/ ?P'// ? yy Columbia ©nitiertfftp mtljeCttpofiftrttijfork College of ^fjpsfitiansf anb burgeons! lUbrarp [1-ll^ALT-l-AkNAn-n-Uj j Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofminorsOOfoot A TEXT-BOOK OF MINOR SURGERY A TEXT- BOOK OF MINOR SURGERY BY EDWARD MILTON FOOTE, A.M., M.D. CONICAL PROFESSOR OF SDRGERY, NEW YORK POLYCLINIC MEDICAL SCnOOL AND HOSPITAL; VISITING SURGEON, NEW YORK SKIN AND CANCER HOSPITAL. AND ST. JOSEPH'S HOSPITAL; CONSULTING SURGEON, RANDALL'S ISLAND HOSPITALS AND SCHOOLS FORMERLY CHIEF IN SURGERY AT THE VANDERBILT CLINIC, AND INSTRUCTOR IN SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS (COLUMBIA UNIVERSITY) o FOURTH EDITION ILLUSTRATED BY FOUR HUNDRED AND THIRTY-THREE ENGRAV- INGS FROM ORIGINAL DRAWINGS AND PHOTOGRAPHS D. APPLETON AND COMPANY NEW YORK AND LONDON 1914 ■1. -f13 Copyright, 1907, 1909, 1911, 1914, bt D. APPLETON AND COMPANY Printed in the United Slates of America THIS BOOK IS DEDICATED TO THE MAN AT THE POINT OF THE KNIFE FOR HIS GRIT AND PATIENCE, AND ESPECIALLY FOR HIS WILLINGNESS TO BE PHOTOGRAPHED THAT OTHERS MAY PROFIT BY HIS MISFORTUNE PREFACE TO THE THIRD EDITION A chapter on General Anesthesia has been added to meet the suggestions of many friends. The aim in writing this chapter has been distinctly a practical one. The subject of anesthesia has excited such widespread interest in the last few years that every physician who takes an inhaler in his hand ought to know the good and bad points of the anesthetics in common use. An attempt is made to give such information in a non-technical form. For the good of the country it is hoped that many young physicians will decide to make anesthetics a specialty. Those who do so will natu- rally provide themselves with books devoted exclusively to the sub- ject of anesthetics. While we are waiting for the arrival of the professional anesthetist in every town, anesthetics must still be given by men engaged in other practice. It is for these men and for the beginner in anesthesia that this chapter is written. If it seems to some that too great a space is devoted to the methods of vapor anesthesia, the answer is that the author is firmly convinced that this is the anesthesia of the future, although, per- haps, the form of apparatus may be different from any at present in use. The skill with which vapor anesthesia is administered to animals in physiological laboratories, and with practically no risk, ought to be a stimulus at least to hospital surgeons to provide equally good facilities for their patients. Edward Milton Foote. 135 West Forty-Eighth Street, New York City. PREFACE In preparing this " Minor Surgery/' it has been my purpose to apply to the less serious, every-day problems of surgical practise the new knowledge which the discoveries of the last twenty- five years have revealed. During this period the advances in diagnosis and treatment have rendered necessary a new surgical literature, and many excellent text-books have appeared, in one, two, and four volumes. In these the more serious surgical conditions are exhaustively dis- cussed, while the treatment of the lesser ailments — the minor surgery which forms the bulk of surgical practise — is condensed into a chapter or two, in which methods of treatment long since outgrown still find their place. JSTor is the importance of minor surgery recognized in the curriculum of our medical schools. And yet this neglected field of minor surgery is the only one into which the average practitioner will ever enter, and is also the one in which most surgeons will find the majority of their patients. What wonder then that the physician, untaught and unread in minor sur- gery, fails to achieve good results, and that more bad surgery is per- formed upon the hand than upon the organs of the abdomen ? Impressed by the need of a text-book which describes in detail the manifold lesser accidents and surgical diseases which the general practitioner is called upon to treat, I commenced eight years ago the preparation of such a book. It has been rewritten several times, until hardly a page of the original manuscript remains; and it ap- pears now in its development, somewhat larger, but the same in pur- pose as when it was first conceived. If this " Minor Surgery " fails to meet the expectations of the reader, this fault does hot lie in the author's lack of experience ; for I had the richest opportunity for the preparation of just such a book in a ten years' almost daily service in the Surgical Department of the X PREFACE Yanderbilt Clinic, with an average annua] attendance of about four thousand new patients. Besides this I have enjoyed the advantages which come from teaching both minor surgery and general surgery in the College of Physicians and Surgeons, and from surgical at- tendance in the Randall's Island Hospitals, the New York City Hos- pital, and the New York Polyclinic Hospital. I have striven to present in compact form the results of this ex- perienee and the best that has been written in hooks, magazines, and journals, taking with free hand from every available source. A mere list of the articles consulted would lill several pages. Very few au- thors' names are mentioned because such simple procedures as are herein described must often suggest themselves to many minds. We all owe so much to our predecessors. The aim has been to illustrate by .photographs as far as possible. Too often medical illustrations show what might be, rather than what is; for the difficulties of making clinical photographs sufficiently clear for good reproduction are tremendous. Mr. H. C. Lehmann has aided me very much in this part of the work, and has also fur- nished all of the drawings. My thanks are also due to Dr. E. J. McKenzie for many good photographs made while he was a student in my clinic; and to Mr. B. F. Puffer, who took for me the photo- graphs to illustrate the chapter on bandaging. Edward Milton Foote. 135 West Forty-eighth Street, New York. CONTENTS SECTION I AFFECTIONS OF THE HEAD PAGE Chapter I. — Injuries op the Head General considerations . 1 Contusions: Subconjunctival ecchymosis — Hematoma of the new- born; of the ear. Hemorrhage: From the nose 2 Abrasions: Removal of powder grains 7 Foreign bodies 8 Foreign body in the eye; ear and nose; mouth and throat. Wounds . 13 Wounds of the eye; mouth; Steno's duct; periosteum. Fractures 17 Fracture of skull; into frontal sinus; of malar; of nasal; of superior maxilla; of inferior maxilla; complications. Dislocation of the jaw: Subluxation 24 Chapter II. — Inflammations of the Head Effects of heat and cold 25 Burns — Sunburn; of lip — X-ray burn — Frost-bite — Dermatitis. Acute inflammations 31 Urticaria — Herpes — Impetigo — Acne — Cellulitis — Erysipelas — Boil — Stye — Boils of the nose and ear — Abscess — Alveolar Abscess. Inflammations of the eye 47 Acute conjunctivitis — Purulent conjunctivitis — Granular lids — Trachoma — Ingrowing lashes. Inflammation of the ear: Otitis media 51 Inflammations of the nose 53 Acute rhinitis — Chronic rhinitis — Suppuration in frontal sinus; in antrum of Highmore. Inflammations of the mouth and throat 55 Stomatitis and gingivitis — Peritonsillar abscess — Retropharyn- geal abscess. Inflammations of the skin . . . . ' 57 Eczema — Ringworm — Ulcer — Anthrax — Noma. Chronic inflammations . . . • . . . . . . . .59 Syphilis: Secondary lesions; tertiary lesions — Tuberculosis of nose and mouth — Actinomycosis. ad Xll CONTENTS p \<; i; Chapter III.— Ti mors and Deformities op the Head Cystic tumors Gl> Milium Comedo— Seliaceous cyst Mucous cysl Salivary cysts — Dental cysi Dermoid cyst— Congenital sinus. Benign solid tumors 76 Papilloma — Mole — Lipoma— - Fibrolipoma -Angioma Nevus — Acne hypertrophies Hypertrophy of tonsil- Adenoids — Epulis — Otoliths — Osl coma Spur. Malignant tumors 92 Epithelioma of scalp; of lace; of li|>; of tongue— Sarcoma —Angio- sarcoma -Parotid tumors — Cancer of tonsil. Acquired deformities 108 Cicatrices — Nasal deformities — Deviation of septum -Elongation of uvula. Congenital deformities 112 Harelip — Cleft palate — Cleft lower lip — Thick lips — Tongue tie — ■ Deformities of ear. SECTION II AFFECTIONS OF THE NECK Chapter IV. — Injuries and Inflammations op the Neck Contusions 117 Foreign bodies 117 Foreign bodies: of larynx; of trachea; of esophagus. Wounds 118 Wounds of vessels; of trachea; of esophagus — Tracheotomy — Intubation Sprain of cervical spine 122 Fractures • • .123 Fracture of hyoid; of larynx; of trachea; of vertebra. Dislocation of vertebra 12-5 Inflammations 125 Burn — Cellulitis — Erysipelas — Boil — Carbuncle — Abscess — An- gina ludovici — Anthrax — Tuberculosis of vertebra. Chapter V. — Tumors and Deformities of the Neck Tumors 135 Sebaceous cysts — Thyroid cyst — Thyreoglossal cyst — Branchio- genic cyst — Lipoma: Simple, diffuse, intermuscular — Fibroma — Lymphadenitis: Acute; tuberculous; syphilitic; in leukemia; in pseudoleukemia; in sarcoma; in carcinoma — Goiter. Acquired deformities 147 Cicatrices — Wryneck. CONTENTS XI 11 SECTION III AFFECTIONS OF THE TRUNK PAGE Chapter VI. — Injuries and Inflammations of the Trunk Contusions . 153 Contusion of breast; of back and ribs; of abdomen. Wounds 156 Hemorrhage from umbilicus — Gunshot wound of back — Pene- trating wound of pleural cavity; of pericardial cavity; of abdomen. Sprains 158 Sprain of back — Railroad spine. Fractures 163 Fracture of clavicle; of scapula; of sternum; of ribs; of vertebra. Dislocations ' 169 Dislocation of clavicle; of costal cartilage; of vertebra. Acute inflammations 170 Burns — Insect bites — Scabies — Herpes zoster — Cellulitis — -Derma- titis — Erysipelas — Abscess of breast; of umbilicus — Bed-sore — Empyema. Chronic inflammations 177 Syphilis — Tuberculosis of sternoclavicular joint; of ribs; of verte- brae; of sacroiliac joint; of mammary gland. Chapter VII. — Tumors and Deformities of the Trunk Cystic tumors 181 Sebaceous cyst — Umbilical cyst — Coccygeal cyst — Dermoid cyst — Cysts of mammary gland. Solid benign tumors of trunk 183 Granuloma — Keloid — Papilloma — Fibrolipoma — Lipoma. Solid tumors of breast 187 Hypertrophy — Adenoma — Early diagnosis of malignant tumors — Tumors of male breast. Malignant tumors of trunk: Carcinoma and sarcoma of skin . .191 Acquired deformities 192 Coccygodynia — Hernia: Umbilical; inguinal; femoral; strangulated — Ascites — Paracentesis. Congenital deformity: Spina bifida . 201 SECTION IV AFFECTIONS OF THE GENITO-URINARY ORGANS Chapter VIII. — -Injuries and Inflammations of the Male Genito- urinary Organs Subcutaneous injuries 203 Contusion of penis and testicle — Hematoma — Hematocele — Fracture of penis — Paraphimosis — Neuralgia of testicle. XIV CONTENTS PAGE Foreign bodies 200 Foreign bodies of penis; of urethra; of bladder. Wounds: Rupture of urethra; of bladder 208 Acute inflammations 210 Burns - Balanitis — Herpes — Urethritis — Abscess — Gonorrhea — Cystitis— Epididymitis — Posterior urethritis — Stricture — Reten- tion of urine — Incontinence — Catheterization — Eczema — Chan- croid — Inguinal adenit is. Chronic inflammations 225 Syphilis — Mixed infection — Syphilitic orchitis — Tuberculosis of testicle. Chapter IX. — Tumors and Deformities of the Male Genito-Urinary Organs Tumors 231 Cysts of skin; of testicle — -Warts — Epithelioma — Carcinoma — Sarcoma — Castration — Tumors of I 'ladder and prostate. Acquired deformities 236 Hydrocele — Hydrocele of the cord— Varicocele. Congenital deformities 244 Phimosis — Circumcision — Short frenum — Narrow meat us — Hypo- spadias — Epispadias — Exstrophy of bladder — Undescended testi- cle. Chapter X. — Affections of the Female Genito-Urinary Groans Injuries 25/5 Contusions — Rupture of hymen; of vagina — Hematoma — -Acute laceration of perineum — Hemorrhage — Rape. Foreign bodies 258 Foreign bodies of vagina; of urethra; of bladder. Acute inflammations 2(i0 Pruritus — Eczema — Simple vulvitis and vaginitis — Acute gonor- rhea; of vulva; of urethra; of Bartholin's glands — Simple suppu- ration. Chronic inflammations 264 Chronic gonorrhea — Endocervicitis — Endometritis — Dilatation — Currettage — Chancroid — Syphilis — Chancre— Condyloma. Tumors 270 Cyst of Bartholin's gland — Urethral caruncle — Cervical polyp — ■ Carcinoma; of vulva; of cervix. Acquired deformities 272 Relaxation of sphincter of bladder — Incontinence of childhood — Retention of urine — Catheterization — Prolapse of urethra — Old laceration of perineum — Prolapse of uterus — Fistula of vagina; of urethra. Congenital deformities 277 Adhesions of clitoris — Imperforate hymen — Stenosis of cervix. CONTENTS XV SECTION V AFFECTIONS OF THE ANUS AND RECTUM PAGE Chapter XL — Injuries and Inflammations of the Anus and Rectum Injuries 280 Examination of patient — Stretching of sphincter ani — Wounds — Hemorrhage. Foreign bodies: Impacted feces 286 Acute inflammations - 286 Intertrigo — Pruritus — Proctitis — Fissure — Abscess — Fistula — Gonorrhea — Chancroid. Chronic inflammations 300 Syphilis — Tuberculosis — Ulcer of Rectum — Stricture. Chapter XII. — Tumors and Deformities of the Anus and Rectum Tumors 307 Venereal warts — Polyp — Hemorrhoids: Acute; chronic — Carcinoma — Sarcoma. Acquired deformities 318 Prolapse: Acute; chronic — Rectal hernia — Incontinence of sphinc- ter ani. Congenital deformities 322 Imperforate anus — Stricture. SECTION VI AFFECTIONS OF THE ARM AND HAND Chapter XIII. — Injuries to the Soft Parts of the Arm and Hand Subcutaneous injuries .• 324 Contusion — Blister — Hematoma — Rupture of muscle. Wounds 32S Minute wounds — Ligation of vessels — Suture of tendons; of nerves — Wounds of joints. Foreign bodies . 336 Sprains 338 Sprain of shoulder — Neuritis — Acute tenosynovitis: Serous syno- vitis—Bursitis. Chapter XIV. — Dislocations and Fractures of the Arm and Hand Dislocations .'.... 347 Dislocation of shoulder; of elbow; of radius; of ulna — Subluxation of radius — Dislocation of wrist; of thumb — Overextension of thumb — Dislocation of finger — Drop-finger. Fractures 363 Separation of epiphysis — Green-stick fracture — Fracture of humerus; of olecranon; of head of radius; of shaft of ulna or radius — Fracture: Colles's; of carpus; of metacarpals; of phalanges — Compound fractures — Crushed fingers — Amputation of fingers. XVI CONTENTS PAGE Chapter XV. Inflammations of the Arm and Hand Effects of heal and cold 393 Burns Mangle injury Frost-bite Chilblains — Gangrene: Car- bolic, etc.; with cellulitis; diabetic. Acute inflammations 399 Infect ion in wounds — Anatomical tubercle — Dermal it is — Erysipe- las — Erysipeloid- -Cellulitis Boil -Paronychia: Acute; chronic — Thecitis — Suppurating synovitis — Arthritis — Bursitis — Lymphan- gitis — Lymphadenitis — Eczema — -Ulcer from vaccination. Arthritic and chronic inflammations 433 Rheumatism — Gonorrheal arthritis — Deforming art hril is- •< lout — Syphilis — Tuberculosis of tendon sheaths; of joints Osteo- myelit is. Chapter XVI. — Tumors and Deformities of the Arm and Hand Tumors 445 Ganglion — Aneurism — Varix — Inclusi* >n cyst — Lipoma — Fibroma — Papilloma — Neurofibroma — Osteoma — Granuloma — Wart — Epithelioma — Sarcoma. Acquired deformities 463 Cicatricial contractions — Dupuytren's contraction. Congenital deformities 467 Weli-Cmger — -Supernumerary finger — Hypertrophy of finger — Deficiency of finger— Too many accessory tendons. SECTION VII AFFECTIONS OF THE LEG AND FOOT Chapter XVII. — Injuries of the Leg and Foot Injuries 471 Contusions — Abrasions — Blister — Hematoma: Subungual; sub- periosteal — Rupture of vein; of tendon. Wounds ■ 475 Wounds of joint; of tendon; of nerve. Bursitis 476 Bursitis: Prepatellar; subgluteal; back of knee; under tendo Achillis; metatarsophalangeal — Serous synovitis — Float ing cartil- age. Sprain 486 Sprain of hip; of knee; of ankle — Chronic synovitis — Rupture of ligament. Dislocation 497 Fractures 497 Fracture of femur; of patella; of tibia (non-union); of fibula; of lower end of tibia and fibula; of astragalus; of os calcis; of meta- tarsals; of phalanges. Amputation 509 CONTENTS XVll PAGE Chapter XVIII. — Inflammations op the Leg and Foot Effects of heat and cold 511 Frost-bite — Burns — Gangrene. Acute inflammation 514 Cellulitis — Lymphangitis — -Phlebitis — Thrombosis — Lymphadeni- tis — -Abscess — Pediculosis. Chronic and arthritic inflammations 519 Eczema — Ulcer — Perforating ulcer — Suppurating synovitis — ■ Rheumatism — Gonorrheal arthritis — Gout — Syphilis — Tuberculo- sis. Chapter XIX. — Tumors and Deformities of the Leg and Foot Tumors 537 Callus — Corn — Varicose veins — Aneurism — -Ganglion — Sebaceous cyst — Lipoma — Fibroma — Osteoma — Sarcoma — Carcinoma. Acquired deformities . . 543 Twisted nail — Ingrown nail — Hallux valgus — Hallux rigidus — Hammer-toe — Flatfoot — Transverse flatfoot — Painful heel. Congenital deformities: Hypertrophy — Supernumerary toes . . .561 SECTION VIII MINOR SURGICAL TECHNIQUE Chapter XX. — Operative Technique Conditions of operation 563 Asepsis — Operating room — Preparation of patient — Hands of the operator — -Instruments — Solutions — Local anesthesia. Treatment of the wound 568 Control of hemorrhage — Tying a ligature — Drainage — Sutures — - Dressings: Dry gauze; cotton-collodion; wet. Some typical operations 575 Opening an abscess — Removal of a tumor — Skin-grafting: Thiersch method; Wolfe method — -Plastic operations — Lumbar puncture — Transfusion — Infusion — Venesection — Cupping — Leeching — Vacci- nation. Chapter XXI. — The Roller Bandage General principles 589 Preparation of a bandage — Application: Anchoring; spiral reverse; overlapping of turns; figure of eight; the spica; amount of pressure; completion. Bandages of head , 595 1 . Horizontal circular — 2. Oblique circular — 3. Double oblique circu- lar — 4. Crossed circular — 5. Knotted — 6. Figure of eight — -7. Single roller — 8. Double roller — 9. Partial recurrent — 10. Figure of eight of one eye — 11. Figure of eight of both eyes — 12. Four-tailed of jaw — 43. Barton's of jaw — 14. Gibson's of jaw — 15. Figure of eight of forehead and chin. Bandages of the neck and axilla, alone and in combination . . . 613 16. Circular — 17. Posterior figure of eight of head and neck — 18. 2 xviii CONTENTS PAGE Anterior figure of eight of head and neck — 19. Figure of eight of neck and axilla— 20. Figure of eight of both axilla? — 21. Oblique circular of neck and axilla — 22. Complete, of neck — 23. Complete, of axilla — 24. Anterior figure of eight of neck and chest. Bandages of the trunk 626 25. Anterior figure of eight of chest — 26. Posterior figure of eight of chest — 27. Spiral of the chest — 28. Spica of one breast — 29. Spica of both breasts — 30. Yelpeau's figure of eight of chest and shoulder — 31. Desault's of chest and shoulder — 32. Descending spiral of abdomen — 33. Many-tailed of abdomen. Bandages of the upper extremity 643 34. Ascending spica of shoulder — 35. Descending spica of shoulder — 36. Spiral of arm — 37. Concentric figure of eight of elbow — 38. Eccentric figure of eight of elbow — 39. Spiral reverse of forearm — 40. Figure of eight of forearm — 41. Figure of eight of hand — 42. Spiral reverse of hand — 43. Spica of thumb — 44. Spiral reverse of finger — 45. Figure of eight of finger — 46. Gauntlet, or figure of eight of fingers and wrist — 47. Recurrent of finger. Bandages of the lower extremity 657 48. Ascending spica of one groin — 49. Descending spica of one gioin — 50. Ascending spica of both groins — 51. Descending spica of both groins — 52. Ascending spica of buttock — 53. Crossed perineal— -54. Spiral reverse of thigh — -55. Concentric figure of eight of knee — 56. Eccentric figure of eight of knee — 57. Figure of eight of both knees — 5S. Figure of eight of the leg — 59. Spiral reverse of leg — 60. Figure of eight of ankle — 61. Figure of eight of foot and leg — 62. Eccentric figure of eight of heel — 63. Modified eccentric figure of eight of heel — 64. Spica of foot — 65. Circular of toe — 66. Spica of great toe — 67. Complex spica of great toe — 68. Recurrent of stump. Chapter NNII. — Surgical Dressings Textile materials 681 Absorbent cotton — Lamb's wool — Gauze; — Gauze sponges; strips; bandages — Muslin — Flannel — Canton flannel — Stockinette — Silk — Rubber — Crinoline — Gutta-percha tissue — Oiled muslin, silk, and paper. Ligatures and sutures 689 Catgut: Plain; chromic — Kangaroo-tendon — Silk — Silkworm gut — Horsehair — Cotton and linen thread — Celluloid thread — Silver wire Drains 694 Glass and metal tubes — -Soft rubber tubes — Gutta-percha drains — Cigarette drains— Gauze drains — Handkerchief drains — Horse- hair drains. Splints 698 Wood — Metal — Wire netting. Gypsum or plaster of Paris 700 Gypsum bandages — Circular splints — Cutting a fenestrum — Molded splints — Reinforcing a splint — Gypsum or plaster casts — Plaster jackets. CONTENTS xix Chapter XXIII. — -General Anesthesia page General remarks 714 Underlying principles — Confidence — Anesthesia in children — By- standers — ■ Physical examination — Preparation — Position — Re- straint — -Place — Preliminary medication — Induction — Respiration —Pulse — Signs of surgical anesthesia. Complications during anesthesia 723 Compressed lips — Displaced jaw — Tongue — Excitement — Saliva in the pharynx — Vomiting — Muscular spasms — Cyanosis — Cessa- tion of respiration — Irregular heart action — Oxygen in anesthesia. Post-anesthetic conditions 731 Recovery from anesthesia — Nausea with vomiting — Shock — Per- spiration — Death — Status lymyhaticus — Acid intoxication — Bron- . chitis and pneumonia — Records. Anesthetics 739 Nitrous-oxid gas — Primary or induction anesthesia with gas — Nitrous-oxid gas for prolonged anesthesia — Ether — Chloroform — Ethyl chlorid — Somnoform — Mixed anesthetics — Hypodermic anesthesia — Rectal anesthesia — Spinal analgesia — Choice of anes- thetic. Chapter XXIV. — Additional Surgical Technique Operations upon blood-vessels 775 Withdrawal of blood for examination — Direct blood transfusion — Injection of salvarsan. Operations upon nerves 782 Injections of alcohol for neuralgia. Vaccine therapy — Serum therapy 787 Index 793 LIST OF ILLUSTRATIONS HEAD FIG. PAGE 1. — Hematoma of ear from a blow 4 2. — Hematoma of ear from a blow, three weeks previous .... 5 3. — Powder grains in face from a recent explosion 7 4. — Powder grains removed by scrubbing with a stiff brush ... 8 5. — Instruments for extracting foreign bodies from the nose and ear . 1 1 6. — Division of Steno's duct by a razor cut 16 7. — Fracture of right malar bone with depression 18 8. — Four-tailed bandage for fracture of the inferior maxilla ... 21 9. — Necrosis and slough of skin due to cellulitis 34 10. — Abscess of the lip 38 11. — Alveolar abscess from upper incisor tooth 40 12. — Alveolar abscess from upper molar teeth 41 13. — Alveolar abscess from upper tooth, secondary in lymphatic gland . 42 14. — Recurrent alveolar abscess 43 15. — Chronic alveolar abscess with sinus 44 16. — Chronic alveolar abscess; chronic edema; no sinus .... 45 17. — Tumor following alveolar abscess; probably malignant ... 46 18. — Sketch of the normal right tympanic membrane, showing the correct site for incision 52 19. — Angular knife for incision of tympanic membrane .... 52 20. — Chancre of lip, of nine days' duration 60 21. — Chancre of lip, of three weeks' duration 60 22/ — Chancre of cheek, developing in burn from cigarette .... 61 23. — Chancre of cheek with a granulating ulcer 62 24. — Papilloma of lip due to syphilis 63 25. — Tuberculosis of the gum, secondary to pulmonary tuberculosis . . 65 26. — Tense sebaceous cyst of forehead, about to rupture .... 67 27. — Sebaceous cyst of scalp, skin prepared for operation .... 68 28. — Sebaceous cyst of scalp, overlying skin divided and retracted . . 69 29. — Sebaceous cyst of scalp, collapsed redundant skin after removal of cyst 70 30.: — Inflamed sebaceous cyst behind the ear 70 31. — Cyst of sublingual gland — ranula 71 32. — Dental cyst, mistaken for alveolar abscess 73 33. — Dermoid cyst of the nose 74 34. — Dermoid cyst in front of the ear . 75 35. — Dermoid cyst behind the ear 75 36. — Papilloma of skin occurring in a scar, diagnosed as cancer . . 77 sad XXII LIST OF II. 1. 1 STRATIONS i : PAGE ;;7. — Lipoma of forehead 79 38. — Fibrolipoma of auditory canal 80 39. — Pulsating angioma of scalp; congenital; fully distended ... 82 40. — Pulsating angioma of scalp, compressed 83 '41. — Rosacea hypertrophies of the nose; <>f seven years' duration . . 84 42. — Rosacea hypertrophica of the nose, of four years' duration . . 85 43. — Same subject as Fig. 42, side view 85 44. — Same subject as Fig. 42, alter two operations 86 45. — Same subject as Fig. 42, after two operations, side view ... 86 46. — Instruments lor the removal of the tonsil 88 47. — Instruments for the removal of adenoids 90 48. — Exostosis of jaw 91 49. — Epithelioma of face near nose 93 50. — Epithelioma of the lip developing in a soft wart which had existed since childhood 93 51. — Same subject as Fig. 50, three months after removal of the tumor . !) I 52. — Epithelioma of the nose, recently growing rapidly .... 95 53. — Epithelioma of the cheek existing two years 96 54. — Epithelioma of face 96 55. — Epithelioma of the scalp 97 56. — Epithelioma of lip, of four weeks' duration 98 57. — Epithelioma of the tongue, showing milky white patches of leuco- plakia and papillomatous growths 99 58. — Longitudinal section of the epitheliomatous tongue in the median line 99 59. — Transverse section of the epitheliomatous tongue .... 100 60. — Epithelioma of lower lip, of one year's duration 101 61. — Epithelioma of lower lip, showing line of incisions .... 102 62. — Epithelioma of lower lip, showing suture after excision of the V- shaped piece 102 63. — Tumor of head, extradural 105 64. — Angiosarcoma of lower jaw 105 65. — Tumor of parotid gland, of twelve years' duration .... 106 66. — Diagram of the septum of the nose 109 67. — Scissors for the amputation of the uvula Ill 68. — Harelip, the cleft, not entering the nostril 113 69. — Harelip, the cleft entering the nostril 113 70. — Congenital cleft of lower lip 114 71. — Cleft of lobe of auricle, congenital 116 72. — Deformity of ear, congenital 116 NECK 73. — Instruments for tracheotomy 121 74. — Carbuncle of neck 128 75. — Carbuncle of neck, of four weeks' duration, incised three times . J 29 76. — Same patient as shown in Fig. 75, eleven weeks later . . . .129 77. — Abscess of neck, secondary to pediculosis capitis 130 78. — Abscess under sternomastoid muscle, probably tubercular . . . 131 79. — The primary lesion of anthrax 132 80. — Thyreoglossal cyst; operation; recurrence 136 LIST OF ILLUSTRATIONS xxiii FIG. PAGE 81. — Simple lipoma of neck, of two years' duration . . , . .138 82. — Diffuse lipoma of neck, bilateral 138 83. — Fibroma of the neck of nine years' duration 139 84. — The tumor of Fig. 83 after removal 140 85. — Single cyst of thyroid 146 86. — Goiter with exophthalmos 146 87. — Cicatricial contractions following burn of the neck .... 148 88. — Torticollis (wryneck) of right side of moderate degree . . . 149 89. — Extreme degree of torticollis (wryneck) 150 90. — Back view of patient, shown in Fig. 89 150 TRUNK 91. — Large hematoma of mammary region, five weeks after a blow . . 153 92. — Strips of adhesive plaster, gridiron pattern, for sprain of back . . 160 93. — Strips of plaster applied diagonally, for sprain of back . . . 160 94. — Tests for injury of the spine. Forward flexion . . . . . 161 95. — Tests for injury of the spine. Backward flexion 161 96. — Tests for injury of the spine. Lateral flexion 162 97. — Tests for injury of the spine. Rotation 162 98. — Fracture of left clavicle, usual situation 163 99. — Sayre dressing for fracture of clavicle. Rear view .... 165 100. — Sayre dressing for fracture of clavicle. Front view .... 165 101. — Multiple burns of body of five days' duration, produced by spatter- ing liquid iron 170 102. — Instruments for drainage of chest in empyema 176 103. — Fibrolipomata of the back of five years' duration . . . .185 104. — Lipoma of back of two years' duration 186 105. — Lipoma shown in Fig. 104 after removal 187 106. — Epithelioma of back at an early stage 190 107. — Cross-section of tumor shown in Fig. 106 191 108. — Melanosarcoma of lower abdomen of four months' duration, growing from a mole or soft wart 191 109. — Cyst under scapula of one week's duration 192 110. — Removal of displaced coccyx 193 111. — Dorsal hernia 196 112. — Method of holding a trocar 200 MALE GENITALS 113. — Edema of penis and scrotum from mercuric ointment . 211 114. — Abscess of scrotum of five days' duration 212 115, — A good type of steel sound 218 116. — Eczema of penis of four months' duration 223 117. — Primary lesion of syphilis in an aged patient 225 118. — Unilateral syphilitic orchitis 227 119. — Gumma of testicle with ulceration 228 120. — Cyst of prepuce; left inguinal hernia 231 121. — Cyst of prepuce after circumcision 232 122, — Squamous celled carcinoma of penis 233 xxiv LIST OF ILLUSTRATIONS FIT.. PAGE 123. — Hydrocele of four months' duration . ....... 237 124. — Hydrocele of ten years' duration; never treated 237 125. — Varicocele of moderate degree 242 126. — Varicocele of fourteen years' duration 243 127. — Tight phimosis; congenital 245 128. — Operation for phimosis. Dorsal and ventral incisions . . . 248 129. — Operation for phimosis. All sutures inserted 249 FEMALE GENITALS 130. — Urethroscope for examining female urethra 259 131. — Multiple syphilitic tumors of vulva 268 132. — Syphilitic condyloma of thigh near the vulva 269 133. — Pessaries for prolapse of uterus 276 134. — Hard rubber plugs for use in stenosis of the cervix .... 279 ANUS AND RECTUM 135. — Suitable rectal speculum for office examination 282 136. — Bivalve rectal speculum 283 137. — Small superficial ischiorectal abscess 292 138. — A larger and deeper ischiorectal abscess 293 139. — Fistula accompanying a syphilitic stricture of the rectum . . . 296 140. — Syphilitic condylomata about anus of a young male .... 300 141. — Venereal warts about the anus of a man 307 142. — Acute external hemorrhoid of one week's duration .... 309 143. — Internal hemorrhoids of sixteen years' duration 312 ARM AND HAND 144. — Hematoma under nail 326 145. — Incision for hematoma under nail 326 146. — Diagram to show position of radial and ulnar arteries . . • . 328 147. — Test for division of the profundus tendon 330 148. — Test for division of the sublimis tendon 330 149. — Traumatic ulcers of the hand 331 150. — Tendon suture. (A) Mattress stitch. (B) Simple stitch . . . 333 151. — Tendon suture, one method of elongation of a tendon .... 333 152. — Tendon suture, a long silk stitch being left in place .... 334 153. — Nerve suture 335 154. — Sprain of finger with serous effusion in joint 339 155. — Plaster strapping for sprain of the thumb 340 156. — Diagram to show the relations of the extensor tendons and the radius 343 157. — Aspiration of shoulder-joint for synovitis 345 158. — Acute olecranon bursitis 346 159. — Dislocation of thumb of seven years' duration 349 16Q. — Radiograph showing the bones seven years after a dislocation of the thumb 349 161. — Radiograph of forward dislocation of the head of the radius and fracture of the ulna 352 LIST OF ILLUSTRATIONS XXV FIG. PAGE 162. — Radiograph showing backward dislocation of both radius and ulna, about five months' duration 353 163. — Overextension of adult thumb 356 164. — Posterior dislocation of finger with radiograph 357 165. — Reduction of dislocated finger by operation 358 166. — Lateral dislocation of finger, due to bite of horse 359 167. — Radiograph of lateral dislocation of finger 359 168.— Drop-finger 361 169. — Traumatic drop-finger of three months' duration 361 170. — Radiograph of traumatic drop-finger, anteroposterior view . . 362 171. — Radiograph of traumatic drop-finger, lateral view .... 362 172. — Radiograph of fracture of the neck of the radius 376 173. — Radiograph of fracture of neck of radius, side view .... 377 174. — Molded gypsum splints for fracture of the lower end of the radius . 382 175. — Molded gypsum splints applied 383 176. — Old fracture of radius (Colles') with marked deformity . . . 384 177. — Fracture of second right metacarpal 385 178. — Compound fracture of the forefinger 387 179. — Injuries of the hand from contact with a buzz-saw .... 388 180. — Amputation through the metacarpal phalangeal joint . . . 389 181. — Amputation of finger with the head of the metacarpal . . . 390 182. — Same hand as in Fig. 181; dorsal surface . . . . . . 390 183. — Amputation of two central fingers with the metacarpals . . . 391 184. — Same hand as in Fig. 183; dorsal surface . . . . .391 185. — Partial gangrene of finger due to carbolic acid 395 186. — Carbolic gangrene of distal half of finger ...... 396 187. — Carbolic gangrene of thumb, complicated by cellulitis . . . 397 188. — Recovery following carbolic gangrene of thumb . . . . . 398 189. — Anatomical tubercle 400 190. — Erysipeloid dermatitis in wound of hand of seven days' duration . 401 191. — Cellulitis of finger with abscess . 402 192. — Moist gangrene of finger, following cellulitis 403 193. — Boil of wrist with secondary pimples 405 194. — Section of the terminal segment of finger to show various sites of suppuration 406 195. — Abscess of tip of thumb with spontaneous rupture .... 406 196. — Acute paronychia of three weeks' duration 408 197. — Acute paronychia, ten days after removal of old nail .... 409 198. — Chronic paronychia of four months' duration 410 199. — Abscess in tendon sheath of thumb from a splinter . . .411 200. — Suppuration in index-finger extending into the palm .... 414 201. — Same subject as Fig. 200. Posterior view 415 202. — Same subject as Fig. 200. Temperature chart 416 203. — Same subject as Fig. 200. Ultimate result 416 204. — Suppuration in tendon sheath of four weeks' duration . . . 420 205. — Same subject as Fig. 204. Dorsal view 420 206. — Cicatricial contraction of finger following suppuration . . . 421 207. — Loss of extensor tendons from suppuration . 422 208. — Suppuration in joint following penetration by splinter . . . 422 209. — Suppurative arthritis and loss of metacarpal ..... 423 XXVI LIST OF ILl.l'STKATlOXS 210. — Radiograph of a hand showing result of suppurative arthritis 211. — Tin splint for use in suppurative arthritis .... 212. — Suppurative olecranon bursitis 213. — Infected wound of finger with secondary lymphatic abscess 214. — Superficial axillary abscess from infection about hairs 215. — Primary lesion of syphilis developing in the finger 216. — Syphilitic ulcer of the hand of four months' duration 217. — Same hand as Fig. 216, after four weeks of treatment 218. — Chronic syphilitic inflammation of hand with sinus 219. — Syphilis of hand with amputation of a finger 220. — Tuberculosis of flexor tendon sheaths of hand 221. — Tenosynovitis, probably tubercular 222. — Diagram to show the range of motion in a joint . 223. — Tuberculosis of the wrist with sinus 224. — Ganglion of wrist of five years' duration 225. — Ganglion of wrist, lateral view 226. — Ganglion of the wrist, the skin incised and dissected 227. — Ganglion of the wrist, showing ligation of the sac 228. — Nevus of hand of seven years' duration . 229. — Extensive varices of the arm and hand . 230. — Inclusion cyst of palm 231. — Simple lipoma of arm 232. — Fibrosarcoma of finger, of six years' duration 233. — Radiograph of fibrosarcoma of finger showing normal 234. — Fibroma of hand 235. — Fibrolipoma of wrist — papilloma .... 236. — Osteoma of finger 237. — Radiograph of osteoma of finger, showing affected bone 238. — Fibrolipoma of finger 239. — Radiograph of the same hand, showing normal bones 240. — Granuloma of finger 241.— Old wart of index-finger 242. — Metastatic carcinoma of the bones of the hand 243. — Same patient as shown in Fig. 242, showing the site tumor, and numerous cutaneous metastases 244. — Spindle-cell sarcoma of hand of ten years' duration 245. — Cicatricial contractions from burns . 246. — A quick method of lengthening a tendon without suti 247. — Dupuytren's contraction of six months' duration 248. — Radiograph of the webbed hand of an infant 249. — Web-fingers of a child 250. — Result after operation for web-fingers . 251. — Supernumerary thumb 252. — Radiograph of supernumerary thumb of the or 'iiial LOWER EXTREMITY 253. — Hematoma of foot produced by turning the ankle .... 472 254. — Hematoma under left great toe-nail 472 255. — Subperiosteal hematoma of the head of the tibia 473 LIST OF ILLUSTRATIONS xxvn Fia. pa<; e 256. — Prepatellar bursitis 477 257. — Suppuration in prepatellar bursa, with rupture of the skin . . 478 258. — Chronic prepatellar bursitis; the bursa laid open 479 259. — Operation for chronic prepatellar bursitis 480 260. — Inflammation of the outer metatarsophalangeal bursa . . . 482 261. — Floating cartilage from the knee-joint ' . 485 262. — Incision for removal of floating cartilage from the knee . . . 486 263. — Relation of the great trochanter to the ilium 488 264. — Demonstration of floating patella 490 265. — -Strapping with adhesive plaster for sprain of the knee . . . 493 266. — Strapping a sprained ankle with adhesive plaster .... 495 267. — Radiograph showing fracture of the great trochanter .... 498 268. — Application of adhesive plaster for fracture of patella .... 499 269. — Correct method of holding foot and leg during the application of a splint — in cases of malleolar fracture 505 270. — Strap splints for fracture of malleoli — in position .... 506 271. — Strap splints for fracture of malleoli — removed 506 272. — Frost-bite of both feet three weeks after injury 511 273. — Frost-bite of both feet; the results after treatment .... 512 274. — Burns of the back of the leg and thigh 513 275. — Gangrene of toe — possibly from frost-bite 514 276. — Abscess in front of the knee from infection on the skin . . . 517 277. — Ulcers of the leg from pediculosis and scratching 518 278.— Ulcer of the leg 519 279. — Chronic ulcer almost encircling the leg 520 280. — Ulcer of leg, spread by a vaseline dressing 522 281. — Chronic ulcer of the leg with proliferation 525 282. — Ulcers of leg due to syphilis 527 283. — Traumatic ulcer of the leg exposing the tibia 529 284. — Perforating ulcers of the foot 530 285. — Perforating ulcers of the toes of two years' duration .... 531 286. — Dorsal view of the same patient as shown in Fig. 285 .... 531 287. — Osteoma of the tibia 541 288. — Osteoma under the nail of the great toe 541 289. — Sarcoma of the great toe from injury 543 290. — Carcinoma of the leg developing in an old ulcer 543 291. — Twisted nails 544 292. — Longitudinal and transverse sections of great toe showing the nail, matrix, phalanx, and joint 545 293. — Ingrown nail 546 294. — Drawings to illustrate operation for ingrown nail 547 295. — Great toe after operation for ingrown nail 548 296. — Great toe ten days after operation for ingrown nail .... 549 297.— Hallux valgus 550 298. — Hallux valgus with hypertrophy of the head of the metatarsal, sup- purative bursitis and synovitis 551 299. — Lateral splint for holding the toe after operation for hallux valgus . 553 300. — Interwoven adhesive strips for correcting the deformity of hammer- toe after operation 555 301. — Testing the degree of rigidity in flatfoot 557 XXV111 LIST OF ILLUSTRATIONS FIG. 302. — Markedly rigid flatfeet put up in corrected position 303. — Congenital hypertrophy of the second toe PAGE 559 561 OPERATIVE TECHNIQUE 304. — Injection of cocain for local anesthesia 305. — Method of tying ligatures 300. — Drains for clean and suppurating wounds .... 307. — Silk and horsehair in straight and curved skin needles 308. — Lumbar puncture: diagrammatic sagittal section of the spine 309. — Lumbar puncture: transverse section of the spine 310. — Lumbar puncture: the lumbar spine as seen from behind . 567 569 571 573 581 582 583 ROLLER BANDAGE 311. — Rolling a bandage on a small machine . 312. — Making a reverse in a spiral bandage 313. — Making a figure of eight turn about the forearm 314. — Fastening a bandage by splitting the end and tying 315. — Occipitofrontal bandage of the head 316. — Oblique circular bandage of the head 317. — Double oblique circular bandage of the head 318. — The crossed circular bandage . 319. — Knotted bandage of the head . 320. — Figure of eight bandage of the head 321. — Single roller bandage of the head 322. — Single roller bandage of the head completed 323. — Double roller bandage of the head . 324. — Double roller bandage of the head completed 325. — Partial recurrent bandage of the head . 326. — Figure of eight bandage of one eye . 327. — Figure of eight bandage of both eyes 328. — Four-tailed bandage of the jaw 329. — Barton's bandage, with first layer completed 330. — Gibson's bandage for the lower jaw 331. — Gibson's bandage completed 332. — Figure of eight bandage of the forehead and chin 333. — Circular bandage of neck 334. — Posterior figure of eight bandage of head and neck 335. — Anterior figure of eight bandage of the head and neck 336. — Figure of eight bandage of neck and axilla 337. — Figure of eight bandage of neck and axilla with additonal 338. — Figure of eight bandage of both axillae . 339. — Oblique circular bandage of the neck and axilla 340. — Complete bandage of the neck at an early stage 341. — Complete bandage of the neck in skeleton form 342. — Complete bandage of the axilla, composed of six parts 343. — Anterior figure of eight bandage of the neck and chest 344. — Anterior figure of eight bandage of chest 345. — Posterior figure of eight bandage of chest turns 589 591 592 594 595 596 597 598 599 600 601 602 604 604 605 606 608 609 610 611 612 612 614 614 615 616 617 618 619 621 622 624 625 627 628 LIST OF ILLUSTRATIONS XXIX FIG. PAGE 346. — Descending spiral bandage of the chest 629 347. — Descending spiral bandage of the chest completed .... 630 348. — Spica bandage of one breast 631 349. — Spica bandage of one breast completed 632 350. — Spica bandage of both breasts 633 351. — Spica bandage of both breasts nearing completion .... 634 352. — Velpeau's bandage, showing the first turn 635 353. — Velpeau's bandage at the beginning of second oblique turn . . 636 354. — Velpeau's bandage nearly completed 637 355. — Desault's bandage, showing the spiral of the chest .... 638 356. — Desault's bandage, showing the fixation of the arm to the chest . 638 357. — Desault's bandage, showing the application of the third roller . . 639 358. — Desault's bandage completed . . . 640 359. — Descending spiral bandage of abdomen 641 360. — Posterior view of many tailed bandage of abdomen .... 642 361. — Anterior view of many tailed bandage of abdomen .... 642 362. — Ascending spica bandage of the shoulder . . . . . . 644 363. — Descending spica bandage of shoulder 645 364. — Ascending spiral bandage of the upper arm 645 365. — Concentric figure of eight bandage of the elbow 646 366. — Eccentric figure of eight bandage of the elbow 647 367. — Spiral reverse bandage of forearm . 648 368. — Figure of eight bandage of forearm in application .... 649 369. — Figure of eight bandage of forearm completed 649 370. — Figure of eight bandage of the hand 650 371. — Spiral reverse bandage of the hand 651 372. — Spica bandage of the thumb . . . » 652 373. — Spiral reverse bandage of the finger 653 374. — Figure of eight bandage of finger 654 375. — Figure of eight bandage of the fingers and hand, the " gauntlet " . 655 376. — Recurrent bandage of the finger 656 377. — Recurrent bandage of the finger at a later stage 657 378. — Ascending spica bandage of one groin 658 379. — Ascending spica bandage of one groin completed 659 380. — Ascending spica bandage of both groins 660 381. — Ascending spica bandage of the buttock 661 382. — Ascending spica bandage of the buttock completed .... 662 383. — Crossed bandage of the perineum in application 663 384. — Crossed bandage of the perineum at a later stage .... 664 385. — Spiral reverse bandage of the thigh 665 386. — Spiral reverse bandage of thigh completed 665 387. — Concentric figure of eight bandage of knee 666 388. — Concentric figure of eight bandage of knee completed .... 667 389. — Eccentric figure of eight bandage of knee 668 390. — Figure of eight bandage of both knees 669 391. — Figure of eight bandage of the leg 670 392. — Spiral reverse bandage of the leg ....... 671 393. — Figure of eight bandage of the ankle 672 394. — Figure of eight bandage of foot and leg 673 395. — Figure of eight bandage of foot and leg, at a later stage . . . 673 XXX LIST OF ILLUSTRATIONS FIG. PAGE 396. — Figure of eight bandage of the foot and le^ completed . . . 674 397. — Eccentric figure of eight bandage of heel 675 39S. — Modified eccentric figure of eight bandage of heel .... (>7t> 399. — Spica bandage of foot 677 400. — Spica bandage of the great toe 678 401. — Complex spica bandage of the great toe 679 SURGICAL DRESSINGS 402. — Two yards of gauze cut and folded to make twenty-four gauze sponges 403. — Angular splint made from wire netting . 404. — Making gypsum bandages from crinoline 405. — Making a "dart" in a gypsum bandage 406. — Making a cast of a foot in gypsum . 407. — Cast of foot in gypsum: the mold removed 684 699 702 704 711 712 GENERAL ANESTHESIA 408.— Wooden wedge for prying open the jaw 722 409. — Two types of mouth gag 723 410. — Suction apparatus to keep throat free from blood and saliva . . 726 411. — Chloroform may be administered with smelling salts .... 729 412. — Simple apparatus for giving nitrous-oxid gas 741 413. — Gwathmey's apparatus for giving warmed nitrous-oxid gas and oxygen 745 414. — Gas-oxygen apparatus with attachments for four cylinders on a foot plate . 746 415. — Apparatus for giving gas and ether, or ether by the closed or open method ■ 751 416. — Junker's apparatus for giving chloroform vapor attached to a hollow Esmarch mask 756 417. — Gwathmey's three-bottle modification of Junker's apparatus for giv- ing warm ether or chloroform vapor 757 418. — Gwathmey's apparatus turned upside down and the bottles removed . 758 419. — Alcock's apparatus for giving a known percentage of chloroform vapor 759 420. — Dubois's apparatus for giving known percentages of chloroform vapor 759 421. — Miller's apparatus for vapor anesthesia 773 ADDITIONAL SURGICAL TECHNIQUE 422. — Withdrawal of blood from a vein for examination 423. — Correct position of the needle in the vein 424. — Radial artery exposed and divided . 425. — Cephalic vein exposed 426. — Gangrene following injection of neosalvarsan 427. — Simple apparatus for the injection of salvarsan 428. — Syringe, stylet and needle for trifacial injection 429. — Needle punctures in relation to the bones of the face 430. — Injection of the superior maxillary nerve, side view 431. — Injection of the superior maxillary nerve, front view 432*. — Injection of the inferior maxillary nerve, side view 433. — Injection of the inferior maxillary nerve, front view 775 776 778 779 780 781 782 783 784 784 786 786 SECTION I AFFECTIONS OF THE HEAD CHAPTEE I INJURIES OF THE HEAD General Considerations. — It is sometimes difficult to deter- mine the extent of an injury to the head either from the history of the accident or from the symptoms. The following two cases from the author's experience will illustrate this fact : A girl fell backward down some stone steps, striking her head on the edge of one of them. Blood flowed freely from a wound in the scalp, and she walked to the hospital to have it dressed. There was no shock, nor any other symptom indicating that she had suffered serious injury, and yet retraction of the edges of the wound showed that there was a compound depressed fracture of the skull. A man of middle age, pushed by a horse, fell against a sloping bank of earth. He was apparently uninjured except for an insig- nificant contusion of the head. Yet subsequent events showed that this slight accident had ruptured a blood-vessel within the skull, as a result of which, many days afterward, the first symptoms of paralysis developed and progressed to complete unconsciousness. Such cases are a warning against a hasty diagnosis in head injuries. Every patient whose head has been injured should be carefully examined, and kept under observation for two or three days, as otherwise serious complications are likely to be over- looked. This is especially important if no clear history of the accident can be obtained, either because the patient is suffering from intoxication or for any other reason. Contusions. — The scalp is firm and well protected by hair from external injury. It is loosely attached to the skull, but the absence of fatty tissue between it and the bone makes it more 1 2 INJURIES OP THE HEAD liable to suffer in the case of a sharp blow. A contusion of the scalp may or may not be accompanied by a great deal of edema. If the swelling is discrete and evenly curved it is usually due to the pouring out of blood underneath the scalp, a hematoma (p. 2). The eyelids, nose, and lips are all frequently the seat of contusion, with marked ecchymosis. Treatment. — If the patient is seen soon after the accident, very hot, wet compresses (p. 7) should be applied and bandaged in place with moderate pressure in order to relieve pain and pre- vent edema and hemorrhage. Later, a wet dressing of acetate of aluminum, four per cent solution, may be applied to prevent infection and facilitate recovery. The hair, even of a man, should not be needlessly sacrificed. In many cases a patient is mortified by the appearance of a black eye, and desires to have the normal color of the skin restored as quickly as possible. The hot, moist applications are of benefit, and in a day or two they should be fol- lowed by very gentle massage in the direction of the lymph cur- rent, for this will facilitate the absorption of the extravasated blood. Considerable improvement in appearance may be obtained by painting over the blackened area with theatrical face paint or with oxid of zinc ointment. If the latter is used most of it should be wiped off and a little face powder dusted over it to remove the shiny, greasy appearance which the ointment causes. Subconjunctival Ecchymosis. — Blows upon the eye may be fol- lowed by an accumulation of blood beneath the conjunctiva, either of an eyelid or of the eyeball, frequently extending as far as the iris. Such a hemorrhage, due to rupture of a small blood- vessel, also occurs as a result of violent coughing or straining, espe- cially in persons past middle life. It is also a symptom of frac- ture of the skull, in which case the blood trickles through a wall of the orbit and collects beneath the conjunctiva. Blood beneath the conjunctiva of the eyeball is so freely supplied with oxygen that it remains a bright red. The treatment for this ecchymosis is similar to that already given for contusions of the face. It is only fair to state that treat- ment has little effect in hastening the resorption of the extrava- sated blood, which usually requires from ten days to two weeks. Hematoma. — Hemorrhage occurring beneath the scalp or be- neath the periosteum, sufficiently free to produce a hematoma, is HEMATOMA 3 most common at those points at which the scalp is most exposed to blows, viz., over the parietal, frontal, and occipital bones, about where a man's hat touches his head. The surface of a hematoma is even and rounded. If small, the swelling rises more sharply from the surrounding surface than if extensive. Edema of the skin may be slight or wholly wanting. Fluctuation can usually be obtained. The overlying skin may be discolored by an accom- panying contusion, but even if this is absent the hematoma will have a bluish look, due to the underlying blood. Absorption of so large a quantity of blood takes place very slowly, but the scalp is so abundantly supplied with blood-vessels that necrosis of the skin rarely follows. However, the time of recovery will be much shortened by removal of the effused blood. Suppuration is an occasional complication in both operated and non-operated patients. Treatment. — Removal of the effused blood may be accom- plished by aspiration if the contents are sufficiently ; fluid, or the fluid and clotted blood may be turned out through a small incision. The head should be prepared by a careful washing with hot water and soap, and then with alcohol. If an incision is to be made it is better to shave a small area, but if sufficient care is given to cleansing the scalp and hair in the vicinity, primary union may be obtained without this. A scalpel, clamps, two small hooked retractors, thumb-forceps, and scissors are the only instruments needed. They should be boiled before using. The skin is divided, one side of the wound is elevated with a retractor or with for- ceps, and the clotted blood is thoroughly wiped out with pieces of absorbent cotton wrung out in weak bichloMe of mercury solu- tion (1: 5,000). The fingers of the operator 1, should not come in contact with the wound. The edges of the incision should then be drawn together with sutures of fine black silk or horsehair, and a firm dressing of dry, sterile gauze applied to keep the involved tis- sue planes in contact and to prevent exudation. A similar dressing should be applied after aspiration. The dressing should be changed on the following day and the pressure kept up for several days. The blood in a recent hematoma is not easily aspirated. Whether or not drainage is required will depend upon circum- stances. A folded gutta-percha drain, if removed in two days, does not materially delay union, and leaves no scar. Such a drain should be inserted at the time of operation, if it seems likely that INJURIES OF THE HEAD the blood will reaccumulate. It should certainly be inserted at the first dressing, if the wound was not drained at operation, and there has been a partial reaccumulation of blood. Hematoma in the New Born. — Blood often collects between the periosteum and the skull of a child that is delivered by forceps. It may be difficult to distinguish between a hematoma of this char- acter and a contusion with edema. Two or three days later, when the edema of the scalp has subsided, but a fluctuating swelling persists beneath it, the diagnosis is clear. This effused blood should be evacuated through a small incision, in the manner de- scribed above, because its resorption is very slow and because the periosteum lifted from the skull continues to form new bone. In this manner in some cases a prominent and permanent thickening of the skull develops. Hence the desirability of removing the blood as soon as possible, and of keeping the loosened periosteum pressed against the skull for a few days until it reattaches itself. Hematoma of Ear (Boxer's Ear) . — Blows upon the ear may give rise to hemorrhage beneath the perichondrium. The effused blood causes a rounded fluctuating tumor (Figs. 1 and 2) which may stretch the ear far beyond its normal size and completely change its appearance, or it may be confined to a small portion of the pinna (Fig. 2). It is more often anterior than posterior. Absorption of the effused blood is extremely slow, and the tumor should therefore be promptly incised, the blood clots thoroughly re- moved, and the wound su- tured. The skin of the ear has a good blood supply, and wounds in it heal promptly if the edges are accurately approximated by sutures. Fig. 1. — Hematoma of Ear from a Blow. The perichondrium is lifted over a con- siderable portion of the pinna. HEMORRHAGE FROM THE NOSE 5 Hemorrhage from the Nose. — Hemorrhage from the nose, or epistaxis, may follow a blow either with or without fracture of the nasal bones, or it may result from picking at the nose or the removal of dried secretion. It is one of the forms of vicari- ous menstruation. It is also a symptom of tuberculosis, of syphilis and malignant tu- mors, and of many fevers. It is one of the signs of fracture of the base of the skull. The blood may flow in drops or in a steady stream, or occasionally it may be seen to spurt from an artery of the septum. Treatment. — In the ma- jority of instances the hemor- rhage will cease spontaneously in a few minutes. The pa- tient should not lean forward nor lie upon his face. The head should be held erect, or it should be bent slightly back- ward, so that the blood may accumulate and form a clot in the nostril. If the blood tric- kles into the naso-pharynx, it should be quietly expectorated. The patient should avoid any attempt to clear the nostrils by blowing. The application of cold in the shape of ice or some metallic object, like a large door-key, to the back of the neck is a well-tried house- hold remedy which has often proved effective. The holding of ice in the mouth or snuffing ice-water up into the nostrils may also suffice to stop the bleeding. Many popular remedies have doubt- less won fame because of the tendency of the hemorrhage in most cases to cease in a few minutes. In adults of a plethoric type fre- quent nosebleed seems to be really beneficial by reducing the ten- sion in the arteries. There are cases, however, in which the hemor- rhage is alarming, and the patient may even be in danger of Fig. 2. — Small, Hematoma of Ear Fol- lowing a Blow Three Weeks Pre- vious. Patient a man aged forty-one years. 6 INJURIES OF THE HEAD bleeding to death. In other cases the bleeding is so annoying that it becomes desirable to cheek it at once. To check the hemorrhage the nostril from which the hemor- rhage comes should be sponged clean and a systematic search made for the bleeding point. The head should be tipped back to allow the blood to How out of the posterior mares. In this manner the anterior nares can be carefully inspected. The bleeding point will often be found low down upon the septum, about half an inch above the floor of the nasal passage and half an inch or more from the anterior orifice. Here it may be touched with a chemical caustic or by a hot probe, the shaft of which has been wrapped in order to avoid burning the tip of the nose, or by the finest point of a thermo-cautery. By far the best styptic is adrenalin or the extract of the suprarenal gland. Cotton moistened with this should be applied to the bleeding spot, or a dilute solution (1:10,000) may be snuffed up the nostril. Peroxide of hydro- gen is another excellent styptic. If the bleeding cannot be stopped in one of the ways mentioned, it may be necessary to plug the nasal cavity through the anterior nares. A narrow strip of gauze about two feet long is soaked with peroxide of hydrogen and squeezed dry. The anterior nares is dilated and the end of the strip passed well back in the nose with slender forceps. The packing is continued from behind forward until the cavity has been filled. Should this packing fail to con- trol the hemorrhage, the gauze should be withdrawn and the pos- terior nares plugged. This disagreeable procedure is best accom- plished by passing through the anterior nares a catheter or small rubber tube, through the eye of which a thread has been drawn. As the catheter appears in the pharynx the thread can be caught with a hook and one end of it drawn out of the mouth. The catheter is then withdrawn, the string remaining in position through the nose and out of the mouth. A specially devised in- strument for this purpose, known as Bellocq's canula, has a curved spring which carries the thread forward beneath the soft palate, thus making its extraction more easy. When the string is once in position, a pledget of cotton may be tied to the end which emerges from the mouth, and passed well into the posterior nares by drawing the string through the nose. The anterior nares should then be plugged with gauze or cotton. Both ends of the ABRASIONS string should be secured by tying them together or fastening them on the cheek by adhesive plaster. Otherwise there may be difficulty in removing the posterior plug. This procedure is at best a clumsy method of stopping hemorrhage, and should not be resorted to unless other measures fail. When once a clot has formed and hemorrhage has ceased, both patient and physician should for a day or two resist the tempta- tion to remove the tampon until the secretions of the nose lift it from the surface of the mucous membrane, so that it can be ex- tracted easily and without starting fresh hemorrhage. After that, gentle irrigation with a weak alkaline solution should be employed to cleanse the nostril. Abrasions. — Abrasions of the scalp and face are of impor- tance as possible sources of infection. Abrasions of the face are important also because they may contain par- ticles of sand, coal dust, etc., which healing in the wound may perma- nently disfigure the pa- tient. Hence the neces- sity that all abrasions of the head should be cleansed thoroughly and then covered with gauze moistened with a weak antiseptic, such as alu- minum acetate (four per cent solution) or creolin (1:200) held in place by a gauze bandage. The dressing should be moistened with cold water every two hours. If kept moist in this way the dressing can be changed every day without irritating the wound. It is more easy to keep a wound of the scalp clean if a border an inch wide has been shaved around it. In a day or two the risk of Fig. 3. -Powder Grains in Face from a Re- cent Explosion. 8 INJURIES OF THE HEAD infection will have passed, and the abrasions may be allowed to dry, or they may be covered by boracic acid ointment until new epithelium lias formed. Removal of Powder Grains. — In abrasions of the face the sur- geon's attention should be directed to the removal of every particle of dirt, as insoluble sub- stances, such as grains of sand, may be covered over by epithelium and form permanent colored marks in the skin, like tattooing. This is es- pecially the case with powder grains. These are so small and soft and numerous that it is hopeless to attempt to pick them out one by one. It is most impor- tant, however, that they be removed. It is best to give the patient an anesthetic and then to scrub the wounded area with a stiff brush until every trace of powder has been scraped away (Figs. 3 and 4), for once the skin has healed over them it is impos- sible to get them all out by cutting or caustics without leaving marked scars. Foreign Bodies. — Foreign bodies frequently lodge in the eye, ear, nose, or mouth, and the rules for their extraction vary in these different situations. Foreign bodies in wounds are described on page 14. Foreign Bodies in the Eye. — A patient will usually make the diagnosis of a foreign body in the eye by a feeling of pain or dis- comfort. Frequently he can locate a small foreign body with great Fig. 4. — Powder Grains Removed by Scrubbing with a Stiff Brush while the Patient is Fully Etherized. All the grains were re- moved in this manner. The dark spots in the photograph are the slight resultant wounds. There was no permanent scar. FOREIGN BODIES 9 exactness, although usually unable to say whether it is in the eyelid or eyeball. The eye should be examined in a good light, first by direct light, and then if the foreign body is not discovered, by side light. The lower lid should be depressed to permit examination of the lower half of the eye. The patient should then be directed to look downward. The eyelashes of the upper lid are seized, and the lid is everted by lifting its lower edge outward and upward at the same time that the upper margin of the tarsal cartilage is depressed with the tip of a finger, or with the end of a glass rod or pencil. When the foreign body is discovered, it may be wiped away with a bit of absorbent cotton wrung out of saline solution, or out of a solution of boracic acid ; or it may be removed with a blunt instrument, such as a spud or a match whittled to a not too fine point. If the cinder or minute particle of steel or glass is embedded in the cornea, it is well to drop a little weak cocain solution (one or two per cent) into the eye to assist the patient in keeping the eyeball quiet while the operator works out every particle of the foreign body. Most writers upon diseases of the eye advocate the use of fairly strong antiseptics for the purpose of disinfecting the wound in which the foreign body lay. This method of treatment was for- merly advocated in the case of larger wounds of the body, but it is now pretty generally understood by surgeons that such solutions have little effect other than that of the fluid itself. The rational procedure, therefore, is to bathe the eye with a weak antiseptic, such as a half saturated solution of boracic acid, or a normal saline solution every two or three hours, and to trust to the antiseptic action of the tears and of the internal fluids of the body to protect the eye from infection. Pain is much relieved by the application of ice cloths, and protection of the eye from strong light. If the foreign body has penetrated more deeply into the eye than the cornea, the aim of treatment is to remove it with as little damage to the eyeball as possible. A patient with such a serious lesion should be treated from the first by a specialist when circum- stances permit. Some writers upon the eye praise the use of a magnet for the removal of bits of steel and iron, while others say 10 INJURIES OF THE HEAD that it is of no use, even when such a foreign body is situated superficially. Foreign Bodies in the Ear and Nose. — Beans, shoe buttons, and other objects arc poked into the ear or nose by children. If they arc smooth they may set up no irritation, but generally there is enough swelling of the mucous membrane to reduce the size of the opening and make their extraction difficult. If a foreign body is sharp, so that the mucous membrane is broken, either at the time or later, there will be a continuous discharge from the affected nostril, or from the ear, as the case may be. A persistent uni- lateral nasal discharge in the case of a child always suggests a foreign body. The amount of pain varies in different cases, according to the situation, size, and shape of the article, and the amount of injury done at the time of its entrance. The diagnosis may be suspected from the history or symptoms, but it rests chiefly upon the results of direct inspection through a suitable speculum. If the patient is a young child, complete anes- thesia is desirable for this examination as well as for subsequent treatment. Teeatment. — It is absolutely necessary that the patient's head should be still during attempts at extraction even if general anes- thesia has to be employed to accomplish this object. If the foreign body is one which may be firmly grasped with mouse-tooth for- ceps, it can be slowly and steadily extracted. The necessary in- struments are shown in Figure 5. If the foreign body is smooth and hard as, for instance, a round glass bead, a bit of shoe- maker's wax may be utilized to obtain a hold upon it, or a probe or blunt hook of bent wire may be passed alongside of it. Light substances, such as insects, may possibly be floated out of the ear on the surface of olive oil poured into the meatus. This is also a good way to drown an insect, and stop its motions in the ear. One of the commonest foreign bodies the surgeon is called upon to extract from the ear is a mass of ear-wax. Normally the wax which is secreted in the ear works outward as a thin, hollow cylin- der, the outer edges of which dry up and break off in scales. If an overzealous individual attempts to free his ear of wax by means of a slender cone, for example, the twisted corner of a wet towel, FOREIGN BODIES 11 it sometimes happens that the edges of the thin cylinder of wax are pushed inward from time to time until a large ball of wax is formed. This is not usually noticed until some jar dislodges it and it falls against the drum-membrane, causing a constant buzz- Fig. 5. — Instruments for the Extraction of Foreign Bodies from the Nose and Ear: A, Cotton carriers made of flattened copper wire; B, Pure silver slender ■ probe; C, Ear specula; D, Nasal speculum; E, Forceps bent at a convenient angle; F, Curette. ing sound and a general feeling of uneasiness inside the head. As this continues and hearing is possibly interfered with, the indi- vidual seeks medical aid, under the supposition that he has some 12 INJURIES OF THE HEAD serious ear trouble. From the symptoms alone the diagnosis can usually be made. An examination through an ear speculum reveals the hall of wax at a greater or less depth from the surface. Through as large a -speculum as the ear will conveniently receive, slender for- ceps bent at a suitable angle may be passed into the ear until they touch the wax (Fig. 5). The ball may be seized and a number of fragments drawn outward through the speculum. The success of this method depends as much upon the consistency <>t' the wax as upon the dexterity of the surgeon. If the wax is firm it can all be removed in a few minutes. If it is soft very little of it can be extracted in this manner, and removal by syringing has to be resorted to. .V fountain syringe or irrigator is filled with a warm dilute solution of bicarbonate of soda (a teaspoonful to the pint) and placed high enough to give slight force to the escaping stream, which is then directed, either with or without the specu- lum, full against the plug of wax, the ear being lifted upward and backward to dilate and straighten the canal. The wax is made less viscid by the fluid, and is separated from the walls of the meatus to a certain extent, and in most cases half an hour's syringing, interrupted by occasional extraction of fragments with the forceps, or with the curette, will suffice to empty the meatus. If not, the procedure can be resumed the following day. When the wax or other foreign body has been removed, the ear should be carefully examined for the presence of inflammation. If the surface is merely excoriated, an occasional antiseptic irrigation or dusting with powdered boracic acid is sufficient treatment. Foreign Bodies in the Mouth and Throat. — Small foreign bodies may become lodged in some crevice of the mouth or throat, or if sharp, they may penetrate the mucous membrane, and thus resist the patient's efforts to eject or swallow them. A fish bone, a splinter, or a fragment of straw is the object that usually be- comes embedded. The sensations of the patient are in most cases a reliable guide to the location of the foreign body. It is possible for a rough object to scratch the throat during the act of swallowing, and leave behind it the sensation of a foreign body. It is the exception, however, for the patient to be mistaken in this way, so that the physician ought in every case to make an examination with a WOUNDS 13 strong reflected or direct light and a throat mirror. The latter is of the greatest service in hunting for small, colorless objects, since it enables the examiner to inspect the tonsil and the pillars of the fauces from diiferent angles. These are the situations in which most small foreign bodies become lodged. When found, the foreign body can be extracted with the forceps, or worked loose with a probe or bent wire. If the search is fruitless, it should be resumed on the following day, provided the symptoms in the meantime have not subsided. Foreign bodies in the larynx and esophagus are described on page 115. Wounds. — The diiferent varieties of wounds — incised, lacer- ated, et cetera — are found with frequency upon all portions of the head. The blood supply of the scalp and of the skin of the face is so free that no matter how jagged a wound may be, the vitality of its points is usually preserved. Owing to the smooth, hard surface of the skull, a blow upon the scalp with a blunt instrument, such as a policeman's club, will produce a fairly clean cut wound, almost like that made with a knife. A careful inspection of its edges, however, will show a con- tused area more or less circular, and about an inch in diameter, which represents the area of contact of the instrument with which the blow was given. Treatment. — The first object of treatment is to control hem- orrhage, either by pressure or ligation of the bleeding vessels; the second is to determine the extent of the wound, the third to remove any foreign bodies which may be present, and the fourth to approximate, by suture or otherwise, the tissues which have been divided, whether skin or deeper structures. It should be an invariable rule never to pass a probe into a wound, especially a wound of the scalp, until the skin has been cleaned as for operation ; otherwise the probe may spread infec- tion to the deeper portions of the wound, which in the particular case mentioned may be the surface of the brain. The skin should be thoroughly washed with soap and water, then with some solvent of grease, such as ether, or turpentine fol- lowed by alcohol, and dried by gauze sponges or cotton swabs wrung out of an antiseptic solution (p. 34). The wound should be cleansed with saline solution, or stronger solutions, according 14 INJURIES OF THE HEAD id circumstances, lis edges should be retracted, and the possi- bility of dot']) injury determined. Small foreign bodies should be removed. If a foreign body such as a splinter passes nnder the skin, the sinus made by it should be split up and thoroughly cleansed, for if allowed to remain undisturbed it is almost certain to cause sup- puration and delay recovery. A bullet of small caliber may pene- trate the seal]) al one point, pass along outside of the skull, and emerge at another, or remain between the periosteum and the skin. In such a ease the bullet should be removed by an incision over it, the sinus irrigated with peroxid of hydrogen solution, 1:8 or weaker, and 1 : 2,000 biehlorid solution, and pressure applied throughout its length except at its ends, which should be kept open by small strips of gutta-percha tissue or gauze. In this manner union can ordinarily- be secured without dividing the intervening Most small wounds of the face and scalp should be sutured without drainage, or at most, a flat gutta-percha or horsehair drain should be employed (Fig. 306). Carefully applied pressure obtained by bandaging a dry compress of gauze to the head will prevent reaccumulation of blood in the wound. While it is generally true that all the ragged points of a wound of the face or scalp will live, it is better for the sake of a clean scar to trim the edges of the wound so that they may be smoothly approximated. Especial attention should be given to the direction of hairs whose roots are often twisted and displaced by rough injuries. Horsehair or fine black silk is the best material for the suture. Some surgeons have advocated a subcuticular suture. This is introduced with a curved needle which passes into and out of the skin, first on one side of the wound and then on the other, without reaching the surface. This suture is more difficult of application than other sutures, and it sometimes fails to approximate accu- rately the overlying epidermis. If the thread used for an inter- rupted suture is a very fine black sewing-silk (JSTo. A), and the ^ sutures are taken out in from two to four days, no permanent scars due to the punctures will remain. Wounds of the Eye. — If a laceration extends through both the skin and conjunctiva of the eyelid, some of the sutures should pass WOUNDS 15 through both structures, so as to approximate the edges of the conjunctiva. Other sutures should be placed in the skin only. All of them should be removable from the outside. In treating wounds of the eyeball, repair with the least disturbance of the nor- mal relations should be the aim of the operator. Protruding por- tions of the iris should be snipped off. Wounds of the sclerotic coat, if sufficiently large, should be sutured with the finest catgut. The eye should be washed with Thiersch's solution (salicylic acid 2, boric acid 12, boiled water 1,000 parts) one-half strength, or u, half-saturated solution of boracic acid, or a normal salt solution.!. A light pad of gauze moistened with one of these solutions should be applied. The bandage (Fig. 326) should be light so that evap-j oration may keep the eye cool. ISTo rubber protective is permissible.; The moisture should be kept up by adding from time to time more of the solution or cold boiled water. If the injury is serious the patient should remain in bed until repair is well established. The services of an ophthalmic surgeon should be obtained in these cases whenever possible. Wounds of the Mouth. — Wounds within the mouth are con- stantly filled with bacteria, some of them pathogenic. Neverthe- less, they usually heal with little delay, owing to constant mois- ture and the extremely free blood supply. It is rare that the surgeon is called upon to treat a bitten tongue or cheek. If, how- ever, so large a flap has been separated from the main tissue that untreated it would cause a permanent roughness in the mouth, one or more sutures of fine black silk should be inserted with a curved needle. Plain catgut soon swells and softens and loses its grip. Catgut prepared so as to resist moisture (e. g., chromicized) is stiff and unpleasant; fine silk, dyed black so as to be readily seen, is therefore the best suture material for the mouth. If the lip or cheek is cut through, cutaneous sutures passed through all the tissues except the mucous membrane will suf- ficiently hold the parts in place, or the mucous membrane may first be sutured with catgut or silk, the knots being tied inside the mouth. If silk is used the sutures should be so placed that their extraction will be easy. The mouth should be kept clean by rins- ing with a mild antiseptic solution, and, if necessary, remnants of food should be wiped with wet cotton swabs from the vicinity of the wound. 16 INJURIES OF THE HEAD Steno's duct, or the facial nerve, may be divided in wounds of the check (Fig. 6). Immediate suture should be performed, or even late suture if the accident is overlooked at first. If the two divided portions of Steno's duct have become separated by scar tissue, the anterior portion of the duct can usually be ]> robed, and the probe thrust into the posterior, then dilated portion. The channel may be re- stored by tying the probe in place for a day or so, or a ligature may be passed through the duct beyond the scar and into the mouth. As soon as the normal channel is re- established, such an arti- ficial fistula will close as soon as the thread is re- moved. A small exter- nal fistula due to an in- cision into the substance of the gland, will usu- ally close of itself in a few days. The paralysis of the mouth, and possibly also of the eyelids due to division of the facial nerve, can hardly be overlooked. The nerve should be sutured at once ; see Chapter XIII for the technic. Wounds of the Periosteum. — In incised and punctured wounds of the scalp, the periosteum is often injured. This serious com- plication can be recognized by retraction of the edges of the wound and inspection and probing of its deeper portion. If merely the overlying aponeurosis is divided, one may be misled into supposing that it is the periosteum. If the latter is also divided the probe will clearly detect the underlying bone. Such a wound should be thoroughly examined, cleansed, and drained. It is better to delay Fig. 6. — Division of Steno's Duct by a Razor. The skin was sutured and the division of the duct was not noticed until the obstructing scar caused distention behind it. This patient was promptly cured by the method described above. FRACTURES 17 union for a few days by the presence of a gauze drain than to suture the periosteum and run the risk of abscess formation be- neath it. The mere exposure of the skull for a few days will not result in necrosis if suppuration does not coexist; whereas an in- fected punctured wound, for example over the eye, may be fol- lowed by suppuration under the periosteum which, if neglected, may pass through the skull and set up a fatal suppurative menin- gitis. Therefore the fresh wound should be only partially sutured, while a strip of gauze should reach to the periosteum in the center of the wound. This drain may be withdrawn in forty-eight hours, and if the wound is still clean it may be allowed to close; if it is suppurating it should be washed out with mild antiseptics and drained again, and a wet dressing applied. Fractures.— Fracture cf the Skull. — In many instances it is impossible to diagnose a simple fracture of the skull except by ac- companying signs. These are local pain and tenderness, hemor- rhage — the blood appearing in the orbit or coming from the ear — headache, shock, partial paralysis, pupils irregularly contracted or dilated, and partial or complete unconsciousness. Shock, even to complete unconsciousness, may be present from concussion of the brain (really contusion of the brain) without fracture of the skull ; and fracture of the skull, especially if it is caused by a fairly sharp instrument and if it involves bone which overlies the less impor- tant portions of the brain, may be unaccompanied by shock. This is especially true of the occipital region. Hemorrhage in the orbit, appearing usually under the conjunctiva, or from the nose (if frac- ture of the nose is absent), or from the ear, or appearing under the skin in these localities, is considered to be pathognomonic of frac- ture of the base of the skull. Under such circumstances operative treatment is out of the question. Absolute quiet in a cool, dark room, with external heat to the extremities, and cardiac stimulants, if necessary, are the best means to be employed. If external wounds are present the most rigid asepsis should be observed in their treatment. If the lesion in the skull is extensive or a por- tion of the bone is depressed, it is better not to attempt repair at the time of the accident, but simply to protect the wound by a moist antiseptic, or dry sterile dressing, until arrangements for a for- midable operation can be completed. Fluctuating hematoma of the scalp, surrounded by a ring of IS INJURIES OF THE HEAD resistant edema, may give the impression thai the bone in its center is depressed. This error is to he avoided by noting the natural curve of the skull outside of the edematous area. Fracture into a Frontal Sinus. — A fracture of the frontal bone just about the orbit may involve only the outer wall of the frontal sinus. This is not usually a serious lesion, but the bone should be replaced in its normal position so that per- manent disfigurement may be avoided. To accomplish this it may be necessary to make an incision be- neath (lie eyebrow. Fracture of the Ma- lar Bone. — This injury is due to direct vio- lence, and the bone is almost invariably dis- placed b a c k w a r d so that one cheek is less prominent than the other (Fig. T). To replace it in po- sition, anesthetize the patient, chisel a hole into the antrum just above the first bicuspid tooth and introduce a curved steel sound. With this instrument as a lever, firm, steady pressure may be exerted upon the inner surface of the malar until it is brought into its normal position. A mouth wash is the only after treatment required. Fracture of the Nasal Bones. — The nose is frequently injured by blows and falls, so that the nasal bones may be fractured, or the cartilages torn loose from them. An injury of this sort is usually followed by more or less hemorrhage from the nares. There is also subcutaneous hemorrhage and edema, so that it is difficult to determine from external examination alone whether the rigid struc- tures have been altered. Gentle manipulation of the bridge of the Fig. 7. -Fracture of Right Malar Bone with Depression from Blow. FRACTURES 19 nose will usually elicit crepitus if there is a fracture. This should be combined with inspection of the nares through a bivalve specu- lum. Deformity may of course have existed previous to the injury, and the patient should be questioned upon this point. ■ The hemorrhage stops in a few minutes, and the pain is slight ; but the patient may be distressed by his appearance, or by the fact that the swelling and hemorrhage prevent him from breathing through his nose; but both nares are not usually obstructed. Treatment. — The chief object of treatment is the reduction of deformity, and the maintenance of correct relations for a few days. Whenever possible, existing deformity should be so cor- rected or overcorrected that there is no further tendency. for the bones to slip out of place. A blunt steel sound, or some similar instrument passed into the nostril, is of assistance in. correcting displacement. If deformity tends to recur, it may be necessary to insert a hol- low, perforated rubber cone into one nostril, or to apply an external splint. This can be made of dental composition, softened in hot water, and molded to the nose, or a pad of gutta-percha tissue may be similarly employed. As the swelling diminishes, the splint must be remolded. The surgeon can then better judge whether all deformity has been corrected, and if not this should be accom- plished before union becomes solid. If the patient is seen several times with this object in view, it, will rarely be necessary to make use of a complicated nasal splint, or to scar the face by passing a hat pin directly through the nose. Fracture of the Superior Maxilla. — This is one of the less com- mon fractures. Deformity is easily overcome, and after reduc- tion the fragments will usually remain in a correct position, since there are no strong muscles tending to displace them. As an addi- tional safeguard, wires and threads may be used to bind together teeth attached to the fragment, and those of the remaining part of the superior maxilla, as described below in connection with frac- ture of the inferior maxilla. Fracture of the Inferior Maxilla or Mandible. — This injury is very common, and often seriously affects the patient's health. Moreover, the difficulty of keeping the fragments in correct posi- tion often taxes the ingenuity of the surgeon to the utmost. The fracture is due to direct violence, and almost always to blows re- 20 INJURIES OF THE HEAD ceived in a fight. The line of fracture usually passes through the body of the jaw, back of the canine or the bicuspid tooth. It may, however, occur at other places, and often there is a second fracture, cither on the other side, or possibly on the same side, in which case it may be above the angle of the jaw. If the fracture is situated in that portion of the jaw occupied by the teeth, it is almost ahvays compound into the mouth. Diagnosis is made from inspection and manipulation, as well as from the subjective symptoms of pain and disability. There is local swelling and tenderness. Inspection of the gums will usually show a break in the continuity of the mucous membrane at the roots of the teeth. The patient cannot open his mouth fully, nor can he bite on a hard substance, for example a cork. Attempts to open and close the mouth may produce motion at the site of frac- ture, shown by changes in the relation of the teeth on either side of the break. Such displacements can be readily produced by the examiner, if, grasping the jaw between his thumb placed under the patient's chin and two fingers placed on the incisor teeth, he rocks it from side to side. The disability due to this fracture is great. The patient is absolutely unable to chew solid food, even if it were desirable to let him do so, or to open the jaw except to a slight extent. Pain pre- vents him from sleeping, and abnormal fermentations within the mouth increase the swelling and, inflammation, and add to his dis- gust and discomfort. Treatment. — The first step in treatment is the perfect reduc- tion of the fragments, under a general anesthetic if necessary. In some cases this is a very simple procedure, and the ends of the bone when reduced show no tendency to become displaced. In other cases reduction is easy, but the moment that the surgeon lets go of the jaw displacement recurs. In a third class of cases per- fect reduction is impossible, or can only be accomplished by the exercise of considerable force. This means that a tooth has become loosened and wedged between the fragments, or that there is a dis- placed small fragment of bone which has intervened in a similar manner to prevent the reduction. Such offending tooth, or frag- ment, should of course be removed. The simplest method of keeping the fractured ends of the bone in apposition is to bandage the jaws firmly together, thus making FRACTURES 21 the upper jaw act as a splint for the lower one. A four-tailed bandage with a slit or narrow ellipse cut in its center through which the point of the chin protrudes sufficiently to keep the hand- age from slipping, is tied across the occiput and over the forehead, one end being left long in each situation (Fig. 8 ) . These two ends are then tied together over the top of the head. The bandage after this application is shown in Figure 328, Chapter XXI. In this manner any desired amount of pressure can be produced upon the jaw, the pull being both backward and upward. This meth- od of treatment makes it difficult for a patient to keep his mouth in proper condition, and in- terferes with feeding, as he has to take fluid nourishment through a tube. Pressure of the bandage over the seat of fracture often adds to the patient's discomfort; but it is by far the commonest method employed on account of its ready application. There are cases in which it answers the purpose admirably, and the patient is even able to open his teeth sufficiently to brush them without disturbing the fractured ends. In other cases the bandage is a miser- able failure. Xon-success is usually due to the fact that reduction has been imperfectly accomplished, or to the fact that the patient has not two full sets of teeth. If a person has all of his natural teeth, pressure of one set against the other, and the repeated slight blows given by the act of chewing will, during the later weeks of convalescence^ correct any slight irregularity of the lower jaw which still exists, provided that reduction does not require much force, and that there are at least two teeth back of the line of fracture. If this simple treatment does not succeed, or if for other rea- sons a more exact method of treatment is indicated, the teeth may be wired together. For this purpose two flat wires should be passed along the lower teeth, one inside of them and one outside of them, and they should be lashed to the teeth and to each other Fig. 8. — Four-Tailed Bandage for Fracture op the Inferior Maxilla. 22 INJURIES OF THE HEAD by threads; but no threads should be placed around the two teeth nearest the fracture, for they are usually loosened and incapable of enduring the strain. In many cases absence of teeth, or the situation of the fracture far back, makes this plan of treatment impossible. Fracture of the lower jaw may be treated by means of an in- terdental splint. Success in the use of tin's form of apparatus depends not a little upon the manual dexterity of the surgeon. The first step is to secure a good impression of the teeth and gums of the whole of the lower jaw. This impression may readily be taken by means of modeling composition such as dentists use, and it is not at all necessary that the fracture be reduced when the impres- sion is taken. It is just as easy to set the fracture in the im- pression as it is in the jaw, but the fracture must be reduced, of course, before the splint is applied. The impression should show the line of the gums both inside and outside the teeth, and should extend well back to the angle of the jaw on the fractured side. From such an impression, if well made, an excellent splint may be ordered from any dental manufacturing house at a cost of ten dollars or more. Counter-pressure is obtained by the four-tailed bandage already described, or the splint may be pressed against the lower jaw by mean's of a pad or a bit of board which is attached to the splint by a broad spring curling over the chin. Another plan is to fix wires in the interdental splint. These come out at the angles of the mouth and turn backward along the cheeks, and are bound together, the bandage passing beneath the jaw. Pres- sure w 7 ill be more exact if a board nearly as long as the distance between the wires is placed under the jaw. If a splint of this character fits accurately, it enables the patient to open his mouth and often to chew soft food, if the interdental splint is made to fit both upper and lower teeth. In many cases, this splint will keep the broken bone in place without the use of a bandage. The form of apparatus selected must be worn for a month or more, depending upon the amount of tendency to displacement and the rapidity with which the ends of the bone unite. Even in favorable cases it w r ill be several weeks before the patient regains the full power of the jaw and the ability to open wide the mouth. If the line of union is a correct one, the surgeon need not hesitate to promise complete restoration of function. FRACTURES 23 Complications of Fracture of the Lower Jaw. — Fracture of the lower jaw is usually compound into the mouth. It is therefore not surprising that infection sometimes develops. In a certain number of cases this is of mild character ; the pus which forms is discharged into the mouth, the wound heals by granulation, and the .union of the fractured bone, although delayed, is not other- wise interfered with. In a good many cases, however, an abscess forms which drains imperfectly and gives rise to pain, swelling and edema of the neck and possibly fluctuation below the margin of the jaw. This is an unfortunate complication, since it may lead to a sequestrum and greatly delay recovery, and possibly make it necessary to perform one or more operations to provide drainage or remove dead bone. It is therefore important to keep the mouth of every patient as clean as possible by the use of astringent and antiseptic mouth washes. If an abscess forms, it should be promptly drained within the mouth if good drainage can be thus secured, and if not, through an external incision. Such an incision should be parallel to the margin of the jaw, and just below it. If the fracture is near the center of the horizontal ramus, the possibility of division of the facial artery or vein should be borne in mind. A drain should be placed in the external wound, but should be of such a character as to favor the escape of pus, and not to prevent it. Frequent irrigation with a solution of peroxide of hydrogen (1:8) assists in keeping the wound free from bacteria. Meanwhile treatment of the fracture itself should be continued as described above. A sinus which has formed spontaneously, or which follows an external incision for drainage usually lasts some weeks. No at- tempt should be made to close the opening in the skin until the deeper portion of the sinus has become filled by granulation. When this takes place, the opening in the skin will quickly close. Persistence of the sinus means that some foreign material is present : either the loosened root of a tooth or a sequestrum of the bone itself. The opening should be enlarged, such foreign mate- rial removed, and another period of drainage instituted. Care should be taken not to break up newly formed bone, which is often thrown out. around the sequestrum in great abundance in cases of compound fracture of the lower jaw. Non-union of the mandible is almost unknown; therefore a 24 INJURIES OF THE HEAD persistent following out of the principles here outlined will lead to complete restoration. If the resulting scar is unnecessarily dis- figuring by reason of its close attachment to the hone, it should be 'removed ; bu1 not until some months have elapsed (p. 47). Dislocation of the Jaw. — This is a rare accident which is brought on by extreme gaping or laughter. The condyloid process on one or both sides slips forward out of its socket. It is impossible to close the mouth, and the pain due to stretching of the ligaments is excessive. The patient should be anesthetized and the jaw grasped firmly with two hands, the thumbs of which, well wrapped about with bandage, are placed upon the molar teeth. Pressure downward and then backward will restore the bone to its correct position. In some persons dislocation of the jaw takes place easily, owing to abnormal laxity of the ligaments. Under these circumstances reduction is readily accomplished without an anesthetic. Xo after treatment is necessary. There are certain long standing cases of unreduced dislocation of the jaw which cannot be reduced in the manner described, and for which resection of the articular portion of the bone has been advised, or the bone may sometimes be dragged into place by a specially contrived hook which is inserted through a small wound in the cheek and is passed around the neck of the jaw. Subluxation. — A few young men and girls — especially the lat- ter — complain of a partial dislocation of one or both maxillary articulations every time the mouth is opened. This trouble occurs at the period of development of the wisdom teeth, and in most cases it is due to the lack of space for the orderly growth of the tooth. If the tooth grows crooked, or if swelling accompanies its eruption, the normal action of the muscles which open and close the jaw is interfered with. Suppuration about the wisdom tooth, or even a blow on the jaw, may cause similar symptoms. The pain is usually slight. The patient is annoyed by its persistence, or by an uncomfortable slipping of the jaw, or by its slipping with a click loud enough to be heard by others when the patient is eating. In the developmental cases, spontaneous cure often results in some months. If the wisdom tooth is much out of line, or is decayed, it should be removed. Pain is often relieved by counterirritants, but great care should be exercised not to permanently stain the skin by their use. CHAPTEK II INFLAMMATIONS OF THE HEAD EFFECTS OF HEAT AND COLD Burns. — The burns of the head which the surgeon is called upon to treat are not usually very deep. The scalp is protected by hair, and if flames or steam rise into the face sufficiently to burn deeply, they will usually be inhaled and produce fatal internal injury. Most of the deeper burns of the face are, therefore, the result of a gas explosion or the electric flash caused by short cir- cuiting. The importance of avoiding a scar is, of course, very great, so that slight burns should be carefully attended to. Burns have been variously classified according to the depth to which the tissue is destroyed. For practical purposes, they may all be placed in three classes. Burns of the First Degree. — The symptoms are swelling, redness, and tenderness of the skin. There is no visible destruc- tion even of the epidermis, although this usually peels off in strips a few days later. A familiar example is a mild sunburn. There is increased redness of the burned area for a week or more, but no permanent scar. Treatment of Burns of the First Degree. — The chief indication for treatment is the relief from pain. This is best accom- plished by smearing the surface with one of the lighter ointments which contains a considerable amount of water, such as rose water ointment, or one of the ointments sold under the names of Let- tuce Cream, Cucumber Cream, etc. Cow's cream is excellent for the purpose. Recovery promptly follows the application of any non-irritating substance. Burns of the Second Degree. — Much of the epidermis within the burned area is destroyed. There are blisters either full of serum or collapsed, or the injured epidermis may have been more or less removed. Hairs within the burned area are also 25 26 lXI'i. ANIMATIONS OF THE HEAD burned away. There is redness, swelling, and tenderness, and a lucre or less free oozing of serum, and possibly of some blood. Repair in this class of burns takes longer than in burns of the first degree, but no slough of the true skin occurs. If the whole thick- ness of the^epiderma] layer is here and there destroyed, these areas •ire very small and are rapidly covered by spreading of the deeper layer of epithelial cells. Then' is, therefore, no permanent scar. Redness will persist longer than in burns of the lirst degree, pos- sibly for a month or more. Treatment oe Burns oe the Second Degree. — The chief indication for treatment is the relief of pain. The permanent result is certain to be good. There are four plans of treatment: One is to apply a dressing soaked with oil or spread with ointment in order to protect the injured surface from the air and from changes in temperature. A second plan is to cover the burn with strips of rubber tissue or with gauze wet with normal saline solu- tion. The third plan is to treat the burned area with an antiseptic dressing, which may be allowed to dry or which may be kept moist. The fourth plan is to leave the burned area exposed to the air in order that it may dry up. Various dusting powders are employed to further this last plan. The author favors the first or the second of these four plans, believing that these dressings are more comfortable to the patient, and that they favor the vitality of those portions of the skin which have been injured but not destroyed by the burn; and because such dressings, provided plenty of ointment is used, or plenty of water if a wet dressing is employed, can be removed with less pain and damage than other dressings which are allowed to dry out. Powders are objectionable, since they form, with the exuded se- rum, hard crusts which are veritable culture tubes for bacteria. It is impossible to make or keep aseptic an area of skin which has been burned below the superficial portion of the epidermis. Protection against infection depends, therefore, on the vitality of the remaining skin rather than on the antiseptic qualities of the dressing. Hence, the latter should be soothing to the skin rather than deadly to the bacteria. A good exam] ile of an oily dressing is carron oil, a mixture of equal parts of linseed oil and lime water. If this is used the gauze should be thoroughly saturated with it, as otherwise the oil BURNS 27 will soak into the outer dry dressings, and the inner layers will become very firmly attached to the skin. For this reason an oint- ment is preferable in most cases. A good one is composed of one dram of boric acid to the ounce of vaseline. The ointment should be sterilized by setting the jar which contains it in a pan of boiling water. It can, of course, be sterilized in a steam sterilizer. The ointment should be used freely. A good plan is to spread it over the burned area with a spatula, much as one spreads butter with a knife. Dry gauze can then be applied in pieces small enough to fit the part, and the dressing fixed by a loose gauze bandage. The principle of the normal saline solution when used as a dressing for a burn is the same .as when used as a dressing for a skin graft. It is to reproduce as far as possible the normal surroundings of growing epithelium. If this plan is adopted, the burned area should be immersed in a saline solution, or lightly sponged with swabs saturated with the same. It is then covered with several thicknesses of gauze saturated with saline, and evapo- ration is prevented by covering the whole with a sheet of gutta- percha tissue, or strips of gutta-percha tissue may be applied directly to the burned surface, and these in turn be covered by the wet gauze. When the dressing is applied in this manner, a sheet of impervious material may be applied externally, or this may be omitted and the gauze kept wet by more frequent saturation with saline or boiled water. Picric acid is recommended by those who favor antiseptics in the treatment of burns of the second degree. Gauze is saturated with a one per cent solution, either before or after it is applied to the burned surface. This dressing is supposed to control the pain, but I have seen patients suffer severely after its employment. It has a tendency to dry up the exudate, so that in many cases burns treated in this way are greatly improved in appearance. The in- tense yellow color of the picric acid stains the clothing. A mild antiseptic solution suitable for use in burns of the second as well as of the third degree, is a four per cent solution of aluminum acetate. The gauze should be saturated with it, and then kept wet by the addition of sterile water from time to time. If it is decided to treat the burn by the dry method, it may be left exposed to the air or cleansed and dusted with a powder, such as bismuth subnitrate, or bismuth subgallate, or nosophen. 28 INFLAMMATIONS OF THE HEAD Burns of the Third Degree. — Portions of the corium, and possibly still deeper structures have been destroyed by the heat. It is easy to be misled in this matter by the early appearance of the skin. In a burn of the first or second degree the affected skin is red from the congestion of the vessels in it. If the vitality of the corium is destroyed, the blood cannot circulate through its vessels, and the skin will therefore appear white. The difference between tli is skin and normal skin is easily recognized if one looks for changes in color due to pressure made upon it. Such changes will, of course, be wanting in the dead skin. Furthermore, such a white, dead area will invariably be surrounded by a hyperemic zone in which the burn is only of the second degree. I have known several instances in which intelligent physicians overlooked a burn of the third degree, being misled by the lack of redness of the skin. This dead skin will, of course, slough, and in time will become entirely loose. During this process, which sometimes takes two weeks or more, there is danger that the slough will interfere with the exit of underlying pus. Treatment of Burns of the Third Degree. — We have, then, in burns of the third degree, three indications for local treat- ment — the relief of pain, protection of the injured but living tis- sues, and drainage of any pus pockets which may form. A moist antiseptic dressing best fulfils the requirements. In most cases morphine should be given either hypodermically or by mouth dur- ing the first twenty-four hours. Few persons can sleep without an opiate the first night after a burn, even if they can endure the pain while awake. The moist dressing should be applied warm and kept warm. The gauze may be saturated with aluminum acetate, as mentioned above, or boric acid, or any other feeble antiseptic. The dressing should be kept constantly moist, and in some instances a continu- ous bath is desirable. Frequent dressings are to be avoided, but if the dressings be- come saturated with pus and serum, the comfort of the patient is usually promoted by changing them. Sloughs should be cut away as soon as they loosen, but not before. If a large area is burned, the central portions of the skin may loosen before the edges. If so, incisions should be made through the slough or portions of it excised to permit free escape of pus and secretions. BURNS 29 The repair after a burn of the first or second degree is accom- plished by the normal growth of the epidermis. In every burn of the third degree the removal of the sloughs is accomplished by the growth of granulations beneath them. These granulating areas must be covered by the lateral growth of the epithelial cells, either from the edge of uninjured skin, or from islands of epithelium which have been left, or from the epithelium which lines the fat and sweat glands. This new epithelium at first has no color of its own, and simply looks like a dark red glaze over parts of the granulating surface. Later, as the epithelial cells multiply, a whitish appearance results. It will be evident, therefore, in two or three weeks whether the burned area will become covered with epithelium within a reasonable time. An epithelial edge will grow about an eighth of an inch a week. A granulating area, therefore, which is an inch in its smallest diameter, will require a month for its complete repair. Areas larger than this, and which are with- out epithelial islands should be skin-grafted (see Chapter XX). There is one other thing to be borne in mind during the repair, and that is the possibility of cicatricial contraction. This can be avoided to a certain extent by the judicious use of plaster ban- dages and splints to keep the burned area fully extended during the healing process; but a far better means of prevention is the early covering of the granulating surface with pedicled flaps, or when this is not practical, with Thiersch, or better, with Wolfe grafts. In this way the amount of scar tissue is kept at a mini- mum and the power of contraction will be slight. Sunburn. — This injury, though not serious, should be pre- vented many times when it is not. Before exposure to the rays of the sun the skin should be rubbed with cold cream or some sim- ple ointment, such as boracic acid ointment, and when the skin shows the first pink color, it should be covered with clothing. If one waits until the sensation of burning is present, the mischief will have been accomplished. The treatment of sunburn is that of a burn of the first degree. Washing with soap is to be avoided. Sunburn of the lip is very annoying because it takes from one to two weeks for recovery. This is because the thinner epithelium in the burned area is totally destroyed, and the little ulcer which results must heal entirely by growth of epithelium from its edges, at the rate of one-eighth of an inch per week. 30 INFLAMMATIONS {)[< THE HEAD X-Ray Burn. — Exposure to the X-ray in some cases for a few minutes only, produces a redness of the skin which somewhat re- sembles sunburn. It does not, however, appear until some hours after the exposure. If the exposure is frequently repeated, an ulcer may form. The milder lesions quickly disappear, and require no other treatment than soothing applications. The ulcers are often very painful. Ointments containing cocain, morphine, menthol, or orthoform should be tried. Stelwagon recommends curettage and skin-grafting in obstinate cases. Frostbite. — The cars, cheeks, and nose are the parts of the head most often frozen. If the part is still frozen wdien t In- patient is first seen, it should be rubbed lightly in the cold until the circulation is reestablished, in order to avoid a violent reaction. Frostbite of the head requiring surgical treatment is almost always confined to the ears. The. symptoms of cyanosis, swelling, pain, and tenderness are here well marked. Occasionally blisters form ; but gangrene is uncommon, at least in this latitude. Various applications have been recommended for frostbite. The good effect of treatment seems to be due merely to the main- tenance of an even temperature which facilitates the flow of blood to the part. Moreover, the dressing protects the ear from sudden changes in temperature. Any astringent, or a simple ointment, such as one containing tannic acid or ichthyol, spread in a thick layer upon gauze applied to the ear and covered with a layer of cotton, forms a satisfactory dressing. If a portion of the ear is gangrenous, it should not be removed until a line of demarcation is well established. It may then be seen that gangrene does not extend deeper than the skin, or pos- sibly the epidermis. (Compare gangrene of the extremities from frostbite, Chapters XV and XVIII.) Dermatitis. — Sunburn and frost-bite are forms of dermatitis due to heat and cold. Dermatitis may also be due to traumatism, the treatment for which is essentially the same as that given for sunburn. In other cases, dermatitis follows the unwise use of drugs externally or internally, while a very common form of der- matitis is due to contact with poison ivy. These have the general name of dermatitis venenata if due to an external application ; if HERPES 31 due to an ingested drug or poison, the name dermatitis medica- mentosa is used. Iodoform, mercury, carbolic acid, cantharides, dyestuffs, etc., will poison certain skins. There may be simply a redness and burning, or there may be a profuse eruption of vesicles. In ivy poisoning these vesicles are of various sizes, and a number of small ones often merge. In most cases of dermatitis, as soon as the cause is removed there is a prompt recovery. Treatment consists, therefore, of soothing applications, such as a two per cent solution of boracic acid, or the application of a simple ointment. Larger vesicles should be punctured and their contents expressed. In some cases an opiate is required. If the eruption is due to the ingestion of a drug, the drug should, of course, be stopped and a diuretic and cathartic should be given. ACUTE INFLAMMATIONS There are four common skin lesions of an inflammatory nature frequently found upon the face, with the diagnosis and treatment of which every physician should be familiar. They are urticaria, herpes, impetigo, and acne. A brief description of these four dis- eases is given here because of their acute character, as well as to differentiate them from forms of inflammation in the skin gener- ally considered surgical. Urticaria. — Urticaria is a form of eruption greatly resem- bling the bites of insects. Indeed these bites are classed as lesions of urticaria by some writers. Other external irritants, and vari- ous articles of food, especially shellfish, pork products, and straw- berries, will produce urticaria in some persons. The lesions come up quickly and usually subside in a few hours. A saline cathartic should be given, or under certain circum- stances an emetic. The affected skin should be bathed with a lotion, usually containing one or two per cent of carbolic acid, to relieve the itching. Three ounces of alcohol, three ounces of cam- phor water, and one dram of carbolic acid, make a good lotion for the purpose. Herpes. — The lesion of simple herpes, or fever sore, is a group of half a dozen vesicles, each of which is about as large as 32 INFLAMMATIONS OF THE HEAD a pin-head. These contain at first serum, hut later the fin id may become purulent. By drying, a crust results which falls off with- out leaving a permanent scar. The lesions are usually found either upon the face or the genitals. They are often seen on the lips in the beginning of acute disease, especially acute inflamma- tions of the respiratory tract. Any one group of vesicles lasts only a few clays, but new vesicles may form in the vicinity. A good plan is to paint the affected skin every two or three hours with spirits of camphor, or with tincture of benzoin. Carbolic salve may be applied to the surrounding skin in the hopes of preventing new lesions from forming. When a crust has formed, cold cream may be applied. Impetigo. — Impetigo contagiosa is an acute contagious dis- ease, the lesions of which are usually found upon the face. There is first noticed a number of vesicles which soon become pustules, and which may coalesce. Crusts form, dry up, and fall off, leaving no permanent scar because the lesion is, in most instances, confined to the more superficial portion of the skin. For the same reason, there is little induration about any pustule. Successive crops of vesicles appear, especially if the patient breaks the formed blisters or pustules by scratching. The essentials of treatment are cleanliness and antisepsis. Blisters should be punctured, crusts removed, and an antiseptic lotion or ointment applied. A good preparation is cold cream to which ammoniated mercury has been added in the proportion of fifteen grains to the ounce, or twenty grains of sulphur to the ounce. The sound skin in the neighborhood should be sponged with an antiseptic solution. A good one for the purpose is given under Urticaria. Acne. — Acne is defined as an inflammatory disease of the sebaceous glands of the face, chest, and shoulders. It is most dis- tressing to the patient when it appears upon the face. It is usu- ally chronic. A careful examination of the skin within the area affected will show that many ducts of the sebaceous glands are blocked up, and contain sebaceous material mixed with dust, hence the common name " blackhead." Other obstructed ducts are the centers of little red, inflamed papules. Pustules have formed around others, while there are numerous scars of similar lesions CELLULITIS 33 which have healed. Many of these lesions run their life history without sufficient suppuration to leave a permanent scar. There are three factors in the development of acne — blocking up of the sebaceous duct, presence of micro-organisms, and a low- ered power of resistance to these organisms on the part of the individual. Thus, digestive disturbances, the use of irritating drugs, menstrual irregularity, and other general causes exert a con- siderable influence. Acne is especially common between the ages of fifteen and twenty-five. Treatment. — Both general and local treatment should be em- ployed. Errors in diet should be corrected, out-of-door exercise encouraged, and such other measures instituted as will tend to improve the patient's general condition. Tree action of the bowels should be secured. Tonics are helpful, but no drugs should be given which are likely to upset the stomach. Local treatment is most important. The affected part should be washed every night with very hot water, and as strong a soap as the skin will tolerate. Tincture of green soap acts well in many cases. The soap should be thoroughly removed by hot water, the skin dried, and a stimulating antiseptic ointment rubbed into it. In the morning this ointment should be washed away with soap and warm water, the skin dried, and a soothing ointment rubbed into it. Cold cream answers the purpose very well. Only a small quantity should be used, and any excess wiped away with a soft cloth. A good stimulating ointment is benzoated lard to which has been added precipitated sulphur in the strength of one or two drams to the ounce. Instead of the ointment a stimulating lotion may be employed, such as one composed of four drams of pre- cipitated sulphur, two drams of alcohol, thirty minims of glycerin, and four ounces of water. The strength of the application used must be varied to suit different skins, and it is often of advantage to change the formula employed from time to time. There are many of these given in every book on dermatology. Individual acne pustules should be stabbed with a fine lancet or a three sided, straight glover's needle, and their contents gently expressed. Acne hypertrophica is described with new growths on page 83. Cellulitis. — Cellulitis of the head, whether it affects the hairy or smooth skin, presents the usual characteristics : namely, edema, 34 INFLAMMATIONS OF THE HEAD heat and redness, and, especially if pus is present, there will be pain on pressure. The scratch or slight wound through which the infection entered can usually be found. Often it is covered with a crust, beneath which will be found a drop or two of pus. Two questions are of importance. Is the cellulitis due to erysipelas? Is there a hidden focus of pus ? The distinguishing marks of ery- sipelas are given below. The presence of pus may usually be known by a greater tension of the swollen skin, and the pain which pressure causes at this point. If there is an abundance of pus fluctuation is a valuable sign, but it is unobtainable at an early stage. ISTote the enlargement of regional lymph glands. They may suppurate also in some cases. Treatment. — If the diagnosis is doubtful, or if pus has been found and evacuated, a moist antiseptic dressing should be applied and kept wet. ]STo gutta- percha tissue, nor other impervious material should be applied in such a manner that evapora- tion is prevented. Any mild antiseptic solution may be used, such as aluminum acetate, four per cent ; bichlorid of mercury, 1 : 2,000 ; creo- lin, 1: 200, or one of the proprietary articles, such as borolyptol, 1 : 4. The edge of the cellulitis should be marked with an indelible pencil or with nitrate of silver, and the temperature and pulse recorded every three hours. Examination on the fol- lowing day will determine whether the case is a simple cellulitis, or erysipelas, or whether the symptoms are due to hidden pus. Fig. 9. — Necrosis and Slough of Skin Due to Cellulitis. ERYSIPELAS 35 The severe effect of a peculiarly localized cellulitis is shown in Figure 9. The inflammation showed no tendency to spread, and no pus was present, but there was a considerahle necrosis of the skin resulting in the small ulcer shown in the photograph. Staphy- lococci were present in the tissues and the discharge. Erysipelas. — The face is the most common seat of erysipelas. It usually begins on one side of the nose as a dark pink blush. The affected skin is slightly edematous, so that the margin of the affected area is raised. This edge spreads at an appreciable rate, an inch or more a day, though not equally fast in all direc- tions. There is often pain in the affected part, and the constitu- tional symptoms are out of proportion to the extent of the skin involved. There is usually an initial chill, and the temperature is commonly above 102° every afternoon as long as the inflamma- tion is spreading in the skin. The infection enters the skin through some scratch or cut, which can usually be found if looked for. In the case of facial erysipelas this break in the skin is usu- ally to be found inside of the nose. The patient will often remem- ber to have forcibly removed some crust from the nose a day or two days previous to the attack. Treatment. — Compresses wrung out of a five per cent solu- tion of carbolic acid in equal parts of alcohol and camphor water will be found agreeable to the patient, and may assist in limiting the spread of the inflammation. The more radical method of em- ploying carbolic acid is to paint the skin immediately in advance of the inflammation with the liquid carbolic acid, ninety-five per cent. If the skin is at once wiped off with pure alcohol no injuri- ous caustic action of the acid will result. In this way extension of the erysipelas may sometimes be cut short; but those who have the opportunity of treating a large number of cases of erysipelas usually doubt the curative power of any application whatever. If abscesses form, they should be incised. The general condi- tion of the patient should be watched. . Laxatives, light or fluid diet, and possibly stimulants, are the essentials of treatment. As ery- sipelas is conveyed from one patient to another by contact, the sur- geon should, if possible, avoid touching the patient or his clothes, and should wash and disinfect his hands at the close of his visit. Similar precautions should be observed by the nurse or attendant. It is a good plan, if the patient is not too ill, to let him make the 36 INFLAMMATIONS <>F THE HEAD applications himself, thereby Lessening the risk of infecting some one else. Boil, or Furuncle. — The face is a common seat for boils, which do not, however, reach a large size, for the reason that the skin is thin and is well supplied with blood. Kvery effort should be made to cut short the infective process, because the lesion is so conspicuous, and also to avoid the disfiguremenl of a permanent scar. The diagnosis is simple. The swelling, redness, and tender- ness early attract the patient's attention. The only point to be decided is whether or not pus has collected in sufficient amount to make its evacuation desirable. If it shows as a yellow spot in the center of the swelling, the patient will usually permit its evacua- tion; and yet the necessity for this is sometimes far greater when the pus does not lie so near the surface. The presence of a tender, tense, and well localized swelling in or beneath the skin, always indicates a collection of pus under these circumstances. Treatment. — The best treatment is prompt incision, to allow the escape of pus and necrotic material. Specific directions for opening boils and abscesses are given in Chapter XX. A minute incision will often suffice for these small boils of the face. (Com- pare the treatment of acne pustules, page 33.) One should resist the temptation to squeeze pus out of the tissues after the incision has been made, as infection is often spread in this manner. A very short incision, say not more than a quarter of an inch in length, which should usually be crucial or T-shaped to prevent the rapid reattachment of the cut surfaces, is long enough for many boils of the face at an early stage. In most cases a minute drain, consisting of a loop of thread or a narrow strip of gutta-percha tissue, should be placed in the wound for twenty-four or forty-eight hours. A wet dressing greatly favors recovery. If it is necessary for the patient to go about, he may cover the wound with a bit of gauze and a piece of rubber plaster, removing this once or twice a day in order to soak the parts with hot water, and at night a large wet dressing should be applied. In some cases the application of ninety-five per cent carbolic acid directly into the center of the boil will stop the process and hasten the expulsion of the necrotic portion. In the case of minute STYE, OR HORDEOLUM 37 boils, the acid may be applied upon a toothpick, even though no incision has been made. The general condition of the patient should be investigated, and necessary advice given concerning diet and exercise. Laxa- tives are usually beneficial. A tablespoonful of brewer's yeast three times a day before meals is thought by many to have a specific action in recurrent cases. Sulphur and its compounds may also be given with benefit; for example, half a grain of sulphid of calcium twice a day. Stye, or Hordeolum. — A small boil at the root of an eyelash is called a stye. If untreated, one of these minute abscesses re- quires several days for its full development. It often causes great pain. Pus then escapes at the edge of the lid, the pain is relieved, and in several days the swelling disappears. There is a strong tendency to recurrence of the trouble in some other portion of the lid, so that it is no uncommon thing for a person to suffer from a series of styes, one or more developing at the same time, the whole series lasting possibly several weeks. Prophylactic treatment, which will also sometimes serve to abort a commencing suppuration, consists in the application of an ointment containing eight grains of the yellow oxid of mercury to the ounce of vaseline. It is also well to wipe the edges of the lids occasionally with a cotton swab wet with a 1 : 2,000 solution of corrosive sublimate. A formed abscess should be punctured with a sharp, narrow lancet. If the blade is thin and very sharp this is not a very painful procedure, and no anesthetic is required. To relieve pain either before or after puncture, hot, moist com- presses may be applied. Constipation should be corrected. Boils of the Nose and Ear. — Small but very painful boils form in the skin or mucous membrane attached to the cartilage of the ear or nose. Because of the close attachment of these struc- tures, the pain caused by the swelling is intense. An early incision is therefore demanded. Even the injection of a local anesthetic is very painful. Hence a strong solution, say a four per cent solu- tion of cocain, should be employed, and only a minim should be injected at first. When this has taken effect, the injection of the amount necessary to benumb the area of incision should be com- pleted. A moist dressing should be applied, or the part should be soaked with hot water every hour or so, in order to keep the cut 38 INFLAMMATIONS OF THE IILAD open until all the discharge has made its escape. As such boils tend to recur, the affected area should be .wiped twice daily with an antiseptic (creolin, one per cent; bichlorid of mercury, 1: 1,000). Abscess. — Suppuration in the deeper tissues of the face, the result of injuries and wounds, is usually prevented by the very free blood supply. Abscess may form, ^* „« however, in the 1 ^BpPMb, cheek, lip, Jr ^^ ' in the tongue. Such an abscess occurring in the lip is shown in Figure 10. Abscess of the scalp, or rather be- neath the scalp, of- ten follows the too hasty suture of a scalp wound; or it may develop from small infected wounds, especially in marasmic chil- dren. This is not to be wondered at. While the blood supply of the scalp itself is very free, there is just beneath it a loose fascia with large spaces and few blood- vessels — a favorable tissue for the multiplication of germs, once they are introduced into it. Diagnosis. — These abscesses are not difficult of recognition. The classic symptoms of heat, redness, tenderness, and edema are well marked. A small abscess in the tongue feels like a buried kernel. An abscess of the lip or cheek causes a very great swelling, which may obscure the exact presence of the pus until it is revealed by palpation. An abscess beneath the scalp yields a distinct wave of fluctuation. Treatment. — The length of the evacuating incision should be determined by the extent and nature of the abscess. In an Fig. 10. — Abscess of the Lip. Infection due to a blow by which the lip was cut against the decayed incisor teeth. Photograph six days after the injury. ABSCESS 3 ( J acute, rapidly spreading, suppurative cellulitis, incision should be made to extend at least as far as the visible pus formation, whereas it is quite unnecessary to apply the same rule to the slowly form- ing abscess of a marasmic child. In the latter case a small open- ing, equal to one-half the diameter of the abscess, is sufficient to effect a cure, and thus hemorrhage is lessened and considerable time is saved in the healing of the wound. The cavity of the abscess should be washed and wiped clean with saline solution or sterilized water and moist cotton swabs or dry sterilized gauze. It has been commonly recommended to break down any septa which may exist, but, unless these interfere with the thorough cleansing of the abscess, they should not be disturbed, as they almost invariably contain blood-vessels, and if broken down, hemorrhage follows and blood clots are added to the con- tents of the abscess cavity, and the nutrition of the overlying skin is interfered with. Many abscesses of a sluggish nature, if emptied and cleansed, will heal without further suppuration. Such a result is favored by the introduction of a granular gelatin containing formalin. This acts as a drain and contains enough formalin to retard suppuration. Or the wound may be kept open by slender strips of gutta-percha tissue or gauze, moistened with a weak antiseptic solution. Alveolar Abscess. — A common and often severe abscess of the face has its origin, as its name indicates, about the root of a de- cayed or broken tooth. The first sign of its presence is almost invariably a toothache. This may be due to congestion merely, but a violent toothache indicates pus with far greater certainty than most dentists are ready to admit. The pain is at first re- ferred to the affected tooth; but as the inflammation spreads the nerves leading to other teeth may be pressed upon, and the pain referred to those teeth. There are three confirmatory tests to deter- mine the exact location of the suppuration. Inspection will show the greatest amount of swelling in the mucous membrane along- side of the tooth involved. Secondly, if the teeth are lightly tapped with a metal instrument, the patient can usually recognize which one is diseased. In the third place, palpation will usually reveal the point at which there is the greatest swelling, and this, at least in the early stages of the trouble, corresponds to the root of the affected tooth. 40 [NFL WIMATInN'S OF THE HEAD The pus first forms between the root of the affected tooth and the bone in which it is placed — that is to say, in the tooth socket. As the pus increases in amount some of it may work its way to the surface and escape into the mouth alongside of the tooth. This Fig. 11. — Alveolar Abscess from Upper Incisor Tooth. Note the site of maximum swelling at the root of the nose. This is not a common type, as the pus usually breaks into the mouth early. will relieve most of the symptoms, and aside from slight tender- ness, the only remaining ones may be a little swelling and the escape of pus when the patient sucks the tooth or pressure is made on the gum. In most cases, however, absorption takes place, and the swelling extends beyond the gum immediately around the affected tooth. This swelling will next be noticeable in the face, and its situation will depend, of course, on the situation of the decayed tooth ; thus, if an upper incisor is at fault, the swelling will appear first at the base of the nose (Fig. 11). If the upper bicuspid or molar teeth are involved, the swelling may appear ABSCESS 41 further back in the cheek; whereas if one of the lower teeth is decayed, the swelling will be most marked just below it. The infection may travel still further, and involve a lymphatic gland. This may be very misleading. The upper teeth drain into lymphatic glands situated at the angle of and below the lower jaw. If the regional swelling above mentioned is slight and the first prominent swelling is due to involvement of the lymphatic glands which drain the sockets of the upper teeth, the most marked swelling will then appear in the vicinity of the angle of the lower jaw. It is well to bear these facts in mind, lest finding a swelling near the an- gle of the lower jaw, one may falsely con- clude that a lower tooth is at fault. This is what happened in the case of the boy shown in Figure 12, and a dentist extracted a sound lower tooth. The infective process con- tinued, of course, until more intelligent treat- ment was instituted. If an alveolar ab- scess starts from one of the lower teeth, the situation of the swell- ing is a more reliable guide to the source of the infection. Course of the Infection. — The pus at the root of the tooth may work its way out along the tooth and discharge into the mouth. Or, it may bore through the periosteum, and possibly a thin layer of bone, and discharge through the gum a little distance away from the juncture of the tooth and mucous membrane — say a quarter of an inch. This sinus is more often on the outer than on the inner side of the jaw. With the discharge of pus the acute Fig. 12. — Alveolar Abscess from Upper Molar Teeth. Note the site of maximum swelling at level of the lobe of the ear. 42 INFLAMMATIONS OF THE 11 HAD symptoms subside, but unless the tooth is tilled or removed the process may repeat itself. The pus may strip the periosteum from the maxilla, rupture the periosteum, burrow between the mucous membrane and the skin, or rupture through the shin externally, either in the cheek or beneath the lower jaw (Figs. 11, 12, 13). At this advanced stage of the process fluctuation can usually be made out. The lymphatic glands swell early in the course of the inflammation, but they do not always sup- purate. "When they do suppurate, the hard swelling which they form below the jaw be- comes fluctuating. Such a condition, secondary to infection from an up- per tooth, is shown in Figure 13. If an alveolar abscess is left to itself, its spon- taneous rupture either into the mouth or ex- ternally may give tem- porary relief of symp- toms or even effect a cure. Such relief is often postponed until a portion of the maxil- lary bone, deprived of its periosteum and bathed in pus, becomes necrotic. The sequestrum thus formed will keep up the suppura- tion. If a patient is examined in this stage he will have a general hard swelling, not easily indented by pressure with the finger, and which varies in size according to the drainage or lack of it through the existing sinus. The decayed tooth which was the cause of the trouble may or may not be recognized. Not infre- quently the patient has had it removed too late to stop the suppu- Fig. 13. — Alveolar Abscess from Upper Tooth, Secondary in Lymphatic Glands. The max- imum swelling is beneath the lower jaw. This is also the site of swelling in cases of alveolar abscess of the lower teeth, without glandular involvement. ABSCESS 4a ration, as the bone has already become necrotic. In other cases several decayed teeth are present, but no longer sensitive, so that it may be difficult to decide which one has caused the trouble. A probe passed into the sinus may or may not touch bare bone. The positive result of such examination is worth more diagnos- tically than a negative result. Furthermore, if bone is bare under such circumstances it is almost certainly dead. If necrotic bom- exists the probe may fail to touch it because the sinus is tortuous. The sequestrum usually lies to the inner side of the lower jaw, and the sinus passes beneath the jaw and reaches the surface of the face on the outer side of the jaw. It is not surprising if so Fig. 14. — Recurrent Alveolar Abscess. Duration, twenty-five days. badly drained an abscess recurs from time to time. Such an ex- perience was that of the patient shown in Figure 14. If the sequestrum is a large one, two or more sinuses may exist. In such a case a part of the swelling which exists is due to the formation of new bone. The periosteum of the lower jaw is abundantly supplied with blood, and does not die easily. If 44 INFLAMMATIONS OF THE HEAD it is stripped up from the old bono by the pus it immediately be- gins to form new bone, so that in long standing cases the removal of the sequestrum may be rendered difficult by the thick shell of new formed bone which surrounds it. Another possible termination of an acute abscess is a persistent sinus. So long as this suffices to carry away the slight discharge, it will prevent the re- formation of an ab- scess. Usually, how- ever, the drainage obtained in this man- ner is imperfect, swelling or granula- tions block the sinus, edema reappears, and if the sinus is not re- opened another abscess forms. Such a sinus giving imperfect drain- age existed in the Chi- nese patient shown in Figure 15. The per- sistent discharge is an indication of the exist- c nee of dead bone or a decayed root of the tooth. A continued swell- ing is usually an indi- cation of decay of the root of the tooth or of the adjacent bone; there are also cases in which, although no sequestrum can be made out and no pus escapes externally, the irritation about the roots of the affected tooth is sufficient to form a chronic swelling. Possibly in such a case there may be a little suppuration which constantly makes its escape into the mouth. Figure 16 shows a patient who gave a his- tory of continued hard swelling long after the active suppuration had ceased. As long as such a patient retains the roots of the de- cayed tooth he is exposed to a recurrence of the acute suppuration. Fig. 15. — Chronic Alveolar Abscess from De cayed Tooth, of Seven Months' Duration The abscess was lanced, but a sinus persisted. ABSCESS 45 Finally, alveolar abscess may lead to the development of a malignant growth, as shown in Figure 17. Treatment. — Treatment at any stage of an alveolar abscess, to be considered intelligent, must be directed toward removal of the cause. If a toothache is due simply to congestion, a local irri- tant, such as oil of cloves, chloroform, etc., with or without the internal administration of morphine or some other anodyne, may be considered appropriate treatment. If, however, the toothache is due to an inflammation about the root of a tooth, it must be looked upon as a real infection, similar, for example, to a cellu- litis preceding from an unclean sliver in the finger. The site of the infection should be thoroughly exposed and drained so that absorp- tion of the poisonous ma- terial may cease. The source of the infection is invariably found in the decay of a tooth or the root of a tooth pre- viously extracted. Such a tooth should be treated or extracted without de- lay, no matter in what stage the infection may be. If the tooth is con- sidered by the dentist to be worth saving, its cav- ity should be cleaned and disinfected so that further absorption shall not take place. The fill- ing of such a tooth may be postponed until the acute symptoms have subsided. If a tooth is too far gone to be saved, it should be immediately extracted. Many dentists object to the removal of a tooth if an abscess is present, and advise the patient Fig. 16. — Alveolar Abscess from Decayed Lower Teeth; lanced inside and outside six weeks previously. Roots of teeth not removed. Swelling due to fibrous induration. No sinus and no pus, as far as can be made out. 46 INFLAMMATIONS OF THE HEAD to wait until the abscess lias been cured. This is bad advice. It would be just as logical to wait for a cellulitis of an arm to subside before extract- ing the splinter in the hand which caused it. In a great many in- stances the extraction of a decayed tooth or of an old root will give the ]>ns formed about its deeper portions a free opportunity to escape into the month, so that the abscess drained in this manner will rap- idly subside in a few hours. Even if suppu- ration has extended so far from the tooth that the extraction of the latter will not afford sufficient drainage, it should still be insisted upon, as removal of the source of trouble will hasten the recovery, will relieve the patient at once of a consider- able amount of pain, and will prevent also the recurrence of the abscess and the other complications spoken of above. If further drainage is necessary, as it is in every advanced case of alveolar abscess, the incision should be made through the gum rather than through the cheek. In suppuration of the lower jaw the drainage through the mouth is an attempt to cause pus to flow up hill, but it will in many cases succeed if the incision through the gum is a wide one and the abscess cavity is syringed out once or twice daily with diluted peroxid of hydrogen and kept open by antiseptic gauze. A day or two will prove Avhether or not this attempt will be successful. If not, an external incision Fig. 17. — Tumor Following Alveolar Abscess, thought to be Sarcoma. Tooth ulcerated three and one-half months previously. ACUTE CONJUNCTIVITIS 47 should also be made. This need not be a very Long one, since the internal incision should still be kept open, and will provide; for the escape of most of the pus. An external incision is to be avoided, not only on account of the annoyance to the patient of a bandage around the head, but because the resulting scar is some- times attached to the jaw bone, and thus forms a prominent dim- ple. This need not be a permanent disfigurement, however, for such a dimple may be removed by excision of the scar, dissection of the skin for a half inch in every direction, and suture of the skin. It is better not to perform this plastic operation till some months have passed, lest viable germs in the tissues may be roused into activity, and suppuration defeat the end of the operation. A sequestrum of the jaw, due to delayed drainage, will usually loosen in a few weeks, so that it may be extracted through an en- larged sinus, either within the mouth or externally. Sometimes it is necessary to chisel away some newly formed bone to make a larger exit. In most cases, if a general anesthetic is given, so that the surgeon does not feel the need of haste, he can twist the sequestrum back and forth, and perhaps break off some portions of it, until it can be withdrawn without chiseling away any living bone. INFLAMMATIONS OF THE EYE There are some inflammations of the conjunctiva which will be here discussed because of their frequency and importance, and because they are amenable to local treatment. Acute Conjunctivitis, or Simple Catarrh. — Acute in- flammation of the conjunctiva may be divided, for practical pur- poses, into the cases which are due to the gonococcus, and into those which are not thus caused. The latter cases are sometimes called simple or catarrhal or muco-purulent conjunctivitis. The usual signs of a mild catarrh are present. The secretion is increased, the blood-vessels are injected, there is a little swell- ing of the conjunctiva. There is a sense of heat and heaviness in the eye. In cases which develop spontaneously both eyes are affected at the same time or one soon after the other. A number of micro-organisms have been isolated from eyes in such a mild state of inflammation, and it has been demon- 48 INFLAMMATIONS OF THE HEAD strated thai catarrhal conjunctivitis may occur in epidemic form. One eve may l>e involved alone as the result of traumatism. The inflammation in catarrhal conjunctivitis may go on until small ulcers are formed, hut this is the exception rather than the rule, and the outcome is complete recovery in almost all cases. Trkatmkxt. — Tt is well to remember that most cases of ca- tarrhal conjunctivitis are distinctly contagious, and the infection may be transferred from one eye to the other, or from one person to another. Anything, therefore, which comes in contact with the affected eye should be immediately sterilized or destroyed. In serious cases the patient should he kept in a dark room, and several pads of gauze, four or five layers thick, should he kept on a lump of ice by the bedside and placed by the patient upon his closed eye. Every few minutes, as they become warm, they should be changed. Several times a day the eye should be irrigated with a three per cent solution of boracic acid. When the irritation is less intense, an application of a twenty per cent solution of argyrol, or a one per cent solution of nitrate of silver, should be applied by the surgeon to the everted lids, and almost immediately neu- tralized by a saline solution. Or the patient may be given a solu- tion of sulphate of zinc, two grains to the ounce, a few drops of which he should instill into the affected eye once or twice daily. The edges of the lids should be smeared at night with a simple ointment, so that they may not adhere and prevent the escape of secretion. Purulent Conjunctivitis. — Infection of the conjunctiva with the gonococcus is a serious affection, since it often produces extensive corneal ulcers, which may perforate and allow the iris to prolapse, and which in any event are likely to heal with opacity. The disease occurs generally in new born infants, or in adults. If the child's eyes are infected during birth, the inflammation ap- pears from the second to the sixth day. If it appears later than this, it is due to postnatal infection. In both infants and adults the inflammation is due to contamination of the eye by the fingers, or some object which has been in contact with a discharge contain- ing gonococci. In the first day or two the patient notices pain in the eyelids and eyeballs, and sensitiveness to light. There are fever and swelling of the lymph glands in front of the ears. Later the dis- GRANULAR LIDS OR GRANULAR CONJUNCTIVITIS 49 charge from the eyes becomes purulent, and the swelling of the lids is so great that they overlap or are everted. Ulcers of the cornea develop. The disease lasts in moderate cases from four to six weeks. Treatment. — Prophylactic treatment is most important for infants and for adults as well. The eyes of every child after birth should be carefully washed with sterile water or boracic acid solution, and if there is the slightest possibility of contagion from the mother, a few drops of a one per cent solution of nitrate of silver should be instilled into each eye. Most cases in adults are due to autoinfection, and therefore every physician caring for a patient with gonorrhea should explain to him the risk of infect- ing his eyes, and give him directions in regard to the use of towels, cleanliness of his hands, etc. The patient with purulent conjunctivitis should remain in bed in a darkened room. Ice compresses should be kept on the eyes at least one-half of the time, and the eyes should be frequently irrigated with a solution of permanganate of potash (1: 10,000). The free use of small doses of calomel will do much to decrease the swelling and lessen the risk of corneal ulcers. The edges of the lids should be smeared with boric acid ointment to prevent their adhering. After the first few days a three or four per cent solution of nitrate of silver may be applied by the surgeon to the everted lids and neutralized with a saline solution. This treat- ment may be repeated once a day, or once every second day. The patient should be careful not to infect the sound eye, and should sleep with this eye uppermost, so that no secretion may trickle into it. At the first sign of redness, the sound eye should be treated with a two per cent solution of nitrate of silver. Stye.— (See p. 37.) Granular Lids or Granular Conjunctivitis. — Eepeated irritation of the eye will often result in an injection of the blood- vessels of the eyelids, and a dry and rough, almost sandy feeling. Badly nourished individuals, such as anemic children and overfed adults with a uric acid diathesis, are especially liable to this con- dition. In many persons it is brought about in a mild degree by the excessive use of the eyes, or by the lack of suitable glasses, or by exposure to wind or dust. An inspection of the lids, and especially the upper one, will 50 INFLAMMATIONS OF THE HEAD show that the normal smooth pinkish lining presents an angry appearance, due to the injection of the blood-vessels, and thai by oblique illumination the surface is irregular, suggesting granu- lations. In mild cases the removal of the cause and the instillation into the eye of a few drops of concentrated boric acid solution twice daily will speedily effect a cure. If lithiasis exists, urinary dilu- ents should be given with several glasses of water daily in addition to the local treatment. If these simple measures fail, the con- junctiva of the lids should be wiped occasionally with a crystal of copper sulphate. Trachoma. — The disease is marked by the formation of whitish or pinkish bodies in the conjunctiva, especially of the upper lid. It is generally considered to be contagious, although it is much more common among anemic children, and those who are crowded together in rather unhealthful surroundings. The affected eye, in addition to the granules above mentioned, usually shows the signs of catarrhal inflammation, and in a later stage there are dilated blood-vessels and the formation of fibrous tissue over the cornea as well as over other portions of the eye. In this manner the vision may be completely lost. Treatment. — One of the best methods of treatment is the application of a smooth crystal of sulphate of copper to the af- fected conjunctiva. For fifteen minutes thereafter, cold wet appli- cations should be made to the eye. In severer cases, the granula- tions are scraped or cut away or squeezed out. For the details of such treatment the reader is referred to special text-books upon the eye. Any treatment to be successful must be continued for months, until the tendency to form new granulations has been entirely overcome. As the presence of this disease keeps a child out of school, and for that reason, even without a permanent impairment of sight, seriously handicaps his future, those in charge of public institutions containing children should spare no pains to prevent this disease and to eradicate it when it occurs. Ingrowing Lashes or Trichiasis. — It sometimes happens that the eyelashes, instead of growing in the normal direction, curve inward and thus become a constant source of irritation to the eyeball. This is one of the complications of granular conjunc- OTITIS MEDIA 51 tivitis. A wedge-shaped strip may be cut from the outer surface of the eyelid and the wound sutured. The wedge must, of course, include the whole thickness of the cartilage of the eyelid in order to secure a permanent eversion of the lashes. The lines of the incisions should be parallel to the edge of the lid, and the one nearest the edge should be distant from it an eighth of an inch, so as to avoid the roots of the eyelashes. For the details of this operation the reader is referred to text-books upon the eye. Single lashes may be extracted by means of smooth forceps — that is, for- ceps whose points are free from ridges or teeth, for the latter would be apt to break the hairs. This is naturally a purely palli- ative procedure, as the lash will soon grow in exactly as before ; but the relief occasioned by it is immediate and so gratifying that the patient will gladly return month after month to have the offending hairs again extracted. If only two or three hairs forming a single group are turned inward, the simplest method of cure is the removal of a small sec- tion of the edge of the lid containing these hairs, and the suture of the gap thus caused. INFLAMMATION OF THE EAR Otitis Media. — This is a common disease of childhood, usu- ally following a cold in the head. The prominent symptom is ear- ache. Every physician ought to be able to recognize the bulging outward of the membranum tympani and to relieve the pressure by incision of the membrane at the most favorable situation — viz., the inferior and posterior portion. The introduction of warm olive oil into the external meatus will sometimes relieve pain, and the application of external heat may also be tried ; but the pain of a severe earache, unless relieved by puncture of the membrane, usually demands the internal administration of morphine. The membrane usually ruptures spontaneously in the course of a day or two. Pain is then relieved, and a muco-purulent discharge be- gins and continues for a time. After it ceases the membrane soon heals over. While the discharge continues, the treatment consists in cleanliness. The ear should be syringed gently once or twice a day with warm normal salt solution, and wiped dry with absorbent cotton. 6 A9 INFLAMMATIONS OF T1IK JIKA1) Unfortunately, this simple termination is not the only one which is possible, for inflammation of the middle ear may extend to the mastoid cells, and result in abscess within the cavity of the mastoid bone. If prompt drainage is qo1 instituted, the suppura- tion may extend into the lateral sinuses and to the membranes of the brain, causing the death of the patient. Hence the necessity of early recognition of the disease and prompt treatment before these serious complications have arisen. The external ear should be cleansed by washing it with small cotton swabs wet with a warm antiseptic solution, and the mem- brane anesthetized by the instil- lation of a few drops of a ten per cent solution of coca in. An ear speculum should then be introduced, the membrane in- spected by reflected light or a headlight, and incised in its lower and posterior portion by means of a long slender scalpel bent in the handle at an angle. N l . Fig. 18. — Sketch of the Normal Right Fig. 19. — Angular Knife for Incision Tympanic Membrane. Showing the of the Tympanic Membrane. correct site for incision. Figure 18 shows the normal membrane, and the correct size of an incision, which should be of sufficient length to permit the escape of the pus and mucus. Figure 19 shows a good knife for making the incision. When the incision has been made through the bulging mem- SUPPURATION IN THE FRONTAL SINUSES 53 brane, a few drops of pus and mucus and often a little blood will escape. Irrigation is not necessary, but the auditory canal should be sponged clean with cotton-tipped probes dipped in a warm antiseptic solution. In the case of a nervous or restless child, it is best to perform this operation in general anesthesia. The inci- sion can then be more accurately made. The after treatment consists in cleanliness. The canal should be wiped or washed clean, and the inner ear protected from tem- perature changes by a small cone of dry absorbent cotton intro- duced after each cleansing and as often as the previous cone be- comes moist. Boils. — A description of boils of the external auditory meatus is given on page 37. INFLAMMATIONS OF THE NOSE Acute rhinitis may be accompanied by a troublesome herpes of the lower portion of the anterior nares and the upper lip. The application of menthol in albolene (gr. x— Sj) gives some relief. The surrounding skin should be smeared with carbolic salve to pre- vent the spread of the process. Chronic Rhinitis. — The usual outcome of chronic rhinitis is hypertrophy or atrophy of the mucous membrane of the nasal pas- sages. Hypertrophy of the inferior turbinate bone in many cases is best cured by removal of the major portion of this bone. This is a minor surgical operation, and one whose technical difficulties are not great, but the decision as to the necessity for its per- formance and as to the manner of its removal demands a thorough knowledge of the pathology of the nose, which the reader will find fully given in books upon that special topic. There are, however, two complications of rhinitis which may require immediate treatment, and which are therefore here de- scribed. Suppuration in the Frontal Sinuses. — In many cases of influenza and other forms of rbii litis the inflammation and swell- ing of the mucous membrane extends to the accessory sinuses of the nose, the most important of which are the frontal sinuses and the antrum of Highmore. Such extension prolongs the attack and 54 INFLAMMATIONS OF THE HEAD increases the discharge, but usually subsides in a few days. In addition to the general symptoms of infection there are usually pain and tenderness throughout the area occupied by the sinus, so that the diagnosis is not difficult to make if its possibility is borne in mind. In certain cases the inflammation becomes purulent in char- acter. Even then the patient is ordinarily relieved by a discharge of pus and mucus through the natural opening. Should relief be not afforded in this manner, the sinus may be drained through l he nose after removal of the middle turbinate. This requires special teclmic. If the symptoms are severe, and especially if there is reason to feel that extension to the brain is threatened, an incision should be made through the eyebrow and the sinus drained directly by chiseling through the bone, either above or below the margin of the orbit. This operation is extremely sim- ple, if one has at hand a small sharp chisel, and in certain cases it saves a person's life. The wound should be drained until the suppuration ceases. There is only a slight permanent scar. Suppuration in the Antrum of Highmore. — Like sup- puration in the frontal sinus, this follows acute coryza, but it may also be secondary to diseases of the teeth, especially of the canine tooth. The symptoms are pain and fulness in the roof of the mouth, usually with intermittent discharge of pus from the nose. This temporarily relieves the symptoms. Transillumination is a valuable means of diagnosis. A small electric lamp held in the closed mouth shines through the affected side with much less power than through the normal. Treatment. — A large, curved trocar and canula should be passed through the septum between the antrum and the inferior meatus of the nose. Through this canula the pus can be washed out. This washing should be repeated daily with warm Dobell's solution. A smaller canula should be employed for the subsequent treatment, so that it can be passed through the opening first made without difficulty. More direct drainage is obtained by chiseling away a part of the anterior wall of the antrum through an incision made at the reflexion of the mucous membrane from the upper jaw to the cheek. This incision should extend from the canine tooth to the PERITONSILLAR ABSCESS . r )5 first molar. If the canine or one of the bicuspid teeth is already diseased, the opening may be made through its socket. The sinus should be irrigated daily for a week or two until the suppuration subsides. Boils.— (See p. 36.) INFLAMMATIONS OF THE MOUTH AND THROAT Stomatitis and Gingivitis. — The occurrence of these low degrees of inflammation in the mouth usually indicates a low degree of vitality, or in certain cases that the vitality has been reduced by poisons — for example, mercury. Treatment. — The general condition should be improved by changes in diet and tonics. If there is a local cause for the trouble, such as decayed or neglected teeth, this should be attended to. The patient should be given a stimulating mouth wash, such as a solution of permanganate of potash, one grain to the ounce ; or a mixture of tincture of myrrh, one part in twenty of water. The inflamed gums may be painted with the tincture of myrrh. Such inflammations, even when severe, rarely lead to suppu- ration, and require no operative treatment. Alveolar Abscess. — (See p. 39.) Peritonsillar Abscess. — Certain cases of acute tonsilitis are followed by the formation of an abscess, either within the tonsil or, as is more common, in the tissues around it. In the latter case the most common situation is above the tonsil. It is of importance to recognize early the collection of pus, either within or outside of the tonsil, since its early evacuation before a large abscess cavity has formed greatly shortens the course of the disease. Sometimes the patient first recognizes the extension of the swelling outside of the tonsil. Inspection will show the mucous membrane over the abscess to be of a dusky red hue, and the palpating finger will reveal an area of induration with fluctuation in its center. Under such circumstances an incision should be promptly made. Nothing but pain is gained by delay. Treatment. — As soon as the abscess is recognized it should be evacuated through a suitable incision. The mucous membrane is readily cocainized by the application to it for five minutes of a swab wet with a ten per cent solution of cocain. If there is any 56 INFLAMMATIONS OF THE HEAD doubt as to the situation <>t' the pus, aspiration should be per- formed. A hypodermic syringe is sufficiently large for the pur- pose, provided a needle of good size be employed. The incision should be made in the center of the abscess, the stroke being from without inward in order to avoid wounding any deep vessel. When the abscess cavity has been opened, the incision may be enlarged with knife or scissors in whatever direction will give the best drainage. If a drain is to be employed, it is a good plan to cut out a small triangular portion of the mucous membrane to insure an opening sufficiently Large to permit the reinsertion of the gauze. It is a good plan to syringe the cavity once or twice a day with a mixture of one part of peroxid of hydrogen to eight of water. Retropharyngeal Abscess. — Abscess between the posterior wall of the pharynx and the cervical vertebrae is usually seen in badly nourished children, and is secondary to infective processes in the nose or throat or ear in the large majority of cases. The immediate symptoms of an abscess in this situation r.re pain and difficulty in swallowing and in breathing. The general symptoms of unrelieved suppuration, high pulse and temperature, anorexia, etc., are well marked. The posterior wall of the pharynx bulges forward toward the soft palate, and may often be felt to fluctuate when palpated. As a further confirmation of the diagnosis, and as a guide to the inci- sion, the boggy swelling should be aspirated with a needle of good size. Pus having been located, should be at once evacuated. It is exhausting to the patient to allow it to remain, and there is in this case the added danger that the abscess may rupture dur- ing sleep, and the patient be drowned in the pus which pours into his throat. Treatment.- — When the pus has been recognized, it should be evacuated through an incision made in the median line of the pharynx as low down as possible. A child should be wrapped and pinned in a sheet so that his arms can be easily controlled, and a good mouth-gag placed in position. A few inhalations of chloroform do not materially add to the risk of operation, and spare the feelings of patient, mother, and doctor. Various posi- tions for the patient have been recommended, all of them with the idea of giving the operator a good view of the throat and pre- ECZEMA 57 venting the evacuated pus from flowing down into the larynx. A horizontal lateral position is perhaps as good as any. The finger should guide the knife, all but the point of which should be pro- tected by wrapping it with adhesive plaster. The most prominent point in the swelling should he punctured, and the incision quickly enlarged either upward or downward, as the case may require. The knife is then withdrawn and the body of the child somewhat elevated and turned so that the pus may flow out of the mouth. The abscess cavity should be irrigated with saline solution, but not drained. By palpation the operator should convince himself that a sufficient opening has been made to assure free drainage. Hemorrhage may be controlled by a temporary packing of the wound with gauze. The after treatment consists in attention to the general health of the child and irrigation of the cavity, should it show any tend- ency to close and allow accumulation of pus. Should this not be the case, it is unnecessary to annoy the child with irrigation, which, of course, has to be carried out in a partially inverted position. It has been recommended to open a retropharyngeal abscess laterally through an incision made in front of the sternomastoid muscle. This route should only be followed in case the pus has already burrowed in that direction. Otherwise the dissection is difficult and not without risk, and the drainage is not always satis- factory by this route. INFLAMMATIONS OF THE SKIN Acute suppurations of the skin are described on page 32. Eczema. — Eczema of the face or scalp is often accompanied, especially in children, by abundant secretion, which as it dries forms crusts. These in turn increase the itching, and as they are torn off, raw surfaces result, so that blood mixes with the serum in the formation of new crusts. It is not surprising under the circumstances that the skin becomes infected and local cellulitis develops, or possibly suppuration in the regional lymph nodes (see Fig. 77, p. 130). The risk of infection is greatest when the eczema involves the scalp of a young child. Treatment. — In order to avoid the complications of infection, the scalp should be saturated with sweet oil for some hours to 58 INFLAMMATIONS OF THE HEAD soften the crusts. These should then be removed and the head gently but thoroughly washed with hot water and soap, and the hair cut short. Compresses saturated with such a lotion as four per cent aluminum acetate, or one half per cent creolin, should then be applied. When the inflammation has somewhat subsided, Lassar's paste or boraeic acid ointment should he used. It is gen- erally supposed that it aggravates an eczema to wash the skin with soap and water, but if this is gently done, the skin thoroughly dried, and some greasy application is at once made to replace the fat extracted by the soap, the benefits of cleanliness are obtained without harmful results. Whatever the remedy chosen, such general measures as tend to improve the nutrition of the child should he attended to, and scratching should be prevented, even though the hands have to be tied. Ringworm. — Ringworm, whether of the non-hairy skin, scalp, or bearded face, is due to the growth in the skin of certain fungi. The disease is therefore contagious, and may be trans- mitted by contact or by an exchange of articles of clothing, towels, etc. The patient affected is usually a child or young adult. The tendency of the infection to spread equally in all directions gives the lesion a more or less circular appearance, and if the skin affected contains few hairs the center of the area may have re- sumed a normal appearance while the growth is still active at the periphery. The rate of growth varies, being at first more active, so that a ring an inch in diameter may he formed in two weeks in the non-hairy skin. Later; there is a tendency for the disease to die out, so that the ring may he incomplete or exist only in spots. If the ringworm occurs in the scalp or bearded face, the scaliness observed upon the non-hairy skin is much exaggerated, crusts are added, and there is incomplete loss of the hair within the affected area. Treatment. — The affected area should be washed free from scales and crusts by green soap and water. If the non-hairy skin is affected, the disease can he speedily cured by washing the part with a solution of bichlorid of mercury, two grains to the ounce of water. Other strong antiseptic solutions are equally efficacious. If the hairy skin is affected, a depilatory should be applied to get rid of the stumps of hair. Stelwagon recommends a mixture of SYPHILIS 59 three drams of barium sulphid and two and a half drams each of zinc oxid and powdered starch. At the time of use, this is rubbed to a paste with a little water and applied for five to ten minutes and then washed off. Sulphur ointment, diluted if necessary, should be rubbed into the area every day or two. Another plan is to paint it with a solution of chrysarobin in chloroform, and to cover this with two or three coats of collodion. Many other anti- septics, both in salves and lotions, have been employed with suc- cess. One should persist in treatment until every trace of the disease has disappeared. Ulcers. — Simple ulcers of the face occurring in marasmic per- sons, especially young infants, are readily healed if the general condition of the patient can be improved. Cleanliness and a sim- ple dressing — for example, a wet dressing of creolin, one per cent — are the only local treatment needed. The question of syphilis ought always to be considered. Anthrax, or malignant pustule, is found on the hands and arms perhaps more frequently than on the face and neck. It is described on page 132, where a clear picture of an early pustule is given. Noma. — This is a localized gangrene of the face and mouth, usually seen in a person exhausted by some infectious disease. It begins in the mucous membrane of the gums or cheeks. The tis- sues are first indurated, and then become gangrenous. There is no fever. The process leads to perforation of the cheek, loss of the teeth, necrosis of the jaw, etc., and usually terminates in death within a w T eek or ten days. CHRONIC INFLAMMATIONS Syphilis. — The primary lesion of syphilis is occasionally found in the lip or cheek or tongue. The unusual site of the lesion and the fact that it may be found here in the pure-minded, often lead to an error in diagnosis. Hence the exact appearance of the indurated sore is of great importance. Infection usually takes place through a visible break in the skin — a cigarette burn in one of the cases figured in the accompanying illustrations — but such a break will be obscured by the primary sore in a few days. In a week or two the induration and redness become marked. (ill INFLAMMATIONS <>K THE HEAD Fig. 20. — Chancre of Lower Lip of Nine Days' Dura- tion. Patient a man aged thirty-six years. Lf the lesion is on the lip (Fig. 20), its dcvelopinenl is similar to thai of a chancre of the penis. There is the same elevated, com- paratively painless swelling with shal- low ulceration, but later the extenl of the deep indura- tion usually ex- ceeds thai found in an unmixed sore of the penis ( Fig. 21). When the pri- mary lesion occurs in still thicker skin (for example, that of the cheek), this induration and the subsequent ulcer are still larger than is usu- ally the ease when the primary sore occurs in the genitals. In a few days the surface is covered with a dry scab (Fig. 22) if the lesion is out of the area bathed with the saliva. The regional lymphatic glands are swollen, but are not very tender. A few days later the scab falls off, and a shallow ulcer is formed (Fig. 23). As healing takes place the induration subsides, the ulcers become filled with granula- tions, and the epithe- lium grows over it. The only permanent disfigurement is a small scar containing, perhaps, a little pig- ment. This is insig- nificant when compared with the active lesion, so that in this respect the patient may be encouraged. The persistence of the lesion for a week or more in a healthy Fig. 21. — Chancre of Lower Lip of Three Weeks' Duration. Patient a man aged twenty-four years. SYPHILIS 61 patient, arid the Large amount of induration without suppuration, serve to distinguish the primary sore of syphilis from a simple ulcer. The possible youth of the patient, and the disappearance of induration either with or without the use of antisyphilitic remedies, serve to distinguish it from cancer. Cancer is the more Fig. 22. — Chancre of Cheek, Developing in Burn from Cigarette. Duration of lesion 2 months. — Patient aged 19 years. unlikely if the lesion is in the skin of the face, away from the mucocutaneous junction of the lip. Treatment.— Local treatment, while not essential, relieves the feelings of the patient. The sore should be covered with a collodion dressing, or with simple ointment and a small patch of muslin. Mercuric ointment, on account of its suggestive color, should not be employed — at least by day. Internal treatment is all important. A tablet of ^ of a grain of mercuric protoiodid 62 INFLAMMATIONS OF THE HEAD should be taken after each meal, or ^ of a grain of mercuric bin- iodid with 10 grains of potassium iodid, well diluted in water. Some physicians prefer treatment by injection — e. g., £ grain of bichlorid of mercury in water three times a week, or 5 to 8 drops of a ten per cent emulsion of the salicylate of mercury in albolene, once a week. Secondary Lesions. — Mucous patches which develop in the mouth and throat (luring the secondary stage of syphilis in some Fig. 23. — Chancre of Cheek from a Bite. The ulcer is granulating. cases make the patient very uncomfortable, and may lead to sup- puration in the cervical lymph glands. Gargles and sprays of mild antiseptics give some relief, but the chief treatment consists in the regular administration of mercury and potassium iodid. The sec- ondary eruption on the skin of the face, and particularly of the forehead, annoys the patient by calling attention to his disease. TUBERCULOSIS 63 Mercuric ointment rubbed into the individual patches at night, and wiped off with a dry cloth in the morning, is thought to hasten the disappearance of these lesions. Occasionally a well-developed le- sion may be mistaken for a new growth (Fig. 24). Tertiary Lesions. — Gumma may develop in the scalp or face, or in the tongue or throat or nose. It produces a deep-seated ulceration which heals only after the permanent destruction of more or less tissue. There is also a chronic syphilitic thicken- ing of the tongue known as glos- sitis. The whole tongue is harder and thicker than normal, and the mucous membrane in particular is furrowed and ridged and more shiny than normal. Gumma of the scalp often involves not only the skin, but the periosteum and a part of the skull, so that there may be necrosis of some portions of the outer table of the skull. The separation of these necrotic portions may re- quire months. Until they are entirely removed complete heal- ing is, of course, impossible. The pus which undermines the scalp around the margins of the sequestrum may require incisions for its perfect drainage. These late lesions of syphilis, with the exception of the glossitis, usually yield readily to antisyphilitic treatment, and especially to the administration of large doses of iodid of potash up to a dram three times a day. Local treatment is unimportant. There is no excuse for keeping a patient's face or head smeared with an offensive mercurial ointment. Mercury can be administered more pleasantly and more accurately by mouth or by injections or inunctions. Moreover, under suitable moist dress- ings, repair takes place more rapidly than when mercuric ointment is used. This has been demonstrated by careful measurements. Tuberculosis. — When the skin is the seat of tuberculosis, the lesion is spoken of as lupus vulgaris. The face is the commonest Fig. 24. — Papilloma of Lip, Found on Microscopical Examination to be Syphilitic. Duration of lesion 2 months. Patient aged 28 years. CA INFLAMMATIONS OF THE ll I. Ah situation for this disease, especially the skin of the nose and cheeks. A number of reddish areas as Large as a pea, perhaps, are firsl noticed in the corium. They pale on pressure, appear- ing yellowish or brownish. As the disease spreads, the tissue first involved may ulcerate, or it may atrophy and hecome cicatricial in character. As the course of the affection is a very chronic one, often lasting for years, the appearances of the lesion vary greatly and a variety of names have been applied to indicate these differ- ent stages, the minute description of which will be found in any hook upon skin diseases. Diagnosis. — Small patches of lupus may he confounded with psoriasis, but inquiry into the history will usually serve to elimi- nate this error. The lesions of psoriasis are persistent, but do not involve the deeper parts of the skin, do not extend so steadily, and do not ulcerate. Lupus may also be confounded with rodent ulcer. In this disease the destructive process is more notice- able, while the reparative is less so; but in certain instances a microscopical examination may be necessary to differentiate the two. Treatment. — The diseased tissue may be removed by the curette, or by caustics, or by the knife. The advance of the growth has sometimes been checked by linear scarifications about one- eighth of an inch apart and crossing each other at right angles. Ultra-violet rays and the x-ray have also been employed with good effect in many cases. These last-named agents have the merit of destroying the pathologic tissue with far less resulting scar than chemical caustics or the knife. Tuberculosis of Nose and Mouth. — Tuberculosis of the nose, mouth, or throat is of rare occurrence, and when seen is usually secondary to tuberculosis of the lung. It appears in two forms, either productive or ulcerative. Both processes may be exhibited in a single lesion. It may be difficult to differentiate tuberculosis from syphilis until a microscopic examination of an excised por- tion of tissue has been made, or the patient has been subjected to treatment by mercury and iodine. Tuberculosis of the mouth, secondary to the pulmonary dis- ease, is shown in the accompanying photograph (Fig. 25). Treatment. — General hygienic treatment is important, Local treatment, such as the application of caustics or the partial exci- GLANUKHS or. sion of tuberculous tissue, has little effect upon the progress of the disease while in this situation a thorough excision is impossible. Fig. 25. — Tuberculosis of the Gum, Secondary to Pulmonary Tuberculosis. Actinomycosis. — This should be borne in mind as one of the chronic inflammatory lesions liable to occur in the face, and espe- cially about the mouth or jaw. It begins as a smooth swelling, but later abscesses form and discharge pus containing yellowish granules. These may be recognized by the naked eye or under the microscope as colonies of the ray fungus. They are character- istic of the disease. The fungus of the disease in man is similar to, but probably not identical with, that of the disease in cattle called " lumpy jaw." Treatment consists in the excision of diseased tissue, and the administration of iodid of potash. It is often unsuccessful. Glanders. — This disease of the horse and other animals, when acquired by man, usually shows its first growth in the mouth, nose, eyelids, or skin of the face. It is characterized by cellulitis, lymphadenitis, and inflammatory nodules which break down into ulcers with undermined borders. Treatment is by excision and drainage. In rapidly spreading cases, the prognosis is grave. CHAPTEK III TUMORS AND DEFORMITIES OF THE HEAD CYSTIC TUMORS Milium. — There are often found in the skin of the face, espe- cially near the eyes, and also in the skin of the external genitals, male and female, little whitish masses. They are called milia. They are made up of closely packed epithelium and sebaceous material, and are situated just beneath the epidermis. A milium is distinguished from a comedo, or blackhead, by the fact that I here is no obstructed duct in the epithelium which covers it. The nature of this small tumor is in doubt. Milia show little tendency to change their form. As they are persistent, their removal is often requested by the patient. The overlying epidermis should be split with the point of a small sharp scalpel and the contents expressed. This method is less painful and more successful than attempts to pick out the mass with a needle. Comedo. — A comedo, or blackhead, is the lesion produced by the blocking of a sebaceous duct. The dark color is due to an admixture of dust with the sebaceous material. They are most often found upon the face and neck. The general treatment which is given for acne (p. 33) is of service. After the skin has been softened by hot bathing, the individual plug may be loosened by a needle and squeezed out by lateral pressure. This pressure should in all cases be slight, lest a sluggish inflammatory process be converted into an acute one. Sebaceous Cyst. — The tumor of the head that most often attracts notice is a sebaceous cyst. These cysts occur either singly or in groups, and vary in size from the smallest nodule which can be recognized to a sac two inches or more in diameter. They are commonest in the scalp, but also occur behind the ear, in the eye- brow, or fin males) in the skin from which the beard springs. 66 SEBACEOUS CYST 67 They are found in young adults, but arc most common in those of middle age. They are due to the blocking np of the duct of a sebaceous gland. The sebaceous material manufactured by the gland collects within its lumen and gradually distends its cavity. As the distention increases, the epithelial lining is also increased by a multiplication of its cells. Within such a cyst are found the cast-off epithelial cells in a state of fatty degeneration. The mate- rial contained in a small cyst is semisolid and pasty, while that contained in a large one is usually more fluid. The tumor grows rapidly at times, but often has long dormant periods during which it seems not to grow at all. Diagnosis. — The cyst at first grows within the skin, and can- not be moved independently of it. As it increases in size, it spreads in the areolar tissue beneath the skin. I.t follows, therefore, that in the case of a large, non- inflamed cyst, the over- lying skin is movable upon it at all points excepting at the cen- ter. This single fact will usually serve to differentiate a sebace- ous cyst from a wholly subcutaneous tumor — for example, a li- poma. If left to itself, a sebaceous cyst may attain a considerable size, possibly having a diameter of two inches, if it is situated in the scalp. The usual fate of a sebaceous cyst situated in the face is to undergo inflammatory changes (Fig. 26), possibly with rupture and discharge of its contents. Such a discharge is, how- ever, but temporary, as the sac generally refills in a short time. Fig. 26. — Sebaceous Ctst of Forehead, Moder- ately Inflamed, and About to Rupture. IIS Ti MORS \\1> DEFORMITIES OF THE HEAD I beatment. — Treatment of a sebaceous cysl is operative. To guard againsl its recurrence, one should remove the whole sac. An operation to accomplish this is readily performed under cocain, unless the patient is more than usually sensitive. In the case of a sebaceous cyst of i lie scalp, one should proceed as follows: First shave and cleanse an area of I lie seal]) a little larger than the tumor (Fig. 27). While shaving adds to the convenience of the operator, it not absolutely nec- essary, and primary union can usually be obtained without it. In certain cases, therefore, it may be better not to sacri- fice any of the hair. The rest of the Lead outside of the field of operation should be covered with towels wrung out of bichlorid solution, 1 : 1,000. A few drops of one per cent cocain solution are next injected along the line of incision. This weak solution is desirable in these cases, since cocain injected into the head appears to have a more pronounced loxic effect than when used in other portions of the body. The writer has known the injection of a few drops of a four per cent solution of cocain into the median line of the scalp to produce such a marked reaction that artificial respiration was twice necessary before its effect passed off. A straight incision should be made directly across the center of (he tumor, from one edge to the other, extending down to the Fig. 27. -Operation for Sebaceous Cyst of Scalp. Skin prepared. SEBACEOUS CYST GO sac without entering it. If the correct tissue-plane is reached, it is usually possible to sweep around (lie entire sac with the bandle of the scalpel, or with a curved, closed scissors, and in this manner to lift the sac out without rupture (Fig. 28). If, however, the sac is ruptured, the operator need not fear that the contents will infect the wound. If this is a risk at all, it is certainly a very slight one, since primary union regularly fol- lows operation in all non-inflamed cases. Even when suppuration is present, union of the sutured skin is often obtainable. Fig. 28. -Operation for Sebaceous Cyst of Scalp. Skin divided to the sac and retracted. If the sac is ruptured, its contents should be at once evacuated, and the sac itself peeled out or dissected out. If the cyst is a large one, there will be considerable redundant skin after the sac has been removed (Fig. 29). This will shrink in time, so that it is not usually necessary to cut any of it away. The wound should be closed by interrupted sutures of fine black silk or horsehair, and pressure applied most carefully to prevent the formation of a blood clot. For this reason a bandage 70 TUMORS AND DEFORMITIES OF TTTE DEAD Fig. 29. — Operation for Sebaceous Cyst of Scalp. The redundant skin collapses after the removal of the sac. feat primary union if the sac is dissected away. It does make it very difficult to recognize the wall of the sac, however, and unless the wall is entirely removed re- currence will take place. If, therefore, the abscess is pronounced, it is better to lance and drain it, explain- ing to the patient that the sac will later fill again with sebaceous material and must then be removed (Fig. 30). An interesting case in which a tumor growing aboul the head, at leasl for l wo or three days, is necessary, ex- cept in the case of a very small cyst. Af- ter that a cotton-col- lodion dressing is preferable. A sebaceous cyst of the face or behind the ear is more apt to suppurate than one of the seal}). This suppuration is of such a mild character that it does not usually de- Fig. 30. — Inflamed Sebaceous Cyst Behind the Ear. Of many months' duration; in- fected three days. DERMOID CYST 71 from or beneath the skull and lifting the scalp was erroneously diagnosed as a sebaceous cyst, is described on page 105 with an accompanying illustration. Mucous cysts may appear in any portion of the mouth as the result of obstruction, to the secretion of a mucous gland. They are more common on the inner surface of the lips and cheeks. They are extremely thin-walled, and are filled with a clear, glairy fluid. It is not possible to dissect out the filmy sac, nor is this necessary, for if a triangular or circular portion be cut from the mucous membrane overlying the sac, the latter will be destroyed by granulation during the healing process, so that recurrence need not be feared. Hanula, or Sublingual Salivary Cyst. — Sometimes a duct of one sublingual gland becomes obstructed, and as the saliva accu- Fig. 31. — Cyst of Sublingual Gland — Ranula. Existing one week. Patient, a woman aged twenty-eight years. mulates a soft cyst forms under the tongue called a ranula (Fig. 31). In rare cases both sides are affected at once. If the cyst 72 TUMORS AND DEFORMITIES <>l THE HEAD is prieked with a scalpe] n teaspoonful of \ i>ci< I opalescent fluid may be expressed. A portion of the wall of the sac should be excised, ami a rubber tissue drain kepi in if possible for several davs, in order I" give the epithelium of the mouth time to unite with that lining the cyst. Otherwise the cysl will refill and the operation musl be repeated. Simple Parotid Cyst. — A similar retention cysl may de- velop from some portion of the parotid salivary gland. As it lies under the skin of the cheek, and is not attached to it, it is most readily mistaken for a lipoma. It should he removed in toto, and if its attachment to the gland is a close one, allowance must he made for a continued salivary discharge. If the wound is com- pletely sutured it will almost invariably fill up with a mixture of saliva, serum, and leucocytes. It is hotter, therefore, to leave a minute drain — for example, four or five horsehairs or threads twisted together and douhled or a flat gutta-percha drain — in the wound, which should elsewhere be sutured. This will allow the slight secretion to escape, and in the course of a few days or perhaps a few weeks the discharge will cease, and in time the indurated nodule caused bv the granulation of the little cavity will entirely disappear, leaving not so delicate a scar as would have resulted from removal of a tumor with primary union, but one which is not very noticeable. Dental Cyst. — A cyst sometimes forms by the side of a root of a decayed tooth. The fluid collects slowly and without the usual signs of inflammation (Fig. 32). When evacuated it is found to he of a mucous character clouded with epithelial debris. Such a cyst is thought to be due to overgrowth of remnants of cells concerned in the embryonic development of the teeth. The cyst forms within the bone, and its projecting portion is partly or wholly covered by a thin layer of hone which may crackle when palpated. The exposed wall of the cyst should be cut away and its cavity filled with iodoform or other antiseptic gauze and al- lowed to heal by granulation from the bottom. Dermoid Cyst. — A dermoid cyst is of congenital origin, and occurs in one of the lines of embryonic closure of the skin. It may be apparent at birth, or it may not be noticed until some years afterward, when its increase in size first attracts the atten- tion of the patient or some friend. Some dermoid cysts are made DEEMOID CYST. 73 up of a single layer of epithelium, with sebaceous contents, in which a few hairs are sometimes found. If the attachment of the dermoid cyst to the deeper structures is slight, its removal is almost as simple as the removal of a sebaceous cyst. Some der- Jnoid cysts have extensive deep attachments, so that their removal Fig. 32. — Dental, Cyst of Six Weeks' Duration. There was freely movable skin and absence of heat, redness, edema, and tenderness, but the cyst was mistaken for alveolar abscess. is difficult and may be followed by a permanent scar. It is of the greatest importance, therefore, that a correct diagnosis of dermoid cyst be made before its removal is attempted. Differential Diagnosis. — A mistake in diagnosis lies chiefly between a dermoid cyst and a sebaceous cyst ; hence the importance of considering in detail the points of difference. The common situations in which sebaceous cysts are found have already been 74 TUMORS AM) DEFORMITIES (»F THE HEAD spoken of. They include nearly all the situations in which a der- moid cv.-t of the head is likely to be found. Dermoids occur chiefly aboul the inner or outer angle of the orbit, or in front of or behind the ear (see Figs. 33, 3 l, and 35). A sebaceous cyst is rare in childhood; dermoids occur in infancy, childhood, and adult life. A sebaceous cysl is always attached to the skin at one point; a dermoid is usually covered by normal, freely movable skin. A sebaceous cyst is invariably movable with the skin on the deeper structures; the base of a dermoid is invariably attached to the deep facia or to the periosteum, or, in case of the ear, to the peri- chondrium. This point is not always easy to make out, since the more superficial portion of the dermoid cyst may swing back and forth upon its own fixed base, but to slide the cyst as a whole backward and forward is impossible. Both cysts plainly fluctuate when they have reached a suf- ficient size. During the operation it will be noticed that the sac of a dermoid cyst is usually thicker than that of a sebaceous cyst, and that this is especially true of its deeper portion. Furthermore, the attachment of its base will be- come more and more manifest as an attempt is made to dissect it free. It can never be freed by blunt dissection, since it is anatom- ically connected with the deeper tissues. If it contains hairs the diagnosis is certain. A dermoid cyst which contains little sebaceous matter and does not fluctuate may be mistaken for a lipoma or a small, deep-seated Fig. 33. -Dermoid Cyst of the Nose, Noticed Soon After Birth. DERMOID CYST 75 angioma. The size of the latter can always be reduced by com- pression, but it is promptly restored when the relief of pressure allows the blood-vessels to refill. Fig. 34. — Dermoid Cyst in Front of the * Ear, Growing for Five Years. Pa- tient aged twenty-two .years. Fig. 35. — Dermoid Cyst Behind the Ear, Closely Resem- bling a Sebaceous Cyst in External Appearance. Pa- tient aged 24 years. Treatment. — The incision for the removal of a dermoid cyst near the orbit should be made through the eyebrow, the hair first having been shaved off, or it should follow the direction of a wrinkle in the forehead or about the angle of the eye, so that the scar shall be insignificant. The separation of the overlying skin from the cyst is easily accomplished, while the dissection of the base of the cyst from the bone may be difficult. For this reason, unless the patient is of a very quiet and courageous disposition, it is better to give a general anesthetic, as it is difficult to obtain complete anesthesia of the part of the cyst adherent to the periosteum by means of cocain or eucain. After most of the sac has been freed, it should be split open and emptied, so that the operator may know exactly how far its cavity extends. Sometimes the cyst can be dissected free from the periosteum without injury to the latter. More often a part of its base is really formed by the periosteum, 70 TUMOKS AM) DEFORMITIES OF THE HEAD so that the complete removal of the cyst will necessitate the re- moval of a little periosteum. This is not a serious matter, as necrosis will not follow unless the wound suppurates. The oper- ative wound should be sutured and a firm dressing applied to obliterate the cavity due to the removal of the cyst. When the dermoid cyst is situated in front of or behind the ear, it may be so closely associated with the cartilage of the audi- tory canal that its inner portion reaches to the base of the skull. Under these circumstances, as much of the cyst as is accessible should be removed and the remainder should be cauterized with carbolic acid. Congenital Sinus. — The first pharyngeal cleft terminates just in front of the ear. This is a region in which inclusion cysts and sinuses are found. Such sinuses are often similarly placed in front of both ears. They are usually small, and being lined with the normal skin, secrete very little. They may become obstructed and form cysts. The only satisfactory treatment is the removal of the whole sinus or cyst by dissection. Any epithelial remainders are apt to develop into cysts. The sinuses formed by the partial closure of the lower phar- yngeal clefts are described in the section devoted to affections of the neck (p. 137). BENIGN SOLID TUMORS Papilloma. — This tumor growing from the skin or mucous membrane usually resembles a more or less pedicled wart. It is composed of fat and fibrous tissue covered with essentially normal skin. Treatment. — It may be snipped off level with the skin, but if at all sessile its base should be removed by two incisions, which remove an elliptical portion of skin containing the base of the tumor. This guards against recurrence, and permits the smooth closure of the wound. A papilloma of the lip may be mistaken for the primary lesion of syphilis; that of the skin for a cancer (Fig. 36). Mole. — A mole is a congenital pigmented fibroma of the skin more or less elevated above the surface. Sometimes in addition MOLE 77 to its excessive pigment, a mole contains hairs abnormally Large for the situation in which they occur. While most moles persist for life without undergoing any change, a few take on sarcomatous growth, either on account of external irritation or for some unknown reason. For this reason one is justified in removing any mole. They are chiefly removed, however, on account of their unsightly appearance. Treatment. — In removing a mole, one should be careful to take away all the cells of which it is composed, lest those remain- Fig. 36. — Papilloma of Skin Occurring in a Scar, Diagnosed as Cancer. The diagnosis was corrected by microscopical examination. Compare Fig. 54, p. 96. ing be stimulated to increased growth For this reason caustics, whether chemical, thermal) or electrical, are not to be recom- mended. Excision is the method of choice, and may be performed in two ways. 78 TUMORS AM) DEFORMITIES OF THE HEAD [f the mole is small it should be seized with fine mouse-tooth forceps and elevated slightly above the surrounding skin. It may then be snipped off with a sharp scalpel or a pair of curved scis- sors. Xo local anesthetic is necessary. When the removal is prop- erly done, all of the pigmented tissue is removed, and in its place there is a small oval loss of epithelium. This defect heals without permanent scar. In the case of larger moles, especially if they are so situated that a linear scar will nn( be objectionable, a different method of ■ removal is preferable. The mole should be excised, together with the underlying portion of the true skin. The area of skin involved should first he cocainized. An ellipse is then marked out, having the mole as its center. The cut which separates this section of skin should everywhere be perpendicular to the surface, in order that the cut edges may fit exactly when sutured. The removal of the elliptical portion of skin is sometimes followed by hemorrhage. This can usually be stopped by a few minutes' pressure, or by crushing the bleeding vessel with an artery forceps. The next step is to undermine the surrounding skin for a distance of a third of an inch or less, so that the tension upon the sutures may be slight. If the skin is lax, as it is about the eyes, this step may be safely omitted. If the skin is firm and is not undermined, the scar may stretch after the removal of the sutures until it is nearly as broad as the portion of skin which was removed. One or two horsehair or fine silk sutures should be inserted. It is well to remove these in three or four days, so that there may be no permanent marks to indicate the stitch holes. Tension upon the scar may thereafter be reduced by a strip of adhesive plaster. Lipoma. — A lipoma is a tumor composed of fat with a mini- mum of fibrous tissue. It usually has a well-marked capsule. Lipoma of the face is most often found in the forehead, where it forms a smooth, flattened tumor usually about three-fourths of an inch in diameter (Fig. 37). Its attachment to the skin is slight, being noticeably less than the attachment of a sebaceous cyst. Moreover, the tension within the sac of a sebaceous cyst is usually greater than that within the capsule of a lipoma. It is well known that an encapsulated tumor will sometimes fluctuate, although it contains no fluid. This is particularly true of a lipoma of the forehead, wdrich gives just as good a fluctuation wave on FIBROLIPOMA 79 account of the hard bone beneath it as a sebaceous cyst can give. A sebaceous cyst is more globular than a lipoma, and projects far more above the level of the surrounding skin (cf. Fig. 20, p. 67). Treatment. — If left alone a lipoma shows little tendency to increase in size, but it is so conspicuous that its removal is desir- able. This is easily accomplished if the lobules of fat are large and the capsule well defined. The skin is cocainized, and an incision made across the center of the lipoma in the direction in which the scar will be least con- spicuous. This is in a horizontal direction in the case of the forehead. The inci- sion should divide the skin and also the capsule of the lipo- ma. When this has been done, the li- poma itself can be shelled out by blunt dissection with little difficulty. If one finds the dissection difficult, it is certain that he is not fol- lowing the plane be- tween the capsule and the lipoma proper. As this tu- mor shows mo incli- nation to recur, it is unnecessary to re- move the capsule. The wound should be closed by interrupted sutures, or the sutures may be omitted, since in this situation there is little tendency for the cut edges to retract. The best dressing is a cotton-collodion one. Fibrolipoma. — A fibrolipoma of the head has the usual characteristics of this tumor when found in other portions of Fig. 37. — Lipoma of Forehead, Duration One Year. so TUMORS AND DEFORMITIES OF THE HEAD in Figure 38 the body i p. L85 ). A fibrolipoma in an unusual situation is shown Its attachmenl was to the skin of the external auditory canal. Angioma. — Angioma of the face is of common oc- currence in early infancy. A small patch of dilated capillaries and veins, often culled ;i nevus, may be pres- ent at birth. This lesion in- creases rapidly, so that early treatment is desirable in or- der to avoid unsightly deform- ity. The vessels dilated are usually those of the super- ficial portion of the skin, al- though in some instances the deeper vessels alone are af- fected, or it may be that the center of the nevus reaches the surface of the skin while its edges extend into the deeper portions of the skin, but are covered with normal epithelium. If the angioma reaches the surface it can scarcely be confounded with anything else, but a deep angioma containing much fibrous tissue may be taken for a fibrolipoma. Possibly a contusion with hemorrhage into the loose tissue around the eyelids might be mistaken for a commenc- ing nevus, but the lapse of a few days would suffice to distinguish the two. Pressure upon a vascular tumor empties its vessels and makes it white. As soon as the pressure is removed, the vessels immediately refill. Pressure upon effused blood causes its disap- pearance only to a slight degree. This difference is most strik- ingly shown if the pressure be made with a bit of transparent glass, so that the effect can be seen through it. Treatment. — Capillary angiomata are successfully treated by punctures with a fine needle which constitutes the negative pole of an electric battery. For this purpose the battery should contain from a dozen to thirty small cells. The positive pole should be a Fig. 3S. — Fibrolipoma of Auditory Ca- nal, Duration One Year. Patient, aged nineteen years. ANGIOMA 81 moist sponge, while a fine cambric needle or, better still, a jeweler's brooch is screwed into the handle co acted with the negative pole, The sponge is held closely against the face, while the needle is thrust into the skin at right angles to its surface from one-fourth to one-third of an inch. It is important that the needle inserted should he the negative pole, for if it is the positive pole bubbles of oxygen will form around it and will produce upon it oxid of iron, some of which, remaining in the tissues after the needle is withdrawn, may cause a permanent discoloration. The current should be sufficiently strong to produce a white zone about the needle one-eighth of an inch in diameter in ten or twenty seconds. If it is too strong the escharotic action is too vigorous and a per- manent scar is produced. If it is too weak the cauterization is insufficient and the puncture is apt to bleed badly when the needle is withdrawn. If the battery is freshly filled, eight or ten cells are usually sufficient. Half a dozen punctures may be made at one sitting, and the treatment may be repeated twice a week. The pain is intense, and a cool assistant is required to hold the head and arms of the child. IsTo anesthetic is required, as the pain does not continue after the removal of the needle, and even a delicate baby suffers no injury from the treatment. If the punctures are judiciously made, and the treatment is continued until every red vessel disappears, a satisfactory result will be obtained in most instances, and in place of the angioma there will be a cicatrized area marked here and there by little pits due to too vigorous cau- terization. If the nevus is wholly superficial and only capillaries are involved, the scar will be extremely slight. The site of a deeper tumor, especially if it contains larger vessels, will be marked by a thickened and more abnormal patch of skin. It may be of advantage to perform a partial excision of such a nevus at some stage of the treatment by electrolysis. Another method of treatment by which good results are ob- tained is the coagulation of blood in the vessels by the injection into the nevus of a few drops of water almost at the boiling point. The effect of heat applied in this way should be great enough to produce coagulation, as shown by the immediate pallor in the portion of the nevus so treated. After a few days the permanent effect of the treatment will be manifest, and if red spots remain additional injections should be made. 82 TUMORS AND DEFORMITIES OF THE HEAD Treatment by Operation. — If an angioma is made up of larger vessels, either veins or arteries, it is readily compressible and may pulsate (Figs. 39 and 40). Electrolysis is useless in such a case, and the tumor must be removed by operation or its Fig. 39. — Pulsating Angioma of Scalp, Congenital. The photograph shows it fully distended. vessels ligated. This operation is serious in the case of an infant, for the bulk of its blood is so small that it will succumb to a hemorrhage which does not seem large to one accustomed to oper- ate only upon adults. Even when the operation is upon an adult, every precaution should be taken to limit the hemorrhage. There should be plenty of artery clamps at hand. One assistant should have nothing to do except to control hemorrhage by pinching the surrounding skin or pressing it against the skull. Even then the bleeding will not be under perfect control, since the vessels of the tumor often anastomose with the veins inside of the skull. As fast as the incision is made the cut vessels should be clamped. Tf there is plenty of skin to cover the wound without using any of ROSACEA HYPERTROPHIC^ 83 that which covers the vessels of the tumor, the whole incisioE should be made before the base of the tumor is cut into. In this way much of its blood-supply will be shut off before the most dif- ficult part of the operation, namely, the dissection of the base, is Fig. 40. — Same Tumor as Fig. 39, but Photographed Immediately after the Fingers which were used to Compress the Tumor had been Removed. As the volume of the tumor increased very rapidly when released, this figure does not show it at its smallest. attempted. If the skin of the tumor is needed, one lateral inci- sion should be made, the base next dissected, and the collapsed tumor cut away from as much of the overlying skin as is needed to cover the wound, which should be accurately closed by suture. The dressing should be a firm one, but sufficiently elastic, so that the pressure exerted may not threaten the vitality of the skin. Rosacea Hypertrophica, or Hhinophyma. — This is an overgrowth of the nose, which is generally considered to be one of 84 TUMORS AND DEFORMITIES OF THE HEAD the forms of rosacea, but is here included with the tumors to which ii belongs clinically, for the appearance of the lesion and the treat- liicni warranl this classification (Fig. 4 1). This is a disease of middle life, or later, marked by a great overgrowth of the sebaceous follicles, with their duds, as well as of blood-vessels and fatty tissue. The skin itself is not greatly thickened, and may even be thinned, apparently the result of over- stretching it. The tumor as a whole is soft and flabby, of dark red Fig. 41. — Rosacea Hypertrophica of the Nose, of Seven Years' Duration. Patient aged sixty-nine years. color, due to the venous congestion. It is not necessarily the result of alcoholism, and many of these patients are unjustly accused of intemperate habits. Lesser degrees of hypertrophic rosacea of the nose are fre- quently found. Such an extreme overgrowth as is shown in Fig- ures 42 and 43 is decidedly exceptional, although even more marked instances are occasionally seen. Although this overgrowth is benign in character, the excess of rosacea hypehthophica 85 tissue should be removed, as this can be accomplished without much risk, and the feelings of the patient will thereby be spared many mortifying re- marks. Treatment. — This consists in the re- moval of wedge- shaped pieces of the growth, so that the normal contour of the nose may be restored. The spongy tissue is very insensitive, so that a small amount of a dilute solution of eucain or cocain is sufficient. IT e m o r - rhage is free, but may be controlled by pres- sure and ligatures. Although these pa- tients are usually plethoric and stand very well the loss of blood, it may be ad- visable to remove only a portion of the growth at one sitting. This plan has the fur- ther advantage of en- abling the surgeon to observe the effect of a partial removal of the tumor before complet- ing the task. Ee- moval may be effected in such a way that pedicled flaps are uti- lized to cover the raw Fig. 42. — Rosacea Hypertrophica of the Nose, Four Years' Duration. Front view. Fig. 43. — Same Subject as Fig. 42. Side view. S6 TOMOHS WD DIMDKMITIES OF THE HEAD ^H ft V .■ Mk ■■ ■-, ■ 1 1 ,9 Fig. 44. — Same Subject as Fig. 42, Showing the Results of Operative Treatment for Rosa- cea Hypertrophica of the Nose; Three Weeks After First Operation, and One Week After Second Operation. Fig. 45. — Same Subject as Fig. 42. Side view, one week after the second operation. spaces. Their vital- ity is low, and unless the pedicle is very 1 1 road, they arc likely to slough. There- fore it is advisable not to undermine them too extensively. The results of I Ids plastic surgery arc \rvy satisfactory (Figs. 44 and 45). Tn sonic cases, if the quality of the skin is too poor, it is better to shave off all of the tissue down to the cartilage and to cover the wound with skin grafts. Hypertrophy of the Tonsil and other Lymphoid Structures in the Naso-pharynx and Pharynx. — The fancial tonsil is fre- quently enlarged, es- pecially iu children, either as a sequence of repeated attacks of tonsillitis or of sonic other infections dis- ease, such as scarlet fever, diphtheria, or measfes. In children hypertrophy of the tonsils is frequently associated with hy- HYPERTROPHY OP THE TONSIL 87 pertrophy of the lymphoid tissue in the naso-pharynx, commonly called adenoids, with hypertrophy of the lymphoid tissue at the base of the tongue, the so-called lingual tonsils, and enlargement of the cervical lymphatic glands. Symptoms produced by tonsillar hypertrophy may be very slight, or the enlargement may be sufficient to interfere with nor- mal swallowing and to favor and make more severe attacks of acute tonsillitis. Adenoids often obstruct the posterior nares to such an extent that the patient breathes through his mouth when asleep, and sometimes during the day as well. For these reasons, sur- gical treatment is frequently indicated. Diagnosis. — The diagnosis of hypertrophy of the tonsils is made by direct inspection. If one can see them during a period of acute inflammation, as well as in the intervals be- tween such attacks, he can best judge of the necessity for their removal. The diagnosis of hypertrophy of the lingual tonsil is made from the image reflected in a throat mirror. The diagnosis of adenoids is made from the image reflected in a rhinoscopic mirror, when this can be obtained. It can also be made by palpation with the forefinger, and can be assumed from persistent mouth breathing, especially if the anterior nares are not obstructed. There is also an alteration in the sound of the voice, and a postnasal catarrh. In extreme cases the facial expression is altered. Partial deafness may result. Treatment. — Tonsilectomy is the term applied to the removal of a hypertrophic tonsil. The ancient practise of destroying a por- tion of such a tonsil by the cautery, or merely excising the pro- jecting portion, has largely yielded its place to a complete removal of the tonsil. This may be done under a local or a general anes- thetic. The choice depends more on the character of the indi- vidual than on the condition of the tonsils. Those called for the first time to operate upon a young child will do well to employ a general anesthetic. The mouth is opened, a mouth gag inserted, the tonsil seized with a slightly curved forceps having two or three prongs, and lifted from its bed. It may then be cut off with a tonsillotome, or dissected with scissors or a knife. If the latter method is chosen, it is only necessary to divide the mucous membrane ; the Fig. 40. — Instruments Used rem the Removal of the Tonsil. A, tonsillo- tome (this instrument is not used by many operators) ; B, mouse-tooth forceps; C, sponge holder, of winch several should be at hand; D, E, blunt pointed knives; F, tongue depressor; G, mouth gag; H, tonsil forceps; 7, long curved forceps; J , long curved scissors. HYPERTROPHY OF THE TONSIL 89 tonsil can then be shelled from its Led by blunt dissection with the finger or a suitable instrument. In this manner the whole tonsil can be removed more perfectly than with a tonsillotome (Fig. 46). If a local anesthetic is decided upon, the mucous membrane should be anesthetized by the application of a strong solution of cocain or stovain, ten or twenty per cent. There is less danger of poisoning if the anesthetic is applied upon a swab rather than in the form of a spray, but the swab should not be so wet as to allow the solution to trickle down the throat. Another good plan is to inject a few drops of a ten per cent solution of stovain in adrenalin, 1 : 2,000, into the tissues before beginning the dis- section. Hemorrhage following the removal of the tonsil is free, but usually subsides promptly. It is well to have at hand small sponges in curved clamps, which can be squeezed out of an adren- alin solution and pressed firmly against the bleeding surface. An astringent gargle is also serviceable. The patient should gar- gle the throat every few hours with iced Dobell's solution some- what diluted. In most cases the pain which results is surprisingly slight, considering the extent of raw surface which results from this operation. Hypertrophy of the lingual tonsil, giving rise to persistent cough or husky speech, may require operation. The excess of tissue can be removed with a galvanocautery or a specially con- structed tonsillotome. Treatment of Adenoids. — Although adenoids tend to atrophy about the period of puberty, it is unwise to wait for their spontaneous disappearance, if they give rise to definite symptoms as described above. They should be removed by operation, pref- erably under a general anesthetic, although the postnasal space is readily anesthetized by a ten per cent solution of cocain in a 1 : 2,000 solution of adrenalin chlorid, applied on cotton wound on a bent probe. If the child is chloroformed, it may lie with its head lower than its shoulders, or not, according to the operator's preference. In any case, a mouth gag is inserted and the adenoids are removed either with a specially curved curette or with a pair of forceps, or, as many prefer, with the finger nail (Fig. 47). 90 TUMORS AND DEFORMITIES OF THE HEAD Following operation, the nose and throat should be frequently sprayed with a diluted Dobell's solution, or some other dilute dis- infectant. Fig. 47. — Instruments Used for the Removal of Adexoids. pressor; B, mouth gag; C, adenoid curettes. ^4, tongue de- Epulis. — A growth which resembles a papilloma in appear- ance, but which is much denser, is called an epulis. It usually springs from the gum, along the outer side of the molar teeth. As it grows it takes on the shape of the space in which it lies, and therefore appears to have a broad attachment. When it is lifted up from the mucous membrane it will often be seen to have an extremely narrow pedicle. It is a dense hard tumor, covered with mucous membrane having a normal appearance. An epulis grows slowly, and without pain, but it should be thoroughly removed because of its constant tendency to increase in size, and also because in structure it closely resembles a spindle- cell sarcoma. If the growing base of the tumor in the mucous OKTIOOMA, OH EXOSTOSIS 91 membrane is excised, it is not likely to recur. The specimen should in all cases he examined microscopically. Otoliths. — Calcareous bodies, called otoliths, often form in the fatty portion of the ear. They are similar in character to the deposits which are found elsewhere in the body in gouty indi- viduals. In the ear these discrete nodules may be so large as to be noticeable and to annoy the patient. They are easily removed through small incisions. Osteoma, or Exostosis. — This is a benign tumor, being a simple outgrowth of bone. It is easily recognized as having the consistence of bone, to which it is firmly attached. It is covered by normal skin, fat, etc. Such a tumor is very rare in the face (Fig. Fig. 48. — Exostosis of Jaw. Two or three years' duration. 48). It is commoner in the skull. If it is decided to remove it, the skin and other parts should be divided and reflected so as to expose the exostosis. This should be chiseled away, together with the periosteum which covers it, as the possibility of recurrence 92 TUMOKS AND DEFORMITIES OF THE HEAD should bo boruo in mind. While this operation takes only a few minutes, it is difficult to anesthetize bone. Therefore, during' the chiseling the patient's sensibilities should be benumbed by chloro- form of nitrous oxid gas, or, if preferred, the whole operation may be performed under a general anesthetic. Such tumors should be examined microscopically. Spur. — An exostosis, or a cartilaginous tumor projecting from the floor or septum of the nose and covered with normal mucous membrane, is called a spur. If of sufficient size to interfere with normal breathing, it should be removed with a blunt-pointed saw, the parts having been first anesthetized by the application of co- cain or stovain upon a cotton swab. Bleeding may be controlled by adrenalin, or by the tip of a galvanocautcry, an instrument which is utilized by some for the removal of the spur. Deviation of the nasal septum is considered on page 109. MALIGNANT TUMORS Epithelioma. — An epithelioma may develop in any portion of the epithelium covering the head or lining its cavities. 'It is common at the mucocutaneous junctions of the eyes, ears, nose, and mouth (Fig. 49). Its origin, like that of malignant tumors in all situations of the body, is sometimes apparently due to a wound or to a long- continued irritation, but often such a provoking cause seems want- ing. Sometimes a wart or mole which has remained of essentially the same size for years will begin to grow rapidly, and if not removed will develop characteristics of a malignant tumor. In other cases the tumor starts as an ulcer almost from the beginning. It is in the class of cases in which a simple wart or mole as- sumes malignant development that surgery has an important part to play. A patient may have noticed such a localized thickening of the epithelium as is shown in Figures 50 and 51 for years. Gradually the cells begin to multiply and the tumor increases a little in size. This should inevitably be the sign for removal of the growth. At this stage it has not begun to infiltrate the skin. Nor has it extended into the deeper tissues. Hence a radical cure can be effected by the removal of the tumor without any of the sur- rounding tissues. Such a simple operation can be performed in a EPITHELIOMA 93 few minutes under local anesthesia, and need not be followed by any permanent scar. On this account a pa- tient will readily con- sent to the operation. "While it is prob- able that many of these hitherto benign tumors will never become ma- lignant, it is certain that some of them will do so, and in any event the operation frees the patient of an annoying blemish. Those that develop into malignant growths infiltrate the skin and ulcerate in the older portions, and gradually assume the usual characteristics of carcinoma of the sur- face with an elevated growing margin, usually of an irregular Fig. 49. — Epithelioma of Face near Nose. ration six years; slight ulceration. Fig. 50. — Epithelioma of the Lip Developing in a Soft Wart which had Existed since Childhood. New growth noticed nine months previous. Patient aged fifty-six years. A similar wart on nose has recently shown increased growth. 94 TUMORS AND DEFORMITIES OF THE HEAD character. But even at this stage epithelioma of the face is no! of rapid growth, and a year or so may elapse before the tumor reaches the diameter of an inch. This is equally true whether the Fig. 51. — Same Subject as Fig. 50, Three Months after Removal of the Epi- thelioma of Lip. The scar could only be seen by close inspection; one of the advantages of early operation. tumor is at first of the papillomatous type (Fig. 52), or whether it early infiltrates the skin and ulcerates (Fig. 53). Epithelioma of the face in some individuals progresses so slowly that the patient will live for years, the tumor gradually eating away more and more of the skin and suffering in its own turn from ulcerative processes until possibly the skin of half the face is in this manner disintegrated. Such epithelioma is known as rodent ulcer. EPITHELIOMA 95 Diagnosis. — The appearance of a well-developed epithelioma is characteristic. First there is the very hard infiltration of the skin with the cancer cells. This raises the level of Hie skin affected above that of the normal surrounding skin. The blood-vessels in the skin involved, and in that adjacent to the new growth, are often dilated. As induration extends, the blood-supply may be shut off from the older portions of the growth and ulceration result. The discharge from the surface of such an ulcer often has a gangrenous odor. The regional lymph-glands may be swollen and hard. This may be the result of metastasis or of the absorption of septic prod- ucts if an ulcer exists. As a diagnostic sign of cancer it has there- Fig. 52. — Epithelioma of the Nose, Recently Growing Rapidly. Diagnosis merely clinical, as the patient would not permit removal of the tumor. fore a greater value when the skin is unbroken than it has after an ulcer forms. The late diagnosis is of little value to the patient. The early diagnosis is life-saving. A beginning epithelioma may be mistaken for a wart or papil- loma (Fig. 54). If there is any doubt a microscopic examination Fig. 53. — Epithelioma of the Cheek, Existing Two Years in a Man Aged Si yexty-Two. Fig. 54. — Epithelioma of Face; Supposed Wart Snipped off Five Weeks before this Photograph was Taken. Compare Figure 36, page 77. 96 EPITHELIOMA 97 should be made or the tumor should be removed. In fact, every such tumor which shows a tendency to grow, should be promptly excised. When this is done at an early stage, before the tumor begins to infiltrate the skin, it is unnecessary to sacrifice any of the surrounding skin, and no disfiguring scar follows. Hence a patient is more likely to submit to operation at this early stage, which is sometimes spoken of as the precancerous stage. Micro- scopical examination of the removed tissue will sometimes show that this term " precancerous " is not justified (see Figs. 57, 58, and 59, and the description of them on p. 98). Epithelioma of the Scalp. — The early appearance of epitheli- oma in the scalp is that of a slightly elevated irregular tumor, the Fig. 55. — Epithelioma of the Scalp Occurring in a Woman Aged Fifty-eight. surface of which is redder in places than the normal scalp, and which is partly covered by the crusts which are prone to form upon the scalp whenever it is irritated (Fig. 55). Illustrations showing different types of early epithelioma of the face have been given in the preceding pages. Epithelioma of the Lip. — One type of early epithelioma of the lip is shown in Figure 56 ; the ulcer of which was said to have ex- isted only four weeks. Another case in which ulceration was of the 98 TUMORS AND DEFORMITIES OF THE HEAD . Fig. .56. — Epithelioma of the Lip, said to be of Four Weeks' Duration. Patient aged forty- two years. most superficial character, although the tumor had Lasted one year, is shown in Figure 60, page 101. This is a favorite scat for epithe- lioma. It often follows long-continued smoking of a clay pipe, arising at the point where the hot, rough stem of the pipe has rested upon the lower lip. It begins as a slight induration which the patient scarcely notices until little scales form upon the surface or a very shal- low Ulcer a1 ion pro- duces slight crusts. These from lime to time are picked off or fall off, but the ex- coriation fails to heal. In the meantime the induration spreads slightly or creeps into the deep tissues, but for many months, by reason of its limited extent and lack of pain, the patient may look upon the lesion as unimportant. Epithelioma of the Tongue. — Early appearances of epithelioma of the tongue are shown in Figures 57, 58, and 59. Attention is especially called to the two types of lesion there shown — namely, the milky white patches of leucoplakia which had existed for sev- eral years, and the elevated, warty nodules which had existed for some months at least. In neither of these had the epithelial cells begun to grow downward at the time the drawing was made. All of the mature cancerous growth for which this tongue was re- moved came from an ulcer on its left margin, which does not show in this drawing. The chief possibility of error in the early diagnosis of epi- thelioma of the face lies in mistaking for it the primary lesion of syphilis. As already pointed out (page 60) the primary sore upon the thick epithelial layer of the skin or even of the lips or tongue has quite a different appearance from the primary sore upon the more delicate epithelium of the head of the penis. Besides illustrating the early appearance of epithelioma of the tongue, Figures 57 to 59 show how misleading the negative micro- Fig. 57. — Epithelioma op the Tongue, Showing Milky White Patches of Leuco- plakia, and papillomatous growths, especially in the median llne of the Tongue. These were shown by microscopic examination to be not epithelioma, the only epithelioma being along the left border and in the center of the tongue. Fig. 58. — Longitudinal Section of Tongue in the Median Line, Showing Two Small "Islands" of Epithelioma in its Posterior Portion. Same subject as Fig. 57. 9 99 100 ruMoRS \\i> Deformities of the head scopic examination of small sections of tissue may be. Such sec- tions were twice removed from the center of this tongue, and were correctly pronounced to be not epitheliomatous. A third section was then taken from the left lateral margin, and was found to pre- sent the usual appearances of epithelioma. Treatment. — The best treatment of a patien.1 who has an epi- thelioma in an early stage is a complete removal of the tumor, together with a reasonable margin of healthy tissue on all sides of it and beneath it. Just how wide this margin should he cannot he stated by a general rule. If the tissue is lax and abundant, it is well to make the incision one-third of an inch away from the vis- it" the Fig. 59. — Transverse Section of the Tongue through the Anterior "Is- land" of Epithelioma Shown in Fig. 58. It will be observed that the whole of this epithelial growth was from the lateral margin of the tongue. ible edge of the tumor, surrounding skin is less flex- ible, or if the tumor is so situ- ated that a scar will be very prominent, one is perhaps justi- fied in removing a narrower zone of healthy tissue with the tumor. This is more likely to be the case if the growth of the tumor is almost wholly upward, and infiltration has not yet taken place. When the tumor has been removed, hemorrhage is controlled by pressure or ligation of vessels, and the surgeon must consider the best manner of covering the defect. In many cases the wound may be closed by direct suture if the surrounding skin is loosened from the deep fascia. In other cases a plastic operation, or skin grafting, or a combination of the two methods, will give the best results. The regional lymph-glands should be examined. If they are palpably enlarged the spaces in which they lie should be thor- oughly freed by dissection of glands and the connective tissue in which they lie. This requires general anesthesia. Some surgeons advocate it as a routine measure in all cases, whether the glands are palpable or not. In such an early stage of the disease as is shown in Figures 54 and 60 it hardlv seems warrantable to add so EPITHELIOMA 101 much to the risk of operation, when the prognosis is so good with- out the more extensive dissection. If the glands are palpably enlarged, prognosis is much more grave, but is still sufficiently good to make a complete removal of glands and tumor desirable. Every tumor of the skin which is removed should be examine I microscopically. The removal of epithelioma of the lower lip is accomplished as follows: The lower lip is shaved and cleansed thoroughly with soap and hot water. The teeth are brushed and the mouth rinsed with a dilute antiseptic. The lip is wiped with cotton wet with a stronger antiseptic solution. An assistant then seizes the lip at its right and left ends, between his thumb and fingers, standing behind the patient and putting the thumbs inside the patient's mouth. This compresses the inferior coronary and inferior labial arteries and absolutely controls hemorrhage. The operator then injects from twenty to forty minims of a one per cent solution of cocain along the lines of incision, and cuts a Y-shaped section Fig. 60. — Epithelioma of Lower Lip. Duration one year. Patient ready for operation. from the lip, the incisions for the purpose (Fig. 61) passing- through the whole thickness of the lip. They start in the free border at least one-third of an inch from the visible margin of the growth. The V should extend well down on the chin. This re- duces the amount of deformity as w T ell as guards against recurrence. The wound is sutured with fine black silk (Fig. 62). If the external stitches include all of the tissues except the mucous mem- 102 TUMORS AND DEFORMITIES <>F THE HEAD brane, apposition will be so perfecl thai the mucous membrane need nol be sutured. This saves a rather difficult extraction of sutures from within the mouth. A narrow strip of gauze should Fig. Gl. — Epithelioma of Lower Lip, Showing the Line of Incisions. be placed over the wound and tension relieved by a strip of adhe- sive plaster from one side of the chin to the other. One-third of the lower lip may he removed with the certainty that no perma- Fig. 62. — Epithelioma of Lower Lip. After excision of the V-shaped piece, the gap in the lip is closed by sutures which need not penetrate the mucous membrane. nent deformity will result. If the tumor is situated very near the angle of the mouth, it may be necessary to extend the incision outward through the cheek to give greater freedom to the rem- nant of the lower lip. EPITHELIOMA 103 Epithelioma of the tongue may occur upon the dorsum of the tongue, or along the edge, or in the vicinity of the frenum. As I he early removal of this tumor has a favorable prognosis, it is ex- tremely important that it should he recognized before the growth is extensive, and before the lymphatic glands in the neck have become involved. Unfortunately patients are indifferent to small sores upon the tongue until they give rise to considerable pain. The saliva soaks off any discharge, so that the sore has not the striking appearance of an epithelioma of the skin with its cover- ing of crusts. For this reason, most physicians fail to recognize epithelioma of the tongue as soon as they should do so. The disease first appears in one of three ways : There may be a white, wartlike growth, without ulceration, and with a scarcely noticeable induration at the base. Second, there may be a flat, slightly raised, smooth, red tumor which feels like a bit of gristle in the surface of the tongue. At a later stage this will ulcerate. Third, an old area of leucoplakia which possibly has existed for years will take on a malignant growth in some portion, showing distinct elevation, and then some induration at the base. This, too, will ulcerate later (Figs. 57—59). If an epithelioma of the tongue is recognized at an early stage, before ulceration sets in, the resection of the tumor with a safe zone of healthy tissue around it is a thoroughly safe operation. Some surgeons advocate the removal of the fascial tissue contain- ing lymph glands from the neck, although at this early stage the glands which are removed can rarely be demonstrated to contain cancer cells. If the disease is allowed to progress until ulceration has taken place, and there is marked infiltration of the tongue, and the lymphatic glands of the neck are palpably enlarged, re- moval of one-half, or even the whole, tongue, and an extensive dis- section in the neck gives slight hope of permanent cure. Radical cure, under such circumstances, is achieved in probably not more than twenty-five per cent of the cases. The indication is, there- fore, strongly in favor of early removal at a time when the opera- tion may be performed under cocain if necessary, and most of the tongue may be preserved. On account of its free circulation and great flexibility the tongue is an excellent subject for plastic work. Methods of Treatment other than Excision. — Epithelioma of the face may be removed by chemical caustics or other agencies 104 Tl MORS V.ND DEFORMITIES OF THE HEAD capable of destroying tissue cells, such as the X-ray. That many eures have been effected l>v these means, every unprejudiced ob- server readily admits. They are generally considered to be less certain methods of removing the growth. They require a long period to effect their object, and evidence is lacking to show that recurrence is less likely to occur when a tumor has been destroyed by caustics than when it has been removed with a knife. Indeed, from what Ave know of the structure of the skin and of the nature of tumor growth, it is probable that recurrence is less likely when a /one of healthy tissue is removed with the tumor than when the tumor cells are killed in situ, so to speak. Methods other than excision are therefore to be adopted only when the patient refuses to allow the removal of the tumor by means of the knife. One of the best caustics to employ is- a one per cent solution of arsenious acid in alcohol. A few drops of hydrochloric acid increase its solubility. This may be painted on with a camel's-hair brush every second day. This is a cleaner method of application than the usual one of arsenic paste. In using the X-ray for the destruction of an epithelioma, the surrounding skin should be protected, and the length of exposure, distance from the tube, etc., should be carefully noted at each treatment. In beginning treatment it is well to err on the side of safety, so that the exposure should be brief, and three days should elapse between treatments. Later, when the full effects of the X-ray can be estimated, treatments may be increased in sever- ity and in frequency. The details of this form of treatment have been frequently published in magazines and monographs. Sarcoma. — Sarcoma of the head, while not very common, oc- curs with sufficient frequency to make the differential diagnosis be- tween it and benign growths of great importance. The diagnosis is often a difficult one in this region on account of the frequency here of sebaceous and dermoid cysts and of gummata and other inflammatory lesions. Two essential points shown by a malig- nant but not by a benign tumor, are the lack of a distinct bound- ary and the presence of enlarged blood-vessels in the vicinity of the tumor. Both of these signs were present in the case shown in Figure 63. This tumor had been growing rapidly for some months, but without pain or cerebral symptoms. It had been diagnosed as a sebaceous cyst by two doctors, and an immediate SA I ICO MA wt office operation advised and a speedy cure promised. An- other doctor had affirmed that it was cancerous and that its removal would prove fatal. The surgeon in whose care the patient finally placed herself removed a section of the tumor for examination. Upon learning that the tumor was not sarcoma, and having found it to be encapsulated, he later removed it without diffi- culty, but with so great a loss of blood that the patient did not rally. It was extradural, but had eroded a circular area of the skull about two inches in diameter. The substance of the tumor itself was on gross and microscopic examination like the tissue of a rapidly hypertrophying thyroid gland. Fig. 63. — Tumor of Head — Extradu- ral — Classified on Pathological Examination as an Aberrant Thy- roid. Fig. 64. — Angiosarcoma of the Lower Jaw of a Colored Girl, Aged Twenty- three. The tumor had been noticed for one month. 100 n.\im;s and deformities of the head Sarcoma of the face is far less common than epithelioma. Sometimes a small and apparently innocent tumor of the skin will prove upon microscopical examination to be sarcoma. Angiosarcoma of the jaw occurs, and has a marked diagnostic importance because in its early stages (Fig. 64) it may be mis- taken for the spongy condition of the gums due to scrofula. The history of the disease and the general condition of the patient will usually suffice for a correct diagnosis. In doubtful cases a micro- scopical examination of a fragment of the tumor should be made. Attention to the diet, and the use of an astringent mouth wash Avhich will speedily improve scrofulous gums will, of course, have no effect upon the development of a sarcoma. Parotid Tumors. — In the region of the angle of the jaw ma- lignant tumors of varied histological structure arise in connection with the parotid gland: carcinoma, sarcoma, chondroma, myxoma, Fig. 05. — Tumor of Parotid Gland, said to have Existed Ten or Twelve Years. The skin was not attached, and the tumor was movable in all directions. CANCER OF TONSIL 1.07 and a combination in one tumor of the various structures which these names imply, may develop in this situation and give rise to a rounded, hard mass, usually composed of more than one lobule, which grows slowly or rapidly and often reaches the size of a small egg before the patient seeks surgical aid (Fig. 65). Such a tumor, like malignant tumors of a parenchymatous nature elsewhere in the body, is most often seen in middle life or later. If the condi- tions warrant it, no time should be lost after the diagnosis is made in accomplishing its thorough removal. As the tumor springs from the gland it is closely attached to it, but is movable with the gland upon the skin and deeper tissues. As it grows it infil- trates the surrounding tissues so that this mobility is soon lost. It may be distinguished from an inflammatory process by the his- tory of its slow development, by its hardness, and by its situation in the parotid. It is most likely to be confounded with tubercu- losis or syphilis of the cervical lymphatic glands. These are usu- ally situated below the angle of the jaw, but they may also extend above it. In affections of the lymphatic glands careful exami- nation will almost always show that two or more distinct glands are involved; whereas if a malignant tumor has nodules they can be shown to be connected, being invariably part of the same growth, except, of course, in case of secondary lymphatic involvement. Furthermore, tubercular and syphilitic glands which have attained any considerable size fall to pieces internally so that fluctuation can usually be made out in them. Cancer of Tonsil. — Tumors of the tonsil of a malignant character are on the border-line histologically between carcinoma and sarcoma. They may he easily mistaken for a chronic hyper- trophy of the tonsil, and if there is the slightest question a large section of the tumor should be taken for examination by a pathol- ogist. Even then the diagnosis may not be an absolute one, and the decision between the risk of allowing the tumor to remain and the risk of an operation for its radical removal is one of the most difficult in surgery. If a presumably hypertrophied tonsil is am- putated by means of the tonsillotome and subsequently recurs, this fact, even more than the result of histological examination, will incline the surgeon to perform a more radical operation for removal of the tumor. These tumors affect the deeper structures, and do not give rise to ulceration until a late stage is reached. 10S TUMORS Wl» DEFORMITIES OF THE HEAD Their treatment is beyond the range of minor surgery, but the subject is mentioned here on account of diagnostic importance. ACQUIRED DEFORMITIES Cicatrices. — Cicatricial contractions in the vicinity of the eye may so pull upon the lids as to cause their partial eversion or prevent the tears from flowing through the tear-duct in a natural manner. To relieve this in certain cases plastic operations may be performed with more or less success, and even where the eyelid bas been partially destroyed a substitute may be found in a flap of skin taken from die adjacent skin. Cicatricial deformity of the lip from a burn of the neck is shown in Figure ST on page 148. Nasal Deformities. — Deformities of the nose are among the commonest disfigurements. When hereditary syphilis attacks the nose of an infant or child, or contracted syphilis the nose of an adult, it often destroys the cartilage to such an extent that there is a hollowing out where normally the bones and cartilage should be prominent. The result is often called a saddle-nose. Treatment. — Numerous attempts have been made to cure these deformities in later life by inserting some rigid substance to make good the lack of bony support. Any support which is fixed to the bones of the face will soon fail, because of the softening of the bones upon which it rests, and its removal will be necessary. A far better plan, therefore, when the tip of the nose is not de- stroyed, is to insert beneath the skin a boat-shaped piece of cellu- loid, the upper surface of which is straight or slightly rounded while the under surface is shaped to fit the sunken bridge of the nose. If the incision made at the side of the nose for the insertion of the celluloid is a small one and made obliquely through the skin, the resulting scar will be quite invisible. Necrosis of bone will not be produced as the periosteum is not disturbed. Before the cellu- loid is inserted, a bed is made for its reception by separating the skin from the cartilage with an appropriate instrument, a favorite one being made like a minute ax upon a very long handle. The bed should be so prepared that the celluloid may lie in it easily, and no attempt should be made to hold it in position by a bandage DEVIATION OF THE SEPTUM OF THE NOSE 109 or plaster. If the result is to be satisfactory, the support must rcsl easily in the cavity prepared for it. Deviation of the Septum of the Nose. — The septum of the nose may be deviated to one side, usually as a result of trau- matism. One air-passage may be closed thereby. Treatment. — A number of operations have been proposed to establish free passage of air through both nasal fossa?. The sim- plest of all is to punch out a large opening in the septum at its most projecting point. The practical result of this is good, but it is a permanent deformity, and as such has not appealed to the minds of either surgeons or patients. Of the many operations which have been devised to straighten the septum, two may be mentioned as comparatively simple in technic, and likely to yield a good result. A tongue-shaped flap of the whole thickness of the septum may be cut from the convex side. While it is still attached posteriorly, it should be pushed Fig. 66. — Diagram of the Septum of the Nose, Showing the Portion Nece&sary to Resect Submtjcously to Cure Deviation of the Septum. through the opening in the septum until it lies in the other nos- tril. A hollow rubber cone may be placed in the nostril to prevent the flap from resuming its original position until healing has taken place. A newer method is submucous excision. Anesthesia and ischemia are produced by the surface application of cocain and IK) TUMORS AND DEFORMITIES OF THE HEAD adrenalin for twenty minutes or more. An incision is made on the convex side about a third of an inch posterior to the junction of skin and mucous membrane. This incision extends through the perichondrium. Through this incision the mucous membrane and perichondrium arc peeled from the convex surface of the septum. The anterior incision is next carried through the cartilage of the septum, and the perichondrium is peeled from the concave, sur- face of the septum. The denuded portion of cartilage is then ex- cised with a special knife and scissors. It is usually necessary to excise with a small chisel a portion of the nasal spine of the supe- rior maxilla, and a portion of the vomer (Fig. GO). In any event the resection should be continued until the septum hangs straight in the middle line. The incision is closed with two or three sutures. AO after treatment is required; or a little gauze may be kept in each nostril for forty-eight hours. It is important to preserve both layers of perichondrium, so that a certain amount of rigidity may be retained, and in order to avoid subsequent per- foration of the septum through atrophy. Elongation of the Uvula. — A catarrh of the naso-pharynx sometimes leads to enlargement and elongation of the uvula. Such elongation is a common accompaniment of acute inflammation of the throat, and disappears as soon as the inflammation subsides. 2s T o treatment of the uvula itself is necessary in such cases. It is quite another matter Avhen the uvula is chronically so elongated that its tip rests constantly on the base of the tongue or even reaches to the epiglottis, causing the patient to gag and cough, particularly when he lies upon his back. The possibility that a persistent dry cough is due solely to uvular irritation should be borne in mind. Inspection of the throat will show at once whether the uvula is long enough to cause irritation. If acute inflamma- tion is present one should, of course, wait until this has passed over before condoning the uvula, as the elongation may be tem- porary. Treatment. — When a uvula is elongated and the cause of irritative symptoms, it should be shortened by appropriate treat- ment. This means first of all attention to the general conditions of health of which the relaxation of the uvula may be only one manifestation. Such general causes are indigestion or constipa- ELONGATION OF THE UVULA 111 tion, too much tobacco or alcohol, over-exertion, bad air at wor] or during sleep, breathing through the mouth, etc. Astringent gargles and sprays, or the application directly to the uvula of stronger preparations than the patient should handle himself, will sometimes result in a cure. Tannic acid, alum, and the salts of silver are remedies worth trying. If local remedies and attention to the general health fail to shorten the uvula sufficiently to cause the disappearance of symp- Fig. 67. — Scissors for Ampu the Uvo toms, a portion of the little organ should he removed. This opera- tion is a simple one, hut it is desirable that the excision should be exact, since the removal of too much or too little may subject the operator to a good deal of criticism, especially if some symptoms persist. The uvula should be anesthetized by the application of one per cent cocain on a cotton swab to its anterior and posterior 112 TUMORS AND DEFORMITIES OF THE HEAD surfaces. The tip of the uvula should then be seized with niouse- tooth forceps and drawn somewhal forward. A sufficient part of the organ is then to be cu1 away with curved scissors. The part removed should extend higher posteriorly than in front. By this means the blunt appearance of the inula is avoided, and the wound is placed on the posterior surface and so is less affected by swallowing. Unless the uvula is held by forceps during the section il is likely to slip from the scissors. A special instrument has been made for the purpose which combines the action of the forceps and scissors. It is called an uvula scissors (Fig. 67). If hemor- rhage follows, it is readily controlled by pressure with a swab we1 with a solution of adrenalin, or peroxid of hydrogen, or one of the other styptics. No after-treatment is required other than the use of iced Do- bell's solution as a gargle, or some similar alkaline solution, and the avoidance of coarse or seasoned articles of diet for a few days. CONGENITAL DEFORMITIES Harelip and Cleft Palate are common congenital deformi- ties. There may be either one or two clefts of the lip and anterior portion of the mouth, hut the posterior portion of the hard palate and the soft palate develop from right and left halves, so that a cleft due to imperfect development is invariably single. If the harelip is double its central portion is connected with the inter- maxillary bone and is attached to the septum of the nose. This deformity may be so extreme that even a successful operation pro- duces a most unsatisfactory result. The opening may be closed, but the scar and disfigurement which persist are most unsightly. If, on the other hand, the development of tissue both of the central portion and margins of the clefts has been abundant, it is possible to produce something like a normal appearance, even though the clefts open into the anterior nares. If the cleft is unilateral and exists in the lip only (Fig. 68), a perfect result may be obtained, so that it is scarcely possible in after-years to perceive that a hare- lip existed. The time for operation has been the occasion of much dispute among surgeons, but it is now pretty generally admitted that a cleft palate should not be operated upon until the child is six or eight years old, whereas a better result is obtained if a HARELIP AND CLEFT LA LATH 113 harelip is operated upon in early infancy, say from the third to the sixth month, or. even earlier if the cleft in the lip interferes with the proper nutrition of the child or causes deviation of the nasal septum (Fig. 69). Sometimes, when the child cannot nurse from the breast it may take milk from the bottle, or, if not, life may still be preserved by pouring milk into its mouth from a Fig. 68. — Harelip, the Cleft not Ex- Fig. 69. — Harelip, the Cleft Exterixg tering the Nostril. The vermilion the Nostril. Note the deviation of of the lip extends into the cleft, but is the septum, even in this comparatively much narrower there. simple case. teaspoon, or the feeding may be accomplished by the passage of a soft rubber catheter into the esophagus. Treatment. — In operating for harelip it is of the first im- portance that the vermilion border be accurately approximated, and, secondly, that a slight excess of tissue at the suture-line be provided ; otherwise the contraction which follows in every scar will draw the lip upward at the line of suture and a slight notch will result. To overcome this, it has been found best to make an oblique incision through the vermilion portion of the lip and to leave a little fulness at this point. If the power of contraction is overestimated it is very easy to reduce this excess at a later period of life. The edges of the cleft must be pared so that they shall be even, and enough tissue must be removed to make the edges to be sutured equal in thickness to the rest of the lip. The suturing is very important. Fine black silk is the best material for the purpose. There may be a number of stitches 114 TUMORS AND DEFORMITIES OF THE HEAD which approximate separately the mucous membrane and the skin. Or fewer stitches may be employed and passed through the whole thickness, or nearly the whole thickness, of the lip. In any case the strain should be evenly distributed upon the stitches. Some operators employ one or two additional stitches set Avell back from the wound, in order to take the strain off the suture-line. This can. however, be accomplished with less disfigurement by placing a narrow strip of strong gauze, such as bolting silk, across the lip from cheek to cheek, fastening its ends to the cheeks by collodion. Another method is to carry two strips of adhesive plaster from the cheeks to the forehead. These two strips make an X, crossing over the bridge of the nose, and fully relieve tension upon the upper lip. The stitches should be removed as early as possible, say in three or five days, in order to avoid a prominent scar, but the strain on the lip must be prevented for a longer period by one of the methods mentioned. In infants operation for simple harelip may be done without any anesthetic, or with a very little chloroform. Cleft of the Lower Lip. — A rare deformity, and one which is always single in the median line, is the cleft of the lower lip (Fig, Fig. 70. — Congenital Cleft of Lower Lip. TO). It is easily cured by a V-shaped excision of the cleft fol- lowed by suture (p. 101). Treatment for Cleft Palate. — If the cleft in the palate involves only the soft palate, the operation for its relief is very TONGUE-TIE 115 simple. It consists in paring the edges of the cleft and carefully approximating them with many fine black silk sutures. If the cleft extends also into the bony portion and is not too wide, it may be closed by suture of the mucous membrane alone. To make this possible, however, it is necessary to make preliminary inci- sions about half an inch from the cleft on either side and separate the strips of mucous membrane from the hard palate. These two strips, right and left, may then be sutured in the middle without great tension. To close a larger cleft a strip of bone and mucous membrane may be chiseled from either side and sutured together in the mid- dle. If this operation is successful, two small clefts remain which can be closed by subsequent operation. The details of these opera- tions will be found in books on major surgery. Complete anes- thesia is necessary. If it is decided to wait some years before operating for cleft palate, a plate of rubber should be fitted and worn. This can be done as soon as the child has double teeth to which the plate can be fastened — generally at two years of age. Such a plate facili- tates swallowing and is a great help to the child in its efforts to talk. Thick Lips. — Persons with very thick lips sometimes become dissatisfied with their appearance and seek surgical aid. An im- provement can be accomplished by the removal of an elliptical shaped piece, the incisions for which should lie fully within the vermilion portion of the lip and should run on either side to a very fine point, in order to produce a smooth appearance. Tongue-tie. — Parents often think their child's tongue is tied if he does not learn to talk as soon as the average child. If the frenum of the tongue is very short, it will pull upon the tip of the tongue and produce a cleft in the tip when an attempt is made to extend the tongue. Even less marked shortening may have an effect upon the pronunciation of certain words, favoring bad habits of speech, or possibly subjecting the child to ridicule. Therefore, if this deformity exists even to a moderate degree, the tongue should be lifted and the frenum snipped with scissors. The reverse end of a grooved director, is often made with a notch for this purpose. Backwardness in acquiring speech is generally dependent on other causes ; but the extra attention given to an older child's efforts to 10 110 TUMORS AXD DEFORMITIES OF THE HEAD speak, following this operation, sometimes leads to an improvement which is quite astonishing. Deformities of the Ear. — The lobe of the car may be cleft, giving the appearance shown in Figure 71. A much commoner deformity is a reduplication of some portion of the auricle, an extreme degree of which is shown in Figure 72. These supple- Fig. 71. -Congenita!, Cleft of Lobe of Auricle. Fig. 72. — Congenital Deformity of Ear. mentary knobs of cartilage may or may not be closely attached to the normal cartilage. Sinuses in front of the tragus are spoken of on page 76. Many of the deformities of the auricle may he perfectly reme- died by a well-planned plastic operation. In closing a cleft, con- genital or acquired, it is well to remember that the essential tissue to be sutured is the cartilage. When the incisions have been made in such a way that the edges of the cartilage come easily together, there will be no trouble in suturing the skin. The first step is to reflect the skin from the perichondrium on all sides for a short distance, but not to cut away any skin until the deep sutures have been inserted in the cartilage. Pieces of adhesive plaster affixed to the ear on either side of the wound, and laeed or sewed together, will relieve tension of the sutures. SECTION II AFFECTIONS OF THE NECK CHAPTER IV INJURIES AND INFLAMMATIONS OF THE NECK Contusions. — Contusions of the neck, if serious, are so be- cause of the injury to the deeper structures. They are usually the result of accidental or attempted strangling. The skin of the neck is tough and freely movable, and if it is pressed against any un- derlying bone, it may escape injury, even though some deeper structure such as the hyoid bone or larynx be broken. An example of this is seen in cases of wheel injury. The wheel of a vehicle, especially if rubber-tired, may pass over the neck and even break one or more of the vertebra? without leaving any mark externally. Foreign Bodies. — A foreign body, such as a morsel of food or some harder substance, may lodge in the larynx, trachea, or esophagus. (For foreign bodies in mouth and pharynx see page 12.) The symptoms vary all the way from a slight irritation and discomfort on swallowing, to complete strangulation and in- tense pain, depending on the shape and characteristics of the for- eign body and the particular position which it occupies. Treatment. — Even when the symptoms are not alarming the foreign body should be removed as promptly as possible, in order to save the patient from the inflammation which is likely to follow its presence, and which may by its swelling completely occlude the air-passages. The patient's efforts — coughing, gagging, and vomiting — may expel the foreign body, or it may be extracted by a finger passed well down the throat. If these simpler means do not suffice, the pharynx and larynx should be inspected with a laryngeal mirror in a good light, and the foreign body extracted with forceps. If the patient lies on his back, with the head lower than the shoulders, extraction is facilitated. A child may be 117 118 INJURIES AND INFLAMMATIONS OF THE NECK turned upside down in an effort to shake out the foreign body, but only for a few moments. If respiration is seriously interfered with and does not improve, tracheotomy is indicated (p. L19). If the foreign body lias entered the esophagus, it is likely to be arrested by the projection of the cricoid cartilage. Tn this case it may still be extracted by forceps introduced through the mouth. If it is of such a nature thai ii is safe to allow it to enter the stomach, the patieni should try to crowd it forward by swallowing pultaceous material, such as well chewed bread. If the foreign body passes the cricoid it may he arrested at the cardiac orifice of the stomach. This has happened a number of times when artificial teeth have been swallowed. This condition will usually require a gastrotomy. Time may be taken for this, however, as the imme- diate distress ends with the passage of the foreign body to the lower portion of the esophagus. If the foreign body is in the trachea or still lower in one of the bronchi, it may be extracted through the natural passages through an opening made in the trachea (tracheotomy, see p. 110), or through an opening made directly into the bronchus. This last will, of course, not be attempted unless the body has been exactly located by means of the X-ray. It will always remain one of the rare major operations, the details of which need not be here dis- cussed. After the foreign body has been removed, the patient should gargle with normal saline solution, or use an alkaline throat spray (Dobell's solution, grycothymolin, etc.). Wounds. — Wounds of the neck, especially stab-wounds, are relatively common. Their interest, too, centers in the injury to the deep structures which may coexist. The jugular vein may be opened by a stab-wound or by a cut, as with a razor. Edema of the lax tissues may speedily become distressing. Death from hem- orrhage is easily possible. Attempts at suicide with a razor often extend no deeper than the jugular vein, although there are in- stances in which an individual has succeeded in dividing most of the structures of the neck as far back as the vertebra?. A cut, even though much less extensive, may open the air-jDassages, usually between the hyoid bone and the thyroid cartilage. Treatment. — Experience has shown that an incised vein may be sutured and its continuity restored, but it is scarcely worth while to attempt this with the external jugular, as interruption of WOUNDS 1J9 its blood current has no significance. In general the decision should be to ligate all the large vessels, to suture with catgut any opening into the air-passages, and to provide for the subsequent performance of tracheotomy should the breathing become difficult through swelling of the larynx. These steps may all be performed under the influence of a local anesthetic unless the patient, very likely insane, refuses to remain quiet. It is better not to trust to pressure to control hemorrhage ex- cept in the most superficial wounds. Pressure may stop the flow of ■blood at the surface, while allowing it to continue in the deeper planes of tissue. This is especially true in the case of irregular or 'punctured wounds, which should be immediately explored to their depths, even though it is necessary to enlarge the wound in the skin. Veins as well as arteries should be ligated with fine catgut. Wounds of the Esophagus. — A stab-wound of the neck, without giving rise to serious symptoms, may penetrate the esophagus. Under such circumstances there will be a slight mucous discharge to which may be added milk, water, etc., when the patient swal- lows these fluids. Such a wound, if it has good drainage, will generally close spontaneously in the course of two or three weeks ; but one should be on his guard against infiltration of the deeper tissues or a burrowing of pus and food along some fascial plane. If necessary the external wound must be enlarged to afford free drainage. If the opening into the esophagus cannot be satisfactorily sutured, a soft rubber tube should be passed into the lower por- tion, through which the patient can be fed temporarily until the wound has time to close by granulation, or permanently, if the loss of the wall of the esophagus is permanent. Tracheotomy. — Tracheotomy performed upon a normal adult is a simple operation. A vertical incision is made in the median line from the cricoid cartilage downward for a distance of an inch or more. This wound is deepened until the surface of the trachea has been bared in the median line for about an inch. A scalpel is then passed through the anterior wall of the trachea. The sides of the incision arc separated by means of sharp hooks or an especially devised dilator, and the tracheotomy tube is in- serted. The whole procedure may be performed without an assist- 120 INJURIES AND INFLAMMATIONS OF THE NECK ant, and in case of need an opening has been made with a jack- knife and death from strangulation thus averted. In an infant, struggling for air and violently moving its larynx up and down, the operation is far more difficult. The principles arc the same, but the neck is so shorl that exposure of the trachea for a sufficient distance and its division in the median line are by no means easy. In adults, under circumstances in which an emergency opera- tion is necessary, the distance from the skin to the trachea is often greatly increased by edema, extravasation of blood, and venous congestion. The instruments which are essential for this operation are a dissecting and mouse-tooth forceps, scalpel, scissors, artery clamps, small sharp and blunt retractors, a curved dressing forceps or a specially constructed tracheal dilator, and a tracheotomy tube (Fig. 73). The patient lies upon his back with the neck fully extended over a hard pillow or sandbag. An incision is made in the median line from the cricoid cartilage downward for an inch and a half. Veins as they appear should be divided between clamps, or clamped as they are cut, until the trachea is reached. The isthmus of the thyroid should be drawn upward. If time per- mits, all hemorrhage should be controlled before the trachea is opened. This is done by a median vertical incision for a distance of three-quarters of an inch. The walls of the trachea are held apart by two narrow blunt retractors or by the tracheal dilator. Mucus or a possible foreign body is sponged away or removed by means of a curved dressing forceps, and the tracheotomy tube is inserted. The wound in the soft parts, if unnecessarily large, should be partly closed by suture. A flat collar of gauze, impreg- nated with some antiseptic, should be placed between the shield of the tube and the wound, while the tube itself is held in position by two tapes tied at the back of the neck. A moist sponge should be kept over the mouth of the tube in order to keep the inhaled air warm and moist. Upon the care of a tracheotomy tube depends in no small meas- ure the early cure of the patient. Mucus may be removed from the tube by a small wisp of wet cotton on a bent probe. If the tube is a single one, it should be removed and cleaned at least once a day. The wound should be frequently cleansed. Only the mild- est antiseptics are permissible in such a situation. A double tube, ■go % $ a S,^ 2q-c 3fc w — S o , (D H u Z 14 s a &,_2 121 122 INJURIES AM) INFLAMMATIONS OF THE NECK while leaving Less space for the air, has the advantage that the inner tube can be removed a1 any time without disturbing the wound, and it can always be replaced without difficulty. Tubes are also made in such a manner that either the outer or inner tube can be removed and replaced without disturbing the other. Thus the tube lefl in place acts as a guide for the insertion of the other. Intubation. — This little operation consists in the introduc- tion into the larynx of a rigid tube so as to permit respiration to go on in spite of swelling, or an accumulation of mucus or mem- brane, which might close the glottis. It is chiefly performed in cases of diphtheria. With the ingenious instrument devised by O'Dwyer, the introduction of the tube is comparatively simple. The patient is held firmly in an upright position, the mouth gag is inserted, and the forefinger of one hand is passed into tbe throat until the tip of the epiglottis can be felt. With this finger as a guide, the tube is passed into the larynx. The instrument with which the tube was introduced is then released and withdrawn, the finger holding the tube in position meanwhile. As a precau- tion against mishaps, the tube may be threaded on a long loop, and the thread removed only when the operator is sure the tube is in position. In removing the tube, the patient is again placed in an upright position, the mouth gag is inserted, and the forefinger passed into the throat until tbe tube can be felt. It acts as a guide to the extracting instrument. The withdrawal of the tube is more diffi- cult than its insertion, so that if a tube is inserted merely as a temporary measure, it is well to leave the loop of thread in posi- tion to facilitate extraction. If this is done the loop may be fas- tened over the patient's ear. Sprain of the Cervical Spine. — The lower portion of the spine is more often the seat of sprain than is the upper portion. This may be due to the greater flexibility of the cervical spine. However, sprain of the neck is by no means uncommon. It may follow falls or blows of various sorts. The symptoms are pain and tenderness, especially when certain movements are made, against which the patient often protects him- self by muscular contraction. External signs, such as edema and ecehvmosis, are usuallv wanting. There is no true deformity, al- FRACTURES 123 though the patient for his own comfort may keep the head out of the median line. Thus an injury of this sort, if not properly treated, may lead to wryneck. Symptoms of shock may be pres- ent, but are usually wanting in cases of simple sprain. Diagnosis. — The essential point in the diagnosis is not to over- look a more serious injury, such as fracture, or injury of the cord, received at the time of accident, or due to pressure of the hema- toma. Hence the patient should be carefully examined, the ex- tent of the various normal motions of the neck tested and recorded (for the method see p. 162), possible paralysis, either sensory or motor, investigated, and any other symptoms noted. This is the more important in cases of spinal injury, out of which damage suits may arise. The possibility that a dislocation lias occurred and has been spontaneously reduced should also be borne in mind. The chief significance of this is the damage to the cord which may have occurred through undue pressure. Another possibility to be thought of is commencing tuberculosis. Treatment. — Treatment consists in rest in a correct position, with hot or cold applications to' relieve pain. Later, massage and passive and active motions should be instituted in order to regain the full range of motion. If the patient has a tendency to hold the head in an abnormal attitude, this should be corrected, even though it is necessary to give an anesthetic and to apply a plaster of Paris bandage to the head, neck, and chest. This should not be continued very long, lest stiffness result. It is therefore better to remove it in a week, and to begin treatment by manipulation. Fractures. — Fracture of the Hyoid. — Attempts at strangula- tion may cause fracture of the hyoid bone. The usual symptoms of fracture, pain on motion, swelling, and ecchymosis, are present but may be rather slight. In case of the hyoid bone, crepitus will probably be obtainable. To these ordinary symptoms there may be added pain on swallowing, or cough, or swelling of the larynx so great that tracheotomy becomes necessary. If no displacement is present, the parts will unite without treatment. If there is displacement, it is better to make an incision and suture the fractured cartilage or bone with catgut, so as to avoid deformity. ]STo apparatus is required to hold the fractured ends in normal position if there is no tendency to displacement, but a few strips 124 INJU1UES AM) INFLAMMATIONS OF THE NECK oi adhesive plaster or immobilization of the head will give the patienl comfort. Fracture of the Larynx. — In fractures of the larynx the thyroid cartilage is usually involved; the fracture may or may not be complete. A- the mucous membrane of the larynx is often rup- tured, l>l»xxl Hows into the trachea and excites a most painful cough. Swallowing and talking are also painful. The thyroid is flattened; there is marked edema, and frequently emphysema. If the fracture is complete, crepitus is easily obtained. This is a very dangerous injury, statistics showing that more i ban one-third of the patients who suffer from it die. As death usually comes during an attack of dyspnea, tracheotomy should be immediately performed, except possibly in simple cases when the patient is so situated that tracheotomy can he performed at a moment's notice. Subsequent treatment should be directed toward keeping the fracture aseptic, controlling hemorrhage, and prevent- ing stenosis. To accomplish these measures it is often necessary to perform laryngotomy. Fracture of the Trachea. — This injury occurs less often than fracture of the larynx. The symptoms in general are similar. Dyspnea and emphysema are the most alarming ones, and are fre- quently the cause of death ; or death may follow at a later period from inhalation pneumonia. The treatment is similar to that recommended for fracture of the larynx. If there is no dyspnea and no emphysema, trache- otomy may be deferred, but the patient should be kept under strict observation for several days. Fracture of the Cervical Spine. — Fracture of the cervical ver- tebrae may be due to direct violence, but it is generally the result of blows or falls upon the head. It is not necessarily fatal, but is often accompanied by injury of the cord sufficient to terminate life either immediately or after the lapse of a few weeks. The symptoms are the usual ones of fracture, namely, pain on pres- sure and on manipulation, abnormal mobility and crepitus, pos- sibly swelling and ecchymosis. Some of these symptoms may be masked by the numerous strong muscles which surround the ver- tebra?, and which are kept contracted to prevent the pain due to motion of the neck. The cord is usually injured, either pressed upon, or partly or CELLULITIS AND ERYSIPELAS 125 wholly crushed. There is, therefore, almost always more or less paralysis, sensory or motor, or both. Prognosis, on account of the injury to the cord, is bad, worse than when the lumbar spine is fractured. Treatment. — If no cord symptoms are present, treatment con- sists in the immobilization of the spine, possibly with extension and counterextension. If there is a partial or complete paralysis, the spinal canal should be opened posteriorly (laminectomy), and depressed fragments of bone or compressing blood-clots removed. Unfortunately the paralysis is usually due to crushing of the cord at the time of the accident, and not to pressure. Hence it is only occasionally that an operation benefits the patient. Dislocation of Vertebrae. — This injury may be due either to direct violence or to a fall. If the dislocation is complete, it is often found to be associated with fracture and to have produced fatal lesions of the cord. There are instances, however, in which dislocation is only partial and in which the cord escapes serious in- jury. This is especially true when a partial dislocation takes place between the axis and atlas. Such a patient may escape paralytic symptoms and may live with the dislocation unreduced. Treatment. — If the head and body are pulled strongly apart and the neck is manipulated, the dislocation may be reduced. This procedure is not without risk of sudden death. It should be performed with the greatest steadiness and gentleness, prefer- ably under an anesthetic. Otherwise the treatment consists in immobilization of the neck, followed by massage and manipula- tions (compare the treatment for Sprain, page 123). INFLAMMATIONS Burns. — The neck is often the seat of severe burns, especially when the clothing catches fire. Such burns, if deep, are likely to result in deforming contractures, even to the extent of draw- ing the chin down upon the chest (Fig. 87, p. 148). For the treatment of burns see page 26. Contraction should be prevented by keeping the burned area extended during healing by means of a plaster of Paris splint fitted to the opposite side of the neck. Cellulitis and Erysipelas. — Superficial cellulitis and ery- sipelas occurring in the neck present no peculiar features. For L26 INJURIES AND INFLAMMATIONS <>1<' THE NECK description and treatment of these disorders see pages 33 and 35. Boil. — The back of the neck is a favorite seat for boils. A furuncle or boil is a local suppuration due to staphylococci. The inflammation begins in the skin usually at the root of a hair. There is a purulent center, surrounded by a red, edematous area. The swelling and pain vary. Sometimes the inflammation is so intense that necrosis of the deeper portion of the skin takes place. This necrotic slough is called the "core" of the boil. If the boil forms where the skin is delicate, the pus very soon breaks through to the surface. In the back of the neck, where the skin is often a quarter of an inch thick, it is sometimes several days before the necrotic center of the boil, popularly called the core, becomes softened and separated from the surrounding skin, so that the contents of the boil are able to discharge themselves spon- taneously ; and sometimes, instead of discharging on the surface, the pus finds its way into the subcutaneous fatty tissue, forming an abscess there. A boil does not tend to spread beyond its immediate vicinity, and after its discharge it usually goes on to recovery without giving rise to other than a local cellulitis. The process, however, is apt to be repeated, often many times, in the vicinity of the first lesion, each new boil developing separately as if it were the only one, from infection through the hair-follicles, due to the smearing of pus on the surface. Treatment. — The best treatment is to evacuate the abnormal products already formed and to hasten or cut short the patho- logical process. At the back of the neck the skin is thick and the inflamed area is proportionately great, so that the introduction of a drop of carbolic acid will not usually stop the infection, as it often will in case of a small boil of the face (p. 36). Most sur- geons still follow the domestic plan of poulticing such a lesion for a couple of days until there is a well marked center to the suppura- tion. This poultice treatment is generally continued too long. To keep up the poultices until there is simply a soft pus-sac to be opened simplifies the operation, but it prolongs unnecessarily the sufferings of the patient, and by increasing the size of the cavity, which lias to be closed in healing, it delays ultimate recovery. Tn most instances, as early as the second day, it is possible to say where the center of the boil is located, and if a short incision CARBUNCLE 127 is made clear through the skin at this point and a wet dressing is applied, not only will the patient be saved one or more days of intense suffering, but the inflammatory process will rapidly subside and there will be very little necrosis of the skin to be made good by the growth of the new tissue. Any violent attempts at curetting or squeezing out the necrotic tissue or pathological products are to be condemned, as these substances will come out of themselves in a few hours, while the violence adds somewhat to the sum total of injured tissue and may set up a severe cellu- litis. A strip of rubber tissue or gauze should be inserted to favor the escape of pus. An injection of cocain or eucain directly into the inflamed skin over a boil is a very painful proceeding. It is therefore bet- ter to begin the anesthetization at a little distance from the in- flamed area, so that as new punctures are made nearer the center they shall enter tissue in which sensation has been benumbed. It is in operations of this character that a freezing spray of ethyl chlorid proves satisfactory. For other details of treatment see Chapter XX. The after-treatment of a boil is simple. The wet dressings should be continued for a couple of days, until the discharge is at a minimum, when an ointment, such as balsam of Peru, one part, vaseline, eight parts, may be substituted. The advantages of the poultice may be obtained without its disadvantages by applying heat to the outside of the wet dress- ing. For this purpose a hot-water bag or bottle, or a hot brick or flat-iron, may be used. It is easy to produce and maintain as high a temperature as the patient can stand, by changing the bottle as soon as its temperature falls. In this manner the gradual cooling of the poultice and discomfort and trouble of its renewal are avoided. Carbuncle. — A carbuncle is a suppuration which, unlike that of a boil, has a tendency to spread laterally through the cutane- ous tissues. Local abscesses are formed in the various hair-folli- cles, and the interstices of the skin become saturated with pus, and there is an extensive cellulitis with necrosis of more or less of the true skin, besides the usual symptoms of infection (Fig. 74). A carbuncle also extends downward, and the subcutaneous fat is usually involved in all except very mild cases. From this brief 12S INJURIES AND INFLAMMATIONS OF Till: M'.i'K description it appears that an extensive carbuncle is a serious trouble which not infrequently terminates fatally. [Treatment. — It is important that incisions should he made through the skin before the process lias extended widely. As many as possible of the small abscesses should ho opened by the incisions, which may be made at intervals of one-fourth or one- Fig. 74. — Carbuncle of Neck. Note the flat top, and several points of suppuration. third of an inch, both vertically and horizontally; or they may radiate from a central point (Fig. 75). Some few surgeons ad- vocate the complete excision of a carbuncle, but this causes the loss of an unnecessary amount of tissue. A compress wet with a strong antiseptic solution should be applied and kept hot in the manner described above. It may be necessary on the follow- ing day or at a later period to make other incisions to permit the escape of newly formed collections of pus. Figure 76 shows the outcome of a very bad case. Fig. 75. — Carbuncle of Neck. Duration, four weeks; incised three times, gangrene of one flap. Scar from similar operation for carbuncle twenty years previous. Patient aged fifty-two years. Fig. 7G — Same Patient as Shown in Fig. 75, but Eleven Weeks Later. 129 130 INJURIES AND INFLAMMATION'S OF THE NECK Abscess. AJbscesses may also form in the neck as the result of infection in some other situation. This is notably the case in neglected children, who scratch their heads to find relief from the itching set up by pediculi. The epidermis is broken, a slight cellulitis results in the scalp, and i lie infection follows the lym- phatics to a cervical gland and produces an abscess in the neck ( Fig. 77). It is usually possible to find the starting-point of the infection under such circumstances. Such an abscess is wholly subcutaneous and is not possessed of the virulence either of the boil or the carbuncle. It should be opened and treated according to the plan laid down for abscesses of the scalp (p. 31). I Fig. 77. — Abscesses of Neck. Duration two weeks, secondary to pediculosis capitis, occurring in a child of two years. The pediculi should be removed to prevent recurrence of the trouble. Applications of benzin, or kerosene, or tincture of delphinium and ether, followed by a shampoo, will accomplish this. Deep suppuration of the neck, due presumably to infection from the mouth, sometimes develops rapidly. In a day or two ABSCESS 131 the whole front or side of the neck may be swollen, brawny, and, later, saturated with pus, while chills and fever show the gravity of the affection. This trouble has often been called angina Ludovici. It deserves early radical treatment or it may Fig. 78. -Abscess. Under Stermqmastoid Muscle. Six months' duration; probably tubercular. Patient aged fifty-six years. speedily lead to a fatal termination. The tension should be re- lieved by incisions sufficiently numerous and deep to open any pockets of pus and allow the escape of the greater part of the exuded fluid. If operation is delayed until the whole front of the neck is involved, the prognosis is decidedly unfavorable. A slowly forming deep abscess' of the neck may be due to breaking down of a tuberculous gland (Tig. 78), or to a mixed infection in case of syphilitic ulcerated throat. Abscess of the cervical lymphatic glands secondary to alveolar abscess, is spoken of on page 42. 11 132 INJURIES AND INFLAMMATIONS OF THE NECK Anthrax.- — Anthrax or malignant pustule is a disease not common in this country. It usually develops in a man who has been handling infected hides. The first lesion appears upon the hand or some part of the body that the hand has touched. It is a hard, raised, flattened, reddish nodule, with a surrounding zone of more or less indurated cellulitis (Fig. 79). It shows little Fig. 79. — The Primary Lesion of Anthrax. Diagnosis confirmed by microscopical examination of discharge from the ulcer, and of the blood. tendency to necrose in the central portion. The constitutional symptoms are severe and out of proportion to the local mani- festations, although they may not become so until several days after the infection has taken place. The diagnosis can only be made with certainty by an examination of the serum and blood obtained from the pustule. The anthrax bacillus is large and has square ends, like the segments of a mature tapeworm, so that it is readily recognized in a stained smear by a simple micro- scopical examination. As confirmatory evidence, cultures should CERVICAL TUBERCULOSIS 133 be made. The bacillus grows readily upon any of the common culture media. If a positive diagnosis is made, the local lesion should be immediately excised. Further operative measures are generally useless, as the disease spreads through the blood as well as through the lymphatic system. A fatal termination is common, but is by no means invariable, so that life should not be despaired of at once. Cervical Tuberculosis. — Tuberculosis in the neck is situ- ated either in the lymph-glands or in the spine. Tubercular lymphadenitis is described, with other enlargements of the glands, on page 142. Tuberculosis of the bones of the neck or cervical Pott's dis- ease, as it is called, is a condition which in its early stages is apt not to be recognized. Owing to the fact that the spines of the vertebrae are not so plainly to be felt as those in the back and in the lumbar region, the diagnosis is not so simple as it is in the latter situations. The first symptoms noticed are pain, stiffness, and rigidity of the neck. Later there is swelling of a diffuse character, making the neck somewhat thicker than before. There is great pain when the neck is bent, either by the patient or by the examiner. The trouble may be differentiated from acute sup- puration by the gradual onset of the disease, by the low fever, and the absence of surface heat, edema, and redness. From wryneck and the acute myositis which precedes wryneck, it can be differen- tiated by the situation of the swelling. In cervical Pott's the swelling is invariably in the median line, though it may extend more to one side or the other. In myositis or wryneck the swelling is lateral or well to the front. In wryneck the chin is directed away from the side on which the sternomastoid muscle is prom- inent. In cervical Pott's the chin is directed toward the affected side. In wryneck correction of the deformity is prevented by the bands which spring into marked relief when correction is at- tempted. In cervical Pott's an attempt to correct the deformity is painful, and will be resisted by the hands of the patient. Cervical Pott's is differentiated from deforming arthritis of the spine by the fever which it causes, by the involvement of the soft parts in the tuberculous inflammation, by the greater tender- ness, and by the age of the patient, much less in tuberculosis than in arthritis in most cases. The progressive rigidity of the spine 134 INJURIES AND INFLAMMATIONS OF THE NECK which occurs in arthritis is absolutely characteristic as the disease becomes more advanced. Treatment. — The object of treatment is to obtain relief from the weight of the head and to keep the parts at rest. This is accomplished by an apparatus known as a jury-mast which lifts the weight of the head by a strap placed under I lie occiput and under the chin. The instrument rests upon the back and shoul- ders and is secured in place either by straps or by a plaster of Paris bandage. Whether the disease will he arrested or progress to an unfavorable termination will depend upon the age of the patient, the hygienic surroundings, etc., more than upon local treatment. Deforming Arthritis. — The spine is involved in deforming arthritis with a frequency not generally recognized. At times the whole spine is involved, hut oftener only a portion of it. The neck is the part most often affected. One writer has stated that, in more than one third of all cases of deforming arthritis the cer- vical vertebra? are involved. On account of the irregular shape and close articulations of the vertebra 1 , the disease is apt to pro- duce a firm ankylosis of the portion of the spine involved. The most marked symptoms are increasing stiffness, and pain due to pressure upon the posterior roots of the spinal nerves. Zoster also occurs. The differentiation of this disease from cervical tubercu- losis has been given on the preceding page. The treatment should be both local and general. Massage, hot baths, and counterirritants may be used to relieve the pain. The general treatment will vary according to the ideas of the physician in regard to deforming arthritis. My own preference is for a resi- dence away from large bodies of water, for an out-of-door life, free from care, and with all the good food that the patient can take without producing symptoms of indigestion. CHAPTER V TUMORS AND DEFORMITIES OF THE NECK TUMORS Sebaceous Cyst. — This variety of tumor is found in the skin of the front and back of the neck, but with less frequency than upon the head. It presents no peculiarities on account of its situation, so that what has been said of the diagnosis and treat- ment of sebaceous cysts of the head is applicable here (see p. 66). Thyroid Cyst. (See Goiter, p. 145.) Thyreoglossai Cyst. — The region of the larynx is a favor- able site for congenital cysts and sinuses developing from some remains of the thyreoglossai duct, which at an embryological pe- riod extends from the base of the tongue through the hyoid to the thyroid cartilage. If the remains of such a duct open externally, one or more sinuses will persist and will discharge mucus. If the remains of the duct do not open externally or into the mouth, the secretion may give rise to a cyst containing mucus. Such a cyst is easily opened and its contents evacuated, and the sutured skin will heal per primam. In the course of a few days or weeks, however, the fluid will reaccumulate and the tumor will reappear. In order to avoid this unpleasant result the treatment should be thorough. The scar following an unsuccessful attempt to remove a thyreo- glossai cyst is shown in Fig. 80. This also shows the situation of the original sinus or cyst. If a sinus exists, it is invariably in the median line. Treatment. — The only successful treatment is the complete removal of the cyst and its duct. The situation is a conspicuous one and it is desirable to leave as small a scar as possible, yet the dissection must be deep enough to expose the abnormal tissue, both above and below the hyoid bone if need be. The skin should be cocainized or the patient given a general anesthetic. The incision 135 136 TUMORS AM) DEFORMITIES OV THE NECK should be mad*-' directly in the median line and more above than below the center of the tumor, as it is necessary to follow it up- ward. The dissection and removal of a rounded cyst is easy; that of a narrow sinus is more difficult, since it is often impossible to recognize it when it becomes attenuated. Even when there is a Fig. 80. — Thyreoglossal Cyst; Operation; Recurrence. Note the position of the cyst in the median line just below the hyoid bone. well marked cyst, an inconspicuous sinus often leads from its upper part. It has been suggested that such a sinus be injected with a solution of methyl blue, so that the operator may follow it more readily. "When the congenital tissue has been followed to the hyoid 1 one there will often be found a perforation of the bone. The lining of this should be curetted away, and if the sinus exists above the hyoid it should be followed and removed. When this l.as been done, the patient will have been given the best chance against recurrence, but a guarded prognosis should be given. The wound should be sutured entirely, or over a minute drain in its lower angle. LIPOMA 137 Branchiogenic Cysts and Sinuses. — Other congenital cysts and sinuses may be found in the sides of the neck, having de- veloped from the remains of the branchiogenic clefts, or at the base of the ear and posterior to it. These tumors are some- times made up of a few larger cysts and innumerable smaller ones, and contain either a clear serous fluid or one made thicker by the presence of mucin and other albuminous substances. They are .benign in character, but on account of the deformity and their tendency to keejj on growing they should be removed as thoroughly as possible. In making a diagnosis of a lateral cervical cystic tumor, aneurism of the carotid or one of its branches should always be considered. One thinks at once of expansile pulsation as a means of differential diagnosis. It should be borne in mind that if a tumor, cystic or solid, lies upon the carotid artery it receives an impulse from the arterial beat. This impulse may be mistaken for expansile pulsation unless a careful examination is made. Lipoma. — A fatty tumor or lipoma is probably the com- monest solid tumor of the neck. It occurs in three forms : simple, diffuse, and intermuscular. A simple lipoma is a well encapsulated tumor lying in the subcutaneous plane of fascia. It seems to form a part of the sub- cutaneous fat, but it soon exceeds this fat in thickness and is usu- ally covered by a thin layer of this fat. It may be found in any portion of the neck (Fig. 81). It tends to grow larger, and this causes an ever-increasing deformity. This is the one reason for its removal. Treatment. — A local anesthetic is sufficient unless the pa- tient is very sensitive. The incision in the skin should usually be parallel to or lie in one of the circular wrinkles of the neck. A transverse incision is also preferable if the tumor is situated at the back of the neck The incision should be deepened until the capsule of the tumor is plainly seen. This is usually covered by some normal subcutaneous fat, and if the operator attempts to dissect out the tumor before the true capsule is reached, the diffi- culties are unnecessarily increased and a ragged cavity will result. When the correct plane is reached the whole tumor can be quickly shelled out with blunt dissection either with the fingers or with closed, blunt-pointed, curved scissors. There is scarcely any bleed- • ■ /I «■ \o* 1 .' Fig. 81. — Simple Lipoma of the Neck of Two Years' Duration. Fig. 82. — Diffuse Lipoma of the Neck. This tumor was symmetrically bilateral. One portion was removed five days before the photograph was taken. 138 LIPOMA 139 ing, but the wound should he inspected for it, and if any Needing vessel exists, it should he ligated with fine catgut lest a hematoma fill the cavity left by the removal of the lipoma, and for a time continue the deformity. The wound should be completely sutured with horsehair or fine black silk and elastic pressure applied by means of a gauze and cotton dressing and a firm bandage. This may be removed in three days and any small dry dressing be Fig. 83. — Fibroma of Nine Years' Duration, Apparently Starting in the Fascia about the Sternomastoid Muscle. reapplied. The stitches should be removed — one-half on the fourth day and one-half on the sixth day, or sooner if the wound is a small one. Diffuse Lipoma. — The second variety of lipoma develops in con- nection with the deep fascia. It is not encapsulated; it contains more fibrous tissue than the other two varieties, and its removal 140 TUMORS AND DEFORMITIES OF THE NECK is difficull and unsatisfactory. It usually develops symmetrically on both sides of the neck (Fig. 82). Fortunately it is rare. Intermuscular Lipoma. — The third variety of lipoma develops in the fascia between the muscles. It is found in the neck, trunk, and extremities. In structure it resembles the simple lipoma, being made up of lobules of almost pure fat, each surrounded by a complete delicate capsule. The dissection for its removal is therefore easy, but the extensive ramification of the tumor between the various muscles sometimes makes necessary a pretty long wound. Fibroma. — A pure fibroma, wholly subcutaneous, is not a very common tumor in any portion of the body. Such a one de- veloping slowly in connection with the left sternomastoid muscle is shown in Figure 83. It was removed without, dif- ficulty, being fully en- capsulated (Fig. 81). Enlarged Lym- phatic Glands. — Acute Lymphadenitis. — The most common tumor of the neck is a swollen lymph- gland. In the strict use of the term this is not a tumor at all but an inflammation, a lymphadenitis. But for clinical reasons it is well to class these enlarged glands with the tumors. The cer- vical glands are especially liable to swell on account of infection from bad teeth, or from throat troubles, such as ulcerated tonsil, or from inflammation in or about the ear, as Avell as from infected wounds of the skin. A very common source of lymphadenitis of Fig. 84. — Same Subject as Fig. 83, Showing the Tumor after Removal. It was fully encapsu- lated and easily removed. ENLARGED LYMPHATIC GLANDS 141 the posterior cervical glands in children is pediculosis capitis. The child scratches the scalp to relieve itself of the intolerable itching, the scratches become infected, and the glands swell. An extreme case in which the glands have broken down and two largo abscesses have resulted is shown in Figure 77, page 130. Whatever the source of infection, the glands lying in the path of the afferent lymph- vessels will become inflamed. One or more of them swells until it presents itself as a smooth, round, movable tumor, above which the skin is also freely movable. If the severity of the inflammation causes the gland to break down, fluctuation is obtainable and the inflammation extending to the skin will prevent movement of the latter over the gland. Later the abscess may break through the skin. Often, however, the infection, being of a milder character, does not extend beyond the capsule of the gland, and the acute symptoms of infection are wanting in the periglandular tissue ; or the inflammation in the glands themselves may be of a more chronic form. In such a case the swelling of the gland will be painless, and there will be little tenderness even on pressure. One should never be satisfied with a diagnosis of simple lymphadenitis. The source of the infection should also be de- termined. If no cause for the swelling of the gland can be ascertained, the possibility of tuberculosis should be kept in mind. Treatment. — If the infection of the gland has not proceeded to demonstrable suppuration, the attention may be directed to the prevention of further infection by the treatment of the infected teeth, or sore throat, or wound of the skin. When the source of infection has been shut off, acute lymphadenitis will take care of itself in many cases. If fluctuation can be made out in a gland, the process will rarely undergo resorption without a discharge of pus. In such cases it is better therefore either to drain the gland or to remove it entirely if this can be readily done. For if the glandular tissue is riddled with pus and germs, but has not necrosed, the relief of tension, when the abscess is incised, will give it a new lease of life, so that this glandular tissue may remain a long time in the wound, discharging constantly a purulent secretion and delaying wouud- healing in an aggravating manner. If the whole gland is removed 142 TUMORS AND DEFORMITIES OF THE NECK with its capsule, union of the sides of the wound will be prompt and often primary. If the infection comes from the front teeth, so that the tumor forms in the situation of the submaxillary gland, this gland is ex- posed first in making the incision. It ought not to be sacrificed, however, because the source of the pns is not in its substance, but in that of one or more lymphatic glands lying just under it. If this caution is not borne in mind, the salivary gland may be need- lessly excised. Chronic Lymphadenitis, or Tuberculous Glands. — The lymphatic, glands of the neck arc also subject to inflammatory processes of a chronic character. Many times the process is distinctly tuber- cular, and can be shown to be such by the presence of tubercle bacilli in the excised gland. At other times, however, the tumor develops in a similar manner and presents the same clinical appear- ances, although no tnberele bacilli can be made out. Such patients are anemic, have a poor digestion, suffer from cold feet and hands, and have an appearance of malnutrition although the subcutaneous fatty tissue may be abundant. Treatment. — The treatment in tuberculosis is primarily hy- gienic. Such treatment should precede and follow the local treat- ment. Just what the local treatment should be must be determined in each particular case. If a single large gland exists, causing a deformity and suggesting the possibility of enlargement of other glands, its removal is absolutely indicated. If there are many slightly enlarged glands operation can be deferred. If there are numerous large glands, some of which are plainly suppurating, removal is necessary both to reduce the number of foci from which the disease may spread as well as to save the patient from abscess formation with resulting sinuses and disfiguring cicatrices. If a single movable gland is to be removed, a local anesthetic suffices in many cases. If many glands are enlarged, and espe- cially if one or more are adherent, the operation is a more formi- dable one and had better not be undertaken except with general anesthesia; for although the enlarged glands may seem to lie close to the surface, they invariably extend deeper than they ap- pear to do, and almost always there are others still deeper which are concealed by the more superficial ones. A thorough opera- tion in such cases means a free incision of the skin and superficial ENLARGED LYMPHATIC GLANDS 143 muscles and wide exposure of the cervical vessels. Such glands often lie just in front of the sternomastoid muscle and close to the internal jugular vein; others are usually found just behind the muscle, or beneath it. Hence the division of this muscle greatly facilitates their removal. A transverse or U-shaped or Z-shaped incision through the skin is advocated on account of the splendid exposure it gives. The resulting scar is prominent, and should he avoided when possible, even though two separate incisions are required — one in front of the sternomastoid and one behind it. In cases of extensive involvement of the glands, it is well to remove as much of the gland-bearing fascia as possible-. This requires a long and difficult dissection, which is fully de- scribed in good text-books on major surgery. The cases which may properly be considered here are those in which there are one or more enlarged glands, freely movable and easily accessible. In such a case it is better to make the in- cision directly over the glands and parallel to the edge of the sternomastoid muscle. When the various planes of tissue, skin, subcutaneous, and deep fascia have been divided, there will be ex- posed the outer capsule of the gland. If this is also divided, the gland may sometimes be shelled out like the pulp of a grape from its skin, especially if it is still solid and the inflammation has not set up adhesions between the gland substance and the outer cap- sule. In that case the dissection may be tedious, but should be persisted in until the gland is removed. The rule should always be to keep close to the gland in removing it. If a little of the gland substance remains, it is easy to remove it after the gland itself has been excised ; whereas if the line of incision strays from the gland itself, serious damage may be done to some important vessel or nerve. The important structures to be kept in mind during the dis- section are the internal jugular vein and pneumogastric nerve in front of the sternomastoid muscle, and the spinal accessory nerve posterior to it. When the enlarged glands have been removed the wound should be cleansed and sutured. Even though necrotic material has been smeared over the wound by the rupture of a softened gland, primary union is still attainable in most cases if all dis- eased glands are removed. The finest of black silk sutures should 1 11 TUMORS AND DEFORMITIES OF THE NECK be placed through the skin wound, thus allowing the deeper parts to collapse and assume their normal relation. Light pressure ob- tained by a piece of sterik' gauze placed on the wound and cov- ered with cotton and a gauze bandage will suffice to keep the deeper parts of the wound in apposition. If the wound is dry before it is sutured no hemorrhage need be feared. Even if the dissection is a limited one, it is better to confine the movements of I he head for two or three days by the application outside of the gauze bnndage of a starch bandage, made by tearing heavy crin- olin into strips t\v< > < >r three inches wide. These strips are rolled and immediately before being used they are wrung out of hot water, care being taken not to squeeze out more of the contained starch than is necessary. In the case of a child, or of a restless adult, the bandage should run around the neck, up the back of the head and around the forehead, and should also extend under one or both arms (No. 22, Chapter XXI). This may seem like a very extensive dressing for a simple wound, but only in this manner can a wound in the neck be properly protected and the head kept quiet. In a day or two, when the starch has thoroughly dried, the parts of the bandage which extend under the arms may be cut away, as by that time the molding of the bandage to the shape of the neck and shoulders will be sufficiently firm. The wound should be dressed in four days, and half of the stitches removed, the rest being left in three or four days longer. From this time on a cotton-collodion dressing will sufficiently protect the wound from outside contamination. If the adult is quiet and the incision does not extend to the upper third of the neck, the bandage around the head may be omitted. Suppurating Tuberculous Glands. — Unfortunately the clean operations above described are often impossible because the pa- tient will not allow any operation until the pus has burst through the skin or at least has ruptured the capsule of the gland and has infiltrated the surrounding tissues. Under such circumstances the abscess-cavity must be drained through a suitable incision, but the operator should not content himself with this alone, but should make an attempt to remove all of the affected gland, either by means of a curette or, what is better, by means of forceps and scissors. If this dissection does not extend beyond the original capsule of the broken-down gland, the risk of spreading the infec- TUMORS OF THE THYROID 01 .AND 145 tion by this treatment is not.3K.Qith considering, and the period of recovery will be materially shortened if one does not Leave behind a half disintegrated gland, which will keep ;i sinus discharging a small amount of pus daily for weeks afterward. If, on the other hand, the gland is wholly removed, and free drainage is given to the wound, it may be able to close by granulation in a week or two. In Syphilis. — The cervical glands may be enlarged in syphilis either as an accompaniment of an ulcerated throat or as a later manifestation of the disease. In the former case, on account of the presence of pus, an incision may be necessary. Glandular enlargement due to syphilis will subside rapidly under antisyph- ilitic treatment, so that removal of the glands is not usually necessary. In Leukemia, Pseudoleukemia, Sarcoma, Carcinoma. — Other causes of chronic lymphadenitis are leukemia, Hodgkin's disease, and the malignant tumors. It is well worth remembering that the cervical glands above the left clavicle have connection with the abdominal organs through the lymphatics which accompany the thoracic duct; and they may enlarge so as to be easily palpable, before the patient seeks advice for a gastric or hepatic cancer. Tumors of the Thyroid Gland, or Goiter. — The thy- roid gland is frequently the seat of hypertrophy and new growth. There may be a diffuse enlargement of a part or the whole of the gland, or there may be well marked nodules, either cystic (Fig. 85) or parenchymatous in structure. Any such benign swelling of the thyroid gland is known as a goiter. This is a common affection in certain mountainous districts in Europe, but it is by no means confined to them, and seems to be increasing in fre- quency in New York City, possibly on account of immigration from such regions. The larger swellings, involving the whole gland if of parenchymatous nature, are sometimes associated with protrusion of the eyeballs and certain nervous symptoms. Such a goiter is called exophthalmic goiter (Fig. 86). Diagnosis. — Tumor of the thyroid may be recognized by the fact that it is drawn strongly upward when the patient swallows, on account of the close attachment of the thyroid gland to the larynx. It is not so easy to tell a cystic from a discrete parenchy- matous swelling. A diffuse swelling of even elastic consistence 146 CICATRICES 147 throughout is invariably parenchymatous. A large cyst will yield a fluctuation wave when tapped upon or compressed. A small cyst and a small parenchymatous nodule react about alike in this respect. An aspirating needle will distinguish the two. Treatment. — The removal of a cystic or a parenchymatous nodule is not a difficult procedure if the surgeon is careful to con- trol hemorrhage step by step. Local anesthesia is sufficient. The best incision is jDarallel to the transverse wrinkles of the neck. The deep fascia is divided, any intervening muscle freed and pulled to one side, and the gland exposed. Its capsule and usually a thin layer of its substance must be divided before the nodule is reached. Hemorrhage is readily controlled by clamp and liga- ture. The nodule is shelled out of its bed. The divided gland is sutured with fine, catgut sutures which pass through its capsule; and the deep fascia is similarly sutured, while the wound in the skin is sutured with fine black silk. Only when there is oozing from the gland should a small drain be employed. The removal of a part of a diffusely enlarged thyroid gland is a much more serious matter and should be undertaken only after all precautions for a major operation have been made, and yet some of the most experienced operators use a local anesthetic in all cases of goiter. In no case should the whole gland be removed, as myxedema or other nervous disturbances are apt to lead to a speedy fatality. ACQUIRED DEFORMITIES Cicatrices. — Burns of the neck (p. 125) are often followed by annoying cicatricial contractions. Besides the disfigurement so caused, the force of the fibrous bands may keep the head twisted to one side or may bring the chin close down to the sternum (Fig. 87). Treatment. — Such a condition of affairs may be greatly im- proved by a suitable plastic operation in some cases and in others by extensive skin-grafting (Chapter XX). If possible, the offend- ing bands should be partially or wholly excised, as their presence will seriously interfere with the result of the operation. The exact details of such an operation cannot be given, as they must be made to correspond to the necessities of each particular case. It is well, however, for both the patient and the surgeon to recognize that 12 148 TUMORS AND DEFORMITIES OF THE NECK the best results under such circumstances are obtained, not by a single extensive operation but by several lesser ones, repeated at Fig. 87. — Cicatricial Contractions Following Burn of the Neck. intervals sufficiently long to reveal the gain made by each opera- tive attempt. Torticollis, or "Wryneck. — Wryneck, or torticollis, is the shortening of one or more of the cervical muscles, so that the head is held in an abnormal position. There may or may not be a spasm of these muscles. The sternomastoid is the muscle most affected, although the posterior cervical muscles are usually involved to a certain extent (Fig. 88). The condition is thought to be due to a unilateral myositis of infancy, secondary possibly to traumatism at birth, or developing as one of the lesions of con- genital syphilis. As the child grows, the lack of exercise of certain muscles from the cramped position in which the head is con- stantly held, adds to the deformity and increases the muscular changes. If nothing is done to relieve the condition, the cervical TORTICOLLIS, OR WRYNECK 149 spine will become much curved, and there vviJl be compensatory curves in both the dorsal and lumbar spine. Even the develop- ment of the head may be affected (Figs. 89 and 90). Strictly speaking, cases of torticollis may be divided into acute and chronic. Usually, however, the acute symptoms will have subsided before the child is brought to the doctor. Diagnosis. — In many cases the parent has already recognized the nature of the deformity. Inspection shows that the mastoid process on the affected side is nearer to the sternum than it should be. This means that the face is turned toward the opposite side and the chin slightly elevated, although the head may be bent toward the shoulder of the affected side. If the contraction is of long standing, the whole head will seem to have slipped over toward the unaffected side. This is due to the curvature of the neck. But the most reliable method by which to ascertain what muscles are af- fected is to make pal- pation and manipula- tion of the head and neck. "When the head is flexed and extended, and abducted to the right and left and ro- tated, the difference in the muscles of the two sides of the neck is at once apparent. Such manipulation is usu- ally not painful unless carried to an extreme degree. A differential diagnosis between torticollis and tuberculosis of the cervical spine has sometimes to be made. In tuberculosis there Fig. 88. — Wryneck of Right Side of Moderate Degree. The position of the head is typical. This patient was made absolutely straight by an operation performed with cocain, and subsequent manipulation. 150 TUMORS AND DEFORMITIES OF THE NECK is extreme tenderness, inability to move the head in any direction without pain, spasm of the cervical muscles when :in attempt is made to do so. Moreover, there is a daily sliehl lexer. Fig. 89. — Extreme Degree of Torticollis, said by Patient to be Congenital. Note the deformity of face, as well as of spine. The ulcer of the nose was due to recent traumatism. Treatment. — The first treatment of acute torticollis is the treatment of the traumatism or acute myositis in which it origi- nates. This consists in the application of heat, and the mainte- Fig. 90. — Back View of Same Patient. TORTICOLLIS, OR WRYNECK 151 nance of the head in a correct position, or at least the prevention of an increase in the deformity. If the condition is considered to be rheumatic, salicylate of soda should be administered. As soon as the pain subsides, treatment by manipulation should be commenced to correct existing deformity. The effort should be to overcorrect the deformity which exists. Therefore the face should be rotated in the opposite direction until the affected sternomas- toid is tight. The chin should then be tilted downward and the head bent away from the affected shoulder. These manipulations should be made a number of times - , and the treatment repeated each day until the deformity is overcome. Even then it is better for the physician to see the child once a week for a few weeks. If the patient is an infant, manipulation described may be carried out upon the mother's lap. If it is an older child, it should sit upright during the treatment. In either case it is an advantage if a second person holds the shoulders while the ma- nipulations are made, so that the manipulator can make traction upon the head while twisting it and bending it. During sleep the pillow should be so arranged that the position of the body will tend to correct the deformity, or at least will not tend to increase it. In chronic cases, treatment by manipulation will succeed only if the affected muscles are still elastic ; otherwise operative treat- ment is indicated. In slight cases, division of the sternomastoid muscle is necessary, whereas in the severer cases the trapezius sple- nitis and other muscles will also require division. The incision may be made parallel to the edge of the sterno- mastoid or parallel to the clavicle. The former leaves a slighter scar. The incision should be at least an inch long. Usually, when the most prominent bands have been divided and tension has separated their cut ends, it will be found that other deeper ones still hold the head to a lesser degree in an abnormal position. Such bands should in turn be divided until motion of the head is free. The restraining muscular bands lie a little outside the sheath of the great vessels, and the latter could be injured only by careless cutting. ISTo deep suture is necessary. Hemorrhage should be stopped and the skin-wound entirely closed with fine black silk sutures. A firm dressing should be applied, and the head put up in an overcorrected position and held so by a plaster 152 TUMORS AND DEFORMITIES OF THE NECK of Paris bandage placed around the neck, over the head, and under both arms I X". 22, Chapter XXI |. If there is no rise of tem- perature or pain, the dressing need not lie changed for a week or ten davs. As soon as the wound has healed, gentle passive rota- tion and other motions of the head should be commenced and repeated every other day for several weeks. As time goes on, the force with which this is done may be increased, and in addition the patienl should practise active motion daily to correct the de- formity and increase the mobility of the neck. The best single exercise thai the patienl can make is the following: Stand erect; turn the chin toward the affected side, without lifting it; incline the head toward the shoulder of the unaffected side, while the face is still turned inward the other side; place the head erect. This exercise should be repented several times morning, noon, and night. At firs! the patient should go through the exercise in the physi- cian's presence, as he will otherwise almost certainly fail to make the motions correctly. SECTION III AFFECTIONS OF THE TRUNK CHAPTER VI INJURIES AND INFLAMMATIONS OF THE TRUNK INJURIES Contusions of the Chest and Back. — Blows upon the chest and back on account of the firm underlying bones usually produce little injury. General directions for treatment of such injuries are given on page 2. Contusion of the Breast. — A blow on the mammary gland may produce a partial rupture with the formation of a hematoma (Fig. Fig. 91. — Large Hematoma of Mammary Region, Five Weeks After a Blow. 91 ; see p. 3 for treatment) or an inflammation, mastitis, or even abscess. It may also be followed by a malignant growth. Hence the importance of immediate intelligent treatment. 153 154 INJURIES AND INFLAMMATIONS OF THE TRUNK Hot, moisl applications should be applied to the breast, or the surface may be covered with gauze thickly spread with ichthyol ointment, and outside of this a layer of non-absorbent cotton or lamb's wool. Moderate, even pressure is to be maintained by a breast bandage, which should be so applied that the breast is sup- ported from the shoulder ( No. l's. Chapter XXI). After a few days gentle massage should be administered. Contusion of the Back and Ribs. — Contusion of the back is con- sidered under the beading Sprain (p. 158), and contusion of a rib under the heading Fracture (p. L67). Contusion of the Abdomen. — Blows or undue pressure upon the abdomen are important less for their effect upon the abdominal wall than upon the abdominal organs, one or more of which may be ruptured or seriously injured by violence which leaves no mark upon the skin. A sharp unexpected blow upon the abdomen is apt to produce a condition of shock which is familiar to every boy under the phrase " it knocked the wind out of him." The abdominal muscles being off their guard, the force of the blow is received upon the sensitive structures beneath, especially upon the sympathetic gan- glia in the region of the solar plexus, and faintness and nausea and possibly vomiting and unconsciousness follow. Such a blow may even produce death, although this is not common in an animal the size of man. When the muscles are forewarned and have time to contract, they can protect the abdominal organs against a very heavy pressure. For instance, a man weighing, say, 170 pounds, can lie face downward bearing his whole weight on a horizontal bar which crosses his abdomen. The rigidity of the recti and other muscles prevents the bar from pressing backward enough to pinch the intestine or mesentery against the spinal column. This ex- plains how so many persons escape serious injury from the wheel of a moving vehicle, even though it passes directly across the abdomen. Such escapes have been frequently noted, even when the vehicle has weighed more than 3,000 pounds (750 pounds weight on each of four wheels). When the wheel is broad and rubber-tired, the possibility of escape from serious injury is natu- rally much greater than with a wheel having a narrow steel tire. Diagnosis. — The principal symptoms of contusion of the abdo- men are general. They are the symptoms which, grouped together, CONTUSIONS OF THE ABDOMEN 155 are spoken of as shock — namely, feeble pulse, pallor, cold, pos- sibly clammy skin, and frequent respiration. These are also the symptoms of internal hemorrhage and of rupture of the stomach or intestine, which are often the result of undue force applied to the abdomen. It is important to separate simple contusion from these other conditions, if possible, since their respective treatments are opposites. Often the progress of the case will alone decide. If there is uncomplicated contusion, the symptoms will rapidly dis- appear. If there is an accompanying internal hemorrhage or rup- ture, the pulse and respiration will increase in rate, the patient will become more restless, and the symptoms of shock will become more marked. Vomiting usually accompanies rupture of an intra- abdominal organ. The vomitus should be examined microscopi- cally to determine the possible presence of blood. There is usually pain at the seat of rupture, extending thence in the direction in which the escaped intestinal contents would be likely to gravitate. If the amount of escaped fluid is large, its presence as free abdominal fluid may be shown by percussion with the patient lying first on his back and then on his side, or in other positions. Abdominal rigidity on palpation is a sign of great importance. It may exist in simple contusion, but it is less marked than it is in more serious conditions and tends to de- crease. In all cases of abdominal injury the whole abdomen should be carefully examined with the stethoscope. By this means one can determine whether the normal peristaltic action of the intestines is going on, whether normal peristalsis is at a standstill, and, roughly, the shape of the air-spaces which distend the abdomen, and the presence of free fluid or gas. All of these factors have their weight in determining the question of operation. If perforation of stomach or intestines is present, immediate operation and suture gives the patient the only chance of recovery. Under such circum- stances the delay of a few hours will reduce such chance by at least one-half, as the successful cases are almost exclusively those operated upon within sixteen or twenty-four hours after the acci- dent. The character of the urine, and the patient's ability to pass it, and the state of the bowels must also be considered, as rupture of the bladder or of one kidney is as urgent an indication for operation as is that of the stomach or intestines. 156 tNJURlES AND INFLAMMATIONS OF THE TRUNK Non-operative Treatment.- — If it is decided that no serious interna] injury exists, and in all cases, before a complete diagnosis can be made, the patient should be kept absolutely quiet in a hori- zontal position. An ice-bag or heal applied to the abdomen usu- ally helps n.ward this end. It is desirable to avoid morphine until the diagnosis is clear. If this is not possible, the doses given should be small, and should be administered hypodermically. Ab- solutely uothing should be given by mouth. If the skin is broken a light, moist, antiseptic dressing should be applied. The symp- toms of the patient should be noted every hour. If they all im- prove steadily, it may be safely inferred that there is a simple contusion. If ihe_\ -row worse, and particularly if local muscular rigidity is noted or increases, laparotomy should be performed. It should be the aim of the surgeon to decide definitely for or against operation in less than twelve hours from the injury. This gives the patient the best chance of recovery after operation, what- ever the character of the injury. If the contusion is uncomplicated, the patient may be allowed water after twelve hours, fluid nourishment on the following day, and solid food after the bowels have been moved. It is well worth remembering that a contusion of the abdomi- nal wall may be accompanied by a contusion of the intestine with- out immediate hemorrhage or rupture. This is particularly apt to be the case after wheel injury. The slough of intestine may give way and allow the intestinal contents to escape into the abdo- men as late as two weeks after the injury. The warning sign is a localized contraction of the muscles of the abdominal wall. The patient should be kept in bed and on the simplest fluid diet until this disappears. Wounds. — Uncomplicated wounds of the trunk should be treated in accordance with the rules given on page 13. Hemorrhage from the Umbilicus. — This occurs in the infant, due to premature separation of the cord. The hemorrhage should be controlled by solution of adrenalin (1: 2,000) and pressure, or by application of peroxide of hydrogen full strength or diluted one-half, or if necessary by ligature. Asepsis should be observed in the dressing. Gunshot Wound of the Back.— Gunshot wound of the back as met with in civil life is frequently not serious, as the bullets WOUNDS 157 of small caliber fired from cheap revolvers do not ponctrnte through the thick muscles in this region. A bullet fired into the back may be deflected by the strong fascial planes or by some vertebra; it is therefore difficult to make out its exact location or to follow its track with the probe. Unless its situation is easily determin- able, the surgeon should recognize that the operation for its re- moval may be a protracted one, and should make preparation accordingly. If the bullet is within easy reach it may be extracted and the wound properly treated without a general anesthetic. The position of the bullet may be shown in a radiograph if the patient is not too stout. Penetrating Wound of the Pleural Cavity. — A . bullet or the point of a knife may pass between two ribs and open the pleural cavity. Air or blood may then occupy the pleural space. There may be more or less shock. If there is no wound of exit, an at- tempt should be made to locate the bullet by means of the X-ray. If the lung is injured there is usually a certain amount of cough and hemoptysis and an effusion of blood into the pleural cavity, revealed by an area of dulness on percussion ; but even these symp- toms may be very slight. If a large artery is broken, death fol- lows rapidly, partly from hemorrhage and partly from suffocation, as the blood which pours into the bronchi is imperfectly coughed out. Treatment. — -Air or a small quantity of blood is readily re- sorbed from the healthy pleural cavity. Even a foreign body such as a bullet may give no trouble. It is best, therefore, not to explore a penetrating wound of the chest unless there is some definite reason for interference, such as the known accessibility of the bullet, continued hemorrhage, or the existence of suppuration (p. 175). Drainage is secured by the resection of two inches of one rib as described on page 177. Penetrating Wound of the Pericardial Cavity — A penetrating- wound of the pericardium alone may be sutured under cocain after the excision of an inch or two of one rib, or the wound may be left to unite of itself. The danger in such a case is not from the extent of the injury, but from the possibility of subsequent in- flammation. Drainage is inadvisable in a recent case, but if pus forms in the sac, extensive drainage will of course be required. If the heart is injured the case is by no means hopeless. Instances 158 INJURIES AND INFLAMMATIONS OF THE TRUNK are on record in which after the resection of a portion of one or more ribs, the pericardial sac has been opened and the wound in the heart successfully closed by suture. Penetrating Wound of the Abdomen. — Every wound of the ab- domen shoujd be explored until the surgeon can either see its bot- tom or can assure himself that it has entered the abdominal cav- ity. Whether it should be explored still further will depend on circumstances. It is generally agreed that the abdomen should be opened after every gunshot wound, and after every stab wound ac- companied by symptoms of hemorrhage or intestinal injury. As to penetrating wounds without symptoms of complication, it may be said that the risk of opening the abdomen with suitable facilities is less than the risk of allowing the injury to go without explora- tion. The younger surgeons at least are acting on this principle. Sprains. — Sprain of Back. — As a result of twists and falls, and less often of blows, the back is sprained, almost always at the junction of the lumbar and sacral regions. Often under such cir- cumstances there is little or no change in its appearance; the usual symptoms are those of stiffness, and pain at the pelvic attachment of one or both lumbosacral muscles, noticed especially when the position is changed after a short period of quiet or when an attempt is made to bend the body in certain directions. Some- times it is almost impossible to stand erect. In the simpler cases the symptoms are due to stretching or bruising of the muscles or of the intermuscular cellular tissue. In the severer cases it is probable that some of the muscular or fibrous threads are broken ; at any rate, the symptoms often persist for a provokingly long period, sometimes for several weeks. It is not always possible to differentiate a sprain of the back from lumbago. The latter is technically a neuralgia in the mus- cles of the back, and usually comes on after exposure to cold. If such exposure is combined with overexertion it may be impossible to tell whether the symptoms are due to sprain or to lumbago. As the treatment is similar in some respects, the doubt is less impor- tant than it would be otherwise. Treatment. — The first indication for treatment is the relief of the pain. This may be constant, or occur only when the mus- cles of the back are contracted. There may be a partial spasm of the muscles which greatly aggravates the pain. The patient should SPRAINS 1 59 remain in bed while the symptoms are acute, and external heat should he applied. This may be moist or dry. A hot-water bag filled with boiling water is a convenient form of iipplirnlion. Hot moist compresses may be applied, covered with flannel, and still further heated by a flat-iron. Massage is indicated, especially around the origin of the strong muscles of the back from the sacrum and ileum. The massage to be effectual must be given with a good deal of force; hence mechanical vibration with a good machine is most service- able in these cases. Dry-cupping is another means of relieving pain in this region which is not used nearly as often as it should be. The various counter-irritants may be employed. No one is better, and none so cleanly, as the thermocautery. The point of the cautery, preferably a round one, should be kept at a pale red heat, and should be swung in circles which just touch the back tangentially. In this manner the cauterization can be performed with a delicacy quite impossible if a forward and backward movement be given to the point. The pain of this treatment is very slight if the point passes swiftly over the skin, so. that the cauterization can be continued until the whole painful area has been thoroughly gone over. The treatment may be repeated the following day, if necessary. Sometimes a single application will effect a cure. It is rarely necessary to give morphin. Acetanilid, or one of the other coal-tar products, is sufficiently powerful if an anal- gesic is necessary. There is one other remedy which is said to stop the pain in lumbago almost instantly, and that is the injection of from four to twelve ounces of sterile normal salt solution into the muscles of the back. In cases of sprain it is important to support the back and to keep the injured parts at rest. For this purpose a proper strap- ping with adhesive plaster is excellent. The use of a porous plas- ter is too well known to require mention. A far more efficient support can be obtained as follows: two strips of adhesive, three inches broad, are applied on either side of the spine from the lower angle of the scapula nearly to the tuberosities of the ischia. There should be a space of a half inch between them. Six trans- 160 INJURIES AND INFLAMMATIONS OF THE TRUNK verse strips, each two inches broad, and long enough to reach a little more than half-way around the body, should cross these ver- tical strips at righl angles (Fig. 92). There should be a space Fig. 92. — Strips of Adhesive Plaster Applied to Give Support to a Sprained Back; Gridiron Strap- pint:. Fig. 93. — Strips of Adhesive Plaster Applied Diagonally to Give Sup- port to a Sprained Back. of hall i.ii inch to an inch between each one of these to allow the perspiration to evaporate and to lessen the itching which follows the application of a broad, unventilated strip of adhesive plaster. Another method of strapping is to apply the strips of adhesive plaster diagonally. It is easier to make the plaster fit a hollow back when it is applied in this manner (Fig. 93). Whatever the method of strapping chosen, the patient should stand upright or lie prone on his face when the strips are applied, so that the back may be fully extended at the time. He should SPRAINS 161 subsequently avoid bending forward, as that loosens the plaster and lessens its usefulness. The strapping should be repeated every two or three days, or as often as it loosens. The old plaster can be peeled off, or washed off with ether or benzin or " carbona." In some cases the administration of the salicylates seems to hasten recovery. This is especially true in cases of lumbago. Eailroad Spine. — The effects of a severe contusion of the back or sprain of the spinal column are sometimes felt for months or years. It is important for the surgeon to know whether the symp- toms complained of are real or are kept in the mind of the patient by an expected suit for damages. This doubt has earned for this Fig. 94. — Tests for Injury of the Spine. The patient bends forward. Note the full normal curve of the spine. Fig. 95. — Tests for Injury of the Spine. The patient bends backward. Note the concavity of the dorsolum- bar region. This attitude is impos- sible in sprain. type of injury the name " railroad spine." Without going into the remote details of this subject, it is worth while emphasizing one point. Whoever examines one of these patients should inspect 162 INJURIES AXD INFLAMMATIONS OF THE TRUNK and palpate the back from the skull to the sacrum, and should then test the functions of the spine in the following manner: The patient should he stripped to the hips and stand erect with Ids back toward the surgeon. 1. lie should bend forward and back- ward several times, keeping the knees straight, while the surgeon notes the flexibility of the different portions of the spine (Figs. 94 and 95). If any portion has been injured the muscles will Fig. 96. — Tests for In jury of the Spine. Fig. 97. — Tests for Injury of the The patient bends to the left, keep- Spine. The patient twists to the right ing the knees straight. The same mo- and then to the left without moving tion should be made to the right. the feet. hold it rigid while the other parts are bending. This is especially striking if one side is involved more than the other. This con- traction of a part of the muscles of the back is something which cannot be imitated, and if present represents real injury. 2. The patient stands erect as before, and then, without flexing the knees, he bends his body toward the right and then toward the left, while the range of motion of the spine and possible irregular muscular action is noted as before (Fig. 96). 3. The patient, without mov- FRACTURES 163 ing his feet on the floor, twists his shoulders around to the right as far as possible, and then around to the left (Fig. 97). The limit of motion in these various directions, and any other points observed, should be recorded for future comparison. Treatment. — The treatment in these cases must be long con- tinued to produce permanent results If tenderness is marked, the spine should be supported by a plaster of Paris jacket (Chapter XXII). In most cases it is better to obtain the support by a re- movable corset, so that there may be daily massage and. exercises. Mechanical vibration is of great service. Out-of-door life and other hygienic measures are of the greatest importance. There is a strong tendency to hysteria in these patients, and the regu- lation of the daily life should be such as will lessen rather than increase this tendency. Fractures. — Fracture of Clavicle. — Sometimes by direct vio- lence, or more often as a result of falls upon the arm or shoulder, Fig. 98. — Fracture of Left Clavicle in the Usual Situation of one Week's Duration. the clavicle is fractured. Any portion of the bone may be broken, but the line of fracture is in the great majority of instances within an inch of the center of the bone (Fig. 98). The normal outline is changed, due to edema and the irregularity of the broken bone. The amount of deformity varies greatly. The line of fracture 13 164 INJURIES AND INFLAMMATIONS OF THE TRUNK is usually an oblique one, and either the outer or inner fragment is displaced backward. There is more or less disability of the arm, extreme motions being- limited by pain. In some cases measuremenl from the ster- nal to the scapular end of the bone will show a shortening, but this is not always the case. There is a swelling and tenderness at the site of fracture, and crepitus can usually be obtained, unless the fracture is near the outer extremity of the bone. In that case motion between the fragments may be prevented by the various ligamentous attachments to the coracoid and acromion processes. Ecchyrnosis is usually present, but is often slight. Treatment. — On account of the impossibility of applying any form of apparatus on both sides of the bone, treatment of a frac- tured clavicle, aiming to reduce the misplaced fragments and to keep them in position, is eminently unsatisfactory. 'This docs not mean that a bad result is to be anticipated. On the contrary, in most cases the bone unites speedily, with little deformity, if the arm is merely kept in a sling. Many times some child's mother has brought it for treatment two weeks or more after the fall occurred, with not the slightest idea that any bone had been broken. The pain disappeared a day or two after the accident, and she only sought medical advice on account of the slight swell- ing at the seat of fracture, or because the child still cried when lifted by that arm. In these absolutely untreated cases there is often union with a minimum of deformity. If no deformity exists, or if it is slight, the patient should not be tortured with unnecessary apparatus. The arm should merely be supported in a sling, or if the patient is restless, or is a child, a simple bandage of the arm to the chest should be applied. A good bandage for this purpose is the Velpeau (Xo. 30, Chapter XXI). This method of treatment is adapted not only to fracture of the outer portion of the clavicle, but to many fractures in the central portion. Sometimes existing deformity may be lessened by pressure directly upon the projecting fragment, obtained by a com- press of gauze and two strips of adhesive plaster crossed over it in an X. This is only advisable in those cases in which slight digital pressure has been found efficacious in replacing a fragment. There remain for consideration those cases in which deformity is considerable. The fracture is usually oblique and the fragments FRACTURES 165 have overlapped. If the fracture is recent, one car usually reduce the overlapping by grasping I lie upper part of I lie arm and pulling the shoulder outward and backward. But while this can be accom- plished manually, and for a few minutes without pain, attempts to keep up this extension for two or three weeks are sometimes very painful, so that the patient wriggles until the pull is less- ened, or, if he fails to do so, the skin where pressure is greatest may become excoriated. I have repeatedly seen instances of this in cases in which a Sayre's dressing has been applied. Extension upon the Principle of the Lever. — There are two ways in which the shoulder may be pried out and backward by means of bandages alone. A pad may be placed in the axilla, and upon this as a fulcrum the humerus may be used as a lever. When the elbow is brought to the side the shoulder is pried outward. This is the principle of the antiquated Desault bandage (Xo. 31, Fig. 99. — Sayre Dressing for Frac- ture of Clavicle. Rear view. Show- ing application of first strip of adhe- sive plaster. Fig. 100. — Sayre Dressing for Frac- ture of Clavicle. Front view. Showing application of second strip of adhesive plaster. Chapter XXI). Gradual flattening of the pad relieves the patient and does away with the extension upon the clavicle. The other method is that of the Sayre dressing and the Moore bandage. In the Sayre dressing the upper part of the humerus is fixed well back- 166 INJURIES AND INFLAMMATIONS OF THE TRUNK ward by a loop of adhesive plaster about the arm and a continua- tion of the same around the back and side of the chest, until it is fastened to itself. The elbow is then pulled well forward and fixed by a second strip of adhesive plaster. The first loop acts as a fulcrum and the shoulder is carried backward (Figs. 99 and 100). Moore's bandage acts on a similar principle, by pushing up- ward the shoulder and drawing backward the arm by means of a strip of cotton cloth twisted around the elbow in two directions. Direct Extension hi/ Mams of Rigid Apparatus. — If a prop- erly padded splint is placed across the back of the shoulders they may be bandaged or strapped to it, and thus extension of a broken clavicle be obtained with a minimum of pressure upon the soft parts. A board used for this purpose is likely to slip unless it is fixed by an upright piece. This makes a veritable cross, and few patients will consent to be bound to snch an apparatus for two or three weeks. It is, however, very efficient in reducing de- formity to a minimum. Another plan which often succeeds is the application of the posterior figure of eight bandage of the chest (ISTo. 26, Chapter XXI) in plaster of Paris. The bandage should be reenforced with a molded strip across the back of the shoulders, or a light wooden splint may be incorporated in it. Reduction hy Operation. — Of course none of the methods of extension above described is applicable unless reduction can be accomplished manually without the employment of much force. In other cases, unless one is willing to allow union to take place with deformity, it will be necessary to make an incision over the site of fracture to bring the ends of the bone into a correct posi- tion, and to keep them there by means of a suture of chromicized catgut or kangaroo tendon. It may seem like an unwarrantable procedure to convert a simple into a compound fracture, but in the experience of the writer the result obtained often justifies the operation, as the bone will unite without deformity, and the scar in a few weeks can scarcely be made out. Such an operation can be performed with cocain if the patient is old enough to appre- ciate the advantages of local anesthesia. The suture material em- ployed should be capable of resisting disintegration for at least four weeks. FRACTURES 167 Fracture of the scapula is far less common than that of the clavicle. If the fracture is of the body of the scapula or of its acromion process it is easily made out, crepitus usually being ob- tained by direct manipulation. ISTo treatment is required other than limitation of the motion of the arm. Fracture of the neck of the scapula is a rare accident, whose exact diagnosis, like that of other fractures about joints, is most surely made by a good radiograph. The arm should be kept at rest for four or six weeks by a shoulder cap and sling (cf. No. 34, Chapter XXI). Fracture of Sternum. — A severe blow is required to break the sternum. Even if this occurs, displacement of the fragments is unlikely. So that diagnosis depends upon the history, tenderness on pressure, and also on pressure at a distance, and in some cases on crepitus. If displacement has occurred, the displaced frag- ment may be lifted by boring into it with a coarse gimlet or a slender corkscrew. Once in place it will remain so without assist- ance. The front of the chest should be strapped with adhesive plaster to limit motion. Fracture of the Ribs. — Fracture of a single rib is an extremely common accident. It usually is the result of a fall upon a sharp edge or corner. The ribs most exposed are oftenest broken. That is to say, the patient falls upon his side, striking upon the seventh, eighth, ninth, or tenth rib, and one of them is broken, usually in the posterior or anterior axillary line. Sometimes the rib is broken in two places two or three inches apart. There is usually little or no displacement of the broken ends. Pain, after the first feel- ing of injury has passed off, is not great, unless the patient coughs, laughs, or sneezes. The pain is apt to increase for a few days, since respiration constantly moves one broken end upon the other. To avoid this the patient breathes as much as possible with his sound side. He often loses some sleep, and is incapacitated for hard, work for three or four weeks. The symptoms due to fracture of the ribs are simulated by those which follow a blow from some sharp object. This may in- jure the periosteum, and possibly crack the bone, although definite signs of this are wanting. There is tenderness on pressure, and perhaps pain, although the pain will not be greatly increased by respiration nor by pressure upon the rib at a distance from the point of injury, as is the case in complete fracture. There is, KiS INJURIES AM) INFLAMMATIONS OF THE TRUNK after a few days, a slight, hard swelling close to the bone which simulates a callus, bu1 is of less extent, and the deformity is less than if the rib were fractured. The symptoms usually last from one to three weeks. Tbeatment. — The pain can be materially lessened by apply- ing a broad strip of adhesive plaster directly over the broken rib. A strip five or six inches vide and long enough to reach half-way around the body, should be fastened posteriorly first and then be drawn strongly and slowlv forward to the front of the chest and made fast by pressing it close to the skin. The more tight and smooth the fit of the plaster, the greater will be the relief to the patient. It is sometimes recommended that when one end of the plaster has been fastened, the patient shall expire vigorously while the surgeon quickly draws the plaster tight and sticks it to the skin; but on the whole a more satisfactory result can be obtained by a slower and more careful application in the manner described. It is better that the plaster should cover only the affected side. This leaves the well side free to expand without pulling upon the injured side, as is the case if the plaster extends all the way around the body. If the skin is hairy it should be shaved before the plaster is put on ; otherwise the patient will hold the one who removes the plaster in lasting remembrance, as most of the hairs will be so firmly embedded in the gum that they will be pulled out by the roots with the removal of the plaster. Fractures of the Vertebrae. — Owing to the closeness of their articulations to one another and to the ribs, the dorsal vertebrae, except the lower two or three, are rarely fractured by indirect vio- lence. Fracture of the lower dorsal vertebras and of the lumbar vertebras may follow a severe fall or blow or be caused by a bullet or sharp instrument. In most cases the fracture of the bone is overshadowed by the injury to the cord. As this does not extend below the first lumbar vertebra the prognosis is more favorable the lower down the seat of fracture. Life may be prolonged almost indefinitely even though the cord be seriously injured, but sooner or later, in spite of the greatest care, the patient dies from sepsis due to the extensive ulcers of the back or legs, or to purulent cystitis, or to pyelitis, caused by the unavoidable catheterization. The immediate symptoms of fracture of a vertebra are pain, tenderness, edema, and at least partial loss of motion and sensa- DISLOCATIONS 169 tion. Ecchymosis is usually slow in making its appearance. All of these symptoms may be present in severe cases of contusion without fracture. Signs due only to fracture are crepitus, the dis- placement of a spinous process, and angular deformity produced when the spine is flexed or extended. In cases in which there is great pressure upon the cord or destruction of the same, there will be inability to urinate or defecate, and loss of sensation and motion. Treatment. — In a doubtful case of fracture the patient should remain in bed until tenderness has disappeared. After that the treatment given on page 158 is applicable. If there is a frac- ture without injury to the cord, a plaster of Paris jacket should be applied in an extended position. The patient may be allowed to get up in two or three weeks, but should wear the jacket for two months. After its removal he should be treated by massage and exercise, with plenty of rest in a horizontal position. The treatment of fracture accompanied by injury to the cord is beyond the scope of this book. Dislocations. — Dislocation of Clavicle. — The clavicle may be dislocated from the sternum. The tendency to displacement is not marked, and a pad upon the overriding bone, with light pressure obtained by adhesive plaster strips and a bandage, will usually prevent its recurrence. If this is not successful, a periosteal suture should be performed. Fixation by either method should be maintained for several weeks. Dislocation of the outer end of the clavicle also occurs. The symptoms are usually slight. The end of the clavicle projects up- ward. It is easily reduced by direct pressure or by drawing the shoulder outward. This, together with absence of crepitus and the absence of shortening of the clavicle when measured from the sternum to the outer projecting end, will differentiate this injury from fracture ; though fracture of the clavicle sometimes occurs without shortening. It may be treated in the same manner as dis- location of the inner end, but any form of apparatus usually fails to keep the end of the clavicle firmly down on the acromion. This can be accomplished by passing a long fine drill through the acro- mion and well into the clavicle, and leaving it in place for eighteen days. The operation should be carried out aseptically. Dislocation of Costal Cartilage. — Sometimes the cartilage of the tenth rib may be separated from that of the ninth at its anterior 170 INJURIES AM) INFLAMMATIONS OF THE TRUNK end, and by its occasional slipping forward and backward give rise to a little pain. The radical treatmenl is the amputation of the anterior tip of the cartilage; or counter irrjtants may be applied until the acute symptoms subside and the patient grows accustomed to the .sensation. Dislocation of Vertebra?. — Dislocation of either dorsal or lum- bar vertebras without fracture rarely occurs, and when it does so it is a partial dislocation in most cases. Attempts at reduction should be made under general anesthesia with great care (see p. 125). If successful, a plaster of Paris jacket should be ap plied. ACUTE INFLAMMATIONS Burns. — The burns which occur on the body or trunk present no especial characteristics. As the body is protected by the cloth- ing, the heat applied, whether of flame, fluid, or vapor, usually affects a consider- able area. An ex- ceptional case is shown in Figure 101. This man was working in an iron foundry, with scanty clothing, when the steam in a wet mold explod- ed and spattered him with small drops of liquid iron. Treatment. — Directions for the treatment of burns have been given on page 26. The im- mediate discomfort from burns of the body is less in pro- Fig. 101. — Multiple Burns of Body of Five Days' . , . Duration Produced by Spattering Liquid Iron. portion to tlieir INSECT BITES 171 area than it is in burns of the head and neck, and on this account one may be misled into making an nnduly favorable prognosis. When the destroyed skin begins to slough the gravity of the situ- ation will be more clear. Hence the importance of saving the strength of these patients in every way from the very first. Insect Bites. — Pediculi. — By the marks of the nails one can usually make a diagnosis of pediculosis corporis. These body lice, which are vulgarly called " graybacks," live not upon the person of an individual, but upon his clothing. The marks of their bites are insignificant. The itching produced is extreme, and the patient has the habit of drawing his nails across the affected part of the skin in long sweeps. Minute excoriations of the skin often mark the track of these long scratches, many of which become infected, so that shallow ulcers result, which heal slowly, often with pigmentation. The diagnosis of the trouble can generally be made from the appearance of the skin. A search in the under- clothing will result in the finding of pediculi. Essential treatment consists in the destruction of the parasites by baking or boiling the clothing, and observance of personal cleanliness. The itching often persists for days, so that an antipruritic may be indicated. Fleas and Bedbugs. — The bites of fleas and bedbugs can usu- ally be distinguished by their distribution. A flea travels quickly from one place to another, so that the bites of a single insect, from six to twelve or more in number, will often be scattered over half the body. A bedbug, on the other hand, makes numerous bites in one locality. These are often strung out in a row like the splashes made by a flat stone when it is skipped over smooth water. It is sometimes difficult to distinguish a bite from the lesions of urti- caria. If the latter have not been scratched, the skin involved will not show any break; whereas the skin of a bite made by a flea or a bedbug will invariably show in its center a small puncture. Treatment. — As infection is often caused by scratching an insect bite, it is important to relieve the itching. A solution of camphor in alcohol, or some other cooling lotion, is good for this purpose. Another excellent method is to brush the involved skin lightly with a whisk-broom or a not too stiff hair-brush. This relieves the itching without breaking the epidermis. Scabies. — Scabies is also accompanied by itching, so that the excoriations may obscure the burrows of the insect. A minute 172 INJURIES AND INFLAMMATIONS OF THE TRUNK examination of the skin will usually reveal the characteristic little row of brownish specks (the fecal masses of the insect) in the substance of the more or less inflamed skin. If the lesions are found on the hands, the differentia] diagnosis from pediculosis corporis is certain, as the body lice do not bite the exposed parts of the body. The treatment of scabies consists in the disinfection of the clothing, and a hot bath at night, followed by a thorough rub- bing of all suspected portions of the skin with sulfur ointment. In the morning another bath with soap and water should be taken. After throe »»r four days, if patches of the disease remain, the skin should be treated again in the same manner. Herpes Zoster. — This disease, on account of its predilection for the area of the intercostal nerves, may be here considered. It develops rather suddenly with pain and some fever, followed by an eruption of groups of small vesicles. Often the skin supplied by a single nerve is affected; sometimes that by two adjacent nerves; rarely that supplied by two opposite nerves, making it bilateral. It runs a natural course to termination with drying up of the vesicles in a few days, but in the mean- time, by the burning and pain, it may make the patient very uncomfortable. Treatment. — The vesicles should be protected from rupture. The burning may be relieved by the frequent application of a solution of menthol in alcohol, twenty grains to the ounce. Mor- phin may be required to control the pain in some cases. Cellulitis and Dermatitis. — Cellulitis, erysipelas, and the various local suppurative processes occur frequently upon the trunk. In so far as they have no peculiar characteristic due to their situation, the description of them and the treatment given on pages 33 et seq., must suffice. Only a few special forms of inflammation will be described in this section. Excoriation of the Breast. — In stout women the constant con- tact of the skin of a pendulous breast with that of the abdomen may lead to excoriation, ulcer, or even abscess. These conditions rapidly disappear under suitable treatment. As a preventive the parts should be bathed frequently, the skin rubbed with alcohol, and dusted with a talcum powder. If an ulcer has formed, wet dressings should be employed. MAMMARY ABSCESS 173 Mammary Abscess. — The common period for the occur- rence of an abscess of the breast is during early lactation, and especially the first lactation. The infection takes place through a crack or excoriation of a too tender nipple, and this can almost always he found upon search. The usual signs of suppuration are present. A portion of the mammary gland and the overlying skin are indurated and tender, and in the center of this affected area there can usually be made out a smaller area of fluctuation. Treatment. — If the inflammation is seen at an early stage, wet applications should be made to the nipple and breast, either cold compresses, or flaxseed poultices, or wet compresses with heat applied externally, as spoken of in connection with abscess of the head (p. 38). A baby should not be put to the inflamed breast, although he may continue to nurse from the opposite one if the mother has only a slight degree of fever. The milk should be drawn regularly from the affected breast, and if in a day or two it is seen that the inflammatory process is increasing, an incision should be made into the center of the indurated area, where, as above stated, a soft spot can usually be felt. If the softened area is plainly palpable, it is useless to further postpone operation. The incision may be made under local or general anesthesia. It should invariably be made in a line radiating from the nipple. Neglect to observe this rule has led to the division of milk ducts and the establishment of a mammary fistula. An abscess of the breast has a strong tendency toward recovery, and the incision therefore does not need to be much longer than the diameter of the suppurating area. The cavity should be thor- oughly washed out with a solution of bichlorid of mercury, 1 : 2,000, and a dilute solution of peroxid of hydrogen, one part to five. A drain should be inserted in the abscess-cavity, but it should not greatly distend it. The hot, moist, gauze dressing should be continued. Under these circumstances any further se- cretion of pus quickly finds its way into the dressing, and the wound has an opportunity to heal just as rapidly as it is able to do so. Not until the repair has reached the subcutaneous fatty tissue should the drain be omitted. Often in an abscess of the breast which has lasted for some time, so that the zone of cellulitis about the pus cavity is not an excessive one, incision and cleansing will terminate the whole 174 LNJUKIES AND [NFLAMMATIONS OF THE TRUNK pathological process so that the sides of the cavity will adhere and almosl primary union of the wound will follow. If this rapid method of cuiv be attempted, tin- dressing should be changed at least every day, and if there is any retained discharge, the cavity should be washed out again and the drain inserted to a greater depth. If the suppuration is more excessive and has passed beyond the capsule of the gland and has lifted up, as is frequently the case, a portion of the gland from the underlying ribs, more than one incision may be necessary to provide suitable drainage. Under such circumstances, one incision should be made at the most de- pendent portion of the abscess-cavity as the patient lies in bed or as she sits up, according to circumstances. If she is up most of the time, the most favorable point for drainage is immediately below the breast, whereas if she is lying in bed the outer edge of the breast or a point between this and the lower edge will be found most serviceable. If the jms shows a tendency to approach the surface at any point, that place should he selected for one of the incisions, as there are other factors connected with perfect drain- age besides the force of gravity, and unless there are plain contra- indications the point chosen by nature for the discharge of pus had best be accepted by the surgeon as the most suitable one. The best drain for these cases is made by cutting the tip from a rubber finger cot and passing through it a wick of gauze. In this manner the gauze will be prevented from sticking to the sides of the wound. The rubber is more flexible and stronger than the gutta percha tissue usually employed in a " cigarette " drain. Preventive Treatment. — The physician who has charge of a pregnant woman should give her directions for the enlargement and toughening of the nipples by daily massage, applications of alcohol, alum, etc., and if they are retracted they should be drawn out with a breast-pump. In this manner they can be prepared for nursing two or three months before the birth of the child, and cracked nipples and mammary abscesses can almost invariably be avoided. Axillary adenitis and suppuration are described in Chap- ter XV. Inguinal adenitis and suppuration are described in Chap- ter VIII. EMPYEMA 175 Umbilical Suppuration. — The skin of the umbilicus may ulcerate or an abscess may form as a result of the irritation which is produced in a deep umbilicus by the dirt and scent inns which may collect there, and even form a hard ball. Cleanliness and moist antiseptic dressings will speedily effect a cure. Umbilical sinus, which may also suppurate, is described on page 181. Bed-sores. — An ulcer of the skin of a bedridden patient caused by pressure upon some one point is called a bed-sore. The sacral region is the commonest situation, both on account of its p° or blood-supply and the habit many patients have of lying the whole time upon their back. There is first a dusky redness over the area about the size of a quarter of a dollar, then the epithelium gives way at the center and a sore is started which gradually involves the whole thickness of the skin, or possibly the whole thickness of the skin is at once involved and becomes dark and gangrenous and sloughs leaving a large ulcer. The skin over the great trochanter is also often the seat of a bed-sore. The rapid- ity with which a bed-sore may form, especially in a patient weak- ened by long disease, is truly amazing. Treatment. — Frequent massage and the use of alcohol will usually prevent the formation of an ulcer if the weight of the body is supported upon soft pillows or an air-ring, so that the pressure upon the bony prominences is avoided. When an ulcer has formed, it should be washed frequently with mild antiseptics and dressed with a mildly stimulatingjpreparation. Compare the treatment of ulcers of the leg, given in Chapter XVIII. Empyema. — Pus in the pleural cavity, or empyema, is a con- dition demanding surgical treatment. The signs of empyema are fever, increased pulse and respiration, dulness or flatness in the lower portion of the affected side of the chest, above which is usually a zone of bronchophony with pleuritic rales. The diag- nosis is not always an easy one to make, and the importance of prompt drainage is great, so that in a doubtful case it is better to make one or more exploratory punctures in order to be certain of the presence and the location of the pus. These punctures should be made with a large hypodermic needle. The needle used by veterinary surgeons for hypodermic injection is just right for the purpose. The syringe need not be a large one ; an ordinary hypo- dermic syringe is large enough. ^TgjTiii -i i rmrigJfriilfBr ^-5 p. .3 O 2 u cq o « ;,: P -^ 176 SYPHILIS 177 Treatment. — When pus has been shown to he present in the pleural cavity, drainage should be accomplished by the removal of an inch and a half of the eighth or ninth rib in the posterior axillary line. The operation may be performed under a general anesthetic, but if the restoration is embarrassed by the amount of fluid in the pleura, a local anesthetic is safer. The instruments required are shown in Figure 102. The soft parts overlying the rib are cut through parallel to its long axis for a distance of two or three inches, the scalpel being pressed firmly against the rib so as to split its periosteum. This is then reflected above and below, and bone shears passed between the inner portion of peri- osteum and, the rib. An inch of the rib is removed and its cut edges trimmed if rough. The pleural cavity is then opened in the long axis of the rib, and when most of the pus has escaped two soft-rubber tubes pierced by the same safety pin are inserted. A stitch at either end of the wound is an advantage. A dry creolin gauze dressing is applied and changed as often as it becomes mois- tened by pus. Forced expiration should be practised as soon as the soreness of the wound has somewhat subsided, say by the fifth day. The patient is shown how to blow colored water from one Wolff bottle to another. This exercise should be kept up for five minutes, and repeated several times a day. It is of the greatest service in stretching the collapsed lung so as to make it resume its normal space in the pleural cavity. The force of expiration can be increased by elevating the second bottle a few inches. Drainage with two tubes should be continued until granula- tions have shut off the pleural cavity from the wound. The tubes may be shortened a half inch at a time as the cavity grows smaller, but they should not be removed as long as they enter the pleural cavity; nor should they be replaced by tubes of smaller caliber. Neglect of this rule has turned acute cases into chronic ones and made secondary operations necessary to reestablish drainage. CHRONIC INFLAMMATIONS Syphilis. — The trunk has its full share of the secondary and tertiary lesions of syphilis. An isolated gumma, appearing long after all other manifestations of the disease have disappeared, is often a puzzle in diagnosis. A common seat for the same is the 178 INJURIES AND INFLAMMATIONS OF THF TRUNK region of the sternum. The constitutional treatment is important. Any protective dressing will answer locally. Tuberculosis. — Tuberculosis involves the skin of the trunk, and especially of the back (lupus). Its essential characteristics arc the same as those of the disease when seated in the skin of the face (see p. 63). Because of the concealed situation, more radical excision and skin-grafting are permissible. Tuberculosis of the bones and joints of the trunk is so fully dis- cussed in larger works upon surgery and orthopedic surgery that it will be considered here chiefly for the sake of early diagnosis. Tuberculosis of the Sternoclavicular Articulation. — This joint is attacked by tuberculosis as well as by syphilis. In either case the periarticular tissues are swollen. In tuberculosis, one or more tender spots in the end of the clavicle can usually be made out. Later an abscess may form and rupture. If treatment by fixation is determined upon, it is easily secured by keeping the arm bandaged to the chest and carrying the fore- arm in a sling. Costal Tuberculosis. — One or more ribs may be attacked by tuberculosis. The general health of the patient suffers little, so that the disease may be disregarded for some time. When the patient first comes for examination, there may be an abscess or a sinus, the pus having already broken through the skin. A probe will follow such a sinus obliquely to the eroded bone. The fingers will recognize that beyond the abscess-cavity the periosteum is thickened. More than one rib is often involved, the extent of the disease being greater in one than in the other. Erosion of the inner surface of the rib is usually more extensive than that of its outer surface. Operative treatment is strictly indicated, and should be car- ried out under general anesthesia. An incision should be made over the affected rib parallel to its long axis, and the diseased bone, periosteum, and other tissues fully removed. This can usually be accomplished without opening the pleural cavity, so that the shock of operation is slight. The wound should be fully drained. Recovery from the operation is prompt, but the patient should be kept under observation for a considerable time, as extension of the process along the same or adjacent ribs is the rule rather than the exception. TUBERCULOSIS 179 Tuberculosis of the Vertebrae. — The symptoms of tuberculosis of the cervical vertebrae have been given on page 133. When the disease is situated in the dorsal or lumbar vertebrae, the symp- toms elicited vary somewhat according to the accessibility of the parts to palpation, and the varying degrees of motion that are their normal possession. An essential to diagnosis in every case is a thorough examination of the whole back, stripped to the skin for the purpose. Such an examination will almost always enable the surgeon to state positively, even in the early stages of the dis- ease, not only that the spine is affected, but that the disease is situ- ated in certain vertebrae. The various symptoms to be observed are: Slight edema along the spinous processes, slight deformity (which often disappears entirely in some positions), tenderness when the affected vertebrae are pressed upon (a sign often absent in children who cannot or will not differentiate pressure upon one vertebra from that on another), and rigidity or a lack of freedom in using the affected part of the spine. Compare the tests for sprain of the back given on page 162. A symptom which is chronologically a late one, but which is sometimes the first thing a patient notices, is the swelling due to an abscess. This may be situated near the spine posteriorly or it may come to the surface at the side of the trunk, or following down the front of the spine it may appear above or below Poupart's ligament. Treatment. — As is well known, the treatment for a tubercu- lous focus which cannot be removed is immobilization, and relief from pressure. In the case of the spine these objects are partially obtained by a plaster jacket or a brace, and more perfectly ob- tained by a stretcher frame, a form of apparatus especially adapted to a child of four years or less. Sacroiliac Tuberculosis. — Another common seat for tuberculosis is the sacroiliac synchondrosis. The difficulty of recognizing the disease in this situation is great, so that a correct diagnosis is often not made for a long time. A history of traumatism is apt to be confusing; the traumatism may have caused the trouble or be entirely independent of it. In either case it is apt to mislead the surgeon into thinking that he has to do with a severe sprain. The early symptoms are pain, slight fever, and a disinclination to exertion. As there is practically no motion between the ilium and sacrum, the best sign of tubercular joint disease, namely, limi- 14 180 INJURIES AND INFLAMMATIONS OF THE TRUNK tation of motion, is in this case wanting; ye1 the patient moves with awkwardness and unusual care when he is asked to stoop, rise, sit, squat, etc. If there is no history of injury the diagnosis of rheumatism is apt to be made. The age of the patient, the limi- tation. of the trouble to a joint to which rheumatism is rarely if ever confined, and the slighl bu1 constanl aftern i fever, serve to differentiate the two diseases. Treatment.- — In tuherculosis, of course, no benefit Eollows the administration of salicylates. Treatment is eminently unsatis- factory. Cases have been recorded in which an early resection of the joint has led to recovery, but owing to the fad that a diagnosis i- usually not made until pus appears either in the groin or in the buttock, the most favorable period for radical treatment has already passed, so that operations are usually palliative, to afford a more direct exit for the pus and so to relieve the patient of pain and some fever. Tl>e usual course is a steady decline through some years to death, unless the resisting power of the patient can be raised by hygienic measures. Tuberculosis of the Mammary Gland. — One of the less common situations for tuberculosis is the mammary gland. Because of its rarity, and because of the similarity of the lesion in its general outline to carcinoma of the breast, this mistaken diagnosis is often made. There will generally be a history of tuberculosis in the patient, or examination of the corresponding lung may show that the primary trouble was located within the chest and has worked outward. If an ulcer or sinus exists its appearance will keep an observant man from making a wrong diagnosis. There will be in the edges of the tubercular ulcer none of the active growth which is always seen in the edges of a carcinomatous ulcer. The axil- lary glands are usually enlarged if an ulcer exists. Treatment.- — In tuberculosis of the breast it is quite unneces- sary to remove more than the affected part. Usually the whole gland is diseased at the time of operation, but unless the axillary glands are plainly diseased it is wrong to subject the patient to the extra shock of an axillary dissection. On account of the pos- sible involvement of an underlying rib, a general anesthetic is preferable. If the disease is plainly limited to the freely movable breast-gland, a complete removal can be satisfactorily effected under local anesthesia if the patient's temperament warrants it. CIIAPTEE VTT TUMORS AND DEFORMITIES OF THE TRUNK TUMORS CYSTIC TUMORS OF THE TRUNK Sebaceous Cysts. — These cysts occur less often upon the trunk than upon the head. They are very rare below the waist line. They have the same characteristics as those of the head (p. 66) and require the same treatment. Umbilical Cysts and Sinuses. — It sometimes happens that the duct which in fetal life leads from the umbilicus to the blad- der, and which is called the urachus, is not completely closed at birth. Or it may be closed in part. As a result there may be a sinus discharging urine, or a short sinus with a slight discharge of sebaceous material, or a cyst lined with epithelium and contain- ing sebaceous material. Or it may have no external orifice and may first manifest itself as a tumor situated below the umbilicus and containing sebaceous material. Treatment. — The cyst or sinus should be removed by dissec- tion through an elliptical incision made close around it. In some cases this is very easy; in others it is necessary to open the peri- toneum for a short distance. As it is impossible to know this beforehand, the operation should be performed with extreme asep- tic precautions. When the cyst or sinus has been removed, the abdominal wall should be closed in three layers — peritoneum, deep fascia, and skin — in order to prevent hernia. As the condition is an annoying one, rather than one which interferes with healthy development, the operation may be safely postponed if the patient is an infant, until it is some years old. Coccygeal Cysts and Sinuses. — These formations are congenital in origin, but they may not be noticeable until adult life. In their simplest form the skin at the lower end of the 181 ]S2 TUMORS AND DEFORMITIES OF THE TRUNK spine is so folded in upon itself that it forms an isolated cyst, lined with epithelium, or a sinus also lined with epithelium, one or both ends of which reach the surface of the skin. As the epi- thelium contains hair-roots, such a cyst or sinus is likely to fill up with sebaceous material and short hairs. If near the surface the contents may discharge from time to time. Such a cyst or sinus is usually situated low down in the median line over the coccyx or sacrum. It is likely to become inflamed from time to time. With the discharge of a mixture of sebaceous material and pus, the acute signs of inflammation subside. Treatment. — To rid the patient of this annoying condition the cyst or sinus should be fully exposed by a median incision and all traces of an epithelial structure removed. The wound may then he closed by suture, and primary union be anticipated even if acute infection is present; although, if the infection is marked, it is advisable to drain with a wick of rubber tissue some portion of the wound. At the change of dressing on the first or second day this should be removed, and if the inflammation has subsided it should not be reinserted. The operation is readily performed under local anesthesia. Dermoid Cysts. — There are other dermoid tumors in the region of the coccyx which may contain, in addition to sebaceous material and hair, fragments of bone and other structures, or even fairly well developed portions of another fetus or twin. They should be removed and the gap closed by a plastic operation or by skin grafts. CYSTIC TUMORS OF THE BREAST Retention Cysts of Infancy. — An infant's breast some- times secretes a milky fluid, which collects in the larger ducts about the nipple, and forms a soft fluctuating swelling. If the secretion is forcibly expressed from the nipple once or twice the swelling will disappear. Retention cyst in the adult may be due to scar tissue, fol- lowing abscess of the breast, or perhaps a misdirected incision. It will usually not be necessary to excise such a cyst. If it is split open and drained the normal granulations will obliter- ate its cavity. (Compare the description of a salivary cyst on page 71.) GRANULOMA OF THE UMBILICUS 183 Simple Cysts and Cystic Adenomata. — Cysts of the mammary gland apparently due to disordered gecretion are very common in young women. Such a tumor is freely movable, rounded, and clastic; but it is very difficult to obtain fluctuation in it on account of its small size. It cannot always be differ- entiated from a solid tumor,, except by aspiration. Moreover, the withdrawal of fluid does not absolutely distinguish the two, as many adenomata and some malignant tumors contain cysts. Naturally, in such a case, the withdrawal of the fluid will not so collapse the tumor as it will a simple cyst. The fluid may be like serum, straw-colored, or it may have a pink, red, or brown tint. Treatment. — Aspiration as a means of diagnosis has been spoken of. It sometimes cures the patient, the fluid not again accumulating. Should this happy result not follow, or should the withdrawal of fluid not cause the immediate collapse of the tumor, operation is indicated. Small tumors can be removed from the breast under cocain; but on account of the sensitiveness of the part, and of the patient, a general anesthetic is better in most cases. If the operation is a short one the patient can rise and go home in a few minutes. It is well to bear in mind that a small, easily movable tumor seems much nearer the surface during pal- pation than it does when one is cutting through skin, fat, and fascia and an outer layer of the mammary gland in the search for it. It is a help to have the assistant seize the gland on either side and stretch the skin tightly over the tumor while the incision is being made. The incision itself should radiate from the nipple. So much of the mammary gland as contains the cyst should be removed by an elliptical or a pie-shaped incision. The wound in the gland should be closed by catgut sutures, and the wound in the skin should be closed by silk sutures. No drainage should be used, or at most a small wick of gutta percha tissue introduced through the skin to provide for the escape of blood. SOLID BENIGN TUMORS OF THE TRUNK Granuloma of the Umbilicus. — Excessive granulation sometimes follows the removal of the stump of the umbilical cord. Owing to the confined situation the mass of granulations gradu- ally assumes a polypoid shape. l.sl TUMORS AM j DEFORMITIES OF THE TRUNK Treatment. — This condition is easily cured by the applica- tion of a drop of pure carbolic acid <>n a wooden toothpick. A .slower hut safer and no less certain method is the daily applica- tion of undiluted hydrogen peroxid upon a minute cotton swab. This method is preferable if the point from which the granula- tions spring is so hidden by folds of fat that it is not readily brought into view. Intra-abdominal Complications. — In rare cases a poly- poid tumor of the umbilicus is covered with mucous membrane; or it may be lined with mucous membrane and communicate with the intestine. It should be removed, but not until one has at hand sutures to close a possible opening into the in- testine, and others to close a gap in the abdominal wall if necessary. Keloid. — -This firm, smooth tumor occurs in scars, especially in those of the trunk. It is made up of fibrous tissue, is inti- mately connected with the corium, projects a quarter of an inch more or less above the level of the skin, and is covered with a shiny epithelium of poor quality, in which dilated vessels are often seen. At an early stage of its development it cannot be told from a hypertropbied scar. As time goes on, however, the hypertrophied scar tends to shrink and lose its pink color, while the keloid maintains its size or continues to grow, exceeding the original limits of the scar, and sometimes sending out prolonga- tions into the skin around, which have been compared to crabs' claws, hence the name keloid. When a keloid develops in a wound which has been sutured, the scars of the individual stitches some- times give rise to a greater growth than the line of incision itself. The skin of the negro is peculiarly susceptible to the formation of keloids. Treatment. — Surgical ingenuity has not yet succeeded in evolving a generally successful cure of keloid. Individual cures by various means have been reported, by dissection, by caustics, by long-continued elastic pressure, and by the X-ray. If the orig- inal scar was a bad one, and the surplus skin in the vicinity per- mits of a complete dissection, with suture of the wound and prob- able primary union, this plan is worth trying. The suture should be an intracuticular one, or the interrupted stitches of fine silk should be removed at the earliest possible moment, about four LIPOMA 185 days. Tension upon the new scar should be prevented by cross strips of adhesive plaster for several weeks. But even when all these precautions are taken recurrence often follows. Papilloma : Fibroma : Fibrolipoma. — These names are given to pedunculated tumors of fat and fibrous tissue covered with essentially normal skin. They vary in size from that of a pin-head to one inch or more in diameter. Frequently the tumors are multiple. The pedicle is usually small, but always contains Fig. 103. — Fibrolipomata of the Back, of Five Years' Duration. Patient a girl aged nineteen years. an artery of a size corresponding to the size of the tumor. In this respect they differ from lipoma in which the blood-supply is very scanty (Fig. 103). A papilloma is a strictly benign growth, but on account of the annoyance caused by it, and its tendency to in- crease in size, it had best be removed. Treatment. — A small papilloma may be snipped off even with the surface of the skin with, a pair of scissors. A larger one should be removed by an elliptical incision close to the base of the pedicle, made through the whole thickness of the skin. Such a wound when sutured will give the minimum of deformity. Lipoma. — Lipoma of the trunk is relatively common, espe- cially upon the shoulders. Such a tumor is lobulated, and while growing in the layer of subcutaneous fat its septa are intimately adherent to the skin. Hence the skin is dimpled when an attempt is made to lift it from the tumor. This is one of the diagnostic 186 TUMOKS AM) DEFORMITIES UK THE TKUNK signs of Lipoma of the simple subcutaneous t \ | >< -. It is well en- capsulate! liv thin plant's of connective tissue, so that it is easily shelled out. Treatment. — On account of the insensitiveness of the parts involved below the skin the removal of even a large lipoma of the trunk can readily be accomplished with a local anesthetic (Figs. 104 and 105). This applies only to the simple or usual type of lipoma. For a description of the diffuse lipoma and of the inter- muscular lipoma, both of which varieties are found in the trunk, Fig. 104. — Lipoma of Back. Two years' duration; removed without pain, with an injection of 40 minims of 2 per cent, cocain solution. Another view of tumor is shown in the upper corner. see page 139. The skin is incised for a distance equal to one-half or more of the diameter of the tumor. If the tumor is covered by a layer of the subcutaneous fat, this is also divided so that the capsule of the tumor shall be exposed. This capsule is next ADENOMA 1X7 divided, and then the fatty tumor can be readily peeled out of its compartments in the fascia, by a blunt and generally blood- less dissection, with the fingers or blunt- pointed curved scis- sors. With the remov- al of the tumor the edges of the wound are to be fully retract- ed and any bleeding points secured and compressed or ligated with fine catgut. The skin is sutured with- out drainage or over a wick of gutta- percha tissue. . 1 '! I — * : ■F WRRk — : jjSftcc j4^ tB& ■ • ?^r ^r 1 or- Fig. 105. — Lipoma Shown in Figure 104 after Re- moval. The scale of inches shows its length. Its weight was 25 ounces. SOLID TUMORS OF THE BREAST Hypertrophy. — Sometimes during adolescence one of the breasts will become abnormally firm and larger than its fellow and rather more sensitive to pressure, but without acute pain. The enlargement is diffuse and uniform, and there is no adhesion of the breast to the structures either beneath or superficial to it. Such a condition has a tendency to resolve in the course of time. This return to the normal state may be hastened by an applica- tion of ichthyol ointment. Adenoma. — An adenoma or an adenofibroma of the breast is a tumor which is composed of a localized increased growth of glandular and fibrous tissue. There are several types of such tumors distinguishable microscopically, but as no adenoma is com- posed only of glandular tissue and no fibroma is without a certain increase in glandular tissue, and as both of these often contain cysts, an exact differential diagnosis between them is not always possible, nor has it more than a pathological significance. The 188 II MORS AND DEFORMITIES OF THE TRUNK tumor is generally painless and is first noticed by the patient durinu ;i hath or by accident. In other cases there is a little pain in the tumor. Treatment. — Such tumors are essentially benign, but they may also change their type of growth into one which has a ten- dency to spread into the surrounding tissues. Hence they should be removed, or at least carefully watched from month to month in order to be sure that they are not growing. Puncture with a hypodermic needle, and aspiration, will differentiate between a cystic ami a solid tumor if fluid is obtained. A negative aspira- tion is not conclusive (p. 1S3). If the tumor is small and freely movable, a local anesthetic will often suffice; but otherwise, and especially if the patient is more than thirty years of age, she should be told beforehand of the possibility of a major opera- tion and should be given a general anesthetic. If the growth is found to be malignant, the operation should be continued until it includes the removal of the breast and dissection of the axillary and clavicular regions, and the excision of one or both pectoral muscles, according to the judgment of the surgeon. It is of great assistance at such times to have a pathologist present, who, by ma- king frozen sections of the excised tumor, can determine whether or not it is of a malignant character. In general, one should be very suspicious of even a small, freely movable tumor which has been growing but a few months and is painful. This is especially the case if the patient is a woman more than thirty years of age. The Early Diagnosis of Malignant Tumors of the Breast. — The treatment of malignant tumors of the breast is quite out of the range of minor surgery, but the importance of a correct diagnosis in the early stages is so great and these tumors are so often first seen in ambulatory practise, that the diagnostic points should be emphasized. In examining a patient's breast these points should be observed : Palpation. — The patient should lie flat on the back with both breasts exposed for the sake of comparison. Some examiners pre- fer to have the patient sit upright, but the recumbent position is better for a thorough examination. Each breast should then be thoroughly examined by rolling its substance between the palmar surface of the fingers and the wall of the thorax. The aim of the examination is to determine the presence of any nodules or other EARLY DIAGNOSIS OF MALIGNANT TUMORS OF THE BREAST 189 irregularities. If there are multiple nodules in both breasts, the case is probably one of chronic mastitis. The same is probably true of multiple nodules in one breast, for if these are cancerous, the disease will of necessity be far advanced, and some of the other symptoms will be present. A single nodule in one breast, or in each breast, may or may not be cancer. It should be further examined. Retraction of the Shin. — This is best shown by pushing the breast, but not the tumor, toward the suspected part of the skin. Retraction of the skin, under these circumstances, is one of the most reliable signs of cancer. A Flattening of the Normal Curve of the Breast Over the Tumor. — This is determined by sighting across it with the eye on the same level. If present it is an indication of malignancy. The Presence of One or More Enlarged Glands in the Axilla or Between the Breast and Axilla. — This is not one of the earliest signs. Both axilla? should be palpated. If the glands in each are equally enlarged, and only one breast contains a nodule, the axil- lary glands are presumably non-cancerous. Palpation of the axilla is best performed as follows : If the left axilla is to be palpated, the surgeon stands to the right side of the patient. He lifts her left arm away from the body, and places the fingers of his right hand well up in the left axilla. The arm is then lowered, or brought to the chest, until the muscles are relaxed. The surgeon is then able to draw his fingers with the skin of the axilla back and forth over the axillary contents, and to feel any glands which are present. Retraction of the Nipple. — This is an early sign of cancer only when the disease begins under or near the nipple. In other cases the growth may be well advanced before retracting the nipple. Hemorrhage from the nipple, either spontaneous or occurring when the nipple is gently squeezed, is a symptom of value if there is no inflammation or other obvious explanation of its occurrence. Failure to Withdraw Fluid through a Fine Aspirating Needle. — A long hypodermic needle is sufficiently large. Fluid indicates cystadenoma in most cases, though some cancers contain fluid. The importance of carcinoma of the breast is so great that, unless the examiner can be sure that the tumor is of a benign char- acter, he had better assume it to be malignant. In doubtful cases 190 TUMOKS VXD DFFOKMITIFS OF TIM-: TRUNK a section should be removed for microscopical examination. This may be successfully done with cocain, unless the patient is of a nervous disposition. If the tumor is malignant, an extensive re moval of breasl and axillary gland and pectoral muscles and fascia is indicate*!. Carcinoma beginning in the nipple, so-called Paget's disease, may be mistaken for eczema. There is redness and scaliness, fol- lowed by a shallow ulceration with a slightly indurated base and narrow indurated margin. It is inexcusable to neglect such a con- dition, since the microscopic examination of a small section of the affected skin will reveal the true nature of the disease. Sarcoma. — Sarcoma of the breast differs somewhat from car- cinoma in its gross characteristics inasmuch as it usually develops at a greater distance from the nipple and forms a diffuse swelling deeply situated beneath the skin, and often ex- tending beyond the mar- gin of the breast in one or more broad lobules before the surgeon's advice is sought in re- gard to it. It grows rapidly, without pain, and forms new nodules by continuity rather than through the lym- phatic system; hence the axilla may be en- tirely free although the tumor has grown to a diameter of two inches or more. Such a free- dom of the axilla is never seen in carcinoma of the breast of a similar size. Sarcoma grows more rapidly than carcinoma, and a thor- ough and early removal is, therefore, not less important. Fig. 106. — Epithelioma of the Back at ax Early Stage. The drawing was made from the tumor after removal. Note the margin of healthy skin on all sides of the epithelioma. CARCINOMA AND SAKCOMA 191 Tuberculosis may be mistaken for a malignant tumor (see p. ISO). Tumors of the Male Breast. — The male breast, as lias al- ready been said, suffers from the same diseases as the female Fig. 107.— Cross-section of the Tumor Shown in Figure 106. Note that the tumor has not yet invaded the subcutaneous tissue. breast. As the fear of disfigurement is not so strong, the male patient will usually seek surgical advice soon after he has discov- ered the tumor of the breast. Hence the prognosis along opera- tive lines is fairly good. If neg- lected, however, cancer of the male breast develops in fully as virulent a manner as that of the female breast, forming metastases, extend- ing inward into the chest, and causing the death of the patient- from exhaustion. MALIGNANT TUMORS OF THE TRUNK Carcinoma and Sarcoma, — The skin of the trunk may be the seat of malignant tumors. They have no especial character- istics due to their situation (Figs. 106 and 107). If seen early, the prognosis after removal is un- usually good, since the surrounding Fig. 108. — Melanosarcoma of Lower Abdomen of Four Months' Duration Growing from a Mole or Soft Wart. Patient a woman aged fifty-four years. 192 TUMORS AND DEFORMITIES OF THE TRUNK Fig. 109. — Cyst under Scapula. One week's duration. Due to subscapular osteoma and traumatism. tissues may be sa e i-i freed wi t h much freedom, and hence the incision is usually carried wide of the growl h i Fig. ins). An instructive mistake in diag- nosis is connected with the patient shown in Figure 109. A fluctuat- ing swelling devel- oped soon after an injury. Aspiration produced a bloody fluid, and the needle touched abnormal bone. A diagnosis of sarcoma of the scapula was made. "When the patient was operated upon it was found that there was an osteoma of the scapula, which had so irritated an adjacent bursa as to cause an accumulation of bloody fluid. ACQUIRED DEFORMITIES Displaced Coccyx : Coccygodynia.— Falls upon the base of the spine may bend the coccyx backward or forward, or otherwise injure it. It may then become the seat of annoying and persistent j)ain, called coccygodynia. The projection forward of the bone may interfere with defecation and prevent its easy performance. The history given by the patient of a severe fall, followed by pain and tenderness which have never entirely disappeared, should lead at once to a physical examination. The patient either stands or lies upon his side with knees drawn up. The surgeon passes DISPLACED COCCYX: COCCYOODYNTA 193 the well lubricated finger high up into the rectum, the palmar surface of the finger being directed backward. The lower part of the sacrum and the coccyx can then be grasped between the forefinger and the thumb. The size and direction of the coccyx and the possible range of motion in the joint between it and the sacrum should be noted; also the existence of any tender spots. Treatment. — If there is reason to attribute the existing pain to the coccyx, or if it is ankylosed or is badly deflected and cannot be brought into normal relation to the sacrum with- out pain, the coccyx, or a portion of it, should be removed. A two inch median incision is sufficient for the purpose. The patient's bowels should be thorough- ly emptied on the previous day. At the time of opera- tion the skin in the vicinity should be thoroughly cleansed, but no enema given nor rectal examina- tion made just before operation. Either local or general an- esthesia is satisfac- tory. The incision is started at the level of the joint between sacrum and coccyx and extended a dis- tance of not more than two inches toward the anus. Skin and fat are divided and the coccyx cut down upon. The soft tissues are dissected from it Fig. 110. — Removal of a Displaced Coccyx. The wound necessary for its removal has been closed by four sutures. Photograph taken four days after operation, and retouched only to make the stitches and wound more prominent. The coccyx is laid on the patient's buttock. 194 TUMORS AND DEFORMITIES OF THE TRUNK posteriorly and along both sides. The joint between sacrum and coccyx is opened and the ligaments divided. If the bones are ankylosed they must be separated with bone shears or a chisel. The upper end of the coccyx is then seized and pulled backward. The soft tissues in front of the coccyx are then pushed and cut away from its anterior surface and the bone is withdrawn from the wound. In this manner it is easy to avoid wounding even the outer coats of the rectum. Bleeding is controlled by pressure or ligation, the cavity is obliterated by buried sutures of catgut, and the skin is sutured with horsehair or fine black silk (Fig. 110). If any drain is employed it should be a small gutta percha one, to be removed in two days. Primary union should be obtained. The patient should lie in bed for two days, and should avoid for '-dine days longer any sitting or other posture which will tend to separate the edges of the wound. Hernia. — A hernial sac is a protrusion of a part of the peri- toneum Through an opening in the abdominal wall. In this sac there may or may not be found portions of the abdominal organs. If they can be " replaced " in the abdominal cavity the hernia is called " reducible." Otherwise it is an " irreducible " hernia. Such reduction may be impossible on account of altered shape of the organs in the sac, its " contents," so-called, or on account of ad- hesions which have formed around the sac and its contents. The hernia may become inflamed as a result of traumatism, etc. This rarely leads to suppuration. It may produce so much swelling of the hernial contents that the blood-vessels which supply them are occluded, and strangulation results (Strangulated Hernia, p. 198). A hernia may exist at birth or develop soon afterward in an abnormally weak spot in the abdominal wall. It may also appear in later life, either suddenly, following some crush or severe strain, or gradually, as the result of oft repeated lesser strains. The subject of hernia, and especially its operative treatment, is exhaustively discussed in works upon major surgery. Still, the general means of correct diagnosis and the ambulant treatment of patients who, for one reason or another, cannot be operated upon, are here in place. General Principles of Diagnosis. — A patient suspected to have a hernia should be examined in both standing and recumbent postures. HERNIA 19.0 Inspection may show variation in size at different limes if the hernia is reducible. Peristaltic movements are often visible in large intestinal hernise. Palpation may reveal the presence of intestinal coils, of gurg- ling gas and fluid, of lumpy omentum, or of pasty. fecal masses capable of being indented. Compression, when the patient is recumbent, may affect the reduction of the hernia. • Percussion will bring out the resonance of intestinal coils con- taining gas. It will also give a thrill in case the swelling is due to a hydrocele or a cold abscess. Auscultation may reveal an intestinal gurgle or, in rare cases, an aneurysmal thrill. An impulse on coughing is obtained in case of most hernise. It may also be obtained, though less marked, in case of a large varicocele or in case of a hydrocele which extends well up into the inguinal canal. Reduction of the swelling upon compression or spontaneously when the patient lies down is very significant of hernia, but may also occur with an imperfectly descended testis or a cold abscess. General Principles of Treatment. — Operation for hernia, wherever situated, to be successful must accomplish these three steps : 1. The reduction of the hernial contents, either before or after the sac has been opened. 2. The closure of the peritoneal cavity at the normal level. The sac is usually tied at this point, its neck, and the surplus removed. 3. The approximation by firm sutures of the damaged wall of the abdomen, or at least of its strongest part, namely, the deep fascia. The various methods of accomplishing these three steps vary in different situations and in the hands of different operators. They are fully described in all surgical text-books. If the condition of the patient and the character of the hernia make it probable that the three steps above described can be car- ried out by operation, and primary union attained, operation should be advised. It is, of course, absolutely indicated in case of strangulated hernia as a relief of acute symptoms, even under circumstances in which a permanent cure of the hernia is not to be expected. A truss is to be recommended in all other cases of reducible 15 191) Tl'MOHS AXD DEFORMITIES OF THE TRUNK hernia. A patient having- an irreducible, inoperable hernia is in- deed in a bad state. Some of them gain relief by an operation which changes the hernia from an irreducible to a reducible one, Fig. 111. — Dorsal Hernia Following Kraske's Operation for Carcinoma of the Rectum. The hernia developing through the gap in the posterior pelvic wall caused by the removal of the sacrum, contained the greater part of the small intestine and the sigmoid flexure. so that a truss can be worn. An unusual type of partly reducible hernia is shown in Figure 111. The symptoms of hernia in different situations vary greatly. A brief description is therefore given of each. Umbilical Hernia. — Hernia of the umbilicus in the new-born is extremely common. The sac is usually small and contains intes- tine or is empty. This hernia has a strong tendency toward recovery, but to facilitate this end it should be constantly kept pressed back by means of a cloth-covered, wooden button-mold and a short strip of adhesive- plaster. This should be changed every day or every second day after the infant's bath, but before the old one is removed the new one should be prepared, and in the interval the hernia should be pressed back by the nurse's fin- ger until the new button is put in place. The plaster should extend in a different direction every day so that the skin may not become irritated. If treated in this manner the great majority of infan- tile umbilical herniae can be cured in a few months. Umbilical hernia in the adult is especially common in stout HERNIA 197 persons of middle age. It first appears as a flabby tumor as large as the terminal joint of the finger, covered with normal skin. It is usually irreducible. Its contents are omentum. As it grows the sac becomes more distended. ; small intestine will often be added to the omental contents. This part of the hernia is usually re- ducible, at least for a consider;! 1 tie period. Such a hernia fre- quently becomes strangulated. A truss is an unsatisfactory appliance for umbilical hernia of the adult. An operation should be performed early, if possible before intestine is involved. Inguinal Hernia. — Inguinal hernia is more common than femo- ral hernia both in the male (39 to 1) and female (3 to 2) ; or, to put it differently, for every 84 inguinal hernias in the male there are 8 inguinal hernias in the female, 6 femoral hernias in the female, and 2 femoral hernias in the male. It is usually indirect, that is to say, the omentum, intestine, etc., which fills its sac leaves the abdomen by the normal route of the inguinal canal, and does not burst through the posterior wall of the inguinal canal to the median side of the epigastric artery (direct inguinal hernia). Inguinal hernia may be congenital or acquired, and if acquired it may develop suddenly as the result of a crush or strain, or slowly. Symptoms. — These symptoms are usually present: normal movable skin; underlying tumor giving impulse on coughing, growing smaller or disappearing entirely under pressure or on lying down; enlarged ring and inguinal canal evident on reduc- tion of tumor; reduced tumor does not reappear when patient stands and coughs if the canal is blocked by the surgeon's finger ; no true fluctuation ; opacity to transmitted light. Possible additional symptoms of intestinal hernia are: reso- nance on percussion, gurgling on manipulation, indentation of doughy fecal masses in large intestine. Treatment.- — Treatment by operation entails only a slight risk, and is generally successful. It should therefore be advised in the case of all healthy children and active adults. Treatment by truss is advisable for feeble and aged persons and for those whose tissues in the inguinal region are so thinned by previous unsuccessful operation that they cannot be made to withstand the intra-abdominal pressure. A truss is a pad held firmly against the lower part of the 19S TUMORS AND DEFORMITIES OF THE TRUNK inguinal canal to prevent the exit of the omentum, etc., from the abdominal cavity. It has been well compared to the stopper of a bottle. Opinions differ as to the best form of truss. A satisfac- tory truss is one which, with a minimum of pressure and without causing the patient any pain, prevents the hernial contents from entering the hernial sac. The hernia must be fully reduced before a truss is applied. This is best done when the patient lies on bis back. A truss should never be applied to a hernia which is only partially re- ducible. It will rarely succeed in keeping back the rest of the hernial contents, and by its pressure on the part already in the sac it will cause pain and possibly serious inflammation, or even gangrene. A truss is rarely needed in case of a very young infant; but before the child is old enough to walk it should be fitted with a truss or should be operated upon. Operation is advisable for large congenital hernia?, as cure is improbable when the neck of the sac is so wide. If the tunica vaginalis communicates with the peri- toneal cavity by a rather narrow passage, and the contents of the hernial sac can be reduced into the abdomen without dragging the testicle upward, a truss may cure the patient in the course of a few years. For this purpose it should be worn constantly day and night, as crying no less than walking will force the abdominal organs into the hernial sac. As the child grows older the truss may be left off at night, and if the neck of the sac becomes oblit- erated the truss need only be worn during exercise, and finally not at all. A cure is sometimes obtained from a truss in adult life, but is far less likely after the patient has attained his growth. Femoral Hernia. — In femoral hernia the protrusion of abdom- inal contents is under Poupart's ligament and through the femoral ring. Such a hernia is usually small, and this fact, added to the tortuous course of the canal, sometimes obscures the impulse on coughing and renders diagnosis difficult. An enlarged lymphatic gland, with which femoral hernia is often confounded, if unilat- eral has almost always an evident cause in some scratch or cut of the foot or leg. Femoral hernia should always be treated by operation. Strangulated hernia always requires treatment in bed or im- mediate operation, but most of the patients are seen by a physician ASCITES-PARACENTESIS 199 while they are still walking about, so that the symptoms should be fixed clearly in mind, ready for instant service. They vary according to the character of the compressed organ. Omentum may become strangulated and give only moderate pain and dis- ability for days. Large intestine, and even small intestine if only a part of the circumference of the bowel is constricted, give the same symptoms in a more marked degree, plus vomiting and more or less distention. If the lumen of the small intestine is com- pletely obstructed there is repeated vomiting, becoming brown and foul-smelling (" fecal "), and absolute stoppage of the bowels even for gas. The various hernial orifices should be examined in all cases of intestinal obstruction. Treatment. — Dorsal decubitus, the steady pressure of a pad of unbleached cotton and a spica bandage, and the cold of a big ice-bag will cause the reduction of many strangulated hernias. This treatment should be tried only in the early hours of strangu- lation, lest one succeed in reducing a loop of intestine already gangrenous. In most cases immediate operation is indicated. Ascites - Paracentesis. — The causes of simple ascites are medical, and its treatment is essentially so, except in one respect, namely, paracentesis or the puncture of the abdomen for with- drawal of the extravasated serum, for the peritoneal cavity may become so distended with serum that it is desirable to withdraw the whole or a part of the fluid. This slight operation is almost free from risk. It is best performed in the following manner: A point is selected two or three inches below the umbilicus, either in or near the median line, or well to the outer edge of the rectus muscle. Thus one chooses the thinner parts of the abdominal wall and avoids the large vessels (deep epigastric) which lie beneath the outer part of the rectus muscle. In making the puncture one naturally avoids any visible veins. The patient should, if possible, be in a sitting posture, with the bladder empty. After cleansing the skin, the sensation may be dulled by ethyl chlorid or by the injection of a few drops of a two per cent solu- tion of cocain. A trocar and cannula is pushed quickly through the abdominal wall. If the peritoneal cavity is so distended with fluid that the wall is tense, the puncture is an easy one; if the distention is less, one must proceed with more care. It will then 200 TUMORS AND DEFORMITIES OF THE TRUNK be found of advantage to turn the instrument hack and forth while pushing it forward, exactly as one uses an awl. In either case it is well to hold the forefinger against the side of the instru- ment as a guide to the depth to which it is plunged (Fig. 112). Fig. 112. — Method of Holding Trocar and Cannula before Plunging it Through the Abdominal Wall. The forefinger acts as a guide to control the depth of puncture. A smaller trocar and cannula are also shown. The size of the cannula employed varies according to circum- stances. If the puncture is made merely for diagnostic purposes, or if the quantity of fluid to he removed is small, one naturally selects a small cannula, possibly as small as No. 6 French. If, on the other hand, several quarts are to be removed, as is fre- quently the case in hepatic cirrhosis, one should select an instru- ment not smaller than 12 or 11 French. The elasticity of the tissues will invariably close the opening in a short time after the cannula is removed. When the trocar is withdrawn serous fluid should flow out in a stream. If it does not, the end of the cannula has not entered the peritoneal cavity, or else it is blocked by omentum or intes- tine. An attempt should be made to push the cannula further inward. If this is impossible its end is not within the peritoneal cavity. In this case the trocar should be reinserted in the cannula, and the combined instrument pushed further inward, or a new site for the puncture may be selected. SPINA BIFIDA 201 If fluid does not flow, although the cannula can be pushed further inward, or if a flow of fluid is suddenly stopped, it is evident that something has obstructed the inner end of the can- nula. This may be overcome by tilting the cannula, or by shift- ing the position of the patient, or by inserting a stiff wire, first sterilized, through the cannula to keep back the obstructing mass. Cannulas have been made with lateral openings in order to pro- vent this annoyance, but it is rarely a troublesome one. The risk of wounding intestine or omentum is a very slight one. Indeed, this accident can scarcely occur unless there are firm adhesions at the point of puncture. In case of repeated puncture it is therefore well to select a new site each time. Some advise the incision of the skin with a narrow scalpel. This makes the puncture easier, but it is an unnecessary precau- tion unless the trocar is dull. Whether all the fluid should be removed at one sitting will depend on the general condition of the patient. In the majority of instances there is no objection to drawing it all off. Should the instrument puncture a vein or an artery in its passage through the abdominal wall, hemorrhage may follow the withdrawal of the cannula. It usually ceases in a minute or two, but if there is any doubt about it a little more cocain should be injected, a longitudinal incision made, the wound retracted, and the vessel ligated. This can be done without opening the peri- toneal cavity. The risk of infection following paracentesis is slight. It has doubtless been performed hundreds of times without any aseptic precaution, and yet without bad result ; but this is no warrant for negligence. When the cannula has been withdrawn the opening should be sealed with a little cotton and collodion, or if the serum continues to trickle from the wound, a pad of sterile gauze should be applied and changed as often as it becomes saturated. CONGENITAL DEFORMITY Spina Bifida. — The only important congenital deformity of the trunk amenable to treatment is spina bifida. (For congenital cysts and sinuses, see p. 181.) Spina bifida is a failure of development in which the bony 202 TUMORS AND DEFORMITIES OF THE TRUNK processes of one or more vertebrae are not united posteriorly. This defecl is mosl often seen in the lumbar or sacral region. The cleft may extend to the surface, in which case the spinal canal will be open, or it may be closed by sonic of the normal structures, even though the epidermis is wanting; or it may be entirely cov- ered with skin. In the marked eases of defect, in which the spinal canal is either open at birth or becomes so by ulceration of the imperfectly formed soft tissues, infection soon extends into the canal, and the child dies of meningitis. In the less marked eases, in which there is a firmer posterior wall made up of the; mem- branes of the cord, and possibly an intact skin, there exists an accumulation of serous fluid, giving a rounded tumor, which fluc- tuates on palpation. The cavity of such a cyst may communicate with the central canal of the spinal cord, or more often with the spaces between the cord and its membranes. If the latter is the case, the tumor is a meningocele. In some cases of spina bifida a certain amount of paralysis exists, due to developmental defect at the affected point of the spine. It should, however, be borne in mind that there may be other associated developmental defects elsewhere in the brain or spinal cord. Spina bifida is amenable to treatment by operation if the de- fect in the spinal column is not too large. Prognosis is most favor- able when there is a simple meningocele, with a small internal opening. But even in such a case the greatest care must be taken to prevent infection of the wound, for this will almost certainly lead to death by septic meningitis. Similar care should be exer- cised in nonoperated cases to prevent ulceration and rupture. The child should be kept off of its back, so that the surface of the tumor may never become contaminated with urine or feces, and may be protected from pressure. Treatment by injection and by ligation has been at times successful in curing a spina bifida, but the risks and uncertainties are such that their performance at the present day is not to be advised. If the communication between the cavity of a meningocele and that of the spinal column is very small, it may become obliterated before birth, so that a solid tumor, composed of fat or fibrous tissue, may exist instead of a cystic one. In removing such a growth the possibility of opening the spinal canal should be kept in mind. SECTION IV AFFECTIONS OF THE GEJSttTO-UPJNARY ORGANS CHAPTER VIII INJURIES AND INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS INJURIES Contusion. — Blows upon the penis and testicles are very com- mon. Owing to the sensitiveness of these structures they produce a degree of shock out of proportion to the local evidence of injury. The freedom of motion of these parts often saves them from severe injury. Swelling, especially of the testicle, may be considerable even after a slight injury. Deep injury may result in extensive extravasation of blood, with or without rupture of the erectile bodies or of the urethra, or it may be accompanied by hemorrhage into the tunica vaginalis, known as hematocele ; while a still deeper injury may cause rupture of the bladder, intraperitoneally or extraperitoneally. Diagnosis. — The diagnosis of the lighter forms of injury is usually not difficult. An inspection of the parts supplemented by palpation will usually reveal the extent of the trauma. Owing to the laxity of the tissues extravasated blood spreads rapidly, while edema finds little restraint and may quickly alter the normal ap- pearance of the penis. The diagnosis of the deeper injuries is considered under the separate titles. Treatment. — This consists in rest, support of the parts, and cooling applications. Compresses wet with a mixture of alcohol and water or fluid extract of hamemelis, should be applied and kept moist. ISTo impervious substance should be used to cover them, as the cooling effect of free evaporation adds greatly to the comfort of the patient in most cases. Or the wet compresses may be covered with flannel, oil silk, or gutta percha tissue, and the 203 204 INJURIES OF THE .MALE GENITOURINARY ORGANS dressing kept cold by an ice-bag placed alongside of it. While the patient is in bed the testicles should be supported on a folded towel placed across the thighs. As soon as he is up the weight of a swollen testicle should be taken off of the cord by a suspensory bandage. .If there is subcutaneous hemorrhage which is not con- trolled by these measures, or if an erectile body has been ruptured, an incision should be made and the bleeding vessel secured or the fibrous envelope sutured. Contusion of the testicle is apt to be followed by pain, more noticeable toward night or after exertion. An ointment contain- ing belladonna or ichthyol should be applied and the testicles sup- ported by a suspensory bandage. Hematoma: Hematocele. — The blood from a ruptured ves- sel usually spreads quickly throughout the loose subcutaneous tis- sue. In this manner penis and scrotum may in a short time be- come a dark garnet or magenta in color. In other cases the blood may accumulate in one place and so form a hematoma. This is most likely to occur if the ruptured vessel empties into the tunica vaginalis. Such a condition is called a hematocele. It may exist without any discoloration of the skin. It gives rise to a smooth, tense fluctuating swelling, the size and shape of the distended tunica vaginalis. Often the swollen testicle is lost in the mass of clotted blood so that it cannot be distinguished. A hematocele can be differentiated from a hydrocele by its rapid formation, by its opacity to transmitted light ; from a hernia by its irreducibil- ity, by the absence of an impulse on coughing, and by the fact that the swelling does not extend into the inguinal canal. Tkeatment. — Extensive hemorrhage in the tissues, if diffuse, will take care of itself. If, on the other hand, there is a large hematoma, an incision should be made into it and the blood clot taken out and the wound closed. The best time for the removal of the effused blood by aspiration is a few days after the accident, when the cutaneous effects of contusion will have subsided and the blood clot will have softened somewhat. If operation is not per- formed the blood clot will remain for months before it is entirely absorbed, even if it does not act as a foreign body and cause necro- sis of the overlying skin. Such an operation is free from risk if asepsis is rigidly observed. The wound may be sealed with a cot- ton-collodion dressing. PARAPHIMOSIS 205 "Fracture " of the Penis. — A too violent effort in coitus, as well as some form of direct violence, may rupture one of the erec- tile bodies of the engorged penis. The result is the immediate escape of blood from the fibrous sheath in which the erector vessels are confined, producing a flabby and distorted penis. If there is also a wound in the skin the blood may escape externally. Treatment. — The non-operative treatment consists in the ap- plication of cold and a firm bandage. The results are often unsat- isfactory, as is to be expected, when one considers the amount of the effused blood and the structure of the penis itself — so ill adapted to a firm bandage. The blood clots are not fully absorbed for a long time, scar tissue forms, and the deformity is often per- manent. The modern surgical treatment in these cases is an immediate exposure of the ruptured tissues by a longitudinal incision, con- trol of the hemorrhage by ligature or otherwise, suture of the fibrous sheath with fine chromic catgut, and suture of the skin- wound with horsehair or fine silk. With reasonable care, wounds in the penis heal aseptically. The operation may be performed with a local or general anesthetic. The blood supply in the organ may be controlled during the operation by an elastic rubber band wound around the root of the penis. This will also facilitate local anesthesia by limiting the diffusion of the solution employed. The rubber bandage should be removed before the skin is sutured in order to test the control of deep hemorrhage. Paraphimosis. — If a too tight foreskin is fully retracted over the corona of the glans, the head of the penis swells so that it is difficult to draw the foreskin down over it. The longer the condition lasts the more difficult it is to relieve it. Soon the fore- skin becomes edematous, and this adds to the difficulty of reduc- tion. The ability to urinate is usually not impaired. Treatment.- — To reduce a retracted foreskin it should be grasped with the thumb and finger of either hand at opposite points of its circumference, the thumbs being nearer the glans penis and firmly fixed upon the foreskin as close to the corona as possible. If the skin is slippery it should first be wiped dry and clean. Most of the obstruction to reduction is on the dorsal side of the penis, and hence the points at which the foreskin is seized should be situated a little more dorsally than ventrally. Steady !>()(} INJURIES OF THE MALE GENITO-URINARY ORGANS tension should now be exerted, the two hands pulling in slightly divergent lines in order to assist in relieving the constriction of the foreskin over the corona. If the efforts a1 reduction arc unsuccessful the surgeon may bandage the penis with a thin rubber bandage, ami so reduce swell- ing, or he may use a gauze bandage and saturate it with an astrin- gent solution and leave it in place a few hours. This treatment may so reduce the swelling that the foreskin can be drawn over the glans. If the condition of the parts, such as marked congestion or threatened gangrene, forbids delay, the foreskin should be di- vided dorsally by an incision parallel to the long axis of the penis (see p. 246). Reduction Avill then be easy. The operation should be completed by- suture, but the longitudinal incision should be sutured laterally, or a partial or complete circumcision may be at once performed. If a tight paraphimosis is left to itself a spon- taneous reduction may take place or the retracted skin may become adherent in its new relations so that reduction is impossible; or it may lead to gangrene of either the constricting skin or of the head of the penis. Neuralgia of Testicle. — Violent coitus may produce neu- ralgia of the testicle, and even a swelling of the organ, which the patient calls a " strain." It is best treated by a suspensory bandage, by the application of cooling lotions, or of belladonna or ichthyol ointment, and by the avoidance of sexual excitement until the symptoms have disappeared. If the patient is troubled w T ith erections during sleep, large doses of bromid of potash should be given during the afternoon and evening, and the bowels should be thoroughly emptied. In many cases of neuralgia of the testicle of sexual origin, relief follows the occasional passage of a steel sound through the deep urethra. Whenever possible, these patients should be encouraged to take up normal sexual life, for frequently and unjustly they mistrust their power to enter into a happy marriage. Experience has re- peatedly shown that all the neuralgic symptoms disappear in a few weeks after marriage. Foreign Bodies of the Penis and Urethra. — A special form of injury of the penis is caused by slipping a ring over the end of the organ. The congestion which results sw T ells the glans so that it is impossible to remove the ring. This congestion FOREIGN BODIES OF THE PENIS AND URETHRA 207 increases as time goes by and if surgical aid is not sought gan- grene will follow. But before this occurs the ring may be so buried in the edematous skin as to be invisible unless a careful examination is made. Foreign bodies are also passed up into the urethra for pur- poses of sexual excitement. They sometimes slip from the grasp of the individual and pass wholly within the meatus. The symptoms vary according to the nature of the foreign body lodged in the urethra. If this is smooth there may be no serious symptoms until a calculus forms about it some weeks later, or infection of the urethra or bladder may be caused. This is more likely to follow the introduction of a sharp object such as a pin. If the urethra is torn, the swelling may make urination dif- ficult or impossible. Treatment. — A ring which has been passed over the penis should be filed or cut in two places and removed. Usually a thin strip of steel can be passed under the ring at some point in its circumference in order to protect the penis from the file. The extraction of a foreign body from the urethra is often extremely difficult. If ^ the body lies near the meatus it may be seized and drawn outward by a pair of thin forceps. Before at- tempting the seizure, firm pressure should be made upon the urethra near the base of the penis so as to prevent the foreign body from slipping upward into the bladder. If the object is sharp-pointed, as a pin, and the point is toward the meatus, it may be pushed out through the wall of the urethra and the penis, reversed, and pushed back into the urethra, so that the head is toward the meatus. The head can then be grasped with forceps and the pin extracted. If the foreign body is not sharp-pointed, as, for instance, a slate pencil, it may be extracted by pinching the urethra firmly above its upper end and crowding the penis upward past its lower end. The lower end is then grasped through the penis, and traction is made in order to stretch the urethra to its fullest extent. While thus stretched the urethra is again pinched above the upper end of the slate pencil, and the penis again crowded up from below. By this means the foreign body can be brought out of the meatus. This method can be easily demon- strated by slipping a slate pencil into a piece of rubber tubing whose caliber is great enough to receive it readily. 208 IXJl'KIES OF THE MALE GENITOURINARY ORGANS If the foreign body cannot be extracted through the meatus, an incision should be made directly down upon it to permit of its prompt removal. The wound of the urethra should be sutured at once, and also the wound of the skin unless infection exists, in which case drainage may be advisable. Foreign Bodies in Bladder. — A foreign body which finds its way into the male bladder, either through the urethra or by penetration of the wall of the bladder, usually becomes tncrusted with urinary salts in a short time. The symptoms depend more or less on the nature of the object, whet her it has sharp angles, etc. They are in general pain, espe- cially at the end of micturition; vesical irritability, as shown by pain when the body is jarred and by frequent micturition; and an admixture of blood with the urine, and perhaps the passage of a couple of drops of pure blood at the end of the act. The foreign body may cause a sudden stoppage of the urinary stream during micturition. If a foreign body remains in the bladder for some time, the urine may become ammoniacal. The symptoms given are also the symptoms of calculus. The diagnosis can be made from the symptoms ; also by means of a short, sharply curved steel sound called a stone searcher ; in some instances by the X-ray, and in some by the eystoscope. Treatment. — The removal of the foreign body is the essential of treatment. This usually requires an incision into the bladder. The suprapubic route is the method of choice. Wounds. — All wounds of the external genitals should be treated by thorough cleansing, control of hemorrhage by ligature, suture of both superficial and deep structures, and if necessary drainage. The tendency of contused wounds to bleed subcutane- ously is very marked, on account of the free blood-supply and lax tissues. All blood clots should be evacuated, and the spaces in which they lie should be suitably drained. Rupture of Urethra. — This may be complete or partial. It is usually due to a fall astraddle of some hard object or to a kick in the perineum. By this violence the bulbous urethra is pressed against the edge of the pubis and divided. The symptoms are pain and swelling at the seat of injury, and usually bleeding from the meatus. There will be either inability to pass water or painful, dribbling micturition, the urine contain- RUPTURE OF URETHRA 209 ing blood, or, as is usually the case, the passage of a little urine from the meatus and the extravasation of a certain amount of urine about the point of rupture. If there is an external wound the urine will escape from it. If not, the passage of an olive- tipped bougie will usually establish the diagnosis. If the urethra is torn clear across the bougie will fail to enter the vesical por- tion, or if it is only partially torn the rent in the membrane may be felt. Sometimes the break may be felt by external pal- pation. A doubtful diagnosis will usually exist only in those instances in which the urethra is divided without the skin being broken. Treatment. — The treatment for all cases of partial or com- plete rupture of the urethra is immediate incision and suture. Only the simplest cases of rupture of the pendulous portion may be left to heal of themselves. If the divided ends are retracted, or if a portion of the urethra is so badly bruised that it has to be cut away, suture of the urethra is still possible by loosening it from its attachments a little distance in both directions. An inch of the urethra has been resected and the urethra sutured with com- plete success. For this purpose fine silk should be used, and only two or three of the sutures should pass clear through the mucous membrane. Unless the wound determines the site of the skin in- cision, it should be a longitudinal one made in the median line of the under surface of the penis. After operation has been com- pleted, a catheter should be left in the bladder for several days. This operation may be easily performed with the aid of a local anesthetic. The stitches should be removed in five days or a week and the catheter two or three days later. In most instances the deeper parts will heal with scarcely any leakage of urine. Should this occur the sinus will in a few days close of itself, since, unlike the condition when an inflammatory stricture is present, the tend- ency after traumatism is toward recovery. All silk sutures should be so placed that they can be removed, and for this purpose their ends should be left long; otherwise plain catgut should be em- ployed. If, in spite of all precautions, suppuration occurs, the catheter must be taken out of the bladder and the wound freely drained. After the inflammation has subsided, a second operation may be undertaken to close a persisting sinus. If the sinus is a large one or traumatic stricture exists, a section of the urethra 210 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS must be eu1 away so that clean fresh ends may he ohtained for suture. Rupture of the Bladder. — The rupture may he extraperi- toneal, hut is usually intraperitoneal. In either case the accident is a serious one and follows a blow or fall, usually when the blad- der is full. When it is overdistended a comparatively slight blow- may rupture it. Symptoms. — Rupture of the bladder has some symptoms in common with rupture of the urethra ; but it may be differentiated by the history of the accident, by pelvic pain and shock, by the absence of visual injury in the perineum or along the penis, by the fact that blood in the urine is thoroughly mixed with it and does not appear simply at the beginning or the end of the urinary act, and possibly by the complete absence of urine, even after the passage of a catheter. Unless stricture is present there will be no difficulty in passing a catheter into a ruptured bladder. Extrava- sation of urine into the deeper parts of the pelvis, or its discharge into the peritoneal cavity, will also cause symptoms which will assist in the diagnosis of the injury. Treatment. — An immediate suprapubic cystotomy is the best form of treatment. In many cases this must be combined with a laparotomy. Rupture of the bladder should be considered a possible com- plication in all cases of fracture of the pelvis. INFLAMMATIONS Burns. — Burns of the external genitals may be of the usual kind, or they may be due to the application of too strong ointments or lotions. The symptoms and treatment are those of burns else- where in the body (see p. 26). On account of the great loose- ness of the skin and the relative firmness of the deep fascia of these parts, the edema resulting from even a slight burn may produce great distortion (Fig. 113). Such an edema is, of course, wholly temporary, and the patient should be so assured. Simple Balanitis. — This is an inflammation of the mucous membrane covering the head of the penis, and the inner layer of the prepuce. It is common in cases of long prepuce, especially if the foreskin cannot be retracted. Under such circumstances the HERPES OF THE PENIS 211 secretions about the corona remain in a moist condition and un- dergo fermentations. Erosion of the delicate epithelial layers results, with foul smelling discharge. Diabetics are especially sub- ject to irritations of the foreskin. Treatment. — Cleanliness, the application of a powder, such as stearate of zinc, or the application of a bland ointment such as cold cream, will heal the simplest cases. The apposed surfaces may be kept apart by a wisp of cotton moistened with a dilute antiseptic. If the foreskin cannot be retracted, or if it is very long, so that the head of the (adult) penis is completely covered, cir- cumcision should be per- formed. The resulting ex- posure of the corona will stimulate the growth of a tougher epithelium, and will dry the secretions more rapidly. In operat- ing upon diabetics, one should remember the possi- bility of a failure to ob- tain primary union. Herpes of the Penis. — The glans penis and the FlG - 113 -— Edema of the Penis and Scr °- tum in Burn due to the Application of inner layer of the prepuce Mercueic Ointment. may break out with the characteristic groups of vesicles by which herpes is known in all portions of the body. In the case of the penis, however, the apposition of the two epithelial layers leads to the speedy macera- tion of the vesicles, so that if the patient is not promptly seen, only shallow ulcers may be found, together with more or less gen- eral inflammation. The treatment is similar to that advocated for balanitis. The apposed surfaces should be kept apart by a wisp of cotton or a layer of gauze moistened with some mild antiseptic, such as a dilute silver solution, or a drying powder may be employed, or a simple ointment. The parts should be frequently cleansed with 16 212 INFLAMMATION'S OF THE MALE GENITO-URINARY ORGANS hot saline solution to prevent irritation from accumulated secre- tion. If the digestion of the patient is faulty, ii should be cor- rected. Simple Urethritis. — Inflammation of the mucous mem- brane of the urethra, not due to the gonococcus, may follow trau- matism, such as the use of sounds, or excessive or unclean coitus, or the ingestion of drugs which, passing out through the kidneys, may irritate the urethra, etc. The symptoms are those of catarrh of mucous membrane everywhere — namely, swelling, tenderness, redness, and an increase in the mucous secretion, which in some cases may be purulent. Micro-organisms may be found in the dis- charge, but they will not be gonococci. The lack of exposure to gonococcus infection, the absence of gonococci from the discharge, and the quick disappearance of symptoms, serve to differentiate simple urethritis from gonorrhea. Treatment. — With the removal of the cause of irritation and dilution of the urine, the inflammation quickly subsides; usually in less than a week. The patient should drink as many as four large glasses of water, preferably hot, and taken an hour before meals and at bedtime. Sweet spirits of niter, or acetate of potash, or some other di- uretic should be given to reduce the acidity of the urine. Abscess. — M o s t of the infections of the external genitals are of a venereal character, due to the organisms of gonor- rhea, chancroid, or syphilis. Cellulitis and abscess due to the ~ , usual pyogenic organ- Fig. 114. — Abscess of Scrotum of Five Days _ rv o o Duration. Patient aged twenty-five. isms do OCCUr, how- SPECIFIC URETHRITIS, OR GONORRHEA 213 ever, both in the penis and in the scrotum. A case of the latter character is shown in Figure 114. The symptoms and treatment are similar to those of abscess in other parts of the body. Specific Urethritis, or Gonorrhea.— Gonorrhea as com- monly seen is an acute inflammation of the anterior urethra due to the presence of a specific microbe called the gonococcus. Ac- cording to the best authorities it can be obtained only by contact with a person who has recently suffered from it, or with some of the discharges from such a person. In most cases it requires from two to four days for the germ to develop in the epithelium after its introduction into the urethra. After this interval free from symptoms, there is noticed an itching or burning, or pain greatly increased during micturition and during an erection, and a puru- lent discharge. The mucous membrane swells, and often pouts from the meatus. The inguinal glands swell and become tender, but rarely suppurate. These symptoms continue for two or three weeks and slowly subside. Treatment. — The varieties of treatment advocated for this very common trouble are numerous indeed. None of them is able to cut short to any great extent the average duration of the disease. The discharge continues usually about six weeks. It is noticeable, however, that in succeeding attacks the disease pursues a briefer and milder course. As is the case in most acute inflam- mations, very hot water is grateful to the patient, who should soak his penis once or twice a day in a large tumbler filled with water as hot as he is able to bear it, with the idea of relieving the mucous membrane from the irritation of its own discharges, as well as in the hope of sterilizing the urethra and thus cutting short the attack. Many specialists upon genito-urinary diseases have advocated the use of irrigation. Tor this purpose a blunt pointed nozzle is pro- vided which contains two openings side by side. With each of these a tube is connected, one coming from the reservoir of irri- gating fluid, the other leading to a waste pail. The nozzle should distend the meatus so as to prevent the escape of fluid around it. Irrigation may be carried out by allowing the stream to flow con- tinuously or by occasionally stopping the outflow in order slightly to distend the penis before the fluid flows out of it. Mild anti- septic solutions can be used for this purpose; permanganate of potash in water, 1 part to 2,000, is one of the favorites. 214 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS It has been claimed that injections and irrigations have a tend- ency to spread the gonorrhea to the prostate, bladder, or testicles, but without injections of any sort being made these secondary in- flammations often develop, so that an injection in which no undue pressure is employed probably does not spread the disease to deeper parts. Xature has provided an irrigation for the urethra in the flow of urine through it at frequent intervals, so that the irriga- tions above described are not as necessary as they otherwise would be. The urine should be kept bland by causing the patient to drink large quantities of water, milk, weak tea, lemonade, etc. If it is desirable to reduce acidity still further, acetate of potash, ten grains every four hours, or some other diuretic may be given. Tiest is another essential of treatment. The patient should lie down as much as possible, and should avoid exercise, tobacco, alco- hol, and. sexual excitement of any kind. If troubled during sleep with erections of the penis, the patient should take during the afternoon and evening thirty or forty grains of potassium bromid. Constipation should be prevented, and the diet should be a simple one. Such are the general principles of the treatment of acute gonorrhea upon which all writers agree. The specific treatment, that is, treatment which has in view the cure of the disease by the use of drugs, is by some writers asserted to be useless ; most specialists, however, administer drugs by the mouth or in injections into the urethra, or by both of these methods. The drugs given internally are chiefly copaiba, cubebs, sandalwood oil, and salol. These are all substances which are rapidly excreted by the kidneys, and give to the urine an aromatic odor and a certain degree of disinfecting power. A good prescrip- tion is as follows : 3 Salol, )„ ,_ .. . . , > aa gr. iv ; Oleoresm cubeb, ) Balsam copaiba? gr. viij ; Pepsin gi*. j. One or two capsules, each containing the above, should be given after each meal. The other method of administering drugs — namely, that of in- jecting solutions into the urethra — opens a wide field for experi- SPECIFIC URETHRITIS, OR GONORRHEA 215 mentation. Astringents of every sort, and most of the old and new disinfectants, have been repeatedly used for this purpose. Their efficacy in limiting an acute gonorrhea is open to grave doubt, though the astringent solutions are of undoubted benefit in the later stages of the disease when the purulent secretion has changed to a thin mucous secretion. The following solution is often employed: tf> Argyrol 3iv ; Aquae destil oviij. Sig. : Use locally after urination. Or at a later stage, when the discharge becomes muco-purulent, the following mixture : I£ Zinc, sulphat gr xv Plumbi acetatis gr. xx; Tinct. opii, . aa oil : Tinct. catechu, ) Aquae ad ovj. M. Sig. : To be injected after urination. Complications. — The prostate, bladder, and testicle may all take part in the gonorrheal inflammation. It requires usually two or three weeks for the disease to spread to these localities, but when it has done so the same symptoms of heavy pain, heat, swell- ing, and tenderness to touch are present in these different locali- ties, and the patient has the constitutional symptom of fever of 100°-102° F. If the bladder is affected, micturition is frequent and urgent, extremely painful, and is often followed by the pas- sage of small quantities of blood. Blood may also be mixed with the urine. Inflammation is situated in the neck of the bladder as well as in the prostate, and most of the pain is referred to the base of the penis and to the perineum. Large doses of alkaline diluents, local application of heat in the form of hot compresses, or a hot sitz-bath and irrigation of the rectum with hot water, or heat applied through a closed rectal tube, will all relieve the pa- tient somewhat, but for a few days morphin will probably be required, and may be administered by the mouth or subcutane- ously or by rectal suppositories. If the inflammation does not subside in a few days the bladder should be irrigated daily through 216 INFLAMMATIONS OF THE MALE OENITO URINARY ORGANS a soft rubber catheter with ho1 saturated solution of boric acid, or with very weak solutions of nitrate of silver (1: 4,000) at the beginning, or a solution of protargo] (1: 2,000). If the disease extends to the testicles it usually attacks only one of tlieni at a time, and involves chiefly the epididymis. This swells rapidly until it is several times the normal size, and is exquisitely painful and tender. Host in bed, support of the tes- ticle by folded towels placed upon the thighs, and the application of pounded ice or hot, moist compresses kept hot by a hot water bottle, will suffice to relieve the pain in a few days. Painting the overlying skin with a mixture of equal parts of guaiacol and olive oil will also relieve pain. Often the swelling persists for weeks, and the testicle should be carried in a suspensory bandage for a long time after the patient is up. Its return to the normal size can be hastened by the application of a mixture of mercurial and belladonna ointment. Chronic Gonorrhea : Posterior Urethritis. — By the treatment described, or even without treatment, the discharge in acute gonorrhea usually ceases in about six weeks. Occasion- ally, however, some few symptoms of the disease remain — a little pain after urination, an occasional drop of clear mucus sufficient to keep the meatus moist and to disturb the mind of the patient, or a few shreds in the urine. The disease has passed into a chronic state and is known as chronic urethritis or gleet. In such a form it resists treatment most persistently. This is due sometimes to irregularities in the urethral canal, either natural or the result of the inflammation. Behind a small meatus there may be a little pouch in which the inflammation continues, and lights up from time to time after any slight irritation. Or there may be a stric- ture at any point in the urethra behind which the inflammation keeps up. Such a stricture is due to the contraction of scar tissue, which occurs everywhere in the body where healing has followed severe inflammation or loss of tissue. The persistence of the in- flammation may also be due to the fact that the gonococci have lodged in the prostatic ducts. In these narrow passages they are Avith difficulty reached by injections, and are not affected by the flow of urine. Treatment. — A narrow meatus or a stricture should be di- vided. If posterior urethritis exists the most successful treatment STRICTURE OF URETHRA 217 is the injection of a few drops of a strong solution of nitrate of silver by means of a deep urethral syringe. The solution first injected may have a strength of one per cent; later, if necessary, stronger solutions may be employed. The instrument should be passed into the membranous urethra, i. e., about six inches from the meatus, before the fluid is injected. The injections should be repeated every two or three days. The effect of the treatment is heightened if the prostatic ducts be emptied once or twice a week by digital pressure applied to the prostate gland through the rectum. Stricture of Urethra. — This is a cicatricial narrowing of the canal, usually due to scar formation after gonorrhea. If the caliber~>is only slightly reduced, the symptoms are not severe. There i§ slight discomfort on urination, and the stream is irregular or interrupted. There may be a discharge of a few drops of clear mucus at times. If the stricture is very tight, the patient is con- stantly exposed to a complete obstruction (see Retention, p. 219). Treatment. — The aim of treatment is to make and keep the caliber of the urethra sufficiently large, and also uniform, so that pouches may be done away with. A narrow meatus should be di- vided downward by a blunt pointed knife, after a little cocain has been injected hypodermically. When this has been done the urethra should be carefully examined with olive tipped bougies or with a urethrometer. These instruments should be sterilized and lubricated with a sterile medium such as boiled olive oil, or one of the manufactured preparations containing sea-moss. These are soluble in water, and in their other physical properties closely re- semble mucus. The meatus having been cleansed, the head of the penis is grasped lightly, and a small bougie is passed slowly in- ward until its point meets an obstruction or reaches the membra- nous portion of the urethra. If no obstruction is found, larger and larger sizes are employed until the limit of that particular urethra has been reached. If a stricture is present it may be dilated gradually or imme- diately, or it may be divided with special cutting instruments. All of these forms of treatment have often been carried out in the surgeon's office or in the dispensary, but sudden dilatation or divulsion, as it is called, is uncertain and is not now in vogue. Division of the stricture with a cutting instrument (internal ure- 218 INFLAMMATIONS OF THE MALE GENITO-URINARY OKUANS throtomy) is not without danger. There is some risk of hemor- rhage. Inn this is usually controlled without difficulty. A greater risk is due to the severe nervous symptoms which sometimes fol- low even a slight insult to the urethra. The choice between gradual dilatation and division of a stric- ture depends somewhat upon the condition of the patient aud his circumstances, as well as upon the character of the stricture. If the latter is elastic, of not too small caliber, and gives only mod- erate symptoms, most surgeons are content with gradual dilata- tion. This should be carried on under strict aseptic precautions, steel sounds (Fig. 115) being passed every two or three days if Fig. 115. — A Good Type of Steel Sound. The shaft is smaller than the shoulder and does not therefore drag the meatus. It should be held as lightly as a pencil. the urethra does not react too violently. Later when a full sized sound is easily passed, the treatment may be performed only once in a week or two. The sound should be held as lightly as a pencil between the tips of the thumb and fingers. If the passage of the sound is too painful, a few drops of a one per cent solution of cocain may be injected into the urethra. A strong solution of cocain should never be used for this purpose, as death from absorption has more than once occurred. On each occasion two or three sounds, each one a little larger than the preceding one, may be passed; but it is well to begin each time with a sound one or two numbers smaller (French scale) than the largest one passed at the previous treatment. This gives the pa- tient confidence at the start, and reminds the surgeon of the par- ticular curves of the patient's urethra. The permanent cure of a stricture is often a matter of several months. Internal urethrotomy is not properly a minor surgical opera- RETENTION OF URINE 219 tion, and need not be considered in detail. Suffice it to say that after the stricture is cut tfye caliber of the urethra should be at once tested by the passage of a full sized sound. This should be repeated again in four or five days, and every few days there- after for a month or so. Retention of Urine. — If a stricture of the urethra is very tight, admitting only the smallest instruments (No. 6 French or less), the symptoms mentioned above are more pronounced and at any time an acute swelling of the mucous membrane about the stricture may shut off the passage entirely. When this occurs, there is a complete retention of urine, one of the most painful con- ditions which can possibly be experienced. Sometimes the strain- ing bladder may force a little urine past the stricture, but without much relief of the symptoms of retention. There will then be a constant dribbling sufficient to keep the patient alive, but not to relieve him of his agony. This condition of affairs requires imme- diate treatment. Although stricture is the commonest cause of retention of urine, it is well to bear in mind that it may be due to a number of other causes, such as enlargement of the prostate gland, a con- dition nbt usually found before middle life ; or a stone in the blad- der; or injury to the deep urethra or the bladder; or a tumor; or it may follow exposure to cold in persons of delicate constitution ; or accompany lesions of the spinal cord. The history of the pa- tient, together with the facts elicited by examination, should enable the surgeon to make a correct diagnosis in most cases. The necessity for immediate relief is equally great, whatever the cause of the retention. Treatment. — The simplest measures should first be tried. Sometimes, to the great relief of patient and surgeon, a medium sized soft rubber catheter, if well lubricated and steadily pressed against the obstruction, will after a few minutes pass the stricture and bring the desired relief. When the bladder has been emptied, or partially emptied if its distention has been very great, and the patient has been put to bed on a light diet and his bowels moved, the power to empty the bladder voluntarily often returns; but should subsequent catheterization be necessary, it is usually easily performed. When acute symptoms have passed over, the stric- ture should be appropriately treated. 221) INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS If a soft catheter cannot be passed, success may follow the use of a silver instrument, although more often the point is pushed through the mucous membrane and burrows outside of the urethra without reaching the bladder. The bladder itself may be aspirated by means of a fine trocar and cannula inserted just above the pubes. As the greatly dis- tended bladder has lifted the peritoneal reduplication, there is no danger that the instrument will enter the peritoneal cavity. When the bladder has been thoroughly emptied, catheterization or normal urination may become possible. In more severe cases of retention three methods of radical re- lief are available: namely, suprapubic cystotomy, internal ure- throtomy, and external urethrotomy. The objection to the first, if the retention is due to stricture, is that it does not relieve the cause of the retention. The second is only possible in case a fili- form bougie can be passed into the bladder. If this can be done, usually enough urine will escape around it to relieve very mate- rially the patient's condition, and after a few hours the stricture will dilate sufficiently to allow the passage alongside of the fili- form of the guide to Maisonneuve's instrument for internal ure- throtomy, or with the filiform alone in position an external ure- throtomy may be performed. This is a comparatively easy oper- ation under the circumstances. If, however, no guide can be passed into the bladder, the external urethrotomy may be ex- tremely difficult, since the finding of the urethra beyond the stricture may tax the surgeon's ability to the utmost. The details of these operations are found in all good surgical text-books. Incontinence of Urine. — Dribbling of urine from an over- full bladder is really a symptom of retention, although it is gen- erally spoken of as incontinence. True incontinence, or the in- ability of the bladder to retain the usual amount of urine, may be due to disease of the bladder itself or to some alteration in its nervous control. An example of the latter is the incontinence of childhood. Incontinence of Childhood. — This is seen in both sexes, and may be diurnal or nocturnal, though the latter is more common. It is a continuation of an infantile condition, but parents do not usually pay much attention to it until the child is five or six years old. It varies greatly in degree, some children wetting the bed INCONTINENCE OF URINE 221 every night or twice a night, others being affected occasionally. The children who are affected in the daytime are seized with a desire to urinate and cannot retain the urine long enough to get to a closet. Treatment. — The urine should be examined, the daily quan- tity determined, and the maximum capacity of the bladder ascer- tained. Acid urine should be rendered bland. The possibility of vesical calculus should not be overlooked. The general health and habits should be attended to. One little girl showed marked improvement as soon as she gave up jump- ing rope. The intelligent cooperation of the child should be obtained. Usually the child has been scolded and punished until it is filled with fright and shame at the mere thought of urination. This is, of course, an unfavorable attitude of mind and should be changed as quickly as possible. To give the child a correct view of the functions of its bladder and of the possibility of strengthening them by exercise and by voluntary retention of urine after the desire is first noticed, will at once gain its sympathy and assist- ance. The amount of urine passed at one time and the length of intervals between urination should be graphically shown by a meas- uring glass and a record. The patient should not drink freely in the evening and should retire with an empty rectum as well as bladder. The clothing should be light. Constipation should be relieved. A long fore- skin should be removed by circumcision. In every case, male or female, a careful physical examination should be made. Some- times seat worms are an exciting cause. Belladonna, quinin, and some other drugs may be tried. Many cures have been reported following their use. In obstinate cases a small steel urethral sound should be passed twice a week. There is always a tendency toward recovery with the growth of the child. Incontinence of Old Age. — This is chiefly found in women who have borne children and who have a laxity of the perineum and of the vaginal walls. Combined with this decrease in mechanical support of the bladder there is also a decrease in muscular power of the sphincter. The result is the inability to retain more than 222 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS a few ounces of urine, so that it escapes upon coughing or motions which increase the intra-abdominal pressure. In other cases a urethral polyp or caruncle may be at fault. Relief is to be looked for in operations which restore the in- tegrity of. the pelvic floor. Sometimes a pessary, by preventing displacement or prolapse of the uterus, will render good service. Abnormally acid or alkaline urine should be brought to a normal reaction. Urethral polyp or caruncle should be removed by opera- tion (see p. 270). Catheterization. — A few w 7 ords upon the best way to per- form this simple act may not be out of place in this connection. It is practically impossible to sterilize the meatus and urethra, so that patients whose condition requires catheterization for months or years usually succumb to infection of the bladder and kidneys. Nevertheless, the advantages of cleanliness are here very marked. Rubber catheters should be boiled or scalded with boiling water after being used, and kept in weak antiseptic solutions until wanted. They should then be rinsed with boiled water and lubri- cated with a sterile medium. The meatus of the patient, as well as the hands of the catheterizer, should be carefully disinfected. In fact, it is better to use rubber gloves, which can be readily dis- infected by boiling. As gloves for this purpose need not be very thin, they wall last a good while. As soon as a rubber catheter loses its smooth surface it should be replaced by a new one. When one calls to mind the fact that men have catheterized themselves for years, carrying a rubber catheter around in the vest pocket, and perhaps never washing it, and have still escaped infection, such precautions as have been above described may seem unnecessary. They are not so, however, and while some persons possess great power of resistance to disease germs, others fall an easy prey, and should be protected as far as possible. Eczema. — The external genitals, both penis and scrotum, are favorite sites for eczema (Fig. 116). This condition is often due to or aggravated by uncleanliness or the larger or smaller parasites (scabies). Chancroid. — A chancroid is a small ulcer appearing on the head of the penis, or foreskin, or possibly on the skin of the penis or scrotum, or even of the thigh. It is due to infection by direct contact with a virulent venereal discharge. Presumablv some CHANCROID 223 slight break in the skin allows the poison to gain a foothold. Such a lesion makes its appearance within a day or two after inocula- tion. It usually grows larger for several days, and. may encircle the penis and eat away a considerable portion of its substance; but such rapid destruction is uncommon and the typical ulcer has the diameter of a quarter or half an inch. There may be more than one ulcer, either because the skin has been inoculated in more Fig. 116. — Eczema of the Penis of Four Months' Duration. than one spot or because of autoinoculation from point to point. This explains the occurrence of ulcers upon the scrotum or thighs. The ulcers are usually shallow, not extending below the cutaneous layer. There is a certain amount of surrounding inflammation, and often lymphangitis and lymphadenitis; the vessels leading to one or both groins carrying the infection into the inguinal glands (inguinal adenitis or bubo). The lesions in both skin and glands are painful, and there is the constitutional disturbance 224 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS always scon in the presence of acute infection. The primary sore, unless -nine caustic has been applied to it, lacks the sur- rounding induration of a primary syphilitic lesion. If the chan- croidal ulcer has been cauterized a differential diagnosis is more difficult. Treatment. — A chancroid is best treated by a local hot bath two or three times daily, followed by careful cleansing- with an antiseptic solution, such as peroxid of hydrogen diluted with four parts of water. Absorbent cotton, wet with a solution of zinc sul- phate 1 to 60, or some other lotion, may either be held in place by drawing the foreskin over it or by a bandage. In the latter case the dressing should be moistened, without removing it, every hour or two to facilitate discharge. Surrounding skin should be pro- tected against contamination and the patient advised of the high degree of infectiousness of the discharge. By this treatment pain will be much relieved, the ulcer will soon take on a healthy appear- ance and will heal in two or more weeks, according to its size and the condition of the patient. The use of strong caustics is never advisable. Excision of the lesion and suture of the wound often fails to give primary union. Treatment of Bubo. — The inguinal glands, if moderately inflamed, may be treated by counter-irritants ; e. g., equal parts of belladonna ointment and an ointment containing ichthyol oj to vaseline oj- This is more likely to succeed in glands swollen from non-venereal causes. If pain and swelling are severe the patient should go to bed and apply an ice-bag or hot moist compresses to the groin. If the glands suppurate, as they usually do, the individual abscesses may be opened or the glands entirely dissected away. If the abscesses are simply incised and drained, the patient will re- quire to be dressed for several weeks, but he will be able to go about without much discomfort. Complete removal of the glands seems a formidable procedure, but in about one-half of the patients so operated upon primary union of the parts may be obtained. This enables the patient to go home, entirely well, after ten days or two weeks of hospital treatment. If primary union is not obtained, the time of healing is probably no longer than would have been the case had a simple incision been made. According to the writer's experience, primary union may be reasonably expected if the skin overlying the glands is not affected. If, however, there are minute SYPHILIS 225 abscesses in the roots of the pubic hairs, primary union need not be hoped for. Syphilis. — A chancre is the primary lesion of syphilis and may occur anywhere upon the surface of the body. Since it is contracted by direct contact with another individual suffering from syphilis in an acute stage, the primary lesion in the male is usu- ally found at the meatus or upon the head of the penis or in the more delicate part of the foreskin just behind the corona; but it may also arise in the tougher skin of the penile body (Fig. 117). It is noticed, in most cases, ten days or two weeks after infec- tion. In some cases an in- terval of four weeks or more elapses. The lesion is then a small indurated nodule in the skin, with only a slight loss of epithelial covering. The ulcer increases some- what in size in the ensuing weeks, but if uncomplicated it never grows very large and is not very painful. It heals slowly and the induration lasts for many weeks after the ulcer has completely cica- trized. This is one of the chief points in the differen- tial diagnosis between a chan- croid and a chancre. The in- guinal glands are usually somewhat enlarged, but they are not as tender as they are in connection with a chancroid, nor do they suppurate. Treatment. — An uncomplicated chancre needs little treat- ment; it may be dusted with calomel or covered with mercurial ointment or some simple ointment. Constitutional treatment is required to cure the disease, and, for obvious reasons, such treat- ment ought to be withheld until such diagnosis is absolutely cer- tain, that is, until the micro-organism has been demonstrated in the serum from the lesion (spirocheta pallida) or secondary mani- Fig. 117. — Primary Lesions of Syphilis in a Patient Aged Seventy-four Years. Diagnosis made from micro- scopical examination confirmed by sub- sequently obtained history. 220 INFLAMMATIONS OF THE MALE CEN1TO-URINARY ORGANS festations of syphilis have appeared. Resection of the chancre lias been practised in the hope of preventing the syphilitic infection from saining access to the bodv ; but such treatment docs not DO * 7 achieve this result for the obvious reason that the syphilitic virus has plenty of time to be absorbed before the surgeon has an oppor- tunity to remove the primary sore. The constitutional treatment is all-important (see p. 61). Mixed Infection. — A chancroid and chancre may be combined, that is, both sorts of infection may enter the body at the same point. In this case the lesion will present the hardness of the chancre and the acute virulence of the chancroid, and the inguinal glands may or may not suppurate. An ulcer of this mixed char- acter is much more difficult to heal than a simple chancroid, and it may eat away a considerable portion of the head of the penis before its processes can be stopped. A patient in this condition requires all the help which can be obtained from the best hygienic surroundings and food. The local treatment is substantially that indicated for a chancroid. The healing process is slow, and it may be advisable to change from one kind of dressing to another, as the stimulating effect of any one application grows less with its continued use. These mixed infections are often puzzles in diag- nosis until secondary syphilitic lesions appear. Previous to that time it may be impossible to say whether the induration is due to the virulence of the infection or to the coexistence of syphilis. If the spirochete can be demonstrated in the discharge the ques- tion is at once settled. Secondary Lesions : Mucous Patches. — The usual papular lesions may appear on the penis and scrotum. If they are so situated as to be kept constantly moist by the apposition of cutaneous surfaces they may take on the characteristics of a mucous patch with a sur- face covered with a grayish, foul membrane, and possibly with hypertrophy of the base, giving a papillary form to the growth. Such lesions are much commoner upon the female genitals and about the anus. (See Fig. 131, p. 268, and Fig. 140, p. 300.) Syphilitic Orchitis. — One form of late syphilitic lesion is the involvement of one or both testicles — syphilitic orchitis (Fig. 118). This may take place a few months after the primary lesion, or at any time afterward up to many years. The only early subjective symptom is a feeling of weight or dull pain in the slowly enlarg- SYPHILIS 227 ing testicle. This when examined is found to be uniformly indu- rated and enlarged. The enlargement involves chiefly the orchis, and the relatively small epididymis can usually be felt as a flat appendage at the rear. This is the common type of syphilitic Fig. 118. — Unilateral Syphilitic Orchitis. Duration, six weeks. Patient aged sixty-eight years. orchitis, though occasionally the process is much more acute, and therefore painful ; or distinct gummata may be noticeable from the beginning, giving the swelling a nodular character and prob- ably leading to involvement of the skin and slough (Fig. 119). Similar gumma and ulceration may occur in the penis. Syphilitic orchitis is a very slow process, both in its develop- ment and in its disappearance. It has one of three outcomes. It may entirely resolve, leaving the testicle as before. It may lead to atrophy of the testicle. It may ulcerate, and ultimately heal with more or less loss of testicular tissue and resulting scar for- 17 228 INFLAMMATIONS OF THE MALE (lEMTo I Til. VARY ORGANS mation. In this third form it is difficult to distinguish it from tuberculosis. In the early stage of these two diseases the difference in loca- tion can usually be made out, syphilis affecting the orchis and tuberculosis beginning in the epididymis. In the later ulcerating stage this distinction may be impossible, because the swelling has so altered normal relations and because of the extension of the inflammation beyond its original site. Another distinguishing mark of tuberculosis is the presence in most cases of several hard nodules due to separate foci of infec- tion. Such are wanting in syphilis. If the tubercular nodules exist also in the vas deferens, the diagnosis is at once clear. Fig. 119. — Syphilis of Testicle. Duration eight weeks. Ulceration through the skin of four days' duration: patient aged twenty-eight years. Tuberculosis breaks down more promptly than a gumma, dis- charges more pus, tends to form flabby granulations, and has less wide-spread induration about a single center of infection. Syphilis of the testicle must also be differentiated from malig- nant disease — either carcinoma or sarcoma. A malignant growth increases rapidly in size, is softer, produces great dilation of the blood-vessels, superficial and otherwise, involves the skin of the scrotum, and often breaks down, forming a gangrenous ulcer. TUBERCULOSIS 229 Treatment. — The patient should wear ;i suspensory bandage. Belladonna ointment may be applied over the swollen testicle. The only curative treatment is constitutional, and. consists in the administration of iodid of potash, either alone or in combination with a mercurial. Tuberculosis. — Tuberculosis of the genito-urinary system usually begins in the testicles in the male, although the kidneys, one or both, or rarely the bladder, may first show signs of the disease. Tubercular cystitis is one of the worst forms of disease a physician is called upon to treat. Tuberculosis in the testicle sometimes follows a slight injury and sometimes develops spontaneously. Its early progress may be unnoticed, or there may be a moderate acute swelling, chiefly of the epididymis, which causes the patient a little pain. In either case the characteristic lesions soon appear. On palpation there will be found one or more moderately tender indurated foci in the epididymis. These are the tubercular nodules. As the disease progresses other nodules may appear either in the epididymis or in the cord, or in the corresponding seminal vesicle, as detected by the finger in the rectum. Possibly no nodule may be felt in the cord or seminal vesicle, these structures simply being harder and larger than those of the opposite side. The testicle itself increases in size, owing to the inflammatory products around the tubercular nodule. Still later the centers of one or more nodules may break down and resulting purulent and necrotic fluid may work its way to the surface and be discharged. A permanent sinus will result, discharging the watery, flaky, seropurulent fluid characteristic of tubercular sinuses. Usually the disease is unilateral, although it sometimes hap- pens that both seminal vesicles will be affected, while only one testicle shows signs of disease. In the beginning of the trouble the patient's health may be good. Later, a careful examination will usually show some evidence of tuberculosis in the lungs or elsewhere. The differential diagnosis of syphilis of the testicle is given above. Treatment. — The appropriate treatment is an early and com- plete removal of so much of the diseased tissue as is accessible. If a single movable node exists it may be allowable to excise it without removing the whole testicle. Usually, however, unilateral 230 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS castration should be performed and as much of the vas deferens as possible should be pulled out with it. Xo dangerous hemorrhage follows this so-called evulsion of the vas. To remove affected seminal vesicles through a perineal incision is a serious operation. Simple castration is described on page 235. When performed for tuberculosis of the testicle, it has to be slightly modified on account of the involvement of the scrotum, and the necessity of removing as much of the vas deferens as possible. The incision should be made in the direction of the cord, and should extend nearly as high up as the external ring. At its lower end it should circle around the involved skin, being carried wide of any sinus, as there will be plenty of surplus skin after the testicle has been removed. When the testicle with its attached diseased skin has been separated from the scrotum, the cord should be freed by blunt dissection up to the external ring. The vas should be isolated, and all of the other structures of the cord cut squarely across. Divided vessels should be separately ligated and an additional ligature placed around the stump of the cord. The testicle is now connected to the body only by the vas deferens. Steady trac- tion is made upon this. The grasp of the fingers is more firm if the vas is wrapped in gauze. As more and more of the vas appears at the external ring, the vas should be grasped higher up so that if it breaks the greatest possible length may be secured. In this manner from six to twelve inches may be pulled out. The wound in the scrotum is sutured with fine silk or catgut. The irregular incision often makes necessary a Y-shaped suture line. Most of the blood supply of the scrotum reaches it through the median raphe, so that particular attention should be given to this part if the excision extends to the opposite side. If there is oozing, a slight drain should be used. Hidden hemorrhage after scrotal excision is very common, and may require reopening the wound and ligation. Hence, it is well to avoid this by a careful ligation of all vessels. One cannot trust to pressure of the dress- ing in this location, as it is safe to do after many other wounds. CIIAPTEK IX TUMORS AND DEFORMITIES OF THE MALE GENITO- URINARY ORGANS CYSTIC TUMORS OF THE EXTERNAL GENITALS Cysts of the Skin. — A retention cyst containing serum or sebaceous material may be found in the skin of the penis (Fig. 120) or scrotum. Sebaceous material retained back of the corona in children Fig. 120. — Serous Gyst of the Prepuce. This occurred in a patient aged fifty-five years, who had a large left inguinal hernia. with long, narrow foreskins frequently becomes encysted. The overlying epithelium in these cases is thin, and can be wiped away 231 232 TUMORS OF THE MALE GENITO-UR1NARY ORGANS with gauze as soon as the foreskin is fully retracted. Deeper col- lections of epithelial cells and sebaceous material may also form in this region (Fig. 121), possibly on account of inexact approxi- mation of the edges of epithelium after circumcision. The scrotum is also a common scat of milia (see p. 60). Treatment. — Smaller cysts may be evacuated and their cavi- ties allowed to granulate; but a better plan for them and for larger cysts is the removal of the lining membrane and suture of the incision in the overlying epi- thelium. Compare the operation for sebaceous cysts of the head, given on page 68. Cysts of the Testicle. — Retention cysts of the testicle are not so very rare. They are usually round, tense, fully movable, and situated in or near the upper end of the epididymis. Ana- tomically they may be connected with the testis or epididymis or the fetal remains of this vicinity, the paradidymis so called. They rarely reach an inch in diameter, and are usually single, but may be multiple. The contained fluid is pearly or whitish, and occasionally contains spermatozoa. Such a cyst in all but the contained fluid closely resembles a hydrocele of the cord (see p. 240). Treatment. — Aspiration is usually performed to establish the diagnosis. It may be followed by the injection of a few drops of carbolic acid or the cyst may be dissected out through a short scrotal incision. Fig. 121. — Cyst <>f Prepuce Follow- ing Circumcision in a Patient of Four Years of Age. SOLID TUMORS OF THE EXTERNAL GENITALS Papilloma. — Multiple papillomata of the penis are often called venereal warts because they may follow an attack of gonor- rhea, though not necessarily so. They are usually found in the uncleanly or those w T ho are unable to retract the foreskin, and are EPITHELIOMA 233 situated in the neighborhood of the corona. They are small, ses- sile or pedicled, and generally multiple. They cause no pain, do not lead to ulceration, and annoy the patient merely by their pres- ence. The best treatment is to snip them off with a pair of sharp scissors, and to cauterize the stumps with a little chromic acid after the bleeding has been stopped by pressure. These warts may also occur about the anus. Epithelioma is by far the most common form of malignant disease connected with the external genital organs. It usually Fig. 122. — Squamous Celled Carcinoma of Penis. begins near the corona, either upon the mucous membrane of the penis or foreskin (Fig. 122). It may, however, occur about the meatus. It may also begin in the scrotum, especially in the case of workers in paraffin and those who become covered with soot. Hence the name " chimney-sweep's cancer." It presents the char- acteristics of epithelioma of the skin in any part of the body. Upon the head of the penis it usually begins to grow upward before it ulcerates so that it looks like a wide-spreading wart, but sooner or later it will lead to hemorrhage and ulceration and present more nearly the usual picture of cancer. If the foreskin is retractable a mistake in diagnosis is scarcely possible. If there is felt through an irretractable foreskin a hard, tender mass in the vicinity of the corona, the foreskin should be 234 TUMORS OF THE .MALI- GENITO I IJINAKY OIUJANS at once incised so as to allow of its retraction and an accurate diagnosis. The lymphatic inguinal glands may not become affected for some months after the appearance of the tumor in the penis. This justifies the hope that an early excision of the disease will com- pletely effect a cure, and statistics show that this hope is a rea- sonable one. Treatment. — The treatment of cancer of the penis is, of course, its early removal. This necessitates amputation of the penis in nearly all cases. The glands in both groins should also be removed. Epithelioma of the scrotum, if small and freely movable upon the underlying tissues, is easily excised. Owing to the great flexi- bility of the tissues there is no excuse for not removing with the tumor a wide margin of apparently healthy skin. The lymphatic glands likely to be involved in cancer of the scrotum are those of the inguinal region. They should also be removed. Sarcoma or Carcinoma of Testicle. — Malignant disease of the testicle is not so very rare. It is of the utmost importance to recognize it early. In the early stages of the disease the testicle is swollen, smooth, but much harder and heavier than normal. There is little or no pain, but a sense of weight. As the disease progresses it may infiltrate the surrounding tissues and involve the skin. Even before this the superficial vessels are much dilated. Sarcoma or carcinoma is easily distinguishable from hydro- cele by the light test. This is the more important as a vascular tumor will often give a feeling of fluctuation, but no matter how vascular it is there will be little or no translucency. It should be borne in mind that hydrocele may be secondary to this and other severe lesions of the testicle. The collection of fluid is usually small, and ought in no instance to conceal the severer lesions from a careful observer. Sarcoma and syphilis have many points in common. The his- tory of syphilis as opposed to that of injury, and the beneficent effect of treatment by potassium iodid as opposed to a continued growth in spite of treatment, are aids in differential diagnosis (see also p. 228). Treatment consists in the immediate removal of the affected testicle, with cord and inguinal glands. TUMORS OF THE PROSTATE: PROSTATIC HYPERTROPHY 235 Castration. — This operation may be performed under a local or a general anesthetic. The latter is preferable in malignant cases, as the dissection should then be carried well up into the groin. In non-malignant cases the skin of the scrotum should be cleansed and shaved, and the penis wrapped in gutta percha tissue or sterile gauze. An incision parallel to the cord should be made from the external ring downward for an inch or more. After divi- sion of skin, cremaster, and fascia, the testicle can be brought out of the wound. If there is any doubt as to the nature of the dis- ease, the testicle should be incised. If it is decided not to remove it, the incision may be sutured. This step is important, for cas- tration has been performed in cases of hematocele and even hydro- cele, a wrong diagnosis having been made. The attachment of testicle to the bottom of the scrotum is next to be divided. The testicle is then withdrawn from the wound and removed with so much of the cord as conditions make neces- sary. There are three arteries to ligate — the cremastric, the sper- matic, and the artery of the vas deferens — and several veins. The stump of the vas may be touched with carbolic acid, or a cautery in infective cases. Skin involved by disease should be removed and healthy skin sutured. If a small gutta percha drain is placed in the lower angle of the wound or through the bottom of the scro- tum, it should be removed in two days, or as soon as the serous flow becomes scanty, so that a sinus may not be formed. TUMORS OF THE BLADDER AND PROSTATE Tumors of the Bladder. — Tumors of the bladder may be either benign or malignant. They are apt to be papillomatous, and first attract attention either by obstructing the flow of urine or by giving rise to hemorrhage. Their diagnosis and treatment are often extremely difficult, and form an important chapter in major surgery. Tumors of the Prostate : Prostatic Hypertrophy. — Tumors of the prostate are rare unless one considers as a tumor the chronic enlargement of the prostate so often found in men past middle age. This may remain unnoticed until its infringe- ment on the urethra causes delay in starting the stream, a feeble 236 TUMORS OF THE MALE UKMTO-URINARY ORGANS stream, and dribbling at the end. Where enlargement is more marked symptoms of urethritis and cystitis are added, and sooner or later the patient is likely to suffer from inability to pass water. Hence prostatic hypertrophy ought always to be borne in mind under such circumstances if the patient is over forty years of age. If the enlargement is not too great or does not press forward too sharply against the urethral canal, a soft rubber catheter can usually he passed to the bladder and the patient be thus tempo- rarily relieved. If this is not possible the surgeon may suc- ceed in passing a silver instrument bent in an extra large curve, the so-called prostatic curve. Failing in this, he must resort to some of the measures spoken of under the caption " Reten- tion of Urine " (p. 219). In the early stages of this difficulty, the administration of urotropin or one of the various manu- factured medicines which contain it, will often cause the prompt disappearance of the symptoms. The relief thus obtained is, of course, not permanent, but it may last some weeks or months. When the prostatic enlargement again forces itself into notice, daily catheterization and irrigation, or cauterization of the pros- tate through the urethra (Bottini's method), or prostatectomy car- ried out through a suprapubic or perineal incision must be con- sidered. The description of these operations will be found in detail in books on major surgery. Castration was at one time extolled as a means of reducing enlargement of the prostate, but it has not proved successful in most cases. ACQUIRED DEFORMITIES Hydrocele. — Hydrocele is an accumulation of fluid in the tunica vaginalis (Figs. 123 and 124). It may occur at any age and be unilateral or bilateral. It may follow an injury or may accompany inflammatory conditions, but in most cases no cause for it is apparent. Diagnosis. — Symptoms, if any, are due to the increased weight which drags upon the cord. Usually a hydrocele is readily recognized. If the accumulation of fluid is moderate, there will be felt alongside of and partly overlapping the testicle a flabby, fluctuating cyst. If the accumulation of fluid is greater, the tunica will be distended, and the cyst thus formed will be tense and flue- HYDROCELE 237 tuating, while the exact location of the testicle may be uncer- tain. If the tunica is fully distended the whole swelling is pear- Fig. 123. — Small Hydrocele. Duration four months. Patient aged sixty-two years. shaped, the small end being upward. A fluctuation wave is easily obtained if the mass is grasped in one hand and tapped with a finger of the other hand first in one place and then in another. Fig. 124. — Hydrocele of Ten Years' Duration. Growing most in the past two years. Never treated. Patient aged fifty-seven years. 238 DEFORMITIES OF THE MALE GENITOURINARY ORGANS A hydrocele may usually be diagnosed by palpation. Occasion- ally, however, even the most skilful fingers will be deceived, so that in every case the light test should be employed. This depends upon the fact that light is more readily transmitted through serum than through a blood clot, a hernia, a swollen testicle, or a fleshy tumor, these being' the conditions most likely to be mistaken for hydro- cele. The test is applied as follows : A tube about a foot long and one inch or less in diameter is pressed against one side of the elevated tumor, while the surgeon puts his eye close to the other end of the tube. A light is so held that its rays may pass through the tumor and tube to the eye of the surgeon. Daylight may be employed for this purpose, but is by no means so accurate as Con- centrated artificial light. This test will serve not only to distin- guish a hydrocele from other swellings, but will show the position of the testicle and will thus enable the operator to avoid it in thrusting in a trocar for the purpose of aspirating the fluid. The light test is more delicate when performed in a darkened room. (For diagnosis of hematocele see page 204.) Hydrocele differs from hernia in that the inguinal canal is empty, there is no cough impulse, the tumor is irreducible, yields an exquisite wave of fluctuation, and generally transmits light. Hernia aud hydrocele may coexist. A chrome hydrocele is differentiated from an inflamed testicle by its fluctuation and translucency, and by the presence of the normal uniuflamed testicle, and by the absence of pain. An acute hydrocele is often a result of inflammation or injury of the testicle, but the amount of fluid is small in these cases. Hydrocele is differentiated from a solid (usually malignant) tumor by the absence of pain, by the better wave of fluctuation, and by translucency. Moreover, the solid tumor will weigh more iu proportion to its size and will produce dilatation of the blood- vessels and possibly enlargement of the inguinal glands. A final diagnostic test is the aspiration of serous fluid. Treatment. — The simplest treatment for hydrocele is the aspiration of its contents. As the fluid usually reaccumulates in a few weeks, it is better in every instance after the aspiration of the fluid to inject a small quantity (five to thirty minims, according to the size of the hydrocele) of tincture of iodine or pure carbolic acid. This causes for a few minutes a burning sensation which is HYDROCELE 239 not unendurable. In a day or so, owing to the effect of the irri- tation, the testicle and tunica may swell until the tumor is almost as large as before aspiration. The swelling gradually decreases, however, and in a majority of instances the hydrocele does not recur. The patient should be informed of this inflammatory reac- tion, otherwise he may believe that the hydrocele has promptly recurred and will probably seek other medical advice. The aspiration and injection can easily be performed at the surgeon's office as follows: The patient should lie on his back. The scrotum should be carefully washed and made surgically clean. It should be supported and distended by an assistant, while the surgeon plunges the needle of a hypodermic syringe into the tunica at some point far removed from the testicle, which ordinarily lies in the lower posterior portion of the tumor. Serous fluid will immediately flow from the needle, which should be left in posi- tion, as the iodine or carbolic acid is subsequently to be injected through it. A small sized trocar and cannula are thrust into the tunica near the hypodermic syringe. The trocar is withdrawn and the hydrocele fluid allowed to escape. The hypodermic syringe containing the fluid to be injected is then screwed on to the hypodermic needle and the injection is slowly made. The cannula and hypodermic needle are then withdrawn and the punc- tures covered with a little gauze, which is strapped to the scrotum and a suspensory bandage is applied. The advantages of this method of procedure are two : the introduction of the hypodermic needle causes little pain and further confirms the diagnosis, while the presence of the two instruments enables the surgeon to be absolutely sure that their points are still within the tunica vagi- nalis before he injects the iodine or carbolic acid, for they can be rubbed together and will produce a distinct click. Another good plan is to tap the hydrocele with a small trocar, to withdraw the same, and when the fluid has run off through the cannula to pass through it a second still smaller hollow blunt needle affixed to the syringe containing the carbolic or iodine. In this way the dosage of the injected fluid may be made accurate, as none is lost in the cannula. Unless some such method is employed it may hap- pen that the collapsed tunica retracts over the point of the cannula, allowing the injected fluid to pass into the scrotum outside of the tunica. 240 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS A hydrocele may recur after injection. This is the rule if a very small quantity of fluid is injected, but the reaction after a small injection is very slight, so that a repetition of the aspiration and the injection, perhaps three or more times, is not objection- able. By this treatment the patient loses no time from his busi- ness and there is always a good chance that the second or third injection may effect a cure. Should a more radical treatment be desired, it may be carried out as follows: Make an incision through the skin of the scrotum anteriorly, parallel to the long- axis of the body, extending from the upper end of the whole swelling to a little below its middle. It will be necessary to divide several layers of fascia and thin muscle (dartos) before exposing the tunica vaginalis. This should be incised throughout nearly its whole length. The fluid is fully evacuated, surplus portions of the sac are removed, and the edges of the sac so stitched to the edges of the skin that the sac remains open. Its cavity is filled loosely with gauze, and allowed to heal by granulation. Another method of operating consists in the removal of the greater part of the parietal portion of the sac. The visceral por- tion should be lightly scratched with a needle to facilitate adhe- sions between it and the subcutaneous tissue. The wound may be closed either partially or wholly. These severer operations require the patient to remain in bed for some days. Unusual Types of Hydrocele. — In the hydrocele, as de- scribed above, the fluid collects in the normal tunica vaginalis. There are several other varieties of hydrocele. Congenital Hydrocele. — The cavity of the tunica vaginalis may extend upward as far as the internal abdominal ring, or may even connect with the cavity of the peritoneum. Under such circum- stances the opening is usually small, but pressure upon the hydro- cele, if the patient is in a recumbent position, will cause the fluid to disappear into the abdominal cavity. It will reaccumulate when the patient resumes an upright position. Hydrocele of the Cord. — Fluid may collect in some unobliter- ated portion of the peritoneal process which accompanies the de- scent of the testicle. This is called a hydrocele of the cord. A hydrocele of the cord may coexist with hydrocele of the tunica VARICOCELE 241 vaginalis, the two sacs being entirely distinct and possibly sepa- rated by an inch or more of normal cord, or the hydrocele of the cord may exist alone, or there may be more than one hydrocele of the cord. The diagnosis of these conditions is sometimes easy, sometimes difficult. They are most likely to be confused with hernia., if the hydrocele extends into the inguinal canal an impulse in the tumor may be produced by coughing. Again, the possibility of reducing the fluid iuto the peritoneal cavity may be misleading, but the fact that it reaccumulates when the patient stands upright, even though the finger of the surgeon be lightly pressed upon the external ring, will usually suffice for a correct diagnosis. A her- nia may coexist with a hydrocele, and here again the diagnosis may be easy or difficult (see pp. 194 and 238). If the hydrocele of the cord is situated low down, it may be impossible to differentiate it from a cyst of the epididymis except by aspiration. The fluid in these cysts is pearly or milky white, while that in a hydrocele is straw-colored. Treatment may be by aspiration and injection of a few drops of carbolic acid or iodine ; but on account of the difficulty of exact diagnosis in many of these cases, it is better to expose the sac through a short skin incision, to dissect it free and to remove it, and suture the wound. In this way one avoids the chance of doing injury by aspiration and injection. It is better that the patient should go to bed for a week or two, with a reasonable cer- tainty of cure, than that he should be subjected to danger because the surgeon is working in the dark. Varicocele. — Another common abnormal condition within the scrotum is varicocele. The essential feature of varicocele is a lengthening, dilatation, and contortion of the veins accompanying the spermatic cord (Figs. 125 and 126). Varicocele is almost exclusively found upon the left side. A number of reasons have been given to explain this. It has been pointed out that the left spermatic vein is longer than the right and empties into the left renal at a right angle, whereas the ter- mination of the right vein is in the vena cava, and the angle is oblique. It seems probable that modern clothing has something to do with the development of varicocele on the left side. The almost 242 DEFORMITIES OF THE MALE GEXITO-URINARY ORGANS invariable habit men have of placing botli testicles and the penis in the left leg of the trousers may drag upon the left cord so as to interfere with its circulation. At least the writer has known Fig. 125. — Varicocele of Moderate Degree. Duration, one year. Patient aged thirty-six years. the pain from a moderate varicocele to disappear soon after the patient made it a practice to put testicles and penis in the right leg of the trousers, thus giving the support of the seam to the weaker (left) organ. Keyes calls attention to the fact that varicocele is almost exclu- sively a condition of young unmarried men, and frequently dis- appears within a short time after marriage. The veins first affected are usually situated just above the testicle or by the side of its upper portion. They may also extend well up to the external ring. A well marked varicocele has been aptly compared to a bag of earthworms from the sensation pro- duced upon the palpating thumb and finger. If the veins are very VARICOCELE 243 large there may be some impulse on coughing. The size of the tumor will be considerably reduced when the patient lies down. The symptoms produced in the patient are a dragging, heavy sensation, often associated with more or less constant pain in the testicle and cord, and possibly in the penis. Aside from this local discomfort the patient is often distressed by the thought that the continuance of the trouble will affect his virility. This does not appear to be true, although the atrophy of the corresponding tes- ticle often seen in connection with a long standing varicocele sug- gest this idea. The scrotum will usually be found relaxed to an uncomfortable extent. These local disturbances, combined with the mental distress, often affect the general health of the patient. f : ' : ',.'■■ ' . ( • , 3jjjs m$ '•■■ ... : ! t3 ■ V 1} 1 nn '5 ' i W't m Fig. 126. — Varicocele of Extreme Degree. Veins unusually large and distinct. Duration, fourteen years. Patient aged twenty-nine years. Teeatment. — In many cases relief follows the use of a sus- pensory bandage, cold bathing and attention to the general health, 18 244 DEFORMITIES OF THE MALE GENITOURINARY ORGANS and particularly to the condition of the bowels. When these simple measures fail to bring relief, operation is indicated. There are several forms of operation which have proved suc- cessful. They are all capable of easy performance under eucain or cocain, unless the nervousness of the individual makes a gen- eral anesthetic desirable. A short incision parallel to the cord is made over the upper portion of the dilated veins. The mass of dilated veins is separated from the surrounding tissues and ligated in two places and divided, lie fore I lie ligatures are tied the sur- geon should convince himself that they do not include the vas ■ deferens by actually feeling it outside of the ligature. A slightly more extensive operation includes the dissection of a part of or the whole mass of dilated veins and the careful ligation of their stumps. The upper and lower ligatures may be tied together, thus closing the gap caused by the removal of the veins and giving extra support to the testicle. The wound in the skin is sutured with fine black silk. If the scrotum is lax the above operation may be combined with removal of its most dependent portion. The major part of the excision should take place on the affected side. The wound is fully sutured. It makes no difference in which direction the suture line in the scrotum runs. Although these operations are simple and the patient can walk home after their performance, it is better for him to go to bed before operation and to remain in bed for a few days afterward to avoid bringing strain upon the parts and to lessen the risk of hemorrhage, always an unpleasant complication when it occurs in the loose tissues of the scrotum. The after-treatment consists in the wearing of a suspensory bandage for a time and attention to the general health. There is seldom recurrence, especially if a considerable part of the dilated veins have been removed. CONGENITAL DEFORMITIES Phimosis. — The commonest malformation of the male geni- tals is phimosis. The foreskin may or may not. be of unusual length. Its opening is too small to permit the retraction of the foreskin over the head of the penis (Fig. 127). It may be so small as seriously to interfere with the passage of urine. If the PHIMOSIS 245 opening is minute the sebaceous secretion around the corona does not readily find an exit, and the slight irritation produced by its presence often causes adhesions between the mucous membrane of the head of the penis and the inner layer of the foreskin. Some- times these adhesions are easily broken up, sometimes the two layers of epithelium are so firmly grown together that ono or the Fig. 127. — Tight Phimosis; Congenital. Patient aged sixteen years. other is torn away in the complete retraction of the foreskin. In a more serious degree of phimosis the entire space between the head of the penis and the foreskin is obliterated, and the skin covering the penis is attached directly around the meatus. Teeatment. — At birth the foreskin is so thin and elastic that even though its opening is very small, it can usually be forcibly retracted. If gauze is employed to prevent the foreskin from slip- ping through the surgeon's fingers, less force is necessary. The passage of a thin, flat probe between the foreskin and the glans penis will be found useful in breaking up any existing adhesions. Or the foreskin may be drawn forward and its opening enlarged by inserting in it the beak of a pointed closed artery forceps, and then separating the blades. The foreskin should then be retracted and the head of the penis smeared with a bland ointment to prevent 246 DEFORMITIES OF THE MALI-: GENITOURINARY ORGANS the formation of adhesions. The foreskin should then be again drawn over the glans, and never left retracted lest paraphimosis be produced (p. 205). This treatment should be repeated every few days until the tendency toward retraction is outgrown. Operative treatment for phimosis consists in making a dorsal incision or two lateral incisions through the foreskin so as to in- crease the size of the orifice; or in the removal of a wide circle of skin about the orifice. Tins last operation is called circum- cision. Incision of the Foreskin. — A dorsal incision is a temporary expedient to be resorted to in the presence of inflammation or edema, especially when the foreskin has been drawn back beyond the corona of the glans and cannot be brought over it again. It leaves an unsightly deformity, and should always be considered merely a temporary measure. It is performed as follows: If the foreskin is retracted, the tightest portion is obscured between the looser folds of skin of the inner and outer portions of the prepuce. These roll up in two rings of edematous skin. By separating them the tense constricting ring will be revealed. A few drops of cocain solution should be injected, and as soon as anesthesia has developed the tight ring should be seized with mouse tooth forceps and cut through with scissors or a scalpel, and the incision continued upward and downward sufficiently to enable one to draw the foreskin down over the head of the penis. When this is done it is easier to estimate the amount of division which is necessary. In general the inner layer of the foreskin should be divided' to the corona ; the outer layer not quite so far. If the foreskin is not retracted, as in many cases of chancroid, the injection of cocain should be made along the line of incision, first in the outer layer of the prepuce and then in its reflected layer. The blunt point of a pair of straight scissors should then be passed between the head of the penis and the foreskin, and both layers of the latter split up for half an inch. The foreskin should then be partially retracted, and a second cut made in the inner layer of the foreskin so that its division shall be carried back to a point opposite the corona. This will enable the foreskin to be fully retracted. The operator must then judge as to the necessity of any further division of the outer layer, or of the wis- dom of an immediate circumcision. This should certainly be per- CIRCUMCISION 247 formed in non-infective cases, and probably in many of the infec- tive ones as well. Two lateral incisions are made in a similar manner to the single dorsal incision. It is claimed for this method that it is never followed by a great edema around the frenum, which is often such an annoying sequel of the dorsal incision. Circumcision. — This little operation can be performed in a number of ways. The practise among the Hebrews when circum- cision is performed as a religious rite is to draw the foreskin well forward, to cut it off with one stroke of a long knife, to immerse the penis in wine held in the mouth of the rabbi to stop the hemor- rhage, and then to wrap it in linen rags. It is not surprising that dangerous hemorrhage and infection sometimes follow this pro- cedure, and a few lives have been lost in consequence. Equally reprehensible is the practise among some surgeons of trying to perform this little operation in the shortest possible time. For this purpose clamps have been devised to hold the foreskin so that both the external and reflected portions can be cut away by a single stroke of the knife. It is obvious that the amount of skin thus removed cannot be controlled with certainty, and even if the line of incision be a perfectly smooth circular one, a thing which rarely happens, the adjustment in length of the external and in- ternal portions of the prepuce is at best uncertain. There is no part of the body concerning which most patients are more sensi- tive, so that the surgeon ought to be willing to give up a few minutes of his time in order to secure a perfect result. An extensive experience, both in the performance of this opera- tion and in the observance of the operation as performed by others, has convinced the writer that a perfect result is most likely to be attained in the following manner : The patient, if a very young baby, requires no anesthetic, or ether may be given. A local anes- thetic had better not be employed in patients under six or eight years of age, as it will not remove the fright of an infant or a young child. The parts should be carefully washed with soap and warm water and a weak solution of bichlorid of mercury, 1 : 2,000 or weaker. Two sharp nosed artery clamps should be fixed upon the orifice of the foreskin to the right and left of the dorsal median line. If the orifice is too small to permit this, it should first be snipped dorsally with a pair of scissors. Traction 24S DEFORMITIES OF THE MALE GENITO-URINARY ORGANS being' made upon the chimps, the foreskin is drawn well beyond the head of the penis and one blade of a straight scissors is passed between the head of the penis and the foreskin. An incision is made which extends nearly back to the reflection of the foreskin Fig. 128. — Operation for Phimosis. Dorsal and ventral incisions and two tension sutures. (Fig. 128). In drawing the foreskin forward in this manner there is danger that its outer portion will he cut farther back than will its inner portion; hence, after the first clip of the scissors the traction npon the clamps should be relaxed and the reflected portion of the foreskin should be cut farther if necessary. Two clamps are then placed upon the orifice of the foreskin at its lower edge and an incision is made hetween them. This incision is far shorter than the dorsal one. The two clamps on the left side are then drawn outward and the left half of the foreskin is removed, care being taken that the incision through the inner layer of the foreskin shall be nearly parallel to the corona of the glans, and that the incision through the external layer shall be directly oppo- site to it when only slight traction is made upon the clamps. The best result is ohtained when the portion of the inner layer which CIRCUMCISION 249 is left is a third or a half of an inch in width. The right half of the foreskin is next cut away. Any bleeding points are clamped and tied if necessary with very fine catgut. If the hemorrhage can be stopped by pressure, so much the better. The edges of the external and internal layers of the foreskin are then approximated by eight or twelve stitches of fine black silk (Fig. 129). The first one should be applied at the frenum, the second upon the dor- sum of the penis, the third and fourth in the middle of the right and left sides respectively. In each of the four spaces thus marked off two or three stitches should be placed. When sutured in this manner the foreskin will not be drawn unevenly in any direction. If preferred, the stitch at the frenum and the dorsal stitch may be introduced before the sides of the divided foreskin are removed. These stitches, if left long, will serve as retractors. In infants no dressing is required, except a little sterile gauze placed between the penis and diaper. The mother should be told to keep the penis clean by letting a little cooled boiled water run over it after each urination. In four or five days the stitches should be removed. Fig. 129.- -Operation for Phimosis. Circular incisions complete; all sutures inserted. Silk is better than catgut, for the latter gives way sometimes and is, besides, more irritating to the tender skin. In older persons the skin should be well retracted and a circular bandage of sterile gauze wound around the penis behind the glans. If this becomes soiled with urine it should be immediately changed. Attention 250 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS on the part of the patient will usually prevent this accident. A good precaution is to lie down to urinate, turning almost upon the face. This prevents any backward dripping of the urine. Dressed in the manner described, the two cut edges of skin are closely approximated, and will unite with the minimum amount of adhesions. Complications and Late Results. — Painful Micturition. — The disability following a properly performed circumcision is very slight. There may be a little burning during the passage of urine for one or two times. Tn an adult, if an erection occurs, it will only be painful in case the dressing is too tight. It can be relieved at once by loosening or removing the bandage. Hemorrhage is unlikely if all bleeding points have been ligated. If it does take place it is usually subcutaneous, and opportunity should be given for the escape of the blood through a gap in the skin incision. If bleeding is free, and is not controlled by digital pressure or cold, the skin wound should be opened sufficiently to permit proper ligation of the bleeding vessel. This does not delay complete repair nearly as much as the presence of a subcutaneous hematoma. Edema is usually due to faulty technique, either malapproxi- mation of the skin, tearing of the tissues, or hemorrhage beneath the skin. It shows itself chiefly about the frenum, and may per- sist long after the wound is healed. It will ultimately disappear. Its disappearance may be hastened by hot applications, counter- irritants, pricking with a glover's needle, etc. Infection. — If the wound becomes infected it should be drained at once by the removal of one or two stitches, by soaking the penis frequently in a mild, hot antiseptic solution, and by wet dressings of creolin 1: 200, borolyptol 1: 4, etc. Retraction is likely to fol- low- the removal of stitches, so that in a suppurative case they should be allowed to remain until granulations have fixed the skin edges in contact. Retraction of the skin of the penis, so that its cut edge is every- where separated from the cut edge of the mucous membrane, takes place in some cases of infection ; and sometimes without infection, if so much skin has been removed that there is undue tension upon the sutures. The immediate result is a circular band of granula- tions, over which new epithelium will creep in the course of a NARROW MEATUS 251 couple of weeks. The ultimate result is generally good, although the immediate result is so discouraging. The skin of the penis is capable of great stretching, so that erection is not permanently interfered with, even by the removal of too much skin. Irregularity in Outline. — An uneven section of the skin should be corrected at the time of operation, but if not noticed then it is better to correct it by a subsequent operation than to allow a patient to go away dissatisfied. A common error is to leave too much skin at the frenum. This projects beneath the tip of the penis and catches the last drops of urine, besides being unsightly. If circumcision is performed to aid the patient in overcom- ing the habit of masturbation, superfluous skin about the frenum should never be left, since it is most abundantly supplied with sensory nerves, and especially invites manipulation. Recurrence of Phimosis. — If the inner layer is left long, say half an inch or more, and the suturing or the dressing has been carelessly done, it may happen that the inner and the outer layers of the foreskin will firmly unite for a distance of a quarter of an inch or more from their free edges. There will then be formed a strong band of cicatricial tissue completely encircling the penis, which by its contraction may so reduce the orifice of the foreskin as to render necessary a second operation. Short Frenum. — The frenum should not take all the strain when the skin of the penis is retracted. If it is so short that it does so, the penis may be curved during erection, or erection may be painful, and normal coitus impossible. Under such circumstances the frenum should be put on the stretch and pierced and cut with a sharp pointed knife, the edge of which is directed away from the penis. Narrow Meatus. — The external orifice of the urethra may be narrow. This condition may be an accompaniment of phimosis or it may exist alone. The narrowing is not usually sufficient to interfere with urination, and it does not ordinarily come to the surgeon's notice until he has occasion to pass instruments or treat the patient for urethral discharge. It is then an interference and should be divided. The narrowing of the meatus is usually due to an extension of the mucous membrane across the lower portion of the urethral 252 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS orifice. Sensibility should be benumbed by the application of a drop of strong solution of cocain (ten per cent) or the hypoder- mic injection of a drop of a weak solution (one per cent). The web should then be divided by a blunt pointed narrow knife suffi- ciently to make the caliber of the meatus fully as great as that of the urethra. The patient should soak the end of the penis in hot mi line, and separate the lips of the meatus once every day to pre- vent them from reuniting. The surgeon should pass a full sized sound through the meatus twice a week for two weeks, to insure the full benefit of the operation. Hypospadias. — This malformation consists in a defect in the lower portion of the urethra, so that the urine is passed through a fistula in the glandular penile or perineal urethra. Usually there is an absence of urethra distal to the fistula. There is often an accompanying flattening of the head of the penis or a down- ward curving of the whole organ. Treatment. — If the opening is not farther back than the mid- dle of the pendulous portion of the penis, a complete restoration of function, both urinary and procreative, may be obtained by a simple plastic operation. The gutter which marks the site where the urethra should be may be covered by skin flaps cut from the edges of this gutter and turned over a small catheter. The raw surfaces of these flaps may be covered by the remaining skin of the penis or in some cases by flaps from the prepuce, if any prepuce is present. Another plan of treatment is to free by dissection the existing urethra, to puncture the blind distal portion of the penis, and to bring forward through the artificial canal thus made the dissected urethra. Its elasticity permits it to be stretched to twice its nor- mal length. The details of these ingenious operations, and others adapted to the more serious cases of fistula of the deeper urethra, will be found in text-books on major surgery and genito-urinary surgery. Epispadias and Exstrophy of the Bladder. — In epi- spadias the urethra opens upon the dorsal surface of the penis. This condition is often associated with exstrophy of the bladder, which renders a perfect restoration of function by means of opera- tion well-nigh impossible ; and the patient is compelled to resort to the constant use of a urinal. UNDESCENDED TESTICLE 253 Undescended Testicle. — One or Loth testicles may be ab- sent from the scrotum, either in infancy or adult life. There is rarely a failure of the testicles to develop, but usually the testicles if not in the scrotum will lie in the inguinal canals, or still higher in the abdominal cavity. They may be functionally perfect. Their absence is due to an arrest of the descent of the testicles from the abdomen to the scrotum, which takes place normally in fetal life. There are varying degrees of undescended testicle. If one tes- ticle, is found in the inguinal canal of an infant, but can be easily pressed out of the canal into the scrotum, the mother should be shown how to press it through the canal and lightly draw it down into the scrotum. If this performance is repeated every day one may safely trust to the growth of the parts to prevent the testicle from lodging permanently in the inguinal canal. In some infants and even in some young boys the inguinal canal is so large that the testicle, although it lies in the scrotum most of the time, may be pushed up into the abdomen at will. The effect of gravity and motions of the body soon bring it back into the scrotum. If this condition is not associated with hernia it need cause no alarm, and the growth of the child may be safely trusted to bring about a normal state of affairs. Treatment. — If the testicle is firmly fixed in the inguinal canal it will be exposed to injury by reason of its position, and it will not develop properly on account of the constant pressure exerted upon it. Attempts should therefore be made to bring it down into the scrotum, or at least to get it out of the inguinal canal and below the external ring. Gentle manipulation by the surgeon every two or three days should first be tried. If no progress is made the overlying parts should be incised and the testicle freed, all of the tissues of the cord except the vas and the vessels being divided. The testicle is brought down as far as the elasticity of the remaining portion of the cord will permit, and after a pouch has been prepared for it in the scrotum, it should be sutured to the subcutaneous tissue at the bottom of the scrotum by fine chromicized catgut. These sutures should of course be passed through the fibrous envelope of the organ and not deep into its substance. The inguinal canal should be strengthened by sutures if it is found weak or had to be split up to permit the 251 DEFORMITIES OF THE MALI; GENITO URINARY ORGANS tlra wing- downward of tin.' testicle. After a few weeks, when all inflammatory reaction has subsided, gentle manipulation and trac- tion should again be resorted to. This will complete the cure in case it was not possible at the time of operation to bring the testicle well down into I he scrotum. If the testicle at operation cannot be brought out of the ingui- nal canal, or if it is located under the skin of the thigh or peri- neum, it is better to push it back into the abdomen and to close by suture the internal ring, so that the testicle shall not be constantly exposed to injury and pressure. Within the abdomen it can carry on its functions normally. For this reason no search should be made for a testicle which is situated above the internal ring. If an undescended testicle is accompanied by hernia, an oper- ation for radical cure of the hernia should be performed at the same time. Some surgeons advocate the removal of an undescended testi- cle because of the fact that sarcoma sometimes develops in such an organ. This is a small risk, and removal should not therefore be made a routine treatment, if the testicle can be moved into a safe place. CHAPTER X AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS INJURIES AND FOREIGN BODIES Contusion. — Contusions of the external genitals are not un- common either as the result of blows or falls, or in the case of young girls as the result of violent attempts at coitus. Bruises and abrasions and wounds should receive the same treatment given to these lesions in other parts of the body (pp. 2 and 13). . Owing to the sensitiveness of the skin and its exposure to contamination from discharges, etc., especial efforts at cleanliness are recom- mended. Rupture of the Hymen — The hymen is frequently rup- tured in early attempts at coitus, although usually the slight tear is not serious and requires no treatment. Sometimes the hemor- rhage is great enough to alarm the patient and may even require ligature. Unless the tear extends beyond the limits of the hymen no suture should be inserted. Irrigation with hot saline solution after urination will add to the patient's comfort and lessen the risk of infection. Rupture of the Vagina. — If the vagina is narrow and non-elastic, it too may be ruptured in violent coitus. Indeed the rupture may extend into the rectum. It may also be ruptured by a fall upon some sharp object. The first step in treatment is a complete speculum examination, in order to determine the extent of the injury. If the breaks in the mucous membrane are slight it is better not to introduce a suture. The parts should be cleaned by irrigation with a hot mild antiseptic solution, and may be kept from adhering by a slender tamponade with aseptic gauze. Hematoma. — A hematoma may be formed in the loose cel- lular tissue about the vaginal orifice. If small, it may be left to 255 256 AFFECTIONS OF THE FEMALE GENITOURINARY ORGANS be absorbed, but it' large or near the surface, a shorl incision should be made — one-half inch will usually suffice — and the blood clot should be evacuated. (See the treatment of hematoma given on p. 3.) The pressure of dry aseptic dressing will quickly cause the walls of the cavity to adhere. If there is any doubt of the asepsis a gutta-percha drain should be inserted. This should merely pass through the skin and not till the cavity. After two days it should be removed, and nol again inserted unless suppu- ration has taken place. If there is suppuration the cavity of the hematoma should be treated like that of an abscess, by free inci- sion and light gauze drainage (p. 3S). Acute Laceration of the Perineum.. — The perineum may be torn by external violence, but the almost invariable cause is childbirth. The tear is usually a straight one in the median line or near it, the variation in different cases being merely one of extent. Slight tears heal with sufficient exactness, even without sutures, but it is a good plan to suture every laceration, as other- wise some deeper ones are sure to be overlooked. The portion of the perineum which tears is wedge-shaped, with the thin edge of the Avedge forward. When torn, therefore, there are two surfaces for the insertion of sutures, namely, the vagina and the skin. The vaginal sutures are the more important, since they should protect the deeper part of the wound from the lochial discharge. The Aveb between the thumb and fingers is similar to the perineum. If it is cut through there will be a palmar skin wound and a dorsal skin wound, corresponding to the vaginal and skin wounds in a perineal tear. Similarly, if the cut extends deeper, muscles Avill be divided. If one bears this analogy in mind, in suturing a torn perineum he Avill have little difficulty in the correct apposition of the torn surfaces. Treatment. — The proper treatment for laceration of the perineum is the immediate aseptic suture of the separated tis- sues in their normal relation. This is very easy under favorable conditions. If the patient weighs one hundred and eighty pounds and lies in the middle of a low soft bed and no trained assistant is obtainable, the task is well-nigh impossible. The patient should lie on the back, Avith thighs Avell flexed and hip close to the edge of the bed and raised on a hard pillow. An anesthetic is a con- venience, but is not absolutely necessary in many cases. The HEMORRHAGE 257 labia are drawn well apart, and the wounded surface wiped dry with a gauze sponge. Blood from the cervix or uterus can be pre vented from flowing over the perineal wound by pushing one or two gauze sponges well up into the vagina. The extent of lacera- tion can then be accurately seen. If any muscles or the perineal body have been torn, deep as well as superficial sutures must be inserted. Plain catgut, No. 2, or ten day chromic catgut, No. 1, is a good material for the deep suture. It saves time to insert it as a continuous suture. The vaginal tear should then be sutured from its upper end down- ward. The same material may be used for suture. It is of the greatest importance that the upper end of the tear shall be accu- rately sutured. Otherwise fluid may trickle down into the wound and defeat union altogether or in part. The wound in the skin should be sutured with fine black silk ; or if it is desired to insert these sutures more deeply, so that they shall aid in holding to- gether the perineal body, silkworm gut is an excellent material. If the tear extends into the rectum, the mucous membrane of the latter should be sutured with fine black silk, in addition to the muscular and cutaneous sutures mentioned above. After-treatment consists in keeping the suture line as clean as possible. The patient may be catheterized ; but if she passes water voluntarily, the line of sutures should be cleansed each time with sterile water, and carefully dried with sterile gauze. The patient should lie on her side and face a part of the time, and not continuously on her back. Non-absorbable sutures should be removed in ten days. For the late treatment of laceration of the perineum, see page 275. Hemorrhage. — In the treatment of hemorrhage of the female genitals, it is all important to locate its source. It is necessary to insist upon this point, since a feeling of delicacy upon the part of the patient and physician as well, may result in the injudicious application of tampons or external compresses by the nurse or patient. The only rational procedure is a complete exposure of the parts in a good light, thorough cleanliness, and the ligation if necessary of bleeding vessels. Slight hemorrhage can be con- trolled by gauze compresses, applied either within or outside the vagina by the surgeon himself, under the favorable conditions mentioned above. If the patient is sensitive an anesthetic should 258 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS be given. The introduction of iiauxi- within the uterine cavity to control hemorrhage is a procedure rarely required and one worthy of the most careful antiseptic precautions and subsequent treatment in bed. The use of dilute solutions of suprarenal ex- tract to control hemorrhage has been spoken of on page 0. Larger bleeding vessels should be ligated with fine catgut, and any wounds closed by sutures of catgut or tine silk. Rape. — A physician is sometimes called upon to examine a woman or young girl in order to determine whether rape has been attempted. lie ought to exercise great caution in making a posi- tive affirmation, unless the laceration of the hymen and possibly of the vagina (dearly show a violent distention of these parts. Purely external injuries may of course have beeen caused by other means. The microscopical demonstration of semen upon the clothes of the female is better evidence, but this is a subject for medico-legal experts. On the other hand, coitus, though forced, may leave no external evidence in case of an adult, so that a negative statement should not be carelessly made. The doctor ought rather to confine himself to a statement of the condition in which he finds the external and internal genital organs. Also in the matter of a purulent vaginal discharge, which in young girls often excites suspicion that they have been improp- erly handled by some man, a physician should be careful not to claim too much. A purulent discharge of this character may or may not be due to gonococci, and, even if it is demonstrated to contain gonococci, it may have been set up by contact with some other female or by the use of a dirty towel, or in some other man- ner than by attempted coitus. Foreign Bodies. — Foreign bodies are frequently introduced into the vagina and urethra for the sake of sexual excitement. The patient seldom loses control of such objects in the vagina, but those which are introduced into the urethra may slip from the fingers or be broken in the canal, and thus medical aid will have to be summoned. The greatest variety of objects have been found under such circumstances, either in the urethra or partially or wholly within the bladder. Slate-pencils, hairpins, and hat- pins are among the commonest. The pins are introduced head foremost, so that their extraction is difficult. Foreign objects in the vagina are usually neglected pessaries, or some objects which FOREIGN BODIES 259 have been introduced by the patient to prevent prolapse of the uterus. The symptoms produced will depend upon the location and character of the foreign body. It may interfere with urination, or cause a bloody or purulent discharge, or set up inflammation of the urethra or bladder. If the foreign body remains a long time in the urethra or bladder, it may become the core about which a calculus is formed. If it is in the vagina it may also become incrusted, or it may partially bury itself in the vaginal walls. Diagnosis. — The diagnosis of a foreign body is made partly from the symptoms above enumerated, but chiefly from the results Fig. 130. — Urethroscope for Examination of the Female Urethra. A portion of the bladder can be seen through such an instrument. It is well to have such instruments of three sizes, ranging in diameter from 5 to 15 millimeters (J to I inch). of physical examination. Digital examination, direct inspection through a vaginal speculum, or through a smaller urethral specu- lum, called a urethroscope (Fig. 130), are the usual methods em- 19 260 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS ployed. When the foreign body is in the bladder, it usually lies transversely, especially when the bladder is empty, since the long axis of the collapsed organ is transverse. Its presence may be rec- ognized by means of a sound or by the finger passed through the dilated urethra, or by the cystoscope. Treatment. — The removal of these foreign objects affords a wide scope for the ingenuity of the surgeon. If the foreign body is in the vagina, this canal should be thoroughly cleansed by irri- gation and sponging with an antiseptic solution, in order to reduce the risk of infection in wounds which may be made intentionally or accidentally in removing the foreign body. An old pessary can usually be extracted without difficulty, even if it is encrusted. Some objects are best removed after being cut into two or three pieces. A blunt pointed object lying in the urethra may possibly be worked out of the canal, a little at a time, in the manner described in connection with foreign bodies in the male urethra (p. 207). If a pin lies in the urethral canal with the point directed out- ward, it may be possible to pass a small rubber tube into the ure- thra and over the point of the pin, so that the latter can then be crowded outward, or safely grasped with a slender pair of for- ceps and extracted. The adult female urethra is capable of dila- tation sufficient to permit the passage of the little finger. This dilatation not only facilitates an exact diagnosis, but it is a mate- rial help in the extraction of foreign bodies by means of slender forceps. Small foreign bodies and calculi can be extracted whole. Larger calculi and friable objects may be crushed and extracted. If the foreign body cannot be moved through the moderately dilated urethra, it is better to perform suprapubic cystotomy than to run the risk of permanent incontinence by too great dilatation of the urethral canal. INFLAMMATIONS Pruritus. — An intense itching of the vulva, most marked in the vicinity of the clitoris, and associated with a thickening of the skin is commonly called pruritus. Objection has been made to this word, since it expresses a symptom rather than a distinct dis- ease, but it serves a useful purpose, and for the present at least had better be retained. SIMPLE VULVITIS ANT) VAGINITIS 261 Pruritus is due to a number of causes, such as an irritating vaginal discharge, or to decomposition of the urine in diabetes, or to parasites, such as pediculi or seat worms. In other cases it is due to the use of drugs, or to improper articles of diet. Some- times no cause for the itching can be ascertained, and the pruritus is assumed to have a nervous origin. In severe cases the patients are most miserable, and scratch and tear the skin until it bleeds. Treatment. — In every case the cause for the pruritus should, if possible, be discovered and removed; but even when this can be done, a certain amount of local treatment is necessary. The parts should be bathed twice a day with very hot water, or hot boracic acid solution. This should be followed by the applica- tion of a five per cent solution of carbolic acid, or a solution of corrosive sublimate, one grain in a half ounce each of alcohol and water. Tincture of iodine, or five per cent solution of creolin or of nitrate of silver, twenty grains to the ounce, have also been used with benefit. The folds of the vulva should be kept from contact by talcum powder or boracic acid or dermatol ; or they may be separated by thin layers of gauze smeared with boracic acid oint- ment or an ointment containing menthol or chloral or cocain. Parasites should be destroyed by mercurial or sulphur ointments. In obstinate cases success has sometimes followed resection of the sensory nerves which supply the clitoris and labia minora. In other cases portions of the labia and the clitoris have been re- moved. Eczema. — Eczema of the vulva often follows vulvitis and pruritus. Its treatment is similar to that of eczema in other por- tions of the body (see p. 57). Simple Vulvitis and Vaginitis. — The delicate skin about the entrance to the vagina and the vagina itself may become in- flamed as a result of many causes. Such predisposing factors as poor health, exposure to cold and wet, and traumatism have to be considered, while more immediate causes are irritating urine, hem- orrhagic and mucous discharges from the uterus or urethra, in- discreet coitus, constant rubbing to relieve pruritus, etc. Inflam- mation due to the gonococcus is considered on page 262. The symptoms are those of inflammation everywhere, edema, redness, increased heat and tenderness, plus a mucopurulent or purulent discharge, which more or less mats together the folds of 2G2 AFFECTIONS OF THE FEMALE GEN1TO-URINARY ORGANS -kin and the hairs. Urination is not usually attended with burn- ing, unless gonorrhea exists. Treatment. — It is desirable to know the cause of the inflam- mation, and in every case in which lliis is obscure, or in which the inflammation is severe, the discharge should be spread on a glass slide, dried and stained for gonococci. Even in the non-specific cases precautions should be taken to prevent the infection of other persons either by direct contact or by the use of towels, etc., which have been used by the patient. Attention to the bowels, rest, and frequent bathing of the in- flamed surfaces with a boracic acid solution or one of aluminum acetate, two per cent, will usually cure these patients in a few days if the cause of the inflammation is not a continuous one. The cleansing is best performed by irrigation both within and out- side of the orifice of the vagina, and the solutions should be as hot as can be borne. In the case of little girls, in whom inflammations of this character are rather common, the irrigation should be made with the utmost gentleness, and care should be taken not to block the orifice in the hymen by the nozzle of the syringe. The folds of skin should be carefully dried and anointed with cold cream or boracic acid ointment to prevent chafing. Acute Gonorrhea.— Gonorrheal Vulvitis. — The acute symp- toms of a gonorrheal infection of the vulva are similar to those of a simple vulvitis excepting that they are more marked. There is more or less constant pain aggravated by walking, and as the urethra is generally involved, there is pain on micturition. The skin is reddened, possibly excoriated in places, and there is a pro- fuse mucopurulent discharge. When this has been sponged away, it will be observed that the mucous membrane at the urethral ori- fice is red and swollen, and pressure of the finger upon the urethra will cause a drop of pus to exude. The orifices of Bartholin's ducts are often similarly affected, and the glands themselves may be swollen (see p. 263). The diagnosis of gonorrhea should always be confirmed by a microscopic examination of the discharge. Treatment. — Gonorrheal inflammation of the vulva is of itself not serious, except in the case of young children. The risk of the infection depends chiefly on its possible spread to the bladder or to the uterus and Fallopian tubes, and through them to the pelvic peritoneum. The treatment recommended by different wri- INFLAMMATION OF BARTHOLIN'S GLAND '2M fcers varies considerably. Some believe that such simple local treatment as a hot vaginal douche is capable of spreading the infection, and should not, therefore, be advised. The majority take the opposite view, and recommend a hot douche with a per- manganate solution of the strength of one part of permanganate of potash to two thousand of water ; or the use of vaginal tampons. One plan is to insert after the douche a tampon saturated witli five per cent argyrol solution, and to remove this in ten minutes, and to follow it by a tampon saturated with boroglycerid or some other astringent, and to allow this to remain in place until the next treatment, twelve hours later. Whatever plan of treatment is followed, the patient should remain absolutely quiet in bed until the acute symptoms have passed over. The diet should be simple, large quantities of water or milk should be given daily, and urotropin or some other urinary antiseptic should be administered. (Compare the medication recommended on page 213.) In the later stages of the disease with profuse leucorrheal dis- charge a douche of sulphate of zinc oj and powdered alum oij to 2 quarts of water is very effective. Gonorrheal Urethritis. — Treatment for gonorrheal urethritis in women is similar to that employed for men. The solutions used for injection through a blunt pointed syringe may be somewhat stronger. When the general inflammation has subsided, local areas of persistent infection may be touched through an endoscope with a cotton swab wet with a solution of silver of a strength of ten per cent or less. Inflammation of Bartholin's Gland. — On either side of the vaginal orifice is situated the gland named after its discov- erer, Bartholin. This gland lies immediately under the skin, and is subject to infection through its short duct. The infection is usually of a gonorrheal origin. Swelling of the mucous membrane of the small duct prevents evacuation of the mucus and pus from the cavity of the gland. Upon examination there will be found by the side of the vagina, just outside of the hymen or its remains, a smooth, rounded, slightly movable swelling, very tender on pressure, and giving an indistinct sense of fluctuation. If the inflammation is a violent one the surrounding cellulitis will obscure these signs, or if the 264 AFFECTIONS OF THE FEMALE GEN ITU- I ULNAR Y ORGANS suppuration bas broken through the gland into the subcutaneous tissue there will be the usual signs of abscess. Treatment. — The skin should be anesthetized and the abscess opened at the point where it lies nearest the surface. When its contents have been evacuated, a small triangular portion of the skin and subcutaneous tissue overlying the abscess should be cut away. This will greatly facilitate subsequent dressings, for if a simple straight incision be made it will be found difficult to rein- sert the gauze necessary to keep open the incision until the cavity of the abscess has granulated from the bottom upward. Simple Suppuration. — The usual forms of suppuration, boils, abscesses, and cellulitis, may occur in the skin of the exter- nal genitals. The treatment is similar to that outlined on page 34 et seq. Chronic Gonorrhea. — When the acute symptoms due to gonorrhea have subsided the trouble may be found to have lodged in the bladder or cervix uteri. The chief symptoms of cystitis will be increased frequency and urgency of micturition, with a sense of discomfort and heaviness or well marked pain. The general health of the patient is a good deal affected by this constant irritation. Daily irrigations of the bladder with mild antiseptic solutions should be practised. Nitrate of silver is the favorite remedy for this purpose. The solution first used should not contain more than one part of this drug in four thousand of water, but this proportion may be increased as the patient be- comes accustomed to the drug. Argyrol in solutions of two per cent or more makes another good fluid for irrigating the bladder. If the gonorrheal process extends to the cervix and uterus, as shown by a persistent leucorrhea, the cervix should be dilated and the lining of cervix and uterus swabbed with cotton moistened with a ten or twenty per cent solution of argyrol every two or three days. Endocervicitis : Erosion of the Cervix. — Inflammation of the cervix uteri may be due to congestion of the uterus caused by malposition, etc., or to laceration or to gonorrhea. There is usually an exposure and hypertrophy of the columnar epithelium, which gives the os a pouting or unnaturally raw red appearance; hence the term ulceration is often used, though incorrectly. The most marked symptom of endocervicitis is an increased ENDOMETRITIS 265 discharge of mucus from cervix and vagina (leucorrhea). Some- times there is a thick yellowish plug of mucus hanging from the os at all times. This is said to be characteristic of gonorrhea, but the diagnosis should be made only after microscopic examination. Leucorrhea may be due to endometritis as well as endocervicitis. It is also found in women who have not borne children. It is the symptom of endocervicitis for which treatment is usually sought. Treatment. — Whether there is a local cause for it or not, the state of the health has an important bearing upon the continuance of leucorrhea, just as it has upon catarrh of other mucous mem- branes, and the treatment of the patient should always include directions calculated to improve the general health. Local treat- ment consists in the use of hot vaginal douches once or twice a day. The fluid used for this irrigation may be pure water or a weak solution of carbolic acid (one teaspoonful to the quart) or any other antiseptic or astringent solution. To the astringent action of douches may be added that of drugs placed upon a cotton tampon and applied through a speculum directly to the cervix. Ichthyol, ten per cent in glycerin, tannic acid, and glycerin and iodine are favorite remedies. Applications of nitrate of silver, ten to twenty per cent, may be made to the cervical canal. If there is any malposition of the uterus or laceration of the cervix or any other condition which may tend to prolong the discharge, it should be made the object of special treatment, the details of which will be found in text-books on gynecology. Gonorrheal endocervicitis is particularly difficult to cure. The canal may be touched with strong solutions of silver, or antiseptics and astringents may be introduced in the form of suppositories into the uterine cavity. Amputation of the cervix is frequently necessary to bring about a cure. Endometritis. — There are various forms of endometritis, both acute and chronic, but the common form and the only one which will be considered here is the hyperplastic form, marked by chronic congestion with thickening of the mucous membrane which lines the uterus. It has various causes, among which con- stipation, stenosis of the cervix, uterine displacement and cervical laceration are the chief. The symptoms are an abnormal discharge of blood either at the menstrual period or at other times, and a discharge of mucus — 266 AFFECTIONS <>K THE FEMALE UENITO-URINARY ORGANS leucorrhea, which for the most pari is due to the accompanying endocervicil is. Diagnosis is made from the symptoms, from bimanual exami- nation, and from examination through a speculum. The uterus is enlarged and soft, and may be variously displaced. Mucus pro- trudes in many cases from the eroded cervix (see p. 264). Pas- sage of a probe shows an elongation of the uterine canal, with a possible relaxation of the internal os. Treatment. — Hot douches and tampons (see p. 265) may give temporary relief, but cannot effect a cure in most cases, since they do no1 remove the cause of the congestion. Constipation should be overcome, bad habits of life corrected, and an effort made to tone up the general system. Operative treatment consists in dilatation of the cervical canal and removal of the hypertrophied mucous membrane. Lacerations should be repaired and malposi- tions corrected. Dilatation of the Cervical Canal. — Dilatation of the cer- vical canal is the most important of minor gynecological opera- tions. This can be performed in many cases under a local anes- thetic, but a general anesthetic is usually more satisfactory for both surgeon and patient. Dilatation is performed for the relief of dysmenorrhea, to over- come sterility, and to permit of curettage or other operations within the cervix or uterus. The technique is as follows : The bowels should be thoroughly emptied the day previous by laxa- tives and an enema. The hair should be removed by shaving, or better, it should be clipped short by scissors, thus saving the patient from a good deal of discomfort when the shaved hairs begin to grow out. The external parts should be cleansed with soap and hot water, and the vagina douched with a five per cent solution of creolin or some other antiseptic. The patient is put in the lithotomy position, and the posterior wall of the vagina is de- pressed with a weighted speculum. The anterior lip of the cervix is seized with a tenaculum forceps and drawn down. If a local anesthetic is employed, three drops of two per cent solution of cocain should be injected into the tissue grasped by the forceps, and similar injections should be made into other portions of the cervix and up the cervical canal. An applicator wrapped with absorbent cotton saturated with a ten per cent solution of cocain CURETTAGE 267 should bu passed into the cervical canal, and allowed l<> remain in place for at least ten minutes. It is necessary that the tip of the applicator pass the internal os, as otherwise the anesthesia will not be complete. The direction of the cervical canal should next be determined by the uterine probe. The knowledge thus gained is of impor- tance in inserting the dilator. The dilator should be fully intro- duced before its blades are opened. A little rotation in one direc- tion or the other facilitates its introduction. Gentle pressure is then made upon the handles for ten seconds. The pressure is then relaxed, the dilator rotated for a sixth of the circle, pressure again exerted, and so on. In this manner, by brief periods of gentle pressure made in different directions, the cervix can be sufficiently dilated to permit the introduction of a curette or other instrument or the insertion of an intra-uterine stem pessary. The patient should remain in a recumbent position for at least twelve hours after this operation. Curettage. — The inner lining of the uterus is frequently scraped out as a means of treatment in cases of endometritis, and also as a means of removing portions of placental tissue remaining after abortion, or as a means of obtaining tissue for a microscopical examination in cases of suspected cancer of the uterus, etc. The cervical canal is first to be dilated. The extent and direc- tion of the uterine cavity is then determined by the uterine probe, and its lining scraped from the fundus to the cervix by a sharp curette. This should be systematically done, as otherwise the scraping is apt to be excessive in certain portions and insufficient in others. The detached shreds of mucous membrane should be thoroughly washed out by means of a double current uterine cath- eter. The fluid used for irrigation should be hot to aid in con- trolling hemorrhage. The patient should remain in bed for two days or more, accord- ing to the cause for which the curettage is performed. A custom which some operators have of packing the cavity of the uterus with gauze is not to be recommended in most cases. If the scrapings from the uterus are of a fungoid or exuberant character, they should be examined microscopically, since they may be part of a malignant growth, 268 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS Chancroid. — A chancroid may occur anywhere about the vaginal orifice or its immediate vicinity. If it is so situated as to lie between two folds of skin, the lesion is often reproduced on the opposing surface. For this reason several chancroids of vary- ing ages and sizes are often found in the same patient. The progress of , the disease and the best method of overcoming it are described on page 222. It is desirable to keep apart, as far as possible, the folds of skin so as to limit the spread of the infec- tion, hence the necessity of frequent dressings and thorough clean- liness. A fold of gauze laid between the labia of the right and left side, and held in place by the perineal strap of a T-bandage, will be found helpful. Fig. 131. — Multiple Syphilitic Tumors of the Vulva. Syphilis. — A chancre, the primary lesion of syphilis, may occur at any exposed portion of the genital organs of the female, SYPHILIS 269 but is most likely to be found upon the labia minora or .some other portion of the delicate skin about the vaginal orifice. It may be single, or two separate lesions may coexist. The primary lesion of syphilis is apt to be overlooked in the female. The surface where it may occur is much greater than is that of the male, and is not so readily examined. Hence, a woman may contract syphilis without knowledge of the fact. This ex- Fig. 132. — Syphilitic Tumor of Thigh near the Vulva. Patient a negress aged twenty-seven years. plains the occurrence of later lesions of the disease in women who deny that they have ever had syphilis, and whose truthfulness there is often no reason to doubt. The diagnosis is not difficult when a primary lesion is found. Its appearance is similar to that of a primary lesion upon the male genitals. The later lesions of syphilis are not infrequently found upon the vulva. The tissues are prone to hypertrophy under the in- fluence of prolonged irritation, so that mucous patches develop strongly and condylomata become extensive, later syphilides often assuming a multiple papillomatous character (Fig. 131). This is the more usual form, although single tumors also occur (Fig. 132), as well as gummatous ulceration. For the local and constitutional treatment of syphilis, see page 61. L>7() AFFECTIONS OF THE FEMALE GENITO-UR1NARY OKiJANS TUMORS Benign Tumors. — The benign tumors of the external gen- itals, such as papilloma, lipoma, etc., require no espeeial descrip- tion. The treatment is the same as when similar tumors are found elsewhere in the body (see p. 185). Cyst of Bartholin's Gland. — The duct of Bartholin's gland may become obstructed, leading to a distention of the cavity of the gland with mucus. This gives a fluctuating, rounded tumor at one side of the vaginal orifice, covered by normal skin, and freely movable on the deeper parts. It should be dissected out through an anteroposterior incision and the wound closed by suture. Or it may lie cut into at the site of the normal opening of the duct, and drained with a small wick of silk threads until the artificial canal thus formed has become lined with epithelium. Suppuration of Bartholin's gland is described on page 283. Urethral Caruncle. — This is a vascular tumor of the meatus, made up of connective tissue and hypertrophied papilla? and nu- merous dilated blood-vessels. It is covered with epithelium. Such a little tumor is often extremely sensitive, so that the passage of urine or the slightest touch will give the patient great pain. The diagnosis is easily made if the labia are separated and the urethral orifice is inspected. There will then be noticed a bright red tumor, usually entirely outside of the urethra, but some- times partly within it, springing from the mucous membrane by a slender pedicle. Sometimes more than one such tumor exists. Treatment. — The caruncle should be thoroughly removed after anesthesia has been produced by cocain. On account of the delicacy of the overlying epithelium, the application of a bit of absorbent cotton saturated with a ten per cent solution of cocain will produce a complete anesthesia in a few minutes. The mucous membrane should then be divided around the pedicle, dissected back for a short distance, so that the base of the tumor may be divided below the level of the surrounding mucous membrane. The vessels should be ligated with fine catgut and the cuff of mucous membrane sutured with fine black silk so as completely to cover the raw area. The stitches should be removed in four days. Polyp of the Cervix. — A polyp of the cervix is a more or less rounded tumor composed of the same tissues as the mucous CARCINOMA 271 membrane from which it springs. It is usually distinctly pedicled. It generally springs from the mucous membrane of the cervical canal, and gives rise to more or less hemorrhage and pain. As soon as it appears in the external os the cause of the hemorrhage is evident. Before such appearance the diagnosis is extremely difficult. Treatment. — The pedicle of a polyp may be seized with for- ceps and twisted off. If the point from which the polyp springs is not distinctly visible, the cervical canal should first be dilated. On account of the possibility that polypoid degeneration of the cervical mucous membrane may be the initial stage of cancer the operation should be a more thorough one in patients who have passed their fortieth year. A general anesthetic should then be given, the cervix fully dilated (p. 266) and the base of each polyp, or the mucous membrane from which the polyps spring, should be resected. In every case the excised tissue should be examined microscopically. Carcinoma. — Carcinoma of the vulva begins in a hard swell- ing which soon ulcerates, infiltrates, and affects the inguinal lym- phatic glands. In other words, its characteristics are those of cancer in other portions of the body. Owing to the abundant blood- supply of the parts its growth is rapid. Carcinoma of the vagina as a primary lesion is seldom seen. Carcinoma of the cervix is very common and may be recog- nized both by palpation and inspection as an indurated swelling, with rough surface, ulcerating, and having a putrid odor. There are, however, some cases of erosion of the cervix, due primarily to laceration and secondarily to inflammatory discharges from the uterus, which do not present the ordinary appearances of cancer, but which upon microscopical examination may prove to be malig- nant. In suspicious conditions of this kind it is important to remove a section of the ulcer for examination by a competent pathologist. This can be easily done through a bivalve or tubular speculum, the pain being prevented by the injection of a few drops of a two per cent cocain solution. Treatment. — A malignant tumor, Avhether beginning exter- nally or internally, should be thoroughly removed if possible. If this is not possible, it had better be left alone. Those who advo- cate a partial removal for the sake of getting rid of foul discharges 272 AFFECTIONS OF THE FEMALE GENITOURINARY ORGANS apparently forget that ulcers will soon form again, and that the ' patient will, sooner or later, be subjected to the annoyance of an ulcerating cancer, unless perchance she succumbs to the so-called palliative operation. £?o 11 uiii inn is made of benign tumors of the body of the uterus, or other abdominal tumors, since the consideration of such lesion is wholly out of the range of minor surgery. ACQUIRED DEFORMITIES Relaxation of the Sphincter of the Bladder. — Inconti- nence of Urine. — Incontinence of urine is an affection of old age whose treatment is most unsatisfactory. With advancing years the sphincter of the bladder becomes relaxed until a woman finds it impossible to hold her water as long as she has been accustomed to do. If the relaxation of the sphincter is slight, incontinence will only take place when the patient coughs or otherwise suddenly increases the pressure upon the bladder. In more marked degrees of the trouble there is a constant dripping of the urine, which keeps the patient in a distressing condition not only for herself, but for those about her. This weakness is often increased by a local condition of cystocele or prolapse of the uterus. The possi- bility of an overfilled and overflowing bladder should be borne in mind, though this condition is less common in women than in men. Before condemning a patient to the constant use of a rubber urinal the urine should be drawn by catheter and carefully exam- ined so that its amount and character may be known. One should not forget the possible presence within the bladder or urethra of a calculus or other foreign body, or a polyp or other tumor, which may be the cause of the incontinence. Attempts should be made to stimulate the sphincter by massage, by astringent applications applied in the urethra or vaginally, by cold bathing, and by elec- tricity. If the urine is found to be neutral or alkaline, benzoic acid may be given, or the benzoate of soda ten grains a day. These drugs are irritating to the stomach and should therefore be given well diluted one hour after meals. More often the urine is scanty or too acid, so that an abundance of drinking-water and alkaline diluents should be prescribed. Cystocele or prolapse of the urethra or uterus should be relieved by a pessary or cured by operation. RETENTION OF URINE 273 Incontinence of Childhood. — Incontinence of urine by night or by day is not uncommonly seen in both male and female children, but is more troublesome in girls than boys (see p. 2 20 ). The attention of the parents should be directed to the general condi- tions which favor this affection, and they should see that the child sleeps under light clothing and drinks plenty of water in the fore- noon and but little or nothing for some hours before going to bed. It is often of advantage to arrange the mattress so that the hips are slightly higher than the shoulders. Cold sponge baths night and morning are also of assistance in overcoming the trouble. In no case should a child be punished for a weakness it cannot avoid and which mortifies it extremely. Among the various drugs which have been tried with more or less success belladonna has attained quite a reputation, and its use is sometimes followed by marked improvement. The urine should always be examined, and if it is unduly acid, alkaline diluents should be given. In obstinate cases the occasional passage of a cold steel sound into the bladder will stimulate and strengthen the sphincter so as to increase its control. Another good plan is to give the child a measuring- glass, and encourage it to retain its water for a time after the first inclination to urinate is noticed. Such restraint should not be carried too far, the idea being a gradual strengthening of the muscles through systematic exercise. One can safely predict that the lack of control will disappear before the age of puberty is reached. Retention of Urine. — Catheterization. — Retention of urine in the female is rarely seen except after an operation or after childbearing. It is due sometimes to the anesthetic, sometimes to the changed abdominal pressure, sometimes to the operative wound in the immediate vicinity, and sometimes simply to the horizontal position. There are women who are unable to pass water lying down, even in health. The risk of catheterization is a slight one, but it should be avoided when possible. It is better, therefore, to postpone it until the patient has made some ineffectual attempts to empty the blad- der and feels pressure. This will usually mean the lapse of twelve or sixteen hours after an operation or delivery. After many gyne- cological operations the nature of the operation makes it unde- sirable to allow the patient to urinate. In such cases the bladder 274 AFFECTIONS OF THE FEMALE GENITOURINARY ORGANS should be emptied regularly by catheter, without waiting for the patient's sensal ions. Catheterization, which is so simple to one accustomed to its performance, may be very embarrassing to the beginner, especially if the nurse announces that she is unable to find the urethra. It is therefore worth description. The old practise of passing a catheter by touch has no place in modern aseptic technique. The operator should sterilize his hands or wear sterile gloves, although if he proceeds properly and a glass catheter is used this is not strictly necessary, for he will not touch any part of the catheter which enters the urethra. The patient Hexes the thighs and separates the knees widely. If she is lying on a soft bed, a pillow should be placed under the hips to raise the vulva well above the level of the bed. With the thumb and fingers of one hand the operator separates the anterior part of the labia minora widely, so as to expose the vestibule. With the other hand he wipes the vestibule clean, using a swab of ab- sorbent cotton Avet with a mild antiseptic. He next drops the swab, and with the same hand takes the sterile catheter, near its outer end, and passes it gently into the meatus. The catheter should be wet with saline solution. No other lubricant is needed, unless the catheter is unduly large. It will readily follow the urethra to the bladder, and the urine at once streams out. When the bladder is empty, the forefinger is placed over the end of the catheter in order to prevent the escape of the urine as it is with- drawn. If a rubber catheter is used, some lubricant is generally necessary, and this fact, together with the necessity of grasping the catheter near the tip, makes it desirable that the hands of the operator shall be sterile. The irritation which follows the repeated use of a glass catheter is probably due to the fact that it is too large, or is taken from an irritating solution before insertion, or that it is not introduced with sufficient gentleness. Prolapse of Urethra. — The female urethra may prolapse from the meatus and cause much discomfort, or even sharp pain. The prolapse may be complete, that is, affecting the whole surface of the mucous membrane, or partial, only one side of the urethra being affected. Astringents will relieve symptoms in mild cases. In severer cases cauterization, both by heat and by chemicals, is often' tried, but usually proves unsatisfactory. It is better to ex- PROLAPSE OP UTERUS 275 eise the protruding membrane and to make