Without operation. The acute cases usually 
 end fatally in the course of a few hours or days ; other 
 cases run a subacute or chronic course, and the fatal 
 termination may be delayed for several weeks. In some 
 cases, when only the branches are blocked and not 
 the main mesenteric artery, recovery follows. Of 120 
 cases collected by Neutra, 12 recovered and 108 died. 
 The following case of recovery came under my own 
 observation. 
 
 A man, aged twenty-three, developed signs of endo- 
 carditis after an attack of articular rheumatism. There 
 was a systolic bruit at the apex, and the second sound was 
 reduplicated. The temperature was high. Enlargement 
 •of the spleen developed suddenly, and then diarrhoea with 
 tenesmus. One stool contained a large quantity of blood 
 and mucus, and there was great abdominal pain, without 
 meteorism or ascites. On the next day there was tenderness 
 on pressure over the left lower part of the abdomen, particu- 
 larly between the navel and the left anterior superior spine. 
 Diagnosis : embolus of the inferior mesenteric artery. 
 Some days later there were signs of embolic infarct of the 
 left kidney. All the symptoms gradually improved except 
 the heart condition, which remained unchanged. 
 
 LITERATURE. 
 
 Neutra. Ueber die Erkrankungen der Mesenterialgefasse. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir., 1902. 
 
 NoTHNAGEL. Erkrankungcn des Darmes und des Peritoneums. 
 2nd Ed., 1903. 
 
 Deckart. Thrombose u. Embolic der Mesenterialgefasse. 
 Mitteil. a. d. Grenzgebiete d. Med. u. Chir., 1900. 
 
 Elliot. Annals of Surgery, 1895. 
 
 Borszeky. Ileus durch Embolic der Art. Mesent. Super. Beitr. 
 ■/.. klin. Chir., 1901. 
 
 Kabartschieff. Thrombose Mesenteriquc. These de Mont- 
 pellier, 1899. 
 
 Watson. Boston Med. and Surg. Jour., 1894. 
 
 Gallavardin. Embolics et Thromboses des Vaisseaux Mcsen- 
 •tcriqucs. Gaz. des Ffojiit.. r90i. 
 
220 INDICATIONS FOR OPERATION IN 
 
 HAEMORRHOIDS. 
 
 Etiology. — The most important etiological factors of 
 haemorrhoids are habitual constipation, general venous 
 stasis from diseases of the heart, lungs, and liver, and local 
 stasis from affections of the pelvic organs. Men are more 
 frequently affected than women, especially middle-aged 
 men with sedentary occupations. 
 
 Pathological Anatomy. — The condition is one of 
 varicosity of the haemorrhoidal veins. External and 
 internal haemorrhoids are distinguished, but the anatomical 
 difference is only one of covering, the former being covered 
 by the skin of the anal canal, the latter by mucous membrane. 
 
 Clinical Signs. — External haemorrhoids cause little 
 trouble beyond itching ; they may attain the size of a 
 hazel nut and have a broad base. If inflammatory throm- 
 bosis takes place, there is great pain and sensation as of 
 a foreign body, and the nodes become tense and firm to 
 the touch. The attack of phlebitis either subsides in a few 
 days, or suppuration takes place and may eventuate in an 
 ulcer or a fissure. Internal haemorrhoids are sometimes 
 single, sometimes arranged circularly in one or more groups. 
 The^' frequently bleed ; this may take place either after 
 or independently of defiecation, and may be profuse and 
 persistent. Haemorrhoids often prolapse through the anus- 
 and may become strangulated ; the pain then is intense, 
 is associated with fever, and sometimes with retention of 
 urine, and even symptoms of intestinal obstruction. The 
 attack often ends in gangrene, and abscess and fistula may 
 result. Rectal catarrh, with excessive discharge of mucus 
 and tenesmus, usually accompanies such an attack. 
 
 Diagnosis. — Simple inspection reveals the presence of 
 external and also of prolapsed internal haemorrhoids ; if 
 not prolapsed, the latter are discoverable by palpation and 
 the use of the speculum. Without proper examination 
 internal haemorrhoids may be confounded with carcinoma, 
 rectal polypi, and syphilitic, gonorrhoeal, or tuberculous 
 ulceration. In dysentery there is tenesmus, and blood in 
 the motions, as in haemorrhoids, but the blood is more or less- 
 altered, and there are tissue fragments also in the faeces. 
 In chronic rectal catarrh without haemorrhoids there is nO' 
 blood passed. 
 
DISEASES OF THE INTESTINES. 221 
 
 INDICATIONS FOR OPERATION. 
 
 External haemorrhoids require operation if they are a 
 continual source of trouble from inflammatory attacks, 
 fissure, eczema, etc. The suppurative complications must 
 be treated by incision, and fissures which do not yield to 
 treatment with ointment require forcible dilatation of the 
 sphincter and incision. 
 
 Internal haemorrhoids call for radical operation when 
 they occasion repeated and considerable loss of blood, 
 when they easily and often become prolapsed and are 
 difficult to reduce or irreducible, and when they become 
 inflamed or give rise to pain in defsecation. There cannot 
 be said to be any contra-indication to operation. The 
 operations practised to-day are free from risk. The patient 
 is often unable to pass water for a day or so, and the first 
 evacuations are painful. Cicatricial narrowing of the anus 
 is very rare, but it has occasionally been recorded after 
 radical excision, which is also usually associated with a 
 considerable loss of blood. The results of operation are 
 good ; the percentage of unsuccessful cases only reaches 
 2 to 3 per cent. 
 
 Prognosis. — Without operation. — Prolonged haemorrhage 
 may give rise to serious symptoms and even prove 
 fatal. A case under my own observation was brought to 
 hospital moribund, and the autopsy showed the cause of 
 death to be haemorrhage from an internal haemorrhoid. 
 As already stated, haemorrhoids are often complicated by 
 suppurative inflammation, fissures, and fistulae. Deep-seated 
 periproctitis and proctitis are also common sequelae, and 
 not uncommonly a troublesome eczema. 
 
 LITERATURE. 
 
 XoTHNAGEL. Erkrankungen des Darmes und des Peritoneums. 
 2nd Ed., 1903. 
 
 F.\LKE. Endresultate der Langenbeck'schen Operation. Beitr. z. 
 klin. Chir., Bd. xxxiii. 
 
 Reixbach. Die Excision der Haemorrhoiden. Beitr. z. klin. 
 Chir., Bd. xxiii. 
 
 Rotter. Haemorrhoiden. Handbuch der prakt. Chir. MickuUcz, 
 Bruns, u. Bergmann. 2nd. Ed., Bd. iii., 1903. 
 
 GooDSALL and Miles. Diseases of the Anus and Rectum, 
 Pt. I., p. 251. 1900. 
 
 Ga.n't. Diseases of the Rectum and Anus. 
 
222 INDICATIONS FOR OPERATION IN 
 
 PoTARCA. Nouveau Procede Operatoire des Hemorrhoides. Rev. 
 de Chir., No. 5, 1902. 
 
 ViRDiA. La Cura Chirurgica delle Emoroidi. Gaz. Internat. 
 di Med. Practica, Nos. 12 & 20, IQ02. 
 
 PROCTITIS. 
 
 Etiology.— Common causes of proctitis are constipation 
 and impaction of fjcces, irritating enemata, foreign bodies, 
 and oxyurides. The disease may also arise from a gonor- 
 rhoea!, syphihtic, or dysenteric infection, and as a comphca- 
 tion of carcinoma and haemorrhoids. 
 
 Pathological Anatomy. — The mucous membrane may 
 simply show catarrhal changes, swelling oedema, and 
 hyperaemia, or there may be ulceration, sometimes very 
 extensive. Not infrequently infection spreads to the 
 cellular tissue around, and a purulent periproctitis results. 
 
 Clinical Course. — In catarrhal proctitis the stools are 
 frequent and often fluid ; there is tenesmus and also pain 
 in the intervals between the stools. A considerable quantity 
 of mucus is passed, and often pus and blood also. The 
 rectum is extremely tender to digital exploration. In 
 many instances the patient also suffers from retention of 
 urine and strangury. After the condition has continued 
 for some time there may be some inefficiency of the 
 sphincter. Fever and general weakness usually accompany 
 the attack, which varies in severity and acuteness. 
 
 Diagnosis. — The signs and symptoms enumerated 
 should be sufficient for a diagnosis, together with a careful 
 digital exploration, and in some cases examination with 
 the speculum. 
 
 Inspection differentiates the condition from haemor- 
 rhoids and anal fissure ; in carcinoma the mucous 
 membrane is felt to be infiltrated with firm growth ; 
 in tuberculous ulceration greyish nodules are seen at the 
 margins of the ulcers, and the discharge contains tubercle 
 bacilli. The history will distinguish an attack of acute 
 dysentery. Tabetic crises are recognized by the presence 
 of other tabetic symptoms. 
 
 INDICATIONS FOR OPERATION. 
 
 In acute proctitis operative treatment is only necessary 
 when there is some complicating purulent process (peri- 
 
DISEASES OF THE INTESTINES. 223 
 
 proctitis), or when the rectal inflammation is secondary to 
 some other condition which requires operation. In chronic 
 proctitis operation has in some cases been undertaken to 
 give the inflamed canal complete rest by means of colo- 
 tomy. This is unnecessary until other therapeutic measures 
 have been tried and failed, and unless the symptoms are 
 intolerably distressing. Operation tlierefore should be 
 considered rather as a last resource. Stricture sometimes 
 follows proctitis, and if this cannot be satisfactorily treated 
 by bougies, operation is called for. 
 
 Prognosis. — In a not inconsiderable number of cases 
 the rest provided by a colostomy is successful in bringing 
 about cure. The operation is not of course a severe one, 
 but not entirely free from risk. Without operation chronic 
 proctitis often proves very obstinate. In some cases it 
 leads to paresis of the sphincter, prolapse of the rectum, 
 cicatricial stricture, periproctitis, or haemorrhoids. 
 
 LITERATURE. 
 
 Arcoleo. Sulla Rectite Ipertrofica Proliferante. II Morgagni, 
 Bd. ii., Feb., 1901. 
 
 Beach. Recto-Colitis. Med. News, Dec. 14, 1901. 
 
 Giordano. Rivista Venet. di Sci. Med., 1901. 
 
 Hermann. Versuche chirurgischer Behandlung von chron. 
 Entziindungsprozessen des Dickdarmes. Centralb. f. d. Grenzgebiete 
 d. Med. u. Chir., 1904. 
 
 Labey-Quenu. De ITntervention Chirurgicale dans les Formes 
 Graves des Oolites Rebelles. 1902. 
 
 MuRR.w. Annals of Surgery, Vol. xxxiii., 1901. 
 
 NoTHNAGEL. Erkrankungen des Darmes und des Peritoneums. 
 2nd Ed., 1903. 
 
CHAPTER XV. 
 
 Diseases of the Intestines 
 
 {continued). 
 
 15 
 
12-J 
 
 Chapter XV. 
 DISEASES OF THE INTESTINES (contd.). 
 
 INTESTINAL STRICTURE. 
 
 Etiology and Pathological Anatomy. — Intestinal 
 stricture is caused by a variety of processes ; by cicatricial 
 contraction after ulceration of a tuberculous, dysenteric, 
 catarrhal, or syphilitic nature ; by torsion of the small or 
 large bowel without complete obstruction ; by internal 
 herniation into a peritoneal recess ; by kinking following 
 the formation of adhesions. Progressive obstruction by 
 scybala, by gall-stones, and by chronic invagination 
 dependent on tumours, are considered elsewhere. 
 
 In all cases of chronic intestinal stricture the bowel 
 below the stenosis is empty, while above it is distended, 
 though rarely to an extreme extent when there is no acute 
 obstruction. Above the stenosis the muscular wall is 
 hypertrophied, the mucosa and submucosa inflamed and 
 often ulcerated (the distension ulceration of Kocher). 
 This complication may lead to secondary peritonitis, 
 diffuse or localized. 
 
 Clinical Course. — Patients with stricture of the colon 
 and rectum as a rule exhibit as the first symptom chronic 
 constipation, which becomes more and more rebellious and 
 is accompanied by a sensation of fullness in the abdomen. 
 Sometimes the constipation is replaced by diarrhoea for a 
 short period, reappearing afresh and in an aggravated form. 
 There are, however, cases of stricture of the large bowel 
 who complain of no irregularity in the motions. 
 
 In stricture of the small bowel, the stage of constipation 
 is often absent. In stricture in this situation, as also in 
 stricture of the colon, there occur attacks of colic, and. 
 this may be the first symptom. The pain is intense 
 during the attack, passes off with gurgling, is often referred 
 
228 INDICATIONS FOR OPERATION IN 
 
 to the same spot, and usually accompanied by nausea, and 
 sometimes vomiting. If an attack lasts for some time, 
 the patient during its presence passes neither flatus nor 
 faeces. The most characteristic sign accompanying the 
 attacks is exaggerated peristalsis ; the intestinal coils are 
 observable through the parietes, and are palpable and firm 
 to the touch, owing to the tetanic contraction of their 
 muscular fibres. This intestinal spasm persists from a 
 few seconds to a minute or two, and then passes off, to recur 
 later. 
 
 Sometimes the interval between two attacks is long, 
 even several weeks, but this is in the early stage of the 
 stenosis, and as time goes on the period of exemption 
 becomes shorter, until finally the pains are never entirely 
 absent, the abdomen is persistently distended, and the 
 spasmodic seizures occur several times a day. 
 
 There is often mucus in the stools, and chronic diarrhoea 
 is not unusual. In some forms of stricture, pus and blood 
 are also present in the motions, that is to say in strictures 
 due to new growth, invagination, and dysenteric ulceration ; 
 in other types these are usually absent. 
 
 Splashing, and even a metallic percussion note, can often 
 be elicited over the distended bowel above the stricture. 
 
 Diagnosis. — If attacks of colic occur from time to time, 
 accompanied by visible and palpable spasmodic contracture 
 of the bowel, if the spasm passes off to the accompaniment 
 of borborygmi, and if the history is suggestive of intestinal 
 stenosis, then a diagnosis of " intestinal stricture from 
 organic lesion " will be made. If the stricture is in the 
 rectum the diagnosis will be made by palpation. The form 
 of the motions is not characteristic in bowel stricture ; 
 ribbon-like stools may be passed without any anatomical 
 stenosis ; blood, pus, and mucus, if present, will aid the 
 diagnosis. Discrimination must be exercised with regard 
 to the interpretation of constipation ; when due to stricture 
 its onset is somewhat sudden, there is an absence of other 
 ascertainable cause, such as neurasthenia, change in habits 
 of life, or diet, preceding acute intestinal catarrh, etc., 
 and it is associated with anaemia, general weakness, and 
 wasting. 
 
 The diagnosis may be aided by a history of some 
 antecedent condition liable to cause stenosis, such as 
 
DISEASES OF THE INTESTINES. 229 
 
 parametritis, cholecystitis, local or general peritonitis, 
 appendicitis, or a reduced hernia, or some bowel affection 
 liable to be followed by stricture, such as tuberculosis, 
 dysentery, and syphilis. 
 
 With regard to the diagnosis of the site of the stenosis, 
 distension of the upper part of the abdomen and of the 
 flanks points to obstruction low in the colon, i.e., in the 
 pelvic colon. Distension of the right flank only points to a 
 situation high in the colon. The distended and hypertro- 
 phied colon is distinguished from small bowel by its size. 
 In stricture of the small intestine the centre of the abdo- 
 men is distended and the flanks are empty, and abnormal 
 peristalsis of small coils lying parallel to one another is often 
 seen. Percussion similarly will aid in localizing the seat 
 of obstruction and demonstrating the distended bowel 
 above it by a highly resonant metallic note. 
 
 Peristalsis and intestinal spasm often indicate the position 
 of the obstruction, but only so at the commencement of an 
 attack ; after the state of spasm has existed for some days 
 it diffuses from its point of commencement and extends 
 elsewhere. 
 
 Regarding the anatomical nature of the lesion, the 
 following facts should be noted. If there is a hernia of old 
 standing, a connection between it and the intestinal 
 stenosis must be considered probable unless some other 
 cause is plainly present (Nothnagel). If there is a history 
 pointing to gall-stones, gall-stone ileus will be suspected. 
 An acute onset in a previously healthy patient suggests 
 a twist, in children under the age of ten intussusception. 
 If fever develops during the first few hours of illness, acute 
 peritonitis will be suspected. 
 
 Differential Diagnosis. — From meteorism from other 
 causes, and from affections with violent peristalsis without 
 anatomical obstruction, intestinal stricture is distinguished 
 by the very pronounced and repeated colic, with spasm of 
 the distended coils. Sometimes there is a possibility of 
 mistaking the dilated coils filled with liquid and gas for 
 ascites, seeing that change of position may produce a very 
 marked change in percussion note. I have myself diagnosed 
 ascites and intestinal stenosis in a case in which operation 
 showed no free fluid in the peritoneal cavity. In such 
 cases, according to Nothnagel, the production of splashing 
 
230 INDICATIONS FOR OPERATION IN 
 
 "by rapid percussion of an area giving a dull note shows 
 the presence of fluid within bowel. 
 
 INDICATIONS FOR OPERATION. 
 
 If the clinical signs point definitely to the presence of a 
 chronic or acute bowel stenosis, and if the symptoms 
 (colic, with painful spasmodic contractions) indicate an 
 anatomical stenosis, there is a strict indication for operative 
 interference. This is true whatever the cause of the stenosis 
 may appear to be. Fsecal obstruction alone, with its 
 consequences, requires no operation. 
 
 In suspected gall-stone ileus it is often justifiable to 
 temporize. The time for operation is as soon as the 
 diagnosis is definitely made ; after this temporizing does 
 not alter the indications, and a risk is run of the onset 
 of acute intestinal obstruction, when the prognosis of 
 operation will be much worse. The operations practised 
 are : exclusion of the stenosis by entero-anastomosis 
 between the coils above and below ; resection, particu- 
 larly in the case of tumours and intussusceptions ; 
 reposition of the bowel in volvulus ; freeing of the gut in 
 kinking by adhesions. If the obstacle cannot be removed 
 or short circuited, an artificial anus is necessary. 
 
 Contra-indications. — If the general condition is bad in 
 consequence of some other complicating affection, and the 
 intestinal stricture is causing symptoms of a comparatively 
 slight degree of severity, then the patient may be advised 
 against operation if the complication is one that will 
 necessarily prove fatal. A bad general condition in itself 
 is no contra-indication, as in the worst cases an artificial 
 anus may be established under local ansesthesia. 
 
 If the chronic obstruction is due to faecal impaction, 
 operation is not necessary, as this can be dealt with by 
 non-operative measures. If definite diffuse peritonitis is 
 present, along with signs, symptoms, and history pointing to 
 stenosis, operation will almost certainly be soon followed 
 by death, and is therefore as a rule not to be advised. 
 
 Prognosis. — Of operation. — In many cases a successful 
 operation is followed by permanent relief, particularly in 
 the case of entero-anastomosis for benign strictures and 
 the separation of adhesions causing kinking. The colic 
 as a rule disappears entirely, but sometimes not until a 
 
DISEASES OF THE INTESTINES. 231 
 
 considerable interval has elapsed ; in all cases it is much 
 relieved at once. If an artificial anus is necessary, this is 
 of course very troublesome to the patient and his entourage. 
 The risks of operation vary with the procedure, in the order — 
 establishment of an artificial anus, entero-anastomosis, 
 resection. 
 
 Without operation. — Without operation the patient 
 gradually gets worse. The prognosis as to time varies 
 according to the cause of the stenosis and the secondary 
 changes in the bowel. A case of simple cicatricial stric- 
 ture will live longer than a case where the stenosis is due 
 to new growth. Sudden dangerous complications are not 
 uncommon, particularly the onset of acute obstruction. 
 A stricture which is not very narrow may be blocked by a 
 faecal mass or a fruit-stone. After the stricture has been 
 present for some time distension ulcers tend to develop 
 above it, and perforation may occur ; there then develops 
 either acute diffuse peritonitis or an encysted peritonitis, 
 with faecal abscess and its associated risks. 
 
 LITERATURE. 
 Vide — Intestinal Obstruction. 
 
 INTESTINAL OBSTRUCTION. 
 
 Intestinal obstruction, or ileus (Schlange) may be produced 
 by a variety of different anatomical lesions which all give 
 rise to a certain group of symptoms, of which the following 
 are the most important : pain in the abdomen, constipation, 
 vomiting at first bilious and then fjecal, and meteorism. 
 
 Dynamic obstruction, the result of paralysis of the 
 intestinal muscular wall, is to be distinguished from 
 mechanical obstruction due to some mechanical cause. 
 Cases of mechanical obstruction are further divided into 
 those in which there is strangulation and those in which 
 there is obturation without strangulation. In strangulation 
 the bowel wall suffers damage owing to interference with 
 its circulation ; in obturation the lumen of the bowel is 
 obliterated by some agent either within or without the 
 channel, and there is no primary damage to the bowel itself. 
 
 Etiology .\nd Anatomy. — Obstruction from paralysis 
 of the gut is most commonly the consequence of acute 
 
232 INDICATIONS FOR OPERATION IN 
 
 peritonitis, but in some cases the paralysis is due to 
 mechanical injury to the bowel, as for example after an 
 extensive abdominal operation, or when a portion of 
 strangulated bowel, although replaced, is unable to resume 
 its functions. Intestinal paralysis from toxic infection is 
 uncommon. 
 
 Strangulation may occur in a variety of ways. Bowel 
 may be caught by peritoneal adhesions, or by an adherent 
 appendix or a Meckel's diverticulum, or may be herniated 
 and strangulated through the diaphragm or in one of the 
 abdominal fossae, the fossa duodenojejunalis for example. 
 The ileum is usually the part involved under these circum- 
 stances. Volvulus, that is to say axial torsion of bowel, is 
 particularly common in the pelvic colon ; the twisted bowel 
 is strangulated as the torsion interferes with its circulation. 
 A long pelvic colon and a long mesentery predispose to the 
 accident, and injury or constipation may lead up to it. 
 
 Intestinal obturation may be due to new growths, to 
 kinking by peritoneal adhesions, or to cicatricial stricture 
 following ulceration (tuberculosis). Tumours of neighbour- 
 ing organs may obstruct the bowel by compression. Gall- 
 stones, faecal masses, and other foreign bodies may also 
 cause the condition. Intussusception is another cause 
 which is considered in a special chapter. 
 
 In all these different types of obstruction, if unrelieved, 
 peritonitis supervenes and is the usual cause of death. In 
 the distended bowel above the obstruction, ulceration 
 occurs after the obstruction has persisted for some time. 
 
 I. Intestinal Paralysis (dynamic ileus). 
 
 Clinical Course. — When intestinal paralysis follows 
 peritonitis the distension of the bowel is usually very great. 
 The amount of distension varies with the extent of the 
 peritonitis. In the acute diffuse form the distension is 
 extreme ; in the acute circumscribed the meteorism is slight 
 and localized and the intestinal movements are not com- 
 pletely abolished. In acute diffuse peritonitis there is 
 general tenderness on pressure, the abdomen is barrel- 
 shaped, and the distension is uniform. The temperature 
 is often, but by no means always, raised. By examining 
 the abdomen in different postures, free fluid is usually to be 
 detected early. 
 
DISEASES OF THE INTESTINES. 233 
 
 Diagnosis. — If the group of symptoms mentioned above 
 is present, if the abdomen is distended and tender to pressure, 
 and if there are signs of free fluid in the peritoneal cavity, 
 then the diagnosis of paralytic obstruction is clear ; if the 
 abdomen is equally distended and the tenderness is diffuse, 
 the condition is one of general peritonitis. The starting 
 point of the infection can at this stage be usually judged 
 only from the history, in which there may be points 
 suggesting cholecystitis, or appendicitis, or some affection 
 of the female genital organs, as the original focus. 
 
 From obstruction due to strangulation, paralytic ileus 
 is distinguished by the inequality of the distension in 
 strangulation, and the fact that the outline of a single 
 greatly distended coil of bowel can usually be recognized. 
 In obstruction from stricture the distension is also unequal, 
 abnormal peristalsis can be made out, and the bowel above 
 the stricture can be felt rigid and hypertrophied. The 
 indications for operation in this condition of paralytic 
 obstruction are discussed in the article on peritonitis. 
 
 2. Strangulation (strangulation-ileus). 
 
 Clinical Course. — The onset is usually sudden, with 
 acute pain, often collapse, and vomiting of bilious matter. 
 After a short time the intestinal functions are entirely 
 suspended, and neither faeces nor flatus are passed, but 
 just at first fasces in small amount may be got rid of. Soon 
 the contour of a distended bowel coil can be made out, 
 remaining absolutely immobile and not tender to pressure. 
 Even in the cases of patients with thick abdominal walls 
 this coil can often be discovered by palpation. Early 
 effusion into the peritoneal cavity is usual. In volvulus 
 of the pelvic colon a small quantity of water only (^ to ^j 
 litre) can be passed per anum; in volvulus of the small bowel 
 this sign is not present. 
 
 Diagnosis. — The mode of onset and the discovery of a 
 largely distended bowel coil often enables a diagnosis to be 
 made. Sometimes the diagnosis becomes certain when a 
 distended coil of small bowel can be made out which cannot 
 be easily displaced upwards, and which extends from the 
 pelvis towards the upper parts of the abdomen ; and in 
 other cases the impossibility of passing any considerable 
 amount of fluid ])er anum clears up the diagnosis. If chronic 
 
234 INDICATIONS FOR OPERATION IN 
 
 intestinal disturbance has followed the reduction of a hernia, 
 and if symptoms of obstruction supervene suddenly, the 
 obstruction will be suspected at the site of the previous 
 hernia. 
 
 Examination of the usual hernial orifices will exclude 
 strangulation of an external hernia, and the absence of 
 forcible peristalsis will exclude obstruction by stricture. 
 
 In general peritonitis there is universal intestinal 
 paralysis; in local peritonitis there is local meteorism, local 
 tenderness to pressure, often fever, and seldom faecal 
 vomiting. The history must be relied upon, along with 
 the symptoms, to exclude biliary and renal colic. In some 
 cases the differential diagnosis is very difficult : the two 
 following cases illustrate this : — 
 
 An advocate, aged fifty-four, who had suffered from 
 heart disease for several years, had for a year and 
 a 1 half had attacks of constipation, with much pain 
 and collapse. The attacks had become more frequent, 
 though not more serious. The first occasion on which I 
 saw the patient he was collapsed, complained of nausea, 
 and had a small, running pulse. Some hours previously 
 pain had come on suddenly and acutely in the left lower 
 portion of the abdomen. He passed neither flatus nor faeces 
 on this day nor the two following, and vomited repeatedly. 
 I found a large distended coil of bowel, which seemed to 
 correspond to the transverse colon. Rectal irrigation with 
 large quantities of water was possible ; there was no 
 abnormal peristalsis, and the hernial orifices were free. 
 As he had previously suffered from uraturia from time 
 to time, renal calculus was thought of, in spite of the 
 absence of other signs of renal colic. On the second day 
 fragments of red cells were found in the urine, and on 
 the third he passed a renal stone and was at once relieved 
 of all his obstruction symptoms. 
 
 A woman, aged 48, was brought to hospital with a 
 diagnosis of subacute nephritis and commencing uraemia. 
 She was collapsed, almost pulseless, but conscious, and 
 complained of acute pain in the neighbourhood of the right 
 costal arch. Vomiting was incessant. During the following 
 days the amount of urine was from 500 to 800 grams, 
 neither flatus nor faeces were passed, the vomiting per- 
 sisted, increasing distension was noticed in a coil of 
 
DISEASES OF THE INTESTINES. 235 
 
 intestine in the right lumbar region ; no abnormal peristalsis, 
 and no tenderness on pressure. The pain had com- 
 menced suddenly two days before admission. In view of a 
 commencing pneumonia, cardiac weakness, and the renal 
 disease, no operation was deemed advisable. At the 
 autopsy a thick omental band was found strangulating 
 the colon in the region of the hepatic flexure, and there 
 was also secondary peritonitis. 
 
 INDICATIONS FOR OPERATION. 
 
 When a diagnosis of intestinal strangulation is made, 
 operation is advisable at once, whether the site of strangu- 
 lation can be determined or not. If, therefore, symptoms 
 of obstruction are present, and a large distended coil of 
 bowel is found, immovable, or showing only slight peristaltic 
 movement, then laparotomy should be done forthwith. 
 If pain, vomiting, and absolute constipation are present, 
 but no distended intestinal coil can be discovered, it is 
 justifiable in some cases to temporize until the second day ; 
 but if the symptoms still persist, an exploratory laparo- 
 tomy must then be done. In every case the pulse and the 
 general condition must be carefully watched, and the onset 
 of the collapse must be anticipated by operation. The 
 impossibility of passing a considerable quantity per anum 
 indicates immediate operation. If initial serious symptoms 
 improve during the subsequent forty-eight hours, if the 
 pulse becomes stronger and less rapid, and the collapse, 
 vomiting, and pain diminish, and particularly if some flatus 
 or faeces are passed, it is well to temporize, and operate only 
 if the symptoms relapse. 
 
 If when the patient is first seen the abdomen is already 
 much distended, but there are definite signs of slight 
 peristaltic movement (some coils of intestine being palpable) 
 and no considerable degree of ascites : operation is indicated 
 if the history — sudden onset with severe pain when the 
 patient was in ordinary health, and the absence of physical 
 signs indicative of any inflammatory focus in the abdominal 
 cavity (appendix, pelvic organs) — points to obstruction 
 from intestinal strangulation rather than peritonitis. 
 
 The object of operation is to free the involved bowel by 
 the section of constricting bands, the restoration of volvulus, 
 etc. When there is great distension the coils are often 
 
236 INDICATIONS FOR OPERATION IN 
 
 emptied by puncture. Resection of bowel is only done 
 when the bowel is so altered by the strangulation that its 
 recovery is considered doubtful. 
 
 If there be pronounced collapse and signs of general 
 peritonitis in a patient who has had symptoms of acute 
 intestinal obstruction for several days, operation is contra- 
 indicated. Initial collapse is not against operation, and if 
 operation be not done in such a case it will probably soon 
 end fatally. 
 
 Prognosis. — Of operation. — Successful operation is 
 followed immediately by disappearance of the symptoms, 
 cessation of vomiting, passage of flatus, and complete 
 recovery. The earlier the operation the better the result. 
 
 Gangrenous bowel may rupture during the operation 
 and acute septic peritonit's be set up. The same danger 
 attends resection of bowel. Sometimes an artificial anus 
 has to be established, with all its consequent inconveniences. 
 Operative shock must be guarded against. 
 
 Without operation. — In the great majority of cases left 
 without operation general peritonitis sets in and is fatal. 
 Cases of recovery from symptoms of apparent strangulation 
 are recorded, but are to be regarded only as curiosities. 
 
 3. Occlusion (obturation-ileus). 
 
 Clinical Course. — The onset of acute obstruction in 
 this condition is usually preceded by the symptoms of 
 stenosis described on p. 227. After such symptoms have 
 been present for some time, total obstruction supervenes, 
 with incessant vomiting, eventually faecal, a rapid pulse 
 of low tension, and pains in the abdomen. Finally in such 
 a case signs of peritonitis appear, and the patient collapses 
 and dies. 
 
 Diagnosis. — When there is a history of the symptoms 
 of intestinal stenosis the cause of the acute obstruction is 
 clear. 
 
 With regard to the actual cause of obstruction, earlier 
 symptoms of intestinal ulceration will point to cicatricial 
 stricture. Tubercular lesions elsewhere, and the presence 
 of a mass in the ileocaecal region, will suggest a tubercular 
 process. Rectal or vaginal examination may reveal a pelvic 
 tumour, and a history of the passage of blood and mucus 
 by the bowel will make one suspect a new growth. 
 
DISEASES OF THE INTESTINES. 237 
 
 A scar the result of injury or suppuration will point to 
 the probability of kinking by peritoneal adhesions. The 
 passage of blood and mucus by the bowel in a young child, 
 associated with a cylindrical shaped tumour in the abdomen, 
 vomiting, and distension, is in favour of intussusception. 
 
 A history of gall-stone colic will suggest that the obstruc- 
 tion is due to a calculus in the bowel. 
 
 Rectal examination and the discovery of large, hard 
 faecal masses will differentiate obstruction from faecal 
 impaction. 
 
 The diagnosis of the seat of obstruction is discussed in 
 the section on intestinal stenosis. 
 
 From strangulation a diagnosis is to be made by the 
 presence of forcible peristaltic movements and hyper- 
 trophied bowel. In peritonitis the bowel is paralyzed and 
 the abdomen is tender to pressure, whereas, in obstruction 
 from intestinal occlusion, pressure on the abdomen rather 
 relieves the pain. 
 
 Exaggerated intestinal peristalsis should be sufficient 
 to distinguish the condition from gall-stone or renal colic. 
 
 INDICATIONS FOR OPERATION. 
 
 If the clinical signs definitely point to obstruction by 
 occlusion, operation is called for unconditionally : (a) In 
 all cases in which the condition has developed progressively, 
 with exaggerated peristalsis and meteorism, even if flatus 
 and faeces are occasionally passed ; {b) In all cases of acute 
 intestinal obstruction. When the latter is apparently due 
 to an impacted gall-stone, operation should be undertaken 
 if the serious symptoms do not clear up in a few hours, or 
 if symptoms of moderate intensity go on increasing in 
 severity. 
 
 When the diagnosis is intussusception, operation becomes 
 necessary when other means have failed. 
 
 In doubtful cases (colic, etc.) operation is to be recom- 
 mended when the symptoms do not improve in spite of 
 medicine and other non-surgical measures. 
 
 In cases which have a long history of symptoms of 
 stenosis increasing in severity, operation must not be 
 ■delayed if the general condition begins to decline, if the 
 pulse previously normal becomes more rapid and feeble, 
 if vomiting becomes more and more frequent and of a 
 
238 INDICATIONS FOR OPERATION IN 
 
 bilious and perhaps slightly faecal type, or, finally, if the 
 meteorism becomes so marked that some intestinal coils 
 give a metallic percussion note. Increasing vehemence 
 and frequency of the colic, and the involvement of an 
 increasing extent of the bowel in the forcible peristalsis, 
 are also signs which militate against delay. The pulse is 
 the most important guide of all. 
 
 In general, it may be said that in intestinal obstruction 
 a good general condition and a pulse of sustained quality 
 alone justify delay, and that never beyond the second day 
 of symptoms. 
 
 According to the condition of the patient and the cause 
 of the obstruction, the surgeon may choose to either establish 
 an artificial anus (in the worst cases under local anaesthesia), 
 or perform an entero-anastomosis excluding the obstruction, 
 or resect the bowel. 
 
 Contra-indications. — If rectal examination shows the 
 presence of large masses of faeces in the rectum, and the 
 symptoms are compatible with obstruction from impacted 
 faeces, the rectum must be cleared out and no operation 
 undertaken unless the symptoms persist. In the course 
 of a few months I saw two cases presenting all the symptoms 
 of intestinal obstruction from occlusion, in which complete 
 recovery followed the manual removal of enormous masses 
 of faeces from the rectum. A bad general condition hardly 
 ever contra-indicates operation, as in the worst cases an 
 enterostomy can be performed under local anaesthesia. 
 
 Immediate operation is not advisable if the condition of 
 the heart is still good and the diagnosis uncertain, but if 
 the symptoms become clearer, and if the pulse begins to 
 fail, it is necessary to intervene surgically. 
 
 Prognosis. — Of operation. — The symptoms subside 
 when the operation is successful, but whether the success 
 is permanent or not depends upon the cause of the occlusion. 
 In tuberculosis other strictures may develop ; in malignant 
 growths complete removal may be impossible ; in other 
 conditions — kinking by adhesions, intussusception, and 
 simple stricture — the relief is permanent. 
 
 The risk of operation varies very much according to the 
 actual operation performed. A simple enterostomy is 
 attended by no more risk than that of a simple opening into 
 the peritoneal cavity; entero-anastomosis is more dangerous. 
 
DISEASES OF THE INTESTINES. 239 
 
 particularly if it involves the large bowel. Resection of 
 bowel is attended by the highest mortality of all. 
 
 The risk from shock depends upon the length and extent 
 of the operation and the amount of exposure of the bowel. 
 An extensive operation may be followed by some paralysis 
 of the gut. In some cases damaged bowel has ruptured 
 in the course of operation, and fatal peritonitis resulted. 
 If the obstruction cannot be removed, a permanent artificial 
 anus is necessary. After entero-anastomosis it is often 
 some time before the abdominal pains completely disappear, 
 so much so that a return of obstruction may be suspected ; 
 as a rule they disappear entirely later. Ventral hernia 
 can usually be avoided. 
 
 Without operation. — Peritonitis supervenes sooner or 
 later, with or without perforation of the gut. In a few 
 exceptional cases recovery has taken place without surgical 
 intervention. According to Nothnagel this is most common 
 in cases of intussusception, of obstruction by gall-stones, 
 foreign bodies, and fgecal masses, and in chronic obstruction 
 suddenly becoming acute ; less common in volvulus, and 
 internal incarceration and kinking of the bowel. 
 
 LITERATURE. 
 
 Baer. Volvulus des S. romanum. Centralb. f. d. Grenzgebiete 
 d. Med. u. Chin, 1903. 
 
 Bergmann. Diagnose und Behandlung der Darmocclusion. Arch, 
 f. Min. Chir. Bd. Ixi. 
 
 Erdmann. Volvulus as a Cause of Intestinal Obstruction. Med. 
 News, Dec. 6, 1902. 
 
 Dalla-Rossa. Contribute alia Diagnosi ed alia Cura dell' 
 Occlusione Intestinale. Riv. Veneta di Sc. Med., Vol. xxxvii., 
 1902, pp. 9-12. 
 
 GuELLioT. Volvulus du Gros Intestin. Bull. et. Mem. de la 
 Societe de Chir. de Paris. T. xxv. 
 
 KocHER. Ueber Ileus. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. 
 Bd. i. 
 
 LiTTLEWOOD. Seven Cases of Volvulus. Lancet. Feb. 18, 1899. 
 
 Naunyn. Ueber Ileus. Mitteil. a. d. Grenzgebiete d. Med. u. 
 Chir. Bd. i. 
 
 Nothnagel. Darmkrankheiten. 2nd Ed. Wien, 1903. 
 
 QuENU. Du Role de I'Angle Colique Grande dans les Occlusions 
 Intestinales. Bullet, et Mem. de la Societe de Chir. de Paris, No. 
 23, 1902. 
 
 RouTiER. Torsion du S. iliaque. Bull, et Mem. de la Societe de 
 Chirurg. de Paris. T. xxv. 
 
240 INDICATIONS FOR OPERATION IN 
 
 PiANTiERi. Sulla Cura Medica e Chirurgica del Volvulo Intes- 
 tinale. Corres. Internationale di Medic. Pratica. No. ii, 1902. 
 
 ScHLANGE. Handbuch d. prakt. Chirurgie. Mikulicz, Bergmann 
 u. Bruns. 3rd Vol., 2nd. Ed., 1903. 
 
 ScHLOFFER. Ileus bel Hysteric. Beitr. z. klin. Chir. Bd. xxiv., 
 P- 392. 
 
 INTUSSUSCEPTION. 
 
 Etiology. — Intussusception is most common in children 
 under the age of four, and particularly common in the 
 first year. In infants it is usually due to intestinal 
 disturbances, colic and diarrhoea ; it is also caused by 
 polypi and other intestinal new growths. 
 
 Pathological Anatomy. — The invagination is solitary 
 in most instances, and descending, that is to say, the 
 intussusceptum advances anal- wards. Several anatomical 
 types are distinguished: the ileocsecal, which is the most 
 common, the enteric, the colic. In the ileocaecal form 
 the ileocaecal valve forms the apex of the intussusceptum. 
 The mesenteric attachments cause the intussusceptum 
 to assume a concave outline, the concavity towards the 
 attachments. The mesentery being compressed, the 
 circulation of the gut is interfered with, and hyperaemia and 
 oedema of the intussusceptum ollow, and haemorrhages also 
 take place from and into it. If the circulatory block is 
 acute, gangrene may follow, and the gangrenous intussus- 
 ceptum may be passed. If adhesions give way when an 
 intussusceptum becomes gangrenous and separates, diffuse 
 perforation peritonitis results. In chronic intussusception 
 the bowel above is dilated and hypertrophied. Local peri- 
 tonitis is common in the course of chronic intussusception. 
 
 Clinical Course. — The onset is usually sudden and 
 associated with very acute griping pains. There is often 
 an initial attack of vomiting, and an evacuation of the 
 bowels. The passage of material by the bowel continues, 
 and the stools consist chiefly, and after a time entirely, of 
 mucus and blood, the child often having marked tenesmus. 
 If the condition runs an acute course, general collapse sets 
 in within the first day, and the vomiting becomes faecal. A 
 firm cylindrical swelling can be felt on abdominal palpation, 
 its extent and position varying according to the length of 
 time that has elapsed since the onset. 
 
DISEASES OF THE INTESTINES. 241 
 
 In the cases where the course is chronic, the symptoms 
 are those of intestinal stenosis, the pains are not excessive, 
 and as a rule there is no bloody diarrhoea. An abdominal 
 tumour is recognizable in these cases also. In some cases 
 the intussusceptum has actually prolapsed through the anus. 
 
 Diagnosis. — If the symptoms described are present — 
 sudden pain, vomiting, tenesmus, blood and mucus in the 
 stools, no passage of faeces and flatus, distension, and 
 abdominal tumour — the diagnosis of acute intussusception 
 is definite. The tumour is the most important sign in the 
 diagnosis of chronic intussusception, which has to be 
 diagnosed from other forms of subacute and chronic 
 intestinal stenosis. 
 
 The acute form is distinguished from other forms of 
 intestinal strangulation by the passage of blood and mucus 
 by the bowel, and from acute obstruction supervening on 
 chronic stenosis by the history of symptoms of the latter. 
 In every case the presence or absence of the characteristic 
 tumour is of much aid in diagnosis, although in early cases 
 it may be impossible to feel it without an anaesthetic. 
 
 INDICATIONS FOR OPERATION. 
 
 If the diagnosis is clear and the symptoms are acute, and 
 medical treatment has proved useless, operation should 
 be undertaken as early as possible. It will consist in either 
 disinvagination or resection. 
 
 The more acute the symptoms, the earlier faecal vomiting 
 begins and the heart begins to fail, the more urgent is the 
 operation, which should be done within twenty-four hours 
 whenever possible. A pulse which soon becomes very 
 rapid and loses tension is the strongest argument against 
 delay. 
 
 When the onset is less acute and the symptoms chronic 
 or subacute, then a more lengthy delay is justified, and 
 during this time the " bloodless " methods of reposition 
 must be tried. If these prove useless and the symptoms 
 persist, the abdomen must be opened and the condition 
 dealt with according to the state of affairs which is found 
 present. In the chronic type of the affection, as well as in 
 the acute, the pulse should be watched and any signs of 
 heart failure interpreted as a call for operation. 
 
 The age of the child does not influence the question of 
 
 16 
 
242 INDICATIONS FOR OPERATION IN 
 
 operation; there should be no hesitation in operating on 
 the young infant when the symptoms call for it. 
 
 In subacute cases operation is not entirely justified, at 
 any rate during the early stage of the disease, and if 
 the general condition is good, until insufflation or water 
 distension has been tried. 
 
 Prognosis. — Of operation. — The earlier the operation 
 the greater is the probability of successful manual reduction, 
 which is only possible so long as no marked peritoneal 
 adhesions have formed. If resection is necessary the 
 chances of success are much lessened, although a consider- 
 able number of recoveries are on record. During the 
 course of operation the bowel may tear. Recovery by 
 operation is relatively uncommon under the age of two 
 years ; the chief risk in infants is shock. According to 
 Wichmann, in children under one year the percentage 
 recovery by operation is 17 ; between the ages of i and 10, 
 28 per cent ; above the age of 10, about 42 per cent. 
 Return of invagination after reduction by laparotomy is 
 very rare. 
 
 Without operation. — Occasionally the course is ultra- 
 acute, and death takes place within twenty-four hours, 
 but this is exceptional. The ordinary acute case has a 
 course of some eight days as a rule ; the mortality in 
 children is about 80 per cent. In the subacute and chronic 
 cases the chances of recovery without operation are better, 
 but not much. In the acute cases death is the result of 
 shock or collapse from the acute obstruction. In the 
 chronic cases peritonitis is the usual actual cause of fatality. 
 Spontaneous recovery by sloughing of the intussusceptum 
 is very unusual in children in the iirst year, less uncommon 
 in older patients. Occasionally spontaneous disinvagination 
 has taken place even when the condition has been present 
 for some weeks. 
 
 LITERATURE. 
 
 D'Arcy Power. Intussusception. Lancet, 1899, P- 29. 
 
 Clubbe. a Clinical Lecture on the Diagnosis and Treatment 
 of Intussusception. Brit. Med. Jour. Mar. 23, 1901. 
 
 Barlow. Intussusception. Lancet, Nos. 34 & 36, 1899. 
 
 Rebuschino. Un Caso di Invaginazzione Intestinale. Gaz. 
 degli Ospedali, No. 18, 1902. 
 
 Chavaillon. Invagination Intestinale. La Province Medicale, 
 No. 24, 1 90 1. 
 
DISEASES OF THE INTESTINES. 243 
 
 LuBOFF. Operative Behandlung der Darmeinschiebungen. 
 Mitteil. a. d. Grenzgebiete d. Med. u. Chir., Bd. iii. 
 
 Haasler. Ueber Darminvagination. Arch. f. klin. Chir. Bd. 
 Ixviii., Hft. 3. 
 
 MoNOD. De r Invagination Intestinale. These de Paris, 1897. 
 
 Onory. Invagination Cohque. Gaz. Hebdom., 1901, No. 49. 
 
 NoTHNAGEL. Erkrankungen des Darmes. 2nd Ed. Wien, 
 1903. 
 
 ScHLANGE. Handbuch d. prakt. Chir. Mikuhcz, Bergmann, u. 
 Bruns. Bd. iii. 2nd Ed. 
 
 S. Weiss. Intussusceptio Intestini. Centralb. f. d. Grenzgebiete 
 ■d. Med. u. Chir., p. 702, 1899. 
 
 INTESTINAL CANCER. 
 
 Intestinal cancer is much more common in the male than 
 in the female. Most patients are between 40 and 60. The 
 disease is almost always primary. 
 
 Pathological Anatomy. — Carcinoma of the intestine 
 is usually solitary, occasionally multiple. In at least half 
 the cases the seat is the rectum, the large intestine coming 
 next, and the small intestine last. In only 5 '6 per cent 
 ■of cases does the disease occur in the latter. In the large 
 intestine the caecum and the pelvic colon are the most 
 common situations, then the hepatic and splenic flexures. 
 
 The disease is usually a cylindrical-celled cancer ; it 
 ■extends around the bowel and gradually causes stenosis, 
 with the usual dilatation and hypertrophy of the bowel 
 above. Ulceration is common, causing haemorrhage and 
 discharge ; an ulcer may perforate into the abdominal 
 ■cavity or a neighbouring organ, or the exterior. Perforation 
 into a neighbouring coil of bowel is not unusual. 
 
 Clinical Course. — There is often a long latent period 
 in cancer of the intestine. The usual sequence of symptoms 
 is as follows : irregularity in the action of the bowels, 
 diarrhoea, or alternating diarrhoea and constipation with 
 intervals of regularity ; there is pain during the constipation 
 period ; later local abdominal fullness and distension, and 
 abnormal peristalsis, with rigid contraction of a certain 
 segment of bowel ; when the attacks become severe, vomiting 
 usually accompanies them. The stenosis symptoms often 
 show marked variations in intensity from time to time. 
 The stage at which the tumour becomes palpable depends 
 upon its anatomical site to a large extent. When palpable 
 
244 INDICATIONS FOR OPERATION IN 
 
 it is often very freely movable, has a nodular outline, and is 
 dull to percussion, and yet not absolutely dull. Blood is 
 often found in the stools : it may be in sufficient quantity 
 to be seen with the naked eye, or may be only discoverable 
 with the microscope. Tenesmus is only present when the 
 growth is in the rectum. Loss of appetite, pallor, and 
 other general symptoms often precede the local symptoms. 
 
 In some cases the onset of acute intestinal obstruction 
 is the first definite sign of intestinal cancer. The higher 
 the cancer the more pronounced and violent as a rule are 
 the stenosis symptoms. Ulceration is a more troublesome 
 complication the lower the growth. Perforation may take 
 place into neighbouring organs, e.g., into the bladder in the 
 case of growth in the sigmoid flexure. 
 
 Diagnosis. — If the symptoms which have been already 
 described as those of chronic intestinal stenosis (p. 227) are 
 present, if there is loss of appetite, loss of strength and 
 pallor, and if blood is found in the stools, a diagnosis of 
 intestinal neoplasm is generally justifiable, even although 
 there is no palpable tumour. A cancer of the small bowel is 
 extremely mobile, as is also a growth of the transverse 
 colon, to a less degree one of the pelvic colon, while in other 
 situations it is commonly fixed. 
 
 There are many conditions which may simulate cancer 
 of the bowel, the most important being tuberculosis and the 
 tuberculous ileocaecal tumour, chronic intussusception, and 
 fsecal impaction. Tumours of other organs may also 
 simulate cancer of the bowel by encroaching on the latter, 
 e.g., tumours of the stomach, gall-bladder, kidney, pancreas, 
 and ovary ; in some such cases a confident diagnosis is 
 impossible. 
 
 INDICATIONS FOR OPERATION. 
 
 If there appears to be a possibility of radically removing 
 a tumour of the bowel, operation is unconditionally 
 indicated. If it is clear that a radical operation is impossible, 
 a palliative operation is only indicated when there are 
 symptoms of marked stenosis or complete obstruction. 
 Radical operation consists in resection in one or two stages. 
 If the bowel above the stenosis is much altered, the two- 
 stage plan gives much the best results. 
 
 Palliative operations are : Complete or incomplete 
 
DISEASES OF THE INTESTINES. 245 
 
 exclusion, simple entero-anastomosis, or the simple 
 formation of an artificial anus. Advanced marasmus is 
 an important contra-indication. If there are signs of 
 metastases, or of encroachment on surroundings, operation 
 will be deemed inadvisable, particularly if symptoms of 
 stenosis or other grave phenomena are absent. 
 
 No operation of a palliative nature should be undertaken 
 unless it is clear that some definite relief can be given 
 thereby ; wide metastasis, ascites, and other such pheno- 
 mena contra-indicate interference of all kinds. 
 
 Prognosis. — Results of operation. — The risk of resection 
 in malignant growths is very high, particularly when the 
 operation is done in one stage ; about a third to a half of 
 the cases have succumbed to collapse, peritonitis, and 
 other operation complications. The operation in two 
 stages gives a lower mortality. The mortality of the 
 palliative operations is also high, but varies considerably 
 in the hands of different surgeons. Amongst the draw- 
 backs which may result is the persistence of an artificial 
 anus. 
 
 Many operations have been completely successful, with 
 entire and permanent relief to symptoms ; palliative 
 operations often prolong life to a marked extent. After 
 entero-anastomosis the patient may live for many months, 
 the average duration of life in Mikulicz's cases being 8^ 
 months. After colostomy the average duration of life is 
 from 10 months to if years, according to different statistics. 
 
 The number of radically cured cases recorded in the 
 literature is not large, and the proportion of cures varies 
 much with the different surgeons. Of 12 patients operated 
 on by Mikulicz, 5 were alive and free from recurrence at 
 periods of from 4 to 9|- years after operation. Of 12 of 
 Korte's cases 4 were free from recurrence 4 years after 
 operation. Other operators have published less satisfactory 
 results. 
 
 Without operation. — The actual cause of death is not 
 always the same. Sometimes it is acute intestinal ob- 
 struction, sometimes cachexia, and in other cases some 
 complication such as perforation, metastasis, etc. The 
 disease is compatible with relatively long life. As a general 
 rule, the nearer the growth is to the anus the longer the 
 patient survives, the exception to this being in the case of 
 
246 INDICATIONS FOR OPERATION IN 
 
 the very malignant rectal cancers. The actual duration 
 from first symptoms to death varies from a few months 
 to six years. 
 
 LITERATURE. 
 
 A. Baer. Die nichtentzundlichen Tumoren der Ileocaecalgegend. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir., 1900. 
 
 R. DE Bovis. Le Cancer du Gros Intestin. Rev. de Chir., 
 No. 6, 1900. 
 
 Hemmeter. Carcinoma. Diseases of the Intestines. 1901. 
 
 KoRTE. Erfahrungen iiber die operative Behandhmg der 
 malignen Dickdarmgeschwiilste. A- ch. f. khn. Chir. Bd. Ixi. 
 
 Legene. Les Tumeurs MaUgnes de ITntestin Grele. These de 
 Paris, 1904. 
 
 V. Mikulicz und Kausch. Krankheiten des Darmes. Handbuch 
 d. prakt. Chir. Mickuhcz, Bergmann, u. Bruns. Bd. iii. 2nd Ed. 
 1903. 
 
 Monprofit. Le Cancer du Gros Intestin. Progres Medical. 
 Nov. 30, 1901. 
 
 NoTHNAGEL. Darmkrankheitcn. 2nd Ed. 1903. 
 
 Stengel. Pathology of Intestinal Carcinoma. Textbook of 
 Pathology. 1899. 
 
 CANCER OF THE RECTUM. 
 
 Cancer of the rectum is much more common in men than 
 in women. Two-thirds of the patients are over 40 years 
 of age, but the affection is not very uncommon in compara- 
 tively young individuals. 
 
 Pathological Anatomy. — The carcinoma cells are 
 usually of the cylindrical type, and may be either adeno- 
 matous or alveolar in arrangement, the latter form being 
 very malignant. Some growths are soft and " medullary," 
 others are hard and " scirrhous " ; colloid cancer is common. 
 The central part of the growth usually breaks down early, 
 the growth advancing by its edges. Surgeons distinguish 
 the following anatomical types : (i) The marginal cancers 
 of the lower part of the rectal ampulla, often originating 
 on the anterior wall and soon encroaching on the whole 
 circumference of the bowel ; this is the commonest form. 
 (2) The high, fibrous carcinoma, which only involve a short 
 length, and very early extend right round the gut. (3) 
 Diffuse infiltrating carcinoma, involving a great part of 
 the rectum. 
 
 In adenocarcinoma the glands are involved in quite an 
 
DISEASES OF THE INTESTINES. 247 
 
 early stage. The neighbouring organs are often encroached 
 upon as the growth extends. Metastasis takes place 
 through the blood stream as well as through the lymphatic 
 system. 
 
 Clinical Course. — The first symptoms are usually 
 those of a catarrh of the rectum, mucus in the stools, 
 tenesmus, the passage of pus and blood, at first in small 
 amounts, but soon more abundantly. In the advanced 
 stages the discharge contains tissue fragments and is very 
 foul smelling. 
 
 Stenosis symptoms are hardly ever absent, and often 
 appear early, especially in the high cancers. The first 
 signs are then fullness of the abdomen, dull pains, and 
 alterations in the action of the bowels (diarrhoea, or 
 alternating diarrhoea and constipation) ; later the colon 
 becomes distended and hypertrophied above the stricture. 
 
 General symptoms are often delayed in appearance until 
 the growth has been present for a considerable time, but 
 once established they usually advance very rapidly. 
 When the growth ulcerates there is often some fever, loss 
 of appetite, general weakness, and aneemia from the septic 
 absorption. 
 
 When the growth extends to other pelvic structures 
 intense neuralgic pains may be caused by involvement of 
 the nerves, septic cystitis by penetration to the bladder, 
 and fulminating peritonitis by perforation into the peri- 
 toneal cavity. 
 
 Diagnosis. — A growth accessible to the finger is felt as 
 a hard, nodular mass sharply separable from the soft 
 mucous membrane. A high cancer can sometimes be 
 palpated with the patient standing up, and since such a 
 growth gradually sinks in the. pelvis, frequent rectal 
 examination may reveal it when a first examination proves 
 negative; this has been my own experience in several cases. 
 In these high growths the ampulla, which is normally 
 collapsed, is often widely dilated. Generally speaking, 
 the diagnosis is based on the presence of the symptoms 
 above detailed. 
 
 Syphilitic and gonorrhoeal ulcers of the rectum are soft 
 and superficial, and the edges not infiltrated. Cicatricial 
 strictures are not nodular and tumour-like, the scar is 
 smooth and funnel-shaped. Digital examination will 
 
248 INDICATIONS FOR OPERATION IN 
 
 distinguish cancer from haemorrhoids, catarrh, and other 
 processes which cause tenesmus and the passage of blood 
 and mucus. 
 
 INDICATIONS FOR OPERATION. 
 
 In carcinoma that can be removed, resection or amputa- 
 tion of the rectum should be done in as early a stage as 
 possible, as soon in fact as the diagnosis is made, and 
 whether the growth is high up or low down. The absence 
 of metastases is generally looked upon as a condition for 
 this radical operation ; some surgeons, however, undertake 
 it in spite of metastases if the local state is favourable. 
 
 In carcinoma that cannot be removed, many authors 
 advise (and I agree) the establishment of an artificial anus 
 when the tenesmus is very pronounced, when the patient 
 passes blood and discharge steadily, and when in spite of 
 purgatives and enemata there is obstinate constipation 
 and considerable meteorism, particularly if there is some 
 fever and septic intoxication. Some authorities (Kraske) 
 only perform colostomy when there are threatenings or 
 actual signs of obstruction. 
 
 Contra-indications. — High cancers which are intimately 
 adherent to bladder or to bone are not suitable for radical 
 operation, and many surgeons take the same view with 
 regard to adherent lower growths. The degree of adhesion 
 can only, however, be properly estimated under anaesthesia. 
 Definite metastases in liver, peritoneum, or elsewhere should 
 be looked upon as a bar to radical operation. 
 
 Advanced age is no contra-indication. Some English 
 surgeons look upon operation under 40 as useless, owing 
 to early recurrence. In incurable cases colostomy will 
 only be withheld when there are no obstruction symptoms, 
 no severe local symptoms, and no signs of chronic sepsis. 
 
 Prognosis. — Results of operation. — Permanent cures are 
 not unusual, considering as such, patients who show no 
 recurrence after 3 years. The percentage varies in different 
 statistics, but most surgeons can show more than 15 per 
 cent. In Czerny's 99 cases, 13 were free from return more 
 than 4 years, and 8 more than 5 years after operation. 
 Hochenegg reports 17 per cent permanent recoveries in 
 174 cases. In incurable cases colostomy usually prolongs 
 life considerably ; of 43 cases of Czerny's, 12 lived more 
 
DISEASES OF THE INTESTINES. 249 
 
 than a year and 3 months and even up to 3|- years after 
 the operation, and 28 hved from 40 days to i-J- years. The 
 functional resuUs after resection are much better than 
 after amputation of the rectum ; in many cases where the 
 sphincter has been retained there has been both permanent 
 recovery and perfect continence. Here again the results 
 vary much in the hands of different surgeons. 
 
 When the rectum is amputated and the sphincter 
 removed there is no sort of continence durmg the first 
 months, but after that there is continence for formed faeces 
 but not for flatus. 
 
 Colostomy usually improves the general condition very 
 much; the fever, meteorism and signs of sepsis improve, 
 and the tenesmus and diarrhoea are lessened. Sometimes 
 the patient even puts on weight, and may be able to go 
 about his work. 
 
 Risks of operation. — The mortality of the radical operation 
 is high. About i case in 5 succumbs. The statistics of 
 Kronlein give a mortality of ig^ per cent in 881 cases, 
 those of Rave 20 per cent in 335 cases. 
 
 The risks are greater in the case of high growths (28 
 per cent, Rave). A surprising fact is that the perineal 
 operation is less fatal in women than men, the contrary 
 being the case as regards the sacral operation. The causes 
 of death are wound infection, heart failure and collapse, 
 and pulmonary complications. 
 
 After amputation the anus is often very troublesome, 
 the incontinence very annoying to the patient. Some- 
 times after resection a stitch or two give way, and a sacral 
 faecal fistula forms and requires closure later. 
 
 The dangers of colostomy are small, yet Czerny lost 
 3 cases out of 43. As a rule the artificial anus can be kept 
 under control. 
 
 Without operation. — The average length of life in en- 
 cephaloid cancer is from one to two years. In the case 
 of the scirrhous growths patients have survived as much 
 as 5 years. In young subjects the disease usually runs 
 a rapid course. Great suffering may be caused by meta- 
 stases in the liver, vertebral column, and other parts. 
 
 LITERATURE. 
 
 Bergmann. Radikaloperation bei Mastdarmkrebs. Arch f. 
 klin. Chir. Bd. Ixii. 1900. 
 
250 INDICATIONS FOR OPERATION IN 
 
 BuTLiN. Rectal Cancer. Operative Surgery of Malignant 
 Disease, 2nd Ed., 1900, p. 275. 
 
 Cardal. Resume des Methodes du Traitement du Cancer du 
 Rectum. Arch. Gen. de Med., 1898, i, p. 582. 
 
 Chalot. Methode Abdomino-perineale. Bull, et Mem. de la 
 Societe de Chirurg. de Paris, xxii, p. 310. 
 
 Goodwin Gant. Diseases of the Rectum. 
 
 HocHENEGG. Ucber die Resultate der Operation des Carcinoma 
 Recti. Verhandlung der Deutschen Gesellsch. f. Chir., 1900. 
 
 Jeanell. Cancer du Rectum. Arch. Provin. de Chir. June, 
 1901. 
 
 Kraske. Erfahrungen iiber der Mastdarmkrebs. Samml. klin. 
 Vortrage, 1897, Nos. 183 & 184. 
 
 Kronlein. Resultate der Mastdarmkrebsoperationen. Verhand- 
 lung der Deutschen Gesellsch. f. Chir, 1900. 
 
 QuENU et Hartmann. Chirurgie du Rectum. Paris, 1899. 
 
 Rotter. Erkrankungen des Mastdarmes. Bergmann, Bruns, 
 u. Mikulicz. Bd iii. 2nd Ed. 1903. 
 
 Santelet. Amputation Perineale du Rectum. These de Paris, 
 1904. 
 
 Senn. Pathology of Carcinoma of the Rectum. Pathology 
 and Treatment of Tumours, p. 336. 1895. 
 
 CONGENITAL DILATATION OF THE COLON. 
 
 This affection is congenital, and more common in boys. 
 The whole colon may be dilated, or only the descending 
 portion. The wall of the dilated bowel is as a rule 
 thickened, rarely thinned ; the mucous membrane often 
 shows catarrhal ulcers. 
 
 Clinical Course. — The most prominent symptom is 
 constipation, lasting for days and even weeks, appearing 
 in early childhood and even in infants at the breast. The 
 abdomen is distended, and metallic resonance is present 
 over the dilated bowel. Forcible peristalsis is often to be 
 made out, and also elevation of the diaphragm. The rectal 
 ampulla is usually empty. It is often possible to feel the 
 dilated thick- walled bowel through the abdominal parietes. 
 
 Diagnosis. — If these symptoms are present, if there is 
 no vomiting, and if it is possible to empty the dilated bowel 
 with a tube passed per anum, if the tube evacuates large 
 quantities of gas and fsecal matter, and the dilated bowel 
 at the same time collapses, the diagnosis is practically 
 certain. A case has been reported where the diagnosis 
 was supported by an X-ray picture after the injection of 
 
DISEASES OF THE INTESTINES. 251 
 
 an emulsion of bismuth. Stenosis or invagination are 
 excluded by the possibility of evacuating the bowel with 
 purgatives and the rectal tube, and by the absence of 
 vomiting. 
 
 INDICATIONS FOR OPERATION. 
 
 When treatment by purgatives and the rectal tube 
 produces no improvement in the condition, when the 
 distension of the colon persists and peritonitis or rupture 
 threatens, then operation is called for. Operation is only 
 indicated when the condition appears to threaten life in 
 some way. The least dangerous plan is to establish an 
 artificial anus ; by this means improvement but not cure 
 is obtained. Radical operation involving the resection 
 of the affected bowel is an extremely severe procedure 
 considering the usual age of the patient. Operation will 
 not be done until an attempt has been made to relieve 
 the alarming symptoms by other measures. In chronic 
 cases operation should not be advised so long as relief is 
 given by purgatives and the rectal tube. 
 
 Prognosis without Operation. — Most children die 
 very young, but sometimes medical measures have allowed 
 the child to be successfully reared. 
 
 LITERATURE. 
 
 Beighing. Megalocolon Congenitum. La Clinica Medica 
 Italiana, xl., Pt. i. 
 
 Fenwick. Hypertrophy and Dilatation of the Colon. New 
 York Med. Jour., Sept. i, 1900. 
 
 Hirschsprung. Jahrb. f. Kinderheilkunde. Bd. xxvii ; and 
 Berl. klin. Wochens., No. 44, 1899. 
 
 JoHANESSEN. La Dilatation du Gros Intestin chez I'Enfant. 
 Rev. Mensu. des Maladies de I'Enfance. Feb., 1900. 
 
 Otto Silberberg. Die Angeborene Colonerweiterung. Cen- 
 tralb. f. d. Grenzgebiete d. Med. u. Chir., No. 23, 1903. 
 
 SUBCUTANEOUS INJURIES OF THE STOMACH 
 AND INTESTINE. 
 
 The commonest accidents giving rise to injuries of the 
 stomach and bowel are kicks from horses, compression by 
 the wheels of vehicles, or by the fall of earth and such like, 
 and falls on the abdomen. 
 
252 INDICATIONS FOR OPERATION IN 
 
 Pathological Anatomy. — The injury may produce 
 contusion, bursting, or tearing. Lesions may be perforating 
 or non-perforating. Rupture is most common in the case 
 of the jejunum and ileum. The stomach injuries number only 
 one in ten (Petry). The typical seat of a rupture of the 
 stomach is at the ksser curvature of the bowel, at the point 
 opposite to the mesenteric attachment. In small tears, 
 the mucous membrane may completely prevent the escape 
 of contents ; large tears, however, gape. In contusion, 
 there are haemorrhages into the intestinal wall, particularly 
 the submucosa. Slight contusions may recover completely, 
 and even the severe types may cicatrize after exfoliation 
 of the necrosed portions of the mucosa. In the worst 
 contusions, late perforation usually takes place by necrosis 
 of the whole thickness of the wall. 
 
 Clinical Course. — Signs of shock appear immediately, 
 whether the lesions are perforating or not. The later 
 symptoms are very vague in non-perforating injuries of 
 the stomach ; the usual are vomiting, htematemesis or 
 melgena, and pain, symptoms in fact which suggest ulcer. 
 Non-perforating duodenal injuries produce the same symp- 
 toms except that vomiting of stomach contents and blood 
 is more unusual. Contusions of the small and large bowel 
 without rupture produce no constant clinical symptoms, 
 at any rate in the early stages. If the injury produces 
 rupture, the shock is preceded or accompanied by agonizing 
 pain at the point of perforation, the abdominal walls are 
 board-like, the breathing is shallow and thoracic, and there 
 is probably vomiting. Free fluid can soon be made out in 
 the abdomen, and gas collects at the highest point. Especi- 
 ally important is the gradual disappearance of the liver 
 dullness. Later, aU the symptoms of septic perforation- 
 peritonitis develop. 
 
 Diagnosis. — A non-perforating contusion of the digestive 
 tract can only be suspected. It is only when a large mass 
 of necrotic mucous membrane is vomited up or passed per 
 rectum that the diagnosis is clear, and this does not take 
 place earlier than several days after the injury. 
 
 Free gas in the peritoneum is a definite sign of perforating 
 injury ; apart from this it should always be suspected 
 when the abdominal parietes persistently remain rigid, 
 when the vomiting is frequent and bilious, and when there 
 
DISEASES OF THE INTESTINES. 253 
 
 is free fluid in the abdominal cavity. Also in favour of 
 perforation are emphysema of the abdominal wall (a rare 
 phenomenon), metallic quality of the heart sounds (also 
 rare), and respiratory sounds which can be heard over the 
 abdomen. 
 
 Intra-abdominal haemorrhage may present the same 
 symptoms as rupture of the stomach or intestine, and gives 
 the signs of an intra-abdominal extravasation. It is 
 distinguished, however, by the phenomena of acute anaemia, 
 pallor, lowness of temperature, small and rapid pulse, and 
 rapid, shallow respiration. 
 
 The liver dullness may be masked by meteorism, but 
 free gas is always associated with free fluid in the abdominal 
 cavity, which will prevent error and distinguish between 
 the two conditions. 
 
 INDICATIONS FOR OPERATION. 
 
 If in a case of injury there is even a probability of 
 perforation of the stomach or intestine, operation is 
 indicated to find the injury and close the opening. The 
 earlier the operation the better the prospect. If there is 
 a commencing general peritonitis, operation is definitely 
 called for, even when two or three days have elapsed since 
 the injury. If an early operation has not been performed, 
 and if the symptoms have remained localized, operation 
 is only indicated when there are definite signs of circum- 
 scribed abscess. 
 
 Contra-indications. — Operation is contra-indicated durmg 
 the initial shock, but not by shock present some hours 
 later, as this may be mainly due to a commencing peri- 
 tonitis. In the case of injury to a stomach known to be 
 empty it is justifiable to wait, but to be ready to operate 
 at the first suggestion of peritonitis. If the time of early 
 operation is passed, with local peritonitis but no signs 
 of generalized peritonitis, it is permissible to temporize and 
 treat the local condition as required. 
 
 Prognosis. — Petry states that of 18 cases of rupture of 
 the stomach by injury operated on within 24 hours, 45 per 
 cent recovered ; of 24 operated on later, only 25 per cent 
 survived. As has been already said, sometimes a rupture 
 recovers spontaneously, and certainly contusions often do 
 so. But if signs of peritonitis develop, which is the rule 
 
254 INDICATIONS FOR OPERATION IN 
 
 after rupture which is not operated on, the patient is usually 
 lost. 
 
 LITERATURE. 
 
 V. Angerer. Operationen wegen Unterleibskontusionen. Ver- 
 handlung d. Deutschen Gesellsch. f. Chir., 1900, Vol ii, p. 475. 
 
 EiCHEL. Subcutane Darm- und Mesenteriumverletzungen. 
 Beitr. z. klin. Chir. Bd. xxii, 219. 
 
 Jeannel. Pathologic Chirurgicale du Duodenum. Arch. Prov. 
 de Chir., 1899, Vol. vii, p. 397. 
 
 V. Mikulicz-Kausch. Verletzungen des Magcns und Darmes. 
 Handbuch d. prakt. Chir. Bcrgmann, Mikulicz, u. Bruns. Pt. iii. 
 2nd Ed. 1903. 
 
 Stern. Traumatische Erkrankung der Magenschleimhaut. 
 Deut. med. Wochens., 1899, p. 621. 
 
 APPENDICITIS. 
 
 Etiology. — Appendicitis is more common in the male 
 than in the female sex; the majority of cases occur between 
 the ages of 10 and 30. It is apparently always due to 
 bacterial infection, except a few cases of amoebic infection, 
 and many different bacterial forms have been described 
 in association with it. Adhesions between the appendix 
 and surrounding structures, and consequent kinking, 
 predispose to the affection. An attack of appendicitis is 
 sometimes preceded by acute tonsillitis, or inflammatory 
 affections of the female sexual organs, or chronic suppurative 
 cholecystitis, in such a way as to point to an etiological 
 relationship between the conditions. The formation of 
 faecal concretions in the appendix seems often to be a 
 determining cause of inflammatory attacks ; foreign bodies 
 only rarely have a like effect. 
 
 Pathological Anatomy. — In the mildest cases there 
 is a catarrhal inflammation, with excessive secretion, and 
 retention of the latter by narrowing of the lumen. Such 
 a process may subside entirely by escape of the secretion, 
 and the appendix may then return to the normal ; often, 
 however, some thickening of the wall remains, and a greater 
 or less degree of inflammatory stricture. If the retention 
 of the secretion persists, a condition of hydrops may be 
 produced, but much more commonly the retained secretion 
 is purulent, and the condition is then one of empyema of 
 the appendix. 
 
DISEASES OF THE INTESTINES. 255 
 
 This catarrhal type often passes into another by ulceration 
 and perforation of the wall ; in some cases the perforation 
 may take place at several spots, in others the whole appendix 
 becomes gangrenous. 
 
 The peritoneum is involved in almost all attacks of 
 appendicitis ; in the slighter forms there is only slight 
 adhesive inflammation, with scanty exudation ; in the severer 
 the exudate is more abundant and often purulent, even 
 when there is no perforation ; in this way the appendix 
 may lie in the centre of an abscess. Such an abscess may 
 disappear by absorption after a more or less prolonged 
 time, or rupture into a hollow organ (most frequently the 
 bowel), or it may be the starting-point of a chronic spreading 
 peritonitis, in the course of which numerous intraperitoneal 
 abscesses of different sizes are formed. The process extends 
 along certain defined routes. Large abscesses are often 
 formed between the bladder and rectum, extending thence 
 over to the left side ; in other cases the process extends 
 upwards, and subphrenic abscesses form which may make 
 their way into the pleura or the lung, or may further extend 
 as an intra- or retroperitoneal process. In such cases 
 all the coils of bowel may be adherent to each other and the 
 abdominal parietes. Rupture through the parietes is 
 unusual. 
 
 In other cases of perforative appendicitis or peri-appendi- 
 cular abscess there is an absence of localizing adhesions, 
 and an acute diffuse and universal peritonitis results. In 
 such cases absence of an inflammatory mass in the right 
 iliac fossa is usual. 
 
 The well-known " lump," which is to be found in so 
 many cases, consists usually of oedematous and infiltrated 
 omentum attached to coils of bowel adherent to each other 
 and to the parietal peritoneum ; in the centre of such 
 masses there is often a collection of pus. 
 
 In some cases venous thrombosis occurs early, and may 
 extend widely. As the thrombosis is often infective, a 
 severe type of pyaemia may result, with the formation of 
 abscesses in distant organs, particularly the liver. 
 
 Clinical Course. — Following the clinical description 
 of Nothnagel, one may say that appendicitis is an affec- 
 tion which presents itself under the form of attacks with 
 intervals. 
 
2s6 INDICATIONS FOR OPERATION IN 
 
 An attack is often preceded by definite prodromal signs, 
 but the onset is also often sudden, with pain, nausea, and 
 vomiting. Signs of peritoneal irritation soon supervene 
 as a rule, and there is usually fever lasting from a few 
 hours to several days. In the right iliac region a cylindrical- 
 shaped body can as a rule be felt, tender to pressure, and 
 corresponding to the thickened appendix adherent to its 
 surroundings. After the inflammation subsides, the thick- 
 ened appendix often remains palpable for weeks ; in other 
 cases there is only a tenderness to pressure in the right iliac 
 fossa, without any other recognizable abnormality. After 
 a time all the subjective and objective signs may entirely 
 disappear, and complete permanent recovery may follow. 
 
 In many cases, however, indefinite symptoms persist, 
 such as a sensation of fullness or pressure, and often some 
 irregularity of the bowels, chiefly in the direction of constipa- 
 tion. After such symptoms have persisted for a time, or 
 after an interval of apparent well-being, another attack 
 comes on which may be of a similar character to the first, 
 or run a much more serious course. Operations have shown 
 that even after a first attack such as has been clescribed, 
 thickening, or adhesions, or kinking of the appendix, or 
 adhesions between coils of bowel, may remain of such a 
 character as to be a source of permanent trouble to the 
 patient. 
 
 The following case is a typical example. A little girl 
 aged 13, previously healthy, after a sore throat, developed 
 an appendicitis, with vomiting, slight fever, and tenderness 
 and swelling of the appendix. The symptoms subsided 
 on the second day, except that the appendix remained 
 palpable and tender. A second slight attack occurred a 
 year and a half later. Two years later, after a slight injury, 
 a third attack came on suddenly, with vomiting, fever, 
 and intense pain on pressure over the appendix. Operation 
 was done by Dr. Schnitzler eight hours after the appearance 
 of the symptoms. The appendix was long, its wall 
 thickened, and its tip adherent to the omentum ; the apex 
 was kinked and globular. Further examination showed 
 a ring stricture 2 cms. from the tip, empyema in the terminal 
 portion, and disappearance of the mucous membrane above 
 and below the stricture. The appendix was removed and 
 the child recovered. 
 
DrSEASES OF THE INTESTINES. 257 
 
 Appendicitis imih tumour and abscess formation may 
 occur as a return attack following one of less severity, or 
 may commence acutely without prodromal symptoms 
 in a patient previously healthy. At the onset there are 
 usually vomiting, intense abdominal pain, rigor, and fever, 
 and even symptoms of collapse (small pulse, sweating, 
 cyanosis) are frequent. After one or two days the general 
 symptoms improve ; the abdominal tenderness, which was 
 at first diffuse, becomes localized in the right iliac fossa ; 
 the general muscular rigidity passes off and becomes 
 confined to the region of the appendix. In this region 
 there appears a firm, fixed, tender, and ill-defined swelling, 
 over which the parietes may be slightly fixed and oedematous. 
 For the next three or four days the swelling either remains 
 about the same size or may become more extensive, in 
 which case suppuration will have taken place. It is rarely 
 possible to make out fluctuation. When abscess forms, 
 the pulse rate as a rule remains high ; the observation 
 of the temperature is of special importance. If fever 
 persists beyond the fifth day there is almost certainly 
 suppuration ; rises of temperature with apyrexic intervals 
 also indicate abscess in the absence of some lesion in some 
 other organ to account for it. It is true, however, that 
 even in the presence of extensive suppuration the fever 
 may gradually subside. The position of the swelling 
 varies with the position of the appendix ; sometimes it is 
 lateral, sometimes near the middle line, and in atypical 
 cases it may be in the lumbar region, or in the pouch of 
 Douglas. 
 
 Appendicitis with diffuse peritonitis and no tumour is 
 usually rapidly fatal, with symptoms of marked collapse, 
 intense abdominal pain, cyanosis, frequent vomiting, a 
 rapid pulse of low tension, and subnormal temperature. 
 In such cases the lesion is usually a large acute perforation, 
 or gangrene of the whole appendix, or rupture of an already 
 existing septic peri-appendicular abscess into the general 
 peritoneal cavity. 
 
 In some cases the peritonitis runs an irregularly progressive 
 course, with fibrino-purulent exudation. The temperature 
 may then show marked irregularities ; the tenderness and 
 resistance which were at first only present in the right iliac 
 fossa extend gradually over the greater part of the abdomen. 
 
 17 
 
258 INDICATIONS FOR OPERATION IN 
 
 Free fluid is not present in the peritoneal cavity, but 
 collections of pus may be found on rectal or vaginal examina- 
 tion, or the diaphragm may be found pushed upwards by 
 a subphrenic abscess. 
 
 Rupture of an abscess into a hollow organ is not uncom- 
 mon, but is less so in these days of early operation than it 
 used to be. 
 
 Repeated rigors, followed by profuse sweating, when 
 no tumour is present but there is tenderness on pressure, 
 point to the onset of pylephlebitis. There is often a kind 
 of correlation between appendicitis and inflammatory 
 processes of the female sexual organs, in the sense that 
 the one leads to an attack or a relapse of the other, and 
 vice versa. 
 
 Diagnosis. — The presence of pain in the right iliac 
 region, associated with a palpable and tender appendix, 
 is diagnostic of appendicitis. Diffuse resistance in this 
 region, with or without signs of peritoneal irritation, also 
 points to appendicitis. When a patient is taken ill with 
 fever, initial vomiting, and signs of peritonitis or septicaemia, 
 the discovery of tenderness over the appendix region often 
 settles the diagnosis. According to Murphy the following 
 category of symptoms is so typical that any departure from 
 it must make the diagnosis uncertain : (i) An attack 
 of abdominal pain ; (2) Nausea or vomiting from three 
 to four hours afterwards ; (3) General abdominal tenderness, 
 but particularly on the right side ; (4) Rise of temperature 
 from two to twenty hours after the onset, never before the 
 commencement of the pain. 
 
 In many cases an exact diagnosis of the type of the 
 disease present cannot be made even by the most experienced 
 clinicians. 
 
 The following symptoms point to the occurrence of 
 suppuration, a matter of great practical importance : 
 sustained fever for at least five days, persistent rapidity 
 of pulse rate or gradual increase of the same, persistence 
 or development of a tender swelling during the first five days. 
 
 Much has been written on the subject of leucocytosis. 
 It is generally agreed that if at a single observation a leuco- 
 cytosis of 20,000 to 25,000 or over is found, an abscess is 
 probably present, if no other cause for the leucocytosis 
 can be found. Absence of leucocytosis on the other hand 
 
DISEASES OF THE INTESTINES. 259 
 
 is not to be looked upon as evidence against suppuration. 
 A gradual increase in the number of leucocytes during the 
 first few days of the disease, up to 20,000 or over, and a 
 maintenance of this increase is strong evidence of abscess, 
 but leucocytosis will never be relied upon alone for the 
 diagnosis. Such observations have not hitherto proved 
 of any value in differentiating between circumscribed 
 abscess and diffuse spreading peritonitis. 
 
 The so-called iodine reaction of the blood, that is to say, 
 the brown staining of certain granules in the leucocytes, 
 supports the diagnosis of suppuration when it is present 
 in a marked degree. 
 
 It has been recommended that exploratory puncture 
 should be utilized to discover the presence of pus, but 
 this is a dangerous proceeding, and is only mentioned to 
 be condemned. A fluctuating swelling in the pelvis con- 
 nected with a resistance in the right iliac fossa, or the 
 presence of a subphrenic affection, is conclusive evidence 
 of suppuration ; when pus makes its way into the pelvis 
 there is often pain on passing water or distinct bladder 
 tenesmus, and the pains often radiate to the right thigh. 
 
 Thrombosis of the portal vein or its branches must be 
 diagnosed when fever of a pyaemic type develops and signs 
 of metastatic sepsis, in association with a tender swelling, 
 or pain, or both, in the appendix region. Sometimes the 
 pyaemic symptoms are present for a long time before it 
 becomes clear that the appendix is the primary cause of 
 the infection. 
 
 A boy, aged 12 years, whom I had the opportunity of 
 examining frequently with a colleague, had an illness 
 the symptoms of which were vomiting and fever of a wholly 
 irregular type. Each day he had one or two marked 
 rigors. In the first few days endocarditis was found 
 present. From the beginning there was a strong suspicion 
 that the appendix was the cause of the whole condition, 
 but until the third week there was neither pain nor tender- 
 ness in the right iliac region. Operation was done the 
 first day these signs made their appearance, and thrombosis 
 of the portal vein was found, the thrombus being partly 
 disorganized and broken down. The boy died. 
 
 Gangrene of the appendix is to be diagnosed when there 
 are signs of severe peritoneal irritation, intense localized 
 
26o INDICATIONS FOR OPERATION IN 
 
 pain, and high pulse frequency, associated with absence 
 of an infiammatory tumour. 
 
 Acute perforative appendicitis will be recognized by 
 the sudden onset of excessively acute pain, collapse, 
 vomiting, intense abdominal rigidity, rapid increase of 
 fluid in the peritoneum, and rapid increase in the pulse rate ; 
 in some cases the condition is distinguished by the disappear- 
 ance of an already formed swelling, along with the develop- 
 ment of marked meteorism. 
 
 A patient, about 40 years old, had an attack of appendi- 
 citis, from which he appeared to have recovered. Some 
 months later, when in apparent health, he was suddenly 
 attacked in the train by vomiting, excessively acute 
 abdominal pain, and collapse. Some hours later there was 
 a subnormal temperature, cyanosis of the extremities, 
 extreme tenderness and rigidity of the abdomen, and signs 
 of fluid in the peritoneum. Operation was performed by 
 Dr. Schnitzler five hours after the onset ; a large perforation 
 was found in a gangrenous appendix, and free pus in the 
 peritoneal cavity. The appendix was removed, the 
 peritoneum was cleansed, and the patient recovered. 
 
 Rupture of an infective focus into the general peritoneal 
 cavity is to be diagnosed (Dieulafoy) when the pulse becomes 
 suddenly more rapid and the meteorism and abdominal 
 rigidity increase, while the other symptoms simultaneously 
 become less marked. 
 
 The diagnosis of acute progressive purulent peritonitis 
 will be made when the abdomen is diffusely tender and 
 distended, when the pulse becomes rapid and cyanosis 
 increases, when the patient has a dry tongue, passes neither 
 flatus nor fjeces, and the abdomen contains free fluid. In 
 the later stage there is a toxic euphoria, coffee grounds 
 vomiting, a rapid and low tension pulse, cyanosis of the 
 fingers, and great distension of the abdomen. 
 
 The subject of subphrenic abscess complicating appendi- 
 citis is discussed in a later chapter. In the early stages, when 
 the pus is travelling upwards, the thigh is usually flexed 
 and there is tenderness in the lumbar region. 
 
 Chronic appendicitis, the " appendicitis larvata " of 
 Ewald, is often mistaken for other affections : nervous 
 dyspepsia, gall-stone, gastric ulcer, affections of the bladder, 
 etc. Sometimes a thickened appendix can be made out 
 
DISEASES OF THE INTESTINES. 261 
 
 on palpation, or the only sign of the disease may be tender- 
 ness on pressure in the right iliac region. 
 
 A young woman, 23 years of age, had been under treatment 
 by several physicians for ulcer of the stomach, without 
 relief to her symptoms. She was much depressed, had no 
 appetite, and complained of various nervous disorders. 
 The appendix was thickened and tender to pressure, and 
 operation showed a chronic inflammatory condition. After 
 the removal of the appendix the patient lost all her gastric 
 symptoms, and remains well two years after the operation. 
 
 An officer complained of attacks of violent abdominal 
 pain, which had been variously interpreted, mostly as 
 stone in the kidney, in consequence of slight vesical 
 symptoms. He had had no fever. The appendix was 
 very tender to pressure, and the pains evoked by pressure 
 were of the same character as those which occurred 
 spontaneously. At the operation the appendix was found 
 doubled up and adherent ; its removal was followed by 
 complete disappearance of the marked neurasthenia which 
 had developed. 
 
 Differential diagnosis. — Many different affections are 
 liable to be mistaken for appendicitis ; I shall refer only 
 to the most important. The history must be relied upon 
 to differentiate perforative appendicitis from other types 
 of perforative peritonitis. Attacks due to gall-stone or 
 renal stone may usually be distinguished by tenderness 
 on pressure over the liver or the kidney, or the onset of 
 jaundice or hsematuria, and by attention to the history. 
 
 Examination of the hernial orifices will exclude incarce- 
 rated hernia. In colic, pressure usually relieves the pain, and 
 there is local meteorism. Psoas abscess is less abrupt in 
 its onset than appendicitis, and is associated with signs 
 of vertebral disease ; hip-joint disease is distinguished 
 by signs referable to the joint itself and the absence of 
 tenderness or dullness in the right iliac region. In favour 
 of perinephritis, and against appendicitis, will be the 
 presence of an affection of the urogenital apparatus. Palpa- 
 tion will distinguish torsion of a floating kidney. 
 
 The gradual development of a tumour in the ileoccecal 
 region, associated with diarrhoea, signs of progressive 
 stenosis, and of tuberculosis elsewhere, points to a tuber- 
 culosis of the bowel. 
 
262 INDICATIONS FOR OPERATION IN 
 
 If a mass in the right ihac region is large, intensely hard, 
 of long standing, and infiltrating towards the surface, 
 actinomycosis will be suspected. In new growth there is 
 cachexia, intestinal stenosis, and hard, painless, and enlarged 
 lymphatic glands. The discovery of a tender palpable 
 appendix will serve to exclude nervous dyspepsia, gastric 
 ulcer, chronic cholelithiasis, and renal stone. If, however, 
 tenderness in the right iliac region is inconstant and varies 
 much at short intervals in a neurotic patient, the condition 
 is probably a neurosis and not chronic appendicitis. 
 
 In enteric fever the history of the disease, the enlargement 
 of the spleen, and the rash, will usually serve for a diagnosis, 
 but confusion between this disease and appendicitis often 
 arises, and I have seen a patient with enteric fever operated 
 on for supposed appendicitis. 
 
 INDICATIONS FOR OPERATION. 
 
 There is much difference among authors as to the indica- 
 tions for operation in appendicitis. I shall give some 
 representative opinions, and also my own views founded 
 on an extensive experience. 
 
 The indications as given by Nothnagel are, in outline, as 
 follows : — 
 
 1. Operation is absolutely indicated for appendicular 
 abscess, wherever situated, and as soon as possible. 
 
 2. In diffuse peritonitis, operation gives the sole chance 
 of recovery, and should always be done unless the patient's 
 general condition is so bad as to contra-indicate intervention 
 of any kind. It is especially urgent in acute perforative 
 peritonitis. 
 
 3. If symptoms of obstruction arise in the early or later 
 stages of appendicitis, and it is not certain that the condition 
 is due to peritonitis, laparotomy must be done for their 
 relief. 
 
 4. In an attack of appendicitis which has already lasted 
 for 12 ^0 36 hours without giving rise to signs of peritonitis, 
 operation is absolutely necessary only if the process is 
 suspected to be of a severe phlegmonous, diphtheritic, or 
 gangrenous type. Such types are especially prone to occur 
 in association with acute infective pharyngitis, and some- 
 times arise in epidemic form. In an acute appendicitis 
 which does not appear to be of a malignant type, it is 
 
DISEASES OF THE INTESTINES. 263 
 
 legitimate to temporize, and if everything goes well it 
 may be possible to avoid operation altogether. 
 
 5. When an inflammatory mass is present, the state of 
 the pulse, the pain, and the progress of the inflammatory 
 condition are the guides to operation. If there is a 
 temperature of 39'5° or over on the fourth day, or if a 
 temperature of 39° is sustained up to the sixth day, operation 
 is necessary. It is also necessary if there is a recrudescence 
 of fever lasting more than twenty-four hours. " In general 
 a high temperature is an indication for operation, but 
 absence of high fever is in no sense a contra-indication." 
 
 My own view is that if fever even of moderate degree 
 persists beyond the fifth day it means suppuration, and 
 operation is required. 
 
 A rapid pulse, and a low tension pulse also, generally 
 indicate the necessity for operation, and the same is true 
 of persistent acute pain or tenderness to pressure, and of 
 increase in the size of the inflammatory mass beyond the 
 first day or two. 
 
 6. In the apyrexic period, after the acute process has 
 subsided, operation is called for {a) When certain troubles 
 persist in a pronounced form, such as pain, sensations of 
 fullness and weight, irregular defaecation, and menstrual 
 disturbances ; {b) On the onset of a relapse. A single 
 attack of appendicitis which is followed by apparent 
 complete recovery justifies operation for removal of the 
 appendix, but it is not absolutely indicated, because three- 
 quarters of the patients who have a single attack escape 
 relapse. 
 
 Many surgeons recommend that operation should always 
 be done after an attack, and at any rate after a severe 
 attack. This recommendation may be accepted without 
 hesitation if the patient lives in some place where surgical 
 aid would not be available in case of a severe relapse. 
 
 Repeated relapses call for operation, particularly if they 
 occur at short intervals, or if the patient is unable to regulate 
 his diet. 
 
 Rotter distinguishes between acute circumscribed 
 appendicitis and diffuse appendicitis, i e., appendicitis 
 with diffuse peritoneal symptoms. In the former he 
 recommends that operation should be done whenever 
 possible in the interval after the attack. He considers 
 
264 INDICATIONS FOR OPERATION IN 
 
 it necessary after a first attack in young patients (up 
 to 35) who cannot be kept on a strict regime, and who 
 are exposed to violent physical exertion. In the acute 
 stage the circumscribed form requires operation when the 
 symptoms are severe and in any way alarming. In the 
 diffuse form it is necessary to operate when the vomiting 
 and pain have not subsided on the third day. 
 
 Many writers uphold the view that all attacks of acute 
 appendicitis call for immediate operation (Beck, MacBurney, 
 Murphy, Dieulafoy, Tufher, Kirmisson) ; others think it 
 only necessary in the presence of disquieting symptoms 
 (Lennander). The following reasons for early operation 
 are given by Bohm : (i) The impossibility of recognizing 
 the exact pathological type at the commencement of the 
 attack ; (2) The impossibility of giving a confident prognosis 
 in the early stages of any attack ; (3) The relatively small 
 risk of early operation ; (4) The relief of the patient from 
 the risk of complications, particularly the post-operative 
 complications, hernia, fistula, etc. ; (5) The support of 
 statistics. 
 
 After a study of the literature Bohm reports a general 
 agreement in the following respects on the question of 
 operation in the acute stage of the disease : (i) Operation 
 should be undertaken when either at the commencement 
 or in the course of an attack alarming symptoms and 
 signs make their appearance, whether local or general; (2) 
 When the symptoms of a typical acute attack do not show 
 a definite tendency to improve during the first day or two 
 in a uniform manner, in spite of careful expectant treatment ; 
 (3) When a sudden aggravation of symptoms occurs and 
 does not rapidly subside in the course of an attack which 
 previously had been of a benign type. 
 
 If appendicitis occurs during pregnancy many authors 
 recommend early operation in view of the risk to mother 
 and child if the infective focus persists. 
 
 Contra-indications. — Nothnagel and other writers advise 
 against operation after a single attack, if the patient remains 
 free from pain and other subjective symptoms and no 
 abnormality can be discovered on abdominal examination. 
 With this view I agree ; for as has already been stated, in 
 about three-quarters of all cases, recovery after a single 
 attack is permanent. 
 
DISEASES OF THE INTESTINES. 265 
 
 Many authorities hold that a patient who is the subject 
 of severe septicaemia and diffuse peritonitis is not a fit 
 subj ect for operation ; it is particularly advisable to abstain 
 from operation when a condition of shock of several days' 
 duration co-exists with a state of comparative euphoria. 
 Occasionally, though very rarely, spontaneous recovery 
 occurs under such circumstances. 
 
 Such a result came under my observation some years ago 
 in the case of a young man with perforative' peritonitis 
 following appendicitis. He had a dry tongue, blue 
 extremities, a very small and rapid pulse, and subnormal 
 temperature ; he was also vomiting constantly, and there 
 was free fluid in the peritoneal cavity. The surgeon who 
 saw the case considered it useless to operate. An explora- 
 tory puncture was made, and foetid pus was withdrawn. 
 For several days he remained in a condition of profound 
 collapse, and then commenced to improve by slow degrees, 
 and at the end of six weeks left the hospital in good condition. 
 
 Haenel expresses the view that in diffuse peritonitis no 
 operation should be done when the intestine is completely 
 paralyzed, when, that is to say, it is impossible to set up 
 peristaltic movements by forcible percussion, and when 
 none can be heard on auscultation. 
 
 Pyaemic symptoms with repeated rigors associated with 
 only slight local signs, and signs which point to thrombo- 
 phlebitis in the radicles of the portal vein, are looked upon 
 by many surgeons as contra-indications to operation ; the 
 only effect of operation would probably be to lessen the 
 small chance which the patient has of spontaneous recovery. 
 
 Some surgeons place the boundaries of justifiable operation 
 very far afield ; Rotter, for example, would only refuse 
 to operate on moribund patients ; others, including Deaver, 
 look upon the presence of constitutional disease, such as 
 advanced phthisis, as a contra-indication. Fowler and 
 others do not approve of early operation when a definite 
 retrogression of all symptoms occurs within from 24 to 36 
 hours of the commencement. 
 
 The bursting of an abscess into the bowel, bladder, or 
 other hollow organ, only contra-indicates surgical mter- 
 vention (Sahli and Baumgartner) when the local and general 
 symptoms are permanently improved thereby. 
 
 Prognosis. — Results and risks of operation. — Removal of 
 
266 INDICATIONS FOR OPERATION IN 
 
 the appendix in the interval after an attack is a relatively 
 slight operation. In 150 such cases Rotter lost one patient 
 only. The risks are considerably higher in operation 
 during the acute stage. In Rotter's cases the mortality 
 between the years 1893-1895 was 7 per cent, between 1896 
 and 1900 5 per cent. These figures are for the circum- 
 scribed disease ; among the cases of diffuse peritonitis due 
 to appendix disease the mortality in the first period was 
 60 per cent, in the second period 34 per cent. 
 
 Sprengel has published figures drawn from the experience 
 of several surgeons. Of 232 " interval " operations 2 died ; 
 among 284 operations during the attack, death occurred 
 in 57. Of the latter cases 47 were operated on within the 
 first forty-eight hours, with 8 fatalities ; 237 later than this, 
 with 49 fatalities. 
 
 Temoin records 179 operations during attack, with 19 
 deaths ; 17 of these were operated on after the fifth day 
 of the attack. 
 
 Mayo records 160 interval operations, without a death, 
 115 operations during attack, with 6 deaths. Lucas- 
 Champonniere lost 12 cases out of 44, with more or less 
 diffuse suppuration in the abdomen ; out of 85 other cases 
 he lost none. 
 
 Early radical operation is specially easy and free from 
 risk only if done within the first twenty-four to thirty-six 
 hours from the onset of the attack. By this early inter- 
 vention, complications, such as hernia, fistula, etc., can 
 in the great majority of instances be avoided. 
 
 According to Sonnenberg, embolus and other pulmonary 
 affections occur relatively frequently after appendix 
 operations. 
 
 The results of operation in chronic appendicitis are often 
 extremely gratifying. The pain and other symptoms 
 disappear, and I have often observed spontaneous regulation 
 of the bowels in patients who had previously been much 
 troubled by constipation. The patients usually also put on 
 weight and improve greatly in appearance. 
 
 Operation during an attack often directly saves life. 
 " Every patient with diffuse septic peritonitis who recovers 
 after operation owes his life to the operation." In 35 cases 
 of this kind Rehn reports recovery in 8. 
 
 Without operation. — It is stated that from two-thirds 
 
DISEASES OF THE INTESTINES. 267 
 
 to three-quarters of all cases of appendicitis recover 
 permanently without operation. Nevertheless, the disease 
 is full of surprises, and an apparently slight case must always 
 be watched most carefully. It is an established fact that 
 the prognosis of the course of an attack cannot be definitely 
 stated, especially in the early stages. In a considerable 
 percentage of cases troubles of various kinds persist after 
 the attack ; these have already been described under the 
 term " chronic appendicitis." In many cases there are 
 return attacks of varying degrees of severity, from the 
 slightest to the most dangerous. 
 
 In perforative appendicitis with peri-appendicular abscess, 
 the abscess may subside to a certain extent but never 
 completely, and is a persistent menace to the patient. I 
 have often seen autopsies on patients dead from septicaemia, 
 in which such small abscesses were the cause of death. 
 Abscesses often, however, run a progressive course, with 
 the formation of fresh collections throughout the peritoneum. 
 The rarity of subphrenic abscess now as compared with 
 some years ago is due to the practice of early operation 
 in appendicitis. 
 
 In other cases perforation leads to death in a few hours 
 to a few days from septic peritonitis or pylephlebitis. 
 
 The percentage of deaths among cases of appendicitis 
 not operated on has been given somewhat variously by 
 various authors according to the manner in which the cases 
 have been grouped. The figures vary between 6-10 per 
 cent (Renvers) and 30 per cent (Beck). By different 
 arrangement of the figures the surgeons seem to arrive at 
 the high percentages, the physicians at the low percentages ! 
 Certainly, the proportion is at least 10 per cent. 
 
 LITERATURE. 
 
 H. BoHM. Die Indikationen zur Chirurgischen Behandlung der 
 Perityphlitis. Sammelreferat. Fortschritte der Medizin, p. 734, 
 1902. 
 
 Cattaneo. Occlusione Intestinale ed Appendicite. La Clinica 
 Moderna, No. 10, 1901. 
 
 Chauvel. De I'Appendicite dans rArmee. Bull, de rAcademie 
 de Medecine de Paris, 1899. 
 
 DiEULAFoy, Reclus, Tillaux, Delorme, Lucas-Champonniere, 
 Ibidem. 
 
 DiEULAFoy. Attendre pour Operer I'Appendicite. La Presse 
 Medicale, No. 55, 1902. 
 
268 INDICATIONS FOR OPERATION. 
 
 Gali.et. Quand et comment faut il operer I'Appendicite. Gaz. 
 Hebdom, No. 79, 1902. 
 
 JuiLLARD. Leucocytose dans I'Appendicite. Rev. de Chir. 
 Mai, Juin, Aout, 1904. 
 
 Lennander. Meine Erfahrungen iiber Appendicitis. Mitteil. 
 a. d. Grenzgebiete Bd. xiii, H. 3. 
 
 Lenzmann. Die entziindlichen Erkrankungen des Darmes in der 
 Regio Ileocaecalis. Berlin: Hirschwald. 1901. 
 
 LocKWOOD. Appendicitis, its Patholog}^ and Surgery. London, 
 1901. 
 
 Murphy. Two Thousand Operations for Appendicitis. American 
 Journal of Medical Sciences, Aug.. 1904. 
 
 NoTHNAGEL. Erkrankungen des Darmes und des Peritoneums. 
 2nd Ed. 1903. 
 
 Payr, Sprengel. Appendicitis. Archiv fiir klinische Chirurgie. 
 Bd. Ixviii. 
 
 RiEPPi. Contributo alia Cura Chirurgica dell' Appendicite. 
 Rivista Veneta di Scienze Mediche, Vol. xxxiv., 1901. 
 
 RussEL CooMBE. Appendicitis. Lancet, June 4, 1904. 
 
 ScHLANGE. Perityphlitis. Handbuch d. praktischen Chirurgie, 
 herausgegeben von Bergmann, Bruns, u. ^Mikulicz. 2nd Ed. Bd. iii. 
 Stuttgart, 1903. 
 
 Spencer. Indications for Surgical Interference in Appendicitis. 
 Edin. Med. Jour., August, 1901. 
 
 Sprengel. Die Bedeutung der Leukocytose fiir die Indikations- 
 stellung bei Akuter Appendicitis. ]\Iiinchener med. Wochens., 
 No. 37, 1904. 
 
 Treves. Appendicitis. Brit. Z^Ied. Jour., June 28, 1902, p. 1594. 
 
 TuRKEL. Die Bedeutung der Leucocytose fiir die Diagnose 
 intra-abdominaler Eiterungen. Centralb. f. d. Grenzgebiete d. 
 Med. u. Chir., No. 14, 1904. 
 
 SoNNENBERG. PcrityphHtis. 4th Ed. Leipzig, 1900. 
 
CHAPTER XVI. 
 
 Diseases of the Peritoneum. 
 
2.7. 
 
 Chapter XVI. 
 DISEASES OF THE PERITONEUM. 
 
 ACUTE CIRCUMSCRIBED PERITONITIS. 
 
 Etiology. — Inflammatory processes of any organ which 
 has a peritoneal covering may lead to a circumscribed 
 peritonitis. Excluding appendicitis, which has been 
 considered in the last chapter, the commonest causes are 
 affections of the female generative organs (puerperal pro- 
 cesses, abortion, gonorrhoea), and of the gall-bladder ; 
 and, less frequently, ulcerative processes of the stomach 
 and intestine and inflammatory affections of the parenchy- 
 matous organs. 
 
 Pathological Anatomy. — The peritoneal inflammation 
 may be fibrinous, serous, purulent, or septic; in this circum- 
 scribed type it remains limited by adhesions to the neighbour- 
 hood of the primarily affected organ, and becomes encap- 
 suled. Under a continuance of the irritation the amount 
 of exudate increases ; if the latter is purulent or septic there 
 is a great tendency for it to make its way from the primary 
 seat to other parts. Rupture of the exudation may occur 
 into the general peritoneal cavity, the vagina, the bowel, or 
 the bladder ; often it is completely absorbed. Sometimes, 
 but rarely, this circumscribed peritonitis is complicated 
 by thrombosis of mesenteric veins and pylephlebitis. 
 
 Clinical Course. — At the commencement of an attack 
 of peritonitis of this type there is usually slight distension 
 of the whole abdomen, diffuse pain, vomiting, and constipa- 
 tion. In the course of from one to two days the general 
 signs recede and the local signs become more prominent. 
 The patient complains of pain in the region of the primary 
 focus, and is tender to pressure here ; about the same day 
 a resistance is felt, which in the course of twenty-four hours 
 becomes sharply defined, and is due to the exudate and to 
 
272 INDICATIONS FOR OPERATION IN 
 
 adhesions between coils of bowel and thickened omentum. 
 With the aid of an enema the bowels can usually be got 
 to act about this time, the meteorism subsides, and rigidity 
 of the abdominal wall is confined to the region of the " lump." 
 In addition to the local exudate some free fluid may be 
 found in the peritoneal cavity, but usually only after the 
 peritonitis has been present several days. After the first few 
 days the general condition is relatively good ; fever is often 
 absent. If fever persists the exudate is probably purulent. 
 The pulse is of good tension and the rate either normal or 
 only slightly increased. If the pulse becomes steadily 
 more rapid the disease is probably extending. 
 
 Diagnosis. — The symptoms just described will establish 
 the diagnosis of circumscribed peritonitis. If the history 
 is indefinite, either the appendix, the female sexual organs, 
 or the gall-bladder will be first suspected as the point of 
 origin of the infection. The diagnosis of acute appendi- 
 citis has been discussed in the previous chapter. Pelvic 
 peritonitis is associated often with functional disturbance 
 of the female sexual organs (sudden pronounced haemor- 
 rhage or onset after haemorrhage) ; pain is also most marked 
 deep in the pelvis and in the neighbourhood of the hip, and 
 there is frequently pain in micturition and defsecation. 
 On vaginal palpation a parametral swelling is found, which 
 may encroach on the rectum behind to a marked extent. 
 Abscesses which result from pelvic peritonitis are usually 
 situated towards the bottom of the pelvis, and are bounded 
 by rectum behind and bowel above ; sometimes they are 
 more in front of the uterus, and may then be palpable above 
 the pubis. The history of the case must be relied upon 
 to differentiate an extra-uterine gestation, which is associ- 
 ated with signs of internal haemorrhage. 
 
 Marked inflammatory effusion around the gall-bladder, 
 particularly in cholelithiasis, may be recognized by the 
 development of a tender swelling below the edge of the 
 liver, usually not moving with respiration, and associated 
 with signs of severe peritoneal irritation, which gradually 
 become limited to the region of the swelling ; it may be 
 possible to make out that the latter is of a definitely doughy 
 consistency, or even fluctuating. Differential diagnosis 
 from cholecystitis is not easy and sometimes impossible, 
 but the tumour of cholecystitis is pear-shaped and moves 
 
DISEASES OF THE PERITONEUM. 273 
 
 with respiration, and the signs of peritoneal irritation are 
 not so pronounced. 
 
 INDICATIONS FOR OPERATION. 
 
 Acute circumscribed peritonitis requires operation when- 
 ever a collection of pus forms. As a rule, such a collection 
 is treated by simple incision, and no attempt is made to 
 deal with the affected organ directly until the acute inflam- 
 matory condition has subsided ; precautions are also taken 
 against the infection of the general peritoneal cavity. 
 
 When can suppuration be diagnosed with certainty ? 
 " Gradual, sometimes comparatively rapid, increase in 
 size of the inflammatory swelling, increase in the local 
 tenderness, alteration in the consistence of the swelling 
 from hard to doughy : these signs, along with alterations 
 in the pulse and temperature, will lead to the diagnosis. 
 Sustained or oscillating fever is an important indication of 
 abscess " (Korte). When an intraperitoneal abscess makes 
 its way into the deeper parts of the abdomen, bimanual 
 examination often gives valuable information. A dull per- 
 cussion note over the resistance is in favour of abscess, but 
 a tympanitic note does not negative it, because an intestinal 
 coil may lie in front, or the abscess may contain gas. 
 
 Exploratory puncture has often been employed to decide 
 the presence of pus, but to pass a needle into an intra- 
 peritoneal abscess is a risky proceeding, and should at any 
 rate never be done unless preparations are made to open 
 the abscess immediately after. 
 
 Blood examination is often valuable. A steadily- 
 increasing leucocytosis, up to twice or three times the 
 normal, points to suppuration. A single observation also, 
 if it reveals a leucocytosis of 18,000 or over, points to the 
 same. Of less value are observations on the presence of 
 glycogen in the white corpuscles, shown by the yellow 
 or brown staining of granules ; little reliance will also be 
 placed on the development of peptonuria. 
 
 Even when an increase in size of the inflammatory 
 swelling cannot be definitely determined, and there are 
 no signs of fluctuation, if the temperature remains up or 
 continues to rise, and if the pulse rate gradually mounts, 
 an abscess is almost certainly present, and operation should 
 be recommended. 
 
 18 
 
274 INDICATIONS FOR OPERATION IN 
 
 Contra-indications. — Operation is not necessary when 
 there are no signs of suppuration ; a serous inflammation 
 tends to recede spontaneously. Generally speaking, early 
 operation is contra-indicated. In peritonitis of this type, 
 adhesions limit the focus, and the later the operation the 
 more securely is the infective process shut off, but operation 
 should never be delayed orice pus is diagnosed. Exploratory 
 puncture is specially contra-indicated if there is a tympanitic 
 note over the swelling. 
 
 If thrombophlebitis complicates the peritonitis, operation 
 is usually inadvisable if there is no definite local inflam- 
 mator}/ swelling ; the general symptoms of thrombophlebitis 
 are marked peritoneal irritation, high fever, repeated rigors, 
 and profuse weating. 
 
 Prognosis. — Results of operation. — In most cases the 
 opening of the abscess is followed by gradual complete 
 recovery. In some instances, however, the inflammatory 
 condition is recrudescent, and secondary abscesses form 
 in the neighbourhood of the first after the latter has 
 been opened, necessitating repetition of the operative 
 interference. 
 
 Sometimes it is necessary to operate afresh later, and 
 remove the primary source of the infection. 
 
 Without operatioji. — In a not inconsiderable number of 
 cases, particularly in those which have their origin in the 
 female genital organs, a kind of natural healing takes place 
 by encapsulation and gradual absorption of the exudate. 
 This eventuality may be expected when the general 
 inflammatory signs subside, the fever lessens, the pulse 
 becomes normal, the local tenderness and resistance 
 disappear, and no fluctuation is to be found. 
 
 In many other cases the inflammatory condition tends 
 to spread ; with the development of abscess comes the risk 
 of septic absorption and septicfemia. Pylephlebitis is 
 another danger ; and lastly there is the risk of rupture of 
 the abscess into the general peritoneal cavity, setting up a 
 diffuse peritonitis. 
 
 LITERATURE. 
 
 KORTE. Peritonitis. Handbuch der praktischen Chirurgie, 
 herausgegeben von Bergmann, Mikulicz, u. Bruns. Bd. iii. 2nd 
 Ed. 1903. 
 
DISEASES OF THE PERITONEUM. 275 
 
 NoTHNAGEL. Erkraiikungen des Darmes und des Peritoneums. 
 2nd Ed. Wien, 1903. 
 
 V. WiNKEL. Peritonitis, von den weiblichen Genitalien ausge- 
 hend. Jena, 1897. 
 
 Charles Mansell. Treatment of Acute Peritonitis. Medical 
 Press, June 8, 1904. 
 
 GuENiOT. Traitement des Peritonites Aigues. Gaz. des Hopit., 
 No. 93, 1901. 
 
 DIFFUSE PERITONITIS. 
 
 Etiology. — In the great majority of cases diffuse 
 peritonitis results from the entry of pyogenic bacteria into 
 the peritoneal cavity. The most common source of the 
 infection is the appendix, and then follow certain other 
 abdominal organs — the female genital organs, the stomach, 
 the intestinal tract, the gall-bladder, the pancreas, etc. 
 The peritoneum may be suddenly flooded with more or less 
 infective material by rupture of a hollow organ. In some 
 cases peritonitis occurs as a metastatic condition, and it 
 may also develop after operation. 
 
 Aseptic peritonitis results from chemical or mechanical 
 irritants ; thus it may follow rupture of a hydatid cyst, or 
 effusion of blood, or injury to the serosa. 
 
 Pathological Anatomy. — Mikulicz distinguishes the: 
 following forms of peritonitis ; the diffuse septic, the pro- 
 gressive fibrino-purulent, and the circumscribed purulent. 
 A fourth type is often described under the term septic£emic 
 peritonitis. 
 
 The diffuse septic form occurs from sudden general 
 infection of the peritoneum by, for example, perforation of 
 one of the hollow organs. Adhesions between intestinal 
 coils are absent ; the exudate is thin and either purulent or 
 serous. 
 
 The progressive fibrino-purulent type occurs when the 
 inflammatory condition progresses by stages, so that in 
 the course of several days the greater part of the peritoneum 
 becomes infected from a small original focus — the appendix, 
 for example. Such a mode of progression is associated 
 with the formation of various adhesions between the 
 intestinal coils and other abdominal organs. 
 
 The third type, circumscribed peritonitis, has been 
 described in the previous pages. 
 
276 INDICATIONS FOR OPERATION IN 
 
 SepticcBinic peritonitis occurs from the introduction of 
 bacteria of very high virulence into the peritoneum, and 
 is most common as a post-operative condition ; patholo- 
 gically, no changes are found particularly characteristic 
 of this excessive^ rapid form. 
 
 Rauenbusch distinguishes the different forms topographi- 
 cally, according as they are supra-omental or infra-omental, 
 descending from above downwards, or ascending from below 
 upwards. 
 
 The digestive tract is the point of origin of the disease 
 in the majority of cases, and most frequently through the 
 medium of perforating ulceration, or direct wounds. 
 Neoplasms and phlegmonous and ulcerative processes may 
 cause peritonitis without actual perforation. 
 
 Other sources of infection are the puerperal and gonorrheal 
 infections of the genital organs, cholelithiasis and its sequelae, 
 abscesses of the liver, and hydatid cysts ; in rare cases the 
 point of origin has been a pancreatitis or a splenic abscess. 
 
 Clinical Course. — This type of peritonitis usually begins 
 acutely, often with a rigor, and as a rule the patient feels 
 extremely ill. The respiration is shallow^ and rapid. The 
 pulse rate is increased, and becomes continuously and 
 markedly accelerated with the progress of the disease. The 
 temperature is often much elevated, particularly in cases 
 where the peritonitis is only part of a general septic infec- 
 tion, as for example in puerperal peritonitis. Absence of 
 fever is not, however, evidence against peritonitis ; even the 
 purulent types may run an entirely apyrexic course. In 
 these cases, it is true, the rectal temperature is often consider- 
 ably higher than the axillary. The patient is restless and 
 distressed, the expression anxious, the nose pinched, and 
 the extremities cyanosed ; he is fully conscious, but may 
 fall into a stupid state later ; not uncommonly there is a 
 sense of well-being before death. The voice is small and 
 without resonance, the tongue dry and coated ; the urine 
 is scanty and concentrated. 
 
 Abdominal pain is often localized at first to the region 
 whence the disease starts, but in other cases the patient 
 complains of general pain, or refers it to the neighbourhood 
 of the umbilicus. As the disease progresses, the pain 
 becomes diffuse, but it may still be greatest at the seat of 
 origin. At the first onset it is very acute ; later, when exudate 
 
DISEASES OF THE PERITONEUM. 277 
 
 forms and septic phenomena develop, it often becomes less 
 violent. The amount and the nature of the exudate vary 
 greatly in the different types of the disease. Sometimes 
 the amount is so small as to be hardly demonstrable by 
 percussion ; in other cases fluid distends all the dependent 
 parts of the abdominal cavity. In some of the gravest 
 forms, the amount of the exudate and other peritoneal 
 symptoms are insignificant compared with the general 
 phenomena. Fluctuation, particularly in the early stages, 
 is often extremely difficult to make out ; its demonstration 
 is best attempted by spreading one hand on the abdomen 
 and imparting movements to the fluid by tapping on the 
 middle finger with the bent thumb of the other hand ; 
 these movements should then be appreciated by the thumb 
 which lies on the abdomen. If the exudate is rich in fibrin, 
 friction is sometimes heard over the liver or spleen. When 
 there is free gas in the peritoneum the liver dullness 
 diminishes with the patient in the dorsal position. 
 
 Vomiting is rarely absent, and is often the most distressing 
 of all the symptoms. It soon becomes bilious ; in septic 
 peritonitis it may be of coffee-ground character, and if the 
 bowel becomes paralyzed it is, as a rule, faeculent. The 
 abdomen is usually distended ; neither flatus nor fseces are 
 passed, and purgatives are ineffectual ; the septic types 
 alone are relatively often associated with diarrhoea. 
 
 Perforative peritonitis often sets in without warning, 
 but in many cases there is a history of previous symptoms 
 referable to one or other of the abdominal organs. The 
 onset is sudden, and the pain agonizing ; in the first few 
 hours the patient is collapsed, the pulse small and rapid, 
 the abdomen retracted, and the muscles board-like, the 
 temperature often somewhat subnormal. After several hours 
 the signs of peritonitis appear — fever, meteorism, vomiting, 
 and general tenderness. 
 
 In perforation of a typhoid ulcer the first symptoms 
 are usually violent pain and shock ; sometimes the patient 
 is very restless some hours before the perforation ; in 
 other cases the early symptoms are not acute and there is 
 no abrupt onset ; this was the case in two instances which 
 I have recently seen. The temperature may fall rapidly 
 or rise abruptly with rigors. The other symptoms are 
 those common to perforative; peritonitis generally. 
 
278 INDICATIONS FOR OPERATION IN 
 
 Circumscribed purulent peritonitis often begins with 
 general peritoneal symptoms, meteorism, diffuse tenderness, 
 vomiting, constipation, rapid pulse, and peritoneal effusion. 
 After some days the inflammation becomes definitely 
 localized and the generalized symptoms subside (see last 
 Section, p. 271). 
 
 In progressive fibrino-purulent peritonitis (Mikulicz) the 
 phenomena are at first fairly localized, and gradually the 
 tenderness to pressure and the distension extend more or 
 less throughout the abdomen. When well established, 
 the phenomena are those of a general peritonitis. The 
 condition may assume a chronic character, and in this case 
 the pain and vomiting subside, the general symptoms 
 improve, the collections of pus increase and may penetrate 
 into some hollow organ, and the disease generally tends to 
 run a latent course for a long period. 
 
 Diagnosis. — Peritonitis is not difficult of recognition 
 if the characteristic symptoms are borne in mind^ — the pain, 
 vomiting, meteorism, intestinal paralysis, and exudation. 
 Often in the early stages it is not -possible to decide whether 
 an attack will result in a localized or a diffuse condition. 
 
 Differential diagnosis. — Cases occur in which it is very 
 difficult to exclude gall-stone or renal colic, and both these 
 forms of colic may be associated with marked signs of 
 peritoneal irritation. The tenderness and pain are, however, 
 more or less localized to the neighbourhood of the affected 
 organ, and the parietes are here more rigidly contracted 
 than elsewhere. A certain degree of meteorism may 
 accompany these forms of colic. Frequent desire to 
 micturate, rectal tenesmus, blood in the urine, or complete 
 anuria, are in favour of renal stone ; bile pigment in the 
 urine, jaundice, and the presence of a gall-bladder swelling, 
 point to gall-stone. 
 
 Uraemia is to be distinguished from peritonitis by the 
 results of the urine examination, by the onset of loss of 
 consciousness and convulsions, and by the physical 
 examination of the abdomen. 
 
 It is sometimes very difficult to make a diagnosis between 
 intestinal obstruction and peritonitis. The presence of 
 well-marked peristaltic movements, particularly if definite 
 local contracture of the bowel can be made out, local and 
 not diffuse tenderness, and the absence of muscular rigidity 
 
DISEASES OF THE PERITONEUM. 279 
 
 of the abdominal walls, point to obstruction rather than 
 peritonitis. Fever, free fluid in the peritoneum, diffuse 
 tenderness, leucocytosis, and very severe general symptoms 
 from the beginning, are in favour of peritonitis. In 
 peritonitis the pain is continuous, in obstruction it tends 
 to come on in attacks. Meteorism, paralysis of the gut, 
 frequent and fseculent vomiting, are symptoms common 
 to both affections. The absence of fever is not a reliable 
 guide alone ; peritonitis may run an apyrexic course. 
 
 INDICATIONS FOR OPERATION. 
 
 In all forms of perforative peritonitis operation is urgently 
 called for. The initial shock which occurs must be treated, 
 and not allowed to delay operation to any considerable 
 extent. 
 
 The abdomen should be opened whenever possible within 
 the first few hours, whether the diagnosis is quite clear or 
 only suspected, whether the symptoms point to perforation 
 of the stomach, duodenum, gall-bladder, or appendix, or can 
 be' traced to the female generative organs or to a typhoid 
 ulcer; or when, the cause of the condition being obscure, 
 a patient previously in health is suddenly attacked with 
 pain in the abdomen, and collapse, and the abdominal 
 parietes are found rigid, and free fluid and gas are shortly 
 afterward found present in the peritoneum. 
 
 In cases of diffuse inflammation which begin without 
 the symptoms of perforation, the rule should be followed 
 to operate as soon as the symptoms point to an extending 
 peritonitis. 
 
 In the progressive fibrino-purulent type of the disease 
 the abdomen should also be opened at as early a stage as 
 possible, and the purulent collections evacuated. 
 
 The operative procedure in these conditions consists of 
 opening the abdomen under general anaesthesia (excep- 
 tionally under local infiltration ansesthesia) and mechanically 
 cleansing the affected peritoneum. Many surgeons irrigate 
 with normal saline solution. A perforation must be closed 
 by suture ; it is often necessary to puncture or incise 
 distended bowel. When paralytic-ileus develops in the 
 course of typhoid fever, recognized by a rapidly-progressive 
 meteorism, it is necessary to establish an artificial anus 
 (Escher). 
 
28o INDICATIONS FOR OPERATION IN 
 
 Contra-indications.—li from the commencement of the 
 illness the signs of general intoxication overshadow the 
 local signs, if, that is to say, there is an early onset of tachy- 
 cardia and cardiac failure, cyanosis, shallow respiration, 
 and shock, whilst the amount of exudate is small, operation 
 will be useless, and is therefore contra-indicated. 
 
 When the signs of what seemed at first a diffuse peritonitis 
 have become localized and restricted, operation should, 
 as a rule, be delayed until the resulting abscess can be 
 opened without risk of contaminating the general peritoneal 
 cavity. 
 
 When peritonitis occurs as a single phenomenon in the 
 course of general puerperal septicaemia its surgical treatment 
 is inadvisable. 
 
 A gonorrhoeal peritonitis secondary to disease of the 
 female genital organs does not call for early operation ; it 
 should be watched and treated on expectant principles ; 
 many cases recover spontaneously. 
 
 Prognosis. — Results and risks of operation. — In perforative 
 peritonitis laparotomy often saves life ; the perforation is 
 closed and further escape of infective material thus 
 prevented, or the perforated structure (appendix) is removed 
 entirely ; much toxic exudate is also removed from the 
 peritoneal cavity, and the intraperitoneal pressure is 
 relieved. 
 
 When operation for perforation is done within 12 hours, 
 two-thirds of the cases are saved, but only one-third of 
 those operated on during the second 12 hours. When 
 there is a delay of 24 hours over 80 per cent die. 
 
 In typhoid perforation from 20-25 P^r cent are saved 
 by operation ; of 87 cases collected by Loison, 16 recovered. 
 Of these 16 cases six were operated on from six to twelve 
 hours after perforation, four between the twelfth and the 
 twenty-fourth hour. The latest statistics are those of 
 Zesas — 95 recoveries in 255 cases. Of Hartmann's cases 
 75 were operated on . within the first 24 hours with 19 
 recoveries, 38 later than this with 6 recoveries. The later 
 in the attack the perforation occurs the more favourable 
 is the operative prognosis ; in the second and third week 
 only 14 per cent recover, in the fourth week 37 per cent, and 
 later than this about half the cases are saved. 
 
 In cases of perforation of gastric ulcer the results of 
 
DISEASES OF THE PERITONEUM. 281 
 
 operation are relatively good : about 50 per cent recover, 
 probably owing to the fact that operation is in most cases 
 resorted to early. 
 
 In diffuse peritonitis originating from the appendix, from 
 28 to 36 per cent are rescued by operation. 
 
 The risk from operative shock is apparently great ; 
 vomiting may persist in spite of operation. Secondary 
 collections of pus may form throughout the abdominal 
 cavity and require opening. Pleurisy and pericarditis 
 may supervene ; in one of my cases bilateral perforation 
 of the diaphragm occurred eight days after operation with 
 a fatal result. Ventral herniae often occur when the 
 abdominal wounds are tamponed. 
 
 Without operation. — When the phenomena of general 
 intoxication predominate the prognosis is excessively 
 grave. Cases of septiceemic peritonitis of this type die 
 as a rule after a period varying from a few hours to a few 
 days. Diffuse purulent spreading peritonitis nearly always 
 ends in death ; occasionally a case becomes chronic and 
 eventually recovers ; the length of time a patient lasts 
 varies very much ; some die in the course of a few days, 
 some survive for several months. 
 
 Acute perforative peritonitis is also usually fatal ; in 
 rare cases the condition localizes itself by adhesions, and 
 the patient recovers. 
 
 Aseptic peritonitis, caused by mechanical or chemical 
 irritation, often ends in recovery, sometimes after very 
 alarming early symptoms. 
 
 LITERATURE. 
 
 NoTHXAGEL. Erkrankungen des Darmes und des Peritoneums. 
 2nd Ed. Wien, 1903. 
 
 KoRTE. Peritonitis. Handbuch der praktischen Chirurgie. 
 herausgegeben von Mikulicz, Bruns, u. Bergmann. Bd. iii. 2nd 
 Ed. Stuttgart, 1903. 
 
 TiETZE. Chirurgische Behandlung der akuten Peritonitis. Mit- 
 teil. a. d. Grenzgebiete d. Med. u. Chir. Bd. v. 
 
 Krogius. Ueber die vom Processus Vermiformis ausgehende 
 citrige Peritonitis. Jena, 1901. 
 
 Cardi. Per la Cure della Peritonitc del Perforazionc nel Tifo. 
 La Clinica Medica, No. 17, 1901. 
 
 Le.n'nander. Beliandlung des perforierenden Magen- und Darm- 
 geschwijrcs. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. iv. 
 
 EsciiKR. Die Behandlung der akuten I^erforalionspcritonitis im 
 
282 INDICATIONS FOR OPERATION IN 
 
 Typhus mittels Laparotomie und Ileostomie. Mitteil. a. d. Grenz- 
 gebiete d. Med. u. Chir. Bd. xi, H. i. 
 
 CuRSCHMANN. Der Unterleibstyplius. Nothnagel's spez. Pathol, 
 u. Therap. Wien, 1898. 
 
 Manger. La Perforation Typhique de ITntestin. Paris : Stein- 
 heil. 1900. 
 
 Terrier. La Perforation Typhique. Soc. ^ledic. des Hopit. 
 de Paris, Feb. 8, 1901. 
 
 Roper. When to Operate in Perforative Peritonitis. Lancet. 
 April 20, 1 90 1. 
 
 Manger. Du Traitement Chirurgical de la Peritonite. Rev. 
 de Chir. Feb. 10, 1901. 
 
 LoisoN. Peritonite Suppuree Diffuse Consecutive a la Perforation 
 Typhoidique. ibidem. 
 
 Zesas. Chirurgische Therapie der typhosen Perforationsperi- 
 tonifis. Wiener Klinik, Wien, 1904. 
 
 CHRONIC EXUDATIVE PERITONITIS, 
 
 Etiology. — Trauma is undoubtedly one of the causative 
 factors of this condition. Nephritis and obstruction of 
 the portal circulation (hepatic cirrhosis) appear also to 
 give rise to it. 
 
 Pathological Anatomy. — The exudate is sometimes 
 free, sometimes encapsuled. After the disease has been 
 present for some time the peritoneum is thickened, and 
 has a pearly-white appearance ; sometimes it is studded 
 with small fibrous nodules, not tuberculous (peritonitis 
 fibrosa). 
 
 Clinical Course. — The disease usually begins insidiously 
 with abdominal pain and distension. There is often a 
 complete absence of fever. The exudate has the general 
 characters of inflammatory effusion ; sometimes there is 
 oedema of the lower extremities and of the abdominal 
 wall. Vomiting, circulatory disturbances, and other 
 symptoms of a general character are usually absent, 
 nor are there recognizable changes in the abdominal 
 organs. 
 
 Diagnosis. — The diagnosis of this condition can only be 
 provisional, as it is impossible before operation to exclude 
 tubercular peritonitis. The fluid gives a negative result 
 on inoculation, and there is no reaction to tuberculin, but 
 these negative results are not sufficient to enable one to 
 be certain on the matter. For the differential diagnosis 
 
DISEASES OF THE PERITONEUM. 283 
 
 from other conditions the section on tubercular peritonitis 
 should be consulted (p. 288). 
 
 INDICATIONS FOR OPERATION. 
 
 If this form of peritonitis is suspected, the abdomen 
 should be punctured if the ascites is marked and troublesome, 
 or dangerous symptoms have arisen ; such symptoms are 
 dyspnoea, tachycardia, arythmia, oedema of the legs, etc. 
 The opening of the abdomen and irrigation, which has 
 been recommended by several writers, is not a proceeding 
 which I approve in the ordinary case, as the prognosis is 
 in general good and the disease usually subsides sponta- 
 neously. Laparotomy is at any rate contra-indicated when 
 the exudate has commenced to diminish. 
 
 Prognosis. — Results of operation. — By m^eans of puncture 
 the patient can be tided over the worst period of his 
 •disease while the fluid is accumulating, and in this way 
 the operation may be directly life saving. Once the 
 inflammatory process has passed its height the patient 
 is out of danger. Laparotomy, with lavage of the 
 abdominal cavity, shortens the period of inflammation and 
 produces a more rapid healing. 
 
 Without operation. — If an expectant tonic treatment 
 is persevered with, the exudate as a rule com.mences to 
 disappear and the pains to diminish in the course of some 
 weeks or months, seldom sooner. There may be remissions 
 and exacerbations. After the disease has subsided there 
 often remain adhesions and thickenings of the peritoneal 
 covering of the abdominal organs. 
 
 LITERATURE. 
 
 NoTHNAGEL. Erkrankungen des Darmes und des Peritoneums. 
 2nd Ed. Wien, 1903. 
 
 KoRTE. Krankheiten des Peritoneums. Handbuch de prakt. 
 •Chir,. V. Mikulicz, Bergmann, u. Bruns. 2nd Ed. Stuttgart, 1903. 
 
 Lenxander. Chronisch exudative Peritonitis. Nord. Med. 
 Arkiv., 1900. 
 
 CHRONIC INDURATIVE AND ADHESIVE PERITONITIS. 
 
 J£tiolo(;y. — This form of j^eritonitis may be caused by 
 bacterial, chemical, or mechanical irritation. It occurs 
 with especial frequency as a residuum of acute and subacute 
 
284 INDICATIONS FOR OPERATION IN 
 
 peritonitis, also in association with chronic inflammatory 
 processes following affections of the female genital organs, 
 the liver and gall-bladder, and with ulcerative processes, 
 and stenoses of the stomach and intestine. 
 
 Constipation, hernia, abdominal wounds, operations, 
 intra-abdominal menstrual haemorrhages, are also factors 
 of etiological importance. 
 
 Syphilitic processes in the liver and spleen may give rise 
 to dense peritoneal adhesions. 
 
 Pathological Anatomy. — The process may lead to 
 adhesions between the surfaces of organs or to the formation 
 of bands. As a result there may be kinking of the hollow 
 organs and displacements or fixation of others. Sometimes 
 the mesenteric structures become shrunken, particularly 
 the mesentery of the sigmoid flexure (an important cause 
 of volvulus), the csecum, and the lower part of the ileum. 
 Typical situations for the development of adhesions are 
 at the point where the descending colon passes into the 
 sigmoid colon, and at the hepatic and splenic flexures. 
 
 A special form of the disease is the chronic hyperplastic 
 perihepatitis (Zuckergussleber), which results in the 
 enveloping of the whole liver in a whitish membranous 
 exudate ; it is almost always associated with chronic 
 pleurisy and pericarditis. 
 
 The diffuse form of chronic peritonitis with general 
 adhesions between all the abdominal organs is very rare. 
 
 Clinical Course. — Extensive adhesions often form 
 without giving rise to any symptoms, but in other cases 
 even slight adhesions cause serious lesions by narrowing" 
 or occluding bowel or by providing the mechanism of an 
 internal strangulation, for example, by fixing the extremity 
 of the appendix or of a Meckel's diverticulum. Adhesions at 
 the flexures give rise to the following symptoms (Gersuny) : 
 persistent chronic constipation, pains on both sides of 
 the lower part of the abdomen, increase of the pain, 
 especially that on the left side, during defaecation and 
 during exercise. 
 
 Adhesions in the neighbourhood of the gall-bladder often 
 simulate chronic cholelithiasis. Two cases under my own 
 care were operated on for supposed gall-stone, all that was 
 found being adhesions around the gall-bladder fixing the 
 neighbouring coils of bowel. Separation of the adhesions. 
 
DISEASES OF THE PERITONEUM. 285 
 
 cured the one, but in the other the symptoms returned 
 again after a month's respite. 
 
 In other cases the symptoms resemble those of gastralgia, 
 renal stone, or intestinal colic, and often the whole course 
 of events is obscure. Among the symptoms, pain always 
 predominates, and it may be aggravated by all the causes 
 which stimulate the functions of the contractile organs 
 and often by simple changes in the position of the body. 
 
 Diagnosis. — In many cases the symptoms are so 
 capricious that some form of neurosis is suspected. Some- 
 times, however, diagnosis is possible, for example, when a 
 band can be palpated, or when, after certain morbid affec- 
 tions, symptoms come on which are difficult to explain, 
 except on the supposition of peritoneal adhesions. 
 
 After cholelithiasis, for example, if signs of pyloric 
 stenosis appear they will be ascribed to adhesions, and 
 diagnosis is also possible where symptoms of intestinal 
 stenosis co-exist with hernia or follow penetrating wounds 
 of the abdomen. 
 
 A patient under my care had an old scar in the ileocaecal 
 region, probably due to an appendicular abscess. He was 
 admitted to hospital on account of acute pains in the 
 abdomen coming on in attacks. A coil of small bowel 
 with thickened wall was found present constantly at the 
 same spot. Diagnosis : Adhesion of the coil to the scar 
 left by the abscess and kinking. No operation could be 
 done. The autopsy revealed adhesion by a band between 
 a coil of small bowel and the parietal peritoneum. 
 
 A workman, 35 years of age, had received a knife wound 
 of the abdomen ; this healed uneventfully. He had since 
 complained of pain over the stomach, especially after a 
 meal. Examination showed a small hernia of the scar in 
 the linea alba. Operation revealed an adhesion here 
 between the bowel and the abdominal wall, and the separa- 
 tion of this was followed by complete disappearance of 
 his symptoms. 
 
 Adhesions will always be suspected when the patient 
 has suffered from some disease likely to cause local peritonitis, 
 and when he complains of persistent or intermittent pain, 
 which the original lesion cannot explain, as, for example, 
 when after an apparently healed gastric ulcer the patient 
 complains of intense pain without tenderness to. pressure 
 
2 86 INDICATIONS FOR OPERATION IN 
 
 particularly after a meal, and when pains are present in the 
 region of the gall-bladder in certain positions of the body 
 subsequently to an attack of cholelithiasis. 
 
 Since the diagnosis is hardly possible before operation 
 the differential diagnosis need not be discussed. 
 
 INDICATIONS FOR OPERATION. 
 
 If the clinical signs suggest peritoneal adhesions, and 
 if there are persistent or intermittent pains, operation is 
 indicated when the patient is depressed by his malady, 
 when his general nutrition is suffering, or when marked 
 neurasthenic or hysterical symptoms supervene. Operation 
 is also called for when the condition interferes with the 
 patient's working capacity, as, for example, when he cannot 
 assume certain attitudes without pain. 
 
 The indication for operation becomes absolute when 
 signs of gastric or intestinal stenosis suddenly or gradually 
 supervene, or when there are signs of obstruction from 
 volvulus, a condition which is liable to occur when the 
 mesentery becomes shortened by cicatricial contraction. 
 
 Contra-indications. — If the symptoms are only slight 
 and occasional, operation is rarely necessary. When there 
 is reason to believe that the adhesions are very extensive, 
 the result, for example, of a general peritonitis which has 
 progressed slowly to recovery, the gravity of the necessary 
 procedure will deter the surgeon ; but even under these 
 circumstances, if the indication is absolute and the sufferings 
 are unbearable, operation must be undertaken. 
 
 Prognosis. — Results and risks of operation. — In many 
 cases the results of operation are to the patient nothing less 
 than miraculous. In some cases the operation proves a 
 very simple matter, but in others it is extremely complicated. 
 The separation of the adhesions may be very laborious and 
 attended by much risk of damage to the bowel, some- 
 times requiring more or less extensive resection. The risk 
 to the patient will of course vary greatly according to the 
 gravity of the operation. It is usually impossible before 
 operation to estimate the risk in any given case, and it is 
 always wise to give the patient and his friends to understand 
 that the operation is a serious one, and to allow them to 
 share in the decision, and gauge the necessity in comparison 
 with the severity of the symptoms. In every case there 
 
DISEASES OF THE PERITONEUM. 287 
 
 is the chance that the adhesions may re-form, and means 
 must be taken by the surgeon to prevent this as far as 
 possible. 
 
 Without operation. — Many patients with peritoneal adhe- 
 sions suffer greatly for many years. When the adhesions 
 obstruct the lumen of the bowel the whole train of 
 symptoms characteristic of stenosis supervene, and may 
 terminate fatally. 
 
 LITERATURE. 
 
 NoTHNAGEL. Erkrankungen des Darmes und des Peritoneums. 
 2nd Ed. Wien, 1903. 
 
 KoRTE. Krankheiten des Peritoneums. Handbuch der prakt. 
 Chir, herausgegeben von Bruns, Bergmann, u. Mikulicz. Bd. ii. 
 2nd Ed. Stuttgart, 1903. 
 
 Horace Wethesill. Chronic Adhesive Peritonitis. Jour. Amer. 
 Med. Assoc, No. 10, 1904. 
 
 CouRTOis-SuFFiT. Maladies du Peritoine. Traite de Medecine, 
 Publie par Charcot, Bouchard, Brisseau. Tome iii. Paris, 1892. 
 
 Gersunv. Ueber eine typische peritoneale Adhasion. Archiv 
 f. klin. Chir. Bd. Hx. 
 
 NoAK. Peritoneale Verwachsungen nach schweren Bauch-. 
 quetschungen. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. iv. 
 
 RiEDEL. Ileus, bedingt durch Schrumpfung des Mesenteriums. 
 idem. Bd. ii. 
 
 Ders. Ueber Adhasiventziindungen in der Bauchhohle. Langen- 
 beck's Archiv. Bd. xlvii. 
 
 Ders. Peritonitis Chronica, ibid Bd. Ivii. 
 
 ScHATJTA. Lehrbuch der Gynakologie. 
 
 HiRSCHFELD. Pcritoncale Adhasionen durch Ulcus. Mitteil. 
 a. d. Grenzgebiete d. Med. u. Chir. Bd. vi. 
 
 TUBERCULAR PERITONITIS. 
 
 Etiology. — Tubercular disease of the peritoneum is 
 rare as a primary condition ; it is usually secondary to tuber- 
 cular affections of the lungs, genital organs, intestine, bones, 
 joints, or lymphatic glands ; it is especially common in 
 children. 
 
 Pathological Anatomy.— Three types of the disease 
 are distinguished (i) That with abundant free serous 
 exudate ; (2) That associated with the formation of 
 adhesions between the coils of intestine and between these 
 and the abdominal parietes, and the development of large 
 masses in tli(; om('ntiim and the peritoneum, and shrinking 
 
288 INDICATIONS FOR OPERATION IN 
 
 of the mesentery ; (3) The purulent ulcerative form with 
 adhesions between the different foci. 
 
 Clinical Course. — The disease often begins insidiously. 
 The first symptom is usually pain in the abdomen of a 
 moderate degree of severity. Exudation then usually 
 •collects rapidly. Fever may be entirely absent, but in 
 most cases there is at any rate an evening rise. Meteorism, 
 difficulties in micturition, constipation, and vomiting, are 
 symptoms which usually then supervene. The exudate 
 is at first free in the peritoneum, and tends later to become 
 limited by adhesions. xA.t this stage, nodules are often 
 palpable, partly due to thickened omentum, partly to 
 infected lymphatic glands, and partly to adhesions between 
 the coils. Such swellings are specially common in the 
 hypogastrium and the right iliac region 
 
 The general condition usually suffers markedly, the 
 appetite fails, and diarrhoea is not uncommon. Symptoms 
 referable to stenosis or kinking of the bowel are rare. 
 
 Diagnosis. — When an intraperitoneal effusion is dis- 
 covered in a patient with tubercular disease elsewhere, 
 without the co-existence of any acute abdominal symptoms, 
 the condition is probably tubercular peritonitis. A charac- 
 teristic livid appearance of the parietes in the neighbourhood 
 of the prominent umbilicus, supports the diagnosis If 
 there is no tuberculous disease elsewhere, an inoculation 
 experiment with the fluid withdrawn by puncture will be 
 of assistance. The reaction to tuberculin may also be 
 tested, but the method must be cautiously employed. 
 The formation of tumour-like masses or bands, particularly 
 in the hypogastrium, associated with some disappearance 
 of or encysting of the fluid, will add confirmation. The 
 presence of peritoneal friction points only to the peritoneal 
 nature of the effusion. The passage of acholic fatty stools 
 is somewhat in favour of the tubercular nature of a 
 peritonitis. 
 
 In carcinomatous peritonitis there is no encysting of 
 the exudate, and the presence of new growth in other 
 organs can be demonstrated. 
 
 Hepatic cirrhosis is associated with enlargement of the 
 spleen, and is characterized b)/ haematemesis and free 
 diarrhoea, and the pain, fever, and other symptoms of 
 peritonitis are absent. 
 
DISEASES OF THE PERITONEUM. 289 
 
 The " ascites of young girls " disappears after the first 
 menstruation, and leaves no tumour-masses behind. 
 
 INDICATIONS FOR OPERATION. 
 
 There is a great divergence of opinion as to the indications 
 for operation in tubercular peritonitis. There is no doubt 
 that laparotomy has been immediately followed by clinical 
 and anatomical recovery in many cases, and on this ground 
 it has been claimed by many writers that the proper treat- 
 ment of the disease is by operation. Some surgeons have 
 advised operation only in the cases with free or encysted 
 exudate ; others have operated on all types, even when 
 tumour-like masses were present. 
 
 Physicians have of late years become more and more 
 inclined to the conservative treatment of the disease in all 
 its forms. 
 
 I consider operation called for under the following 
 circumstances : (i) When the exudate is free, and is present 
 in such amount as to cause serious symptoms and endanger 
 life ; (2) When perforation-peritonitis supervenes, provided 
 that there are no serious tuberculous lesions in other organs ; 
 in all my cases there has been advanced disease in other 
 organs, and I have, therefore, never advised operation. 
 (3) When, in the serous or the adhesive forms of the disease, 
 internal and external treatment has proved unavailable 
 after several months' trial, and when the other organs are 
 either free from disease or only slightly affected. 
 
 The indications under the two last headings are not 
 absolute. Practitioners will do well to follow as a general 
 rule the present trend of opinion, and incline towards 
 conservative rather than operative treatment. 
 
 The operative procedure adopted in most cases has been 
 the opening of the abdomen, with or without wiping over 
 or washing out the cavity. Other surgeons have injected 
 sterilized air or irritating substances— iodoform, naphthol- 
 camphor, etc. The separation of adhesions has rarely been 
 undertaken. Relatively often the abdomen has been 
 punctured to relieve dangerous symptoms caused by the 
 accumulated fluid. 
 
 Contra-indications. — The advocates of operation look 
 uprm advanced tuberculosis of other organs as the only 
 contra-indication to operation, and do not consider as such 
 
 19 
 
290 INDICATIONS FOR OPERATION IN 
 
 the presence of fever or tuberculosis of other serous mem- 
 branes. Others, however, consider that the form of the 
 disease which is associated with sustained fever, particularly 
 when there are also masses formed in the abdomen, is 
 unsuitable for operation, and is unfavourably influenced 
 thereby. According to Borchgrevink, when there is no 
 fever the disease usually runs a favourable course, and 
 operation is not required. 
 
 Prognosis. — Results of operation. — It is difficult to gauge 
 the value of operation from the quoted statistics, as they 
 have been compiled from such opposite points of view. It 
 is true that many cases recover after laparotomy, but it has 
 been objected by those who are against operation that the 
 same result might have been obtained without opening the 
 abdomen. All, however, who have watched the course of 
 such cases must admit that clinical and anatomical recovery 
 often results and is permanent. The percentage of recoveries 
 given by different writers varies between the 33 per cent 
 of Frees and the 94 per cent of Mazzoni ; but the figures 
 for the most part do not deal with the question of permanent 
 recovery. Those given by Konig are important in this^ 
 respect : in 161 operations there were 65 per cent of recoveries, 
 but permanent cure after 2 years in 24 per cent only. 
 Margarucci also gives somewhat similar figures, 253 opera- 
 tions, 75 per cent recoveries, 26 per cent permanent cures. 
 
 Risks of operation. — Simple abdominal section for tuber- 
 cular peritonitis is relatively free from risk ; in very few 
 cases has death occurred ascribable to the operation. 
 Insufflation is also a harmless procedure. The presence 
 of complications makes the prognosis graver ; within 
 one year I lost three cases on this account ; in one there 
 was an intestinal tuberculosis, and in the other two there 
 was a complicating liver affection. Puncture when the 
 fluid is free is not dangerous, but accidents may happen 
 when it is encysted ; two cases of my own succumbed to 
 a wound of the bowel, although in each case the surgeon 
 was experienced ; the punctured bowel was adherent, 
 empty, and dull to percussion. 
 
 Faecal fistula has developed relatively often after operation ; 
 according to Friedlander this complication occurs in about 
 4 per cent of fatal cases which are not operated on, while 
 among the cases fatal after operation it is present about a 
 
DISEASES OF THE PERITONEUM. 291 
 
 quarter (Borchgrevink) or even a half (Korte). It must be 
 noted that these figures refer to fatal cases, not to all cases 
 Without operation. — Spontaneous recovery often occurs 
 after a varying duration of time, even when at one stage 
 or another the symptoms are marked and alarming, 
 and I have seen many cases in which this recovery was 
 permanent. The figures of A. Frank and Borchgrevink 
 appear to show that spontaneous cure is more common 
 among the non-operated than among the operated cases. 
 Frank records cure in a half, Borchgrevink in 81 per cent, 
 of the first, while among the operated cases the recoveries 
 are given by these writers respectively as 38 per cent and 
 63 per cent. In regard to the late history of the unoperated 
 cases, the figures given by Rose from Naunyn's clinic are 
 interesting ; of 56, two-thirds died, one-third, including 
 some severe cases, recovered. 
 
 LITERATURE. 
 
 L. Teleky. Die Bauchfelltuberkulose und ihre Behandlung. 
 Zusammenfassendes Referat. Centralb. f. d. Grenzgebiete d. Med. 
 u. Chir. 1899. 
 
 G. Zesas. Ueber die Laparotomie bei tuberkuloser Peritonitis. 
 Zusammenfassendes Referat. Ebendaselbst. 1903. 
 
 Borchgrevink. Zur Kritik der Laparotomie bei der Bauchfell- 
 tuberkulose. Mitteil. a. d. Grenzgebiete. Bd. vi. 
 
 Frank. Operative Behandlung der Chronischen Bauchfelltuber- 
 kulose. Ibidem. 
 
 Rose. Ueber den Verlauf und die Heilbarkeit der Bauchfell- 
 tuberkulose. Ibid. Bd. viii. 
 
 Herzfeld. Zur Chirurgischen Behandlung der tuberkulosen 
 Bauchfellentziindung. Ibid. Bd. v. 
 
 Nothnagel. Erlsrankungen des Darmes und des Peritoneums. 
 2nd Ed. Wien, 1903. 
 
 Terrier. Peritonite Tuberculeuse Chronique. La Presse 
 Medicale, 8 annee, No. 71. 
 
 Banteignie. De 1' Occlusion Intestinale dans la Peritonite Tuber- 
 culeuse. These de Paris. 1902. 
 
 Mainot. Traitement des Peritonites Tuberculeuses par les 
 Lavages d'Eau Sterilisee. These de Paris, 1901. 
 
 Lejars et QuENU. LTntervention Chirurgicale dans la Peri- 
 tonite Tuberculeuse. Bullet, et Memoires de la Societe de Chirurgie 
 de Paris. Tome xxiv., Nos. 22, 34, 35. 
 
 Fenger. Treatment of Tuberculosis. Annals of Surgery, 1901. 
 
 Schwarz. Cura della Peritonite Tuberculosa. Riv. Veneta 
 di Scienzc Mediche. Tome xxxvii., No. 4. 
 
 Macart.vey. Laparotomy in Tubercular Peritonitis. Glasgow 
 Med. Jour., August, 1901. 
 
CHAPTER XVII. 
 
 Diseases of the Peritoneum 
 
 [continued). 
 
295 
 
 Chapter XVII. 
 DISEASES OF THE PERITONEUM (contd.). 
 
 TUMOURS OF THE PERITONEUM, OMENTUM, AND 
 MESENTERY. 
 
 Etiology. — Cystic tumours may make their appearance 
 at any age ; diffuse new growths of the peritoneum are 
 most common in advanced age. 
 
 Pathological Anatomy. — The malignant growths are 
 usually metastatic, secondary in particular to cancer of 
 the uterus, stomach, bowel, pancreas, or gall-bladder. 
 Diffuse sarcomatous growths (sarcomatosis peritonei) are 
 comparatively very rare. Both carcinoma and sarcoma 
 usually take the form of diffuse growths of various sizes 
 throughout the peritoneum. The primary malignant 
 growths are usually endotheliomata, forming dense plate- 
 like thickenings of the peritoneum. 
 
 The benign tumours usually originate in the subserous 
 tissue, and may attain large dimensions ; they are usually 
 solitary. The cystic growths are either hydatids, or of 
 serous, hsemorrhagic, or chylous nature, developing between 
 the layers of the mesentery and the omentum, and situated 
 below the umbilicus. 
 
 Clinical Course. — The development of malignant 
 growth is almost always associated with marked ascites, 
 and the fluid is usually haemorrhagic. Large masses are 
 often palpable, and the plate-like masses of endothelioma 
 are most often found in the hypogastrium. As a rule, 
 symptoms referable to the primary growth precede the 
 peritoneal disease, but in some cases it is impossible to 
 trace the origin of the disease. 
 
 The solid and cystic growths of the omentum and mesen- 
 tery are distinguished by their marked mobility ; they lie 
 
296 INDICATIONS FOR OPERATION IN 
 
 as a rule about the level of the umbilicus or below it. In 
 about seven-tenths of the cases they give rise to attacks of 
 severe pain, usually associated with constipation. Some- 
 times the growth of the tumour is intermittent. 
 
 Diagnosis. — The presence of a rapidly-increasing haemor- 
 rhagic ascites, which does not diminish under treatment with 
 cardiac and diuretic remedies, and re-collects soon after 
 puncture, is almost diagnostic of malignant disease, and 
 the diagnosis will be confirmed if a primary growth or 
 metastases are discovered. Sometimes tumour elements 
 are to be found in the exudate. Cachexia usually co-exists 
 with the ascites. 
 
 In cirrhosis of the liver the exudate is rarely hsemor- 
 rhagic, and the spleen is hypertrophied ; the discovery of a 
 primary cancer will distinguish the condition from tuber- 
 cular peritonitis. 
 
 Cysts and solid growths of the omentum and mesentery 
 are very mobile ; pelvic examination will distinguish them 
 from ovarian tumours. If the large bowel is blown up it 
 is found encircling the growth like a collar, and the distended 
 stomach lies above it ; these anatomical points will 
 distinguish it from a pancreatic cyst, and from a cyst of 
 the liver. In children, the question of chronic intussuscep- 
 tion has to be considered, but this is associated with a train 
 of symptoms which is absent in the case of omental and 
 mesenteric growths. 
 
 INDICATIONS FOR OPERATION. 
 
 When the condition is one of peritoneal cancer the only 
 justifiable procedure is puncture and removal of the fluid 
 if asphyxia threatens. 
 
 When a tumour is present which appears to have had 
 its origin in the omentum or mesentery, operation is uncon- 
 ditionally indicated : (i) When the tumour is growing 
 rapidly ; (2) When severe pain, repeated vomiting, and 
 perhaps slight fluid effusion and meteorism suggest torsion 
 of the pedicle, or, in the case of cystic growths, suppuration ; 
 (3) When the discovery of cystic swellings in other organs 
 points to the hydatid nature of the growth. 
 
 The only contra-indications to operation in the case of 
 large solid growths of the omentum and mesentery are 
 such as would discountenance laparotomy in general. The 
 
DISEASES OF THE PERITONEUM. 297 
 
 solid growths are removed entirely ; the cystic growths 
 are either dissected out, or, if this is impossible, incised, 
 sutured to the abdominal wall, and drained. 
 
 Prognosis. — Results of operation. — The drawing off of 
 fluid is a palliative measure which often gives very great 
 relief to the patient. In the case of cystic and simple 
 solid growths operation is often very successful ; of 40 
 such cases 27 were permanently cured (67 per cent). 
 
 Risks of operation. — The statement that by the drawing 
 off of haemorrhagic effusion a risk is run of severe consequent 
 haemorrhage, is not supported by my own experience, and 
 is, at any rate, not to be feared as much as some writers 
 appear to suggest. In one case of endothelioma I observed 
 an implantation metastasis develop in the puncture track. 
 
 In the course of extirpating a tumour the mesenteric vessels 
 may be injured and the bowel deprived of its nutrition ; 
 under such circumstances resection becomes necessary. 
 
 When a cyst is drained the sinus may persist for a long 
 time, as long as a year in some cases ; the scars left are 
 often troublesome, and ventral hernia frequently results. 
 
 The prognosis of operation differs much (Blum), according 
 as it is done at the time when intestinal obstruction is 
 present (31 per cent of recoveries), or during quiescence of 
 symptoms (75 per cent of recoveries). Death may occur 
 from shock or sepsis. 
 
 Without operation. — Abundant and increasing ascites 
 presses on the diaphragm and causes asphyxia. If 
 torsion of the pedicle of a tumour occurs, and extirpation 
 is not proceeded with, necrosis and fatal peritonitis may 
 supervene. In the case of hydatids and other cysts, suppura- 
 tion and septicaemia, or rupture and peritonitis, are always 
 to be feared. 
 
 LITERATURE. 
 
 NoTHNAGEL. Erkrankungen des Darmes und des Peritoneums. 
 2nd Ed. 1903. 
 
 V. Blum. Ueber cystiche Tumoren des Peritoneums. Zusam- 
 menfassendes Referat. Centralb. f. d. Grenzgebiete d. Med. u. Chir. 
 1902. 
 
 Narath. Lymphcysten. Archiv f. klin. Chir. Bd. 1. 
 
 Garre. Echinococcen der Bauchhohle. Archiv f. kUn. Chir. 
 Bd. lix, p. 393. 
 
 Begouin. Traitement des Tumeurs SoUdes ct Liquides du Mesen- 
 tfire. Rev. d. Chir. No. 3. 1898. 
 
298 INDICATIONS FOR OPERATION IN 
 
 Hanot. Traite de Chirurgie. T. vii, p. 294. 
 
 SouPAULT Des Kystes Hydatiques du Peritoine. Gaz. des 
 Hopit. No. 87, 1895. 
 
 MoYNiHAN. Mesenteric Cysts. Medico-Chirurg. Society of 
 London, May, 1897. Tumours of the Mesentery. The Medical 
 Chronicle, September, 1902. 
 
 Bernavs. Sarcoma of the Mesentery. Annals of Surgery, June, 
 1902. 
 
 Cheinisse. Des Kystes Hydatiques de la Cavite Abdominale. 
 La Semaine Medicale, No. 38, 1902. 
 
 D'Urso. Cisti da Echinococco del Mesentere. II Policlinico, 
 Vol. viii., 1 90 1. 
 
 Nallino. SuUe cisti del Mesenterio. II Policlinico, Vol. ix, 
 Fasc. I, 2, 1902. 
 
 ASCITES. 
 
 Etiology and Pathological Anatomy. — Fluid collec- 
 tions in the abdomen of a non-inflammatory nature occur 
 as a result of obstruction to the portal circulation, as in 
 portal thrombosis and hepatic disease, or as part of a 
 universal dropsy from cardiac and renal disease, or in 
 general cachexia. A non-inflammatory ascites also 
 occasionally occurs in young girls before the onset of 
 menstruation. The fluid is usually of a light yellow colour 
 and clear, its specific gravity 1005 to 1015, and contains a 
 relatively small amount of albumin : from "i per cent to a 
 maximum of 2 '5 per cent, usually less than i per cent. In 
 chylous ascites there is fat in the fluid, giving it a milky 
 appearance, due to rupture or obstruction of lymphatic 
 vessels. 
 
 Clinical Signs. — The presence of free fluid in the peri- 
 toneal cavity is shown by dullness in the dependent parts, 
 which varies as to its limits with changes in the position 
 of the patient. When the amount of fluid is large a fluid 
 wave is to be felt on percussing the abdomen. The 
 distension of the abdomen is uniform, the umbilicus pro- 
 trudes, the abdominal wall is often oedematous, and its veins 
 are dilated. If there is some general affection of the 
 circulation there is usually oedema of the legs in addition 
 to ascites, and this is also often present when the ascites 
 is due to renal disease or general cachexia. When the 
 diaphragm is pushed upwards by a large collection of fluid 
 a serious embarrassment of respiration results. 
 
DISEASES OF THE PERITONEUM. 299 
 
 Diagnosis. — The clinical signs just mentioned are as 
 a rule sufficiently clear to establish the diagnosis. The 
 absence of meteorism, pain, and tenderness to pressure, 
 exclude peritonitis. Vomiting may be frequent even in 
 ascites due to circulatory disturbance. When the fluid 
 is present in small quantity it may be difficult to detect ; 
 examination in the half upright position, and palpation by 
 the vagina or by invaginating the scrotum, may be useful 
 under such circumstances. 
 
 Cases occur of fluid collections in enormously dilated 
 intestine which may be difficult to distinguish from ascites ; 
 but the observation that in the latter the fluid changes its 
 position when the patient is moved, and makes its way 
 to whatever is the most dependent part for the time being, 
 will usually make the condition clear, and careful examina- 
 tion on the same lines will also differentiate cystic tumours, 
 an enlarged uterus, and a dilated bladder. 
 
 INDICATIONS FOR OPERATION. 
 
 Operative treatment for ascites, with the exception of 
 Talma's operation, which is discussed in the section on 
 cirrhosis of the liver, is confined to puncture with the 
 trocar or permanent drainage through cannulae. Withdrawal 
 of the fluid is justified under the following circumstances : 
 (i) When the fluid is present in such amount that asphyxia 
 is threatened ; (2) When a large ascites remains stationary 
 or increases, in spite of medical treatm.ent ; (3) In cardiac 
 and renal disease, when the heart is embarrassed and 
 diuretics fail to relieve ; (4) In pure hepatogenous ascites 
 and in its earlier stages, without waiting for the effect of 
 diuretics. 
 
 Permanent drainage is comparatively rarely necessary ; 
 it is indicated (True) when the fluid rapidly reaccumulates 
 after puncture, and when a fistula becomes established at 
 the point of previous puncture. 
 
 Contra-indications. — It is advisable to avoid puncture, if 
 possible, when some inflammatory affection of the abdominal 
 parietes or other parts of the body is present. Erysipelas 
 of the extremities is not uncommon in general dropsy. A 
 tendency to gastric and intestinal haemorrhages also contra- 
 indicates tapping, as intense distension of the abdominal 
 vessels always follows the proceeding. If the general 
 
300 INDICATIONS FOR OPERATION IN 
 
 condition is very bad, puncture should be repeated as 
 infrequently as possible on account of the loss of albumin. 
 The ascites of young girls does not call for tapping ; it may 
 disappear spontaneously when menstruation begins. 
 
 Prognosis. — Results and risks of abdominal puncture. — In 
 cirrhosis of the liver, permanent relief sometimes follows 
 several tappings if appropriate dietetic treatment is instituted 
 at the same time. Circulatory compensation may follow the 
 relief given by tapping in diseases of the heart and kidneys. 
 In a case of mitral stenosis and incompetence under my care 
 the abdomen was tapped for the relief of intense dyspnoea, 
 and for several years afterwards there was no return of the 
 ascites. Sudden severe collapse may follow tapping if the 
 precaution of moderately compressing the abdomen after- 
 wards is not taken. Even when tapping is done with 
 careful aseptic precautions a non-purulent peritonitis may 
 ensue after it has been done several times. The deep 
 epigastric artery has occasionally been wounded The 
 puncture hole sometimes leaks for several days ; eczema 
 of the surrounding skin and secondary infections occasionally 
 occur. 
 
 Prognosis without puncture. — Although a patient with 
 ascites may live long, the condition remains always a 
 great menace to life if unrelieved ; oedema of the lower 
 extremities supervenes, and the heart becomes embarrassed. 
 Hernia may occur from diastasis of the recti ; occasionally 
 ascitic fluid makes its way to the exterior through the 
 umbilicus ; I have twice seen this occur without untoward 
 result. 
 
 LITERATURE. 
 
 NoTHNAGEL. Erkrankungen des Darmes und Peritoneums. 2nd 
 Ed. Wien, 1903. 
 
 GuMPRECHT. Die Technik der speziellen Therapie. 3rd Ed. 
 Jena, 1903. 
 
 Bargebuhr. Ascytes Chylosus. Deutsches Arch. f. klin. 
 Med., Bd. li. 
 
 Quincke. Ascites. Ibidem. Bd. xxxvi. 
 
 Ilo und Ousi. Zur chirurgischen Behandlung des Ascites. 
 Deutsche Zeit. f. Chir. Bd. Ixii. 
 
 Cheadle. Prognosis and Treatment of Ascites. Brit. Med. 
 Jour. Vol. ii, p. 1102. 1892. 
 
 Thomson. Prognosis and Treatment of Cirrhotic Ascites. Lancet, 
 June 15, 1901 
 
DISEASES OF THE PERITONEUM , 301 
 
 SUBPHRENIC ABSCESS. 
 
 Etiology. — Subphrenic abscess is caused by inflam- 
 matory affections of the abdominal cavity, appendicitis, 
 disease of the genital organs, cholecystitis, hepatic and 
 splenic abscess. Many cases are due to chronic perforation 
 of gastric and intestinal ulcers. In rare cases it occurs in 
 the course of a general septic infection or as a result of 
 trauma. 
 
 Pathological Anatomy. — The abscess may be intra- 
 peritoneal or retroperitoneal ; it may reach large dimensions, 
 and may be loculated. It is often connected by fistulous 
 tracks with other intra- or extraperitoneal purulent collec- 
 tions. The pus may make its way into the pleural cavity, 
 and there set up a subpleural abscess or an empyema, 
 or a pneumothorax. Rupture into the lung and discharge 
 through a bronchus is also fairly common. The pus often 
 has a faecal odour, and the abscess frequently contains air. 
 The condition is often bilateral ; perforation of the dia- 
 phragm may occur at several separate points. Sub- 
 phrenic suppuration secondary to a suppurative process 
 in the thorax is extremely rare. 
 
 Abscesses on the left side are usually connected with 
 the stomach, abscesses on the right with the appendix, the 
 liver, or the duodenum. 
 
 Clinical Course. — The symptomatology of subphrenic 
 abscess is extremely variable. As a rule the temperature 
 is high ; pain may be complained of over the lower ribs, 
 but is often entirely absent. The diaphragm is usually 
 considerably pushed upwards ; the liver and spleen are 
 commonly depressed, the heart dislocated upwards, and to 
 the side. When the abscess is on the right side the liver 
 dullness is often continuous upwards towards the axilla in 
 the form of an arc, declining towards the back, A sign 
 of much importance is oedema of the overlying soft parts, 
 particularly common when the abscess is retroperitoneal. 
 
 Diagnosis. — The condition will always be suspected 
 when relief is not afforded by the local treatment of 
 suppurative foci in the abdomen, especially suppurative 
 appendicitis. When the general symptoms of such affec- 
 tions persist, the physical signs of subphrenic suppuration 
 will be sought for, and if found, in association with marked 
 
302 INDICATIONS FOR OPERATION IN 
 
 leucocytosis, the diagnosis is practically certain. Radio- 
 graphic examination will prove of value. Strong 
 corroboration will be afforded by the presence of cutaneous 
 oedema. 
 
 Air in the abscess will give characteristic physical signs, 
 similar to those of pneumothorax. 
 
 If rupture takes place into the thoracic cavity and 
 symptoms of pneumothorax develop, the diagnosis will be 
 clear. Sometimes a subphrenic abscess is associated with 
 a serous pleural effusion. 
 
 Lately a young man was admitted to hospital under 
 my care with high fever. At the base of the chest behind 
 there was dullness and diminished breath sounds, and on 
 puncture here a sterile serous exudation was removed. 
 As there was some tenderness on pressure and slight resis- 
 tance in the region of the left kidney, I made a diagnosis of 
 perinephritis and probable subphrenic abscess, with secondary 
 serous pleurisy. The resistance became more marked, 
 the fever persisted, and the soft parts in the loin became 
 oedematous. Incision was made here, and more than half 
 a litre of pus was evacuated, the abscess extending upwards 
 into the dome of the diaphragm. The patient recovered. 
 
 In view of such cases, when a subphrenic abscess is 
 suspected, puncture should be made in the lower spaces if 
 serous fluid is first obtained above ; I have several times 
 demonstrated an abscess in this manner. 
 
 It is sometimes very difficult to differentiate between 
 subphrenic pyopneumothorax and an encysted pyopneumo- 
 thorax at the base of the lung ; the history of the earlier 
 symptoms, whether they have been abdominal or pulmonary, 
 must be enquired into. A liver abscess which does not 
 contain gas, and which is situated close under the diaphragm, 
 cannot be distinguished from a subphrenic abscess with 
 certainty, and the two are in fact often associated. 
 
 INDICATIONS FOR OPERATION. 
 
 As soon as the diagnosis is made of a purulent inflamma- 
 tion which may lead on to subphrenic abscess, operation is 
 urgently called for If the patient already presents signs 
 of subphrenic abscess when first seen, it is necessary to 
 freely open the collection at once and drain it. The incision 
 will either be carried through the pleura or will be made 
 
DISEASES OF THE PERITONEUM. 303 
 
 below the costal border, according to the situation of the 
 abscess. 
 
 Since it has become the habit to treat cases of suppurative 
 appendicitis and other abdominal suppurative affections 
 by early operation, subphrenic abscess has become much 
 less common than previously. Its best treatment is 
 prophylactic. 
 
 It must not be forgotten that bilateral abscess is not rare, 
 and that after one side has been opened suppuration may 
 continue to extend on the other side, necessitating a second 
 incision. 
 
 Contra-indications. — Subphrenic abscess is associated with 
 such grave risk to life that operation is only contra-indicated 
 if the patient is actually moribund. Perhaps in an extremely 
 feeble patient it is legitimate to temporize if pus is discharg- 
 ing by the bowel, but the collection usually forms anew and 
 gives rise to dangerous complications again. 
 
 Prognosis. — Results of operation. — Operation is often suc- 
 cessful in saving life in subphrenic abscess ; when there is a 
 pneumothorax, or a fistula between intestine and bronchus, 
 or some other complication involving the thoracic organs, 
 operation usually palliates but does not cure. Other 
 suppurative foci are often associated with the subphrenic 
 collection, and the opening of the latter may be followed 
 by no improvement if others persist. 
 
 In a young girl under my observation appendicitis was 
 followed by a slowly progressive purulent peritonitis. The 
 clinical signs pointed to a right-sided subphrenic abscess, 
 and a second larger collection to the left side of the urinary 
 bladder. The right subphrenic abscess was opened by the 
 surgeon, and another large abscess on the left, apparently 
 not subphrenic. The girl improved, and the temperature 
 fell. On the sixth day there developed intense dyspnoea, 
 and death followed. The autopsy showed that a small 
 subphrenic abscess had ruptured into the left pleura, and 
 that this abscess cavity communicated with the other 
 abscess on the left side, which had been opened, by a fistulous 
 track. 
 
 On the other hand, a subphrenic abscess, even when 
 associated with severe complications, may be successfully 
 dealt with by operation. In a recent case which I saw, a 
 subphrenic abscess, apparently originating from the liver. 
 
304 INDICATIONS FOR OPERATION. 
 
 ruptured into the left pleura, and produced a large empyema ; 
 three ribs were excised, the empyema was drained, and the 
 patient recovered. In general the prognosis depends upon 
 the condition of the patient, the size of the abscess, the 
 nature of the original disease, and the complications present. 
 In 60 cases operated on by Korte 40 recovered, 20 died. 
 Of 75 cases collected by Maydl 35 died (47 per cent). The 
 least favourable cases are those in which the intestine 
 (except the appendix) is the point of origin of the abscess. 
 In addition to the danger of collapse, there is a risk of 
 infecting the general peritoneal cavity if adhesions are 
 torn during operation. 
 
 Without operation. — In rare cases spontaneous recovery 
 has followed after rupture of the abscess into the bowel, 
 the exterior, a bronchus, or the stomach. Thoracic complica- 
 tions are the cause of fatality in many cases ; in others 
 general pyaemia is the cause of death. 
 
 LITERATURE. 
 
 NoTHNAGEL. Erkrankungen des Darmes und des Peritoncums. 
 2nd Ed. Wien, 1903. 
 
 Maydl. Subphrenische Abscesse. Wien, 1894. 
 
 Umber. Pyopneumothorax Subphrenicus. Mitteil. a. d. Grenz- 
 gebiete d. Med. u. Chir. Bd. vi. 
 
 Mason. Cases of Subdiaphragmatic Abscess. Boston Medical 
 and Surgical Journal, Vol. cxxi, pp. 149 and 469. 
 
 Meltzer. On Subphrenic Abscess. New York Med. Jour., 
 June 24, 1893. 
 
 Sachs. Der Subphrenische Abscess. Archiv fiir Klinische 
 Chirurgie. Bd. 1. 
 
 V. Leyden und Renvers. Ueber Pyopneumothorax Sub- 
 phrenicus und dessen Behandlung. Berl. klin. Wochens., No. 46 
 (mit Diskussion), 1892. 
 
 WiNKELMANN. Zur Kasulstik der operativ Behandelten sub- 
 phrenischen Abscesse. Deut. med. Wochens., 29 Jahrgang, No. 7. 
 
 MuscHER. Pneumothorax Sousphrenique. Gazette Medicale de 
 Paris, p. 529, 1895. 
 
 Lejars. Le Suppurations de la Zone Sousphrenique. La 
 Semaine Medicale, No. 13, 1Q02. 
 
CHAPTER XVIII. 
 Diseases of the Gall-Bladder and Bile-Ducts. 
 
307 
 
 Chapter XVIII. 
 
 DISEASES OF THE GALL-BLADDER AND 
 BILE-DUCTS. 
 
 CHOLELITHIASIS (GALL-STONES). 
 
 Etiology. — The formation of gall-stones is favoured by 
 stasis of the bile ; micro-organisms, and particularly the 
 Bacillus coli, play a part in their production, and probably 
 reach the gall-bladder from the intestine. The affection is 
 more common in women than in men ; it is rare in childhood, 
 and becomes steadily more frequent as advanced age is 
 approached. Tight clothes, particularly corsets and belts, 
 appear to play some part in etiology ; also pregnancy, a 
 sedentary life, and the feebleness of abdominal muscles 
 found in old age. Another apparent causative factor is the 
 uric acid diathesis, and many authors have credited heredity, 
 atheroma, and incontinent habits of life with a similar 
 influence. In rare instances foreign bodies have reached 
 the biliary channels and have caused gall-stone formation. 
 Attacks of colic may be set up by injury, and possibly also 
 by emotional influences. 
 
 Pathological Anatomy. — Gall-stones are formed in the 
 gall-bladder and are most often found there, but also in the 
 cystic and common bile-ducts ; stones of secondary forma- 
 tion are not uncommonly found in the intrahepatic bile- 
 ducts. Usually the stones are multiple and faceted, but 
 it is not unusual to find a single stone ; this may reach the 
 size of a walnut, and it is usually rough on the surface. 
 When a single calculus is lodged in the neck of the bladder 
 it often attains large dimensions ; when a stone is thus 
 lodged other stones often form within the bladder, but only 
 rarely forwards in the cystic duct. Stones appear to form 
 in batches ; the gall-bladder itself may meanwhile be little 
 
3o8 INDICATIONS FOR OPERATION IN 
 
 changed, but when an " attack " occurs there is inflammatory 
 sweUing of the mucous membrane, with effusion of serous or 
 purulent fluid. Inflammation of the gall-bladder may be 
 serous, seropurulent, purulent, septic, or diphtheritic ; it 
 often spreads to surrounding parts, and adhesions form 
 which interfere with the flow of bile, particularly by causing 
 kinking of the cystic duct. In recent inflammation the 
 gall-bladder is distended, often cucumber-shaped, and the 
 walls are thinned ; repeated attacks lead to cicatricial 
 shrinking. After the passage of calculi the cystic duct may 
 remain enormously dilated, or may be constricted and even 
 obliterated by the cicatrization of ulceration ; ulceration 
 may lead to the formation of a choledocho duodenal fistula. 
 
 The gall-bladder may entirely get rid of its stones by the 
 ducts into the intestine, and the affection be spontaneously 
 cured. Not uncommonly chronic perforation of the bladder, 
 more rarely of the cystic duct, takes place, with the formation 
 of an intestinal fistula ; occasionally a fistula is connected 
 with other organs ; acute rupture into the peritoneal cavity 
 is rare. 
 
 If a stone remains a long time in the neck of the gall- 
 bladder an inflammatory hydrops occurs, or, in case of 
 infection, an empyema. In 183 cases of stone in the 
 bladder neck and cystic duct, operated on by Riedel, there 
 was bile in the bladder in 27, and serous or purulent fluid 
 in 156. When a stone is lodged in the common duct, 
 inflammatory affections of the surrounding structures are 
 not uncommon ; in particular, chronic pancreatitis and 
 thrombosis of the portal vein ; the bile-ducts above may 
 also be infected, leading to an infective cholangitis and liver 
 abscess. In purulent cholangitis inflammatory changes are 
 often found in distant organs : the kidney, the endocardium, 
 and the lung (abscess). In old-standing cases of chole- 
 lithiasis, carcinoma of the gall-bladder is often found at 
 autopsy. 
 
 Clinical Course. — In many cases gall-stones cause no 
 symptoms. Often there is only a dull pain, which the 
 patient refers to the stomach. The attacks of colic are 
 characteristic, sometimes mild in type, sometimes agonizing ; 
 their intensity bears no relation to the extent of the affection 
 present ; they are localized in the region of the gall-bladder. 
 In this region also there is tenderness on pressure, and often 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. 309 
 
 a tumour. As a rule, vomiting accompanies the attacks. 
 If the bladder is infected there is fever, often intermittent 
 in type, and frequently there are signs of the spread of 
 the inflammatory process to surrounding parts : meteorism, 
 constipation, and perihepatic friction. Jaundice is absent 
 in most cases of gall-stone colic, but if the stone reaches the 
 common duct it is usually present along with enlargement 
 of the liver ; this, however, is not always the case even with 
 large stones. When a stone is long impacted in the common 
 duct the jaundice is intense, fever is often pronounced, and 
 in late stages there may be hsemorrhages from the mucous 
 membranes. When the common duct is thus blocked, the 
 gastric and intestinal functions are interfered with, and 
 when the condition is prolonged the patient's general state 
 of health suffers very much. 
 
 It is not common for stones to be evacuated through the 
 intestine ; if such a stone is larger than a cherry-stone it 
 will probably have made its way through a fistulous opening 
 into the intestine ; such fistulse may develop early or late 
 in the progress of the disease, and may give rise to no 
 particularly troublesome symptoms. 
 
 The intervals between attacks of colic are variable ; 
 frequently an interval is as long as a year. If during this 
 time the cystic duct is blocked and the inflammatory 
 reaction subsides, a painless distended gall-bladder may 
 persist, but in many such cases the tumour which is present 
 in the early stages subsides and disappears after a few days. 
 Riedel distinguishes between the " unsuccessful " attacks, 
 in which the stone does not pass beyond the cystic duct, 
 and the " successful," in which it reaches the common duct 
 or the intestine. 
 
 Diagnosis. — In a period of quiescence diagnosis may be 
 impossible if there is no exact history, as local signs may be 
 entirely wanting ; but often it is possible to elicit tenderness 
 over the gall-bladder when an attempt is made to press 
 up the liver during inspiration. The history is often 
 characteristic ; if the patient tells a story of attacks of 
 pain in the stomach region, accompanied by vomiting and 
 jaundice, which have been going on for a year or more, the 
 condition is in all probability cholelithiasis. The diagnosis 
 is made clear by the discovery of calculi in the faeces, or by 
 the presence of a painful pyriform tumour in the gall-bladder 
 
3IO INDICATIONS FOR OPERATION IN 
 
 region. Such a tumour may have a characteristic mobihty, 
 pressure with the hand causing it to disappear, to reappear 
 shortly in its former position ; it is often hard, but I have 
 never been able to make out the grating of the calculi on 
 each other so often described by writers. Exploratory 
 puncture is inadvisable, owing to the risk of infecting the 
 peritoneum. Biliary calculi have hardly ever been demon- 
 strated by radiograph. 
 
 General diagnosis is not all that is necessary ; an attempt 
 must be made to diagnose the exact local condition present ; 
 the following points are based on the descriptions of Kehr : — 
 
 Acute obstruction of the common duct is characterized by 
 the appearance of intense jaundice following or during a 
 typical attack of colic associated with vomiting, often with 
 fever, and the radiation of pain to the chest and back. 
 
 In chronic obstruction of the common duct there is often 
 no enlargement of the gall-bladder and liver ; the former 
 is, in fact, often shrunken ; there is intermittent fever. 
 Jaundice and decoloration of faeces vary in degree from 
 time to time ; the patient usually complains of a dull 
 epigastric pain, and the spleen is often enlarged. Cachexia 
 is frequently present and a tendency to haemorrhage from 
 the mucous membranes. 
 
 In acute cholecystitis of a gall-bladder previously more 
 or less normal, a tumour forms ; there is no enlargement 
 of the liver, but a tongue-like process of liver substance 
 (Riedel's lobe) may project downwards in front of the gall- 
 bladder. Jaundice is present in only about lo per cent of 
 cases; when this jaundice is associated with a palpable 
 gall-bladder tumour it is usually, according to Riedel, 
 inflammatory in origin and nature. There is always acute 
 pain and tenderness, sometimes peritoneal friction, and 
 usually fever, with general constitutional disturbance. 
 
 Acute cholecystitis of a shrunken gall-bladder is usually 
 associated with obliteration or constriction of the cystic 
 duct, and the presence of multiple adhesions around the 
 bladder. As a rule, there is no gall-bladder tumour and no 
 jaundice, but there is definite local tenderness to pressure. 
 When there is a collection of pus in the bladder there is 
 usually high fever, and when the affection is of a severe type 
 it will be associated with rigors and pronounced symptoms 
 of septic intoxication. 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. 311 
 
 Empyema of the gall-bladder associated with calculi is 
 characterized by the presence of a tender swelling in the 
 gall-bladder situation, and subjective pain referred chiefly 
 to the same spot. Fever and rigors commonly, but not 
 invariably, occur, and often there are signs of a local 
 peritonitis, with meteorism, vomiting, slight ascites, and 
 perihepatic friction. As a rule, the calculi do not pass into 
 the intestine. 
 
 Acute perforation of the gall-bladder gives rise to sudden 
 excessively severe local pain, with collapse, rapid pulse, and 
 subnormal temperature. The abdominal wall is rigid, and 
 after a time some distension appears and there are signs of 
 free fluid in the peritoneal cavity. 
 
 In a patient of mine, about 30 years of age, the family 
 medical attendant had for several years suspected gall- 
 stones, and several courses of treatment at Carlsbad had 
 been undergone. Finally, the pain becoming much worse, 
 and being associated with fever, he came from Roumania 
 to Vienna. When seen he had had fever for fourteen days, 
 ushered in by a single rigor ; there was a firm, tender 
 swelling in the gall-bladder region, no jaundice, no ascites, 
 no collapse. Immediate operation was advised, but was 
 not agreed to until eight days later, when the general con- 
 dition was worse and the pain intense, though not exactly 
 insupportable. At the operation a perforation of the gall- 
 bladder was found, the resulting peritonitis being localized 
 by adhesions. Both within and outside the gall-bladder 
 there were numerous calculi, small and large, and a quantity 
 of foetid pus. The patient recovered. 
 
 Chronic obstruction of the cystic duct is characterized by 
 hydrops of the gall-bladder forming a cystic tumour ; the 
 most common symptom is an indefinite epigastric pain. 
 There is no enlargement of the liver or jaundice. A 
 " Riedel's lobe " is often present. 
 
 The groups of symptoms which have been mentioned are 
 those which are generally characteristic of the lesions noted, 
 but they must not be looked upon as absolutely diagnostic 
 of these particular lesions. 
 
 In general it should be noted that the presence of a 
 distended gall-bladder in a first attack points to a severe 
 inflammatory condition of the bladder which may be serous 
 or purulent. A distended gall-bladder in a case of chronic 
 
312 INDICATIONS FOR OPERATION IN 
 
 recurrent cholelithiasis usually means a serous exudation 
 if there is no jaundice ; more rarely an empyema. If 
 jaundice is present in such a case it will be of the " infia m- 
 matory " type, and in either case there will be a calculus in 
 the cystic duct or the neck of the bladder. The disappear- 
 ance of a gall-bladder tumour when jaundice persists or 
 increases indicates the passage of the obstructing calculus 
 into the common duct towards the duodenum. Inter- 
 mittent fever with rigors may be associated with calculus 
 in any situation, and points to the occurrence of suppuration. 
 
 Differential Diagnosis.— In an attack of colic the question 
 will arise as to the possibility of its being of renal origin. 
 Renal colic is distinguished by frequency of micturition, 
 scanty urine, rectal tenesmus, radiating pain along the 
 ureter to the glans penis, and tenderness on pressure 
 over the kidney and often along the ureter. 
 
 In appendicitis the situation of the pain and tenderness 
 is lower in the abdomen and more lateral ; dullness on 
 percussion, if present, is in the right iliac fossa, and the 
 enlarged appendix can often be felt. 
 
 In intestinal colic meteorism is often present, and pressure 
 on the abdomen lessens the pain, which passes off with 
 intestinal gurgling ; if there is actual bowel stenosis there 
 will be excessive peristaltic movements. 
 
 A movable kidney will be distinguished by its shape, but 
 a hydronephrotic kidney may resemble the outline of a 
 distended gall-bladder. Such a renal tumour can often be 
 pushed upwards under the liver, and is obscured by distension 
 of the colon and small bowel, whereas a gall-bladder tumour 
 remains prominent under these conditions. In tumours of 
 the stomach and pylorus the diagnosis will be assisted by 
 inflating the stomach, by chemical examination of the 
 stomach contents, by attention to the history, and by the 
 presence of exaggerated stomach peristalsis. Hydatid cysts 
 of the liver can usually be distinguished by the history of a 
 slow-growing, painless tumour, associated with a relatively 
 good general condition and the probability of echinococcus 
 infection. 
 
 Tumours of the omentum when displaced with the hand 
 do not usually return to the same spot in the way that is 
 characteristic of gall-bladder tumours. 
 
 Carcinoma of the gall-bladder and liver is distinguished 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. SU 
 
 from cholangitis by the intense hardness of the tumour 
 present in the gall-bladder region and by the onset of ascites. 
 Sometimes hysterical gastralgia may be simulated by gall- 
 stone colic, with obstruction of the cystic duct, as in a case 
 under my care, in which the pains due to calculus were for 
 several years ascribed to the former condition, 
 
 INDICATIONS FOR OPERATION. 
 
 There is a considerable amount of disagreement as to the 
 indications for operation in cases of gall-stone disease. 
 There are many who disagree with Winiwater's view, that 
 the presence of gall-stones constitutes in itself a sufficient 
 indication for operation, and, in view of the many cases in 
 which calculi cause no symptoms, this opinion is certainly 
 extreme ; Korte's opinion is that the necessity for operation 
 should be judged from the type and degree of inflammatory 
 disturbance caused by calculi, either periodically or 
 persistently. 
 
 Riedel advocates early operation ; he considers that an 
 attack of colic calls for operative interference if no small 
 stones are evacuated, either during or immediately after 
 the attack ; but as many patients have only a single attack, 
 and without getting rid of calculi have no further troubles of 
 the kind, in the opinion of many physicians, including myself, 
 such a single attack is not a sufficient indication. Signs of 
 infection may follow operation in cases which had been free 
 from any such signs before. Riedel's statement that nine- 
 tenths of cases of gall-stones require operation, requires 
 more evidence to support it than has yet been advanced. 
 Kehr holds that there is an absolute indication for operation 
 under the following conditions : (i) In acute purulent 
 cholecystitis and in chronic obstruction of the cystic duct, 
 internal treatment being useless in either case ; (2) In 
 persistent colic, or continuous pain, when internal treatment 
 gives no relief, particularly when it renders the patient unfit 
 for work, or if the patient has developed morphine hunger 
 and himself desires operation ; (3) When a firm gall-bladder 
 tumour gives rise to a suspicion of carcinoma, and when 
 there are signs of perforation or suppuration in the surround- 
 ing parts. 
 
 The first of these indications is incontestable ; and opera- 
 tion is called for also in the cases of " quiet " common duct 
 
314 INDICATIONS FOR OPERATION IN 
 
 obstruction, characterized by chronic jaundice without 
 fever, loss of flesh, and absence of bile from the stools 
 following an attack of colic ; and equally in common duct 
 obstruction complicated by infection. When suppuration 
 is suspected, a rapidly increasing leucocytosis indicates early 
 operation, and this is specially important in relation to the 
 chronic apjTexic empyema of the gall-bladder. Kehr's 
 second indication is of special importance in dealing with 
 the w^orking classes, and wdth patients on whom the affection 
 has a specially marked effect, physically or morally. In 
 such cases it may be necessary to operate even when the 
 diagnosis is not very clear. Operation must always be 
 advised in these patients w'hen, in addition to pain, there 
 are signs of gastric stasis from obstruction at the pylorus, a 
 state of affairs which wdll increase in severity if left alone. 
 Regarding the third class, Kehr himself is somewhat 
 doubtful as to the indications to be based on a probably 
 cancerous tumour ; by the time such a tumour is discovered 
 the time for successful removal has, as a rule, passed. 
 
 With regard to the time for operation in persistent 
 jaundice, Ewald's opinion should be borne in mind, that 
 operation should never be delayed more than a month ; if 
 it is put off longer the prospect of healing becomes bad, 
 there is risk from hgemorrhage, sutures tear through, and 
 adhesions do not form. 
 
 Operative Methods. — When the wall of the gall-bladder 
 is sound, cystostomy is performed either in one or, less 
 commonly, in two stages, and the calculi are removed from 
 the bladder and the cystic duct. When a stone is in the 
 cystic duct the duct itself has often to be incised. Cyst- 
 ectomy is a more dangerous procedure ; it is necessary when 
 the gall-bladder is shrunken, brittle, or fistulous, whether 
 there are calculi within it or not, and when the cystic duct 
 is obliterated, or has been long obstructed by a stone. 
 Cholecystenterostomy is sometimes called for in cases of 
 chronic obstruction of the common duct when the duct is 
 inaccessible. Suppuration around the gall-bladder may be 
 dealt wdth in one or two stages, the pus being first evacuated, 
 and the gall-bladder itself being opened later. In chronic 
 obstruction of the common duct choledochotomy, with 
 drainage of the hepatic duct, is called for ; this is the 
 most difficult of the operations on the bile-ducts. In 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. 315 
 
 almost all operations on the bladder and ducts drainage 
 is necessary. 
 
 Contra-indications. — When the condition causes little 
 pain, and attacks of colic are infrequent, no operation is 
 necessary. In frequent slight attacks, associated with 
 jaundice, and the successive passage of several small stones, 
 it is well to temporize, particularly if the patient is free from 
 pain between attacks. The presence of ascites contra- 
 indicates operation for gall-stone disease, as also diabetes, 
 extreme obesity, advanced arteriosclerosis, and cardiac or 
 serious pulmonary disease. Advanced age is not an absolute 
 contra-indication. Acute obstruction of the common duct 
 (see under diagnosis) may terminate after several weeks in 
 recovery, and, therefore, one should wait in such cases. 
 Intense jaundice of some months' duration, with or without 
 haemorrhage from mucous membranes, contra-indicates 
 operation on account of the great risks of serious parenchy- 
 matous hcemorrhage, particularly in old people. Advanced 
 cancer of the biliary passages forbids operation ; several 
 cases of my own, with only moderate infiltration of the liver 
 around, have died the day after operation. 
 
 Risks of operation. — The mortality varies much according 
 to what operation is necessary. Kehr's mortality in 720 
 cases is 15-5 per cent. The least dangerous are the con- 
 servative operations : cystostomy, cysticotomy, cystendysis, 
 with 2 per cent, then extirpation of the gall-bladder, with 
 3 per cent. Choledochotomy was attended by a 6-5 per 
 cent mortality in 137 cases. Among cases in which 
 operations had to be done at the same time on other organs 
 (stomach, intestine, pancreas, etc.), or in which there was 
 some serious complication, the proportion of deaths was 
 very high : ninety-three in 191 operations. Mortality is 
 specially high when carcinoma or diffuse cholangitis 
 complicates the disease. 
 
 In many cases an exact diagnosis is impossible, and one 
 is often unable to foretell the risk of operation because, 
 until the abdomen is opened, it is not certain what particular 
 operative procedure will have to be undertaken. 
 
 Sometimes biliary fistulae persist for a long time, but 
 they almost always heal eventually. Operation has 
 sometimes to be repeated for stones left behind, or for 
 adhesions, causing kinking of the cystic duct, and profuse 
 
3i6 INDICATIONS FOR OPERATION IN 
 
 mucous secretion. Recurrent haemorrhage may call for a 
 second operation, and sometimes torsion of the pylorus 
 and duodenum makes it necessary to reopen the wound. 
 Ventral hernia is common. 
 
 When choledochotomy with hepatic duct drainage is 
 the operation done, Kehr mentions three comparatively 
 common complications : (a) pneumonia in 8 per cent of 
 cases ; (6) acute dilatation of the stomach, with vomiting, 
 and sometimes diarrhoea (lesions of the mesenteric arteries), 
 (c) haemorrhage into the stomach and intestine, and 
 hsematemesis, which can sometimes be checked by washing 
 out the stomach and other treatment. 
 
 Prognosis. — Results of operation. — In very many cases 
 opening the gall-bladder and removal of the stones result 
 in complete and permanent recovery. Even after long- 
 continued high fever from a severe infection of the biliary 
 passages, complete restoration to health may follow opera- 
 tion. In one such case under my care high fever had 
 been present for some weeks, and severe septic absorption ; 
 pus was found in the gall-bladder and came freely from 
 the cystic duct ; the patient recovered completely (of course 
 after a long illness), after the removal of a large number 
 of calculi from the gall-bladder, and the spontaneous 
 discharge of others. Still better are the results of total 
 extirpation of the gall-bladder and drainage of the common 
 duct. When this operation is done it is rare for stones to 
 be overlooked and cause subsequent trouble. 
 
 The possibility of a true re-formation of calculi after 
 operation is admitted by all authors, but such an event is 
 rare. Stones left behind will, of course, cause trouble 
 later. Sometimes they form round silk sutures left in the 
 bladder. Almost always recurrence of symptoms is due to 
 stones overlooked, and although this happens from time to 
 time, it is of no importance as an argument against surgical 
 treatment when the indications are clear ; defective tech- 
 nique, or the difficulties of the operation, are responsible 
 for the accident ; it is well to bear in mind the possibility 
 of its occurrence when stating the prospects of the operation 
 to the patient. Other troublesome eventualities may 
 follow operation, in particular, the development of adhesions, 
 which, as in one of my cases, may make the last state of the 
 patient worse than the first. In many of my cases operation 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. 3U 
 
 has given perfect results ; occasionally stones overlooked 
 have necessitated a second operation, but all such cases 
 have recovered. 
 
 Without operation. — In most cases gall-stones do not 
 lead to any condition threatening life, and in this respect 
 the prognosis is relatively good. It is necessary to insist 
 on this fact, because several authors have written of the 
 condition as if it usually produced serious lesions, and have 
 expressed in consequence much too comprehensive a view 
 of the necessity for operation. According to my own 
 experience, and that of several other clinicians, expectant 
 treatment gives a very low mortality : about 4 to 5 per cent. 
 Other writers, on the basis usually of a relatively small 
 material, take a more serious view, thus Binder in 96 cases, 
 52 of which were kept under observation for a long time, 
 recorded eleven deaths. The most serious complications 
 and eventualities have been noted above. Carcinoma of the 
 gall-bladder is one of the possible results of gall-stone disease 
 not operated on. Unfortunately this occurs just in those 
 cases in which the calculi have given rise to no symptoms. 
 
 The onset of complications (suppuration, long-continued 
 jaundice, peritonitis, and perforation) increases the gravity 
 of the prognosis. Although the affection rarely ends in 
 recovery without operation, there is no doubt that, in many 
 cases, except those presenting urgent symptoms, the regu- 
 lation of diet, and treatment with mineral waters, is able to 
 produce a latency of symptoms satisfactory to the patient 
 and his medical attendant. 
 
 LITERATURE. 
 
 Kehr. Cholelithiasis. Handbuch der prakt. Chir. v. Bergmann, 
 Mikulicz, u. Bruns. 2nd Ed. Bd. iii. 
 
 KoRTE. Indikat. z. chir. Behandlung der Cholelithiasis u. Chole- 
 cystitis. Deut. med. Wochens., 1903, No. 15. 
 
 Fink. Erfolge der Karlsbader Kur u. d. Chir. Behandlung d. 
 Gallensteinleidens. 1903. 
 
 RiEDEL. Die Pathogenese, Diagnose, u. Behandlung d. Gallen- 
 steinleidens. G. Fischer. 1903. 
 
 Langenbuch. Chirurgie der Leber u. d. Gallenblase. Deut. 
 Chir., Stuttgart, 1898. 
 
 Naunyn. Klinik der Cholelithiasis. Leipzig. 1892. 
 
 Quincke u. Hoppe-Seyler. Krankheiten der Leber. Noth- 
 nagel's Handbuch d. spez. Pathol, u. Therap., Wien, 1899. 
 
 Lejars. Contribution a I'Etude des Indications de la Chole- 
 cystotomie. Rev. de Chir., 1896, No. 9. 
 
3i8 INDICATIONS FOR OPERATION IN 
 
 Naunyn. Ueber die Vorgange bei der Cholelithiasis, welche 
 die Indikat. z. Operat. entschieden. Mitteil. a. d. Grenzgebiete d. 
 Med. u. Chir. Bd. iv. 
 
 Herrmann. Beitrage zur Frage : 1st die Cholelithiasis intern 
 Oder chirurgisch zu behandlung ? Ibidem. 
 
 LoBKER. Ibidem. 
 
 Merk. Beitr. z. Path. u. Chir. der Gallensteine. Ibidem. Bd. ix. 
 
 Petersen. Gallensteinkrankheit. Bruns'. Beitr. Bd. xxiii. H. 3. 
 
 Jeannel. Contribution au Traitement Chirurgicale de la Lithiase 
 Biliaire. Arch. Prov. d. Chir., 1896, No. 9. 
 
 Vautrin. De FObstruction Calculaire du Choledoch. Rev. de 
 Chir., T. xvi., p. 446. 
 
 Mayo. Some Observations on the Surgery of the Gail-Bladder. 
 Annals of Surgery, Oct. 1899. 
 
 Richardson. The Indications for Extirpation of the Gall-Bladder. 
 Med. News, May, 1903. 
 
 Murphy. The Diagnosis of Gail-Stones. Ibidem. 
 
 Mayo. Operations on the Gall-Bladder and Ducts. Boston 
 Med. and Surg. Jour., May 21, 1903. 
 
 F. A. Berg. The Indications for the Surgical Treatment of 
 Cholelithiasis. Med. Record, No. 18, 1902. 
 
 MiLHiET. De la Cholecystectomie dans la Lithiase Biliaire. 
 These de Paris. 1902. 
 
 Terrier et Auvray. Chir. du Foie et des Voies Biliaires. Paris, 
 1 901. Felix Alcan. 
 
 Pauchet. Chirurgie des Voies Biliaires. Paris, 1900. Bailliere 
 et Fils. 
 
 MoYNiHAN. Gall-Stones and their Surgical Treatment. 1905. 
 
 CHOLELITHIASIS (ASSOCIATED CONDITIONS). 
 
 (A.) HYDROPS OF THE GALL-BLADDER. 
 
 Etiology. — This condition is .caused by obstruction of 
 the cystic duct by stone, scar, or kinking. Often also it is 
 present as a comphcation when a mahgnant tumour involves 
 and compresses the cystic or common duct. 
 
 Pathological Anatomy. — The gall-bladder is often 
 enormously dilated, and the wall much thinned in parts ; 
 it is filled with a colourless ropy fluid. 
 
 Clinical Course. — Hydrops of the gall-bladder is only a 
 complication of other morbid processes. A spherical or 
 pyriform swelling presents below the lower border of the 
 liver, it moves with respiration, and often can be displaced 
 with the hand, but returns to its original situation. It is 
 not tender to pressure, in consistence it is elastic, but 
 fluctuation cannot, as a rule, be made out. When the 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. 319 
 
 primary cause is a malignant growth, ascites and jaundice 
 may be present. When the gall-bladder is enormously 
 distended it is liable to be confused with other cystic 
 abdominal tumours. Ovarian cysts are distinguished by 
 their pelvic origin and attachments ; a hydronephrotic 
 kidney comes forward from the loin, and is liable to sudden 
 variations in size. A pedunculated hydatid cyst of the 
 liver is difficult to distinguish from a distended gall-bladder 
 except by its slow growth. A movable kidney presents the 
 characteristic renal outline, and can be replaced in the loin. 
 I am aware of a case of distended and very movable gall- 
 bladder which was mistaken by several observers for a 
 hydronephrotic and mobile kidney, the true nature of the 
 condition being only discovered at operation. 
 
 INDICATIONS FOR OPERATION. 
 
 A distended gall-bladder which is not due to inflammatory 
 causes only calls for operation when the distension develops 
 rapidly and threatens rupture, or when it interferes by 
 pressure with the functions of neighbouring organs, and 
 causes serious symptoms, such as repeated vomiting, a 
 troublesome sense of fullness, and intestinal disturbance. 
 When operation is necessary the abdomen is opened, and 
 a fistula is established ; puncture without opening the 
 abdomen is unjustifiable, on account of the risks of leakage. 
 
 Contra-indications. — When the condition which causes the 
 distension is irremediable by operation (new growth about 
 the hilum of the liver), and when the distension itself is not 
 extreme, no operation should be done. Extreme age, 
 arteriosclerosis, old-standing jaundice, with haemorrhage 
 from the mucous membranes, constitute contra-indications. 
 
 // no operation is undertaken, and the distension increases 
 rapidly, the gall-bladder may rupture and fatal peritonitis 
 follow ; but this accident is rare. As a rule, the condition 
 is of small importance compared with the primary affection 
 which causes it. 
 
 LITERATURE. 
 
 Martin. Diagnostik der Bauchgeschwiilste. Deut. Chir. Stutt- 
 gart: F. Enke, 1903. 
 
 Machard. Des Dilatations et Ruptures Spontanees de la 
 Vesicule Biliaire. Arch. Gener. des Med., 1900. 
 
 See also Quincke, Langcnbuch, Terrier ct Auvray, above. 
 
320 INDICATIONS FOR OPERATION IN 
 
 (B.) CHOLECYSTITIS : 
 EMPYEMA OF THE GALL-BLADDER. 
 
 Etiology. — Inflammation of the gall-bladder is caused 
 by the invasion of micro-organisms. It is often consecutive 
 to some general infective disease, particularly enteric fever, 
 pneumonia, dysentery, and pyaemia. Other common causes 
 are calculi, foreign bodies (intestinal worms), and any 
 condition which causes constriction of the bile-ducts. 
 
 Pathological Anatomy. — -Cholecystitis is usually associ- 
 ated with cholangitis. When the condition is recent, the 
 gall-bladder is usually dilated ; when it is of old standing 
 the bladder is often shrunken. The bladder contains either 
 a mixture of bile and mucus, or pus. When the wall 
 ulcerates, perforation not uncommonly follows ; usually in 
 such cases there are adhesions around, and perforation 
 occurs into a preformed localized cavity ; under such 
 circumstances a vesico-intestinal fistula may be established 
 later. 
 
 Clinical Course. — Tenderness on pressure and enlarge- 
 ment of the gall-bladder are the cardinal symptoms of 
 cholecystitis. There is also subjective pain ; the tenderness 
 is particularly noted when pressure is made over the gall- 
 bladder on deep inspiration. The distended gall-bladder 
 is often distinctly pyriform in shape, but adhesions to the 
 omentum may render its outline quite indistinct ; often it 
 may be made out to move with respiration, but not always. 
 There is frequently either continuous or remittent fever, 
 and sometimes it is definitely intermittent. When the 
 cholecystitis is of a severe type, vomiting, meteorism, and 
 temporary intestinal paresis are often present, and there is 
 much general disturbance. When jaundice supervenes it 
 is evidence of cholangitis, and its intensity will vary with 
 the extent of the latter. 
 
 Diagnosis and Differential Diagnosis. — If the cardinal 
 symptoms are present, if there is a history pointing to 
 cholelithiasis, or if the symptoms develop in the course of 
 an attack of typhoid fever, the diagnosis presents no 
 difficulties. 
 
 Perforation may often be recognized by a sudden aggrava- 
 tion of pain, accompanied by vomiting, increased pulse-rate, 
 low temperature, and collapse. In most cases the abdominal 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. 321 
 
 walls are intensely rigid, and palpation impossible. Free 
 fluid in the peritoneal cavity can often be made out a few 
 hours after perforation. 
 
 The condition is to be distinguished from appendicitis, in 
 which the local signs are prominent in the right iliac fossa, 
 and there is an absence of history pointing to gall-stones ; 
 from renal colic, in which there is tenesmus, blood in the 
 urine and oliguria; from chronic perforation of gastric ulcer 
 by an absence of any history of hsematemesis, and by the 
 immobility of any tumour that is present ; and from 
 intestinal tumour and faecal obstruction by the history, 
 the absence of any marked tenderness on pressure, 
 and the presence of exaggerated peristalsis in these 
 conditions. 
 
 INDICATIONS FOR OPERATION. 
 
 The gall-bladder must always be opened whenever there 
 are signs of the presence of pus. Operation is especially 
 urgent when the gall-bladder rapidly distends and is very 
 tender to pressure, when there are fever, rigors, and marked 
 leucocytosis, and especially if such a condition occurs after 
 typhoid, because perforation is particularly liable to occur 
 in typhoid infections. Operation must, of course, be done 
 at once when there is reason to believe that perforation has 
 occurred. When the physical signs point to non-purulent 
 cholecystitis associated with cholelithiasis, the indications 
 for surgical intervention follow the same rules as those 
 already given for gall-stone disease. 
 
 Contra-indications. — -The rules for operation in cases of 
 acute perforation are those which are followed in all cases 
 of perforation of hollow viscera ; when the patient is in 
 extremis from diffuse peritonitis, operation will only hasten 
 death from shock. Opening of the gall-bladder is contra- 
 indicated when the cholecystitis is only part of a general 
 pyaemic infection, or if it is due to carcinoma involving the 
 bile-ducts. 
 
 Unless operation is required to save life, as in acute 
 perforation, it will not be recommended to patients the 
 subjects of diabetes, arteriosclerosis, and other serious 
 organic disease. 
 
 Prognosis. — Risks and results of operation. — In most 
 cases operation results in complete recovery. Death occurs 
 
322 INDICATIONS FOR OPERATION IN 
 
 in some cases from shock, in others it is due to concurrent 
 disease. Only rarely is there any trouble from persistent 
 biliary fistula. 
 
 A case under my care was that of a young woman about 
 twenty years of age. Agonizing pain in the region of the 
 gall-bladder supervened after several days of fever with 
 rigors, and I felt in this situation an ill-defined swelling. 
 The temperature was high, the pulse rapid, there was 
 jaundice and a coated tongue, and free fluid was present in 
 the peritoneal cavity. The diagnosis was cholecystitis and 
 perforation. At the operation there was found to be 
 tubercular peritonitis, with adhesions between the omentum 
 and liver. The patient died next day, and behind the 
 adherent omentum a perforated empyema of the gall- 
 bladder was found. 
 
 // no operation is undertaken, there is risk of general 
 peritonitis, either by propagation, by contiguity, or through 
 the medium of a perforation. Empyema may end in 
 septicsemia. When the inflammatory process extends 
 outside the gall-bladder to neighbouring structures, dense 
 adhesions tend to form, and sometimes there are established 
 flstulse between the gall-bladder and the intestine, or the 
 exterior. 
 
 LITERATURE. 
 
 QuiNXKE. Erkrankungen der Leber u. Gallenblase. Nothnagel's 
 Handbuch d. spez. Path. Bd. xviii. 1899. 
 
 DuNGERN. Cholecystitis Typhosa. Miinch. med. Wochens., No. 
 26, 1897. 
 
 Hawkins. On Jaundice and on Perforation of the Gall-Bladder 
 in Typhoid Fever. ]\Iedico-Chir. Transactions. Bd. Ixxx. 1897. 
 
 Langenbuch. Chirurgie der Leber u. Gallenblase, 2nd Part, 1 897. 
 
 Pruszynski. Pathogenese der Erkrankungen der Gallenwege. 
 Wien. klin. Wochens., No. 11, 1904. 
 
 W. Thompson. Cholelithiasis, Cholecystitis. New York JNIed. 
 Journ., April 19, 1892. 
 
 Terrier et Auvray. Chir. d. Foie. Paris, 1901. 
 
 (C.) INTESTINAL^OBSTRUCTION BY GALL-STONE. 
 
 Pathological Anatomy. — Gall - stones which cause 
 obstruction find their way into the intestine through fistulae, 
 usually into the duodenum (28 in 30 cases examined post 
 mortem), rarely into the colon. The stone usually becomes 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. .^23 
 
 impacted in the region of the ileocaecal valve, next in 
 frequency in the duodenum and jejunum. Obstruction 
 occurs the more easily if there is already some narrowing of 
 the intestine due to other causes ; sometimes there are signs 
 of a local peritonitis at the seat of impaction ; in other cases 
 a local spasmodic contraction of the gut appears to have 
 determined the seat of the obstruction. 
 
 Clinical Course. — As a rule, the attack of obstruction is 
 immediately associated with a previous attack of biliary 
 colic. Often there is a typical history of cholelithiasis, and 
 signs also of definite localized peritonitis around the gall- 
 bladder preceding the appearance of the symptoms of 
 obstruction. When the seat of impaction is in the upper 
 part of the digestive tract, stomach symptoms predominate : 
 frequent bilious vomiting, rapid development of gastric dila- 
 tation, marked wasting, absence of meteorism, but, as a rule, 
 obstruction to faeces and flatus, with a retracted abdomen. 
 When the seat of obstruction is lower, pain is the first symp- 
 tom, tenderness to pressure is only slight, and develops later, 
 vomiting occurs early and soon becomes fsecal, complete 
 obstruction is soon established, but, according to Naunyn, 
 sometimes flatus fcan pass. Sometimes the calculus is 
 palpable, and the patient, or his medical attendant, may be 
 able to make out its onward passage. If the calculus is 
 arrested in the large bowel there is gaseous distension in 
 the flanks, vomiting and collapse are delayed, and the 
 phenomena of intestinal obstruction are often remarkably 
 intermittent. If peritonitis supervenes the pulse-rate rises, 
 pyrexia appears, the tongue becomes coated, meteorism 
 becomes extreme, and there are signs of free fluid in the 
 peritoneal cavity. 
 
 The Diagnosis is clear when obstruction occurs in a 
 patient known to have gall-stones, and immediately following 
 a definite attack of colic. If the seat of obstruction is in 
 the small intestine, the stone may sometimes be palpated, and 
 its arrest at the ileocaecal junction be made out. Of special 
 significance in diagnosis is the presence of obstruction of 
 an intermittent type, and the passage of flatus while the 
 fiecal obstruction is complete and the vomited matter is 
 f cecal. At the end of an attack the calculus may be found 
 in the rectum. 
 
324 INDICATIONS FOR OPERATION IN 
 
 INDICATIONS FOR OPERATION. 
 
 Naunyn considers that operation may generally be 
 avoided in view of the relatively slight degree of obstruction 
 symptoms and the fluctuating course of the condition. It 
 is specially necessary to operate when the stone is lodged 
 in the neighbourhood of the ileocaecal valve. Other 
 writers, particularly surgeons, hold different view^s. 
 
 Considering the difficulties in diagnosis, and the possi- 
 bilities of mistake, it is well to follow the course of treatment 
 recommended by Korte. He advises first the administra- 
 tion of opium, with stomach lavage and enemata ; if at the 
 end of a period not longer than forty-eight hours the vomiting 
 has not stopped, and the abdominal pain and distension 
 persist, then operation should be 'proceeded with. The 
 abdomen is opened, and the intestine is incised ; occasionally 
 this may be done under local anaesthesia. 
 
 Contra-indications. — If peritonitis is established, and the 
 patient's strength already much exhausted, it will usually 
 be wise to abstain from operation. As above stated, it is 
 well in most cases to allow a period of forty-eight hours to 
 elapse before operation, when there are sufficient grounds 
 for believing that the obstruction is due to a gall-stone. 
 
 Prognosis. — Dangers and results of operation. If only 
 the worst cases are operated on, the mortality is very high ; 
 but, since 1891, earlier operations have been generally 
 undertaken. In 34 cases operated on between 1891 and 
 '1900 recovery followed in more than 50 per cent. The 
 percentage of recoveries in the operated and not-operated 
 cases cannot be compared, because it is the slight cases 
 that are treated by expectant methods, and those which 
 are operated on would probably have gone to swell the 
 fatalities without it. 
 
 The causes of death are exhaustion and peritonitis, 
 occurring most frequently when operation is done at a late 
 stage. 
 
 Without operation. — Schiiller gives 44 per cent recoveries 
 in 150 cases ; Courvoisier, 56 per cent in 125 cases ; 
 Kirmisson and A. Borchard record a 70 per cent mortality 
 in 105 cases. In cases where the stone is passed death 
 may foUow from intestinal ulceration and diarrhoea, or 
 perforation ; the consequences of ulceration may give 
 rise to troublesome symptoms. 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. 325 
 
 LITERATURE. 
 
 HcNiGMANN. Ueber Gallenstein-Ileus. Centralb. f. d. Grenzge- 
 biete d. Med. u. Chir. 1900. 
 
 Garin. Contribution a I'Etude des Complications de la Lithiase 
 Biliaire (Occlusion Intestinale). These de Paris. 1897. 
 
 KiRMissoN et BoRCHARD. De rOcclusion Intestinale par 
 Calculs Biliaires. Arch. Gener. de Med., 1892. 
 
 KoRTE. Ueber den Darmverschluss durch Gallensteine. Arch. 
 f. klin. Chir. Bd. xlvi. p. 321 ; and Deut. med. Wochens. 1894. 
 p. 171. 
 
 Naunyn. Ileus. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. 
 Bd. i. 
 
 Rehn. Gallenstein-Ileus. Arch. f. klin. Chir., Ix. 
 
 Bradbury. Two Cases of Obstruction of the Small Intestine by 
 Gail-Stones. Brit. Med. Jour., 1897, p. 796. 
 
 NoTHNAGEL. Erkrankungcn des Darmes. Obturation durch 
 Gallensteine. 2nd Ed., p. 375. 1903. 
 
 CARCINOMA OF THE GALL-BLADDER. 
 
 Etiology. — Carcinoma of the gall-bladder is often 
 associated with the presence of gall-stones in individuals 
 above the age of forty. 
 
 Pathological Anatomy. — Carcinoma may develop in 
 any part of the gall-bladder, and tends to extend early to 
 the liver either as a diffuse infiltration or in the form of 
 secondary circumscribed nodules. The cystic duct becomes 
 involved as the disease advances. Lymphatic glands in 
 the portal fissure are often involved early and encroach on 
 the common and hepatic ducts. The growth is usually of 
 the " scirrhous " type. 
 
 Clinical Course. — In many cases the disease in its early 
 stages gives rise to no symptoms, the latter making their 
 appearance first when the liver is involved. Localized 
 subjective pain is an early sign, and associated with it a 
 tender, firm gall-bladder tumour niay be made out ; hydrops 
 of the gall-bladder is not uncommon. In the earlier stages 
 at any rate the tumour moves with respiration. Jaundice 
 and emaciation make their appearance later and become 
 gradually more marked. The observations of many 
 writers, which my own confirm, go to show that the progress 
 of the disease is usually extremely rapid, and from the 
 appearance of the first symptoms lasts only from a few 
 weeks to a few months. 
 
326 INDICATIONS FOR OPERATION IN 
 
 Diagnosis. — ^When there is present in the region of the 
 gall-bladder a hard nodular tumour which has the general 
 configuration of the gall-bladder and moves with respiration, 
 there can be little doubt as to its character ; the later signs 
 of infiltration of the edge of the liver, jaundice, ascites, and 
 enlargement of the liver, confirm the diagnosis. The 
 persistence of jaundice associated with a bladder tumour is 
 in favour of cancer and against calculus. The discovery 
 of enlarged hard glands in the neck or elsewhere may aid 
 in diagnosis. Tumours of the pylorus are sometimes only 
 with difficulty distinguished from gall-bladder tumours. 
 X-ray examination with the aid of a shot-loaded catheter 
 may be of assistance, but more important is the examination 
 of the stomach contents as to the presence of hydrochloric 
 acid, and the length of time they are retained ; a digestive 
 leucocytosis is absent in stomach cancer. 
 
 INDICATIONS FOR OPERATION. 
 
 It is only in early cases that operation can promise 
 good results. Unfortunately, the disease is not usually 
 discovered in its early stage ; occasionally it has been 
 found in the course of a gall-stone operation or some 
 other abdominal operation. Cholecystectomy, with re- 
 moval of adjacent liver tissue, is only permissible when 
 the disease is confined to narrow limits, when the liver 
 is not yet invaded or only to a very slight degree, and 
 when there are no metastases. 
 
 Contra-indications. — A large hard tumour in the gall- 
 bladder region, signs of liver infiltration, metastases, 
 cachexia, ascites, and intense jaundice, all contra-indicate 
 operation. It is obvious from what has already been said 
 that the signs of the disease when discovered are usually 
 sufficient to contra-indicate operation. 
 
 Prognosis. — Results of operation. — In sixteen cases 
 collected by Laspeyres, eight months after operation only 
 one showed no signs of recurrence, eight had died from 
 recurrence or metastases, three from sepsis and peritonitis. 
 As matters at present stand in regard to diagnosis, the 
 prognosis of operation is bad. In my opinion, the chances 
 of success are such that proposals to operate for gall-bladder 
 cancer should be resisted. 
 
DISEASES OF GALL-BLADDER AND BILE-DUCTS. 327 
 
 LITERATURE. 
 
 Laspeyres. Das Carcinom der Gallenblase. Centralb. f. d. 
 Grenzgebiete d. Med. u. Chir., 1901. 
 
 RoBSON. Partial Hepatectomy for Primary Cancer of the Liyer. 
 Brit. Med. Jour., Oct. 29, 1898. ' 
 
 RoLLESTON. Malignant Disease of the Gail-Bladder. Clin. 
 Journ. April 7th, 1897. 
 
 Heidenhain. Carcinom der Gallenblase. Deut. Zeit. f. Chir. 
 Bd. xlyii. 
 
 Hollander. Totalexstirpation der Gallenblase wegen Carcinom. 
 Deut. med. Wochens., No. 26, 1898. 
 
 DuRET. Tumeurs Operables de la Vesicule Biliaire. Rev. de 
 Chir., No. 11, 1898. 
 
 Terrier et AuyRAV. Rev. de Chir., Feb. and March, 1900. 
 
 De Saint Fuscien. Cancer Primitif de la Vesicule Biliaire. 
 These de Paris, 1897. 
 
CHAPTER XIX. 
 Diseases of the Liver. 
 
331 
 
 Chapter XIX. 
 DISEASES OF THE LIVER. 
 
 TUMOURS OF THE LIVER. 
 
 Etiology. — Many types of liver new growth are con- 
 genital, others are metastatic, others primary. Traumata 
 are often etiologically important. Syphilis may give rise 
 to tumours of large size. 
 
 Pathological Anatomy. — These tumours are benign 
 or malignant. The benign tumours may be cystic and 
 either solitary or multiple, and if the latter, there may be 
 •similar cystic growths in other abdominal organs. The 
 more common benign solid tumours are fibromata, adeno- 
 mata, angiomata, and syphilomata ; these are usually solitary 
 and sharply defined. The malignant growths are primary 
 and secondary carcinomata and sarcomata. Primary car- 
 cinoma usually takes the form of a solitary tumour occupying 
 one lobe and often causing great enlargement, but primary 
 -cancer may also be diffuse. The secondary cancerous 
 growths are much more common than the primary. 
 
 Clinical Course. — The non-parasitic cysts exhibit the 
 same signs and symptoms as the hydatid cysts {vide infra). 
 Benign liver tumours grow slowly and are not infrequently 
 pedunculated. They are often tender to pressure, and cause 
 gastric disturbance, and abdominal pain of a sharp, shooting 
 character. The malignant tumours may be buried in the 
 substance of the liver, or present as nodular growths on the 
 surface. The bile-ducts and the portal vein may be com- 
 pressed, with resulting jaundice and ascites. Cachexia is 
 not uncommonly present in the early stages ; metastases are 
 to be expected in the peritoneum, lungs, and pleura. Syphilis 
 often causes diffuse enlargement of the liver, and later, a 
 coarse cirrhosis or large gummatous tumours may be formed 
 wiiich yield to sj^ecific treatment. 
 
332 INDICATIONS FOR OPERATION IN 
 
 Diagnosis. — In enlargement of the liver, either dilfuse 
 or circumscribed, the history must be enquired into for 
 syphilis ; the effect of antisyphilitic treatment and coarse 
 cirrhotic intersection indicates the diagnosis. Gradual 
 growth, fluctuation, and the examination of fluid obtained 
 by exploratory puncture, will point to hydatid cyst. 
 Exploratory puncture is not without risk. Chronic abscess 
 is associated with more or less fever, and has a different 
 history. Cystic liver is a very chronic process and usually 
 painless. Diffuse carcinoma of the liver, which is of no 
 surgical interest, may be with difficulty distinguished from 
 amyloid disease, hypertrophic cirrhosis, and other conditions 
 in which the liver is much enlarged. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation is but rarely indicated for liver tumours. If 
 there is present a definite pedunculated tumour causing 
 troublesome symptoms, and if there are no indications of 
 its being metastatic in character, an exploratory laparotomy 
 is justifiable for the purpose of removing the growth if the 
 local conditions are favourable. 
 
 Contra-indicaiions. — Signs of syphilis contra-indicate 
 operation until antisyphilitic remedies have been given a 
 prolonged trial. Bilateral cystic kidneys associated with 
 signs of cystic disease of the liver contra-indicate operation. 
 No operation will be done when there is reason to believe 
 that the growth is metastatic, when there are multiple 
 growths, when there is serious circulatory disturbance or 
 atheroma, or when the patient is of advanced age. 
 
 In one of my cases (a man about forty-five years of age) 
 nodes could be felt on the upper surface of the liver. One 
 day a large amount of reddish pus, containing hsematoidin 
 crystals, was coughed up, and the size of the liver diminished. 
 Diagnosis — ^liver abscess, and rupture into the lung. At 
 the operation the liver was studded with numerous large 
 and small whitish hard nodules, and the operation was 
 abandoned. Syphilis was denied, but iodide was adminis- 
 tered internally, and in the course of a year his general 
 condition became excellent, and the liver diminished in size. 
 
 Prognosis. — Risks and results of operation. — Hsemorrhage 
 is a serious risk in any operation for the removal of a liver 
 growth. As a rule an exploratory operation is necessary 
 
DISEASES OF THE LIVER. 333 
 
 before it can be settled whether the growth is removable 
 or not. Benign tumours, fibromata, angiomata, adenomata, 
 and cysts have been successfully removed, and in rare 
 instances it appears that primary carcinoma has been 
 successfully dealt with. 
 
 // no operation is undertaken. — Malignant growths of 
 course cause death ; benign growths often attain enormous 
 proportions, but are only rarely dangerous to life. 
 
 LITERATURE. 
 
 Langenbuch. Chirurgie der Leber. Deut. Chir. Stuttgart, 
 1898. 
 
 Kehr. Lebergeschwiilste. Prakt. Chirurgie v. Bergmann, 
 ^likulicz, u. Bruns. 2nd Ed. 1903. 
 
 QuI^'CKK, HopPE - Seyler. Leberkrankheiten. Nothnagel's 
 Handbuch d. spez. Pathol, u. Therap., 1898. 
 
 Ahlenstiel. Lebergeschwiilste und ihre Behandlung. Arch. f. 
 klin. Chir., Bd. lii. 
 
 Leppmann. Ueber der echten Cysten der Leber. Deut. Zeit. f. 
 Chir., Bd. liv. 
 
 Terrier et Auvrav. Les Tumeurs du Foie. Rev. de Chir., 
 1896. 
 
 Langer. Hamangiom der Leber. Arch. f. klin. Chir., Bd. Ixiv. 
 
 Keen. Liver Resection. Annals of Surgery, Sept., 1899. 
 
 HYDATID CYST OF THE LIYER. 
 
 Etiology. — Hydatid cyst is caused by the entrance by 
 Avay of the digestive tract of the eggs of TcBnia echinococcus. 
 The embryo penetrates the walls of the intestine, and 
 is carried to the liver by the portal vein. Hydatid cyst is 
 exceptionally common in some regions, particularly in 
 Australia, Iceland, Pomerania, and Mecklenburg. Women 
 are more commonly affected than men. The multilocular 
 cyst is probably not caused by the same parasite as the 
 common single cyst, and has a different geographical 
 distribution ; it is comparatively rare. 
 
 Pathological Anatomy. — There is usually a single cyst 
 situated in the right lobe of the liver ; it is filled with a 
 watery fluid, and often contains numerous daughter cysts. 
 The fluid is limpid or slightly opalescent, its sp. gr. is 1007 
 to 1009, and it contains no albumin. When the cyst is 
 situated in tlie centre of the lobe there is a diffuse enlarge- 
 ment of the organ, but when near the surface it is found as 
 
334 INDICATIONS FOR OPERATION IN 
 
 a circumscribed swelling. Neighbouring organs may be 
 much compressed, particularly the lung, as the cyst is often 
 on the upper convexity of the liver. Rupture into lung, 
 bowel, or peritoneum is not unusual; secondary suppuration 
 is common ; the bile channels are rarely compressed. When 
 there are multiple cysts* the liver is often enormously 
 enlarged and may be of a stony hardness. On section the 
 organ is studded wdth numerous small cavities, like a 
 Gruyere cheese. The biliary channels are more frequently 
 involved in this form, and jaundice and hydrops of the gall- 
 bladder may develop. Secondary cysts may be found in 
 the lungs and the peritoneum ; suppuration and calcification 
 are not uncommon. 
 
 Clinical Course. — Often a cyst produces no symptoms. 
 When of considerable size, the liver is enlarged, but not 
 tender to pressure, and there is no jaundice or enlargement 
 of the spleen. If the cyst can be directly palpated a charac- 
 teristic thrill can often be felt, fluctuation cannot usually 
 be made out, and often the swelling is intensely hard. When 
 a cyst is very large it produces symptoms by compression 
 of adjacent organs ; for example, it may cause dyspnoea, 
 cough, and palpitation by pressure on the diaphragm, and 
 through it on the lung and the cardiac area ; and when 
 encroaching on the stomach it will cause nausea, loss of 
 appetite, and a sense of fullness in the epigastrium. If 
 suppuration supervenes there is high fever of an intermittent 
 or remittent type, with rigors and rapid loss of strength ; 
 occasionally, however, there is no pyrexia. Perihepatic 
 friction is usually heard when suppuration occurs, and the 
 pus may rupture into a neighbouring organ or space : 
 pyaemia is relatively frequent as a result of this complication. 
 When a cyst ruptures into the lung, scolices are usually 
 coughed up ; when rupture takes place into the bile-ducts 
 or intestine, the scolices may be found in the faeces. Rupture 
 externally is rare. If some injury ruptures a cyst into the 
 peritoneal cavity, severe peritonitis is set up. 
 
 In Echinococcus multilocularis jaundice is often the 
 first and persistent symptom. Melanotic jaundice is 
 frequent. The liver is large, hard, nodular, and sometimes 
 
 * This form is exceedingly rare, except in certain districts of Germany 
 and Switzerland. 
 
DISEASES OF THE LIVER 335 
 
 presents many fluctuating spots ; enlargement of the spleen 
 and ascites are common. When the condition is long stand- 
 ing, haemorrhages often occur ; the faeces are often clay- 
 coloured. 
 
 Diagnosis. — The history is often of assistance in regard 
 to the patient's place of residence or his association with 
 dogs. Apart from this the diagnosis will be founded on 
 the chronic nature of the condition, the absence of fever 
 and pain, the presence of an elastic tumour with the charac- 
 teristic hydatid thrill. When the cyst is subphrenic the 
 upper outline of liver dullness is markedly dome-shaped 
 towards the axilla, the lower thoracic outlet is much 
 widened, and a radiograph will often demonstrate the cyst 
 clearly. Exploratory puncture has frequently settled the 
 diagnosis, but it is a dangerous proceeding and not to be 
 recommended. 
 
 The diagnosis of Echinococcus multilocularis will be 
 assisted by enquiries as to the patient's residence ; the 
 disease is very chronic in type, and the general condition 
 is relatively good ; the liver is nodular and exceedingly 
 hard in parts ; there is jaundice and enlargement of the spleen, 
 and sometimes fluctuating areas may be discovered. 
 
 Acute liver abscess is sometimes distinguished with diffi- 
 culty from a suppurating hydatid, but the history of the 
 preceding illness will generally clear up the diagnosis. Chronic 
 liver abscess in its fever-free stage has no such close resem- 
 blance to a suppurating hydatid. Malignant tumours of the 
 liver develop more rapidly and produce cachexia earlier ; 
 they are usually tender to pressure. A distended gall-bladder 
 has a characteristic site and outline, and is usually associated 
 with attacks of gall-stone colic, either recent or at some 
 earlier period. A hydronephrotic kidney is prominent in 
 the lumbar region, the colon overlies it, and it often shows 
 marked variations in size ; it does not bulge forward the 
 lower costal arches. Pancreatic cysts lie behind the 
 stomach when distended. Ovarian cysts are attached to 
 the genital organs in the pelvis. 
 
 A syphilitic liver usually shows deep furrowing of the 
 anterior border, and is seldom associated with such intense 
 jaundice as in multilocular hydatid. Large gummata may 
 simulate cysts, but the diagnosis will be cleared up by 
 antisyphilitic treatment. It is sometimes difficult to 
 
336 INDICATIONS FOR OPERATION IN 
 
 distinguish hypertrophic cirrhosis from muhilocular hydatid, 
 but, as a rule, there are not the bosses of various sizes on the 
 Uver surface which are characteristic of the latter ; the 
 residence of the patient is an important aid in diagnosis. 
 
 Sometimes the diagnosis is extremely difficult, as in 
 the following case. A woman, aged forty- five, was admitted 
 into hospital under my care with a rapidly-growing abdominal 
 swelling ; in the abdomen there was a freely movable cystic 
 tumour the size of a man's head ; it did not move with 
 respiration. The general condition was good, and there 
 was no fever. On distending the colon the growth moved 
 upwards and to the right up against the liver ; no connection 
 could be made out with ovaries or kidney. The patient 
 had been operated on twenty-three years before for a " liver 
 cyst," and it seemed probable that a portion of the cyst 
 had been left behind, and it had re-formed. At the operation 
 a large hydatid cyst was found at the point of junction of 
 the right and left lobes of the liver, containing vesicles in 
 part suppurating. The patient had noticed a swelling 
 about the size of a small apple immediately after the first 
 operation ; this had remained stationary for twenty-two 
 years, but had lately begun to enlarge. 
 
 INDICATIONS FOR OPERATION. 
 
 Whenever it seems reasonably certain that a palpable 
 tumour of the liver is hydatid in nature, operation should be 
 advised. Both forms of hydatid are to be treated surgically. 
 Operation may consist of puncture through the abdominal 
 wall with or without injection, opening the cyst with the 
 knife, or enucleation of the cyst. The first-mentioned 
 procedure has been for the most part abandoned ; the two 
 latter may be performed in one stage or in two stages. 
 Cysts which are subphrenic in position are often opened 
 through the pleura. Operation is urgent when a cyst 
 ruptures into the peritoneal cavity ; when a previously 
 recognized tumour disappears or diminishes in size, it may be 
 consequent on some abdominal trauma, and when this is 
 associated with severe peritoneal symptoms — rigidity, 
 meteorism, fever, abdominal pain, signs of free fluid in the 
 peritoneal cavity — and collapse, the diagnosis of rupture 
 is clear. The appearance of an urticarial eruption will 
 confirm the diagnosis. The patient will often say that he 
 
DISEASES OF THE LIVER. 337 
 
 felt something burst in the abdomen. Operation is also 
 urgent when suppuration occurs in a cyst ; this will be 
 shown by the appearance of high fever, rigors, rapid 
 increase in size of the tumour, and increased tenderness to 
 pressure. 
 
 Contra-indications. — Exploratory puncture of a hydatid 
 cyst is not a justifiable proceeding ; subsequent leaking 
 may give rise to fatal peritonitis, or to diffusion of the 
 hydatids throughout the peritoneum. There are the same 
 objections to puncture with a trocar through the abdominal 
 parietes. 
 
 Risks of operation. — Puncture followed by drainage is 
 particularly dangerous ; it is attended by a mortality of 
 28 per cent. Peritonitis has often followed immediately 
 after this procedure. Profuse haemorrhage may follow 
 enucleation. Operation in two stages and drainage of the 
 cyst is a safe proceeding ; all the forty-eight cases reported 
 by Langenbuch recovered. 
 
 Prognosis. — Results of operation. — Almost all cases of 
 unilocular cyst may be successfully treated by operation. 
 Occasionally there are troubles from ventral hernia or 
 adhesions. 
 
 // no operation he done, hydatid cysts tend to suppurate ; 
 whether suppurating or not, they may rupture into neigh- 
 bouring organs. Rupture into the peritoneal cavity is 
 fatal in 90 per cent ; rupture into the pleura, fatal in 80 per 
 cent ; rupture into the bile channels, in 70 per cent of cases. 
 A suppurating hydatid may cause general septicaemia. 
 
 Both types of hydatid are compatible with life for long 
 periods. In the case which I have described above the cyst 
 had been present for twenty-three years. 
 
 LITERATURE. 
 
 Hoppe-Seyler (Quincke). Krankheiten der Leber. Nothnagel's 
 Handbuch d. spez. Pathol, u. Therap. Bd. xviii. 1899. 
 
 Langenbuch. Chirurgie. der Leber. Deut. Chir. Stuttgart. 
 
 Kehr. Krankheiten der Leber. Handbuch d. prakt. Chir. v. 
 Bergmann, MikuUcz, u. Bruns. 2nd Ed. 1903. 
 
 KoRTE. Erfahrungen iiber die Operation von Leber-Echinococcen. 
 Beitr. z. klin. Chir. Bd. xxiii. 
 
 Bruns. Leberresektion bei multilocularem Echinococcus. Beitr. 
 z. khn. Chir., Bd. xvii. 
 
 Posadas. Traitement des Kystes Hydat. Rev. de Chir., 1899. 
 
 -Madelung. Chirurgischc Bchandlung der Leberkrankheitcn. 
 
 22 
 
338 INDICATIONS FOR OPERATION IN 
 
 Spez. Therap. von Penzoldt-Stintzing. 3rd Ed. ; also : Post- 
 operative Pfropfung von Echinococcencysten. Mitteil. a. d. Grenzge- 
 biete d. Med u. Chir. Bd. xiii. 
 
 PossELT. Der Echinococcus Multilocularis. Deut. Arch f. klin. 
 Med. Bd. xli. 
 
 RouTiER. Bull, et Mem. de la Societe de Chir. de Paris, 1899, 
 p. 715. 
 
 QuENU, PoTHERAT, TuFFiER. Ibidem, 1900, p. 314; and 1903, 
 p. 719. 
 
 Deve. De rEchinococcose Secondaire. These de Paris, 1901. 
 
 ABSCESS OF THE LIVER. 
 
 Etiology. — Dysenter}' is the most common primary 
 cause of liver abscess. The condition may also follow 
 inflammatory affections in any part of the portal system, 
 for example, appendicitis ; it may result from direct injury 
 to the liver, wound infection, and pyaemia. Gastric ulcera- 
 tion, inflammatory affections of the gall-bladder and ducts, 
 particularly that consequent on cholelithiasis, may also 
 cause liver infection. A hydatid cyst may become a liver 
 abscess by suppuration. The tropical abscess is the most 
 common type ; it occurs much more frequently in men 
 than in women, and is preceded by dysentery. 
 
 Pathological Anatomy. — Liver abscesses are single 
 and multiple ; 75 per cent of tropical liver abscesses are 
 single. Multiple abscesses result from infection conveyed 
 to the liver by the portal venous system or the hepatic 
 artery or the bile -ducts. An abscess may be acute and 
 surrounded by an area of necrotic liver tissue, or more 
 chronic in type, in which case it is often more or less encap- 
 suled ; old abscesses are sometimes in part calcareous. Not 
 uncommonly rupture occurs into some neighbouring 
 structure ; this takes place most frequently into the lung 
 (about 10 per cent of cases), following an adherent peri- 
 hepatitis ; rupture through the abdominal wall or into the 
 peritoneum is comparatively uncommon. Some abscesses 
 contain as much as several litres of pus. The solitary 
 abscess occurs five times more frequently in the right than 
 the left lobe ; peritoneal adhesions to the site of the abscess 
 are very often absent ; the contents are often sterile. 
 
 Clinical Course. — Pygemic abscesses of the liver do not 
 as a rule give rise to any very prominent signs ; those which 
 
DISEASES OF THE LIVER. 339 
 
 follow intestinal affections present, on the other hand, a 
 characteristic group of symptoms. There are the general 
 symptoms : prostration, nausea and vomiting, remittent or 
 typically intermittent fever, and rigors ; and the local 
 symptoms. The liver is enlarged, either as a whole or in 
 one particular direction ; if the abscess is near the convexity 
 the enlargement upwards is dome-shaped in the direction 
 of the axilla. There is usually pain, referred to the region 
 of the liver, and the organ is also often tender to pressure ; 
 there are intestinal disturbances, vomiting and diarrhoea, 
 and radiating pains in the direction of the shoulder, but these 
 are seldom severe. Occasionally it is possible to make out 
 a definitely local enlargement, with fluctuation. As the 
 disease progresses, rigors, followed by profuse perspiration, 
 become more frequent. If perforation occurs into the lung, 
 the patient coughs up first a red blood-stained sputum, 
 and then quantities of purulent matter containing hsema- 
 toidin crystals or bile. There is usually no jaundice ; this 
 is most commonly associated with abscesses originating 
 in a septic cholangitis. 
 
 In chronic liver abscess, progressive weakness and loss of 
 flesh are the chief symptoms which attract attention. 
 
 Diagnosis. — Very important is a careful enquiry into 
 the history as to the existence of some one of the already- 
 mentioned antecedents of liver abscess. The diagnosis 
 will be based on the presence of the symptoms just 
 enumerated. According to Koch, the attitude is charac- 
 teristic : the patient bends to the right to relax the pressure 
 on that side. Leucocytosis and peptonuria will point to 
 the presence of pus. A skiagram will sometimes show 
 an abnormal outline of the upper border of the liver shadow ; 
 exploratory puncture will decide the question. An impor- 
 tant rule is that a diagnosis of liver abscess is only justifiable 
 when it is possible with certainty or great probability to 
 diagnose the original source of suppuration (Leube). 
 
 Regarding the diagnosis of the site of the abscess, the 
 following points are important : — If the diaphragm is pushed 
 up to the third or fourth rib, and the liver enlargement is 
 sharply defined on percussion, the abscess must lie imme- 
 diately under the diaphragm. If the inferior border of the 
 liver is exceptionally low, the abscess is not necessarily here ; 
 only if the enlargement here is localized and circumscribe 
 
340 INDICATIONS FOR OPERATION IN 
 
 is one justified in so deciding. When palpation of the liver 
 reveals a constantly tender spot the abscess is probably 
 close beneath the surface here. If the liver dullness alters 
 with changes of position there are probably no peritoneal 
 adhesions ; fixity of the liver does not, however, absolutely 
 indicate their presence ; this can be diagnosed only from the 
 existence of true local inflammatory oedema of the thoracic 
 or abdominal wall. 
 
 Differential diagnosis from carcinoma may be particularly 
 difficult, because a nodule of growth may soften and be 
 associated with typical intermittent fever ; the discovery 
 of metastases would decide the question. Gastric cancer 
 may be confused with an abscess of the left lobe, but will 
 be distinguished by signs of obstruction to the passage 
 of stomach contents and alteration in the stomach secretion 
 (absence of hydrochloric acid). Exploratory puncture 
 and radiographic examination will exclude pleurisy or 
 pneumonia. Differentiation from pleurisy will be further 
 facilitated if one remembers that in liver abscess the dullness 
 will probably show a characteristic and circumscribed 
 outline, and the line will descend as it approaches the 
 vertebral column. Hydatid cyst develops more slowly 
 than abscess, and runs an apyrexic course. Empyema of 
 the gall-bladder is distinguished by its characteristic shape 
 and position. In perinephritic abscess there is usually 
 a history of antecedent renal disease, tenderness on pressure 
 over the kidney, and oedema in the loin. Hydro- and 
 pyonephrosis are characterized usually by variations in the 
 size of the swelling, associated with intermittent polyuria. 
 In malaria there is splenic enlargement, which is not present 
 in liver abscess. 
 
 INDICATIONS FOR OPERATION. 
 
 If clinical signs point to abscess of the liver, operation, 
 that is to say puncture or incision, should be done without 
 delay. Exploratory puncture should be done only when 
 the surgeon is prepared at once to open the abdomen if 
 necessary. When the liver abscess is complicated by 
 empyema, suitable surgical treatment must be undertaken 
 for this condition also ; that is to say, rib resection and 
 drainage. 
 
 Signs of perforation into thorax or abdomen demand 
 
DISEASES OF THE LIVER. 341 
 
 immediate operation. Perforation into the peritoneal 
 cavity is shown by sudden agonizing abdominal pain, 
 collapse, and muscular rigidity, associated with rapid 
 alteration in the configuration of the liver demonstrated by 
 palpation, percussion, or radiography. 
 
 Contra-indications. — When the signs of abscess are distinct, 
 the only contra-indications are such collapse as will neces- 
 sarily render any operation fatal, and the presence of 
 universal pyaemia with multiple septic foci. When the 
 diagnosis is doubtful, the advisability of exploratory opera- 
 tion will be judged from the condition of the patient. 
 Exploratory puncture must never be done below the costal 
 border, and is never justified unless operation can follow 
 at once. 
 
 Prognosis. — Of operation. — The earlier the operation the 
 better the prognosis ; this is shown in statistics. Some 
 surgeons report only one fatality in seven, others record a 
 mortality of 70 per cent and over. Perutz has collected 
 182 cases from the literature of the last ten years, with an 
 operative mortality of 24 per cent. Out of 48 cases operated 
 on abdominally 35 recovered ; in 132 transpleural operations 
 1 01 recovered. Of 25 cases, in which at the time of the 
 operation there was some complication (subphrenic abscess, 
 empyema, rupture into the lungs), 8 recovered and 17 died. 
 In most cases the recovery was complete. Koch reported 
 42 cases, 38 of which were cured by operation. The healing 
 process is slow and runs to six weeks or more. The statistics 
 of Jimenez show that puncture is a dangerous proceeding 
 owing to the risk of infection of the peritoneum ; of 297 cases 
 punctured 82 per cent died. Puncture may cause death 
 from haemorrhage, or allow the abscess to empty itself 
 slowly into the peritoneum and set up peritonitis. 
 
 // no operation is done, the abscess may become encapsuled 
 and give rise to few symptoms for a long time ; it often, 
 however, progresses again in consequence of some trauma. 
 In most cases the abscess steadily enlarges, and usually 
 ruptures into a neighbouring organ ; rupture into the air 
 passages and bowel often ends in recovery. The mortality 
 from liver abscess not operated on is the same for tropical 
 and non-tropical cases, according to Langenbuch, that is to 
 say, one recovery to four deaths. The average duration of 
 life in cases not operated on is from i to 5 months. 
 
34^ INDICATIONS FOR OPERATION IN 
 
 LITERATURE. 
 
 LANGEN3UCH. Chirurgie der Leber. Deut. Chir. Stuttgart, 
 1899. 
 
 Quincke und Hoppe-Seyler. Leberkrankheiten. Nothnagel's 
 Handbuch f. d. spez. Pathol, u. Therap. Wien. 
 
 Kehr. Leberkrankheiten. Handbuch d. prakt. Chir. Bergmann, 
 MikuHcz, u. Bruns. 2nd Ed. 1903. 
 
 Perutz. Der Leberabscess. Centralb. f. d. Grenzgebiete d. Med. 
 u.'Chir., 1903. 
 
 Zancarol. Sur la Pathogenic des Absces du Foie. Rev. de 
 Chir., 1893 ; and Traitement Chirurgical des Absces du Foie. 
 Paris, 1893. 
 
 ^IcLeod. Tropical Liver Abscess. Brit. ^led. Jour., 1900. 
 
 British Medical Associaticn. Discussion on Dysentery and 
 Tropical Liver Abscess. Lancet, August 16, 1902. 
 i Bertrand et FoNTAN. Traite de Hepatite Suppuree des Pays 
 Chauds. Paris, 1875. 
 
 Gasser. Absces du Foie. ^lanuel de iNIedic. de Debove et 
 Achard. Tome vi. 
 
 Koch, J. A. Ueber tropische Leberabscesse. Mitteil. a. d. 
 Grenzgebiete d. Med. u. Chir. 1904. xiii. 
 
 Scheube, B. Die Krankheiten der warmen Lander. 3rd Ed. 
 Jena, 1903. 
 
 RoBiNSCN. Tropical Abscess of the Liver. Jour. Amer. Med. 
 Assoc, 1901, No. 19. 
 
 Smith. The Diagnosis and Surgical Treatment of Tropical Liver 
 Abscess. Brit. ^led. Jour., Sept. i, 1900. 
 
 Boinet. Diagnostic des Formes Latentes de I'Absces du Foie. 
 Gaz. des Hopit. March 5, 1901. 
 
 Lesage. Absces du Foie d'Origine Dysenterique. Soc. de 
 Biologic, No. 21, 1902. 
 
 i Malbot. Les Absces du Foie en Algerie. Arch. Gener. de Med. 
 Oct., 1899. 
 
 ATROPHIC CIRRHOSIS OF THE LIVER. 
 
 Etiology. — Alcoholism is by far the most common 
 cause of atrophic cirrhosis ; it is occasionally due to syphilis, 
 malaria, and chronic intoxications. 
 
 Pathological Anatomy. — In this affection the liver 
 shows primarily a diffuse hyperplasia, and, secondarily, 
 shrinking and contraction of the interlobular connective 
 tissue. A considerable amount of the hver parenchyma 
 atrophies, and many of the branches of the portal venous 
 system are obhterated. In the later stages the liver as 
 a whole is shrunken and the surface corrugated, the portal 
 
DISEASES OF THE LIVER. 343 
 
 vein and its brandies are distended, and the spleen is usually 
 enlarged. Collateral venous channels are often enlarged 
 and varicose, and particularly those at the lower extremity 
 of the oesophagus. 
 
 Clinical Course. — The stage of enlargement is often 
 undetected clinically ; it is followed by the stage of shrinking, 
 in the course of which the liver becomes firmer to the touch. 
 The surface is uneven and the edge firm and easily palpable. 
 When the condition has made considerable progress the 
 spleen is found to be enlarged. Ascites often appears at a 
 relatively early stage, but is occasionally late. It develops 
 sometimes insidiously, sometimes suddenly ; it is painless 
 throughout, and is often extreme. 
 
 Haemorrhages from the gastro-intestinal tract frequently 
 occur, and often constitute one of the early symptoms. 
 Varicose distension of the veins of the abdominal wall is often 
 to be seen, and sometimes has the formation of the so-called 
 " caput medusae " around the umbilicus. Occasionally 
 the exudation is hsemorrhagic, and when a pleural effusion 
 is also present it may have the same characters. Tubercu- 
 losis of the lungs frequently complicates the condition ; it 
 is rare to find jaundice, but it is occasionally present in 
 advanced cases. 
 
 Diagnosis. — The diagnosis will be based on the charac- 
 teristic changes in the consistence and size of the liver, 
 the presence of ascites and enlargement of the spleen, and 
 the occurrence of haemorrhages into the gastro-intestinal 
 tract. When a mitral or tricuspid affection is present and 
 the hepatic symptoms improve after the administration of 
 cardiac remedies, the case is one of venous congestion of 
 the liver. Chronic hyperplastic perihepatitis is often 
 difficult to distinguish from cirrhosis ; in its early stages 
 there is often perihepatic friction, and this condition must 
 always be thought of in cases where there is no alcoholic 
 history, when there is an accompanying non-tubercular 
 pleuritic and pericardial affection, and the ascites remains 
 stationary for some years. 
 
 Obstruction at the hilum of the liver, for example by 
 new growth, causes intense jaundice as well as ascites. 
 Tubercular peritonitis does not run an apyrexic course 
 throughout, and shows a marked tendency to the formation 
 of localized collections. 
 
344 INDICATIONS FOR OPERATION IN 
 
 INDICATIONS FOR OPERATION. 
 
 Surgical treatment may consist simply of puncture for 
 the temporary relief of ascites, or an attempt may be made 
 to give permanent relief by the opening up of new venous 
 channels to supplement the obstructed portal circulation. 
 
 Tapping is indicated (a) when the pressure of the fluid 
 threatens death from suffocation ; {b) in the earlier stages 
 when the respiration, circulation, and nutrition are embar- 
 rassed. Many writers advocate drawing off ascitic fluid 
 at a still earlier period, but my own opinion coincides with 
 that of the majority, who are in favour of postponing the 
 tapping until one or other of the above-named symptoms 
 has made its appearance. Tapping frequently repeated 
 entails a not inconsiderable risk owing to the loss of albumin, 
 and should therefore be avoided when possible ; it is not 
 necessary to repeat it until the patient again shows signs 
 that his circulatory, respiratory, or digestive systems are 
 suffering from the ascites. 
 
 The Talma-Morison operation, which consists of fixation 
 of the omentum, liver, and spleen to the abdominal parietes 
 for the purpose of opening up new venous channels, is indi- 
 cated when medical treatment fails to influence the reaccumu- 
 lation of fluid and tapping has to be repeated, whether the 
 liver is small and shrunken or not. The diagnosis must be 
 definite before the operation is advised ; if postponed to 
 the late stages, changes in the peritoneum may render it 
 ineffective. I view also as an indication for this operation 
 the occurrence of repeated profuse haemorrhage into the 
 stomach and intestine, even in cases where ascites is absent 
 or slight, and there is no jaundice ; these hjemorrhages 
 point to pronounced engorgement of the portal circulation, 
 and not infrequently cause death ; I have seen several fatal 
 cases. 
 
 Contra-indications. — Talma cites as contra-indications to 
 his operation the presence of long-standing jaundice, 
 urobilinuria, acholia or hypocholia of the faeces, and 
 xanthoma. Serious cardiac or vascular lesions also contra- 
 indicate it. Operation is also inadvisable in cases where 
 the cirrhosis is of long standing and the general symptoms 
 are of a serious type, as under these circumstances the 
 function of the liver cells is largely destroyed and there is 
 
DISEASES OF THE LIVER. 345 
 
 considerable risk of auto-intoxication. Another contra- 
 indication is the occurrence of repeated haemorrhages from 
 the mucous membranes, associated with jaundice. 
 
 Risks of operation. — Out of 164 cases of omentofixation 
 collected by Zesas, 72 ended fatally. Purulent peritonitis 
 figured relatively frequently as a cause of death among 
 these. There is a possibility of auto-intoxication, owing to 
 the exclusion of the liver function in removing toxic 
 material from the blood. The intestine may be kinked if 
 the omentum is made taut by suture (Franke). Usually 
 the dangers of anaesthesia have been avoided by performing 
 the operation under a local anaesthetic. The operation 
 should not take long, but the patients are always in an 
 enfeebled condition, and the statistics show that many 
 of the deaths have occurred from shock. Puncture of 
 the abdomen under aseptic precautions is practically free 
 from risk ; in one of my cases fatal heemorrhage from 
 dilated oesophageal veins followed tapping, but whether 
 the tapping had anything to do with the accident is 
 uncertain. 
 
 Prognosis. — Results of operation. — Of Zesas' 164 cases 
 51 were cured, but it must be stated that the after history 
 was followed in only a small proportion of the cases for 
 periods of from three months to two and three-quarter 
 years. Twenty-six of the remainder were improved, 
 and eleven showed no improvement. Of seven cases 
 reported by Pal and Frank three were cured, in two the 
 ascites returned, and two died, but not in consequence of 
 the operation. Of great interest is a later communication 
 by Pal, that in one patient in whose case the operation had 
 been classed as a failure clinical signs of recovery commenced 
 a year and a half later. The operation opens up new 
 channels for the portal blood, and these remain permanently 
 open.* 
 
 Without' operation. — Most cases of cirrhosis of the liver 
 end fatally after a variable period when, after the first 
 tapping, the fluid reaccumulates in spite of a rigidly- 
 restricted diet and diuretics. Death is in many cases 
 
 * Of 255 cases collected by Bunge, 66 were cured, 27 improved ; in 35 
 there was no improvement, and in the remainder death was recorded, not 
 necessarily connected with the operation [Trans.]. 
 
346 INDICATIONS FOR OPERATION IN 
 
 due to repeated haemorrhages from the gastro-intestinal 
 tract. In a small number of cases spontaneous arrest has 
 occurred and even clmical recovery, when the habits 
 causing the affection were surrendered. 
 
 LITERATURE. 
 
 Zesas. Die Talma'sche Operation bei Lebercirrhose, ihre Erfolge 
 u. Resultate. Centralb. f. d. Grenzgebiete d. Med. u. Chir. 1904. 
 
 Friedmaxx. Die operative Behandlung der Lebercirrhose. 
 Ibid, No. 15, 1900. 
 
 Quincke. Leberkrankheiten. Nothnagel's Handbuch d. spez. 
 Path. u. Therapie. Wien. 
 
 Talma. Berl. khn. Wochens., Sept. 19, 1S98, and July 30, 1900. 
 
 ^NIuLLER. Zur Frage der operativen Ascitesbehandlung. Arch. 
 f. khn. Chir. 1902. 
 
 Leport. Chirurgie du Grosse Ascites. La Semaine Medicale. 
 May 25, 1903. 
 
 Lenzmaxn. Zur Frage der Indikationen und der Erfolge der 
 Talma' schen Operation bei der Atrophischen Lebercirrhose. Deut. 
 med. Wochens. Xo. 48. 1903. 
 
 J. Pal. Operative Behandlung der Lebercirrhose. Gesellsch. d. 
 Aerzte in Wien, Feb. 28, 1902. Wiener khn. Wochens., 10 and 
 II, 1902, and 1 1, 1904. 
 
 BuxGE. Die Talma-Drummonsche Operation. Jena. 1905. 
 
 MOVABLE LIYER. 
 
 Etiology. — Hepatoptosis may be due to congenital 
 anomalies, to the pressure of tight corsets, to injury, to 
 rapid loss of flesh, or to multiple pregnancies. 
 
 Pathological Anatomy. — The liver is displaced from 
 the right hypochondrium downwards, and is no longer 
 in contact with the under surface of the diaphragm. The 
 organ may descend horizontally and rotate on its frontal 
 axis, or the right lobe may be chiefly affected and reach the 
 iliac crest. It is often fixed by adhesions in its new position, 
 and may be much altered in shape. There is often an 
 accompanying ptosis of other organs, for example, the 
 spleen and the kidneys. 
 
 Clinical Course. — In cases where the dislocation takes 
 place suddenly there are acute symptoms, abdominal pain, 
 and collapse. The subacute and chronic cases present a 
 great variety of symptoms. There are often vague pains, 
 which come on in attacks, particularly when the patient 
 
DISEASES OF THE LIVER. 347 
 
 sneezes, coughs, or raises the arms ; jaundice is sometimes 
 present, due to kinking of the bile-ducts ; palpitation 
 is common. The displacement of the liver is revealed by 
 palpation and percussion ; it is not tender to pressure. 
 When the patient stands the epigastrium usually shows 
 depression. 
 
 Diagnosis. — The physical signs render the diagnosis 
 easy, particularly when the liver can be replaced upwards 
 into its normal position. It is distinguished from a 
 movable kidney by the presence of intestine in front of the 
 latter ; a renal swelling is shown to be distinct from 
 the liver by percussion and palpation, and the physical 
 signs also differentiate it from tumours of the liver, of the 
 intestine, or of the peritoneum. 
 
 INDICATIONS FOR OPERATION. 
 
 If the liver is considerably displaced, and the displacement 
 gives rise to persistent and marked symptoms which cannot 
 be relieved by bandage or other appliance, if also the patient 
 is unable to follow his occupation and is depressed by his 
 condition, then operation is justifiable. The operation 
 consists in fixing the liver in its proper position after 
 freshening its upper surface in order to obtain adhesions 
 over as wide an area as possible. 
 
 Contra-indications. — If the symptoms are slight and 
 principally hysterical, operation is not advisable ; under 
 such circumstances it is quite possible that operation 
 will neither cure nor relieve. There is little prospect of 
 success when hepatoptosis is merely part of a general 
 enteroptosis. Operation is contra-indicated in advanced age. 
 
 Prognosis. — Results and risks of operation. — The imme- 
 diate risks of operation under strict asepsis are slight, but 
 damage may be done to the bowel or some other organ in the 
 course of separating adhesions. The majority of patients 
 operated on are relieved of their symptoms, and are 
 enabled to resume work. 
 
 Without operation. — There are no serious risks attached 
 to this condition, but so long as it is unrelieved the patient 
 will probably complain of persistent and severe pain and 
 sensations of dragging, and will be permanently unable to 
 work. 
 
348 INDICATIONS FOR OPERATION IN 
 
 LITERATURE. 
 
 Teleky. Die Wanderleber. Centralb. f. d. Grenzgebiete d. Med. 
 u. Chir. 1901. 
 
 Quincke. Krankheiten der Leber. Nothnagel's Handbuch d. 
 spez. Pathol, u. Therap. Wien. 1899. 
 
 Langenbuch. Chirurgie der Leber u. Gallenblase. Deut. 
 Chirurgie, 45c. Stuttgart: Enke. 
 
 EiNHORN. Die Wanderleber und ihre klinische Bedeutung. Zeits. 
 f. diat. u. physikal. Therapie. Bd. iv. 1900. 
 
 BoTTicHER. Ueber Hepatopexie. Deut Zeit. f. Chir. Bd. Ivi. 
 1900. 
 
 Pantaloni. Chirurgie du Foie et desVoiesBiliaires. Paris. 1899. 
 
 Terrier et Auvray. Le Foie Mobile, etc. Rev. de Chir., 1897, 
 p. 621, and 1898, Nos. 5 and 6. 
 
 Treves. Ptosis of the Liver. Lancet, May 12, 1900. 
 
 THE CONSTRICTED LIYER. 
 
 Etiology. — The long-continued compression of the 
 thorax by tight corsets produces a characteristic series of 
 anatomical changes and symptoms. 
 
 Pathological Anatomy. — There are various types of 
 the deformity which may be produced by tight lacing. 
 In the only type which presents any surgical interest, a 
 portion of the right lobe is more or less separated off from 
 the rest of the liver in advanced cases the hepatic tissue 
 is completely destroyed at the point of greatest pressure, 
 and the thickened and bulky mass of separated liver is 
 attached to the rest of the organ only by connective tissue, 
 vessels, and bile-ducts. 
 
 Clinical Course. — In most cases compression by the 
 corset gives rise to no symptoms. Sometimes the separated 
 lobe, when swollen and oedematous, causes a sense of 
 weight and pressure which gives rise to a considerable 
 amount of distress. The pain may radiate to the thorax 
 and the shoulder. There may be vomiting and tenderness 
 on pressure over the mass. Sometimes the artificially- 
 formed lobe is very mobile ; movable kidney is a frequent 
 complication. The line of intersection has a horizontal 
 direction, and the vertical measurement of the liver is 
 increased, especially towards the right. 
 
 Diagnosis. — In cases which are not very advanced it 
 is easy to make out on palpation that the strangulated 
 
DISEASES OF THE LIVER. 349 
 
 mass belongs to the liver, and in such cases it moves with 
 respiration. At a later stage it becomes more movable 
 and more displaced, and does not move in respiration. As 
 a rule it is easily distinguished from a movable kidney, 
 as the latter occupies chiefly the lumbar region, while the 
 liver mass is easily felt on palpation of the abdomen from 
 the front. It is often useful to place the patient half over 
 on the left side, when the liver lobe sinks to the left and 
 the movable kidney is more easily palpable. The ascending 
 and transverse colon lie behind the mass. Careful examina- 
 tion will be necessary to distinguish this condition from 
 new growths of the intestine and of the gall-bladder and 
 from perityphlitis, etc. However enlarged and swollen 
 the lobe may become, it remains mobile; jaundice is practi- 
 cally never present. 
 
 INDICATIONS FOR OPERATION. 
 
 Operation is only justified in advanced types of the 
 condition, where the anatomical changes are extreme and 
 a freely-movable lobe is present which has caused pronounced 
 symptoms for some considerable time, making the patient 
 unable to work and low-spirited. Other treatment should 
 always be tried before operation is advised. Notwith- 
 standing the frequency of this deformity operation is rarely 
 indicated, if one may judge from the small number of cases 
 recorded. The symptoms are rarely so extreme as to make 
 it necessary. I have myself seen many marked cases, but 
 have never judged it necessary to advise operation. The 
 procedure employed is either fixation of the lobe to the 
 abdominal parietes or resection. 
 
 Contra-indications. — When the separated lobe is swollen 
 and painful, and this state of affairs has been present only 
 a short time, expectant treatment should always be tried 
 first, and under its influence the pain and swelling will 
 usually disappear. When there is reason to believe that 
 most of the symptoms are hysterical and nervous rather 
 than due to strangulation of the lobe, no operation should 
 be done. 
 
 Prognosis. — Risks of operation. — Neither ventrofixation 
 nor resection is free from risk ; serious haemorrhage may 
 complicate the latter. 
 
 Results of operation. — In most cases which have been 
 
3SO INDICATIONS FOR OPERATION. 
 
 operated on the results have been quite satisfactory. 
 Ventrofixation of the lobe appears to be a satisfactory 
 method of permanently anchoring it. 
 
 Prognosis without operation. — If a suitable bandage or 
 apparatus be fitted, the gastro-intestinal functions regulated, 
 and the general defects of the circulation energetically 
 combated, the symptoms produced by this condition 
 become supportable after a short time as a general rule. 
 It is only rarely that any serious symptoms (e.g., peritonitis) 
 are produced. 
 
 LITERATURE. 
 
 Langenbuch. Chirurgie der Leber u. Gallenblase. 2nd Pt. 
 Deut. Chirurgie. Stuttgart. 1897. 
 
 Quincke. Krankheiten der Leber. Nothnagel's Handbuch d. 
 spez. Pathol, u. Therap. Wien. 1899. 
 
 Kehr. Leberkrankheiten. Handbuch der prakt. Chirurgie. 3rd 
 Vol. 2nd Ed. Bergmann, Bruns, u. Mikulicz. 1903. 
 
 BoTTiCHER. Ueber Hepatopexie. Deut. Zeitr. f. Chir. Bd. Ivi., 
 p. 252. 
 
 Chevalier. Technique de I'Hepatopexie. These de Paris, 1898. 
 
 Terrier et Auvr.w. IMaladies du Foie et des Voies Biliaires. 
 Paris. 1 90 1. 
 
CHAPTER XX. 
 
 Diseases of the Spleen. 
 
353 
 
 Chapter XX. 
 
 DISEASES OF THE SPLEEN. 
 
 TUMOURS AND CHRONIC HYPERPLASIA OF THE 
 SPLEEN. 
 
 Etiology. — Chronic hyperplasia of the spleen may be 
 due to some " blood disease " (leucaemia, pseudoleucaemia), 
 or to one of the infections and intoxications (syphilis, 
 malaria, alcohol), or may arise without recognizable cause, 
 and is then styled idiopathic. Enlargement of the spleen 
 also occurs in some affections of the circulatory system : 
 cardiac dilatation, pericardial adhesions, and hepatic 
 cirrhosis. The etiology of splenic tumours is that of 
 tumours in general ; cystic growths often follow injury, 
 or may be of hydatid nature. 
 
 Pathological Anatomy. — Hydatid cysts are sometimes 
 of enormous size ; they are usually unilocular, rarely 
 multilocular, and not uncommonly suppurate. The non- 
 parasitic cysts are usually single ; their contents may be 
 serous, serohsemorrhagic, or haemorrhagic ; they may be 
 of large size, and may reach a weight of lo kilograms. Both 
 types of cystic growth may become much adherent to 
 surrounding parts, but this is not the rule ; cysts are 
 proportionately common in " floating " spleen. The solid 
 growths are rare ; sarcomata, angiomata, and other forms 
 have been described ; tubercle and syphilis may give rise 
 to masses of granulation tissue formation. Metastatic 
 growths also occur. " Idiopathic " chronic hyperplasia 
 occurs in association with a secondary cirrhosis of the 
 liver, the so-called Banti's disease. Hyperplasia may be 
 secondary and may be due to hepatic cirrhosis, portal 
 obstruction, amyloid degeneration, syphilis, tuberculosis, 
 and chlorosis. In all forms of tumour and hyperplasia 
 the adhesions may be extensive. 
 
 23 
 
354 INDICATIONS FOR OPERATION IN 
 
 Clinical Course. — Tumours of the spleen may manifest 
 themselves, according to the nature of the fundamental 
 cause, by local symptoms alone (pain, tenderness on 
 pressure, fullness, gastric and intestinal disturbances), or 
 by general constitutional signs. The parasitic and the 
 non-parasitic cysts occur with special frequency in women 
 of middle age ; they may be situated in the body of the 
 spleen, or at its lower pole. The presence of these cysts 
 does not, as a rule, affect the general health ; there is often 
 a history of preceding trauma. A fluctuating tumour is 
 found, but the hydatid thrill is rarely to be made out. 
 Inflammatory affections of the pleura and lungs often occur 
 as complications. 
 
 When a solid growth is present the surface of the organ 
 is uneven, and sometimes nodules are to be felt. Malignant 
 growths develop rapidly and affect the general health. 
 
 Hyperplasia may reach large dimensions in chronic 
 malaria, and remain stationary in spite of energetic treat- 
 ment with quinine and arsenic preparations ; in this and in 
 the hyperplasia of leucsmia and pseudoleucaemia there 
 is a tendency to the occurrence of haemorrhages. 
 
 Primary chronic hyperplasia affects particularly women 
 between the ages of 30 and 40, and often persists for 
 several years ; its etiology is obscure. The enlargement 
 of the organ is the solitary morbid phenomenon, and is 
 the sole cause of the existing symptoms. 
 
 In all forms of hyperplasia the enlargement is usually 
 uniform, downwards, and to the right. The organ moves 
 freely with respiration, is deeply notched, and, as a rule, 
 there is no intestine in front of it. If the peritoneal surface 
 becomes inflamed, friction is often to be heard. When the 
 enlargement is great the lower thoracic outlet is widened, 
 the diaphragm is pushed upwards, and the heart and lung 
 are displaced. The upper pole of a splenic enlargement can 
 often be well seen on a radiograph. 
 
 Diagnosis. — The diagnosis of a splenic tumour rests on 
 its position, its remarkable mobility on respiration, the 
 notches of the lower border, the relations with the intestine, 
 its mobility in an upward direction towards the left side 
 of the epigastrium, and its position underneath the costal 
 arches. The characters of true new growths, cystic and 
 solid, have already been referred to. Examination of the 
 
DISEASES OF THE SPLEEN. 355 
 
 blood will reveal the true nature of the hyperplasia which 
 occurs in leucaemia, pseudoleucaemia, and malaria, and 
 changes will also be present in the lymph glands, the liver, 
 and other organs. Secondary hyperplasia will be diagnosed 
 when the morbid states which have been mentioned as 
 causing this condition are found. Idiopathic hyperplasia 
 will be diagnosed by a process of exclusion, when none of 
 the recognized causes can be discovered. Banti's disease 
 is associated with anaemia in the first stages, and later with 
 ascites and secondary cirrhosis of the liver. 
 
 INDICATIONS FOR OPERATION. 
 
 When a cystic growth of the spleen is definitely diagnosed, 
 operation is indicated. The necessity for operation is 
 the more urgent the more acute the local symptoms and 
 the greater the rate of growth. Operation is urgent when 
 fever is associated with the presence of a cyst, pointing 
 to the supervention of suppuration. If the tumour is 
 stationary, if the local symptoms are slight, and if there is 
 no fever, there is no immediate call for surgical treatment. 
 
 When a splenic enlargement appears to be due to true 
 primary new growth, and is rapidly increasing, splenectomy 
 is indicated. In the case of malarial hyperplasia, if the pain, 
 sense of weight, and other local symptoms are distressing, 
 if the enlarged organ is very mobile, suggesting the possi- 
 bility of torsion of the pedicle, or if other dangerous 
 symptoms are induced, removal is advisable if medical 
 treatment fails. The indications are the same in cases of 
 idiopathic splenomegaly. When the general health is 
 good the presence of hyperplasia alone, in the absence of the 
 complications just mentioned, cannot be considered a strict 
 indication for removal in view of the risks of operation. 
 
 Contra-indications. — In cases of cystic tumour or of 
 multiple hydatids, splenectomy is not to be advised when 
 there are serious complications in other organs, or waxy 
 disease. 
 
 Exploratory puncture is dangerous ; peritonitis may be 
 set up, which may be fatal if the cyst contents are purulent, 
 or hydatids may be in this way distributed throughout the 
 peritoneal cavity. 
 
 Leucaemia is an absolute contra-indication to splenectomy ; 
 in all the reported cases death has resulted ; Jordan has 
 
3S6 INDICATIONS FOR OPERATION IN 
 
 collected 28, all with the same result. Pseudoleucaemic 
 hypertrophy is equally unsuitable for operation ; the dangers 
 are considerable, and the results are ?iil. In malarial cases, 
 severe cachexia, marked anaemia, general oedema, a tendency 
 to haemorrhages, and the probability of extensive adhesions, 
 all contra-indicate operation. The idea of operation will 
 not be entertained in cases where the splenic enlargement 
 is secondary to hepatic cirrhosis, or to venous congestion 
 from heart disease or portal obstruction, in waxy disease, 
 tuberculosis, or syphilis, or where a splenic tumour is of 
 metastatic origin. 
 
 Prognosis. — Of operation.— In cases of cystic disease the 
 prognosis is favourable. All the cases of blood cyst hitherto 
 operated on, 12 in number according to Jordan, have' 
 recovered, the cases being treated either by splenectomy, 
 resection, incision, or enucleation. In hydatid disease, 
 in spite of the existence of extensive adhesions in several 
 cases, 15 out of 17 recovered (Jordan). In one case which 
 I saw some years ago the sac was punctured and iodine 
 injected with good result, but this proceeding must be 
 considered risky. 
 
 The five cases of primary splenic sarcoma which have 
 been operated on up to the present, all recovered, one 
 permanently. Extirpation is therefore indicated in primary 
 malignant disease, although in some cases recurrence has 
 been rapid. 
 
 Extirpation of the enlarged malarial spleen is very 
 dangerous. In 117 cases there was a mortality of 27 per 
 cent (Fevrier). If the organ is mobile the risk is much 
 lessened ; in 26 such cases there was but one death (Bessel- 
 Hagen). It is necessary, therefore, to be very careful in 
 recommending operation ; the local symptoms are quickly 
 relieved thereby, but the general symptoms improve only 
 slowly. 
 
 The cases of idiopathic hyperplasia show an operative 
 mortality of 13 per cent, two deaths in fifteen cases. 
 
 There is no physiological objection to removal of the 
 spleen. Experience has shown that the individual can 
 get on quite well without the organ, and that its functions 
 are quickly replaced. 
 
 Without operation. — Primary new growths and hydatid 
 cysts, unless operated on, are eventually fatal. Blood 
 
DISEASES OF THE SPLEEN. 357 
 
 cysts may be dangerous in a high degree if some com- 
 phcation supervenes, such as suppuration, torsion, or 
 bursting. 
 
 The large malarial spleen may be a continual source of 
 suffering, may be the cause of some fatal complication, 
 and may compromise the general health by interfering with 
 digestion. Chronic primary hyperplasia is only dangerous 
 when the spleen is very mobile, or of very large size. 
 
 LITERATURE. 
 
 Jordan. Die Exstirpation der Milz, ihre Indikationen und 
 Resultate. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. xi, H 3. 
 
 Laspeyres. Indikat. u. Result, totaler Alilzexstirpationen. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir. 1904. 
 
 LiTTEN. Die Krankheiten der Milz. Nothnagel's Handbucli d. 
 spez. Eathol. u. Therap. Bd. viii. 
 
 Bessel-Hagen. Ein Beitr. z. Milz-Chirurgie. Arch. f. klin. 
 Chir. Bd. Ixii. 
 
 Simon. Splenectomie bei primaren sarkom der Milz. Beitr. z. 
 klin. Chir. Bd. xxxv. 1902. 
 
 Braun. Chirurgie d. Milzkrankheiten. Handbuch der prakt. 
 Med. V. Ebstein-Schwalbe. Bd. ii. 
 
 Jonnesco. La Splenectomie. Rev. de Chir. No. 11, 1899, and 
 No. 9, 1900. 
 
 Llobet. Splenectomie Totale. Ibidem. 1900. 
 
 MiCHAiLOWSKY. Splenectomie dans la Splenomegalie Malarique. 
 Ibidem. 1900. 
 
 Fevrier. Chirurgie de la Rate. Rev. de Chir. Oct., 1901. 
 Gaz. des Hopit. Oct., 1901. 
 
 Bovee. Splenectomy for Congestive Hypertrophy. Annals of 
 Surgery, June, 1900. 
 
 Warren. The Surgery of the Spleen. Annals of Surgery, May, 
 1901. 
 
 BANTFS DISEASE. 
 
 Etiology. — The etiology of this affection is unknown ; 
 it develops relatively often in young individuals. 
 
 Pathological Anatomy. — The knowledge of the 
 pathological anatomy of this condition is scanty. The 
 spleen is enlarged, and this enlargement is chiefly due to 
 an overgrowth of connective tissue. The liver exhibits 
 the condition of atrophic cirrhosis, and is sometimes 
 divided up by dense cicatricial septa. Marked athero- 
 matous changes have been described in the portal and 
 splenic veins. 
 
3S8 INDICATIONS FOR OPERATION IN 
 
 Clinical Course. — Banti has described three stages 
 of the disease. The first stage is that of gradual splenic 
 enlargement, associated with anaemia. The spleen becomes 
 very large and firm, with a smooth surface. The symptoms 
 of anaemia become steadily more and more intense : palpita- 
 tions, lassitude, oedema of the feet, epistaxis, etc., but 
 they do not necessarily advance in proportion with the 
 splenic enlargement. There is a fall in the number of both 
 red and white cells, and in the proportionate amount of 
 haemoglobin. There is no fever, no enlargement of 
 lymphatic glands, no ascites, and no abnormal constituent 
 in the urine. This stage lasts usually about three to five 
 years, but may be prolonged to ten years. The second 
 stage is characterized by diminution in the quantity of 
 the urine, the appearance of bile pigment in the urine, 
 jaundice, and gastro-intestinal disturbance. It lasts for 
 several months. The third stage is that of secondary 
 cirrhosis of the liver, with ascites. The ascites sometimes 
 disappears temporarily. There are evening rises of 
 temperature ; the anaemia, jaundice, and tendency to haemor- 
 rhages become more and more marked. Death occurs 
 usually at the latest about a year after the onset of the 
 third stage. Several times cholelithiasis has been found 
 co-existent. 
 
 Diagnosis. — All the other recognized causes of splenic 
 enlargement — malaria, pseudoleucaemia, etc. — are absent, 
 and the course of the disease is sufficiently characteristic 
 to make the diagnosis clear. 
 
 INDICATIONS FOR OPERATION. 
 
 In several cases arrest of the disease and even cure has 
 been obtained by splenectomy. This operation is indicated 
 when the size of the spleen is such that it is giving rise to 
 serious local symptoms, and when the accompanying liver 
 cirrhosis threatens danger to life (Jordan). Operation may 
 be necessary on account of the enlargement of the spleen 
 alone when it is mobile and torsion of the pedicle threatens. 
 Inability to work and the necessity of earning a living will 
 influence the surgeon towards undertaking operation. 
 Early operation should not be advised in the absence of 
 the indications mentioned, as the course of the disease is 
 uncertain and operation must always be a serious risk. 
 
DISEASES OF THE SPLEEN. 359 
 
 Contra-indications. — Operation will be inadvisable when 
 the general condition is very bad. It should not be recom- 
 mended when the general condition is still good, anaemia 
 absent, local symptoms slight, and the signs of hepatic 
 disease insignificant. Extensive adhesions are a contra- 
 indication ; their presence will be diagnosed when the 
 organ does not move with changes of position and respiration, 
 when during the course of the disease friction has been 
 heard over it, and when it cannot be displaced by the 
 palpating band. 
 
 Prognosis.— 0/ operation.— -In 16 cases collected by 
 Bessel-Hagen, 13 were cured by the operation ; the remaining 
 three died. The operation is, therefore, always attended 
 by risk, whether adhesions are present or not. Tansini has 
 performed splenectomy during the third stage ; five months 
 later the patient had all the appearance of perfect health. 
 In cases which progress favourably the general condition 
 shows no permanent damage. If no operation is done 
 the affection inevitably terminates fatally in the third stage. 
 
 LITERATURE. 
 
 Jordan. Die Exstirpation der Milz. Mitteil. a. d. Grenzgebiete 
 d. Med. u. Chir. Bd. xi., H. 3. 
 
 Senator. Ueber Anaemia Splenica mit Ascites. Berl. klin. 
 Wochens., No. 46, 1901. 
 
 FiCHTEUR. Zur Kenntniss der Banti'schen Krankheit. Miinch. 
 med. Wochens., No. 11, 1903. 
 
 Pribram, Chiari. Banti'sche Krankheit. Prag. med. Wochens., 
 Nos. 2 and 24. 1902. 
 
 Laspeyres. Total Milzexstirpation. Centralb. f. d. Grenzgebiete 
 d. Med. u. Chir., 1904. 
 
 Tansini. Die Splenectomie bei Banti'schen Krankheit. Arch, 
 f. klin. Chir. Bd. Ixvii. 1902. 
 
 Harris and Herzog. Splenectomy in Splenic Anaemia. Annals 
 of Surgery, July, 1901. 
 
 Fevrier. Chirurgie de la Rate. Rev. de Chir., Oct., 1901. 
 
 FLOATING SPLEEN. 
 
 Etiology. — The most important etiological factors are 
 congenital anomalies, such as abnormal length of the liga- 
 ments, and acquired lengthening of the ligaments by trauma 
 or by the increased weight of the enlarged organ. Such 
 enlargement is most commonly due to malaria, leucaemia, 
 
36o INDICATIONS FOR OPERATION IN 
 
 or^pseudoleucaemia. The non-hypertrophic floating spleen 
 is most common in women. 
 
 Pathological Anatomy. — The dislocated spleen has 
 been found in all the regions of the abdomen. Most 
 commonly it is in the left hypogastrium ; in many cases 
 the position of the hilum is much modified. Such a 
 dislocated organ is often hypertrophied, and sometimes 
 profoundly altered in structure, by torsion of its pedicle ; 
 it may be atrophied and shrunken, or sometimes gangrenous ; 
 in the latter case the afferent and efferent vessels are 
 obstructed or entirely obliterated. The pedicle may have 
 more than one complete turn. A dislocated spleen may 
 be fixed by adhesions in its abnormal position. 
 
 Clinical Signs — A movable abdominal tumour is found, 
 and the spleen is absent from its nonnal position. Unless it 
 is fixed by adhesions it can be replaced in its normal situ- 
 ation. There may be no symptoms ; but often the patient 
 complains of vague troubles, feelings of distension, nausea, 
 dyspepsia, headache ; sometimes there are neuralgic pains, 
 and even paralyses of the legs or bladder tenesmus. Cases 
 presenting symptoms of intestinal obstruction have often 
 been described. Frequently there is general enteroptosis. 
 
 Diagnosis. — If the movable tumour has the characteristic 
 shape of the spleen, with the notch of the internal border, 
 and the hilum containing pulsating vessels ; if percussion 
 is tympanitic over the normal splenic area and changes 
 when the tumour is replaced, there can be no doubt as to 
 the diagnosis. The condition is often mistaken for floating 
 kidney and movable ovarian tumours, and sometimes for 
 tumours of other abdominal organs. The outline of the 
 tumour is important, and the examination of the loin for 
 the kidney, and of the pelvis for connections with the 
 generative organs. Friction over the tumour indicates 
 perisplenitis. Torsion of the pedicle must be diagnosed if 
 the patient has a sudden attack of acute pain, associated 
 with enlargement and exquisite tenderness of the splenic 
 tumour,'if the latter is noted to have altered its position, and 
 symptoms of early peritonitis and of collapse supervene. 
 
 INDICATIONS FOR OPERATION. 
 
 If, in spite of internal treatment prescribed with a view 
 to lessening the size of the spleen, and in spite of the wearing 
 
DISEASES OF THE SPLEEN. 361 
 
 of suitable bandages, the pains persist to such an intense 
 degree that hfe is made miserable, or if the spleen is of such 
 a size that in itself it constitutes a danger to life, then opera- 
 tion is advisable. 
 
 If torsion of the pedicle appears probable, extirpation 
 should be performed with a view to avoiding this very 
 dangerous complication. Some surgeons consider that a 
 movable spleen, whether enlarged or not, should be extir- 
 pated in view of the possibility of torsion of the pedicle. 
 This radical advice has not, however, at present many 
 supporters ; statistics show that the operation is not free 
 from risk, and, on the other hand, torsion is very unusual 
 when the organ is of normal size. Fixation of the spleen 
 by suture has been often recommended for such cases on 
 account of the smaller risk, but even this operation should 
 not be recommended for simple mobility unless the condition 
 is giving rise to marked symptoms. 
 
 Contra-indications. — If the patient's general health is 
 very bad, or if there are lesions in other organs, operation 
 will not be advisable ; leucaemia or pseudoleucaemia are 
 absolute contra-indications. Even when the pains and 
 other local disturbances are intense, operation should not 
 be done if they are present only for short periods and if 
 the spleen is of normal size, unless torsion of the pedicle 
 is suspected. Such symptoms may disappear entirely for 
 a long time after reposition of the organ. Seven years ago 
 I had under my care a young girl with floating spleen who 
 had attacks of intense pain of short duration ; these 
 disappeared after the application of a bandage. Although 
 she has been without the bandage now for some five years, 
 she has had no further attacks. 
 
 When the tumour is of very large size the danger of 
 operation is great, and in such cases extirpation is only 
 exceptionally indicated. Pregnancy does not absolutely 
 contra-indicate extirpation. 
 
 Prognosis. — Risks of operation. — Up to 1900, 92 cases of 
 floating spleen (of different etiology, hypertrophied, and 
 also of normal size) had been treated by extirpation (Bessel- 
 Hagen). Of these 17 died from the operation. The opera- 
 tive mortality is very high in cases of torsion of the pedicle, 
 on account of the serious nature of the condition. The 
 prognosis is relatively good in cases of malarial enlargement 
 
362 INDICATIONS FOR OPERATION IN 
 
 without torsion (i fatality in 15 cases), and in simple hyper- 
 trophy (2 deaths in 28 cases). 
 
 Results of operation. — Almost all cases regain their 
 capacity for work in a short time, and completely lose their 
 pains. 
 
 Withoiit operation. — In many cases mobility of the spleen 
 is well tolerated without symptoms or with only slight 
 disturbances. If torsion of the pedicle occurs, necrosis 
 follows and death results unless operation is done. 
 
 LITERATURE. 
 
 LiTTEN. Die Krankheiten der 'SlWz. Nothnagel's Handbuch 
 d. spez. Pathol, u. Therapie. Wien. 1898. 
 
 Bessel-H.\gen. Ein Beitrag zur Milz Chirurgie. Arch. f. kUn. 
 Chir. Bd. Ixii, H. i. 
 
 Laspeyres. Indikationen u. Resultate totaler Milzexstu-pation. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir. 1904. 
 
 Stierlix. Ueber die chir. Behandlung der Wandermilz. Zeit. f. 
 Chir. Bd. xlv. 
 
 ScHW'ARTZ. Alilzexstirpation. Wien. klin. Wochens., No. 52. 
 1900 ; and Centr. f. Gynak. Bd. xxiii., No. 31. 
 
 Christomanos. Ein Fall von vollstandiger Milznekrose. Beitr. 
 z. Path. Anat. Bd. xxiv, p. 519. 
 
 Fevrier. Chirurgie de la Rate. Rev. de Chir. Oct., 1901. 
 
 JoNNESco. La Splenectomie. Rev. de Chir., No. 11, 1894, and 
 No. 9, 1901. 
 
 Chandeleux. Splenectomi'i pour Rate Mobile. Lyon Medicale. 
 No. 13, 1900. 
 
 Scott Stone. Splenectomy for Floating Spleen. Annals of 
 Surgery, Sept., 1899. 
 
 W.\rren. The Surgerj- of the Spleen. Annals of Surgery, May, 
 1 90 1 . 
 
 RUPTURE OF THE SPLEEN. 
 
 Etiology? — The spleen is ruptured by injury, and the 
 accident may happen to the normal or the enlarged organ. 
 When altered by disease, slight injury may be sufficient 
 to cause rupture, and this is especially true of the malarial 
 spleen. 
 
 Pathological Anatomy. — Rupture of the spleen may 
 be the sole result of an abdominal trauma. Extravasation 
 of blood takes place into the abdominal cavity in large 
 quantity, and collects in its most dependent parts, or may 
 be limited by adhesions. In one of my cases an extravasa- 
 
DISEASES OF THE SPLEEN. 363 
 
 tion limited by adhesions around the spleen simulated an 
 enormous fixed splenic tumour. 
 
 Clinical Course and Diagnosis. — The symptoms of 
 rupture of the spleen are those of serious internal haemor- 
 rhage. First excruciating pain, pallor, vertigo, vomiting, 
 and syncope ; then the pulse becomes small and rapid, the 
 abdomen becomes distended, and there are signs of fluid, 
 either free in the peritoneal cavity or confined to the splenic 
 area. If the size of the hypertrophied spleen is already 
 known before the accident, its diminution is an important 
 aid in diagnosis. The diagnosis is, as a matter of fact, 
 only exceptionally possible, because internal haemorrhage 
 from other abdominal organs produces the same symptoms, 
 but it is probable when the fluid signs extend from the left 
 iliac fossa towards the right, and the previously enlarged 
 spleen diminishes in size. 
 
 INDICATIONS FOR OPERATION. 
 
 When the signs and symptoms point to internal 
 haemorrhage from splenic rupture, the abdomen must be 
 opened at once to discover the source of the haemorrhage 
 and remove the spleen. 
 
 Prognosis. — Risks and prospects of the operation. — 
 According to Jordan, in 29 cases operated on between 
 1893 and 1903, life has been saved by splenectomy. 
 Considering the gravity of the affection the operation 
 must, of course, be considered a serious undertaking. The 
 prognosis by " expectant " treatment is exceedingly bad ; 
 the great majority of cases so treated die. 
 
 LITERATURE. 
 
 LiTTEN. Krankheiten der Milz. Nothnagel's Handbuch d. spez. 
 PathoL u. Therap. Bd. viii 1898. 
 
 Jordan. Die Exstirpation der Milz., etc. Mitteil. a. d. Grenzge- 
 biete d. Med. u. Chir. Bd. xi, H. 3. 
 
 Laspeyres. Indikat. u. Result. Totaler Milzexstirpation. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir. 1904. 
 
 Berger. Die Verletzungen der Milz u. ihre chirurg. Behandlung. 
 Arch. f. klin. Chir. Bd. Ixviii. 1902. 
 
 Ballancb. On Splenectomy for Rupture without External 
 Wound. Practitioner, April, 1898. 
 
 LoisoN. Ruptures Traumatiques de la Rate dans les Contusions 
 de I'Abdomen. Bullet, de la Soc. de Chirurg. de Paris, xxvii, p. 40. 
 
 M.\uclaire. Rupture de la Rate. Ibidem. Nos. 4 and 24, 
 1901. 
 
364 INDICATIONS FOR OPERATION IN 
 
 ABSCESS OF THE SPLEEN. 
 
 Etiology. — Splenic abscess is usually due to injury, 
 to suppuration in the neighbourhood of the spleen, or to 
 embolus in ulcerative endocarditis. It occurs exceptionally 
 in cases of recurrent fever and enteric. 
 
 Pathological Anatomy. — Splenic abscesses may be 
 central or peripheral, solitary or multiple. The size varies 
 enormously up to that of a child's head. Sometimes the 
 suppuration spreads beyond the spleen, and a subphrenic 
 abscess is formed, and in such a case the spleen may be 
 suspended in the middle of the abscess cavity. Dense 
 adhesions may be formed to surrounding structures. The 
 pus may be sterile. 
 
 Clinical Signs and Diagnosis. — The diagnosis of this 
 rare affection is only occasionally possible. In a case of 
 ulcerative endocarditis or enteric fever, if the patient 
 complains of severe pain in the splenic region radiating to 
 the left shoulder, if there are perisplenic friction, rigors, and 
 fever which becomes remittent after a time, the diagnosis 
 will be clear. If a liuctuating area is discovered in an 
 enlarged spleen, exploratory puncture will clear up the 
 diagnosis, and if pus is found laparotomv must be done 
 forthwith. Sometimes the pus makes its way into a 
 neighbouring hollow viscus, sometimes into the abdominal 
 cavity or the lung, and the size of the enlarged organ will 
 then markedl}^ diminish. Among several cases which 
 have been under my care, the diagnosis was made in one 
 only by exploratory puncture. Most frequently I have 
 seen it in cases of endocarditis, and once in a case of pyle- 
 phlebitis secondary to disease of the appendix. 
 
 INDICATIONS FOR OPERATION. 
 
 If the diagnosis is certain operation is absolutely 
 indicated. The operation will consist either of puncture, 
 which is dangerous, on account of the risk of infecting the 
 peritoneum, or incision, or extirpation when the spleen is 
 bathed in pus and free from adhesions. 
 
 The only contra-indications are the presence of multiple 
 suppurative foci in the kidneys and elsewhere, and such a 
 state of general weakness that the patient will stand no 
 operation whatever. 
 
DISEASES OF THE SPLEEN 
 
 365 
 
 Prognosis.— Splenic abscess is usually fatal. It may 
 become encapsuled, and after long latency recrudescence 
 may take place. The case to which I have alluded was that 
 of a woman who had had puerperal fever some years 
 previously ; when seen she complained of severe pain in the 
 region of the spleen, but had no fever. 
 
 Laspeyres has collected 11 cases which were submitted 
 to operation ; recovery took place in all. It is probable 
 that there have been fatal cases which have not been 
 published. 
 
 LITERATURE. 
 
 LiTTEN. Die Krankheiten der Milz. Nothnagel's Handbuch d 
 spez. Pathol, u. Therap. Bd. viii. 
 
 Laspeyres. Indik. u. Result. Totaler Milzexstirpationen. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir. 1904. 
 
 Kehr. Chirurgie der Milz. Handbuch der prakt. Chir. Mikulicz, 
 Bruns, u. Bergmann. Bd. iii. 
 
 Bessel-Hagen. Ein Beitrag zur Milzchirurgie. Arch, f khn 
 Chir. Bd. Ixii, H. i. 
 
 Murphy. Note on Successful Splenectomy. Brit. Med. Jour 
 Nov. 3, 1894. 
 
 Fevrier. Chir. de la Rate. Rev. de Chir., 1901 ; and Gaz. 
 des Hopit., Oct., 1901. 
 
CHAPTER XXL 
 Diseases of the Pancreas. 
 
369 
 
 Chapter XXI. 
 DISEASES OF THE PANCREAS. 
 
 INFLAMMATION AND NECROSIS. 
 
 Etiology. — Pancreatitis may be secondary to ulcerative 
 processes in the stomach and duodenum, or may be due to 
 injury, spontaneous haemorrhage, cholelithiasis, or pan- 
 creatic calculus. Fat people are predisposed to pancreatic 
 necrosis. 
 
 Pathological Anatomy. — Suppurative, acute, haemor- 
 rhagic, and necrotic pancreatitis have been distinguished 
 pathologically ; these are not distinct types, but pass into 
 one another. Frequently small foci of fat necrosis are 
 found distributed throughout the peritoneal cavity. As a 
 result of inflammation and necrosis, large purulent and 
 septic collections may form, surrounding the necrosed 
 gland, and often encapsuled by extensive peritoneal 
 adhesions ; these abscesses usually occupy the upper part 
 of the abdomen. Many cases are complicated by infective 
 cholangitis of long standing, not uncommonly with im- 
 paction of a calculus in the ampulla of Vater, and regurgi- 
 tation of infected bile from the common bile-duct into the 
 pancreatic duct. 
 
 Clinical Course. — Mayo Robson has distinguished three 
 clinical types of pancreatitis : the acute, the subacute, and 
 the chronic. In corpulent individuals the disease often has 
 an acute and sudden onset. It commences with severe pain 
 in the epigastric region, vomiting, nausea, and peritoneal 
 symptoms. Meteorism rapidly develops, and diffuse 
 tenderness of the abdomen, with obstruction of fseces and 
 flatus. The pulse is small and rapid, and the patient 
 usually much collapsed ; fever is often absent. 
 
 If the patient does not die early from shock, an 
 
 24 
 
370 INDICATIONS FOR OPERATION IN 
 
 inflammatory swelling develops gradually in the upper 
 part of the abdomen, accompanied by pronounced loss 
 of strength and remittent fever. If the stomach and 
 colon are distended with air, the physical signs will show 
 that the swelling lies behind both. Enemata will often 
 empty the bowel, and later even diarrhoea may appear. 
 Sometimes the stools are fatty, and may contain undigested 
 muscle fibres ; in several cases glycosuria has been present. 
 There is persistent nausea and vomiting. 
 
 The skin is sometimes of a greyish brown colour. 
 Jaundice is often present, particularly when the pancreatitis 
 is of the chronic type, and in this form the enlarged head 
 of the pancreas may be felt as a hard tumour. The rapid 
 wasting causes a suspicion of new growth, and the attacks 
 may resemble gall-stone colic in such a way that this 
 condition may be diagnosed. As has already been stated, 
 the disease is often secondary to impaction of a stone in 
 Vater's ampulla. The gall-bladder is frequently distended 
 and palpable. 
 
 Diagnosis. — The diagnosis is often very difficult, and 
 in the early stages of acute pancreatitis it cannot as a 
 rule be made with certainty. In . most cases the condition 
 has been diagnosed as intestinal obstruction or perforative 
 peritonitis. Later the difficulties are less when there is 
 a history of a sudden onset, with pain in the epigastrium, 
 vomiting, constipation, and distension, when the tempera- 
 ture is raised and a swelling is present in the characteristic 
 position. If the stomach and colon be distended and are 
 found to lie in front of the tumour, the latter cannot belong 
 to liver, gall-bladder, or spleen. Confusion must sometimes 
 occur with obstruction, perforative peritonitis, perinephritis, 
 or a burrowing abscess, but this will not often happen if 
 the points mentioned are carefully considered. 
 
 In the case of a corpulent woman of middle age who had 
 been under the care of Ewald and myself for some years, 
 severe peritoneal symptoms suddenly appeared, and were 
 followed by the development of a large inflammatory and 
 apparently retroperitoneal swelling in the left hypochon- 
 drium. Seeing that the swelling extended across the 
 middle line and was confined to the upper part of the 
 abdomen, it was thought that we had to do with an inflam- 
 matory affection of the pancreas (? necrosis). The 
 
DISEASES OF THE PANCREAS. 371 
 
 abscess was opened, and throughout the peritoneum spots 
 of fat necrosis were found. Recovery took place. 
 
 Chronic pancreatitis is specially frequently mistaken 
 for carcinoma ; the head of the organ may be transformed 
 into a large hard nodular mass, which, even on operation, 
 cannot be distinguished from cancer. 
 
 INDICATIONS FOR OPERATION. 
 
 When a diagnosis of subacute pancreatitis is made, and 
 even when the signs and symptoms point only to the proba- 
 bility of the condition, operation should be undertaken unless 
 the general condition is extremely bad, particularly if there 
 is a palpable inflammatory swelling in the upper abdomen. 
 The abscess will be opened through an abdominal wound, 
 and drained. When chronic pancreatitis is suspected, 
 and serious symptoms, such as intense jaundice, rapid 
 wasting, and severe pain, are present, operation is advised 
 by many. Laparotomy is performed, and if a calculus is 
 found it is removed and the pancreatic duct drained, or a 
 biliary fistula is established, or cholecystenterostomy into 
 the duodenum. 
 
 In acute pancreatitis many surgeons are in favour of 
 operation, either simple opening of the abdomen and 
 drainage, or exposure and incision of the pancreas ; others 
 are opposed to this practice. The decision as to operation 
 depends almost always on the surgeon, not on the practi- 
 tioner or physician, for most cases are operated on under an 
 erroneous diagnosis or as exploratory laparotomies. 
 
 Contra-indications. — In the first stage, when this is 
 recognized, operation is considered inadvisable by many 
 surgeons, for most of the patients have died of shock either 
 during or soon after the operation. Whilst symptoms of 
 severe peritoneal irritation (universal meteorism, frequent 
 vomiting, obstruction to faeces and flatus) are present, 
 and the patient is much collapsed, many surgeons think it 
 well to suspend operation, but others, Mikulicz for example, 
 advise operation even under these conditions. 
 
 Prognosis. — Results of operation. — In seventy-five cases 
 of acute pancreatitis operated on early and late, twenty- 
 nine recovered ; of the latter twenty-five belonged to a group 
 of thirty-seven cases, in which the pancreas itself was dealt 
 with, whilst four only recovered out of forty-one cases 
 
372 INDICATIONS FOR OPERATION IN 
 
 in which the pancreas was left untouched (v. MikuHcz). A 
 considerable number of deaths have occurred immediately 
 after the operation ; others have taken place at variable 
 periods from profuse suppuration or secondary haemorrhages. 
 Sometimes a pancreatic fistula forms, but this almost always 
 heals. According to Mikulicz the prognosis of operation 
 in chronic pancreatitis is good ; of thirty-eight cases 
 thirty-three recovered and five died. Truhart has collected 
 seventeen cases of recovery after operation, in cases with 
 multiple abdominal fat necrosis. 
 
 Without operation. — In subacute pancreatitis or necrosis 
 death usually occurs with progressive marasmus. Either 
 universal peritonitis develops, or venous thrombosis, or 
 abscess of liver or spleen, or a subphrenic abscess may 
 form and involve the pleura and lung by penetrating 
 the diaphragm. In rare instances spontaneous recovery 
 has taken place in cases with multiple fat necrosis 
 after elimination of the necrotic pancreas per rectum, 
 or the spontaneous rupture of an abscess through 
 the abdominal wall. Truhart has collected eight such 
 cases. 
 
 Chronic pancreatitis in many cases causes death from 
 cachexia and cholaemia by compression of the bile-ducts. 
 I can call to mind a not inconsiderable number of such 
 cases which I have had the opportunity of examining 
 post mortem. 
 
 LITERATURE. 
 
 KoRTE. Die chirurgischen Krankheiten des Pankreas. Deut. 
 Chir. Stuttgart: Enke. 1898. 
 
 OsER. Krankheiten des Pankreas. Nothnagel's Handbuch d. 
 spez. Pathol, u. Therap. 1898. 
 
 H. Truhart. Pankreas-Pathologie. Teil i. Multiple abdominelle 
 Fettgewebsnekrose. Wiesbaden: F. Bergmann. 1902. 
 
 Takayasu. Beitr. z. Chir. d. Pankreas. Mitteil. a. d. Grenzge- 
 biete d. Med. u. Chir. Bd. iii. 
 
 v. Mikulicz. Ueber den Heutigen Stand der Chirurgie des 
 Pankreas. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. xii, 
 Hf. I. 
 
 Mayo Robsok and Moynihan. Diseases of the Pancreas and 
 their Surgical Treatment. 1903. 
 
 Newton Pitt. Five Cases of Acute Pancreatitis. Trans. Qin. 
 Soc, London. 1899. 
 
 Page. Traitement des Pancreatites Suppurees et Gangreneuses. 
 These de Bordeaux. 1898. 
 
DISEASES OF THE PANCREAS. 373 
 
 Faure. Pancreatite Suppuree. Bullet, et Mem. de la Soc. de 
 Chirurgie de Paris, Dec. 8, 1899. 
 
 M. Heger. La Chirurgie du Pancreas. Jour. Med. de Bruxelles, 
 5 annee, No. ;i^. 
 
 PANCREATIC CALCULUS. 
 
 Etiology. — Nothing is known as to tlie nature of the 
 processes which give rise to the formation of pancreatic 
 calcuh, except that anything which causes stagnation of 
 secretion appears to conduce to their formation. They 
 occur most frequently in men, between the ages of thirty-five 
 and forty-five. 
 
 Pathological Anatomy. — As a rule more than one stone 
 is found, and in some cases the canal of Wursung is' encrusted. 
 The place of lodgement is frequently in the neighbourhood 
 of the duodenal opening ; a calculus may reach the size 
 of a cherry, the usual composition is calcium phosphate 
 or carbonate. Frequently there are inflammatory changes 
 in the pancreatic parenchyma and ducts, and abscesses 
 may result therefrom. 
 
 Clinical Course. — The commonest symptom is the 
 occurrence of severe attacks of colic, resembling biliary 
 colic and localized in the epigastrium. Often the pain 
 radiates markedly to the left. Greyish- white calculi of 
 the characteristic composition are sometimes passed after 
 an attack. Intense ptyalism has often been noted during 
 an attack ; late symptoms sometimes found are diarrhoea, 
 with the discharge of quantities of unchanged muscle fibre 
 and abnormal amounts of unabsorbed fat, and diabetes. 
 There is sometimes jaundice during or after an attack ; 
 fever is unusual. 
 
 The diagnosis is based on the occurrence of attacks of 
 colic, followed by the evacuation of characteristic concretions 
 and sometimes by slight jaundice. Later symptoms which 
 may appear are glycosuria, steatorrhoea, and disturbances of 
 digestion. At these late stages the diagnosis is only 
 possible in rare cases. 
 
 INDICATIONS FOR OPERATION. 
 
 According to v. Mikulicz, pancreatic calculi rarely give 
 rise to characteristic symptoms unless they are discharged 
 in tlie fa;;ces, and it is only the secondary changes produced 
 
374 INDICATIONS FOR OPERATION IN 
 
 by them which, as a rule, come to the notice of the surgeon. 
 These changes are the result of obstruction of the pancreatic 
 duct and its branches, and eventuate in a chronic or sub- 
 acute pancreatitis. Surgical intervention finds an indication 
 only in the symptoms produced by this condition of 
 pancreatitis, but in all cases of this nature the possibility 
 of the presence of a calculus should be borne in mind. 
 The indications for operation will therefore depend upon 
 the appearance of a palpable inflammatory swelling in the 
 position of the pancreas, accompanied by pain, fever, and 
 other pronounced symptoms. 
 
 Contra-indications. — The existence of colic without 
 discharge of characteristic calculi, and without the appear- 
 ance of a swelling in the position of the pancreas, leaves the 
 diagnosis so uncertain that operation should not be recom- 
 mended. If calculi are discharged and the symptoms are 
 relatively slight, operation will again be inadvisable. 
 
 Prognosis. — With regard to the risks of operation and 
 the prognosis as to recurrence if a stone is successfully 
 removed, clinical experience is not sufficiently extensive 
 for the formulating of a definite statement. Of three cases 
 operated on two died from the operation, the third being 
 cured by removal of a calculus through the duodenum. 
 
 LITERATURE. 
 
 G. Zesas. Beitr. z. Diagnose der Lithiasis Pancreatica. Centralb. 
 f. d. Grenzgebiete der Aled. u. Chir., 21, 1903. 
 
 V. Mikulicz. Ueber der Heutigen Stand der Chirurgie des Pan- 
 creas. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. xii, Hf. i. 
 
 Mayo Robson and Moynihan. Diseases of the Pancreas and 
 their Surgical Treatment. Saunders & Co. 1903. 
 
 KoRTE. Die chirurgischen Krankheiten des Pancreas. Deut. 
 Chir. Stuttgart. 1898. 
 
 OsER. Pankreaskrankheiten. Nothnagel's Handbuch d. spez. 
 Pathol, u. Therap. Wien. 1898. 
 
 M. Heger. La Chirurgie du Pancreas. Jour. Med. de Bruxelles. 
 5 annee, No. 33. 
 
 Movnihan. Lancet, August, 1902. 
 
 PANCREATIC CYSTS. 
 
 Etiology. — Injury and chronic interstitial inflammatory 
 affections appear to be of considerable etiological importance. 
 Individuals of middle age are most frequently affected. 
 
DISEASES OF THE PANCREAS. 375 
 
 Pathological Anatomy. — These cysts may be of great 
 size and contain up to 20 litres of fluid. They grow 
 forwards, as a rule, in the bursa omentalis, between the 
 stomach and the transverse colon ; more rarely they 
 present above the lesser curvature or below the transverse 
 colon. They are usually sessile, exceptionally pedunculated. 
 They contain a colourless or dark-coloured fluid, in which 
 the pancreatic ferments are usually demonstrable. 
 
 Clinical Signs. — Symptoms which are often present 
 early are epigastric pain, vomiting, rapid wasting, and 
 jaundice. The rounded, elastic, and generally immobile 
 cyst is more usually in the middle line than laterally in 
 the hypochondrium. Glycosuria or fatty stools are rarely 
 found, and the intestinal digestion is as a rule 
 unaffected. The growth is usually very gradual ; periodic 
 enlargement and dwindling have often been noted. 
 
 Diagnosis. — The diagnosis will be based on a history 
 of trauma or chronic inflammation, on the presence of 
 symptoms due to pressure on the stomach and intestine, 
 and on the localization of the tumour and its relation to 
 these organs. When the stomach is distended the cyst is in 
 many cases partially covered, in most cases from above down- 
 wards, more rarely from below upwards. Distension of the 
 colon will show that the cyst lies above it when it occupies 
 the usual position between this and the stomach. Explora- 
 tory puncture is dangerous and not to be recommended. 
 
 Differential diagnosis from other cystic abdominal 
 affections is often very difficult. In even a very large 
 ovarian cyst the stomach is not found overlying, and when 
 an ovarian cyst is situated high the uterus is dragged up. 
 Cysts of the liver are never covered by the distended or 
 inflated stomach. The enlarged gall-bladder hardly ever 
 has intestine in front of it ; cysts of the head of the pancreas 
 are almost always overlaid in part ; however, in one case 
 of pancreatic cyst, verified by operation, I diagnosed 
 a gall-bladder affection on account of the extreme mobility 
 of the cyst and the history of the case. Splenic cysts are 
 also to be differentiated by the absence of stomach or 
 intestine in front of them. A hydronephrotic cyst does 
 not develop forwards from the epigastrium, and when the 
 colon is blown up it is easily palpable in the loin, this bowel 
 being then often found medianwards of the swelling. Cysts 
 
376 INDICATIONS FOR OPERATION IN 
 
 of the^mesentery and retention cysts of the cavity of the 
 omentum are often indistinguishable from pancreatic cysts 
 extending forwards. 
 
 INDICATIONS FOR OPERATION. 
 
 Seeing that pancreatic cysts left to themselves become 
 progressively larger, operation is advisable as soon as there 
 is a reasonable certainty of the condition. Operation will 
 be hastened by the presence of marked symptoms, particu- 
 larly pain. Sudden collapse, associated with disappearance 
 of the cyst and signs of peritoneal shock, point to rupture, 
 and constitute an absolute indication for immediate 
 operation. Operative intervention will consist in either 
 opening the cyst after suture to the abdominal wall in 
 either one or two stages, or in extirpation of the cyst. 
 Puncture, either for diagnostic or therapeutic purposes, 
 is a very dangerous proceeding ; five out of seven cases so 
 treated died. 
 
 Contra-indications. — There cannot be said to be any 
 contra-indications except the presence of such general 
 weakness, or intercurrent disease, or advanced age, as to 
 render any operation inadvisable. 
 
 Prognosis. — Risks and results of operation. — Of 141 cases 
 treated by suture and drainage seven died as a result of the 
 operation, one from a late infection from the fistula. 
 Peritonitis resulting from escape of the fluid into the general 
 cavity is especially to be feared. In 22 cases of extirpation 
 there was a mortality of four ; this method is more serious 
 and more risky. A fistula may persist for a long time after 
 operation, even for several years ; a troublesome eczema 
 often develops around the fistulous opening ; in one case 
 death occurred from erosion of the splenic artery. Necrosis 
 of the cyst wall, often seen after incision, may give rise to 
 septic infection. 
 
 Complete recovery is frequent after both drainage and 
 extirpation. Ten cases reported by v. Mikulicz recovered 
 entirely ; in two the cyst was extirpated ; in eight it was 
 incised. In most cases recovery is permanent ; in a few 
 cases of incision recurrence has occurred. As a rule the 
 symptoms disappear after operation. 
 
 Without operation. — In many cases death has occurred 
 from rupture of the cyst or severe haemorrhage into it. 
 
DISEASES OF THE PANCREAS. Z77 
 
 The tendency is for the cyst to grow steadily, and produce 
 all the painful and serious symptoms associated with large 
 growths of the upper abdomen. 
 
 LITERATURE. 
 
 KoRTE. Die chirurgische Krankheiten des Pankreas. Deut. 
 Chirurgie. Stuttgart. 1898. 
 
 KoRTE. Pankreaskrankheiten. Handbuch d. prakt. Chir. v. 
 Mikulicz, Bruns, u. Bergmann. Bd. iii. 1903. 
 
 OsER. Krankheiten des Pankreas. Nothnagel's Handbuch d. 
 spez. Pathol, u. Therap. Wien. 1898. 
 
 Takayasu. Beitr. z. Chir. d. Pankreas. Mitteil. a. d. Grenzge- 
 biete d. Med. u. Chir. Bd. iii. 
 
 MUNZER. Pancreascysten. Centralb. f. d. Grenzgebiete d. Med. 
 u. Chir. 1903. 
 
 V. Mikulicz. Ueber den Heutigen Stand der Chirurgie des 
 Pankreas. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. xii, 
 H. I. 
 
 Barker. A Case of Pancreatic Cyst. Brit. Med. Jour., March 
 18, 1899. 
 
 Pollard. Three Cases of Cyst of the Pancreas. Brit. Med. 
 Jour., March n, 1899. 
 
 DelagexNIere. Des Kystes Glandulaires du Pancreas- Arch. 
 Provin. de Lyon., No. 4, 1900. 
 
 M. Heger. La Chirurgie du Pancreas. Jour. Med. de Bruxelles. 
 5 annee, No. 33. 
 
 Tulasne. Contribution a I'Etude des Kystes Glandulaires du 
 Pancreas. These de Paris. 1899. 
 
 SOLID TUMOURS OF THE PANCREAS. 
 
 Etiology. — The etiology of tumours of the pancreas 
 is that of new growths in general. Most patients affected 
 are about middle age. Primary cancer is more frequently 
 met with in men than in women. 
 
 Pathological Anatomy. — The most common of the 
 primary tumours is carcinoma (scirrhus, medullary, 
 cylindrical-celled carcinoma) ; much less common are 
 adenoma, sarcoma, tubercle, and gumma. Primary cancer 
 is met with most commonly in the head of the pancreas ; 
 the duct is sometimes obliterated, and marked compression 
 of the common bile-duct is also frequent. Perforation 
 into the stomach is not very unusual. 
 
 Clinical Signs. — Intense, sometimes intermittent, pain 
 in the epigastrium is often present. In more than three- 
 fourths of all cases the infiltrated head of the pancreas 
 
378 INDICATIONS FOR OPERATION IN 
 
 compresses the common bile-duct and causes jaundice and 
 clay-coloured stools. It is not often that a palpable 
 epigastric tumour is found ; if present it much assists the 
 diagnosis. Such a tumour will usually have the pulsations 
 of the aorta transmitted to it. Glycosuria and fatty stools 
 have only rarely been recorded. Sometimes the pylorus 
 is compressed and dilatation of the stomach caused. 
 
 Cachexia often occurs early, and once established it 
 steadily progresses ; intense general weakness is also often 
 an early symptom. 
 
 Diagnosis. — In a case of jaundice associated with 
 distension of the gall-bladder, where symptoms of calculus 
 are absent and a tumour is to be felt in the epigastrium 
 which does not follow the movements of the stomach, a 
 pancreatic new growth should be suspected (Korte). In 
 obliteration of the bile-duct by calculus the gall-bladder 
 is usually small and shrunken. Stomach tumours are 
 associated with chemical changes in the gastric secretions, 
 and gastric stagnation. Tumours of the colon may be 
 differentiated from tumours of the tail of the pancreas by 
 inflating the stomach and colon ; a tumour of the tail of 
 the pancreas will present between the stomach and transverse 
 colon. 
 
 INDICATIONS FOR OPERATION. 
 
 Korte has formulated the following indications : "If 
 a tumour of the pancreas is discovered which is giving rise 
 to symptoms, and if after careful and prolonged examina- 
 tion there appears to be a chance of removing it entirely, 
 operation should be undertaken." Radical operation con- 
 sists of extirpation through an abdominal incision. The 
 palliative operations are the establishment of a biliary 
 fistula, cholecystenterostomy, and gastro-enterostomy (for 
 duodenal obstruction). Such measures will only be taken 
 when the symptoms are intolerable ; when, for example, 
 there is pronounced intestinal stenosis, with much suffering, 
 or some other very troublesome symptom, such as intense 
 pruritus from jaundice, and a distended gall-bladder. 
 
 Contra-indications. — Long-standing intense jaundice is a 
 contra-indication to operation on account of the tendency 
 to haemorrhage and to the onset of severe shock. In the 
 absence of jaundice no operation will be done when the 
 
DISEASES OF THE PANCREAS. 379 
 
 general condition is low, when metastases are present, or 
 when the new growth has encroached on neighbouring 
 organs. 
 
 Prognosis. — Risks and results of operation. — It is only 
 rarely that a chance occurs of ridding a patient of a 
 carcinoma of the pancreas, on account of the difficulties of 
 early diagnosis ; yet several successful cases have been 
 placed on record. The risks of the operation are con- 
 siderable ; several patients have succumbed immediately 
 after the operation, one case from gangrene of the colon. 
 Cholecystostomy obviates cholsemia but produces all the 
 inconveniences of a biliary fistula for the rest of the 
 patient's life — discharge, eczema, etc. In 20 cases life 
 was prolonged not more than three months after the 
 operation in any one. Cholecystenterostomy may be 
 followed by cholangitis ; nevertheless, in one case the 
 patient survived the operation 19 months, in another 12 
 months ; operative death occurred in 2 cases out of 12. 
 On the whole the palliative operations for pancreatic tumour 
 do not give much satisfaction. One of my patients suc- 
 cumbed some weeks after opening the gall-bladder ; he 
 derived no real benefit from the operation. 
 
 Without operation. — In most cases carcinoma of the 
 pancreas terminates in death from four to five months 
 after the appearance of symptoms. Benign pancreatic 
 growths may attain enormous dimensions, and cause 
 intolerable suffering, particularly by compression of the 
 bile-duct. 
 
 LITERATURE. 
 
 KoRTE. Krankheiten des Pankreas. Deut. Chirurgie. Stuttgart. 
 1898. 
 
 OsER. Krankheiten des Pankreas. Nothnagel's Handbuch d. 
 Pathol, u. Therap. Wien. 1898. 
 
 Takayasu. Beitr. z. Chir. des Pankreas. Mitteil. a. d. Grenzge- 
 biete d. Med. u. Chir. Bd. iii. 
 
 Franke. Ueber die Exstirpation der krebsigen Bauchspeichel- 
 driise. Arch. f. kUn. Chir. Ixiv, H. 2. 
 
 M Heger. La Chirurgie du Pancreas. Jour. Med. de Bruxelles. 
 5 annee, No. 2ii- 
 
 Terrier. Carcinom. des Pankreaskopfcs. Rev. de Chir. 1896. 
 
 Mayo Robson and Moynihan. Diseases of the Pancreas. 1903. 
 
CHAPTER XXII. 
 
 Diseases of the Kidney and Renal Pelvis. 
 
38: 
 
 Chapter XXII. 
 
 DISEASES OF THE KIDNEY AND RENAL 
 
 PELVIS. 
 
 BRIGHT'S DISEASE. 
 
 Etiology. — Acute Bright's disease may follow one of 
 the infective diseases or develop during the course of the 
 same, or may be due to one of the intoxications, or may 
 arise from an unknown cause. Chronic nephritis often 
 supervenes on the acute disease, or may be due to some 
 chronic infective disease (syphilis, tuberculosis), or to a 
 chronic intoxication (alcohol, lead). Granular contracted 
 kidney occurs from the same causes, but also from diseases 
 of nutrition (gout) and from arteriosclerosis. 
 
 Pathological Anatomy. — In post-mortem examinations 
 both kidneys have always been found diseased, but surgical 
 autopsies appear to show that the disease is more often 
 at first unilateral. The inflammatory condition is not 
 always diffuse ; sometimes it is circumscribed. The 
 following forms have been distinguished : acute parenchy- 
 matous nephritis, usually associated with enlargement of the 
 organ ; chronic parenchymatous nephritis (the large white 
 and the large mottled kidney), with secondary atrophy ; 
 and the genuine contracted kidney, with indurated patches, 
 and often associated with marked endarteritis of the renal 
 arteries. 
 
 Clinical Course. — Acute nephritis often runs an apyrexic 
 course. Pain in the loin and tenderness on pressure are 
 often to be noted. The amount of urine is usually dimi- 
 nished, high coloured, of high specific gravity, and contains 
 much albumin, blood, and numerous granular casts beset 
 with red cells and epithelial cells. Marked general cedema 
 is usually, but not always, present. Cardiac hypertrophy 
 
384 INDICATIONS FOR OPERATION IN 
 
 does not occur in the first weeks, but later is not uncommon. 
 Uraemia often develops. 
 
 In chronic parenchymatous nephritis the amount of 
 urine passed is usually but little less than normal, and 
 of about normal specific gravity, containing albumin 
 and blood in considerable quantity. The deposit contains 
 numerous granular casts, blood corpuscles, and renal 
 epithelia. Occasionally, but rarely, pure blood is dis- 
 charged for a considerable time. Hypertrophy of the left 
 ventricle is the rule, and albuminuric retinitis is frequently 
 present. Uraemia is relatively uncommon in this form of 
 nephritis. Exceptionally there occur cases of nephritis 
 without albuminuria or casts, and characterized by the 
 onset of attacks of colic and haemorrhages. Such cases 
 are of special surgical interest, and the condition appears 
 to be usually unilateral. 
 
 In secondary and primary contracted kidney the arterial 
 tension is high and the hypertrophy of the left ventricle 
 pronounced. The urine is abundant, clear, and of low 
 specific gravity ; contains little albumin and few casts 
 or renal elements. Cerebral haemorrhage and advanced 
 anasarca are common. 
 
 Spontaneous recovery often takes place in acute nephritis ; 
 in some cases death occurs from uraemia or heart failure, in 
 others chronic nephritis supervenes. Chronic parenchy- 
 matous nephritis often produces intense oedema, and 
 terminates fatally in the course of twelve to twenty-four 
 months. The progress of the disease is often intermittent ; 
 in such cases periods of improvement are followed by acute 
 haemorrhagic exacerbations. When the .condition passes 
 into that of contracted kidney the duration of life is 
 prolonged. 
 
 In the different forms of contracted kidney the patient's 
 existence is threatened by cardiac insufficiency and uraemia ; 
 uraemia may have an acute or a subacute onset. The 
 diagnosis of the different forms of nephritis is based chiefly 
 on the urine examination. 
 
 INDICATIONS FOR OPERATION. 
 
 The question of operative interference in Bright's disease 
 has been discussed for some years, but opinions still differ 
 much as to the indications. Most writers are in agreement 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 385 
 
 on the following point : that in acute nephritis, where there 
 is marked oliguria or anuria, when the general condition is 
 good, and there is marked pain and tenderness on pressure 
 over one or both kidneys, operation should be recommended 
 (Lennander). The same holds true for acute and for acute 
 exacerbating nephritis. The operation consists in exposing 
 the kidney and removing the fibrous capsule (nephrolysis) ; 
 many surgeons also make an incision into the kidney to 
 relieve tension. 
 
 A second indication, not generally agreed upon, is the 
 onset of acute unilateral or bilateral pain in cases of nephritis 
 which have become chronic ; here, too, nephrolysis is 
 practised. 
 
 A third indication is the occurrence of attacks of 
 hsematuria associated with colic ; in such cases operation 
 is sometimes necessary to save life. 
 
 When acute uraemia supervenes, and anuria appears 
 suddenly in the course of nephritis, operation should be 
 undertaken, according to Israel, in the first forty-eight 
 hours, whether lumbar pain is present or not. The operation 
 will consist of incision of at least one kidney for the relief 
 of tension. In acute uraemia, when operation for some 
 reason or other is impossible, venesection is urgently called 
 for, and must be repeated if necessary, and followed by the 
 injection of large quantities (^ litre) of normal saline (Leube). 
 When universal oedema is present and cardiac and diuretic 
 remedies are ineffectual, the lower extremities should be 
 scarified, or capillary trochars inserted to relieve the heart 
 and overcome the local tension. 
 
 Contra-indications. — Direct operation on the kidney is 
 contra-indicated by the presence of severe complicating 
 disease, especially heart failure, atheroma, and organic 
 heart disease, unless the renal condition immediately 
 threatens death, as, for instance, when anuria supervenes. 
 If the diminution in urine secretion is only slight, operation 
 is not called for, since spontaneous improvement often 
 occurs. Operation is not justifiable for haematuria of 
 moderate amount and short duration. 
 
 Chronic urcemia with remissions and exacerbations 
 contra-indicates repeated venesection. 
 
 Extensive eczema of the legs or inflammatory affections 
 of the skin contra-indicate scarification ; if done under 
 
 25 
 
386 INDICATIONS FOR OPERATION IN 
 
 such conditions there is a risk of the eczema becoming" 
 acute and spreading. 
 
 Prognosis. — Risks of operation. — The patient must as a 
 rule be anaesthetized for an operation on the kidney ; the 
 risk from the anaesthetic is relatively considerable on 
 account of the changes in the heart muscle frequently 
 present ; the danger of heart failure is particularly great 
 when uraemia with complete anuria has been present for 
 several days. Even when done earlier the risk is not small, 
 for the anaesthetic preparations, and particularly chloroform, 
 exercise a deleterious effect on the renal parenchyma, and 
 may intensify the inflammatory process. 
 
 It is not improbable that incisions into the kidney tissue 
 are followed by secondary cicatricial contraction. In 
 one case it was necessary to proceed to nephrectomy eight 
 days after the operation on account of secondary haemor- 
 rhage ; in one instance gangrene followed operation. A 
 urinary fistula may be left behind by the operation. 
 
 Puncture and scarification may be followed by erysipelas 
 or phlegmonous inflammation, processes which are specially 
 prone to affect patients with Bright's disease ; repeated 
 scarification may, however, be done without these affec- 
 tions supervening ; in one of my own cases this was done 
 more than a dozen times in six months without any such 
 complication. 
 
 Results of operation. — In many cases of oliguria or anuria 
 nephrolysis or incision of one kidney alone, although both 
 were affected, has been followed by re-establishment of 
 secretion and disappearance of the symptoms threatening 
 the patient's life. Not only oliguria but also serious renal 
 haemorrhage has been sometimes permanently checked by 
 intervention. In uraemia marked improvement is often 
 produced by venesection and injection of saline solution ; 
 not infrequently the alarming symptoms disappear. 
 
 Scarification often remarkably improves the condition 
 of the cedematous extremities, and, more important still, 
 relieves the heart. In one of my own cases 29 litres of 
 fluid came from the legs in two days. In many cases one 
 has seen improvement in diuresis and diminution of oedema 
 follow this small operation. 
 
 One case under my care was that of a young man who, 
 following gonorrhoea, had high fever, and complained of 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 387 
 
 intense pain in the left loin. There were traces of albumin 
 in the urine, pus corpuscles in the sediment, no casts. 
 The kidney was markedly enlarged and tender to pressure. 
 The fever persisted several weeks, suppuration was suspected, 
 and the kidney was cut down upon ; it was found only 
 to be enlarged and dark red in colour, and on section the 
 details of structure were obscured. After the operation 
 the fever disappeared entirely and suddenly, the pains 
 diminished, the albumin soon disappeared from the urine, 
 and the patient made a rapid recovery. 
 
 Abstention from operation means in many cases that 
 the patient is given up as hopeless, but in others is 
 dictated by the prospect of relieving or possibly curing 
 the patient without it. 
 
 LITERATURE. 
 
 .P. K. Pel. Nierenentzundung (M. Brightii) vor dem Forum der 
 Chirurgen. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. viii. 
 
 J. Israel. Ueber der Einfiuss der Nierenspaltung auf akute u. 
 chronische Krankheitsprozesse des Nierenparenchyms. Mitteil. a. 
 d. Grenzgebiete d. Med. u. Chir. Bd. v. 
 
 Idem. Chir. Khnik der Nierenkrankheiten. Berhn. 1901. 
 
 Naunyn. Hamaturie aus Normalen Nieren und bei Nephritis. 
 Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. v. 
 
 Senator. Die Erkrankungen der Niere. 2nd Ed. 1903. 
 
 Strubell. Der Aderlass. Centralb. f. d. Grenzgebiete d. Med. 
 u. Chir. 1902. 
 
 KoRTEWEG. Die Indikationen zur Entspannungsincision bei 
 Nierenleiden. Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. viii. 
 
 KuMMEL. Die Grenzen erfolgreicher Nierenexstirpation. Arch. 
 f. klin. Chir. Bd. Ixvii. 1902. 
 
 Lennander. Wann kann akute Nephritis Veranlassung zu 
 chirurgischen Eingriffen werden ? Mitteil. a. d. Grenzgebiete d. 
 Med. u. Chir. Bd. x. 
 
 Lepine. Sur rOpportunite d'une Intervention Chirurgicale 
 dans la Nephrite Chronique. La Semaine Medicale. No. 49, p. 397, 
 1902. 
 
 A. PoussoN. Traitement Chirurgical des Nephrites Medicales. 
 Paris. 1904. 
 
 RENAL NEURALGIA 
 
 {Nephralgia Hcematurica, Angioneurotic HcBmaturia). 
 
 Etiology. — There is no single etiological cause of these 
 affections. The attacks are caused sometimes by changes 
 in the kidneys themselves, sometimes by changes in their 
 
388 INDICATIONS FOR OPERATION IN 
 
 surroundings, and sometimes are due to nervous affections 
 (tabes). 
 
 Pathological Anatomy. — The many histological in- 
 vestigations which have been carried out on extirpated 
 kidneys or portions of the organ have shown that in a 
 considerable number more or less extensive nephritic 
 processes are present. This inflammatory condition may 
 be unilateral or bilateral, and it. is sometimes the latter 
 when the clinical signs are all referred to one side. Some- 
 times there is displacement or adhesions or torsion of the 
 kidney. 
 
 Clinical Course. — Renal neuralgia is characterized by 
 very intense paroxysmal pain, often associated with or 
 followed by haematuria ; the bleeding may consist of a 
 single large haemorrhage. The pain and haemorrhage are 
 limited to one side ; in the intervals there is no albumin 
 in the urine. In rare instances casts — hyaline, granular, 
 or epithelial — are found, without albumin. The pain often 
 radiates to the urinary bladder and the glans penis. The 
 affection may persist for years ; between the attacks 
 there may be long periods of quiescence, extending to 
 several years. 
 
 Diagnosis. — The attacks resemble those which are 
 associated with calculus, tuberculosis, and new growths. 
 If there are no signs which point to one or other of these 
 morbid affections, such as calculi, tumour particles, pus, 
 tubercle bacilli, etc., the diagnosis of renal neuralgia becomes 
 probable by exclusion, but no certainty can be arrived at 
 as to the actual anatomical change present. Rarely in 
 granular contracted kidneys a similar train of symptoms 
 occurs. 
 
 INDICATIONS FOR OPERATION. 
 
 If a probable diagnosis of renal neuralgia is arrived at ; 
 if the attacks are so frequent that the patient is insistent 
 on relief ; if frequent and profuse haemorrhages are sapping 
 his strength, and if internal treatment fails, an exploratory 
 operation should be done and means taken to deal with 
 whatever abnormality may be found, for example by the 
 release of adhesions, by decapsulation, or fixation. If 
 haemorrhage is the predominant symptom, incision of the 
 kidney is indicated. Operation is contra-indicated by the 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 389 
 
 presence of serious intercurrent disease, particularly cardiac 
 disease. 
 
 Prognosis. — Results and risks of operation. — In many 
 cases operation has had a favourable influence on the 
 condition, and not infrequently brings about complete 
 relief. In some cases the attacks have recurred after 
 a variable period : in six out of eleven of Israel's cases 
 this happened. The risks of operation appear to be 
 considerable ; there is the risk of diffuse bilateral renal 
 inflammation, increased by narcosis, and tending to 
 produce a condition of uraemia, and there are the 
 risks associated with degenerate heart muscle. Of the 
 cases operated on by Israel, three died as a result of the 
 operation. If no operation be undertaken, a very grave 
 state of affairs may supervene from anaemia of high grade 
 and continued attacks of pain. 
 
 LITERATURE. 
 
 Senator. Die Erkrankungen der Niere. 2nd. Ed. Wien. 
 1903. Nothnagel's Handbuch d. spez. Pathol, u. Therap. Bd. xix. 
 
 Israel. Chirurgische Klinik der Nierenkrankheiten. Berlin. 
 1901. 
 
 ZiEGLER. Hsematuria renalis. Centralb. f. d. Grenzgebiete d. 
 Med. u. Chir., No. 11, 1900. 
 
 RovsiNG. Operation chronisch. Nephritiden. Mitteil. a. d. 
 Grenzgebiete d. Med. u. Chir. Bd. x. 
 
 Klemperer. Behandlung von Nierenblutungen. Therapie der 
 Gegenwart. January, 1901. 
 
 PoussoN. Bull, et Mem. de la Societe der Chir. de Paris. No. 
 20, p. 590. 1898. 
 
 RENAL CALCULUS. 
 
 Etiology. — Hereditary tendencies play an important 
 part. Gouty families are often affected. The condition 
 is common above the average in certain localities ; it is 
 most frequent in chfldren up to the age of five years, and 
 in men from the age of forty upwards. Foreign bodies 
 (distomum and fragments of tissue debris), and traumatic 
 haemorrhages may act as causative factors. The catarrh 
 of the urinary passages associated with affections of the 
 spinal cord predisposes to calculus. Renal and biliary 
 calculi have often been found present simultaneously in 
 
390 INDICATIONS FOR OPERATION IN 
 
 the same patient. The Distomum hcBmatohium is an 
 important etiological factor in tropical countries. 
 
 Pathological Anatomy. — The number of calculi in 
 a kidney varies from one to several hundred. The oxalate 
 stones are usually single ; the multiple stones are usually 
 composed of urate and phosphate. In more than half the 
 cases one kidney alone is affected, particularly the left. 
 Calculi may be spherical or cylindrical or branched, some- 
 times ring-shaped; they may reach the size of a walnut. 
 They are almost always in the pelvis, calices, or ureter, very 
 rarely in the parenchyma. Most common are the yellow 
 brown uric acid stones, next the dark grey mulberry oxalate, 
 then the greyish white phosphate ; rare forms are composed 
 of calcium phosphate and carbonate, cystin, xanthin. 
 When the condition is bilateral the composition of the two 
 calculi is sometimes different. Associated with the calculus 
 there is sometimes incrustation of the renal pelvis with 
 calcium phosphate. 
 
 The renal changes may be aseptic or infected. The 
 aseptic changes consist of chronic interstitial inflammatory 
 processes of the renal tissue, processes due to retention 
 of the urinary secretion, and hyperplasia of the two capsules. 
 Israel speaks of the large hard calculous kidney, the 
 shrunken calculous kidney, the hydronephrotic calculous 
 kidney with and without hypertrophy, and of the lipomatous 
 calculous kidney. The fatty capsule is often thickened 
 and adherent to the capsula propria, and this fibroid 
 change may extend to the connective tissue of the kidney 
 itself. 
 
 A calculous kidney may be infected either by way of 
 the blood stream or from the bladder, more often the 
 former ; a peri- and paranephritis follows, either of acute 
 purulent or chronic type ; the condition of the kidney 
 itself is one of pyelitis or pyonephrosis. If a calculus block 
 the ureteral channel, hydronephrosis develops, or pyone- 
 phrosis if the urine is infected, with general atrophy of the 
 renal tissue. 
 
 The opposite kidney is sometimes hypertrophied. General 
 pysemia does not often occur from calculous pyelitis. When 
 the condition is of long standing the other kidney is almost 
 always altered (inflammation, suppuration, sclerosis, 
 atrophy, etc.). Of 76 cases collected by Legueu, in 36 the 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 391 
 
 other kidney contained no calculus, but in 31 there was 
 some other affection of the opposite organ. 
 
 Ureteral stones sometimes form a complete cast of the 
 ureter. They are usually single and most frequently in 
 the lower part of the channel, where they may be palpated 
 from the vagina or rectum. 
 
 Clinical Signs. — A renal calculus may be present for 
 a long time without giving rise to symptoms. Usually 
 they are attended by a dull pain in the loin increased by 
 pressure on the abdomen, by movement (walking, jumping, 
 riding, etc.), and by lumbar compression. The pain often 
 radiates along the course of the ureter, and is frequently 
 referred to the glans penis and is associated with violent 
 tenesmus. I have several times noted anaesthesia or 
 hyperaesthesia of the skin along the course of the ileo- 
 hypogastric nerve. 
 
 Between the attacks of colic the urine may be entirely 
 clear ; violent exercise may cause a blood tinge to appear, 
 or the amount may be only microscopic, and be found 
 in the sediment as washed-out red cells. Profuse h^ematuria 
 without colic is more frequent in the early than in the later 
 stages. In the intervals a brick-red sediment or a sediment 
 of phosphates is not uncommonly found. If the calculi 
 are large and numerous, they may sometimes be felt on 
 palpation, provided the abdominal wall is thin. Radio- 
 graphy gives a shadow which varies in density according to 
 the composition of the calculus. 
 
 The attacks of colic are of excessive severit}^, and may 
 come on without warning, or be preceded by slight prodromal 
 symptoms. The pain is usually lumbar, but may be ill- 
 defined ; it radiates most frequently to the testicle, less 
 commonly to the thorax and shoulder. There is frequent 
 and painful desire to make water, and at the commencement 
 of an attack rectal tenesmus and vomiting ; meteorism is 
 also common. Later, but occasionally at the beginning, 
 there is insuperable constipation, with constant fruitless 
 tenesmus. 
 
 The amount of urine is small, and after a time complete 
 anuria may come on : either a true reflex anuria, or bilateral 
 blocking of both ureters, as in a case of my own which was 
 examined post mortem. Reflex anuria may last for several 
 days, and cause death by unemic poisoning. In one of 
 
392 INDICATIONS FOR OPERATION IN 
 
 my patients, after five days' anuria, the urinary secretion 
 returned copiously, the other kidney showing no permanent 
 lesion. In other cases the amount of urine is only lessened ; 
 it is turbid, and contains blood and muco-pus ; but if one 
 kidney is blocked, the urine passed, coming from the other 
 side, may be clear and abundant. 
 
 The duration of an attack may be from an hour to several 
 days, and it may or may not be accompanied by fever. If 
 the calculus passes into the bladder, or backwards into 
 the renal pelvis, the pain ceases abrupth^ After an attack 
 small concretions or gravel are often discharged ; blood 
 corpuscles are almost always found in the urinary sediment; 
 traces of albumin are also present, and occasionally hyaline 
 casts. 
 
 Long-established calculous disease is almost always 
 associated with inflammatory changes in the renal pelvis, 
 and pus in the urine to a greater or less extent. Such 
 a pyelitis may eventuate in perforation of the pelvis and 
 the formation of a perinephritic abscess. In other cases 
 the kidney becomes pyonephrotic. 
 
 During the attacks the kidney is swollen, but not usually 
 to such an extent as to be noticeable on palpation. When 
 the attacks are frequent, and a hydronephrotic or pyone- 
 phrotic condition is established, the enlargement is marked 
 and permanent. Israel found that in 30 cases of renal and 
 ureteral stone not associated with hydro- or pyonephrosis, 
 in 17 the kidney could be felt enlarged on palpation. 
 
 Diagnosis. — When a calculus is evacuated after an 
 attack of colic the diagnosis is simple and clear. In other 
 cases it is difficult and is founded on a careful consideration 
 of the history, on the presence of marked tenderness on 
 bimanual examination, on the constant occurrence of slight 
 or considerable haemorrhage after exertion, on the presence 
 in the urine of albumin, pus cells, crystals, and sometimes 
 casts, on the radiation of the pain to the penis or testicle, 
 on sensory disturbances in the course of the ileohypogastric 
 nerve, and on the positive results of radiographic examina- 
 tion. The oxalate and uric acid stones give a dense shadow ; 
 the phosphatic are much less satisfactory in this respect. 
 
 I think it necessary to utter a warning against basing 
 the diagnosis only on a radiographic picture ; in a case 
 which I saw in consultation with others of pain in the loin 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 393 
 
 and occasional microscopic traces of blood in the urine, 
 a radiograph showed what was apparently a distinct group 
 of facetted calculi, but operation showed no calculus in 
 either pelvis or ureter ; possibly the sharply-defined shadows 
 were due to uric acid infarcts in the renal pyramids. 
 
 In other cases radiography is of much assistance in 
 support of the diagnosis when the symptoms are not typical. 
 
 Ureteral catheterization for purely diagnostic purposes 
 is too risky a proceeding for routine use. 
 
 Differential diagnosis is sometimes very difficult. Chronic 
 appendicitis may simulate nephrolithiasis, but the charac- 
 teristic radiation of the pain is absent, and there are no 
 changes in the urine, although there may be dysuria. 
 
 In attacks of biliary colic without jaundice the gall-bladder 
 is enlarged and tender, and the physical diagnosis is made 
 easier if the patient is turned over on to the left side. In 
 intestinal colic there is no tenderness on pressure in the 
 painful area. Local examination will usually exclude 
 disease of the genital organs. In ulcer of the stomach 
 or duodenum the situation of the pain is away from the 
 kidney, and there are no urinary changes. Colic due to 
 sudden distension of the renal capsule may be confused 
 with nephrolithiasis. In occlusion of the ureter causing 
 hydronephrosis the organ is much enlarged, and when 
 the obstruction is relieved hsematuria often occurs, the 
 kidney returning to its normal size. In renal tuberculosis 
 pus and albumin are usually persistently present in the 
 urine ; sometimes the bacilli may be demonstrated and 
 fever is frequent, while characteristic changes at the ureteral 
 orifices may often be demonstrated by the cystoscope. 
 Torsion or dislocation of a floating kidney may usuallv 
 be distinguished by a careful physical examination and 
 attention to the history. 
 
 In pyonephrosis the urine is often clear during an attack 
 of colic and full of pus after it has passed. Renal tumours 
 are usually not tender to pressure ; the haemorrhages to 
 which they give rise usually occur suddenly, without 
 reference to exertion or movement, and clots are often 
 passed. 
 
 Hysterical nephralgia can sometimes only be distinguished 
 from stone by the constant absence of blood cells and 
 albumin from tlie urine. 
 
394 INDICATIONS FOR OPERATION IN 
 
 INDICATIONS FOR OPERATION. 
 
 Under some circumstances renal calculus threatens life, 
 and operation is then absolutely indicated. This is the 
 case in the presence of calculous anuria, a condition which 
 may be due to bilateral occlusion of the ureter, or to occlusion 
 of one and reflex inhibition of the opposite kidney, or to 
 the occlusion of one ureter when there is but one kidney. 
 Spontaneous disappearance of reflex anuria, after treatment 
 with drugs, hot baths, etc., is improbable when the pains 
 of colic have ceased, and when after the cessation of colic 
 the patient still does not pass urine. 
 
 Disorganization of the renal parenchyma, leading to 
 fatal uraemia, frequently sets in by the third day, although 
 it may be delayed to the sixth or even the tenth, so that 
 the possibility of spontaneous disappearance in calculous 
 anuria must not be relied upon for longer than twenty-four 
 hours after onset. 
 
 On which side is the operation to be done ? 
 
 When there is unilateral nephrolithiasis the affected 
 kidney is to be dealt with ; when bilateral the kidney which 
 appears from clinical signs to have been last occluded, 
 because the onset of complete anuria will have been due 
 to this. If the clinical symptoms and the radioscopic 
 examination do not afford any definite information (for 
 example, when coma supervenes without antecedent colic), 
 that kidnej' should be operated on which, judging from 
 the history, it seems probable has suffered least destruction. 
 If no calculus is found on the one side the other kidney 
 should then be exposed if urjemic symptoms are actually 
 present, but if the uraemia has not at that time come on 
 the second operation may be postponed a day or two, 
 because sometimes incision on the one side reflexly relieves 
 the opposite kidney. If, however, at this operation the 
 kidney is found much altered although there is no calculus, 
 the other kidney should be at once incised even though 
 there is no present ursemia. 
 
 The difficulties that may arise are illustrated by the 
 following case. In a man, aged 40, after shooting pains 
 along the course of tlie ureters and slight transient hsema- 
 turia, anuria suddenly came on, with intense vesical 
 tenesmus. The left kidney was found enlarged and tender. 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 395 
 
 Operation was done on the third day ; a large calculus was 
 removed from the left side, and this kidney at once resumed 
 function. The next day anuria came on again, and soon 
 passed into fatal uraemia before a second operation could 
 be done. At the autopsy a calculus was found blocking 
 the right ureter ; there were no symptoms during life 
 pointing to the right side. 
 
 A second absolute indication for operation is the onset 
 of symptoms pointing to acute pyelonephritis of one kidney. 
 Such symptoms are : — Fever, sometimes pyjemic in charac- 
 ter, with frequent rigors and profuse sweating, dry tongue, 
 vomiting, marked pain and tenderness on pressure in the 
 region of the kidney, pus, and occasionally hyaline and 
 granular casts in the urine. Even if fever is absent and 
 the general condition is not seriously affected, operation 
 is indicated when the urine contains pus and the cystoscope 
 shows that this is coming from one side. 
 
 A third absolute indication is the onset of hcemonhage 
 in renal calculus in such quantity as to threaten life ; this, 
 however, rarely happens. A fourth absolute indication 
 is met when a calculus is impacted in the ureter, and has 
 remained there for some considerable time ; such cases 
 always terminate either in retention or infection if left alone. 
 
 Operation is further indicated, although not as an indicatio 
 vitalis, in the following conditions : — 
 
 (a) When hydronephrosis and calculus co-exist, because 
 the first is often provoked by the second. If such a calculous 
 hydronephrosis becomes infected and pyonephrosis super- 
 venes, removal of the kidney is urgently called for. 
 
 (b) Even when the symptoms are slight, pus in the urine 
 is a sign which indicates operation, whether the kidney is 
 enlarged or not. 
 
 (c) When the patient has to work for his living, and is 
 prevented from doing so by continuous dull pains or repeated 
 colic, with or without the passage of calculi. This indication 
 holds whether the calculous kidney is infected or not. 
 
 {d) In patients better situated, when there is much com- 
 plaint of pain and distress and consequent mental depression. 
 
 [e) When a patient lives or travels out of the reach of 
 surgical assistance ; in particular when he has already had 
 pronounced attacks of colic, and radioscopy shows a stone 
 present. 
 
396 INDICATIONS FOR OPERATION IN 
 
 Almost all authors are agreed that the conditions which 
 I have enumerated should be accepted as indications for 
 operation. Others, for example Rovsing, Tuffier, and 
 Henry ]\Iorris, go further ; they consider operation called 
 for in all cases where a definite diagnosis of renal stone can 
 be made, whether the condition is aseptic or infected, 
 simple or complicated. Other surgeons operate even 
 when the question of the presence of stone only amounts 
 to a reasonable probability ; they hold that the dangers 
 of delay are greater than those of prompt operation, and 
 that to wait for signs of infection is to increase the risks 
 of operation. 
 
 This latter opinion probably goes too far, and the practi- 
 tioner should not base his advice as to operation upon it 
 without hesitation. Operation even on a non-infected, 
 uncomplicated, and- " silent " kidney, is not so free from 
 risk as some of its advocates argue. Rovsing admits a 
 mortality of 7 in 115 cases. One cannot, therefore, promise 
 the patient that such operations are free from risk, since, 
 as Israel remarks, the prognosis of each case has some 
 uncertainty about it, even though statistics show that 
 no other major operation can show so small a mortality 
 (Morris). It is a fact that the presence of a renal stone 
 is compatible in many cases with long life and good health, 
 even when there are occasional slight attacks and haemor- 
 rhages. This is my own experience, and it is supported 
 by Rosenstein, and I may express my opinion on the matter 
 by saj'ing that, in my view, the presence of a renal stone 
 does not in itself constitute an indication for operation, 
 but that some one of the complications already mentioned 
 should be present before operation is recommended. 
 
 The operation most frequently employed is nephrotomy, 
 with incision through the renal cortex, less frequently 
 through the wall of the pelvis. Extirpation (when the 
 kidney is completely disorganized by suppuration) and 
 partial extirpation are only rarely called for. According 
 to Kiister total extirpation is required under the following 
 conditions : — 
 
 (a) Atrophy of the parenchyma, owing to the presence 
 of numerous large calculi. 
 
 (b) In sacciform purulent kidneys, and when pyelo- 
 nephritis has largely destroyed the organ. 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 397 
 
 (c) In septic paranephritis around a kidney more or less 
 disorganized. 
 
 (d) In persistent fistula after nephrolithotomy. 
 
 {e) In stenosis of the ureter after nephrotomy, which 
 cannot be treated by other means. 
 
 Contra-indications. — According to what has been already 
 said, when the attacks are infrequent and slight, no operation 
 is called for. Even when small stones are passed repeatedly 
 with or without colic, operation is not indicated if the 
 patient is quite well in the intervals, and the urine is clear 
 and contains no renal-formed elements. Operation cannot 
 influence the disposition to the formation of fresh calculi 
 (Israel). Bilateral non-infected nephrolithiasis is not a 
 contra-indication to operation, but it is otherwise with 
 double infected calculous disease, especially if the general, 
 condition is bad. Advanced age is also a contra- 
 indication. 
 
 Prognosis. — Risks of operation. — The risks vary with the 
 nature of the operation and the state of the kidney. The 
 operative mortality in non-infected calculous disease amounts 
 only to a small percentage, but in the infected form it is very 
 high (as much as a fourth of all cases), whether for nephro- 
 lithotomy or nephrectomy. Death occurs usually from 
 heart failure or uraemia. Operation is sometimes followed 
 by urine infiltration, septic paranephritis, and sometimes 
 gangrenous inflammation of the soft parts. Occasionally 
 serious post-operative haemorrhage has occurred. 
 
 In 61 cases of nephrolithiasis without anuria operated 
 on by Israel, the operative mortality was 147 per cent, 
 and one later accidental death. Of 12 with calculus in 
 the ureter 4 died, of 5 with calculous anuria two died. 
 The operative mortality is lowest (i in 29) in aseptic or 
 only slightly-infected cases, highest in highly-infected cases 
 when conservative operations are done (38 per cent), so 
 that in the latter class nephrectomy is indicated as the 
 least dangerous procedure. Kiister collected 493 cases 
 of unspecified types treated by nephrotomy, and of these 
 90 (18 per cent) died after operation ; of 193 treated by 
 nephrectomy 44 died (over 20 per cent). 
 
 After operation, and particularly after pyelolithotomy, 
 fistulae sometimes persist for a long time ; in some cases 
 faecal fistulae have been recorded from operative lesion of 
 
398 INDICATIONS FOR OPERATION IN 
 
 the intestine. If the kidney is spht, some of the parenchyma 
 must atrophy, though the amount may be small ; different 
 authors have held the opinion, and in my view with reason, 
 that such loss of substance is not insignificant from the 
 point of view of the renal function. 
 
 Results of operation. — Having laid stress on the risks 
 and mortality of operation, it is right to state that many 
 cases are completely and permanently cured of their 
 disease. It appears that the formation of fresh calculi 
 after operation may be avoided by suitable dieting. Israel 
 states that in his experience re-formation is rare in the 
 case of uric acid and oxalate calculi. 
 
 Without operation. — If operation is withheld in the 
 presence of what have been enumerated above as absolute 
 indications, death will occur from heart failure or 
 uraemia, or there may develop a state of general infection 
 from the infected kidney. In a kidney whose ureter is 
 blocked by a stone, desquamative processes usually take 
 place which may damage the function of the organ, and 
 this damage may persist after the stone is gone. In other 
 cases, when there is marked pyelitis, the condition may 
 spread to the whole of the urinary passages and the other 
 kidney, and induce amyloid disease. In acute pyelo- 
 nephritis of one side, severe toxic infection may be induced 
 on the other side and seriously endanger life. 
 
 Under the conditions which have been enumerated as 
 relative indications, the patient, if no operation is done, 
 may become quite incapable of work, and his life may be 
 a burden to him on account of persistent pain. 
 
 When hydronephrosis develops from retention in a 
 calculous kidney, the parenchyma will atrophy from 
 pressure unless operation is done to relieve the block. 
 If the hydronephrosis becomes infected, and operation be 
 withheld, the one kidney becomes disorganized, and secon- 
 dary infection may occur in the other. 
 
 LITERATURE. 
 
 RosENSTEiN. Krankheiten der Niere. Handbuch d. prakt. 
 Med. V. Ebstein-Schwalbe. Bd. iii. 
 
 ScHEDE. Nierenkrankheiten. Handbuch d. prakt. Chir. Berg- 
 mann, Bruns, u. Mikulicz. 2nd Ed. 1903. 
 
 Wagner. Nephrolithiasis. Centralb. f. d. Grenzgebiete d. Med. 
 u. Chir. 19CX). 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 399 
 
 Senator. Krankheiten der Niere. Nothnagel's Handbuch d. 
 spez. Pathol, u. Therap. 2nd Ed. 1903. 
 
 Israel. Chir. Klinik der Nierenkrankheiten. Berlin. 1901. 
 Operationen bei Nierensteinen. Langenbeck's Arch. Bd. Ixi. 
 1900. 
 
 RovsiNG. Diagnose und Behandlung der Nierensteine. Arch, 
 f. klin. Chir. h. 1895. 
 
 Sendler. Indikationen chirurg. Eingriffe bei Nierenkrankheiten. 
 Miinch. med. Wochens., 5 & 6, 1899. 
 
 Morris. Surgical Diseases of the Kidney and Ureter. 
 
 KiJSTER. Chirurgie der Nieren. Deut. Chir. 1902. 
 
 PiEDVACHE. De la Nephrolithotomie comme Traitement d^ 
 la Lithiase Renale. These de Paris. 1896. 
 
 Annales des Maladies des Organs Genit.-urin., 1895-1900 — Pousson 
 (i898),Resnikoff-Grube (1895), Regnier (1899), Secchi (i897),Tedenat 
 ( 1 898 ), Vignard (1898), Tuffier (1898). 
 
 RENAL CONTUSIONS. 
 
 Etiology. — The accident which usually produces this 
 lesion is a blow in the lumbar region. Blows inflicted 
 more laterally or anteriorly may also cause it, or forcible 
 compression between two resistances. Occasionally it 
 is due to sudden forcible contraction of the abdominal 
 muscles. As a rule one kidney only is affected. 
 
 Pathological Anatomy. — The lesions vary in extent. 
 There may be simply a splitting of the capsule, or there may 
 be a tear in the kidney substance without involving the 
 pelvis, or the tear may extend through into the pelvis. 
 Sometimes part of the kidney is completely separated, 
 especially in lesions near the poles. The haemorrhage 
 is always considerable, and the renal pelvis is usually 
 full of clots. Secondary abscesses frequently develop 
 in or around the kidney. 
 
 When the injury is very severe the whole kidney may be 
 destroyed, in which case a gangrenous condition supervenes 
 if the patient survives. Occasionally the pelvis is torn 
 away from the kidney proper, or the ureter and other 
 structures of the hilum may be torn through ; if the artery 
 and vein are torn the whole kidney necroses. 
 
 Symptoms. — The general symptoms are shock or profound 
 collapse, vomiting, and profuse perspiration ; they may 
 appear at once, or come on some hours after. 
 
 Locally, there is blood extravasation into the loin, and 
 
400 INDICATIONS FOR OPERATION IN 
 
 later, days, or it may be weeks after, into the skin in the 
 region of the inguinal canal. Usually there is intense 
 local pain, generally much increased on movement. If 
 clots pass down the ureter, pain radiates to the testicle, 
 the hip, or the groin, and the testicle is retracted. These 
 pains are often very persistent, and may last for weeks. 
 
 There is usually blood in the urine, and when there are 
 clots great pain may accompany its passage. At the same 
 time symptoms of severe internal hfemorrhage may develop 
 and prove fatal, but death is exceptional from this cause 
 within the first twenty-four hours ; when it occurs it 
 is due to the fall in blood pressure produced by the state 
 of shock. 
 
 When the acute symptoms have passed, a condition of 
 traumatic nephritis may be left, signalized by the presence 
 of albumin and casts in the urine. 
 
 Immediately after the accident there may be oliguria, 
 and in some cases this amounts to a reflex anuria ; occa- 
 sionally polyuria has been recorded. Marked meteorism 
 is present in many cases. 
 
 If the peritoneum be torn and urine Irnd its way into 
 the peritoneal cavity the patient may die from septic 
 peritonitis. 
 
 Diagnosis. — Contusion of the kidney is to be diagnosed 
 when a lumbar or abdominal injury is followed by swelling 
 and tenderness on pressure in the loin, haematuria in greater 
 or lesser amount, and meteorism of the large bowel. If 
 the pulse and temperature rise gradually, and if the abdo- 
 minal pain extends and increases, extravasation into the 
 peritoneal cavity is indicated. 
 
 INDICATIONS FOR OPERATION. 
 
 If after an injury there are signs of serious renal hsemor- 
 rhage, operation is called for. Such haemorrhage, without 
 being copious at first, may be continuous, and in this way 
 become serious in itself after some days or even weeks. 
 •Operation consists in nephrotomy and arrest by packing ; 
 if the organ is much damaged it must be removed. If 
 the signs point to the peritoneum being involved, a trans- 
 peritoneal operation will be advisable. 
 
 Operation may also be called for on account of the onset 
 ■of signs of inflammatory reaction around the kidney ; 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 401 
 
 such signs are increase in the local pain and tenderness, 
 fever, and perhaps rigors. When operation reveals a 
 collection of septic urine or pus around the kidney, nephrec- 
 tomy is the only procedure from which a good result is 
 to be expected. 
 
 Contra-indications. — The presence of pronounced shock 
 from serious lesions to other organs makes it necessary 
 to postpone operation for the renal condition. It is unneces- 
 sary to operate simply for slight haemorrhage of short 
 duration, because minor renal contusions often heal 
 spontaneously ; nor should operation be undertaken simply 
 on account of the presence of a haematoma in the loin, 
 unless this becomes progressively larger, is associated 
 with ansemia, or shows signs of infection. 
 
 Prognosis. — Results of operation. — In many cases 
 packing of the wound in the kidney or nephrectomy 
 has given excellent results. Schede has collected 16 
 cases of nephrectomy for serious haemorrhage, with 14 
 recoveries. 
 
 Without operation. — Of 306 cases collected by Maas 
 and Kiister, in 222 the condition was uncomplicated by 
 lesions of other organs, and among these there was a 
 mortality of 30 per cent. A half of all the cases taken 
 together ended fatally. The deaths due to shock all 
 occurred within 24 hours. Haemorrhage was the cause 
 of death in about half the fatal cases ; in some the death 
 took place late, but in most within a month. Septic infec- 
 tion accounted for most of the other fatalities, and most 
 frequently within the first four weeks. 
 
 These figures show that the prognosis of renal injuries is 
 always very serious, on account of the risks from haemor- 
 rhage or infection. Recovery is often also incomplete ; 
 long-persisting fistuke may be left, and hydronephrosis 
 may occur from dislocation of the organ. Interstitial 
 nephritis and calculi also occur as sequelae. 
 
 LITERATURE. 
 
 KusTER. Die Chirurgie der Nieren. Deut. Chir. P. 52b. 
 
 Schede. Chirurgische Nierenkrankheiten. Handbuch d. prakt. 
 Chir. Bruns, Bergmann, u. Mikulicz. 2nd Ed. Stuttgart. 1903.' 
 
 Edelfsen. Niercnquetschung oder Nierenentzundung ? Munch, 
 med. Wochens. Nos. 5 & 6, 1902. 
 
 Albarrax. Traite de Chirurgie. Bd. iii. Paris. 1899. 
 
 26 
 
402 INDICATIONS FOR OPERATION IN 
 
 MOVABLE KIDNEY. 
 
 Etiology. — Congenital anomalies are the most important 
 etiological factors in this condition. Other, and for the 
 most part, contributory causes, are relaxation of intra- 
 abdominal support (from repeated pregnancy, rapid wasting, 
 the removal of large abdominal tumours, or the development 
 of large ventral hernise), vertebral scoliosis, injury, severe 
 muscular exertion. The condition is also ascribed to 
 tight-lacing and the wearing of high-heeled shoes. It also 
 occurs from increase in weight of the kidney itself, and 
 when the diaphragm is pushed down from one cause or 
 another. 
 
 Pathological Anatomy. — The movable kidney may 
 or may not be surrounded by its fatty capsule ; it usually 
 rotates in its descent, so that the hilum looks upwards, 
 but this may not occur if the vessels are long, extensile, or 
 implanted low. The displaced organ may be fixed by 
 perinephritic adhesions. Hydronephrosis is relatively 
 common, torsion of the pedicle relatively rare. Many 
 cases have been recorded complicated by inflammatory 
 changes in the appendix. 
 
 Clinical Signs.— i\Iost patients with movable kidney 
 suffer no inconvenience, and it is often discovered by chance. 
 Sometimes the symptoms are extraordinarily manifold, 
 but many may be due to other morbid conditions present : 
 enteroptosis, disease of the genital organs, etc. Israel 
 places the symptoms in three groups : — 
 
 1. Pain on standing, walking, sitting, which disappears 
 when the patient lies down. 
 
 2. Dyspeptic symptoms of the " nervous " type. 
 
 3. Attacks of typical renal colic, which must be looked 
 upon as due in part to kinking of the ureter and in part 
 to circulatory disturbances evoked by twisting of the 
 vessels. 
 
 The attacks of pain are violent, and come on suddenly, 
 associated with faintness, collapse, nausea, cold perspiration, 
 and a small, rapid pulse. The kidney is felt to be enlarged 
 and tender to pressure. In many cases the attack passes 
 off suddenly, and is followed by polyuria. When attacks 
 are often repeated the condition takes the form of periodic, 
 hydronephrosis. 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 403 
 
 If the attacks of pain caused by renal mobility do not 
 soon disappear when the patient lies down and the kidney 
 is replaced, or if they occur during rest in bed, there is 
 reason to suspect that the condition is due to some organic 
 renal disease, or to disease in some other abdominal organ, 
 or to some form of neuropathy. According to Stiller 
 there is often some abnormal mobility of the tenth rib. 
 The condition is often bilateral ; when unilateral the right 
 is more frequently affected than the left. 
 
 Diagnosis. — The diagnosis is easy when the kidney is 
 to be felt out of its normal position and can be replaced. 
 When lying in its bed a movable kidney descends abnormally 
 low during inspiration and can be easily displaced downwards 
 with the hands. If the tumour corresponds with the kidney 
 in size and shape, and is smooth on the surface, and if the 
 vessels of the hilum are palpable, the diagnosis is clear. 
 Confusion with other structures frequently occurs ; a 
 detached lobe of the liver presents a sharp edge at least at 
 one of its borders, and if the patient is examined lying 
 on the left side the right kidney will be felt in place. An 
 enlarged gall-bladder with a long pedicle may be displaced 
 from right to left but not downwards, nor can it be mani- 
 pulated into the renal region ; in spite of this such cases 
 may present great diagnostic difficulties. Tumours of 
 the ascending colon are associated with colic and are not 
 always easy of palpation, but can usually be distinguished 
 from movable kidney by careful examination ; the distended 
 gut will be seen to collapse with loud intestinal gurgling, 
 and the tumour itself is movable in a transverse but not 
 in a sagittal direction. Pyloric tumours are distinguished 
 by an examination of the gastric function and by distension 
 of the stomach. An ovarian tumour will be differentiated 
 by the pelvic connections of its pedicle. 
 
 INDICATIONS FOR OPERATION. 
 
 The indications for operation in movable kidney have 
 been with reason considerably restricted of late years, 
 since it has been recognized that the condition is often 
 present without causing any inconvenience, and that 
 many symptoms previously ascribed to it are really due 
 to affections of other organs. A movable kidney in itself, 
 therefore, constitutes no absolute indication to operation. 
 
404 INDICATIONS FOR OPERATION IN 
 
 Formerly also movable kidneys have been removed, but 
 this is now recognized as absolutely inadmissible, and if 
 operation is necessary nephropexy is performed. 
 
 Operation is required when the patient suffers from 
 severe attacks of colic, with transient or persistent retention, 
 as the result of kinking or twisting of the pedicle. When, 
 again, a patient suffers considerably from symptoms which 
 must be ascribed to a movable kidney, and when there is 
 no well-established neuropathic condition present, fixation 
 of the kidney by suture is advisable, provided that treatment 
 by diet, apparatus, and hygienic regime has been tried and 
 failed. 
 
 Contra-indications. — In the absence of the more serious 
 symptoms due to interference with the renal functions by 
 torsion and kinking, operation will not be recommended 
 until other treatment has been tried. If a nervous 
 individual attributes a whole series of vague troubles to 
 a movable kidney, operation should not be done simply 
 because she desires it, because the suggestive effect of such 
 operation is often of very transient benefit. Operation 
 will not be done on a movable kidney when there is some 
 complicating disease of the digestive or genital system, 
 nor is it advisable, according to the opinion of many 
 surgeons and physicians, when the condition is only a part 
 of a general enteroptosis. 
 
 Prognosis. — Results of operation. — The operative mor- 
 tality of nephropexy is i"i8 per cent in a total of 846 
 cases ; some surgeons have had a mortality of 3 per cent. 
 Kiister has reported two cases of pulmonary embolism 
 immediately following operation. Nephrectomy for the 
 condition is never now done ; it was attended by a large 
 mortality, more than 25 per cent in the cases published. 
 Hcematuria, albuminuria, and oliguria have been described 
 as sequelae of the operation, and in a few cases severe 
 peritoneal irritation, post-operative hsemorrhage, and 
 urinary fistula. In several instances it has been recorded 
 that the opposite kidney has subsequently become mobile. 
 
 The success obtained by operation is not entirely 
 encouraging. In 34 non-complicated cases 85 per cent 
 were cured, but in 47 complicated cases the percentage 
 was only 44 ; if the two groups are combined the cases 
 form 58 per cent. Satisfactory results are especially 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 405 
 
 obtained when the condition is associated with some nervous 
 taint, and in these suggestion no doubt plays a part. In 
 particular the immediate result is good in these cases, but the 
 late result often leaves much to be desired. The operative 
 result is by no means always good, and in the hands of some 
 surgeons the percentage of return of mobility is high. 
 
 Without operation. — In many cases the symptoms can 
 be relieved by appropriate palliative treatment, bandages, 
 belts, and massage. In a very small number serious com- 
 plications sometimes supervene, such as hydronephrosis, 
 new growth, and calculi. Death from collapse or peritonitis 
 is excessively rare. 
 
 LITERATURE. 
 
 J. Fischer. Die operative und die nichtoperative Therapie 
 der Wanderniere. Centralb. f. d. Grenzgebiete d. Med. u. Chir. 
 Bd. i. 1898 
 
 BuDiNGER. Ueber Wanderniere. Mitteil. a. d. Grenzgebiete 
 der Med. u. Chir. Bd. ix. 
 
 Israel. Chirurg. Klinik de Nierenkrankheiten. Berlin. 1901. 
 
 O. Wyss. 2 Decennien Nierenchirurgie. Bruns' Beitr. z. klin. 
 Chir. Bd. xxxii. 
 
 Senator. Die Krankheiten der Niere. 2nd Ed. Wien, 1903. 
 
 WOLKOW und Delitzin. Die Wanderniere. 1899. 
 
 KusTER. Nierenkrankheiten. Deut. Chir. 1896. 
 
 Albarran. Traite de Chirurgie. Tome ii. Paris, 1899. 
 
CHAPTER XXIII. 
 
 Diseases of the Kidney and Renal Pelvis 
 
 {continued). 
 
409 
 
 Chapter XXIII. 
 
 DISEASES OF THE KIDNEY AND RENAL 
 PELVIS (contd.). 
 
 TUMOURS OF THE KIDNEY. 
 
 Etiology. — Injury and calculous disease are sometimes 
 concerned in the etiology of renal new growths. The 
 malignant growths, and carcinomata in particular, are 
 comparatively common in childhood ; more than a third 
 of the cases of carcinoma and two-thirds of the cases of 
 sarcoma belong to the first ten years of life. Renal new 
 growths are also comparatively frequent between the ages 
 of 50 and 70. 
 
 Pathological Anatomy.— Both malignant and simple 
 growths occur in the renal tissue ; the pelvis is the seat 
 of origin in a few cases only. Primary carcinoma and 
 sarcoma usually lead to enlargement of the kidney, but 
 the organ may be destroyed by growth without notable 
 increase in size. Carcinoma is often nodular in growth, 
 and the tumour may present to the touch a very irregular 
 outline ; the growth often makes its way into the venous 
 channels, and may extend in this way right into the vena 
 cava. Some forms of growth are less nodular than infiltrat- 
 ing in character, and may have extended to a considerable 
 extent into surrounding structures before any tumour 
 is clinically demonstrable. The lymphatic glands of the 
 neighbourhood are seldom affected ; Israel found enlarged 
 glands in only 7 out of 44 cases operated on, although 
 several were considerably advanced. The most common 
 type of carcinoma appears to be the adenocarcinoma. 
 
 Sarcomata are usually round-celled or spindle-celled, 
 and may be single or multiple. 
 
 Other forms of malignant growth are the endothelioma 
 and perithelioma, and the embryonal adenosarcoma of 
 
4IO INDICATIONS FOR OPERATION IN 
 
 childhood. The hypernephroma (Growitz) is sometimes 
 simple, sometimes malignant. Of the benign growths, for 
 the most part it is only the uncommon lipomata and 
 fibromata that reach large dimensions. Israel computes 
 that 70 per cent of the circumscribed cases develop about 
 the lower pole and the middle section of the kidney. 
 
 Clinically the aneurysms of the renal artery have been 
 classed with the tumours ; usually they are small, 
 occasionallv very large ; true and false aneurysms have 
 been described. 
 
 Clinical Course. — The most important clinical signs 
 of malignant tumour are haematuria, enlargement of the 
 kidney entirely or principally of solid character, pain, and, 
 later, cachexia and metastasis. Haematuria is often the 
 initial symptom ; it occurs as such in a fourth of all cases, 
 and in later stages is present in a half. In Israel's cases 
 early haematuria, with or without colic, was present in 
 70 per cent, and of 66 cases only 5 had no haemorrhage. 
 The bleeding is sometimes slight and infrequent, sometimes 
 first follows an injury, but for the most part it is considerable 
 and even profuse. It is usually symptomless, has no 
 relation to exertion or position, and varies extremely in 
 frequency. In one of my cases a very severe haemorrhage, 
 producing marked anaemia, occurred three years before the 
 appearance of a tumour. Usually the blood is passed 
 mixed with the urine, sometimes in clots which may cause 
 colic during their passage, and may even block the ureter 
 and cause hydronephrosis, though this is rare. The urine 
 may show no abnormality except the blood, and the passage 
 of fragments of growth is unusual, but with or without 
 blood there is usually albuminuria, sometimes of advanced 
 grade. Casts are often present, coming from that part of 
 the kidney involved in the aseptic inflammation which 
 accompanies the new growth. 
 
 Israel describes as a characteristic sign the presence 
 of worm-like coagula enclosing red cells, large granular 
 corpuscles, atypical epithelia, and detritus derived from 
 destroyed red cells in a fibrinous ground substance. 
 
 In the later stages a palpable tumour is almost always 
 found ; the date at which this is discovered depends upon 
 the skill of the examiner and the position of the tumour 
 in the kidne^^ Tumours of the lower pole or front surface 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 411 
 
 are relatively easily felt ; examination is best carried out 
 in half lateral decubitus. Malignant tumours are as a rule 
 irregular, firm, and nodular, and often tender to pressure. 
 Israel has often recognized by palpation quite small tumours, 
 down to the size of half a cherry. As the tumour grows 
 the neighbouring organs are pressed upon and the diaphragm 
 may be pushed upwards ; intestinal resonance is found 
 in front of the mass. 
 
 In about a quarter of the cases there is initial pain in the 
 kidney region and along the course of the ureter; this is 
 sometimes dull, sometimes most intense. On the side where 
 the tumiour is situated a varicocele often develops, some- 
 times oedema of the lower limb and swelling of the inguinal 
 glands. Fever is occasionally present ; cachexia appears 
 late. The duration of the disease is, in children, usually 
 only a few months, seldom a year ; but in adults it is 
 sometimes prolonged up to even 10 years, with a mean of 
 about 2^. The course is, therefore, more prolonged than 
 is usual in carcinoma elsewhere (Robert). Death occurs 
 from cachexia or haemorrhage, rarely from uraemia or 
 rupture of the kidney. 
 
 Diagnosis. — In presence of the cardinal symptoms — 
 hsematuria, tumour, and lumbar pain — the diagnosis is 
 easy ; intermittence in the haematuria is a helpful sign, 
 and tumour particles may be found in the urine. Careful 
 bimanual examination, distension of the colon and of the 
 stomach, examination of the rectum and vagina, radioscopy 
 and. cystoscopy, will decide whether a tumour is renal or not. 
 
 If haematuria is the first symptom diagnosis must 
 be made from tuberculosis and calculus, and also from 
 hydronephrosis, cystic kidney and haemorrhagic infarct. 
 The absence of tubercle bacilli, of characteristic nightly 
 fever and perspirations, and the negative result of a tuber- 
 culin injection, will decide against tuberculosis. Cystoscopic 
 examination of the ureteral orifice will also be of much 
 assistance. In renal stone there is not, as a rule, a large 
 tumour, colic is always associated with the haemorrhage ; 
 there may be a history of the passage of calculi previously, 
 and radioscopy will materially assist. Congenital cystic 
 kidney is often associated with haematuria, but the condition 
 is usually bilateral, whereas new growth is almost always 
 unilateral. The tumour of hydronephrosis is regular on 
 
412 INDICATIONS FOR OPERATION IN 
 
 the surface and elastic ; it is rarely associated with hcematuria 
 in any quantity, and is often intermittent and varying 
 in size from time to time. In children enlarged retro- 
 peritoneal glands may simulate renal tumour, but the 
 absence of changes in the urine and careful examination 
 will not fail to make the case clear. 
 
 INDICATIONS FOR OPERATION. 
 
 If the presence of a malignant neoplasm of the kidney 
 has been definitely ascertained by observation of the cardinal 
 symptoms, or if the question amounts only to a great 
 probability, provided that the other kidney is functioning, 
 operation should be undertaken. The operation is explora- 
 tory if the diagnosis is uncertain ; when tumour is present 
 total extirpation of the organ is the rule. There are cases 
 in which, in spite of the presence of metastases, operation 
 is still indicated, in particular when profuse haemorrhage 
 threatens life, provided that cachexia is not too advanced. 
 I have seen one case where this indicatio vitalis called for 
 operation. 
 
 Contra-indications. — If metastases are present (the 
 skeleton should be examined for them), if the growth is 
 bilateral, and if the tumour is immovably fixed to its 
 surroundings, operation is inadvisable. Signs pointing 
 to obstruction of the vena cava inferior also negative 
 operation, because they indicate that the tumour has 
 extended to this channel. Any serious complicating 
 affection, such as diabetes, also excludes operation. If 
 fever is present without apparent cause it is against opera- 
 tion, because it only occurs in renal growths when they 
 have extended beyond the limits of the renal capsule. 
 Complete absence of function in the other kidney excludes 
 operation, but not if the function is only in part interfered 
 with, as by amyloid disease or chronic nephritis ; operation 
 is justifiable under such circumstances in view of the hope- 
 lessness of the disease without it. 
 
 Prognosis. — Results of operation. — The end results of 
 extirpation for tumour are unhappily not very favourable. 
 Israel found that of 25 patients who had survived operation 
 and intercurrent affections, 19 succumbed to recurrences ; 
 many of Israel's cases were operated on at comparatively 
 early stages. Favourable results have, however, been 
 
. DISEASES OF THE KIDNEY AND RENAL PELVIS. 413 
 
 obtained in many cases. At the least, operation improves 
 the patient for a time, relieves him of pains, and may enable 
 him to return to work. 
 
 Risks of operation. — Many patients operated on succumb 
 to heart failure. Among 43 of Israel's cases 5 died from 
 this cause and 4 from some other condition due to the 
 operation. According to Heresco and Israel the operative 
 mortality is about 20 per cent. Disease of the opposite 
 kidney is relatively rarely the cause of death. 
 
 Without operation. — Patients with malignant disease of 
 the kidney inevitably die unless rescued by surgery ; yet 
 the duration of life is sometimes as much as several years. 
 It is not very unusual for such patients to live about 
 four years, and in a sixth of the cases the period actually 
 extends to ten years. In one of my cases seven years 
 elapsed between the first h^ematuria and death ; the patient 
 refused operation when the disease was in its early stages. 
 
 LITERATURE. 
 
 Senator. Krankheiten der Nieren. 2nd Ed. Nothnagel's Hand- 
 buch der spez. Pathol, u. Therap. Wien. 1903. 
 
 ScHEDE. Krankheiten der Nieren. Handbuch der praktischen 
 Chirurgie, herausgegeben v. Bergmann, Mikulicz, u. Bruns. 
 Bd. iii, 2nd Ed. Stuttgart : F. Ehke. 1903. 
 
 V. Hansemann. Zeitschrift fiir klinische Medizin. Bd. xliv. 
 
 RovsiNG. Die Diagnose und Behandlung der bosartigen Nieren- 
 geschwiilste beim Erwachsenen. Arch. f. klin. Chir. Bd. li. 
 
 Israel. Chirurg. Klinik der Nierenkrankheiten. Berlin. 1901. 
 
 Heresco. De ITntervention Chirurgicale dans les Tumeurs 
 Malignes du Rein. These de Paris. 1899. 
 
 RosENSTEiN. Die Krankheiten der Niere. Handbuch der prakt. 
 Med., herausgegeben v. Ebstein-Schwalbe. Stuttgart: F. Enke. 
 1900. 
 
 CYSTIC KIDNEY. 
 
 Etiology. — Cystic kidney is a congenital affection in the 
 majority of cases ; in adults it is usually found only after 
 maturity ; of 187 cases two only belonged to the second 
 decennial period. Several instances have been recorded of 
 its occurrence in more than one member of a single family. 
 
 Pathological Anatomy. — It is almost always a bilateral 
 condition in congenital cases and young children. In older 
 subjects the records show it to be bilateral in about four- 
 
414 INDICATIONS FOR OPERATION IN 
 
 fifths. The affected organ is usually much enlarged ; it is 
 riddled throughout with cysts of various sizes. It may 
 present the characteristic renal shape or may form an 
 irregular-shaped nodular tumour. The cyst contents are 
 sometimes clear and yellow, sometimes turbid, and not 
 infrequently haemorrhagic. In a third of the cases the con- 
 dition is associated with cystic disease of the liver. The 
 causation of the disease has been ascribed to a chronic 
 inflammatory change ; others consider it of the nature of a 
 malformation, while others again look upon it as due to 
 true new growth. 
 
 Clinical Signs. — Congenital cystic kidney is not of 
 much surgical importance for the reason that most of the 
 children with this affection die early from pressure on the 
 diaphragm or some other malformation. In adults it often 
 runs its course without giving rise to symptoms, and some- 
 times is found accidentally at a post-mortem examination, 
 as in two cases under my care whose urine showed no 
 abnormality. Occasionally the enlargement is so marked 
 that it can be recognized by palpation, and it may even be 
 possible to make out individual nodular cystic swellings on 
 the surface of the tumour. Pain is sometimes a symptom, 
 sometimes not ; occasionally it is colicky in character. 
 
 The urine is often normal, but sometimes contains albumin 
 and blood in quantity ; it may also contain corpuscles of 
 rosette shape, or resembling leucin. In some cases the 
 urine is like that of chronic interstitial nephritis. Explora- 
 tory puncture shows that the bulging nodules contain fluid, 
 and in this may be found the concentric or rosette-shaped 
 bodies. 
 
 In many cases it will be found that the liver is enlarged 
 and it may be possible to make out fluctuating areas in it. 
 Cardiac hypertrophy and increased arterial tension are often 
 present ; usually the general condition is good, but there 
 are occasionally digestive troubles and fever. The latter 
 usually means suppuration in the cysts, but may be present 
 without it. In one of my cases there were frequent rises 
 of temperature without apparent cause, and the autopsy 
 revealed no focus of suppuration to account for them ; 
 possibly they were due to uraemia. 
 
 Severe uraemic attacks are common, and death may result 
 from this cause. 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 415 
 
 Diagnosis. — The diagnosis may be difficult. It is 
 indicated by the presence of a bilateral renal tumour with 
 irregular surface and fluctuating areas, particularly if 
 associated with periodic hsematuria and with simultaneous 
 enlargement of the liver of a similar type. A history of a 
 similar condition in some other member of the family should 
 be enquired into. The rosette-shaped corpuscles appear to 
 be diagnostic of the condition ; they are apparently found 
 in no other renal affection. 
 
 Hydatid cyst of the kidney is usually unilateral, and the 
 same is true of other renal tumours, and when bilateral the 
 enlargement of both kidneys is never simultaneously the 
 same as may be the case in cystic disease. 
 
 Differentiation from pyonephrosis and hydronephrosis 
 may be very difficult, as these affections may be bilateral, 
 but in these the surface of the tumour is smooth, not nodular, 
 and it often varies in size from time to time and may be 
 lessened by pressure. 
 
 INDICATIONS FOR OPERATION. 
 
 In most cases surgical intervention is inadvisable owing 
 to the bilateral nature of the condition. In exceptional 
 instances some conservative surgical procedure is called for : 
 nephrotomy or puncture of the cysts. The circumstances 
 which may call for this are : violent or continuous pain in the 
 loin making life a misery, suppuration in the kidney, 
 copious hsematuria, and sometimes pressure on neighbouring 
 organs from the large size of the tumour. If anuria super- 
 venes it forms an absolute indication for operation with a 
 view to relieving tension. 
 
 Prognosis. — Risks of operation. — Of twenty-five cases 
 collected by Mohr, seven died in connection with the 
 operation, so that the operative mortality appears to 
 be high. 
 
 Results of operation. — In many cases anuria, severe 
 hsematuria, and suppuration have been successfully dealt 
 with by operation. In unilateral cases the removal of one 
 kidney has been successfully performed many times, but in 
 most, cystic degeneration of the other organ has followed 
 after a varying period. It must be remembered that cystic 
 kidneys which are apparently in an advanced state of 
 degeneration are often functionally active. 
 
4i6 INDICATIONS FOR OPERATION IN 
 
 LITERATURE. 
 
 ]MoHR. Die Behandlung der polycystischen Nierenentartung. 
 Mitteil a. d. Grenzgebiete d. Med. u. Chir. Bd. vi. 
 
 Stiller. Zur Diagnostik der polycystischen Nierenentartung. 
 Berl. klin. Wochens. P. 215. 1892. 
 
 Senator. Die Krankheiten der Nieren. 2nd Ed. Wien. 1903. 
 
 Israel. Die Chirurg. Klinik der Nierenkrankheiten. Hirsch- 
 wald. Berlin. 1901. 
 
 ScHEDE. Die Krankheiten der Xieren. Handbuch der prakt. 
 Chir. V. Bergmann, Bruns, u. ^Mikulicz. 2nd Ed. Wien, 1903. 
 
 HYDATID CYST OF THE KIDNEY. 
 
 Etiolosy. — Hydatid cysts are most frequent between 
 the ages of 20 and 30, and in the male sex. They occur less 
 commonH' in the kidney than either the liver or the lung ; 
 in Neisser's 900 cases there were 80 examples, in the 970 
 cases collected by Vegas and Cram well only 20. 
 
 Pathological i\NATOMY. — One kidney alone is affected 
 in almost all cases, and the cyst develops in the cortex of 
 the upper or lower poles. It may attain large dimensions 
 and causes pressure atrophy of the surrounding renal 
 parenchyma ; but even in the case of very large cysts 
 part of the kidney substance always remains and retains 
 functional capacity. A cyst may calcify and atrophy, or 
 may suppurate. The latter complication may produce 
 serious symptoms, and the suppurating cyst may perforate 
 into the renal pelvis, the pleura, or on to the surface in 
 the loin. Rupture into the renal pelvis is common with or 
 without suppuration (48 out of 67 cases). 
 
 Clinical Course. — Small cysts are often present without 
 giving rise to any symptoms. The large cysts are to be 
 felt as tumours in the renal region ; sometimes they appear 
 solid, in other cases fluctuation can be made out. Pressure 
 on the tumour is usually painless. Sometimes there are 
 subjective pains, and if vesicles are discharged into the renal 
 pelvis and block the ureter, distinct attacks of colic result. 
 
 The urine may be clear, or turbid from an associated 
 pyelitis, or it may be mixed with cyst contents. In the 
 latter case it is turbid and more or less milky, or may con- 
 tain blood or pus. Such an alteration in the urine is usually 
 preceded by pain of a colicky character. The microscope 
 will show the presence of scolices and fragments of membrane, 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 417 
 
 and occasionally whole vesicles are discharged. It is not, 
 however, in every case that such direct evidence is obtained 
 in the urine ; a kidney may contain hundreds of vesicles 
 and yet the urine may show no characteristic deposit. If 
 infection takes place in a cyst, high fever and other signs of 
 septic absorption supervene. A cyst may rupture and 
 discharge vesicles into a neighbouring hollow organ. 
 
 Diagnosis. — Hydatid cyst of the kidney will be diagnosed 
 when an elastic rounded tumour is found connected with 
 the kidney, associated with the discharge of vesicles, booklets, 
 or fragments of membrane in the urine, or when exploratory 
 puncture yields a clear fluid, poor in albumin, rich in 
 chloride of sodium, and containing succinic acid. The 
 diagnosis becomes certain if the tumour subsides simul- 
 taneously with the discharge of vesicles. 
 
 Hydatid cyst is not infrequently mistaken for hydro- 
 nephrosis and solid tumours, and the diagnosis may be 
 impossible if an exploratory puncture cannot be made and 
 no booklets are discharged in the urine. Regarding the 
 diagnosis of renal swellings in general, reference should be 
 made to the article on tumours of the kidney. 
 
 Renal hydatid may simulate ovarian cystoma ; it is to 
 be distinguished by its comparative immobility, and by the 
 situation of the bowel in front of and to its inner side ; 
 rectal and vaginal examination will also aid in the differentia- 
 tion. In the case of a patient under my care, a diagnosis 
 of ovarian cyst had been made by several gynaecologists ; I 
 saw her only after several years' illness and when she was 
 in extremis ; the urine was turbid and milky, and hydatid 
 membrane was found in it. The autopsy showed the 
 presence of a hydatid ruptured into the renal pelvis, the 
 kidney being much displaced downwards. 
 
 The unilateral character of the condition is sufficient, as 
 a rule, to distinguish it from cystic kidney. 
 
 INDICATIONS FOR OPERATION. 
 
 If the diagnosis is certain, operation should be undertaken 
 without delay if the general condition admits of it. If the 
 diagnosis is uncertain, but an elastic swelling exists in the 
 renal region, an exploratory operation is justified, particu- 
 larly if fever points to the possibility of suppuration in the 
 cyst, or a rapid increase in size of the tumour is noted. 
 
 27 
 
4i8 INDICATIONS FOR OPERATION IN 
 
 The operation usually practised is incision, with suture of 
 the cyst wall to the parietes. 
 
 Contra-indications. — Considering the dangerous nature of 
 the disease, and the relatively slight risks attached to 
 operation, there cannot be said to be any contra-indications. 
 
 Prognosis. — Risks and results of operation. — Since incision 
 has become the practice rather than removal, the risk of 
 the operation is slight relatively to the serious nature of 
 the disease. Of twenty-three cases treated by incision one 
 died, the cause being heart failure. In one of these cases 
 secondary nephrectomy was necessary ; the remainder 
 recovered completely without further intervention. 
 
 Without operation. — The risks attached to suppuration 
 are always imminent. Spontaneous recovery after discharge 
 into the urinary channels is not very infrequent, but not 
 sufficiently common that it can be relied on. 
 
 Reflex anuria may be induced in both kidneys if one 
 ureter is blocked by vesicles. External rupture of the cyst 
 may give rise to serious complications. On the other hand 
 it must be noted that hydatid cyst of the kidney may be 
 present for years without actually endangering life, and 
 that escape of vesicles through the urinary channels not 
 infrequently results in spontaneous recovery. 
 
 LITERATURE. 
 
 Paul Wagner. Zur Operation des Nierenechinococcus. Centralb. 
 f. d. Krankheiten der Harn- und Sexualorgane. 1894. 
 
 Popper. Echinococcus der Harnwege. Berliner klin. Wochens. 
 No. 9, 1898. 
 
 HoNZEL. Contribution a I'Etude des Kystes Hydatiques du Rein. 
 Revue de Chirurg. 1898. 
 
 ScHEDE. Echinococcus der Niere. Handbuch der prakt. Chir., 
 herausgegeben v. Bergmann, Mikulicz u. Bruns. Bd. iii, 2nd Ed. 
 Stuttgart. 1903. 
 
 Senator. Die Krankheiten der Nieren. 2nd Ed. Wien. 1903. 
 
 RosENSTEiN. Krankheiten der Niere. Handbuch d. prakt. Med. 
 herausgegeben v. Ebstein-Schwalbe. Bd. iii, i Teil. F. Enke. ' 
 Stuttgart. 1900. 
 
 HYDRONEPHROSIS AND PYONEPHROSIS. 
 
 Etiology. — Hydronephrosis may occur as a congenital 
 affection, or may be acquired after birth. Congenital 
 hydronephrosis is due to some malformation or to intra- 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 419 
 
 uterine chronic inflammatory processes, with consequent 
 atresia of the urinary passages. Acquired hydronephrosis 
 may be due to obstruction to the urinary flow either by 
 some mechanical cause (tumour, calculus, foreign body), or 
 by adhesions to surrounding structures and kinking of the 
 ureter, or by swelling of the mucous membrane in the 
 narrower portions of this channel. Pregnancy and a floating 
 kidney are both predisposing causes to the condition. In 
 order that marked hydronephrosis may occur it is usually 
 the rule that the obstruction should be of gradual develop- 
 ment or intermittent (Cohnheim). 
 
 An infection in some part of the body may secondarily 
 cause infection of a hydronephrosis by way of the blood 
 stream. Pyonephrosis is often, however, secondary to an 
 infection in the urinary passages below, for example, cystitis, 
 infection by catheterization, ulcerating tumours of the 
 prostate and bladder, etc. Hydronephrosis is relatively 
 common in childhood ; pyonephrosis is rarely found before 
 puberty. 
 
 Pathological Anatomy. — The terms hydronephrosis and 
 uronephrosis Israel applies to the conditions of retention, 
 which, resulting from some antecedent obstruction to the 
 urinary flow, are at first aseptic but may later become 
 infected. The term pyonephrosis he applies to a condition 
 arising in direct connection with an infective inflammatory 
 process without antecedent aseptic retention, the inflamma- 
 tory process either from the commencement or subsequently 
 causing the retention. Hydronephrosis may be unilateral 
 or bilateral, open or closed. If the condition is advanced, 
 the altered organ presents as a large ovoid elastic tumour, 
 with contents either clear or turbid. The remains of the 
 kidney substance is set laterally on the ovoid sac ; the 
 interior often presents several sacculations. 
 
 The most frequent causes of acquired hydronephrosis are 
 changes in position of the kidney, renal calculi, tumours of 
 the pelvis (especially uterine), compression of the ureters, and 
 inflammatory swelling of the mucous membrane of the 
 ureter. In a pus kidney due to infection of a hydronephrosis, 
 the ureter is thin-walled and usually lengthened and in part 
 distended, but when the condition is due to a primary 
 ascending infection the ureter is shortened, thick-walled, 
 and often shows circumscribed stenoses. When secondary 
 
420 INDICATIONS FOR OPERATION IN 
 
 to hydronephrosis the tumour is often very large and 
 unilocular ; when due to primary infection it usualty only 
 reaches moderate dimensions and is multilocular. 
 
 Perinephritic suppuration often takes place without there 
 being any actual communication between the perirenal 
 abscess and the interior of the sac. 
 
 Clinical Course. — Hydronephrosis often develops with- 
 out giving rise to symptoms. The most important sign is 
 a tumour recognized as involving the kidney. Bimanually 
 the tumour is well defined and as a rule not tender to 
 pressure ; fluctuation can as a rule be made out, but not 
 always. There is usually a tympanitic note on percussion 
 in front. The size may vary extraordinarily from time to 
 time ; the kidney may be mobile or immobile. Rapid 
 diminution is associated with evacuation of large quantities 
 of urine ; while occlusion persists there is usually oliguria. 
 The evacuated urine is sometimes clear; sometimes, although 
 large in amount, it is turbid from admixture with mucus, 
 pus, or blood. Sometimes casts or concretions are present. 
 Persistent polyuria is less common. 
 
 The enlarged kidney often causes visible bulging in the 
 loin ; but if the organ is mobile the bulging will be in the 
 lower part of the abdomen ; even when hydronephrosis is 
 bilateral, one side is usually larger than the other. Mobility 
 on respiration is almost always present, though it may be 
 only slight. As a rule the patient complains of a sense of 
 fullness, but severe spontaneous pain is relatively uncommon ;. 
 when present it is usually of a colicky character, resembling 
 the pain of calculus. If it occurs in this form the affected 
 kidney is usually also tender to pressure, and reflex 
 inhibition of the secretion of the other kidney may occur. 
 Sometimes when a hydronephrosis develops rapidly it is 
 associated with fever ; fever is usual in pyonephrosis, and 
 may be intermittent, continuous, or remittent. Haemor- 
 rhage may occur into the sac during the stage of occlusion, 
 so that the urine which comes away after the attack may 
 be haemorrhagic. 
 
 In intermittent hydronephrosis there is a periodicity 
 about the attacks of pain and the enlargement ; once the 
 occlusion has become permanent the pain often disappears. 
 Uraemia develops if the function of the other kidney fails. 
 Occasionally a hydronephrotic sac ruptures, either in 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 421 
 
 consequence of extreme distension, or some trauma ; if 
 this takes place there is great pain and collapse. 
 
 Cardiac hypertrophy is only occasionally present. 
 
 Diagnosis. — If a cystic tumour is present in the renal 
 region, and there is tympanitic bowel in front of it, if 
 cystoscopy shows that no urine is coming from one ureter, 
 and no other condition is present to account for this, the 
 tumour is probably a hydronephrosis. Absence of a 
 tympanitic note in front of the swelling does not exclude 
 hydronephrosis ; under such circumstances artificial disten- 
 sion of the stomach and colon may be of assistance. A 
 tympanitic area will be present between the tumour and the 
 liver or spleen, as the case may be. If the tumour diminishes 
 either spontaneously or under palpation, and the fluid 
 empties into the bladder, the diagnosis is practically certain. 
 Exploratory puncture is risky, and does not give any 
 decisive evidence. 
 
 If intermittent fever has been present for some time, and 
 if the patient passes pus in considerable quantities from 
 time to time, pyonephrosis must be diagnosed. 
 
 Differentiation from other cystic tumours, particularly 
 of the kidney, is often very difficult. Ovarian cysts have 
 attachments with the uterus and grow upwards from the 
 pelvis. Other cystic renal tumours may be differentiated 
 by catheterization of the ureter. In hydatid cyst scolices 
 are often present in the urine. In hepatic and splenic 
 tumours the dullness is continuous with that of the liver and 
 the spleen. A hydronephrosis may move freely with 
 respiration. In one of my cases the free mobility on respira- 
 tion seemed to point to a splenic tumour, until pyuria 
 cleared up the diagnosis. 
 
 Diagnosis from calculous kidney may be far from easy. In 
 both conditions there may be attacks of colic ; in hydro- 
 nephrosis the tumour rapidly increases in volume during 
 the occlusion stage, and red blood-cells are absent in the 
 intervals of the attacks of colic, whereas they occur in stone 
 cases after exercise. 
 
 A distended gall-bladder can usually be distinguished 
 from a hydronephrosis if the patient is placed in the left 
 lateral position ; in this position the gall-bladder passes 
 towards the left away from the kidney. 
 
422 INDICATIONS FOR OPERATION IN 
 
 INDICATIONS FOR OPERATION. 
 
 If pyonephrosis is diagnosed operation is indicated with- 
 out delay. Nephrectomy is usually necessary, more rarely 
 nephrotomy. 
 
 For diagnostic, and above all for palliative purposes, 
 puncture of a hydronephrosis may be indicated. When 
 sudden occlusion gives rise to a large hydronephrosis, with 
 much pain, oliguria, and other serious symptoms, if a more 
 radical operation is not permissible, puncture with drainage 
 is the best plan. 
 
 In cases of hydronephrosis without such acute symptoms, 
 operation is called for when there is persistent long-continued 
 pain, when non-surgical treatment of the cause (e.g., 
 bandaging in floating kidney, reposition of uterine displace- 
 ment) proves useless or cannot be carried out for some 
 reason, and when the sac cannot be completely emptied by 
 massage. 
 
 Torsion of the pedicle of a hydronephrosis or rupture call 
 for immediate intervention. In occlusion with reflex anuria 
 or oliguria, intervention is equally justified, since continuous 
 catheterization of the ureter is dangerous. 
 
 Operation will be designed to deal with the cause of the 
 retention, and the kidney will be extirpated only if it is 
 very large, if the parenchyma is atrophied, if the ureter 
 is obliterated, if the cause is an inoperable tumour 
 situated in the pelvis, and if conservative methods prove 
 useless. Nephrectomy is of course only justifiable when 
 one is certain that a second and functioning organ is 
 present. To be sure of this it is necessary to obtain the 
 urine from each side. If only one organ is secreting, i.e., 
 that on the apparently healthy sid§, it is necessary to 
 examine its molecular concentration and the amount of 
 urea. The phloridzin test is also of importance ; 5 mgr. 
 of phloridzin are injected subcutaneously, and the amount 
 of sugar secreted is measured. The less the functional 
 capacity of the kidney, the less urea is excreted, and the less 
 sugar is passed after phloridzin injection. 
 
 External circumstances, such as the patient's position, 
 may contra-indicate conservative methods, and point to the 
 advisability of radical operation. 
 
 Contra-indications. — Against operation will be hydro- 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 423 
 
 nephrosis of both kidneys, the presence of some pernicious 
 inoperable causative disease, such as uterine cancer, 
 defective functional capacity of the second kidney, or the 
 complete absence thereof. 
 
 In bilateral primary pyonephrosis any serious operative 
 interference is, as a rule, contra-indicated. 
 
 Prognosis. — Without operation. — There is often insupport- 
 able pain, sensations of distension, and frequent renal 
 haemorrhage. In the case of large tumours there is the risk 
 of rupture ; in hydronephrosis of a floating kidney the pedicle 
 may become twisted. There is always the risk of a secondary 
 infection in a case of hydronephrosis. Pyonephrosis may 
 prove fatal from septic intoxication, or from spread of the 
 inflammatory condition to other structures around. 
 
 Risks of operation. — Of forty cases of aseptic and infected 
 hydronephrosis operated on by Israel, five died, three of 
 these after primary nephrectomy. The operative mortality 
 of pyonephrosis is still higher : a third of Israel's cases 
 succumbed. According to this surgeon this is to be 
 explained by the frequency of bilateral infection, by the 
 small resistance of the primarily infected kidney to the 
 infection, by the failure of compensatory hypertrophy of 
 the other kidney, and finally by the fact that pyonephrosis 
 is most common at a relatively advanced age (the ages of 
 half of his cases lay between 50 and 70). 
 
 Results of operation. — Of Israel's 40 cases, 32 were entirely 
 cured by operation, 3 relieved. In 19 cases of true primary 
 pyonephrosis, the same surgeon obtained a complete cure 
 in 58-8 per cent of those treated by primary or secondary 
 nephrectomy, in only 5 '2 per cent when conservative 
 methods were employed. In many cases treated by 
 conservative methods, particularly by incision for pyone- 
 phrosis, a urinary fistula persisted which necessitated 
 nephrectomy later. 
 
 LITERATURE. 
 
 Senator. Die Nierenkrankheiten. 2nd Ed. Wien. 1903. 
 Nothnap;crs Handbuch d. spez. Pathol, u. Therap. 
 
 Israel. Chirurgische Klinik der Nierenkrankheiten. BerUn. 
 1901. 
 
 Wagner. Behandhing der Nierenkrankheiten. Handbuch d. 
 spez. Therap., herausgegeben v.,Penzoldt-Stintzing. 3rd Ed. 
 
 Navarro. Contribution a I'Etude de I'Hydronephrose. These 
 
424 INDICATIONS FOR OPERATION IN 
 
 de Paris. 1899. Societe de Chirurgie de Paris. 1901. Bary, 
 Albarran. 
 
 GossET. Traitement des Retentions Renales. Rev. de Chir. 
 1900. 
 
 Boucher. Intermittent Hydronephrosis. New York Med. Jour., 
 Vol. Ixxvi, No. 8. 
 
 C. Adriasj. Diagnostische Bedeutung des Ureterenkatheterismus. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir , 1902. 
 
 TUBERCULOSIS OF THE KIDNEY. 
 
 Etiology. — Tuberculosis of the kidney may arise from 
 infection by way of the blood stream, or from the urinary 
 channels below. Sometimes the kidney is the only organ 
 in the body showing tubercular infection ; that is to say, 
 primary renal tuberculosis occurs. The acute form of the 
 disease is most common in children, the ascending form of 
 chronic tubercle in men between twenty and forty, the 
 primary disease in women. Tubercular foci in some part 
 of the male sexual organs is not uncommonly an antecedent 
 of a secondary renal invasion. 
 
 Pathological Anatomy. — There are two chief anatomical 
 types, the acute disseminated and the chronic. The chronic 
 type is often unilateral in the early stages, affects the left 
 kidney more frequently than the right, and not uncommonly 
 finds its seat towards the lower pole.* Fairly large caseous 
 foci are produced in this way which tend to break down. In 
 advanced stages the greater part of the renal parenchyma 
 is often destroyed ; the kidney is then enlarged as a whole. 
 The renal pelvis and ureter are frequently invaded, and as 
 the disease extends downwards the bladder becomes involved, 
 in the first place round about the ureteral orifices. Israel 
 records secondary bladder tuberculosis in 40 per cent of his 
 cases. The disease may spread through the renal capsule 
 and involve neighbouring structures. 
 
 It is a fact of great practical importance that unilateral 
 primary tuberculosis does occur without any other discover- 
 able tubercular lesion in the body. 
 
 * Israel speaks of three types of the chronic disease : (i) The most 
 common — the caseous-excavating type from which pyonephrosis may 
 develop by mixed infection; (2) Tubercular ulceration of the apices of 
 the papillae ; (3) The chronic disseminated nodular typ3. 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 425 
 
 In other cases autopsy has shown the bladder disease to 
 be of old standing and extensive, the ureteral and renal 
 infection being recent and at an early stage. 
 
 Clinical Course. — The disease often remains latent for 
 a long period. The symptoms of chronic renal tuberculosis 
 are general and local. Sometimes the general symptoms 
 make their appearance before the local : loss of appetite and 
 power of digestion, increasing anaemia, wasting, hectic fever 
 (especially if the bladder is involved), and profuse sweating. 
 As a rule other localizing symptoms co-exist with these : 
 disturbances of micturition and changes in the composition 
 of the urine. The patient passes water more frequently than 
 usual, and sometimes complains of tenesmus or uncomfort- 
 able sensations after the act. Blood and pus are usually 
 present in the urine, and not infrequently mucopurulent 
 masses and shreds ; the reaction remains acid. Hematuria 
 is often the first symptom, and supervenes independently of 
 exercise or exertion. Tubercle bacilli are to be demonstrated 
 in the urinary sediment in about a third of the cases only. 
 Casts are not common, and albumin is usually present only 
 in small quantities. There is as a rule a complaint of pain, 
 either constant or intermittent ; it may be confined to the 
 loin or may radiate towards the bladder and the thigh. 
 Sometimes it is of a colicky character. Severe pain during 
 micturition is almost entirely confined to cases where the 
 tuberculosis has invaded the ureter and bladder. 
 
 The affected kidney can usually be palpated and its 
 enlargement noted (19 times in 24 of Israel's cases), 
 particularly if the surrounding tissues are involved in the 
 inflammatory changes or if a hydronephrosis is associated 
 with the tubercular lesion. Tenderness on palpation is 
 slight unless there is acute suppurative perinephritis. 
 
 The duration of the disease is seldom more than five years 
 from the appearance of the first symptoms until death. 
 The propagation of the disease from kidney to bladder 
 may occur at any stage of the disease. 
 
 Diagnosis. — The discovery of tubercle bacilli in the urine 
 (to be distinguished from the smegma bacillus), may make 
 the diagnosis certain ; but even without this a definite 
 diagnosis can usually be made. 
 
 If a unilateral renal disease is present, and the cystoscope 
 shows evidence of tuberculosis limited to the ureteral papilla 
 
426 INDICATIONS FOR OPERATION IN 
 
 or its immediate neighbourhood, it is clear that the disease 
 is descending. Any purulent renal affection should raise 
 a suspicion of tubercle ; according to Israel a third of all pus- 
 forming processes in the kidney are tubercular in nature. 
 
 In all cases of rebellious cystitis also, tubercle should be 
 suspected ; an evening rise of temperature, night sweats, 
 tubercular lesions elsewhere, especially in the genitals, pallor, 
 loss of appetite, renal pain, occasional hsematuria and colic 
 are sufficient to make the diagnosis clear, even if no tubercle 
 bacilli can be found. 
 
 If, after an injection of tuberculin (^-i mgram of the old 
 tuberculin), there is pain in the kidney, hsematuria, and 
 tubercle bacilli in the urine, the diagnosis is also established. 
 
 The condition of the other kidney. — Before deciding on 
 operation it is most important to have precise information 
 about the other kidney. If urine is obtained from this side, 
 and more than traces of albumin are found in it, it. may be 
 concluded that it is affected in some manner. A large 
 quantity of albumin indicates a grave renal lesion if the 
 heart is sound ; a small quantity, however, does not 
 necessarily mean a slight lesion. A lesion in this kidney 
 may be actual tuberculosis, or waxy disease, or some 
 accidentally associated condition, such as stone, or there 
 may be simply a toxic nephritis of a relatively benign type, 
 subsiding rapidly when the other — the tubercular — organ 
 is removed. If tubercle bacilli are found in the urine from 
 this side it will of course point to an actual tuberculosis 
 here also ; leucocytes, casts, and other pathological elements 
 will not show whether the condition is actually tuberculous 
 or waxy, or merely a toxic nephritis, and neither will 
 cryoscopy and the phloridzin test give any absolutely 
 reliable information on this point. These difficulties must 
 be taken into account when the question of surgical treat- 
 ment comes to be decided. 
 
 Differential diagnosis. — The diagnosis from an infected 
 nephrolithiasis is specially important. The history of the 
 passage of gravel or calculi previously, repeated colic, 
 absence of tubercular lesions in other organs, and of tubercle 
 bacilli in the urine, and examination with the X-rays, are 
 usually sufficient to demonstrate the presence of calculus. 
 Pyuria is not a common sign in new growths, and sometimes 
 fragments of growth are to be found in the urine. If the 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 427 
 
 alterations in the urine and in the act of micturition are very- 
 pronounced it is sometimes difficult to distinguish tubercle 
 from pyelitis. If, however, fever is constantly present, if 
 the kidney is not particularly tender to pressure, and if the 
 urine is only slightly turbid, tuberculosis is the more 
 probable. The tuberculin reaction is also available as a 
 means of differentiation, as has already been remarked. 
 
 In a female patient under my care, with tuberculosis of 
 the bladder, an acute h^emorrhagic nephritis supervened 
 and gave rise to a suspicion of renal tuberculosis ; the 
 presence of numerous casts, however, were against a chronic 
 tuberculosis, and the autopsy showed that the kidney was 
 free from tuberculous infection. 
 
 INDICATIONS FOR OPERATION. 
 
 Surgical treatment consists for the most part of total or 
 partial nephrectomy. The evacuation of confined pus and 
 broken-down tissue by nephrotomy is more rarely indicated. 
 The indications for operation vary somewhat according to 
 the stage of the disease. If one is fortunate enough to be 
 able to diagnose a unilateral renal tuberculosis in the early 
 stages, it is justifiable to institute a general expectant 
 treatment if the surroundings of the case are favourable, and 
 no severe general or local symptoms are present. If serious 
 symptoms supervene, surgery must be resorted to, and it 
 is in this way, rather the complications of the disease than 
 the disease itself, which make operation urgent. Colic, fever, 
 hsemorrhages, pyuria, retention processes, vesical pains, 
 loss of flesh and appetite : these are the signs which call for 
 intervention. If cystoscopy shows the disease extending to 
 the ureteral papilla, nephrectomy is definitely indicated. 
 The same is true when a primary renal tuberculosis is 
 recognized, already well advanced and associated with fever, 
 loss of flesh, anaemia, and night sweats, and the disease 
 appears to be probably confined to one side. 
 
 A primary, unilateral, renal tuberculosis should also be 
 operated on, even if the vesical mucous membrane is 
 extensively involved. If a perinephritic tubercular abscess 
 is present which has originated from the kidney, it must be 
 opened and nephrotomy performed. If the disease is of 
 the ascending type, operation is only indicated, according to 
 Israel, when the renal disease gives rise to special and 
 
428 INDICATIONS FOR OPERATION IN 
 
 severe symptoms, or when the retention of pus, fever, 
 anaemia, and disorders of nutrition are breaking down the 
 patient's powers of resistance. 
 
 Contra-indications. — Serious comphcations in other organs, 
 and particularly serious tubercular lesions in lungs, bones, 
 and glands, contra-indicate surgical intervention, as does 
 also any well-established disease in the other kidney. It 
 has already been remarked, that it is impossible to be certain 
 whether disease in the other kidney is of a slight (toxic) or 
 of a severe type in cases where the urine from this side 
 contains little albumin and no tubercle bacilli ; but if this 
 urine contains much albumin, or renal elements in quantity, 
 or pus, or tubercle bacilli, operation is correspondingly 
 inadvisable. On the other hand, a slight amount of albumin 
 and scanty renal elements does not contra-indicate operation 
 when the disease on the other side is pronounced. 
 
 The methods of investigating renal function by cryoscopy 
 and the phloridzin test do not give such certain results that 
 they should be considered indispensable in deciding the 
 question (Israel). Secondary tuberculosis of the bladder, 
 unless advanced, is no contra-indication to nephrectomy, 
 as experience has shown that this usually improves after 
 removal of the kidne}^ 
 
 When, however, a primary bladder tuberculosis is associ- 
 ated with advanced disease in one kidney, and the other is 
 not entirely healthy, even when the albumin from the latter 
 is small in quantity, operation is not advisable, because 
 primary bladder tuberculosis is usually followed by tuber- 
 culosis of the kidney on both sides. 
 
 Prognosis. — Risks and results of operation. — Israel has 
 recorded 22 cases of primary renal tuberculosis (8 with 
 secondary disease in the bladder) ; 16 were permanently 
 cured by operation, and four died either immediately after 
 or later. Of 8 cases of secondary renal tuberculosis 
 or combined renal and vesical disease in which the 
 primary seat was unknown, 3 were cured and 5 died. 
 The same surgeon estimates the mortality of nephrectomy 
 for tuberculosis at 28'5 per cent. The risk of the 
 operation is therefore considerable. If the operation 
 is successful recovery may be complete ; cases are on 
 record of perfect health eight years later. A toxic 
 nephritis of the opposite kidney may also disappear 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 429 
 
 completely after removal of the tuberculous organ. Even 
 vesical tuberculosis may disappear after nephrectomy, if not 
 advanced. 
 
 Without operation. — Spontaneous recovery is exceptional, 
 and occurs only when the disease focus is of small dimensions. 
 Once the disease has given rise to symptoms it progresses, 
 unless the kidney is removed, and slowly but surely leads 
 to marasmus and death. 
 
 LITERATURE. 
 
 Senator. Die Nierenkrankheiten. Nothnagel's Handbuch d. 
 spez. Pathol, u. Therap. 2nd Ed. . Wien, 1903. 
 
 Israel. Chirurgische Klinik der Nierenkrankheiten. Berlin, 
 1901. 
 
 ScHNURER. Die primare Nierentuberkulose. Kritisches Sammel- 
 referat. Centralb. f. d. Grenzgebiete d. Med. u. Chir., 1899. 
 
 KusTER. Die chirurgischen Krankheiten der Niere. Deut. 
 Chir. Bd. lii. Stuttgart. 
 
 Wagner. Die Behandlung der Nierenkrankheiten. Handbuch 
 d. spez. Therap. v. Penzoldt-Stintzing. Bd. vii. 
 
 Leyden. Die Diagnose der Nierentuberkulose. Berliner klin. 
 Wochens., No. 17. 1896. 
 
 Kapsammer. Flint geheilte Falle von Nieren- und Blasentuber- 
 kulose. Wiener klin. Wochens., No. 16, 1904. 
 
 Albarran, Bary, Delbet, Kirmisson, Tuffier, Routier, 
 Vortrage von. Societe de Chirurgie de Paris, 1899, 1900, 1901. 
 
 Bezaguet. Tuberculose Renale. These de Paris, 1898. 
 
 PYELITIS AND SUPPURATIVE NEPHRITIS. 
 
 Etiology. — Suppurative renal affections are more 
 frequently met with in adults than in children, and in men 
 than in women. Pyelitis is often caused by the presence of 
 some foreign body in particular calculi, more rarely new 
 growths and parasites; it also occurs from ascending 
 infection from the bladder, and also from the action of 
 irritant diuretics. Venous engorgement, injury, and 
 adjacent inflammatory lesions (either in the renal paren- 
 chyma or the surrounding tissues) are all of etiological 
 importance. Suppurative nephritis also occurs by 
 metastasis from some septic focus elsewhere in the body, 
 and supervenes sometimes in the course of certain of the 
 acute exanthemata : variola, scarlatina, and typhoid. 
 
 Pathological Anatomy. — Suppurative nephritis may 
 
430 INDICATIONS FOR OPERATION IN 
 
 be secondary to infection conveyed upwards from the 
 urinary passages or conveyed by the blood stream, or it may 
 result from an inflammatory affection of neighbouring 
 structures or a penetrating wound. In haematogenous 
 infection the original focus is often in the lower urinary 
 passages, or may be in some distant part of the body. The 
 disease is more frequently unilateral than bilateral, not only 
 when calculus is the cause, but also in ascending infections. 
 
 Acute catarrhal, chronic catarrhal, purulent and ulcerative 
 forms are recognized, the ulceration in the last being often 
 very destructive. If the escape of the urine is prevented in a 
 case of pyelitis, the condition becomes one of pyonephrosis. 
 The inflammatory condition of the pelvis often extends to 
 the parenchyma, and abscesses develop frequently in large 
 numbers. 
 
 A purulent pyelonephritis may be the precursor of 
 perinephritic abscess. When a renal abscess develops 
 irom blood infection, the secondary involvement of the renal 
 pelvis, if it occurs, is usually not of a pronounced character. 
 Abscesses originating in this way may be multiple ; by 
 confluence, cavities of considerable size may develop, and 
 tend to make their way through the capsule. Such abscesses 
 are often entirely shut off from the renal pelvis and urinary 
 passages. 
 
 Clinical Course. — In cases of pyelitis the urine is turbid, 
 often purulent, and sometimes bloody. If the renal 
 parenchyma is not involved the amount of albumin is small ; 
 n pyelonephritis, on the other hand, both albumin and casts 
 are present in the urine. If discharge from the kidney is 
 obstructed the urine may be quite clear, coming from the 
 opposite kidney alone ; in such a case the diseased organ 
 will be enlarged, painful, and tender to pressure, signs which 
 subside if the obstruction disappears, and the urine again 
 becomes turbid. 
 
 In acute pyelitis the amount of urine is often diminished, 
 and sometimes there is marked tenesmus ; even in cases 
 where the opposite kidney is sound, reflex anuria may 
 develop. In renal abscesses following blood infection the 
 amount of urine is often lessened, and albumin and renal 
 elements are present in quantity. In such a case pyuria 
 occurs when the abscess ruptures into the renal pelvis, and 
 the fever and pain then often subside simultaneously. If a 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 431 
 
 parenchymatous inflammation is associated with pyehtis, 
 casts of various kinds will be present in the deposit. If, 
 however, an abscess is encapsuled in the kidney substance 
 the urine may be normal in every respect. 
 
 Pains, sometimes of a distinct colicky character, are 
 frequent in acute pyelitis ; in the chronic disease they are 
 only present when some obstruction occurs to the emptying 
 of the renal pelvis. In acute purulent nephritis, pain and 
 tenderness on palpation are usually very acute, and the 
 same is true of traumatic suppurative nephritis. In the 
 latter, hsematuria and rigors are common, and sometimes 
 reflex anuria. Fever is the rule in acute pyelitis, and occurs 
 in the chronic disease when there is absorption of the 
 infective products. A palpable tumour is to be felt in 
 pyelonephritis only when retention occurs. 
 
 In acute renal abscess fever is often high and sustained ; 
 in the subacute and chronic abscess it is often present in 
 an intermittent form, with rigors and sweating, but is 
 sometimes absent altogether. In acute abscess the patient 
 usually loses strength rapidly, and enlargement is commonly 
 to be made out, as well as tenderness. 
 
 When an ascending inflammation invades the kidney the 
 amount of urine is diminished and the amount of pus 
 increased. The opposite kidney is often affected with a 
 toxic nephritis or with amyloid disease in the chronic cases. 
 
 Diagnosis. — Pyelitis will be diagnosed when pus is 
 present in the urine but there is no disturbance of 
 micturition, when there are no casts and only traces of 
 albumin, when one of the kidneys can be felt as a tender 
 swelling in the loin, and when, after washing out the bladder, 
 purulent urine is withdrawn by catheter after pressure on 
 the swelling. 
 
 The diagnosis is established if the cystoscope shows pus 
 coming from one ureter, whether the bladder is healthy or 
 not. If the signs point to pyelitis, and at the same time 
 there are numerous casts and much albumin in the urine, 
 the diagnosis will be pyelonephritis. 
 
 Hiematogenous renal abscess with subsequent rupture 
 into the renal pelvis is usually to be recognized from the 
 presence of some infective focus, an acute commencement 
 with rigor, high fever, local sweHing and tenderness, and the 
 sudden appearance of pus and often blood and renal elements 
 
432 INDICATIONS FOR OPERATION IN 
 
 in the urine. The enlargement of the kidney is the sign of 
 most importance. 
 
 The conditions which may be confused witli a pyehtis are 
 tumours of kidney, hver, spleen, ovary, and intestine. 
 Repeated bimanual examination is of special value, under 
 anaesthesia if necessary. If the intestine is inflated a renal 
 swelling is found to be behind the colon, and below and 
 behind an inflated stomach. Pelvic examination will 
 exclude ovarian tumours. Inflation of the colon will show 
 up a liver or splenic tumour. If the tumour subsides 
 coincidently with the appearance of pus in the urine, this 
 will aid the diagnosis. If there is a fistula in the loin, and 
 methylene blue is injected into this, it will be seen within a 
 minute issuing from the ureter. Pus with a urinous odour 
 may be found with an exploring syringe, but such an 
 exploration must not be done unless preparations are made 
 to operate at once. 
 
 INDICATIONS FOR OPERATION. 
 
 The discharge of pus from one kidney is an indication for 
 operation, whether the suppuration is the consequence of an 
 ascending infection, a direct renal trauma, the spread of an 
 inflammatory condition from surrounding structures, or a 
 blood-borne infection. High-fever, rigors and sweating, and 
 other acute signs indicate the necessity for immediate 
 intervention, even in cases where the inflammatory condition 
 is chiefly but not exclusively unilateral. In every case it is 
 necessary to ascertain whether there are two ureters opening 
 into the bladder, and which is the one discharging 
 urine ; also as much as possible about the functional 
 capacity of the healthy or comparatively healthy organ. 
 Without information of this kind nephrectomy cannot be 
 performed. 
 
 Contra-indications. — In a hsematogenous suppurative 
 affection of the kidney associated with multiple foci else- 
 where, operation is inadvisable, particularly when the 
 causal condition cannot be treated (ulcerative endocarditis) ; 
 bilateral renal suppuration is not in itself a contra-indication. 
 Other serious complicating affections also contra-indicate 
 intervention. As a rule the demonstration of a severe 
 bilateral pyelitis secondary to bladder disease is a deterrent 
 to operation. If cysto-pyelonephritis supervenes in the 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 433 
 
 course of some central nervous disease (tabes), any surgical 
 intervention will also be entirely unsatisfactory. 
 
 Prognosis. — Results of operation. — Suppurative renal 
 affections are often cured by nephrotomy. In many cases 
 of small multiple abscesses, recovery has been obtained by 
 splitting the kidney or resection of the affected portion 
 (Rovsing). Even in the ascending infections, with suppu- 
 ration of the kidney, operation often produces marked 
 amelioration and cure. 
 
 Risks of operation. — -If one kidney is removed and the 
 other is defective in functional capacity, a fatal ursemia is 
 to be expected. Patients who have been much weakened 
 by long suppuration are very susceptible to the risks of 
 general anaesthesia. 
 
 Without operation.- — A suppurative renal affection may 
 be the starting-point of a general septicaemia. Chronic 
 disease tends to produce waxy changes in other organs. 
 Sometimes the pus evacuates itself through the renal pelvis. 
 The rupture of abscesses is signalized by a sudden pyuria 
 and the subsidence of fever, pain, and the general symptoms. 
 
 In two cases recently under observation, the following 
 was the course of events. Both were about to be submitted 
 to operation, and the only delay was the necessity for 
 completing the clinical examination. After the onset of 
 pyuria, the fever, tenderness, and leucocytosis disappeared. 
 In both there was a short recurrence of symptoms, termi- 
 nating in the same manner as before, and then complete 
 recovery followed. In neither was the original seat of 
 infection discovered. Such a happy course of events is not, 
 however, usual ; the suppurative focus usually extends to 
 the whole organ, and then ruptures through the capsule, 
 and may reach the exterior. A fistula thus established 
 continues to discharge and shows no tendency to heal, and 
 waxy disease or some secondary wound infection may result. 
 In some cases the pus makes its way into the bowel or some 
 other organ. 
 
 LITERATURE. 
 
 Senator. Die Krankheiten der Niere. Nothnagel's Handbuch 
 d. spez. Pathol, u. Therap. 2nd Ed. Wien, 1903. 
 
 ScHEDE. Krankheiten der Niere. Handbuch d. prakt. Chir., 
 herausgegeben v. Bergmann, Mikulicz, u. Bruns. 2nd Ed. 
 Stuttgart, 1903. 
 
 28 
 
434 INDICATIONS FOR OPERATION IN 
 
 Israel. Chirurgische Klinik der Nierenkrankheiten. Berlin, 
 1901. 
 
 RovsiNG. Operation chronischer Nephritiden. Mitteil. a. d. 
 Grenzgebiete d. Med. u. Chir. Bd. x. 
 
 Jaffe. Zur Chirurgie des metastatischen Nierenabscesses. 
 Mitteil. a. d. Grenzgebiete d. Med. u. Chir. Bd. ix. 
 
 WiLiNis. Spaltung der Niere bei akuter Pyelonephritis mit 
 miliaren Abscessen. Miinch. med. Wochens., 1902, No. 12. 
 
 Lennander. Spaltung der Niere bei akuter Pyelonephritis mit 
 miliaren Abscessen. Nord. Med. Arch. 1901. 
 
 Albarran. Maladies Chirurgicales du Rein. Traite de Chirurgie. 
 Paris, 1898. 
 
 GuYON. Die Krankheiten der Harnwege. Teil ii. Translated 
 by O. Krauss u. O. Zuckerkandl. Wien. 1899. 
 
 KusTER. Die Chirurgischen Krankheiten der Nieren. Deut. 
 Chir. Stuttgart. 1897. 
 
 Herszky. Nierenabscess und Perinephritis. Kritisches Sammel- 
 referat. Centralb. f. d. Grenzgebiete d. Med. u. Chir. 1903. 
 
 PERINEPHRITIS. 
 
 Etiology. — Perinephritis is sometimes secondary to 
 lumbar injuries ; it is often due to extension from neighbour- 
 ing structures, and in this way it may follow renal abscess, 
 pyelitis, pyelonephritis, pelvic abscess, vertebral disease, 
 and abscesses of the liver and spleen. It may occur as a 
 metastatic process in pyaemia. 
 
 It is especially common about middle life, and in men. 
 
 Pathological Anatomy. — The condition is usually uni- 
 lateral. Israel distinguishes three chief forms : (i) The 
 fibrosclerotic ; (2) The lipomatous ; (3) The phlegmonous. 
 The fibrosclerotic form transforms the fatty capsule into a 
 dense fibrous mass. In the lipomatous there is sometimes 
 a very pronounced overgrowth of fat surrounding the whole 
 kidney. The phlegmonous type originates either in the 
 fatty capsule itself, or by extension from a neighbouring 
 suppurative focus, or as a metastatic infection. 
 
 In many of the cases where the perinephritis apparently 
 originates in the fatty capsule, the real starting-point is a 
 small abscess of the kidney ; of 43 cases operated on by. 
 Israel, 34 originated in this way. 
 
 The phlegmonous inflammation may start as a sub- 
 capsular process, or in the fatty capsule, or in the retro- 
 peritoneal fatty tissue. Most frequently the purulent 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 435 
 
 collection forms behind the kidney ; it tends to spread 
 upwards through the diaphragm to the subpleural tissue, 
 and may rupture into a bronchus. In other cases the 
 pus makes its way downwards to the thigh, or becomes 
 superficial in the lumbar region, or may discharge into 
 the bowel. 
 
 Clinical Course. — The commencement of the affection 
 is often associated with general symptoms only — -fever, 
 exhaustion, and rigors ; local symptoms either succeed these 
 or may appear at the same time. Pain is localized in the 
 loin, and is exaggerated by deep inspiration, by pressure, 
 and by active movement ; it may be absent during the 
 earliest stages. I have found hyperaesthesia in several cases 
 over the area supplied by the ileohypogastric nerve, and 
 sometimes there is distinct cutaneous hyperaesthesia in the 
 loin. Meteorism is often present, and the respiratory 
 movements are usually shallow. 
 
 Sometimes the onset is characterized by vomiting and 
 urinary tenesmus, and renal elements are found in the urine, 
 which owe their presence to the nephritis, to which the 
 perinephritis is secondary. 
 
 Sometimes in the early stages the hip on the affected 
 side is kept flexed, but it is only extension which is limited, 
 the other movements remaining free. Pain may radiate 
 down the sciatic nerve, and the lumbar spine may be kept 
 rigid. The condition may be present for some considerable 
 time before an actual lumbar swelling makes its appearance, 
 but sooner or later this develops. A local oedema of the 
 skin in the loin is a diagnostic point of much value. The 
 swelling, although involving the kidney region, has not the 
 well-defined shape of an enlarged kidney, its margin being 
 irregular, it does not move with respiration, and it gradually 
 increases in size. It may be possible to make out fluctuation. 
 If left alone it comes to the surface and ruptures, or it may 
 perforate into the bowel, the bladder, or some other organ. 
 In other cases there is a tendency towards the diaphragm 
 from the early stages, and the abscess becomes subphrenic, 
 and may further make its way into the thorax and perforate 
 into the pleura or the lung. In such cases a dry pleurisy 
 often develops early. A radiograph may show the 
 diaphragm pushed up on one side and comparatively 
 immobile. 
 
436 INDICATIONS FOR OPERATION IN 
 
 One of my cases was that of a young man who developed 
 a dry pleurisy at the base of the right lung, with fever and 
 rigors. The fever remained high in spite of the absence of 
 exudation and any recognizable lung affection. Dull pains 
 in the loin early gave rise to a suspicion of perinephritis, and 
 a resistance developed here with an overlying inflammatory 
 oedema. A large retrorenal abscess was opened, extending 
 upwards to the diaphragm, and the man recovered. The 
 pleurisy soon subsided after the operation. 
 
 Diagnosis. — If the cardinal symptoms — fever, pain, and 
 swelling — are all present, the diagnosis is clear. The most 
 instructive and important sign is the swelling, particularly 
 if it extends along the course of the psoas, which a renal 
 tumour does not. Extension and protrusion towards the 
 loin, without any large palpable tumour, is characteristic of 
 perinephritis, but not of renal tumour. Marked tenderness 
 on pressure in the loin is characteristic of perinephritis ; in 
 inflammatory swelling of the kidney the tenderness is more 
 in front. Normal urine points to the absence of any other 
 complicating renal disease. Against " lumbago " is the 
 pyrexia and the unilateral nature of the complaint. 
 
 In tubercular abscess some tubercular bone lesion above, 
 of vertebrse or rib, will be discoverable. An appendix 
 abscess or an abscess originating in the genital organs has 
 been mistaken for perinephritis. Extension towards the 
 loin is not frequent in these conditions. In perinephritis 
 there is no rigidity of the abdominal wall, and no resistance 
 in the crecal region. 
 
 INDICATIONS FOR OPERATION. 
 
 If there is only a definite suspicion of perinephritis, 
 operation is necessary. Early diagnosis is of the greatest 
 importance in order that early relief may be given. If fever 
 is present, if there is a resistance in the loin and tenderness 
 on pressure, and leucocytosis, the signs are sufficiently 
 marked to warrant incision. Operation will be justified 
 even when there is no definite resistance if there is an 
 inflammatory oedema of the skin. If an exploratory 
 puncture reveals pus, incision is of course called for. 
 
 There cannot be said to be any contra-indication unless 
 there is some complication which makes the case hopeless. 
 
 Prognosis. — Risks of operation. — Since only a simple 
 
DISEASES OF THE KIDNEY AND RENAL PELVIS. 437 
 
 incision is usually necessary, the operative risk is small. 
 Sometimes the kidney is completely disorganized and has 
 to be removed, and the risk is thereby increased. Suppu- 
 ration of an undamaged kidney is only to be feared when 
 some operative measure encroaching on the kidney (removal 
 of a stone, for example) has to be associated with the 
 opening of the abscess. 
 
 Results of operation. — Complete relief usually follows the 
 evacuation of the pus, and the patient usually makes a 
 rapid recovery. 
 
 Without operation. — It has already been remarked that 
 the pus often makes its way into the thorax ; according 
 to Fischer, in 20 per cent of the unoperated cases the lung 
 becomes involved ; the pus may also come to the surface, 
 or rupture into a hollow abdominal organ. Such extension 
 to other organs may give rise to dangerous complications. 
 Spontaneous recovery does sometimes occur in this way, 
 but it will of course never be deliberately counted on. Even 
 if the pus does not penetrate in this way, all the symptoms 
 caused by retention of such collections in the body will tend 
 to supervene, i.e., pyaemia and septicaemia, and a remediable 
 may become an irremediable affection. 
 
 LITERATURE. 
 
 Israel. Chirurgische Klinik der Nierenkrankheiten. Berlin. 
 1901. 
 
 Senator. Die Erkrankungen der Nieren. 2nd Ed. Wien. 
 1902. 
 
 ScHEDE. Krankheiten der Niere. Handbuch d. prakt. Chir, 
 herausgegeben v. Bergmann, Mikulicz, u. Bruns. 2nd Ed. 
 Stuttgart. 1903. 
 
 Herszky. Nierenabscess und Perinephritis. Zusammenfassendes 
 Referat. Centralb. f. d. Grenzgebiete d. Med. u. Chir. No. i, 1903. 
 
 Albarran. Maladies Chirurgicales du Rein. Traite de Chir., 
 Paris. 1898. 
 
 Sachs. Der subphrenische Abscess im Anschlusse an peri- 
 nephritische Eiterung. Arch. f. klin. Chir. Bd. 1. 
 
 Maydl. Der subphrenische Abscess. Wien : Safar. 
 
 Prior. Peri- und Paranephritis. Handbuch d. Krankheiten d. 
 Harnund Sexualorgane, herausgegeben v. Oberlander u. Zenker. 
 
CHAPTER XXIV. 
 Diseases of the Bladder. 
 
441 
 
 Chapter XXIV. 
 DISEASES OF THE BLADDER. 
 
 CYSTITIS. 
 
 Etiology. — Cystitis is always caused by micro-organismal 
 infection, which may be conveyed either by the urethra or 
 from the kidney. In the latter case the process may be 
 either directly descending, or the bladder may be infected 
 by microbe-containing urine from an unaltered kidney. 
 Finally the vesical mucous membrane may be infected 
 through the blood stream, or by extension from some 
 adjacent focus. 
 
 Associated causes are calculi, growths, and foreign bodies. 
 Diseases of the central nervous system and of the prostate, 
 pregnancy and labour, and senile changes are all pre- 
 disposing causes. 
 
 Pathological Anatomy. — Superficial, parenchymatous, 
 and ulcerative forms are distinguished, and the condition 
 may be circumscribed or diffuse. In chronic cystitis the 
 mucous membrane and muscular coats are hypertrophied, 
 the wall is thus thickened, and prominent trabeculse are 
 formed. 
 
 Clinical Course. — The characteristic symptoms are, 
 intense and frequent desire to pass water, and pain during 
 the act. The bladder is sensitive, for example, on 
 catheterization, and tender to pressure. Cystoscopic exami- 
 nation shows injection of the mucous membrane, which 
 bleeds readily, and in some cases ulceration. The urine 
 contains pus, sometimes blood, the reaction is often acid, 
 but if there is retention of urine it is frequently alkaline and 
 ammoniacal. The organisms most frequently found are 
 staphylococci, streptococci, B. proteus, B. coli, and gonococci. 
 An acute attack may be followed by chronic disease persisting 
 for several years, with acute exacerbations. In other cases 
 
442 INDICATIONS FOR OPERATION IN 
 
 the process rapidly extends to the upper urinary passages. 
 If the inflammatory process spreads to the deeper layers of 
 the wall, the bladder may become shrunken, and the patient 
 in this condition will have an almost constant desire to pass 
 water. In some cases a cystitis is followed by a perivesical 
 cellulitis which may extend to the peritoneum, the perineum, 
 or the perirectal connective tissue. 
 
 Diagnosis. — Painful micturition, tenesmus, and purulent 
 urine are present in many renal affections (tuberculosis, 
 infected calculous disease, etc.), as well as in cystitis, and 
 some of the symptoms are present in inflammatory affections 
 near the bladder. If the vesical symptoms undergo a sudden 
 unexplained change, while the pyuria remains constant, 
 some extravesical inflammation must be suspected. Careful 
 examination of the kidneys and the urine, cystoscopy, and 
 separation of the urine will show whether the symptoms are 
 due to renal disease. Tenderness on catheterization, on 
 pressure from the vagina or the rectum, point to a vesical 
 rather than a renal affection. The two-glass test differ- 
 entiates a vesical from a urethral suppuration. 
 
 INDICATIONS FOR OPERATION. 
 
 If strangury and painful contractions of the bladder 
 persist in spite of persevering and energetic local treatment, 
 and in spite of drainage by catheter and medicinal treat- 
 ment, the organ must be placed at rest by incision and 
 drainage. The fistula will be maintained only as a tem- 
 porary measure, and will be allowed to heal when the 
 cystitis begins to improve. If the changes in the mucous 
 membrane show no improvement in spite of persistent local 
 treatment, and the cystoscope shows fungous granulations 
 or ulceration, these must be dealt with by the sharp spoon 
 and by the cautery. The ulcerative and membranous form 
 of the disease must be treated by cystotomy and local 
 treatment when there is intense pain and haemorrhage, and 
 the membranous deposit does not clear up. 
 
 Contra-indications. — No operation should be done until a 
 proper attempt has been made to cure the condition by 
 lavage, internal medication, or drainage by catheter. 
 Disease of the central nervous system is in general a contra- 
 indication to operation ; if improvement takes place, which 
 is exceptional, recurrence soon follows. 
 
DISEASES OF THE BLADDER. 443 
 
 Prognosis. — Results of operation. — In many cases, after 
 opening and draining the bladder, the pain and tenesmus 
 improve greatly, and the urine also becomes clearer. 
 Cauterization and scraping are procedures from which good 
 results are often obtained. 
 
 LITERATURE. 
 
 ZucKERKANDL. Die lokalcn Erkrankungen der Harnblase. 
 Wien. 1899. Nothnagel's Handbuch d. spez. ' Pathol, u. Therap. 
 Bd. xix. 
 
 GuYON. Klinik der Krankheiten der Harnblase. Translated 
 by Mendelsohn. 1893. 
 
 NiTZE und SoNNENBURG. Verlctzungen und Erkrankungen der 
 Harnblase. Handbuch d. prakt. Chir., herausgegeben v. Bruns, 
 Mikulicz, u. Bergmann. 2nd Ed., Bd. iii. Stuttgart. 1903. 
 
 NOCTURNAL ENURESIS. 
 
 . There are two chief types of this affection : (i) The 
 symptomatic type, due to some pathological lesion of a local 
 nature, or of the spinal cord or brain ; (2) Essential enuresis 
 without changes in the urogenital apparatus, the central 
 nervous system, or the urine. The latter type alone will 
 be here considered ; it is of the nature of a neurosis. It is 
 sometimes due to psychic abnormalities ; in other cases it 
 is ascribable to diseases of nutrition, scrofula, anaemia, and 
 the uratic diathesis. In many cases some local affection 
 appears to be the cause ; thus it occurs in vesical calculus, 
 stricture of the urethra, phimosis, atony of the sphincter. 
 Occasionally there is an hereditary predisposition. It is 
 more common in boys than girls, and usually disappears in 
 all cases before the age of fourteen. 
 
 Symptoms. — The enuresis occurs usually in deep sleep 
 after the child has been some hours in bed, and the urine is 
 usually passed in considerable quantities. The child does 
 not necessarily wake. Not uncommonly there is some 
 spasmodic contraction of the leg muscles, especially the 
 adductors. Faecal incontinence is unusual. Other neuroses, 
 hysterical and neurasthenic symptoms, are often present. 
 
 INDICATIONS FOR OPERATION. 
 
 If all the recommended general and local methods 
 of treatment prove ineffectual, if the enuresis is persistent 
 
444 INDICATIONS FOR OPERATION IN 
 
 and frequent and is causing eczema, and if the child is 
 some distance removed from the age when spontaneous 
 cure is usual, intervention is justifiable. This will take 
 the form of an epidural injection of cocaine, or saline 
 solution (^ per cent), and will be made into the sacral 
 canal. Cathelin has carried out this treatment on more 
 than 1000 occasions, and Kappsammer on more than 300, 
 and neither has to record any unfavourable results. 
 Kappsammer records 25 cases which were followed up, all 
 being cured of the affection ; Cathelin and Albarran also 
 report recoveries and improvement. 
 
 When left alone the affection is very persistent. It may 
 recur even after some months of freedom. 
 
 LITERATURE. 
 
 V. Frankl-Hochwart und Zuckerkandl. Die nervosen Er- 
 krankungen der Blase. Nothnagel's Handbiich d. spez. Path. u. 
 Therap. Bd. xix. Wien. 1898. 
 
 Landau. Enuresis Nocturna. Kritisches Sammelreferat. Cen- 
 tralb. f. d. Grenzgebiete d. Med. u. Chir., No. 11, 1903. 
 
 G. Kappsammer. Ueber Enuresis und ihre Behandlung mittels 
 epiduraler Injektionen. Wiener klin Wochens., No. 29, 30, 
 1903. 
 
 Albarran et Cathelin. Traitement des Incontinences d' Urine 
 par les Injections Epidurales. Annales des Maladies des Voies 
 Urinaires. 1901. 
 
 Cathelin. Les Injections Epidurales. Paris, 1903. 
 
 TUBERCULOSIS OF THE BLADDER. 
 
 Etiology. — Vesical tuberculosis is usually secondary 
 either to renal tuberculosis, or, in the male, to tuberculosis 
 of the genital organs. Occasionally, however, it is found 
 as the sole focus of the disease clinically discoverable. 
 Gonorrhceal cystitis appears to predispose to the tubercular 
 disease. It is much more common in males than in females, 
 and among the poor than the well-to-do class. 
 
 Pathological Anatomy. — Circumscribed foci are often 
 present ; these are most common about the ureteral orifices 
 when the disease has descended from the kidney, and about 
 the neck of the bladder when it has had its origin in the male 
 genital organs. In other cases the whole mucous membrane 
 is beset with nodules. When these caseate and break down. 
 
DISEASES OF THE BLADDER. 445 
 
 superficial ulcers of considerable size develop, and on these 
 ulcers incrustations are often formed. When the ulceration 
 is extensive, the whole inner lining of the bladder is red, 
 swollen, and hasmorrhagic. In some cases a purulent peri- 
 cystitis occurs in consequence of the deep extension of the 
 ulceration. 
 
 Clinical Course. — The first symptoms of bladder 
 tubercle are increased frequency of micturition, intense 
 desire to empty the bladder, and pain during the act. 
 During the intervals the pain persists in the penis and 
 the perineum. As the process of ulceration develops, 
 spontaneous haemorrhages occur ; these are frequent, but 
 rarely profuse, and are often among the early signs of the 
 disease. Occasionally incontinence of urine sets in, and in 
 some cases this is complete. Severe general symptoms — 
 hectic fever and profuse night sweats — are common in the 
 more advanced stages of the disease. 
 
 Usually a tubercular focus in some other organ can be 
 discovered. 
 
 In the early stages the urine is acid, clear, or slightly 
 turbid from pus. Later the amount of pus increases and 
 blood is also present, but blood may also occur at an early 
 stage. When the pyuria is well marked, the reaction is 
 often alkaline. Palpation often demonstrates tenderness 
 and contraction of the bladder wall. 
 
 Diagnosis. — The spontaneous occurrence of hasmaturia 
 in young individuals who have never had gonorrhoea, and 
 have never had an instrument in the bladder, is almost a 
 pathognomonic sign of tuberculosis (Zuckerkandl), par- 
 ticularly if renal calculus can be excluded. The onset of 
 cystitis, without apparent cause, in an individual with a 
 tuberculous family history, or with tubercular lesions else- 
 where, suggests vesical tuberculosis, and the discovery of 
 tubercle bacilli in the urine and cystoscopic examination will 
 settle the diagnosis. The presence of nodular masses in 
 the prostate, seminal vesicles, vasa deferentia, or epididymes 
 will point to tuberculosis. New growths will be excluded 
 by the slightness and at the same time the persistence of 
 the hsematuria, and by the positive discovery of tubercle 
 bacilli. Chronic cystitis has usually some definitely known 
 cause, is improved by treatment, and does not tend to 
 produce hsematuria. 
 
446 INDICATIONS FOR OPERATION. 
 
 INDICATIONS FOR OPERATION. 
 
 There is no general rule for surgical interference, the 
 advisability of operation depending frequently on the 
 condition of the associated organs. If the bladder disease 
 is secondary to a unilateral renal tuberculosis, the indication 
 is to attack the disease in the kidney ; the elimination of 
 the renal disease is usually followed by healing of the bladder 
 lesions. If the bladder disease is associated with genital 
 lesions, the latter should be operated on first and the bladder 
 later. If the bladder disease is clinically the primary lesion, 
 if local therapeutics fail, and the pain and distress are great, 
 operation is indicated. This will consist in eradication of 
 the disease foci, with or without cystotomy, of excision in 
 the case of solitary ulcers, or finally in resting the bladder 
 by the establishment of a fistula. 
 
 Contra-indications. — If there is extensive genital tuber- 
 culosis, or bilateral renal tuberculosis, or advanced 
 tubercular lesions elsewhere, operation on the bladder is 
 useless. Cases in which the disease is florid and making 
 rapid progress are unsuitable for operation. 
 
 Prognosis. — Results of operation. — Operation often pro- 
 duces a rapid improvement in the subjective symptoms. 
 After opening the bladder, the pain, distressing tenesmus, 
 and haemorrhage may all improve. In some cases cure has 
 been obtained by direct eradication of the disease. In 
 many cases there occurs, however, a local return, and in 
 others other parts of the urogenital apparatus are attacked 
 by the disease. If the tubercular products are not dealt 
 with by operation, the extension of the disease tends to be 
 the more rapid, and dangerous complications supervene 
 the earlier. 
 
 LITERATURE. 
 
 ZucKERKANDL. Die lokalen Krankheiten der Harnblase. Noth- 
 nagel's Handbuch d. spez. Pathol, u. Therap. Bd. ix, Teil 2. 
 Wien, 1899. 
 
 KuMMELL. Die Krankheiten der Blase. Handbuch d. prakt. 
 Med., herausgegeben v. Ebstein u. Schwalbe. Bd. iii, Teil i. 
 Stuttgart, 1900. 
 
 Fritsch. Die Krankheiten der weiblichen Blase. Veit's Hand- 
 buch d. Gynakologie. Wiesbaden, 1897. 
 
 Stoeckel. Zur Diagnose und Therapie der Blasen-Nierentuber- 
 kulose bei der Frau. Beit. z. Klin, der Tuberkulose. Bd. i. H. 2. 
 A. Stuber's Verlag. Wurzburg, 1903. 
 
CHAPTER XXV. 
 
 Diseases of the Joints and Bones. 
 
449 
 
 Chapter XXV. 
 DISEASES OF THE f JOINTS AND BONES. 
 
 THE NERYOUS ARTHROPATHIES. 
 
 Etiology. — These affections occur in patients suffering 
 from organic disease of the nervous system, especiahy tabes 
 and syringomyeha. Trauma appears to play a considerable 
 part in their causation. 
 
 Pathological Anatomy. — -Investigation of specimens 
 lias shown that the changes in the joints are of similar 
 character in the various nervous diseases in which these 
 affections occur. From the appearances of a specimen 
 alone it would be impossible to say whether the patient 
 had suffered from tabes or syringomyelia. These joint 
 ■changes assume two forms, the atrophic arid the hyper- 
 trophic. In the former, the articular ends of the bones are 
 gradually worn away, and even a considerable portion of 
 the diaphysis may be absorbed if the patient continues to use 
 Iiis limbs ; in a tabetic patient under my care, a fourth of 
 the length of the femur disappeared in this way. The 
 absorption of articular cartilage and bone, the exudation in 
 the joint, and the relaxation of ligaments often permits 
 very considerable dislocation to take place. In the hyper- 
 trophic form the joints are enlarged ; the articular cartilage 
 disappears, and its place is taken by exuberant newly- formed 
 connective . tissue. The synovial membrane is often 
 distended and shows numerous ragged outgrowths, and 
 there are often cartilaginous or osseous loose bodies in the 
 joint. The joint capsule is much thickened, and there are 
 often exostoses, and sometimes ossified muscles, around it. 
 Sometimes the capsule gives way at one or more points. 
 Occasionally the atrophic and hypertrophic forms are 
 •combined. 
 
 29 
 
450 INDICATIONS FOR OPERATION IN 
 
 Clinical Course. — The affection often has a sudden 
 onset, with enormous effusion into the joint, and sometimes 
 marked swelhng of the whole extremity. There is no fever. 
 The effusion may remain stationary or be absorbed, to 
 reappear after a time either spontaneously or following some 
 slight trauma. After each effusion the joint changes become 
 more advanced, and, as already remarked, they may be either 
 atrophic or hypertrophic in character. In the former case 
 the articular surfaces separate and the joint becomes 
 flail ; in the latter the joint becomes enormously enlarged 
 and deformed. The thickening and distension of the capsule, 
 the building up of new connective tissue, the formation of 
 exostoses and intra-articular masses may reach extra- 
 ordinary proportions. Spontaneous fracture of the bones, 
 near the joint frequently occurs. There is absence of pain 
 throughout. 
 
 In tabes the joints of the lower limb are those usually 
 affected : the knee and the hip ; in syringomyelia, on the 
 other hand, it is the joints of the arm that are usually 
 involved : the shoulder, the elbow, and wrist. In tabes the 
 affection is often bilateral ; in syringomyelia, rarely so. 
 
 These joint changes may occur early in the course of the 
 disease to which they. are due. Serious complications may 
 supervene ; a local necrotic process may set in, involve the 
 bones, and extend to the joint. A suppurative arthritis 
 is thus set up. This may also occur as a metastatic process. 
 It is usually attended by high fever and rigors. Sometimes 
 a fistula forms communicating with the joint and discharging 
 a serous fluid. The patients, as a rule, tolerate these septic 
 processes surprisingly well. 
 
 With regard to differential diagnosis, arthritis deformans 
 is the only condition with which there might be some 
 confusion ; the painful nature of this process is sufficient tO' 
 distinguish it. 
 
 INDICATIONS FOR OPERATION. 
 
 Since these arthropathic lesions occur in the course of 
 progressive nervous maladies, and often spontaneously 
 retrocede, most surgeons have with good reason advised 
 against operation when they run an uncomplicated course, 
 and have confined treatment to the use of some orthopaedic 
 apparatus. Sometimes, however, even if no complication 
 
DISEASES OF THE JOINTS AND BONES. 45: 
 
 is present, operation is advisable ; if the effusion becomes 
 excessive and persists for a long time, and if the sensation 
 of distension is very troublesome, puncture followed by 
 compression is indicated. The more extensive operations 
 — resection and arthrodesis — are not called for on account 
 of pain, but may be justified by other circumstances. If 
 the limb has been rendered flail, and the patient is quite 
 incapacitated from work thereby, operation is to be recom- 
 mended, and when it is the upper limb that is affected, 
 resection will be chosen. A further indication is provided 
 when the lower limbs are affected, and the patient is unable 
 to walk without help, or when his helplessness confines him 
 to bed. If the articulation suppurates, operation must 
 of course be done, also if the fluid makes its way to the 
 surface and creates a fistula, or if there is bony necrosis 
 and the sequestrum does not separate spontaneously. 
 In all such cases the joint must be opened and resected or 
 the limb amputated. 
 
 Contra-indications. — If the affection is present only in a 
 moderately severe form, if it is recent and uncomplicated, 
 and has not made the limb useless, no operation should be 
 done. Severe complications and a bad general condition 
 (waxy disease) are also contra-indications. One would 
 hesitate also if the lesions were multiple and of a severe type. 
 
 Prognosis. — Results and risks of operation. — In uncom- 
 plicated cases the functional usefulness of a joint may be 
 improved. I have seen this after resection of the shoulder 
 in several cases of syringomyelitic arthropathy, and also 
 in cases of tabes with advanced arthropathic deformity of 
 the knee. The joint condition is not, however, curable by 
 operation. If the 'indications already given are followed, 
 no serious risk is attached to operation. If the joint 
 suppurates or threatens to suppurate, operation may be 
 directly life-saving. 
 
 When no operation is undertaken and the affection is 
 complicated, death may take place from septicaemia or 
 pyaemia, or, when a more chronic course is followed, from 
 waxy disease of the internal organs. 
 
 LITERATURE. 
 
 SoKOLOFF. Erkrankheiten der Gelenke bei Syringomyelie. 
 Deut. Zeits. f. Chir. Bd. xxxiv. u. ci. 
 
452 INDICATIONS FOR OPERATION IN 
 
 H. ScHLESiNGER. Die Syringomyelie. 2nd Ed. Wien, 1902. 
 
 Gnesda. Lehre von spinalen Oedeni. Alitteil. a. d. Grenzgebiete 
 d. Med. u. Chir. Bd. iv. 
 
 BuDiNGER. Ueber Tabische Gelenkerkrankungen. 1896. 
 
 Chipault. Las Arthropathies Trophiques. Nouv. Iconogr. de 
 la Salpetriere. 1894. 
 
 KLEMJii. Ueber Arthritis Deformans bei Tabes u. Syringomyelie. 
 Deut. Zeits. f. Chir. Bd. xxxix. 
 
 ARTHRITIS DEFORMANS. 
 
 Etiology. — Age, trauma, heredity, and anomalies of 
 nutrition, all appear to exercise some causative influence. 
 
 Pathological Anatomy. — The disease gives rise on the 
 one hand to erosion of the cartilages of the joint and 
 eburnation of the bones, and on the other to osseous and 
 cartilaginous proliferation, thickening of the capsule, and, 
 at least temporarily, to considerable effusion. Following 
 relaxation of the ligaments, luxation or subluxation is 
 frequent, and is encouraged by the changes in contour 
 which the joint undergoes. Not uncommonly hyperplastic 
 fringes are present in the articulations, and these may become 
 free and form loose bodies. The disease may be confined 
 to one joint or be present in several. 
 
 Symptoms. — Pain on movement is present from the 
 beginning, and increases. Movement gives rise to a grating 
 sensation in the joint, and the functions of the latter are 
 early interfered with. As the disease progresses the joint 
 becomes swollen ; sometimes it becomes softer, sometimes 
 firmer to palpation. The changes can be demonstrated 
 by radiograph at a relatively early period. The swelling 
 increases, movement becomes more and more restricted, 
 the joint surfaces correspond less accurately, and there is 
 often considerable effusion. The skin over the joint becomes 
 smooth and shiny ; the bones remain normal in the neigh- 
 bourhood of the joint. 
 
 Diagnosis. — This is based on the clinical characters. 
 Nervous arthropathy is distinguished by its painlessness. 
 In chronic rheumatism there is no deviation of the joint 
 surfaces. Gonorrheal rheumatism produces fixation of the 
 joint from an early stage. Tuberculosis is distinguished by 
 the rounded and doughy character of the joint swelling. 
 
DISEASES OF THE JOINTS AND BONES. 453 
 INDICATIONS FOR OPERATION. 
 
 Operation is not often called for. It may take the form 
 of the injection of some irritating fluid into the joint, or 
 the removal of fringes and loose bodies, or resection. 
 Resection is only practised when the disease is mono- 
 articular (it is usually mono-articular when of traumatic 
 origin) ; it is indicated when the pain is intolerable, when 
 considerable deformity has taken place, and when the patient 
 is becoming unfitted for work, and when he is still com- 
 paratively young. 
 
 Loose bodies and fringes should be removed when they are 
 causing marked disability. When the effusion is large and 
 persistent the joint should be punctured and washed out. 
 
 Contra-indications. — No operation should be done when 
 the patient is old, when the process affects several joints, 
 or when serious complications (e.g., diabetes) are present. 
 Puncture should not be performed in the case of a recent 
 effusion ; this is frequently absorbed spontaneously. 
 
 Prognosis. — Results of operation. — Pain is almost always 
 relieved by operation, function is also frequently improved, 
 but not often completely restored. Injection and washing 
 out of the joint often has a good influence on the disease, 
 and the exsection of fringes and loose bodies often removes 
 disability. 
 
 The dangers of operation are slight when the usual 
 precautions are taken and the indications which have been 
 laid down are followed. 
 
 LITERATURE. 
 
 Pribram. Osteoarthritis Deformans. Nothnagel's Handbuch d.. 
 spez. Path. Bd. vii. 5 Teil. 
 
 ScHUCHARDT. Krankhciten der Knochen u. Gelenke. Stuttgart, 
 1899. Deut. Chir. 
 
 ScHULLER. Polyarthritis Villosa, etc. Berl. khn. Wochens. 
 5-7. 1900. 
 
 W. MiJLLER. Operative Behandlung der Arthritis Deformans. 
 Langenbeck's Arch. Bd. xlvii. 
 
 OSTEOMALACIA. 
 
 Etiology. — Frequent pregnancies at short intervals, 
 difficult labours with slow convalescence, predispose to 
 the disease ; malnutrition and unhealthy and damp 
 surroundings also appear to favour its onset. 
 
454 INDICATIONS FOR OPERATION IN 
 
 Pathological Anatomy. — Osteomalacia renders the 
 bones soft and brittle. It may be described as a 
 chronic ostitis, with decalcification and the formation 
 here and there of masses of new bone tissue. The 
 decalcification takes place from within outwards, and is 
 not uniform. Usually there are multiple fractures, which 
 do not consolidate; the deformity of the pelvis is charac- 
 teristic. 
 
 Symptoms. — The first symptoms are usually pain in the 
 pelvis and difficulty in movement. Contraction of the 
 adductors prevents rapid abduction of the thighs. At an 
 early stage there is tenderness on pressure over the ribs, 
 sternum, long bones, and pelvis. When the ilia are forcibl}^ 
 and rapidly compressed there is a sensation of resiliency. 
 The patient becomes shorter in stature, the gait becomes 
 awkward and waddling, and she usually requires a stick 
 or the support of a companion. Curvatures of the bones 
 become marked ; the pelvis acquires its characteristic 
 beaked shape, the ribs almost touch the iliac crests, 
 and the thorax is greatly deformed. Spontaneous frac- 
 tures are common occurrences. The patellar reflexes are 
 exaggerated. 
 
 At a later stage contractures occur throughout the mus- 
 cular system, the skin atrophies, the muscles degenerate, and 
 dyspnoea and cachexia supervene. 
 
 The disease usually makes its first appearance during 
 pregnancy ; labour takes place normally, and the patient 
 improves ; but if she become pregnant again the disease 
 progresses rapidly, and succeeding pregnancies still further 
 aggravate it. 
 
 Dl^gnosis. — The early tenderness of the bones, the con- 
 tracture of the adductors, the waddling gait, and the loss 
 of stature make the diagnosis certain. It may be confounded 
 with certain spinal affections if its characteristics are not 
 kept clearly in mind, and its symptoms may be in part 
 simulated in cases of multiple myeloma and of pseudo- 
 leucaemia. Multiple myeloma will be distinguished by the 
 presence of albumosuria and swelling of the lymphatic 
 glands and spleen, by the radiographic examination of 
 the bone swellings, and the appearance of symptoms of 
 spinal cord compression. In hysteria there are no bony 
 deformities. 
 
DISEASES OF THE JOINTS AND BONES. 455 
 
 INDICATIONS FOR OPERATION. 
 
 Fehling has collected evidence to show that castration 
 can cure osteomalacia. Internal treatment with phosphorus 
 is also often successful, and therefore operation will only be 
 recommended under certain conditions (Latzko). If the 
 patient is not pregnant, castration should be done when 
 internal treatment with phosphorus for six months or more 
 has failed. In pregnancy the child should only be considered 
 if medical treatment has succeeded so far as to check the 
 symptoms ; these are aggravated, as a rule, as pregnancy 
 progresses, and when this is the case premature labour 
 should be induced. When treatment with phosphorus 
 fails during pregnancy and the pelvis is narrow, one should 
 be content with procuring abortion, because treatment 
 may be successful after this, and a living child born. If 
 pregnancies rapidly follow each other, or if abortion is 
 frequent, Porro's operation should be done, or total extirpa- 
 tion through the vagina. When the pelvis is extremely 
 narrow, and abortion cannot for that reason be procured, 
 Porro's operation should be done, with or without castration. 
 
 Contra-indications. — No operation will be done unless 
 internal treatment has been tried. No success follows 
 operative treatment in the virgin or the aged, and it will, 
 therefore, be avoided. Occasionally the affection is associated 
 with disease of the central nervous system (tabes, syringo- 
 myelia), and when this is the case, or when there is some 
 other complication such as tuberculosis, no operation is 
 advisable. 
 
 Prognosis. — Risks of operation. — These are not slight in 
 any of the methods recommended. Sixty-nine cases of 
 Porro's operation for osteomalacia published up to 1898 
 showed a mortality of nine. Death occurred from heart 
 failure, bronchitis, bronchopneumonia, and sepsis. 
 
 Results of operation. — In many cases removal of the ovaries 
 has permanently cured the disease ; in a minority the con- 
 dition has progressed in spite of it. Late recurrence has 
 been observed in some cases. I have seen a case in which 
 the symptoms advanced in spite of castration, and even the 
 bones of the skull were affected ; in another case recovery 
 was complete. Pain is usually very rapidly relieved by 
 operation, and, as a rule, entirely disappears by degrees. 
 
456 INDICATIONS FOR OPERATION. 
 
 First the pains in the bones of the trunk improve, and then 
 those in the long bones. The deformities of course remain 
 in spite of the recovery. 
 
 // no operation he undertaken internal treatment with 
 phosphorus is often successful ; untreated puerperal osteo- 
 malacia is fatal in 80 per cent of cases. Treatment with 
 phosphorus can claim results equal to those of operation, 
 and after an experience of many cases, I can endorse the 
 opinion of Latzko that the prospects of success with this 
 drug are very favourable ; the pains diminish, the bones 
 consolidate after some months of treatment, and finally 
 the patient is able to get about again. In none of the cases 
 which I have seen in virgins and in puerperal women has 
 this treatment been without some measure of success; in 
 senile osteomalacia the results are not so favourable. Those 
 who advocate early operation for this condition should take 
 note of these facts, especially in view of the comparative 
 risks of the two methods*. 
 
 LITERATURE. 
 
 V. WiNKEL. Osteomalacic. Handbuch der Therapie innerer 
 Krankheiten (Penzoldt-Stintzing). 2nd Ed. Jena. 
 
 Latzko. Beitr. zur Diagnose u. Therapie der Osteomalacic. 
 Monats. f. Geburtshilfe u. Gynakol. 1897. 
 
 Laufer. Osteomalacic des Weibes. Zentralb. f. d. Grenzgebicte 
 d. Med. u. Chir. 1900. 
 
 ViERORDT. Osteomalacic. Nothnagel's Handbuch der spez. 
 Path. Wien. 
 
 ScHUCHARDT. Krankhcitcn der Knochen u. Gclenke. Stuttgart, 
 1899. Deut. Chir. 
 
 * In one of my cases death occurred from subacute phosphorus 
 poisoning ; the patient had much exceeded the daily dose prescribed. 
 
APPENDICES. 
 
459 
 
 APPENDICES 
 
 Appendix I. 
 
 INDICATIONS FOR THE INDUCTION OF 
 PREMATURE LABOUR. 
 
 I do not propose to discuss the various obstetric conditions 
 which call for the induction of premature labour, such as 
 the death of the foetus, narrow pelvis, and the like, but to 
 consider the circumstances under which it may be necessary 
 on account of the presence of some internal disease in the 
 mother. It must be remarked that absolute indications 
 can be laid down only in a relatively small number of cases, 
 and that opinions on the matter change considerably from 
 time to time. 
 
 CARDIAC DISEASE. 
 
 If endocarditis supervenes during pregnancy it is not 
 necessary to arrest the latter if the heart function remains 
 unimpaired and the organ retains its tone, that is to say, 
 if signs of actual heart failure are absent. If the endo- 
 carditis is recurrent in type ; if it is associated with high 
 fever ; if dyspnoea, arythmia, cyanosis, and signs of conges- 
 tion of the liver, spleen, and kidneys are present, and the 
 lower limbs are oedematous : then premature labour should be 
 induced, unless the condition improves rapidly under internal 
 treatment. Abortion and premature labour not infrequently 
 occur spontaneously under such circumstances. 
 
 If valvular disease or a heart muscle affection exists 
 when pregnancy begins, it is not necessary to induce labour 
 if compensation is satisfactory. Many women pass through 
 pregnancy without any untoward symptoms in spite of such 
 lesions. 
 
46o INDICATIONS FOR OPERATION. 
 
 On the other hand, grave defects in compensation, 
 extensive oedema, arythmia, dyspnoea, pulmonary and 
 hepatic congestion, justify induction of labour in my opinion, 
 even if cardiac "remedies diminish the symptoms of defective 
 compensation. In such cases a return of symptoms is 
 to be feared, and during the further course of the pregnancy 
 they may run a rapid course and prove fatal. But the 
 operation will not be undertaken while the symptoms of 
 defective compensation are at their height, unless there is 
 good reason to believe that no further improvement under 
 treatment can be expected ; if induced under such unfavour- 
 able circumstances the labour may further embarrass an 
 already grave condition. 
 
 When defective compensation is of long standing, 
 even though only of small degree and unassociated 
 with oedema, premature labour should, in my opinion, 
 be induced. 
 
 In mitral disease, particularly mitral stenosis, if disturb- 
 ances of compensation, even of a slight degree, supervene 
 in the course of pregnancy, it is advisable to interfere, if 
 improvement does not rapidly occur under treatment. 
 Experience has shown that it is in this form of cardiac 
 disease that sudden and dangerous symptoms are particu- 
 larly liable to arise ; 42 per cent of the cases of this kind 
 reported in the literature have ended fatally, but this 
 percentage is of course unduly high, the fatal cases being 
 those usually reported. 
 
 In general it is legitimate to persist in expectant 
 treatment in the second half rather than in the first 
 half of pregnancy, the strain on the heart increasing 
 only slightly during the second half. Spontaneous abortion 
 occurs in about a fifth of women suffering from heart 
 disease. 
 
 If heart disease is complicated by renal disease, it is 
 necessary to interrupt pregnancy, even if there are no 
 defects of compensation ; the same is also indicated in 
 the rare association of recent phthisis and cardiac 
 disease. 
 
 Labour may be induced in cases of well-compensated 
 heart disease by the bougie ; in grave disturbance of 
 compensation with pulmonary oedema by puncturing the 
 membranes. 
 
INDUCTION OF PREMATURE LABOUR. 461 
 
 LITERATURE. 
 
 Baranger. Cardiopathies et Grossesses. Tliese de Paris. 1898. 
 
 Fellner. Die Beziehungen innerer Krankheiten zu Scliwanger- 
 schaft, Geburt, u. Wochenbett. Wien : Deuticke. 1903. 
 
 Luck. Mitral Stenosis in Pregnancy. Med. News, 1893. 
 
 LwoFF. Maladies du Coeur et Grossesse. Annales du Gynec. et 
 d'Obstetr. T. xlviii., p. 489. 
 
 Marier. On Cardiac Disease During Pregnancy. Amer. Journ. 
 of Gynsec. and Paed. x., 1895. 
 
 R. PoLLAK. Herzfehler und Schwangerschaft. Zusammen- 
 iassendes Referat. Centralb. f. d. Grenzgebiete d. Med. u. Chir. 
 1902. 
 
 DISEASES OF THE RESPIRATORY ORGANS. 
 
 Laryngeal Tuberculosis. — There is general agreement on 
 the fact that laryngeal phthisis progresses rapidly during 
 pregnancy, and may give rise to alarming symptoms. 
 I have seen this rapid progress of the disease in several of 
 my own cases. The induction of premature labour has 
 ■consequently been urged in this condition by many authori- 
 ties ; it should be done as soon as possible once the diagnosis 
 has been definitely established. The progress of the disease 
 is usually arrested by the operation ; if it is not done it is 
 often necessary to have recourse to tracheotomy. 
 
 Pulmonary Tuberculosis. — As in the case of laryngeal 
 ■disease, pulmonary phthisis is usually aggravated by 
 pregnancy. Old-standing stationary disease becomes 
 progressive, and recent disease progresses with increased 
 rapidity. Florid tuberculosis or subacute miliary tuber- 
 culosis is thus found by no means rarely among pregnant 
 women, and most authorities counsel the induction of labour, 
 the only difference of opinion being as to the stage at which 
 it should be brought about. Thus Paddok would undertake 
 it only when the child has reached a viable age ; Heymann 
 advises it when there is evidence that the pregnancy is 
 influencing the lung condition unfavourably ; whilst Acconi 
 recommends it even when the disease is in an early stage. 
 
 From my own experience, and a study of the literature 
 on the subject, the following indications appear to me to be 
 sound : — 
 
 I. When a case of old-standing phthisis shows signs of a 
 reawakening of the disease, however moderate, with the 
 
462 INDICATIONS FOR OPERATION. 
 
 onset of pregnancy ; for example, when fever or an attack 
 of hgemoptysis supervenes, abortion or premature labour 
 should be induced at once ; in several instances of this kind 
 where I have delayed I have seen florid tubercle or miliary 
 tubercle develop. 
 
 2. When the physician, from previous knowledge of the 
 patient, is aware of the presence of the so-called erethic 
 form of tuberculosis, pregnancy should be interrupted as 
 early as possible, to escape the development of fatal lesions 
 in the lungs. 
 
 3. When pulmonary tubercle is associated with other foci 
 of the disease elsewhere, the induction of premature labour 
 is absolutely indicated. 
 
 4. It is advisable even in stationary tubercle, when the 
 patient is a multipara, and it is known that the pulmonary 
 disease has increased in gravity during previous pregnancies. 
 
 5. Some writers have expressed the view that in the case 
 of miliary tubercle the induction of labour should be delayed 
 with a view to obtaining a living child. With this opinion 
 I do not agree. The disease in the mother is aggravated 
 by the pregnancy, and there is no guarantee that a healthy 
 child will be obtained. 
 
 Pneumonia. — Abortion or premature labour often occurs 
 spontaneously in this disease. Judging from the literature, 
 it may be expected in about half of the cases, although 
 Fellner's statistics do not show so high a percentage as this. 
 Seeing that labour throws extra strain on the already over- 
 tried heart, and that experience shows that pulmonary 
 oedema is especially to be feared in cases in which abortion 
 takes place, it is generally unwise to induce labour. Accord- 
 ing to Fischer, the mortality in patients who are left alone 
 is about 14 per cent, in cases in which labour is induced 
 about 72 per cent. 
 
 Pleurisy. — In pleurisy the case is very much the same as 
 in pneumonia. Since labour adds increased risk to the 
 attack, and the latter as a rule has no harmful influence on 
 the further progress of the pregnancy, the induction of 
 abortion or premature labour is inadvisable. 
 
 LITERATURE 
 
 AccoNi. Tuberculosi e Gravidanza. La Clinica Moderna. 
 Firenze. 1895. 
 
INDUCTION OF PREMATURE LABOUR. 463 
 
 Boyd. The Indications for and Technique of the Induction of 
 Premature Labour. Albany Med. Annals, xviii., 1897. 
 
 Chop. Tuberculose Pulmon. et Grossesse. Arch, de Tocol. et 
 Gynecol., viii., 1894. 
 
 Durante. Tuberculosi e Puerperalita. La Riforma Medica, 
 Vol. viL, 1898. 
 
 Fellner, Otto. Die Beziehungen innerer Krankheiten zu 
 Schwangerschaft, Geburt, u. Wochenbett, p. 19 ff. Wien : 
 Deuticke. 1903. 
 
 Hantke. Die Medizinischen Indikationen zur Unterbrechung 
 der Schwangerschaft. Sammelbericht. Monatsschr. f. Gynak. 
 H. iii: 1902. 
 
 HiGGiNS. The Propriety, Indications, and Methods for the 
 Termination of Pregnancy. Jour. Amer. Med. Assoc, November 19, 
 1904. 
 
 Kammer. Ueber den Einfiuss von Schwangerschaft und Ent- 
 bindung auf den phthisischen Prozess. Deut. ■ med. Wochens. 
 No. 35, 1901. 
 
 Kuttner. Larynxtuberkulose und Graviditat. Deut Aerzte- 
 Zeitung, Heft 22, 1901. 
 
 ScHOHL. Pneumonic et Grossesse. Presse Medicale, p. 491, 1896. 
 
 Wilson. Phthisis in Pregnancy. Amer. Journ. of Obstr., Vol. 
 xxxix., 1899. 
 
 DISEASES OF THE BLOOD. 
 
 According to Sanger, pregnancy aggravates the course 
 of Leuccsmia. This author and Fellner advise that, if the 
 disease is not of a serious type, premature labour should 
 not be induced until there is a prospect of obtaining a 
 living child, but that if the type is grave and the symptoms 
 increase in severity on the onset of pregnancy, labour should 
 be induced without delay. 
 
 In Progressive Pernicious Ancemia the production of 
 abortion is not indicated in the interests of the mother ; it 
 cannot save her, and only hastens the progress of the 
 disease. It is also contra-indicated in the interests of the 
 child, except in an occasional case. 
 
 In Scorbutus and in the rare condition of HcEmophilia in 
 the female, profuse haemorrhage is to be feared, whether 
 parturition takes place naturally or is brought on artificially. 
 No case of fatal post-partum haemorrhage due to these 
 affections is, however, on record, and in view of this and 
 the fact that induction of labour has no particular influence 
 in arresting or improving the diseases in question, it is not 
 advisable to interfere. 
 
464 INDICATIONS FOR OPERATION. 
 
 States of marked Cachexia, resulting from malignant 
 growths, malaria, and other affections, call for the induction 
 of abortion, with a view to giving the patient relief. There 
 is no necessity to consider the matter from the point of view 
 of the child, as in most cases, even when the pregnancy 
 goes on to term, a viable infant is hardly ever obtained. 
 
 LITERATURE. 
 
 O. Fellner. Beziehungen innerer Krankheiten zur Schwanger- 
 schaft. Wien : Deuticke. 1903. 
 
 Merttens. Chorea und Leukamie als Indikationen zur Ein- 
 leitung des kiinstlichen Abortus. Monatsschr. f. Gynak. H. xii., 
 1900. 
 
 PiNARD. L'Avortement Medicalement Provoque. Annal. de 
 Gynec, 1899. 
 
 W. Stempel. Die Hamophilie. Zusammenfassendes Referat. 
 Centralb. f. d. Grenzgebiete d. Med. u. Chir., 1900 
 
 ViNAY. Traitement de I'Anemie Pernicieuse de la Puerperalite. 
 Med. Moderne. Paris, 1898. 
 
 THE INFECTIOUS FEYERS. 
 
 In most of the acute infective fevers the interruption of 
 pregnancy is contra-indicated, as the effect on the mother 
 is to aggravate the disease. 
 
 In Enteric Fever labour brings with it increased risk of 
 pulmonary complications, intestinal haemorirhage, and 
 perforation. In many cases the course of pregnancy is 
 not interrupted by the disease, and it is useless and dangerous 
 to induce labour artificially. In two cases under my care 
 the patients passed through an attack without accident ; 
 in a third case, of a severe type, labour came on only when 
 a relapse supervened, and a living child was born. 
 
 In Scarlatina induction of labour is contra-indicated, 
 ■on account of the danger of septic infection ; the same is 
 true of Small-pox and Diphtheria, and, in my opinion, of 
 Erysipelas, although, according to Fellner, intervention 
 can be undertaken in the latter without this risk. I have 
 never come across a case in which it was necessary. 
 
 Measles is especially dangerous during the puerperium, 
 so that labour should never be induced in this disease. It 
 is necessary in the course of Influenza only when there are 
 complications which specially call for it. 
 
INDUCTION OF PREMATURE LABOUR. 465 
 
 In Tetanus the attacks are liable to be increased in severity 
 if labour comes on ; therefore it is never to be induced. . 
 
 In Malaria, if the attack is slight or only of mean severity, 
 there is no necessity to interfere ; but if the condition is 
 one of marked malarial cachexia, pregnancy should be 
 terminated ; it seriously compromises recovery, and with 
 the mother in this condition the child is usually ill-developed 
 and rarely lives. 
 
 LITERATURE. 
 
 Abrahams. Influenza in Puerperal Women. Medical Record; 
 1898. 
 
 Archambrand. Le Tetanos pendant la Grossesse. La Rev. 
 Med. Dec, 1896. 
 
 Bar et Boulle. Grippe et Puerperalite. L'Obstetric, iii., 1898. 
 
 CuRSCHMANN. Der Abdominaltyphus. Nothnagel's Handbuch 
 der spez. Pathol, u. Therap. Wien. 
 
 Edmonds. Malaria and Pregnancy. Brit. Med. Jour., 1899. 
 
 O. Fellner. Die Beziehungen innerer Krankheiten zu 
 Schwangerschaft, etc Wien: Deuticke. 1903. 
 
 Mangiagalli. Ileotifo in Gravidanza. Arch. Ital. die Ginec. 
 Napoli, 1 90 1. 
 
 Salus. Masern in der Schwangerschaft. Prager med. Wochens., 
 1899. 
 
 ViNAY. Variole dans la Grossesse. Lyon Medicale. Mar., 1900. 
 
 Zampetti. LTnfluenza nel Parto. Gaz. degli Ospedali. Milano, 
 1901. 
 
 DISEASES OF THE KIDNEY. ECLAMPSIA. 
 
 Albuminuria occurs in a relatively large number of 
 pregnant women. The onset of nephritis, with abundant 
 elimination of corpuscular elements and albumin, although 
 not so common, occurs in a considerable number, and the 
 question of terminating pregnancy by artificial means 
 often arises in connection with this condition. Cases in 
 which nephritis has been present before the pregnancy 
 commenced offer the same problems. 
 
 If albumin and casts are found in the urine, and no 
 alarming symptoms are present, it is advisable to leave 
 things alone for a short time and see the effect of a milk 
 •diet. If the albumin and casts diminish under this regime 
 the pregnancy may be allowed to run its course, the patient 
 meanwhile being watched with great care. If, however, 
 any dangerous symptoms arise, or if the signs of renal 
 
 30 
 
466 INDICATIONS FOR OPERATION. 
 
 irritation do not completely disappear in the course of 
 about a fortnight under strict milk diet, it is necessary to 
 procure abortion or labour as the case may be. 
 
 The following must be interpreted as dangerous symptoms : 
 reduction in the amount of the urine, marked oedema of 
 the legs or elsewhere, severe headache, frequent vomiting 
 dating from the onset of the renal symptoms, paralytic 
 phenomena, increase in the amount of albumin, and signs 
 of cardiac disturbance. If albuminuric retinitis or urgemic 
 amaurosis supervene, intervention is urgent, and the risk 
 of delay great ; according to Silex, of 22 cases with these 
 symptoms 6 became blind, and in 10 the sight was 
 permanently damaged. 
 
 Pregnancy is associated with great risk to a patient with 
 chronic nephritis, and it is justifiable to interrupt it ; 
 according to Fellner the mortality in this condition is 40^ 
 per cent, but this figure is based on a small number of cases 
 only. Eclampsia occurs in a third of these cases. If the 
 patient has already passed through the first half of her 
 time when first seen, without any untoward symptoms,, 
 it is justifiable to wait until a living child may be expected, 
 and then induce labour. The mother must, of course, be 
 carefully watched during this time of waiting. 
 
 When there is a history of nephritis during a previous 
 pregnancy from which the patient recovered, the progress 
 of events must be watched, and if signs of the disease 
 reappear labour must be brought on. Of 26 such cases 
 in Schauta's clinic 22 showed no renal symptoms during 
 the later pregnancy. 
 
 Eclampsia constitutes a vital indication for terminating 
 pregnancy if the attacks are in the least degree frequent 
 or severe. The mortality is 12 '5 per cent in Fellner's 
 tables ; other writers give a higher figure (Schniirer 21 per 
 cent). I would not hesitate for a moment to recommend 
 immediate interference after a single attack of any severity. 
 Intervention offers practically the only hope if the patient 
 is in a state of coma following eclampsia. 
 
 In the presence of slight seizures some obstetricians 
 recommend waiting, provided the attacks do not follow 
 one another rapidly, and the patient is in good condition 
 in the intervals. 
 
 In about half the cases labour ends the seizures (Schniirer) ;, 
 
INDUCTION OF PREMATURE LABOUR. 467 
 
 others record higher percentages of recovery, up to 80 per 
 cent. Intervention should be practised under deep 
 anaesthesia. 
 
 Hcematuria of renal origin presents the same indications 
 as albuminuria. It may be present as one of the signs 
 of nephritis. When due to some other renal condition it 
 will necessitate interruption of pregnancy if oft repeated 
 and copious ; the pregnancy aggravates the tendency 
 to haemorrhage. 
 
 If Pyelonephritis is discovered in a pregnant woman, and 
 if ordinary therapeutic measures have no marked effect, 
 abortion should be procured. But if the affection has 
 developed during the pregnancy, and no dangerous symp- 
 toms are present, it is justifiable to wait until a living child 
 can be obtained, and then induce premature labour. 
 
 LITERATURE. 
 
 Anderodias. Pyelonephrite dans la Grossesse. Compt. Rend, 
 de la Societe Obstetr. de Paris, 1901. 
 
 CoNDRAY. Des Indications de ITnterruption de la Grossesse chez 
 les Femmes Enceintes Albuminuriques. These de Paris, 1900. 
 
 O. Fellner. Die Beziehungen innerer Krankheiten zu 
 Schwangerschaft, etc. Wien : Deuticke. 1903. 
 
 A. Manry. Le Traitement de FEclampsie Puerperale. These 
 de Paris, 1903. 
 
 Marx. The Indications for Premature Delivery, etc. Med. News. 
 June, 1900. 
 
 Miranda. La Patogenesi e la Cura dell' Eclampsia Puerperale. 
 Arch, di Ost. et Gyn., ix., 1899. 
 
 Pestalozza. Eclampsia Puerperalis. Firenze. 1900. 
 
 ScHNTJRER. Ueber die Puerperaleklampsie. Kritischer Sammel- 
 bericht. Centralb. f. d. Grenzgebiete d. Med. u. Chir., 1903. 
 
 ScHULZ. Treatment of Albuminuria of Pregnancy. Annals of 
 Gyn. and Ped., 1900. 
 
 Thiebaud. Hematurie de la Grossesse. Jour, de Med.etde 
 Chir., Tome Ixxxi. 
 
 Webster. Affections of the Kidney in Relation to Pregnancy. 
 Journ. Amer. Med. Assoc, April, 1900. 
 
 DISEASES OF THE STOMACH. 
 
 HcBmatemesis. — Haematemesis is met with from time to 
 time in pregnant women, and is usually due to gastric ulcer. 
 If it docs not yield to careful medical treatment, and recurs 
 to such a degree as to threaten a fatal issue, the pregnancy 
 
468 INDICATIONS FOR OPERATION. 
 
 must be interrupted to enable complete rest to be given 
 to the stomach. The question will sometimes arise during 
 the second half of pregnancy, and premature labour may 
 then be indicated with a view to obtaining a living child. 
 
 Hypereniesis Gravidarum. — In the great majority of 
 •cases this is a transitory condition, or can be checked 
 sufficiently to avoid any serious risk to the mother. If, 
 however, all internal and external methods of treatment 
 have been exhausted without success, and the vomiting 
 continues to such a degree that the development of a viable 
 child becomes doubtful, it is justifiable, and under such 
 circumstances often absolutely necessary, to bring the 
 pregnancy to an end. This, however, must be looked 
 upon only as a last resource, when all other methods have 
 failed. 
 
 In a case which I saw several times in consultation during 
 the second month of pregnancy, the patient was so reduced 
 by a fortnight's persistent vomiting that her life was seriously 
 endangered. She vomited incessantly day and night, she 
 wasted rapidly, and her condition was one of collapse, with 
 subnormal temperature and starvation-delirium. Abortion 
 was procured, and she rapidly recovered from her very 
 dangerous state. 
 
 LITERATURE. 
 
 CoRADESCHi. Ematemesi durante la Gravidanza. Gaz. d. 
 Osped. e delle Cliniche, 1898. 
 
 Fellner. Die Beziehungen innerer Krankheiten zu Schwan- 
 gerschaft, Geburt, u. Wochenbett. Wien : Deuticke. 1903. 
 
 APPENDICITIS. 
 
 Appendicitis during pregnancy is not rare. Most writers 
 have taken a very grave view of this complication, and, 
 judging from recorded cases, the mortality is very high. 
 As a matter of fact the combination is not a particularly 
 dangerous one. I have seen a considerable number of 
 first attacks of appendicitis which supervened during 
 pregnancy. Perhaps there is an element of chance in the 
 fact that none of these cases were fatal, nor, in fact, presented 
 any particularly serious symptoms. Labour during appen- 
 dicitis certainly increases the risk of the latter ; an abscess 
 
INDUCTION OF PREMATURE LABOUR. 469 
 
 may rupture or the process may extend after delivery, 
 and induction of labour is contra-indicated. It not 
 uncommonly occurs spontaneously. Fellner's view that 
 in the catarrhal form of the disease the induction of labour 
 might be advantageous, is really only of theoretical interest, 
 as we have no certain guides to distinguish the purulent 
 from the non-purulent type. If it is necessary to intervene 
 in a case where appendicitis is complicated by pregnancy, 
 the appendix, not the uterus, should be attacked. 
 
 LITERATURE. 
 
 Jarca. Contribution a I'Etude de I'Appendicite pendant la 
 Grossesse. These de Paris, 1898. 
 
 Keiler. Perityphlitis und Graviditat. Miinch. med. Wochens., 
 No. 18, 1902. 
 
 KoNiG. Appendicitis und Geburtshilfe. Hegar's Beitrage. Bd. 
 ii. 1900. 
 
 McRae. Appendicitis in the Female. New York Med. Jour., 
 ■1900. 
 
 PiNARD. Nouveaux Documents pour Servir a I'Histoire de 
 I'Appendicite dans ses Rapports avec la Grossesse. Annal. de 
 Gynec, Tome liii., 1900. 
 
 Pollack. Appendicitis und weibliches Genitale. Centralb. f. 
 d. Grenzgebiete d. Med. u. Chir. No. 5 u. ff. 1904. 
 
 DISEASES OF THE LIYER. 
 
 Cholelithiasis. — The frequency of attacks of biliary colic 
 during pregnancy is recognized ; they are at any rate not 
 uncommon. They are often of a severe type and associated 
 with fever. It is never, however, necessary to provoke 
 labour on account of such attacks ; if interference is neces- 
 sary, operation for removal of the biliary calculi is what is 
 indicated. 
 
 Jaundice. — The so-called " icterus gravidarum," which 
 is a very rare affection, is an indication for the induction 
 of premature labour. It is characterized by subcutaneous 
 and submucous haemorrhages, with high fever and delirium, 
 and leads up to acute atrophy of the liver. It attacks 
 women at about the mid-period of pregnancy, and appears 
 to be favourably influenced by the termination of the preg- 
 nancy. If the affection is diagnosed, it is necessary to 
 bring on abortion or labour without delay. 
 
470 INDICATIONS FOR OPERATION. 
 
 LITERATURE. 
 
 H. Benedikt. Zur Kenntnis des Schwangerschaftsikterus. 
 Deut. med. Wochens.. Xo. i6, 1902. 
 
 Chiavextone. Atrofia Giallo Acuta in Gravidanza. Annal. 
 Ost. e Gin., 1899. 
 
 Le ^Iassox. Les Icteres et la Colique Hepatique chez les Femmes 
 en etat de la Puerperalite. Paris. 1898. 
 
 Young. Simple and ^Malignant Jaundice of Pregnancy. Medical 
 News, 1898. 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Hysteria. — It is generally held, and with the opinion I 
 agree, that even in the case of hysteria of a very severe 
 type it is very rarely necessary to end the pregnancy 
 artificially. Such a necessity may arise occasionally, for 
 example, if a patient refuses to take food and vomits 
 repeatedly when forcibly fed ; but in the great majority of 
 hysterical patients there is no need for interference. 
 
 Epilepsy. — According to Binswanger, pregnancy often 
 exercises a harmful influence on the course of this disease, 
 and results in permanent aggravation. If the attacks 
 become more frequent in spite of suitable treatment, if 
 they are of a severe type and the free intervals become 
 shorter, if psychic symptoms supervene which were not 
 present before the pregnancy, it is necessary, in the opinion 
 of many authors, to procure abortion. In my opinion, the 
 necessity is urgent under such circumstances ; there is an 
 imminent risk of the onset of a status epilepticus and a fatal 
 ending. 
 
 Chorea. — Chorea gravidarum is an affection in which the 
 prognosis is grave, and differs in this respect entirely from 
 ordinary chorea. The mortality is very high, and according 
 to Schrock and Rust reaches 25 per cent. Some of the 
 fatalities occur during labour itself, and this is a critical 
 time. Of 95 women delivered at term, 8 died in labour 
 (Schrock) ; delivery in the earlier months is much less 
 dangerous. 
 
 The disease, therefore, makes it necessary to terminate 
 pregnancy in the first few months whenever possible, if 
 the woman is to be saved from serious risk. If the pregnancy 
 is already far advanced when the patient is lirst seen. 
 
INDUCTION OF PREMATURE LABOUR. 471 
 
 premature labour will only be induced if she is already 
 much enfeebled and is the subject of psychic disturbances. 
 Once the pregnancy has passed its mid-term, labour becomes 
 as serious a risk artificially procured as when it is allowed 
 to take place naturally ; it wiU, therefore, be induced during 
 this period only when the enfeeblement or psychic troubles 
 referred to have supervened. 
 
 Tetany. — The painful cramps of tetany usually disappear 
 after labour. Although the affection is painful and distressing 
 it is not, as a rule, associated with any danger, and there is 
 usually no necessity to induce labour. If, however, the 
 seizures' are very frequent and tend to increase in duration, 
 and, as I have seen, hardly give the patient an hour's peace, 
 when the infant is viable, it is an act of humanity to induce 
 labour. 
 
 If the attacks become generalized and involve laryngeal 
 and respiratory muscles, it is necessary to terminate the 
 pregnancy without delay, as the risk to life under these 
 circumstances is great. 
 
 Polyneuritis Gravidarum. — If a severe type of polyneuritis 
 involving the upper and lower limbs supervenes during 
 pregnancy, and if no cause other than the pregnancy can 
 be discovered, it is advisable to induce abortion or prema- 
 ture labour, on account of the very serious prognosis of this 
 form of the disease. In such cases, if the pregnancy is 
 allowed to continue, the motor and sensory phenomena tend 
 to increase in severity and to extend to new regions, 
 whereas if the pregnancy is brought to an end the inflam- 
 matory affection of the nerves rapidly disappears. 
 
 LITERATURE. 
 
 BiNSWANGER. Die Epilepsie. Nothnagel's Handbuch d. spez. 
 Pathol, u. Ther. Wien. 1899. 
 
 Dakin. Five Cases of Chorea in Pregnancy. Practitioner, 1897. 
 
 O. Fellner. Die Beziehungen innerer Erkrankungen zu 
 Schwangerschaft, Geburt, u. Wochenbett. Wien: Deuticke. 1903. 
 
 V. Frankl-Hochwart. Die Tetanic. Nothnagel's Handbuch d. 
 spez. Pathol, u. Ther. Wien. 1897. 
 
 Jolly. Die Indikationen des kiinstlichen Abortus bei der 
 Behandlung von Neurosen und Psychosen. Versammlung Deutscher 
 Naturf. u. Aerzte, Ixxiii., 1901. 
 
 Mastin. Chorea Gravidarum. These de Lyon, 1900. 
 
 Mattiesen. Zur Kenntnis der Neuritis Puerperalis. Arch. f. 
 Gynakologie, Bd. Ixiii. 
 
472 INDICATIONS FOR OPERATION. 
 
 Merttens. Chorea als Indikation zur Einleitung des kxinstlichen 
 Abortus. Monatsschr. f. Gynakologie, Vol. xii., 1900. 
 
 PiNARD. De rAvortement Medicalement Provoque. Annal. de 
 Gynecol, 1899. 
 
 Stembo. Schwangerschaftspolyneuritis nach unstillbarem Er- 
 brechen. Deut. med. Wochens., No. 29, 1895. 
 
 Stewart. Puerperal Polyneuritis. Philad. Med. Jour., May, 
 1901. 
 
 Thomas. Tetany in Pregnancy. Johns Hop. Hosp. Bull., May, 
 1895. 
 
473 
 
 Appendix II. 
 OPERATIONS ON DIABETICS. 
 
 The frequency of diabetes, and the fact that surgical 
 comphcations are not uncommon in the disease, makes the 
 discussion of the indications for and contra-indications to 
 operation often necessary. 
 
 The indications have to be considered from two points 
 of view : (i) The indications for operation in the case of 
 actual complications of the disease ; (2) The indications 
 for operation in affections which are not etiologically 
 connected witli the diabetes itself. 
 
 The most frequent surgical complications of diabetes 
 are : gangrene of the lower limbs, perforating ulcer of the 
 foot, diabetic mastoiditis, phlegmonous or gangrenous 
 inflammations of the skin, carbuncle, cataract. 
 
 I. The indications for operation in the complications of 
 diabetes. 
 
 (a.) In all surgical inflammatory complications of diabetes 
 it is necessary to operate if the complication involves risk 
 to life whether the diabetes is slight or severe in type. 
 
 (b.) In inflammatory diabetic gangrene, operation must 
 not be delayed if diet and conservative treatment do not 
 arrest the progress of the condition, and also if there are 
 signs of threatening general infection, lymphangitis, rapid 
 pulse, and high fever. 
 
 (c.) When operation is not urgent, almost all writers 
 advise the reduction of sugar to the lowest possible point 
 before it is undertaken ; but when the diabetes is of a mild 
 type this preliminary treatment is thought unnecessary 
 by many (Korner, Sternberg). 
 
 {d.) In diabetic cataract operation may be undertaken 
 as soon as the cataract is sufficiently ripe ; antidiabetic 
 treatment is useful, but it is not necessary to wait until 
 tlie sugar has gone from the urine. 
 
474 INDICATIONS FOR OPERATION 
 
 Many surgeons advise operation in the inflammatory 
 complications if the pain is severe and the patient cannot 
 be well looked after. In the non-inflammatory type of 
 gangrene it is advisable on the other hand to await the 
 formation of a line of demarcation, and meanwhile to 
 institute antidiabetic treatment. 
 
 Contra-indications. — When there is no urgent call for 
 operation, it should be avoided in severe diabetes with 
 diaceturia ; if it is necessary to operate under such cir- 
 cum.stances, a general anaesthetic should be avoided if 
 possible. 
 
 2. When are operations allowable in diabetes ? When 
 a diabetic has some other affection which will endanger 
 life if left alone, most physicians and surgeons agree that 
 operation should not be delayed. A malignant growth 
 is an example of such an affection. 
 
 If it is possible, however, to wait awhile, the sugar should 
 be reduced as much as possible. In the opinion of many 
 it is not necessary to delay until the sugar has disappeared 
 from the urine, but operation should not be done if acetone 
 and acetic acid are present. 
 
 " In many cases the time for operation is when treatment 
 has freed the urine of sugar " (Kausch). One will hesitate 
 less when the operation called for is only a slight one, and 
 the necessary narcosis short. Regnier's view that absence 
 of patellar reflex is a strict contra-indication to operation 
 is not now entertained. 
 
 Contra-indications. — Operations which are not absolutely 
 necessary, such as cosmetic and orthopaedic procedures, 
 are not advisable in the presence of diabetes. The disease 
 is always an argument against operation. Operations 
 which require a prolonged anaesthesia should not be done 
 unless for some affection which threatens life. Furunculosis, 
 gangrene, and other such complications, are generally to 
 be viewed as contra-indications to operation elsewhere. 
 Other contra-indications are acetonuria and diaceturia, 
 advanced arteriosclerosis, signs of heart muscle degeneration, 
 and marked albuminuria. 
 
 The risks of operation. — In a considerable number of 
 cases diabetic coma has supervened directly on narcosis ; 
 this consequence is especially to be feared if diacetic acid 
 is present in the urine before operation. It is true that 
 
ON DIABETICS. 475 
 
 many surgeons have seen no instance of coma among a 
 large number of cases (Gersuny-Sternberg 85 cases). 
 
 It does not appear to be of any moment whether ether 
 or chloroform is employed, but many prefer the former. 
 
 Coma may also supervene some days after operation. 
 In 100 cases of diabetic gangrene recorded by Wolf with 
 50 deaths, 19 died from coma ; of 22 of the fatal cases 
 who were not operated on, coma was the cause of death 
 in 6 (27 per cent), whereas it was responsible in 13 
 cases (46 per cent) out of 28 on whom an operation 
 was performed. 
 
 In several cases serious hsemorrhage has been recorded 
 .either at or after the operation, apparently to be ascribed 
 to some affection of the small vessels. 
 
 Wounds are specially easily infected in diabetics, and 
 gangrene of skin flaps after amputation is relatively common, 
 especially in the lower limb. To avoid an acid intoxication 
 Naunyn recommends that bicarbonate of soda should be 
 administered for some time before operation, either by 
 the mouth or intravenously. 
 
 Results of operation. — -By careful aseptic methods much 
 better results can be obtained than used to be thought 
 possible ; this is true both with regard to operation for 
 ordinary affections in diabetics and also for the complications 
 of the disease itself. According to Wolf's tables, which 
 relate only to diabetic gangrene, 50 died out of no treated 
 by expectant methods (45 per cent), 28 out of 75 operated 
 on (37 per cent) ; of the first, 13 recovered completely (12 per 
 cent), of the latter three times as many. Korner's statistics 
 deal with diabetic mastoiditis ; in 13 with slight diabetes the 
 wounds healed on an average in nine weeks ; in no case did 
 the operation permanently aggravate the diabetes. In 
 5 cases where the disease was of moderate severity the 
 wounds healed completely, and no aggravation of the 
 diabetes occurred. Of 9 cases of severe type death 
 followed operation in 4, in 2 transitory coma occurred. 
 
 Sternberg collected 10 cases of diabetes operated on in 
 Gersuny's clinic, 4 of which suffered from the disease in a 
 severe form. In spite of the fact that in several the operation 
 was an extensive one (cholecystectomy, major operation on 
 the maxilla, etc.), death resulted from the operation in none, 
 and in more than half complete recovery followed. Of 
 
476 INDICATIONS FOR OPERATION. 
 
 75 cases suffering from carbuncle, 5 died from sepsis in 
 spite of free incisions. 
 
 LITERATURE. 
 
 Wolf. Diabetische Gangran und ilire Behandlung. Zusammen- 
 fassendes Referat. Centralb. f. d. Grenzgebiete d. Med. u. Chir. 
 1901. 
 
 TuFFiER. Diabete et Neoplasma. Arch. Gener. de Med, 
 Bd. ii, p. 318, 1888. 
 
 Julius Sternberg. Ueber Operationen an Diabetischen. Wien. 
 med. Wochens., p. 213, 1903. 
 
 Becker. Die Gefahren der Narkose fiir den Diabetes. Deut. 
 med. Wochens., p. 359, 1894. 
 
 KoRNER. Der Einfluss von Operationen auf den Verlauf und 
 Ausgang des Diabetes MeUitus. Mitteil. a. d. Grenzgebiete d. Med. 
 u. Chir. Bd. xii, H. 5. 
 
 Lepine. Intervention Chirurgicale chez les Diabetiques. Lyon 
 Medicale, p. 234, 1900. 
 
 Smith and Durham. Glycosuria and Surgery. Guy's Hosp. 
 Reports, p. 335, 1893. 
 
 Kausch. Der Diabetes in der Chirurgie. Centralb. f. Chir., 
 p. 1 196, 1902. 
 
 O. Fellner. Ueber den Diabetes in der Chirurgie. Wien. 
 klin. Wochens., No. 34, 1903. 
 
 Naunyn. Der Diat)etes MeUitus. Nothnagel's Handbuch d. 
 spez. Pathol, u. Ther. Wien. 1900. 
 
 Demons et Begouin. Note sur I'Amputation dans la Gangrene 
 Spontanee des Membres chez les Diabetiques. Bull, et Mem. de la 
 Societe de Chir.. de Paris. T. xxvii. 
 
 W. Kausch. Beitrage zum Diabetes in der Chirurgie. Arch. f. 
 klin. Chir. Bd. Ixxiv, H. 4. 
 
477 
 
 Appendix III. 
 
 THE GENERAL INFLUENCE OF OPERATIONS 
 ON THE BODY. 
 
 By Dr. Julius Schnitzler. 
 
 Operations have been robbed of their terrors by anaes- 
 thesia, their risks by asepsis, and of the greater part of their 
 uncertainties by improvements in technique ; yet every 
 operation produces a certain amount of psychic and somatic 
 trauma, which must be taken into account in calculating 
 its therapeutic effect. It is necessary to enquire into this 
 traumatic influence with a view to lessening it as far as 
 possible in all cases. 
 
 POST-OPERATIYE PSYCHIC DISTURBANCES. 
 
 Operation has a psychic influence on the patient from the 
 moment when it is suggested to him by his medical attendant, 
 and often persists for a considerable time after recovery is 
 otherwise complete. The degree of apprehension varies 
 very much according to the temperament of the patient, 
 but it cannot usually be exactly foreseen ; some phlegmatic 
 individuals are stirred up into a state of terror by the word 
 operation, whilst others of a neurotic type show no particular 
 alarm, and agree readily. The nature of the affection for 
 which operation is necessary, the pain, and the degree of 
 inanition, etc., play a considerable part. The slight psychic 
 disturbance which is inevitable in all cases is usually of 
 short duration, but occasionally operation is followed by 
 permanent mental effects ; happily, this is rare. 
 
 Apart from the occurrence of delirium tremens and 
 inanition delirium, alcoholism, advanced age, and inanition 
 are sometimes responsible for post-operative psychoses. 
 Operations on tlie eye are specially liable to be followed by 
 
478 GENERAL INFLUENCE OF OPERATIONS 
 
 menta disturbance, and retention for a long time in a 
 darkened room appears to favour this tendency. 
 
 Both in the female and the male, operations on the 
 sexual organs sometimes cause mental disturbance ; in 
 the male, this is especially notable in the case of ablation 
 of the testes and removal of the prostate. 
 
 The prognosis of post-operative psychoses is not parti- 
 cularly favourable ; a fatal result is not uncommon in old 
 men and patients suffering from inanition ; and apart from 
 the danger to life such mental disturbances tend to persist. 
 They must be looked upon as the result of operative shock 
 on predisposed individuals, and are therefore quite different 
 in etiology from the toxic delirium which sometimes follows 
 operation, for example, the delirium of iodoform poisoning. 
 
 SHOCK, PNEUMOTHORAX. 
 
 The risk from the onset of these conditions must always be 
 discussed in forming an opinion as to the advisability of opera- 
 tion ; it is only in rare instances that the risk from mental 
 disturbance has to be taken into consideration. Operative 
 shock is a term which needs definition ; it is now used not 
 for the temporary syncope which may occur in the course 
 of operations done without anaesthetics, but for the state 
 which is to be expected after all operations of magnitude 
 whose chief sign is a more or less pronounced fall in blood 
 pressure. It may be principally due in any given case to 
 excessive loss of blood, or to long exposure and chilling 
 of wound surfaces, or to the handling of organs which 
 possess special nervous sensibility. In degree it varies 
 from a slight transient effect passing off in the course of a 
 short time to a condition so profound that no remedies 
 are capable of warding off a fatal result. In every case 
 the amount of shock to be anticipated should be estimated 
 beforehand, and means taken to obviate its onset. 
 
 The sudden development of pneumothorax in the course 
 of an operation on the chest is attended by risk to life. 
 This is due, not to the fact that the respiratory 'function of 
 the lung is suspended, but to the sudden change of pressure 
 on the right side of the heart and the sudden deviation of 
 the mediastinal structures towards the opposite side. In 
 
ON THE BODY. 479 
 
 order to avoid this accident in the course of operations on 
 the lung the latter may be fixed to the pleura in such a way 
 as to prevent the sudden inrush of air. Other means, 
 recently suggested, are the performance of such operations 
 in a chamber in which the air pressure is kept low by artificial 
 means, or the introduction of air under increased pressure 
 into the respiratory channels. These methods are still on 
 their trial. Obviously the danger from pneumothorax is 
 greater if the opposite lung is not functioning normally. 
 If adhesions exist between the visceral and costal pleura, 
 pneumothorax can be avoided ; it is, therefore, important 
 to examine for signs of such adhesions, and in cases where 
 they do not exist they are sometimes produced artificially 
 by sutures ; sutures of silk soaked in turpentine have been 
 employed for the purpose. There is comparatively no 
 risk in opening the pleural cavity when the lung has been 
 already compressed by effusion ; the danger varies with the 
 suddenness of the onset of the increased pressure, and when 
 a pneumothorax is inevitable it is important to ensure 
 that the entry of air takes place slowly and steadily, and 
 to cut short the duration of the pneumothorax as much as 
 possible by suturing the lung to the pleural wound. 
 
 THE EFFECTS OF OPENING THE ABDOMEN, THE 
 CRANIUM, AND THE SPINAL CANAL. 
 
 Opening the abdomen is in itself free from danger ; 
 certain complications alone call for remark. If a large 
 quantity of fluid is suddenly withdrawn from the abdomen, 
 the blood pressure may be suddenly lowered in such a 
 manner as to seriously embarrass the heart. When the 
 abdomen is greatly distended, laparotomy is followed by 
 herniation of the intestinal coils, and the manipulations 
 necessary to retain and replace them may produce severe 
 shock and syncope. The ordinary manipulations of the 
 abdominal organs are, generally speaking, well borne, 
 and in deep anaesthesia their effect on the pulse is minimal. 
 In incomplete aucesthesia, for example in aucEsthesia by 
 the local infiltration method, the effects of these manipula- 
 tions on the pulse is more marked. Pulling on the mesenteric 
 attachments of organs in particular tends to produce shock, 
 
48o GENERAL INFLUENCE OF OPERATIONS 
 
 irregular pulse, and a fall in blood pressure, but in ordinary 
 cases there is no actual risk to the patient. More danger 
 is associated with prolonged exposure of the abdominal 
 organs ; pneumonia after laparotomy is probably due to 
 this cause, and there is no doubt that chill produced in this 
 way is responsible for shock and an increased susceptibility 
 to infection. Means must be taken to prevent this by 
 protecting any exposed organs and wound surfaces, not 
 only in laparotomy but in all other operations. 
 
 Exposure of the cranial cavity or the spinal canal is not 
 in itself associated with any degree of risk to life. The 
 alterations in the cerebral circulation which follow trephining 
 are not of so much importance as some authors have thought. 
 When the resulting defect in the skull persists, there are 
 special dangers, in particular hernia cerebri and adhesions 
 between brain and meninges. 
 
 When the intracranial pressure is much above the normal, 
 as, for instance, in cases of cerebral tumour, the sudden 
 escape of cerebrospinal fluid may give rise to alarming 
 symptoms, respiratory and cardiac failure, and even sudden 
 death. Haemorrhage may also occur into the tumour, an 
 accident which has also been observed after the withdrawal 
 of fluid by lumbar puncture. It is, therefore, necessary to 
 prevent any sudden escape of the fluid, especially when it 
 is under great pressure. The brain, however, tolerates 
 well the mechanical irritation of the ordinary intracranial 
 operations ; for example, the prolonged retraction with 
 a spatula which is necessary during resection of the Gasserian 
 ganglion. 
 
 There is greater risk attached to the exposure of the 
 spinal cord ; the operation is more severe, and therefore 
 more likely to be followed by shock. In addition to this 
 the cord itself is less tolerant of pressure, and the removal 
 of tumours from the canal is more likely to be followed by 
 paralyses and other phenomena of trauma than in the case 
 of the brain. As has been already said, in ordinary cases 
 opening the skull is free from any considerable risk, and 
 in the more serious cases the risk does not compare in 
 gravity with the affection which it is sought to relieve. 
 
 In cases where the opening in the skull is left patent, or 
 cannot be closed, epilepsy is particularly liable to occur 
 as a late effect. At one time it was held that it was 
 
ON THE BODY. 481 
 
 inadvisable to close such defects, and they were left open, 
 with the idea of providing against the evil effects of varia- 
 tions in intracranial pressure, and as a prophylactic against 
 epilepsy. It is now known that the results of this recom- 
 mendation are liable to be the opposite to those desired, 
 and that, in addition to epilepsy, mental disturbances are 
 common. Cerebral hernia has already been mentioned ; 
 it occurs, of course, only in cases where the skull defect is 
 not closed, and may lead up to epileptiform attacks and 
 other disturbances of cerebral function. Skull defects 
 should, therefore, be closed, except where trephining is 
 done simply for the relief of intracranial pressure, as in 
 the case of inoperable brain tumours. 
 
 THE EXTIRPATION OF GLANDULAR ORGANS. 
 
 Permanent effects follow the extirpation of the whole, 
 or more than three-fourths, of the thyroid gland ; operative 
 myxoedema supervenes, and tetany also if the parathyroids 
 are removed at the same time. About a third of the gland 
 should always be left ; but it is, of course, necessary to 
 break this rule in the case of carcinoma. In the latter 
 case the onset of myxoedema must be combated either by 
 transplantation or administration of thyroid substance. 
 The surgeon is hardly likely to be called upon to remove 
 any considerable portion of the pancreas. Certain cases 
 of suppuration and necrosis of the organ have shown that 
 the loss of the greater part of the pancreatic tissue is liable 
 to be followed by diabetes, so that there are physiological 
 as well as technical objections to its removal. 
 
 Reference has already been made to the mental disturb- 
 ances which may follow castration ; for the purpose of 
 iniluencing prostatic enlargement the operation is now 
 practically abandoned ; in subjects who have passed 
 puberty no somatic changes of importance have been noted. 
 
 The removal of the ovaries from women who have reached 
 puberty produces an acute menopause which is liable to 
 be associated with subjective cardiac symptoms, and 
 certain mental affections, irritability or melancholia, and 
 even mania ; progressive obesity is often also a conse- 
 quence. The nearer a woman is to her natural menopause 
 
 31 
 
482 GENERAL INFLUENCE OF OPERATIONS 
 
 the less liable is she to be disturbed by extirpation of the 
 ovaries. The operation is justified, not only in the case of 
 malignant disease, but in certain forms of inflammatory 
 disease also (tuberculosis) and in osteomalacia. Proof is 
 still wanting that it is a justifiable proceeding in inoperable 
 breast cancer. 
 
 The surgeon need never hesitate to resect liver tissue on 
 physiological grounds ; the individual is capable of doing 
 without a greater proportion of his liver substance than 
 any surgeon would find it possible to remove. 
 
 In the case of the bilateral glandular organs, if one be 
 removed, the other, when healthy, is capable of undertaking 
 the work in virtue of its capacity for compensatory hyper- 
 trophy. This is particularly exemplified in the case of the 
 kidneys. Cases, however, are met with from time to time, 
 where after nephrectomy the opposite organ not only refuses 
 to take up the extra work, but ceases to functionate 
 altogether ; this accident is usually ascribed to reflex action, 
 and the condition is termed reflex anuria. As a matter 
 of fact, no complete explanation has yet been offered ; it is 
 analogous to the anuria which sometimes follows the 
 impaction of a calculus in the ureter of one side. Sometimes 
 this occurs when the kidney left appears to be entirely 
 healthy, but it is far more liable to happen if the function 
 of the latter is compromised. Hence the great importance 
 of investigating the functional efficiency of the opposite 
 organ when nephrectomy appears to be indicated. Formerly 
 it was held that if the amount of urea excreted was less than 
 half the normal, no operation on the kidney of any kind was 
 justifiable. To-day the examination of the renal function 
 is carried further; means are taken, either by catheterization 
 of the ureters or by the use of the urine separator, to obtain 
 urine from each kidney, and the specimens so obtained 
 are examined as to their cryoscopic point, and also as to 
 the amount of sugar excreted after the injection of 
 phloridzin. The cryoscopic point of the blood is also 
 ascertained ; it is held that if this is below "56 the prognosis 
 of nephrectomy is doubtful. No absolute conclusion can, 
 however, be based on the latter method ; nor does the 
 discovery that the kidney which it is proposed to leave is 
 of normal function enable one to predict with absolute 
 certainty that it will respond satisfactorily to the extra 
 
ON THE BODY. 483 
 
 demands made upon it by nephrectomy. These methods 
 of examination are, however, of great value, and should be 
 employed in all cases. Too much weight must not be 
 given to unfavourable results from these methods when 
 the affection of the kidney which appears to call for 
 nephrectomy is one which menaces life ; for example, in 
 advanced suppurative nephritis, the removal of the affected 
 kidney may be the patient's only chance of regaining health. 
 Extirpation of the spleen is well borne as far as functional 
 conditions are concerned ; this has been proved by many 
 operative experiences. After splenectomy the blood shows 
 no permanent alteration. 
 
 ANESTHETICS. 
 
 The question of the influence of an anaesthetic on a 
 patient is always one of importance. 
 
 -Local AncBsthetics. — In using cocaine in strong solutions its 
 toxicity must be remembered ; not more than 5-6 centigrams 
 ought to be injected, and half this amount in the region of 
 the head. As far as possible its absorption should be pre- 
 vented by placing some form of tourniquet above the seat of 
 injection. The injection of the stronger solutions (several 
 grams per cent) into the urethra and bladder is undoubtedly 
 risky. Reclus, it is true, considers the drug harmless after a 
 large personal experience of its use, but the practitioner will 
 do well to remember that serious symptoms of intoxication do 
 occur in a certain number of cases, and that special suscepti- 
 bility to its action is by no means rare. In these cases, 
 vertigo, nausea, vomiting, respiratory spasm, and loss of 
 consciousness may supervene. If they occur they must 
 be met by artificial respiration and amyl nitrite, and later 
 by the administration of coffee and brandy. 
 
 It is best to avoid strong solutions of the drug altogether 
 for subcutaneous injection, and either employ one of the 
 substitutes, eucaine or tropacocaine, which are almost if not 
 quite non-toxic, or to use it in the dilute solutions (1-2 : 
 1000) recommended by Schleich. The solutions of Schleich 
 are in normal salt solution, with the addition of small 
 quantities of morphine. Although it is possible by the 
 use of these solutions to render painless even operations 
 of considerable magnitude, yet most surgeons prefer a 
 
484 GENERAL INFLUENCE OF OPERATIONS 
 
 general aneesthetic under these circumstances, to avoid 
 psychic shock and the being dependent on the intelhgence 
 and character of the patient. 
 
 Of the weakest solutions of Schleich as much as 50 ccm. 
 may be used without risk of intoxication ; although such 
 an amount contains 5 centigrams of cocaine, in this weak 
 dilution the toxic effect is much less than when injected in 
 concentrated solution. The addition of adrenalin, recently 
 recommended, ensures a more intense and a longer anaes- 
 thesia ; the small amounts which have been employed 
 have no general effect, but occasionally some local necrosis 
 has been caused. The method of spinal anaesthetization, 
 introduced b}^ Bier, has several disadvantages. It is 
 uncertain, it can only be used for operations on the lower 
 part of the body, and it has in several cases caused death. 
 It has yet to be shown whether toxic effects can be obviated 
 by substituting tropacocaine for cocaine. In a certain 
 number of cases the latter causes fever, malaise, nausea, 
 vomiting and intense headache, and has no advantage 
 over a general anc^sthetic in this respect. 
 
 General Ancesthetics. — Of the general anaesthetics, 
 reference will be made here only to chloroform and ether. 
 The other substances, bromethyl, ethyl chloride, pental. 
 etc., are of less practical importance, and experience has 
 shown that they are no safer. 
 
 In the case of chloroform, risk of paralyzing the respira- 
 tory centre is to be avoided by regulating the dose. This 
 paralysis must not be confused with the spasm of the 
 respiratory muscles which occurs in the early stages of 
 narcosis. If respiratory arrest takes place, recovery will 
 follow withdrawal of the anaesthetic and artificial respiration 
 if the pulse remains good. With regard to the effect of 
 chloroform on the heart, it has been shown that it is 
 particularly in abnormal conditions of the heart muscle 
 that danger is to be anticipated, whilst patients with valvu- 
 lar disease which is well compensated stand the anaesthetic 
 well. Death from heart failure during or immediately 
 following chloroform anaesthesia takes place relatively 
 frequently in patients with the so-called status thymicus, 
 and, according to the recent researches of Wiesel, this is 
 due to the deficiency of chromafiine substance, which has 
 a regulating effect on the blood pressure. Unfortunately, 
 
ON THE BODY. 485 
 
 the diagnosis of this dangerous state is not easy ; it is 
 shown by dullness over the manubrium sterni, slight hyper- 
 trophy of the spleen, a goitre of small dimensions, and, 
 most important of all, hypertrophy of the tongue follicles. 
 Patients with this condition tolerate badly surgical inter- 
 vention of all kinds ; therefore, only absolutely necessary 
 operations should be performed on them, and either under 
 ether or local anaesthesia. 
 
 Pulmonary disease is no contra-indication to chloroform, 
 unless it is acute, or, if chronic, of a very extensive type. 
 
 Slight diabetes does not contra-indicate chloroform 
 narcosis, but in the case of severe diabetes, coma is liable 
 to follow anaesthesia, especially if the urine contains acetone 
 or acetic acid. Patients who are suffering from septicgemia, 
 or some acute febrile disorder, only require small doses 
 of anesthetic ; with larger doses there is grave danger of 
 heart failure. Great care is necessary in administering 
 chloroform in cases of patients with extreme meteorism ; 
 the movements of the heart are embarrassed by the elevation 
 of the diaphragm. There is risk also of aspiration of vomited 
 matters, but this can usually be avoided by previously 
 washing out the stomach. In every case the degree of 
 anaesthesia necessary must be specially considered, and 
 the anaesthetic not pushed beyond this ; it should be 
 remembered that large doses of chloroform may cause 
 serious organic lesions ; albuminuria and jaundice are 
 sometimes directly attributable to its toxic effect, and 
 it sometimes also has a distinct deleterious action on the 
 myocardium. 
 
 Ether is a distinctly less harmful anaesthetic than chloro- 
 form. In the dose which is necessary for anaesthesia it 
 has a distinct stimulating effect on the heart, and it has no 
 such marked tendency to paralyse the respiratory centre 
 as chloroform. Its effect on the respiratory passages is, 
 however, greater, and in a certain number of cases it is 
 responsible for pneumonia and bronchitis. This effect may 
 be for the most part avoided by administering the anaesthetic 
 in proper dilution and gradually. It does not appear to 
 have any harmful influence on the kidney or the liver. 
 
 Ether is, therefore, preferable to chloroform for patients 
 with cardiac or renal disease ; it is contra-indicated in 
 emphysema and bronchitis. 
 
486 GENERAL INFLUENCE OF OPERATIONS 
 
 For operations of short duration, such as tooth extraction 
 and simple incisions, it is only necessary to use small 
 amounts of ether to produce a condition of intoxication 
 rather than narcosis, in which there is analgesia rather 
 than actual anaesthesia. 
 
 It is often the most rational plan to use a mixture of 
 chloroform and ether ; and the mixture of Billroth which 
 contains alcohol also is one very largely in use. 
 
 Morphine is an assistant to narcosis which is not so 
 much used as it deserves. I advocate a dose of 1-2 centi- 
 grams about half an hour before the general anaesthetic. 
 It is contra-indicated only in children and in patients 
 suffering from septicaemia. Less of the general anaesthetic 
 is required if this be given beforehand ; in alcoholics in 
 particular it is often hardly possible to obtain satisfactory 
 narcosis without it. 
 
 Certain effects of narcotics on already existing affections 
 must be noted. In certain states of intoxication and infec- 
 tion chloroform appears to aggravate the condition, and in 
 particular its effect on the state of the heart. This is 
 sometimes seen in the case of operations on septic abdominal 
 foci ; even though the operation itself may be slight, the 
 symptoms, and particularly the heart symptoms, are in 
 certain cases markedly augmented after anaesthesia. In 
 patients suffering from such intoxications and infections, 
 ether is certainly to be preferred to chloroform. 
 
 THE INFLUENCE OF CERTAIN DISEASES ON THE 
 INDICATIONS FOR OPERATION. 
 
 The indications for operation in the case of patients 
 suffering from some complicating disease vary according 
 to the seriousness of the condition which the operation is 
 designed to relieve. On the one hand, affections which 
 imminently threaten life will be operated on whatever 
 associated disease may be present, unless the patient is 
 moribund ; and, on the other hand, one will hesitate to 
 operate for the relief of some cosmetic disability if the patient 
 has some affection which increases the risk. Between 
 
ON THE BODY. 487 
 
 these two extremes there are a whole series of conditions, 
 each of which must be judged on its merits. 
 
 It has already been remarked that well-compensated 
 Heart Disease does not contra-indicate operation when this 
 is called for by some disability of importance. Intervention 
 in the presence of defective compensation is always risky, 
 but is not contra-indicated when life is threatened, and, 
 in particular, in the case of operations undertaken to relieve 
 the circulatory embarrassment, evacuation of ascitic or 
 pleuritic effusion, the removal of large abdominal tumours, 
 and the like. Sometimes, when valvular disease is well 
 compensated, a troublesome tachycardia follows operation, 
 but this usually yields to the application of an ice-bag and 
 to drugs, such as digitalis and strophanthus. 
 
 In Arteriosclerosis there is risk of cerebral haemorrhage, 
 and I have seen this fatal in two cases ; the one a case 
 of carcinoma of the breast, the other a myoma uteri. In 
 the latter case the operation was done with the pelvis 
 elevated, a position to be avoided under such circumstances. 
 In the presence of serious disease of heart or vessels, each 
 case must be judged separately. I consider that a patient 
 who has a scirrhous cancer of the breast or a squamous 
 carcinoma should be left unoperated on if there is at the 
 same time a serious cardiac lesion ; both are slow-growing 
 cancers, and the patient will probably live longer if left 
 alone. On the other hand, in such a condition as chronic 
 intestinal stenosis in a patient with heart disease, the 
 stenosis should be operated on, the danger from this being 
 greater than that from the cardiac affection. 
 
 In patients suffering from Tuberculous Disease it is well 
 known that operative interference on local tuberculous 
 foci may be occasionally followed by dissemination. It is 
 impossible to foresee such a deplorable consequence, and 
 the great majority of such operations are well borne. In 
 the case of patients with pulmonary tuberculosis the effect 
 of the disease on operative procedures elsewhere depends 
 upon its stage. In the presence of florid phthisis, radical 
 procedures not involving a long convalescence are preferable 
 to the more conservative ; but when the pulmonary disease 
 is not active the latter measures are more justiliable. Ether 
 as an amesthetic is generally to be avoided for phthisical 
 subjects. Circumscribed tuberculous foci of the intestine 
 
488 GENERAL INFLUENCE OF OPERATIONS 
 
 which are interfering with nutrition should be operated on, 
 even when there is pulmonary disease, provided that the 
 intestinal lesions are not too advanced ; this particularly 
 applies to stenosis and abscess. 
 
 In the case of patients suffering from Bright' s Disease 
 it is well to follow the rule that when the condition for 
 which operation is required is more menacing to life than 
 the nephritis, operation should be undertaken ; when this 
 is not £0 it is well to abstain. Conditions such as rapidly 
 growing malignant disease, intestinal stenosis, appendicitis, 
 and such like, will be operated on in spite of nephritis ; while 
 benign tumours, malformations, and other conditions of 
 this type will be left alone. Chloroform should never be 
 given to a patient with Bright's disease. 
 
 In the case of patients with Leuccsmia or P seudoleuccsmia 
 only operations whose indication is vital should be under- 
 taken. The risks are, first, post-operative haemorrhage, 
 and secondly, delay in healing of wounds. Extirpation 
 of the spleen or of pseudoleucsemic glands are irrational 
 procedures, and*should not be practised. 
 
 It is sometimes necessary to operate on HcEmophilics, 
 and cases are on record where the arrest of haemorrhage 
 has not presented the difficulties anticipated. No operation 
 will, however, be done that is not absolutely of vital 
 importance. Calcium chloride should be administered 
 beforehand in order to aid local haemostasis. 
 
 Operations have many times been performed on patients 
 suffering from chronic diseases of the spinal cord : tabes, 
 syringomyelia, etc. In addition to the cases operated on 
 in error (e.g., laparotomy for gastric crises diagnosed as 
 gastric ulcer) a considerable number of cases of nervous 
 arthropathy have been operated on. The results are not 
 imiform, but it appears that if strict asepsis is practised 
 the wounds heal quite satisfactorily. 
 
 IMPORTANT COMPLICATIONS AFTER OPERATION. 
 
 Pneumonia is sometimes embolic (particularly in opera- 
 tions on the intestines), sometimes hypostatic, sometimes 
 due to aspiration of vomited matter into the air passages. 
 
ON THE BODY. 489 
 
 and sometimes induced by chill during the course of the 
 operation. Except for the embolic form the complication 
 is one that can be avoided by due precautions. The treat- 
 ment is the same as in pneumonia of ordinary type : sup- 
 port the heart, give stimulants, then expectorants. Fever 
 and rapid respiration after operation will always indicate 
 careful examination of the chest. 
 
 Among intestinal complications attention has recently 
 been drawn to the occasional occurrence of obstinate and 
 sometimes fatal Diarrhoea after gastro-enterostomy, but 
 this is very rare. Peptic Ulcer is another complication 
 which may follow this operation, but it also is quite 
 uncommon. The possibility of its occurrence should be 
 borne in mind especially in cases where hyperchlorhydria 
 is demonstrated before operation. In such cases alkalies 
 should be given after operation and the diet regulated with 
 much care. 
 
 Stomach Paralysis is an accident which may follow 
 anaesthesia for operations of any kind. The signs are 
 uncontrollable vomiting, at first of bilious matter and later 
 of blood, and marked distension of the stomach. Some- 
 times the condition has a mechanical cause, such as kinking 
 at the duodenojejunal junction, but in most cases it is a 
 condition of primary paralysis and dilatation. In marked 
 cases death is not unusual. 
 
 Intestinal Paralysis occurs after abdominal operations. 
 When at all marked, peritonitis will always be suspected. 
 Probably most of the mild cases are examples of slight 
 peritonitis, though direct trauma by handling, etc., is no 
 doubt also sometimes responsible. If a purgative and 
 enema do not relieve the symptoms within the course of 
 twenty-four hours or so, there is probably either peritonitis 
 or some mechanical obstruction of the bowel. 
 
 The Pulse usually returns to normal during the twenty- 
 four hours which follow the operation ; in some patients 
 about the age of puberty, and in some women and infants, 
 there is tachycardia for several days later without any 
 definite cause. 
 
 The Temperature is alwa^^s carefully watched after opera- 
 tion. A normal temperature does not of course mean that 
 all is well, nor fever that there is some serious complication. 
 The temperature is always to be compared with the other 
 
490 GENERAL INFLUENCE OF OPERATIONS. 
 
 symptoms, and particularly with the pulse. A rising 
 temperature and a rapid pulse usually mean some inflam- 
 matory complication. Special attention should be given 
 to the comparison of temperature and pulse, particularly 
 after abdominal operations ; while a rise of temperature 
 and pulse together point to infection, in the worst cases 
 the temperature is often normal or subnormal and the pulse 
 rapid. It is when the pulse and temperature part company 
 that the most serious complications are to be feared. 
 
491 
 
 INDEX. 
 
 Abdomen, Effects of Opening . . 
 Abortion, Indications for Procur- 
 ing 
 
 — in Osteomalacia 
 Abscess, Appendicular 
 
 — Cerebellar 
 
 — Extradural 
 
 — Frontal 
 
 — Intraperitoneal 
 
 — of the Brain . . 
 
 — • Kidney 
 
 Liver . . . . 255, 
 
 Lung . . 
 
 Spleen 
 
 — — — Sternum 
 
 — — — Temporal Lobe 
 
 — in Tubercular Spondylitis . . 
 
 — Perinephritic . . 
 
 — Retropharyngeal 46, 47, 94, 
 
 — Subphrenic . . 177, 255, 
 Actinomycosis of the Intestine 
 
 Lung . . 
 
 Adhesions, Peritoneal 
 Albuminuria, in Pregnancy 
 Alexia, in Cerebral Tumour 
 Anal Fissure 
 Anaemia, in Pregnancy 
 Anaesthesia, Local 
 Anesthetics, General 
 Anasarca . . 
 Aneurysm 
 
 Aortic . . 
 
 — Intracranial . . 
 
 — of the Renal Arteries 
 Angina, Ludwig's 
 Angioneurotic Haematuria 
 Angular Curvature 
 Anuria in Renal Calculus 
 Anus, Artificial, in Dilatation of 
 
 Colon 
 
 — — — Intestinal Cancer 
 Ulcers 
 
 — — — — Stenosis 
 
 — — — Mesenteric Embolism 
 
 — — — Membranous Enteritis 
 
 — — — Proctitis 
 
 — — — Rectal Cancer 
 Aortic Aneurysm . . 
 
 Aphasia in Cerebral Haemorrhage 
 
 — Motor . . 
 
 — Optic 
 
 — Sensory 
 
 ='AGE 
 
 
 PAGE 
 
 479 
 
 Appendicitis 
 
 • . 254 
 
 
 — in Pregnancy . . 
 
 468, 264 
 
 459 
 
 Arteriosclerosis and Operation . . 487 
 
 455 
 
 Arthritis Deformans 
 
 • • 452 
 
 257 
 
 Arthrodesis in Poliomyelitis . . 59 
 
 16 
 
 Arthropathy, Nervous 
 
 • • 449 
 
 17 
 
 Artificial Anus (see Anus) 
 
 16 
 
 Ascites 
 
 .. 298 
 
 272 
 
 Ataxia, Cerebellar 
 
 6 
 
 15 
 
 — in Frontal Lobe Abscess . . 16 
 
 430 
 
 Aura, Epileptic . . 
 
 .. 28 
 
 338 
 
 
 
 105 
 
 
 
 364 
 
 Banti's Disease . . 
 
 •• 357 
 
 134 
 
 Bile-ducts, Diseases of 
 
 • • 307 
 
 16 
 
 • Obstruction of 
 
 ■ • 310 
 
 44 
 
 Biliary Calculus . . 
 
 • ■ 307 
 
 435 
 
 — Colic . . 
 
 . . 308 
 
 161 
 
 Bladder, Inflammation c 
 
 )f the . . 441 
 
 301 
 
 — Tuberculosis of the . 
 
 424, 444 
 
 211 
 
 Bleeding (see Venesectio 
 
 n) 
 
 III 
 
 Blood, Diseases of, in Pregnancy 463 
 
 284 
 
 — Iodine Reaction in 
 
 . • 259 
 
 465 
 
 Blood-vessels, Diseases 
 
 of . . 141 
 
 5 
 
 — Paralysis of . . 
 
 50 
 
 221 
 
 — in Graves' Disease 
 
 81 
 
 463 
 
 Bones, Diseases of 
 
 • • 449 
 
 483 
 
 Brachial Neuralgia 
 
 .. 67 
 
 484 
 
 Brain, Abscess of the 
 
 15 
 
 148 
 
 — Cysticercus of the 
 
 8 
 
 143 
 
 — Diseases of the 
 
 I 
 
 143 
 
 — Gumma of the 
 
 . . I, II 
 
 8 
 
 — Glioma of the . . 
 
 I 
 
 410 
 
 — Hernia of the . . 
 
 . . 481 
 
 161 
 
 — Hydatid Cyst of the 
 
 7 
 
 387 
 
 — Tuberculosis of the 
 
 . . I, II 
 
 44 
 
 — Tumours of the 
 
 I 
 
 394 
 
 Brasdor's Operation 
 
 146 
 
 
 Bright's Disease . . 
 
 ■• 383 
 
 251 
 
 — — and Operation 
 
 . . 488 
 
 245 
 
 Bronchi, Diseases of 
 
 99 
 
 214 
 
 Bronchiectasis 
 
 99 
 
 230 
 218 
 
 Bronchitis, Putrid 
 
 .. 103 
 
 216 
 223 
 
 Cachexia, in Pregnancy 
 
 . . 464 
 
 248 
 
 Calculus, Biliary.. 
 
 • • 307 
 
 143 
 
 — Pancreatic 
 
 •■ 373 
 
 33 
 
 — Renal . . 
 
 .. 389 
 
 5 
 
 — Ureteral 
 
 ■ ■ 394 
 
 16 
 
 Carcinoma of the Cardia 
 
 . . 184 
 
 5 
 
 Gall-bladder 
 
 .. 325 
 
492 
 
 INDEX. 
 
 PAGE 
 409 
 
 377 
 
 295 
 193 
 
 246 
 183 
 
 439 
 487 
 455 
 473 
 
 Carcinoma of the Intestine 
 
 — — — Kidney 
 
 — - — — Liver . . 
 
 — — — CEsophagus 
 
 — — — Pancreas 
 — — Peritoneum 
 
 — — — Pylorus . . 18 
 — Rectum 
 
 — — — Stomach 
 Cardiac Disease in Pregnancy . . 
 
 — — and Operation 
 Castration, for Osteomalacia 
 Cataract, Diabetic 
 Cauda Equina, Lesions of 51, 
 Cellulitis, Retropharyngeal 
 Cerebellum, Abscess of the 
 
 — Tumours of the 
 Cerebral Abscess . . 
 
 — Diplegia 
 
 — Hemorrhage . . 
 
 — Palsy, in Children 
 
 — Puncture . . 12, 
 
 — Tumour 
 
 Cerebrospinal Meningitis 
 Cervical Muscles, Spasm of 
 
 — Rib 
 
 Chloroform Anaesthesia . . 
 Chlorosis, Venesection for 
 Cholecystectomy 
 
 Cholecystenterostomy . . 314, 
 
 Cholecystitis, Acute . . 310, 
 
 Cholecystostomy, in Pancreatic 
 
 Tumour. . 
 
 — in Gall-stones 
 Choledochotomy . . 
 Cholelithiasis 
 
 — in Pregnancy . . 
 Chorea Gravidarum 
 Choroid, Tubercle of the 
 Circulatory Embarrassment, Vene- 
 section for 
 
 Cirrhosis of the Liver, Atrophic 
 Cocaine, Toxicity of 
 Caecotomy. . 
 Colic, Biliary 
 
 — Intestinal . . . . 227, 
 
 — Renal 385, 388, 391, 400, 402, 416, 
 
 420, 425, 431 
 Colitis, Mucous . . 
 
 — Ulcerative 
 
 Colon, Congenital Dilatation of 
 Colostomy 
 
 Common Bile-duct Obstruction 
 Complications after Operation. 
 Contusions, Renal . . . . 399 
 
 Conus Terminalis, Lesions of . . 51 
 Convulsions in Cerebral Abscess 16 
 
 — — — Haemorrhage . . . . 33 
 
 — — — Tumour . . . . 4 
 
 — — Epilepsy . . . . . . 28 
 
 — — Hydrocephalus . . . . 24 
 
 — — Meningitis . . . . 37 
 
 — — Tubercular Meningitis . . 35 
 Craniotabes . . . . . . 25 
 
 Cranium, Effects of Opening . . 479 
 
 P.\GE 
 
 92 
 
 482 
 311 
 413 
 414 
 
 161 
 
 16 
 
 6 
 
 15 
 
 32 
 
 33 
 
 31 
 
 6, 38 
 
 I 
 
 37 
 
 74 
 
 67 
 
 484 
 
 155 
 
 314 
 
 378 
 
 320 
 
 379 
 314 
 314 
 307 
 469 
 470 
 35 
 
 154 
 342 
 483 
 214 
 308 
 237 
 
 213 
 250 
 248 
 
 Croup 
 
 Cryoscopy in Renal Disease 
 
 422, 426, 
 Cystic Duct, Obstruction of 
 
 — Kidney ■ . . 
 
 — Liver . . 
 
 Cysticercus of the Brain . 
 Cystitis . . . . . . . . 441 
 
 Cystotomy . . . . 442, 446 
 
 Cyst, Hydatid 7, no, 333, 353, 416 
 
 — Omental and Mesenteric . . 295 
 
 — Splenic . . . . . . 354 
 
 — Pancreatic . . . . . . 374 
 
 Delirium in Cerebral Abscess . . 16 
 
 Dermoid Cyst, Mediastinal .. 135 
 
 Diabetes and Ana?sthesia . . 474 
 
 Diabetics, Operations on . . 473 
 
 Diarrhoea, Post-operative . . 489 
 
 Diffuse Peritonitis . . . . 275 
 
 Dilatation, Congenital, of the 
 
 Colon . . . . . . . . 250 
 
 — of the CEsophagus . . . . 167 
 
 — — — Stomach . . . . 192 
 Diphtheria . . . . . . 92 
 
 — in Pregnancy . . . . . . 464 
 
 Diplegia, Cerebral . . . . 32 
 
 Di\'erticulum of the CEsophagus 168 
 
 Dropsy . . . . . . . . 148 
 
 Ductus Choledochus, Occlusion 310 
 
 — Cysticus, Occlusion .. .. 311 
 Duodenal Stenosis . . . . 204 
 
 — Ulcer . . . . . . . . 201 
 
 Dysentery, Chronic . . . . 213 
 
 Eclampsia, Induction of Labour 
 
 in . . . . . . . . 466 
 
 — Venesection for . . . . 154 
 Ectasis of the Stomach . . . . 192 
 Embolism, Mesenteric . . . . 217 
 Empyema of the Gall-bladder 311, 320 
 
 — — — Pleura .. 117, 301 
 Enteric Fever in Pregnancy . . 464 
 Enteritis, Membranous . . . . 215 
 Entero-anastomosis for Actino- 
 mycosis . . . . . . 212 
 
 — — Cancer . . . . . . 245 
 
 — — Obstruction . . . . 238 
 
 — — Stenosis . . . . . . 230 
 
 — — Tuberculosis . . . . 209 
 
 — — Ulceration . . . . 214 
 Enterostomy in Intestinal 
 
 Obstruction . . . . . . 238 
 
 Enuresis, Nocturnal . . . . 443 
 
 Epigastric Hernia . . . . 180 
 
 Epilepsy . . . . . . . . 27 
 
 — after Trephining . . . . 480 
 
 — during Pregnancy . , . . 470 
 
 — in Cerebral Palsy . . . . 31 
 
 — — — Abscess . . . . 16 
 
 — — — Tumour . . . . 5 
 
 — Jacksonian .. . . 4, 9, 16, 28 
 Erysipelas during Pregnancy . . 464 
 
INDEX. 
 
 493 
 
 Ether Anaesthesia 
 Exophthalmic Goitre 
 Eyelids, CEdema of, in Sinus 
 Thrombosis 
 
 ^85 
 
 8i 
 
 Fat Necrosis 
 
 • 369 
 
 Facial Spasm 
 
 73 
 
 Fevers, Infectious, during Preg- 
 
 nancy . . 
 
 • 464 
 
 Fifth Cranial Nerve, Neuralgia 
 
 of 63 
 
 Fistula of Gall-bladder . . 
 
 ■ 378 
 
 Flanks, Meteorism of the 
 
 220 
 
 Flexure, Volvulus of the Sigmoid 233 
 
 Floating Kidney . . 
 
 . 402 
 
 — Spleen 
 
 • 359 
 
 Foot, Perforating Ulcer of 
 
 75 
 
 Foreign Bodies in the Lungs 
 
 102 
 
 Qisophagus 
 
 • 133 
 
 Stomach . . 
 
 190 
 
 Frontal Lobe, Abscess of 
 
 16 
 
 Tumours of 
 
 5 
 
 Fusiform Dilatation of OEsophag 
 
 us 167 
 
 GALL-bladder, Carcinoma of 
 
 • 325 
 
 — • Diseases of . . 
 
 • 307 
 
 — Empyema of . . 
 
 ■ 320 
 
 — Extirpation of 
 
 • 314 
 
 — Fistula of 
 
 • 378 
 
 — Hydrops of . . 
 
 • 318 
 
 — Perforation of 
 
 ■ 311 
 
 Gall-stones 
 
 • 307 
 
 Gall-stone, Obstruction by 
 
 
 204, 227, 2 
 
 30, 322 
 
 Galvanopuncture in Aneurysm 
 
 147 
 
 Gangrene of the Lung . . 
 
 20, 102 
 
 Gasserian Ganglion, Removal 
 
 of 64 
 
 Gastralgia, Hysterical . . 
 
 . 180 
 
 Gastric Dilatation 
 
 . 192 
 
 — Ulcer 
 
 • 177 
 
 Perforating 178, 2 
 
 77, 301 
 
 Gastro-enterostomy in Hour-gla 
 
 ss 
 
 Stomach 
 
 • 195 
 
 Gastro-enterostomy in Duoden 
 
 al 
 
 Stenosis 
 
 ■ 205 
 
 Gastric Cancer . . 
 
 . 187 
 
 Ulcer . . 
 
 . 182 
 
 Gastrostomy in CEsophageal 
 
 
 Stricture 
 
 . 172 
 
 — in Stomach Cancer . . 
 
 .■ 187 
 
 Gelatin Injections in Aneurysn 
 
 1 146 
 
 Glandular Organs, Extirpation 
 
 of 481 
 
 Glaucoma 
 
 . 64 
 
 Glioma of the Brain 
 
 I 
 
 Goitre, Exophthalmic . . 
 
 81 
 
 — Intrathoracic 
 
 • 135 
 
 Graves' Disease . . 
 
 81 
 
 Gumma of the Brain 
 
 . I, II 
 
 Liver . . 
 
 • 331 
 
 Meninges 
 
 I 
 
 H/KMATE.VIESIS . . . . I 
 
 78, 201 
 
 — during Pregnancy 
 
 • 467 
 
 Haematuria in Bladder Tubercle 
 
 — Angioneurotic 
 
 — in Hydronephrosis 
 
 — — Nephralgia 
 
 — — Pregnancy 
 
 — — Pyelitis 
 
 — — Renal Calculus 
 
 — — — Contusions 
 
 — — — Tuberculosis 
 
 — — — Tumours 
 Hemophilia and Pregnane}^ 
 Haemophilics, Operations on 
 Hemorrhage, Cerebral . . 
 
 — Intra-abdominal 
 Hemorrhoids 
 Hair-ball in Stomach 
 Heart, Diseases of 
 
 Heart Disease and Chloroform 
 
 — — — Operation 
 
 — — — Pregnancy 
 
 Heat Stroke, Venesection for 
 Hemianopsia in Cerebral Abscess 
 
 — — — Tumour 
 Hemiathetosis 
 Hemichorea 
 Hemiparesis in Cerebral Abscess 
 Hemiplegia in Cerebral Abscess 
 
 — — — Haemorrhage . . 
 
 — — — Palsy . . 
 
 — — — Tumour 
 Hepatic Duct, Drainage of 
 Hernia, Epigastric 
 
 — and Intestinal Stricture 
 
 — of Brain 
 Herpes Zoster 
 Hour-glass Stomach 
 Hydatid Cyst of the Brain 
 
 — — — — Kidney 
 
 — — — — Liver 
 
 — — — — Lung 
 
 — — — — Spleen 
 
 — — Muitilocular 
 H^'drarthrosis, Intermittent 
 Hydrocephalus 
 
 — Acquired 
 
 — Acute . . 
 
 — and Cerebral Tumour 
 
 — Rupture of 
 Hydronephrosis . . 
 Hydrops Anasarca 
 
 — of the Gall-bladder . . 
 Hydrothorax 
 Hyperemesis Gravidarum 
 Hypernephroma . . 
 Hyperplasia of the Spleen 
 Hypertrophy, Congenital Pyloric 
 
 — of the Tonsils. . 
 Hysteria during Pregnancy 
 Hysterical Gastralgia 
 
 PAGE 
 
 445 
 387 
 420 
 388 
 467 
 430 
 391 
 400 
 
 425 
 410 
 463 
 488 
 
 33 
 253 
 220 
 190 
 141 
 484 
 487 
 459 
 153 
 
 16 
 
 3 
 
 31 
 
 31 
 
 16 
 
 16 
 
 33 
 
 31 
 
 5 
 
 314 
 
 180 
 
 229 
 
 481 
 
 69 
 
 192, 
 
 7 
 416 
 
 333 
 no 
 
 353 
 
 334 
 
 84 
 
 23 
 3> 25 
 
 23 
 4 
 
 27 
 418 
 148 
 318 
 126 
 468 
 410 
 353 
 196 
 
 159 
 470 
 
 206 
 
 Ileoc/ECal Tuberculosis 
 Ileus (see Intestinal Obstruction) 
 Infectious Fevers in Pregnancy 464 
 Infiltration Anaesthesia . . . . 484 
 
494 
 
 INDEX. 
 
 Influenza in Pregnancy 
 Injuries of the Intestine 
 
 — — — Kidney 
 
 — — — Spleen 
 
 — — — Stomach 
 Insolation, Venesection for 
 Intercostal Neuralgia 
 Intermittent Hydrarthrosis 
 Intestinal Actinomycosis 
 
 ■ — Carcinoma 
 — • Colic . . 
 
 — Diseases 
 
 — Exclusion 
 
 — Injuries 
 
 — Obstruction 
 
 227, 
 
 209, 214, 
 
 231, 2 
 
 — — by Gall-stone 204, 227, 
 
 — — — Occlusion 
 
 — — — Strangulation 
 Paralytic . . 
 
 — Paralysis 
 
 — Puncture 
 
 — Resection 230, 236, 238, 
 
 — Rupture 
 
 — Stenosis 
 
 — Torsion 
 
 — Tuberculosis . . 
 
 — Ulcer, Peptic . . 
 Intoxications, Venesection in 
 Intrathoracic Goitre 
 Intubation in Diphtheria 
 Intussusception . . 
 Iodine Blood Reaction . . 
 
 PAGE 
 
 464 
 
 251 
 
 399 
 
 362 
 
 251 
 
 153 
 
 68 
 
 84 
 
 211 
 
 243 
 
 237 
 
 201 
 
 230, 245 
 
 • ■ 251 
 284 
 
 230, 322 
 
 • • 236 
 ■• 233 
 
 232 
 
 489 
 
 236 
 
 241, 244, 
 
 251 
 
 ■ • 252 
 
 243 
 
 233 
 
 206 
 
 182 
 
 153 
 
 135 
 
 94 
 
 240 
 
 259 
 
 232, 
 
 227, 
 
 Jacksonian Epilepsy . . 4, 9, 16, 28 
 
 Jaundice 309, 319, 320, 325, 331, 343, 
 
 347, 378 
 
 — after Anaesthesia . . . . 485 
 
 — in Pregnancy.. .. .. 469 
 
 — — Sinus Thrombosis . . 20 
 Jejunum, Peptic Ulcer of . . 182 
 Joint Arthrodesis . . . . 59 
 
 — Infection in Sinus Thrombosis 20 
 
 — Intermittent Hydrarthrosis of 84 
 
 — Movable Bodies in . . . . 452 
 
 — Resection . . . . 451, 453 
 Joints, Diseases of . . . . 449 
 Jugular Vein Thrombosis . . 20 
 
 of 
 
 Kernig's Sign . . 
 Kidney, Abscess of 
 
 — Angioneurotic Haemorrhage 
 
 — Bright's Disease of . . 
 
 — Calculus of . . 
 
 — Carcinoma of . . 
 
 — Contusions of . . 
 
 — Cystic Disease of 
 
 — Disease in Pregnancy 
 
 — Diseases of . . 
 
 — Fixation of . . 
 
 — Floating 
 
 — Functional Value of the 
 
 422, 426, 482 
 
 •36, 37 
 430 
 387 
 383 
 389 
 409 
 
 399 
 413 
 465 
 383 
 404 
 402 
 
 Kidney, Hydatid Cyst of 
 
 — Hydronephrosis of 
 
 — Movable 
 
 — Neuralgia of . . 
 
 — Rupture of 
 
 — Sarcoma of 
 
 — Tuberculosis of 
 
 — Tumours of . . 
 
 Labour, Induction of . . 
 Laminectomy in Pott's Disease 
 Spinal Fracture . . 
 
 — — Tubercular Meningitis 
 Laryngeal Paralysis 
 
 — Tuberculosis . . 
 
 — Tumours 
 
 Laryngotomy for Stenosis 
 Larynx, Diphtheria of . . 
 
 — Diseases of . . 
 
 — Intubation of the 
 
 — Stenosis of 
 Lateral Sinus, Thrombosis of 
 
 the 
 
 Leptomeningitis, Acute . . 
 Leucffimia and Operation 
 
 — — Splenectomy 
 
 — in Pregnancy.. 
 Leucocytosis in Appendicitis 
 
 — — Peritonitis 
 Liver, Abscess of . . 
 
 — Diseases of 
 
 — Atrophic Cirrhosis of 
 
 — Gumma of 
 Local Anaesthesia 
 Lumbar Puncture in Cerebral 
 
 Abscess . . 
 — Tumour . . . 
 
 — — — Meningitis 
 Lung, Abscess of . . 
 
 — Actinomycosis of 
 
 — Bronchiectasis of 
 
 — Disease and Anaesthetics 
 
 — Diseases of 
 
 — Foreign Bodies in the 
 
 — Gangrene of . . 
 
 — Hydatid Disease 
 
 — Tuberculosis of 
 
 — Tuberculosis in Pregnancy 
 Lymphosarcomata of the Media 
 
 stinum . . 
 
 PAGE 
 
 416 
 418 
 402 
 387 
 399 
 409 
 424 
 409 
 
 459 
 45 
 52 
 36 
 90 
 
 461 
 
 92 
 
 93 
 
 Malaria in Pregnancy . . 
 
 — the Spleen in. . 
 Measles in Pregnancy 
 Mediastinitis, Suppurative 
 Mediastinum, Diseases of the 
 
 — Tumours of the 
 Membranous Enteritis . . 
 Meninges, Gumma of the 
 Meningitis, Acute 
 
 — Serous 
 
 — Tubercular 
 Meningo-encephalitis 
 
 20 
 37 
 
 488 
 
 355 
 463 
 258 
 273 
 ), 338 
 331 
 342 
 331 
 483 
 
 17 
 
 12 
 
 36,38 
 
 105 
 
 III 
 
 99 
 
 485 
 
 99 
 
 99 
 
 102 
 
 no 
 
 109 
 
 461 
 
 135 
 
 465 
 355 
 464 
 
 133 
 133 
 135 
 
 215 
 
 I 
 
 37 
 37 
 35 
 37 
 
INDEX. 
 
 495 
 
 }'AGE 
 
 Meralgia Parsesthetica . . . . 70 
 
 Mesenteric Vessels, Embolism of 217 
 
 Mesentery, Tumours of . . . . 295 
 
 Meteorism and Anaesthetics . . 485 
 
 — and Laparotomy . . . . 479 
 
 — of the Flanks . . .. •• 229 
 Migraine . . . . . • • • 64 
 Moebius' Symptom . . . . 81 
 Morphia Narcosis . . • • 486 
 Mouth, Diseases of the . . . . 159 
 Movable Kidney . . . . . . 402 
 
 — Liver . . . . . . . . 346 
 
 Motor Aphasia . . . . . • 5 
 
 Mucous Colitis . . . . . . 215 
 
 Muscles, Spasm of Neck . . . . 74 
 
 Myoma of the Stomach . . . . 191 
 
 Nasal Diphtheria . . . . 92 
 
 Neck Rigidity in Cerebral Abscess 16 
 
 — — — — Tumour . . . . 5 
 
 ■ Meningitis . . . . 37 
 
 Necrosis, Fat . . . . . . 369 
 
 — of the Pancreas . . . . 369 
 Nephralgia Haematurica. . . . 387 
 Nephrectomy, Risks of . . . . 482 
 
 — for Renal Calculus . . . . 396 
 Contusions . . . . 401 
 
 — — — Tuberculosis . . . . 427 
 
 — — ^— Tumour . . . . 412 
 
 — in Pyelitis . . . . . . 432 
 
 — — Pyonephrosis . . . . 422 
 Nephritis . . . . . . . . 383 
 
 — Suppurative . . . . . . 429 
 
 — in Pregnancy . . . . . . 465 
 
 Nephropexy . . . . . . 404 
 
 Nephrotomy in Renal Calculus. . 396 
 
 — for Cystic Kidney . . . . 415 
 
 — — Renal Contusion . . . . 400 
 
 — — — Tuberculosis . . . . 427 
 Nerve, External Cutaneous . . 70 
 
 — Facial . . . . . . . . 73 
 
 — Occipital . . . . . . 65 
 
 — Sciatic . . . . . . 71 
 
 — Supra-orbital . . . . . . 73 
 
 — Trigeminal . . : . . . 63 
 Nerves, Diseases of the . . . . 63 
 
 — Intercostal . . . . . . 68 
 
 Nervous Arthropathy . . . . 449 
 
 — Disease and Pregnancy . . 470 
 Neuralgia of Brachial Plexus . . 67 
 
 — — External Cutaneous Nerve 70 
 
 — — Fifth Cranial Nerve . . 63 
 
 — — Occipital Nerve . . . . 65 
 
 — — Sciatic Nerve . . . . 71 
 
 — in Spinal Tumours . . . . 54 
 
 — Intercostal . . . . . . 68 
 
 — Renal . . . . . . . . 387 
 
 — Trigeminal . . . . . . 63 
 
 Neuritis in Pregnancy . . . . 471 
 
 — Peripheral . . . . . . 58 
 
 Neuroses . . . . . . . . 81 
 
 Nocturnal Enuresis . . . . 443 
 
 Nystagmus in Hydrocephalus . . 24 
 Leptomeningitis . . . . 37 
 
 Obstetric Paralysis 
 
 
 59 
 
 Obstruction, Intestinal . . 
 
 231 
 
 — by Gall-stones 204, 227, 23 
 
 0, 322 
 
 Occipital Lobe, Abscess of 
 
 16 
 
 Tumour of 
 
 5 
 
 — Neuralgia 
 
 65 
 
 Occlusion, Intestinal 
 
 236 
 
 CEsophagotomy . . 
 
 173 
 
 CEsophagus, Carcinoma of 
 
 171 
 
 — Diseases of . . 
 
 167 
 
 — Diverticulum of 
 
 168 
 
 — Foreign Bodies in . . 
 
 133 
 
 — Fusiform Dilatation of 
 
 167 
 
 — Resection of . . 
 
 172 
 
 — Stricture of . . 
 
 171 
 
 Omentum, Tumours of . . 
 
 295 
 
 Operations, Complications after 
 
 488 
 
 — General Influence of . . 
 
 477 
 
 Optic Aphasia 
 
 16 
 
 — Neuritis in Cerebral Abscess . 
 
 16 
 
 Tumour . . 
 
 4 
 
 Hydrocephalus 
 
 24 
 
 Sinus Thrombosis 
 
 20 
 
 Osteomalacia . . 
 
 453 
 
 Osteomyelitis of the Vertebrae. 
 
 47 
 
 Otitic Cerebral Abscess . . 
 
 15 
 
 Ovaries, Effects of Removal of. 
 
 481 
 
 Pachymeningitis, External 
 
 
 Purulent 
 
 17 
 
 Palsy of Children, Cerebral 
 
 31 
 
 Pancreas, Calculus of . 
 
 
 373 
 
 — Carcinoma of . . 
 
 
 377 
 
 — Cysts of 
 
 
 374 
 
 — Diseases of . . 
 
 
 369 
 
 — Inflammation of 
 
 
 369 
 
 — Necrosis of . . 
 
 
 369 
 
 — Resection of . . 
 
 
 378 
 
 — Tumours of . . 
 
 
 377 
 
 Pancreatitis 
 
 
 369 
 
 Paralysis, Laryngeal 
 
 
 90 
 
 — of Blood-vessels 
 
 
 50 
 
 — Intestinal 
 
 23 
 
 2, 489 
 
 — Obstetric 
 
 
 59 
 
 Pelvic Peritonitis 
 
 
 272 
 
 Peptic Ulcer 
 
 182, 489 
 
 Perforating Ulcer of the Foot . 
 
 75 
 
 — — — — Stomach . . 
 
 178 
 
 Perforative Peritonitis 179, 252 
 
 . 257. 
 
 
 275 
 
 Pericarditis 
 
 141 
 
 — Purulent 
 
 142 
 
 Perihepatitis, Chronic . . 
 
 284 
 
 Perinephritis . . 390, 420, 434 
 
 Peripheral Nerves, Diseases of. 
 
 63 
 
 — Neuritis 
 
 58 
 
 Periproctitis 
 
 222 
 
 Peritoneal Adhesions 
 
 284 
 
 — Cavity, Effects of Opening. 
 
 479 
 
 Peritoneum, Diseases of . . 
 
 271 
 
 — Tumours of . . 
 
 295 
 
 Peritonitis, Acute Circumscribed 271 
 
 — Adhesive 
 
 283 
 
 — Chronic Exudative . 
 
 
 282 
 
496 
 
 INDEX. 
 
 PAGE 
 
 Peritonitis, Chronic Indurative. . 283 
 
 — Diagnosis from Obstruction 278 
 
 — Diffuse . . . . 257, 275 
 
 — Fibrino-purulent . . 257, 275 
 
 — in Appendicitis . . . . 257 
 
 — Pelvic . . . . . . . . 272 
 
 — Perforative . . 179, 252, 257, 275 
 
 — Traumatic . . . . . . 282 
 
 — Tubercular . . . . . . 287 
 
 Pernicious Anasmia in Pregnancv 463 
 
 Petit Mai '. 28 
 
 Pharyngitis, Septic . . . . 160 
 
 Pharynx, Diseases of the . . 159 
 
 Pleura, Diseases of .. .. 117 
 
 — Empyema of .. .. 117, 301 
 
 — Tumours of . . . . . . 128 
 
 Pleurisy . . . . . . . . 117 
 
 — in Pregnancy.. .. .. 462 
 
 Plexus, Brachial, Neuralgia of. . 67 
 - — Cervical, Neuralgia of . . 65 
 Pneumonia and Anesthesia . . 485 
 Pulmonary Abscess . . 105 
 
 — — — Gangrene . . . . 102 
 
 — in Pregnancy.. .. .. 462 
 
 — Post-operative . . 4S0, 48S 
 
 — Venesection for . . . . 154 
 Pneumothorax . . . . 123, 301 
 
 — Operative . . . . . . 478 
 
 — Traumatic . . . . . . 125 
 
 Pneumotomy for Abscess . . 107 
 
 — — Bronchiectasis . . . . 100 
 
 — — Gangrene . . . . . . 103 
 
 Hydatid Cyst . . . . 1 11 
 
 — — Tuberculosis . . . . 109 
 Poliomyelitis, Acute . . . . 57 
 Polyneuritis in Pregnancy . . 471 
 Porro's Operation for Osteo- 
 malacia . . . . . . 455 
 
 Portal Thrombosis . . . . 259 
 
 Post-operative Psychic Disturb- 
 ances . . . . . . . . 477 
 
 Pott's Disease . . . . . . 43 
 
 Pregnancy, Albuminuria in . . 465 
 
 — Anaemia in . . . . . . 463 
 
 — Appendicitis in . . 264, 468 
 
 — Cachexia in . . . . . . 464 
 
 — Cardiac Disease in . . . . 459 
 
 — Cholelithiasis in . . . . 469 
 
 — Diphtheria in. . .. .. 464 
 
 — Diseases of Blood in . . . . 463 
 
 — Enteric Fever in . . . . 464 
 
 — Epilepsy during . . . . 470 
 
 — Hsmatemesis during .. 467 
 
 — and Haemophilia . . . . 463 
 — - — Heart Disease . . . . 459 
 
 — Hysteria during . . . . 470 
 
 — Infectious Fevers in . . . . 464 
 ■ — • Influenza in . . . . . . 464 
 
 — Jaundice in . . . . . . 469 
 
 — Kidney Disease in . . . . 465 
 
 — Leucaemia in . . . . . . 463 
 
 — Malaria in . . . . . . 465 
 
 — Measles in . . . . . . 461 
 
 — Nephritis in . . . . . . 465 
 
 — and Nervous Disease . . 470 
 
 Pregnancy. Neuritis in 
 
 — Pernicious Anemia i, 
 
 — Pleurisy in 
 
 — Pneumonia in 
 
 — Polioneuritis in 
 
 — Pyelonephritis in 
 
 — Scarlatina in . . 
 
 — Scurvy in 
 
 — Small-pox in . . 
 
 — Tetanus in 
 
 — Tuberculosis in 
 
 — Typhoid Fe\-er in 
 
 — Vomiting in . . 
 Premature Labour, Induction of 
 Proctitis . . 
 
 Pseudoleucffimia and Operation 
 Psychic Disturbances after Opera- 
 tion . . . . . . 477, 
 
 Pulmonary Tuberculosis 
 
 — Gangrene and Pneumonia . . 
 
 — Abscess and Pneumonia 
 Pulse after Operations . . 
 Puncture for Anasarca . . 
 
 — of the Cerebral Ventricles 12, 
 
 PAGE 
 
 471 
 463 
 462 
 462 
 471 
 467 
 464 
 463 
 464 
 465 
 461 
 464 
 468 
 
 459 
 222 
 356 
 
 109 
 102 
 105 
 
 — Intestinal 
 
 — Lumbar 
 
 — of the Pericardium 
 
 Pyelitis 
 
 Pyelonephritis 
 
 — in Pregnancy . . 
 Pylephlebitis, Septic 
 Pylorus, Carcinoma of . . 
 — ■ Congenital Stenosis of 
 
 — Stenosis of 
 Pyonephrosis 
 
 12, 17 
 
 148 
 
 25, 
 
 36, 38 
 
 236 
 
 36, 38 
 
 142 
 
 429 
 
 • • 430 
 
 .. 467 
 
 .. 274 
 
 185, 193 
 
 196 
 
 181, 192 
 
 390, 418 
 
 390, 
 
 Pyopneumothorax, Subphrenic. . 124 
 
 Rectu.m, Carcinoma of . . . . 246 
 
 — Inflammation of . . . . 222 
 
 — Stricture of . . . . . . 223 
 
 — Ulcers of . . . . . . 247 
 
 Renal Abscess . . . . . . 430 
 
 — ■ Arteries, Aneurysm of . . 410 
 
 — Calculus . . . . . . 389 
 
 — Colic 385, 38S, 391, 400, 402, 
 
 416, 420, 425, 431 
 
 — Contusions . . . . . . 399 
 
 — Disease, Cryoscopy in 422, 426, 482 
 
 — Neuralgia . . . . . . 387 
 
 — Pelvis, Disease of . . . . 383 
 
 — Tuberculosis . . . . . . 427 
 
 Respiratory Organs in Pregnancy 461 
 Retropharyngeal Abscess, 46, 47, 94, 161 
 
 — Cellulitis . . . . . . 161 
 
 Roth-Bernhardt's Disease . . 70 
 
 Rupture of the Intestine . . 252 
 
 — — — Kidney . . . . 399 
 
 Spleen . . . . 362 
 
 — Stomach .. .. 251 
 
 Sarcom.a. of the Brain . . . . i 
 
 — — — Kidney . . . . 409 
 
INDEX. 
 
 497 
 
 Sarcoma of the Liver . . 
 
 — Spleen 
 
 Scarification for Anasarca 
 Scarlatina in Pregnancy. . 
 Schleich's Infiltration Anassthesia 
 Sciatic Nerve, Neuralgia of 
 Sclerosis, Multiple 
 Scurvy, in Pregnancy 
 Sensory Aphasia. . 
 Sepsis and Chloroform . . 
 Septic Pharyngitis 
 Shock, Operative 
 Sigmoid Flexure, Volvulus of . . 
 Sinus Phlebitis . . 
 
 — Thrombosis . . 
 Sinus, Thrombosis of Cavernous 
 
 — Lateral 
 
 Skull, Effects after Opening 
 
 — Erosion by Tumour . . 
 
 — Trephining for Haemorrhage 
 
 — — — Meningitis 
 Palsy . . 
 
 — — — Tumour 
 Small-pox in Pregnancy 
 Spasm, Facial 
 
 — of Cervical Muscles . . 
 Spasmodic Torticollis 
 Spinal Anaesthesia 
 
 — Canal, Opening of . . 
 
 — Column and Cord, Diseases of 
 
 — Cord Compression . . 45, 
 
 — — Partial Lesions of 
 
 — — Section of . . 
 Traumatic Affections of 
 
 — — Tumours of 
 Spine, Fracture of 
 
 — Osteomyelitis of 
 
 — Tubercular Disease of 
 Spleen, Abscess of 
 
 — Chronic Hyperplasia of 
 
 — Diseases of 
 
 — Floating 
 
 — Hydatid Cyst of 
 
 — in Banti's Disease 
 
 Malaria 
 
 Pseudoleucaemia . . 
 
 — Rupture of . . 
 — • Tumours of . . 
 Splenectomy 355, 358, 361, 363 
 
 •• 331 
 353. 356 
 
 464 
 
 484 
 
 71 
 
 10 
 
 463 
 
 5 
 
 485 
 
 160 
 
 478 
 
 233 
 
 19 
 
 19 
 
 21 
 
 19 
 480 
 7 
 34 
 38 
 31 
 
 ID 
 
 464 
 
 73 
 
 74 
 
 74 
 
 484 
 
 480 
 
 43 
 
 47, 49 
 
 50 
 
 44 
 
 48 
 
 54 
 
 Splenopexy 
 
 Spondylitis, Traumatic . . 
 
 — Tubercular 
 Status Thymicus. . 
 Stenosis, Congenita], of Pylorus 
 
 — of Duodenum. . 
 
 — — Intestine . . . . 227 
 
 — — Larynx 
 CEsophagus 
 
 — — Pylorus 
 Sternum, Abscess of 
 Stomach, Atonic Dilatation of.. 
 
 — Carcinoma of . . 
 
 — Chr'Miic Catarrh of . . 
 
 — Dilatation of . . 
 
 47 
 43 
 364 
 353 
 353 
 359 
 353 
 357 
 355 
 356 
 362 
 353 
 364, 
 483 
 361 
 45, 49 
 43 
 484 
 196 
 204 
 244 
 
 89 
 171 
 192 
 
 134 
 194 
 183 
 1 80 
 192 
 
 Stomach, Diseases of 
 
 — Ectasis of 
 
 — Foreign-body Tumours of 
 
 — Hair-ball in . . 
 
 — Hour-glass 
 
 — Injuries of 
 
 — Myoma of 
 
 — Paralysis after Operation 
 
 — Perforating Ulcer of. . 
 
 — Resection of . . 
 
 — Rupture of . . 
 
 — Simple Tumour of . . 
 
 — Subcutaneous Injuries of 
 
 — Ulcer of 
 
 Strangulation, Intestinal 
 Stricture of Rectum 
 Stridor, Laryngeal 
 Subphrenic Abscess 177, 
 
 Succussion, Hippocratic. . 
 Sun-stroke 
 
 Suppurative Mediastinitis 
 Sympathetic, Resection of 
 Syringomyelia 
 Syringomyelic Arthropathy 
 
 PAGE 
 
 .. 177 
 
 192 
 
 igo 
 
 190 
 
 192 
 
 .. 251 
 
 . . 191 
 
 .. 489 
 
 .. 178 
 
 .. 182 
 
 • • 251 
 
 190 
 
 ■ ■ 251 
 
 .. 177 
 
 •• 233 
 
 223 
 
 91, 92 
 
 255, 301 
 
 124 
 
 153 
 
 133 
 
 83 
 
 59 
 
 449 
 
 Tabetic Arthropathy . . . . 449 
 
 Tachycardia, Post-operative . . 489 
 
 Talma-Morison Operation . . 344 
 
 Tapping, for Ascites . . . . 299 
 
 Temperature after Operation . . 489 
 
 Tendon, Section of, in Torticollis 75 
 
 — Transplantation . . . . 59 
 Testicle, Removal of . . . . 481 
 Tetanus, in Pregnancy . . . . 465 
 Tetany in Dilatation of the 
 
 Stomach . . . . . . 194 
 
 — in Pregnancy.. .. .. 471 
 
 Thoracocentesis . . . . . . 119 
 
 Thoracotomy . . . . . . 121 
 
 Thrombosis of Mesenteric Vessels 217 
 
 — Jugular Vein . . . . . . 20 
 
 — Lateral Sinus.. .. .. 20 
 
 — Portal . . . . . . . . 259 
 
 Thyroid, Resection of . . 83, 481 
 
 Tic Douloureux . . . . . . 63 
 
 Tonsillotomy, Indications for . . 159 
 
 Tonsils, Hypertrophy of . . 159 
 
 Torsion, Intestinal . . . . 233 
 
 Torticollis, Spasmodic . . . . 74 
 
 Tracheotomy in Aneurysm . . 147 
 
 Diphtheria . . . . 93 
 
 -^ — Exophthalmic Goitre . . 82 
 
 — — Laryngeal Paralysis . . 91 
 
 — — — Stenosis . . . . 89 
 Trephining, Epilepsy after . . 480 
 Trigeminal Neuralgia . . . . 63 
 Tubercle of the Choroid. . • • 35 
 Tubercular Disease of Spine . . 43 
 
 — Meningitis . . . . . . 35 
 
 — Peritonitis . . . . . • 287 
 
 — Spondylitis .. .. .. 43 
 
 Tuberculosis and Operation . . 487 
 
 — of the Bladder . . 424, 444 
 Brain i, n 
 
 32 
 
498 
 
 Tuberculosis of the Intestuie . • 
 
 Kidney 
 
 Larynx 
 
 Lung . . • • 109 
 
 Vertebrae 
 
 Tumours, Cerebral 
 
 — Laryngeal 
 
 — of the Brain . . 
 
 Cerebellum 
 
 Frontal and Occipital 
 
 Lobe 
 
 Kidney 
 
 . Liver . . 
 
 l Mediastinum . • 
 
 Mesentery 
 
 Omentum 
 
 Pancreas 
 
 Peritoneum . ■ 
 
 Pleura 
 
 Rolandic Region 
 
 Spinal Cord • . 
 
 Spleen 
 
 • Stomach 
 
 Typhoid Fever, Perforation m . . 
 _1 — in Pregnancy 
 
 Ulcer, Duodenal 
 — Gastric 
 
 INDEX. 
 
 PAGE 
 206 
 424 
 461 
 
 , 461 
 
 43 
 
 5 
 409 
 
 331 
 135 
 295 
 295 
 377 
 295 
 128 
 
 14 
 
 54 
 
 353 
 
 190 
 
 277 
 464 
 
 201 
 177 
 
 Ulcer, Rectal 
 
 Ulcerative Colitis 
 Ulcers, Intestinal, Artificial Anus 
 in 
 
 — Peptic Intestinal 
 
 Urzemia . . 384. 39i» 4i4. 
 Diagnosis from Peritonitis . . 
 
 — Venesection for 
 Ureteral Calculus 
 
 Venesection in Chlorosis 
 
 Circulatory Disturbance . . 
 
 Eclampsia 
 
 Insolation.. 
 
 Intoxications 
 
 Pneumonia 
 
 Ursomia 
 
 Vertebra3, Angular Curvature of 
 
 — Fractures of . . 
 
 — Luxation of • ■ 
 
 — Osteomyelitis of 
 
 — Tuberculosis of 
 
 — Tumours of • • • • • • 
 
 Vertebral Canal, Opening of • • 
 Volvulus of the Sigmoid Flexure 
 Vomiting, Excessive, m Preg- 
 nancy 
 
 PAGE 
 247 
 213 
 
 214 
 
 420 
 278 
 153 
 
 394 
 
 155 
 154 
 154 
 153 
 153 
 154 
 153 
 44 
 48 
 
 49 
 47 
 43 
 54 
 480 
 
 233 
 468 
 
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